Knowledge, Attitudes and Concussion Information Sources Among First Nations in Ontario.

OBJECTIVE: Hockey is a popular sport played by many First Nation youth. Concussion frequently goes unrecognized and unreported in youth hockey. Unintentional injuries among Indigenous youth occur at rates three to four times the national Canadian average. The study sought to examine knowledge, attitudes and sources of concussion information among First Nations people attending a provincial hockey tournament. METHODS: A cross-sectional survey was undertaken. The survey by Mzazik et al. were modified to use in this study. Participants included youth (6-18 years) hockey players (n=75), parents (n=248) and coaches (n=68). The main outcome measure was total knowledge index (TKI) which consisted of the sum of correct responses to 15 multiple choice questions. Additional data gathered included demographics, concussion history, attitudes toward concussion and sources of information. Descriptive statistics included proportion comparisons. Variables were tested using χ 2 and analysis of variance. RESULTS: Overall TKI scores (out of a total of 15) were low; players (5.9±2.8), parents (7.5±2.6) and coaches (7.9±2.6). Participants with higher knowledge scores reported more appreciation of the seriousness of concussion. Sources of information about concussion differed by study group, suggesting the need for multiple knowledge translation strategies to reach youth, parents and coaches. CONCLUSIONS: Future initiatives are urgently needed to improve education and prevention of concussion in First Nations youth hockey. Collaborating and engaging with communities can help to ensure an Indigenous lens for culturally safe interventions.

Exploring concussion awareness in hockey with a First Nations community in Canada.

OBJECTIVE: The purpose of this pilot study was twofold: (1) to begin to understand concussion in youth hockey in a First Nations community in Canada and (2) to determine the impact of a novel concussion education workshop. DESIGN: A one-group quasiexperimental time series study was undertaken. SAMPLE: A total of 41 participants consented, with 71% (n = 29) completing data collection at all three study time points. MEASUREMENT AND INTERVENTIONS: Two nurses one from the First Nations community and one from the tertiary care center collaborated to develop and deliver the intervention on concussion specifically general, hockey and symptom knowledge. The primary outcome was Total Knowledge Score (TKS), whereby correct responses to a self-reported questionnaire were summed and then converted to a percentage. RESULTS: The TKS were similar across study time points; preworkshop 71.7%, postworkshop 71.8%, and 6-month follow-up 72%. CONCLUSIONS: Nurses worked collaboratively with cultural experts from a First Nations community to integrate Indigenous ways of knowing into concussion awareness and safety for First Nations youth playing hockey.

Is Age Associated With the Severity of Post-Mild Traumatic Brain Injury Symptoms?

BACKGROUND: Mild traumatic brain injury (mTBI) is a significant public health concern. Research has shown that mTBI is associated with persistent physical, cognitive, and behavioural symptoms, leading to significant direct and indirect medical costs. Our objective was to determine if age impacts the type and severity of post-mTBI symptoms experienced. METHODS: Retrospective analysis of prospectively collected data at a level 1 tertiary care outpatient head injury clinic. Participants (N=167) were patients seen at the clinic following an mTBI. The Rivermead Post-Concussion Symptoms Questionnaire was used to assess symptom severity. RESULTS: In our sample, the mean age was 44±16 years with 51% males. Compared with other age groups, patients >66 years of age were significantly more likely to report an mTBI between 6 AM to 12 PM (69%). Middle-aged patients (36-55 years) were more likely to report higher severity of certain post-mTBI symptoms (headache, nausea and vomiting, irritability, poor concentration, sleep disturbance, blurry vision, light sensitivity, and taking longer to think) compared with patients >66 years of age. CONCLUSIONS: In general, middle-aged patients reported higher severity of post-mTBI symptoms compared with the oldest patients. Thus, there was a significant association between age and the severity of specific mTBI symptoms, which highlights the need for targeted management. Additional research is needed to understand the mechanisms that could be contributing to the higher symptom severity experienced by the middle-aged group.

Common Data Elements for Concussion in Tertiary Care: Phase One in Ontario.

BACKGROUND: Standardized data collection for traumatic brain injury (TBI) (including concussion) using common data elements (CDEs) has strengthened clinical care and research capacity in the United States and Europe. Currently, Ontario healthcare providers do not collect uniform data on adult patients diagnosed with concussion. OBJECTIVE: The Ontario Concussion Care Strategy (OCCS) is a collaborative network of multidisciplinary healthcare providers, brain injury advocacy groups, patient representatives, and researchers with a shared vision to improve concussion care across the province, starting with the collection of standardized data. METHODS: The International Framework of Functioning Disability and Health was selected as the conceptual framework to inform the selection of CDEs. The CDEs recommended by the OCCS were identified using key literature, including the National Institute of Neurological Disorders and Stroke-Zurich Consensus Statements for concussion in sport and the Ontario Neurotrauma Foundation Concussion/mTBI clinical guidelines. RESULTS: The OCCS has recommended and piloted CDEs for Ontario that are readily available at no cost, clinically relevant, patient friendly, easy to interpret, and recognized by the international scientific community. CONCLUSIONS: The implementation of CDEs can help to shift Ontario toward internationally recognized standard data collection, and in so doing yield a more comprehensive evidence-based approach to care while also supporting rigorous research.

Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms.

OBJECTIVE: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries. QUALITY OF EVIDENCE: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence. MAIN MESSAGE: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations. CONCLUSION: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

Clarifying the link between traumatic brain injury and homelessness: workshop proceedings.

PURPOSE: To disseminate the proceedings of a 1-day multidisciplinary stakeholder workshop aimed at examining the inter-relationship between traumatic brain injury (TBI) and homelessness. METHODS: Thirty-seven stakeholders participated in the workshop, including frontline workers with individuals who are homeless, physicians, nurses and other healthcare workers, researchers, policy-makers, students and individuals with lived experience of homelessness. Didactic presentations, large group discussions and break-out sessions were used to disseminate knowledge, identify service and research gaps, develop a research agenda and facilitate networking. RESULTS: The participants identified barriers to service provision for individuals who are homeless and have sustained TBI with a focus on age- and gender-related issues, co-morbid TBI and mental illness and jurisdictional differences. Challenges and strategies related to engaging stakeholders in research with this population, as well as disseminating knowledge were discussed and research questions were identified. CONCLUSION: There is very little empirical literature on the topic of TBI and homelessness. The workshop identified key issues for consideration, including gaps in knowledge related to this topic.

Traumatic brain injury among people who are homeless: a systematic review.

BACKGROUND: Homelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research. METHODS: A systematic literature search was conducted in PsycINFO (1887-2012), Embase (1947-2012), and MEDLINE/Pubmed (1966-2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies. RESULTS: Eight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature. CONCLUSIONS: The rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.

Controlled blast exposure during forced explosive entry training and mild traumatic brain injury.

BACKGROUND: There is a paucity of data regarding the pathophysiology and short- and long-term neurologic consequences of primary blast injury in humans. The purpose of this investigation was to test the feasibility of implementing a research protocol in the context of a forced explosive entry training course. METHODS: Instructors (n = 4) and students (n = 10) completing the Police Explosives Technicians-Forced Entry Instructors course were recruited to participate in the study. Participants underwent a physical examination, tests of postural stability and vestibular ataxia, and a neurocognitive battery 1 day before and 10 days following practical forced explosive entry exercises. RESULTS: The instructors reported significantly more blast exposures in their careers than the students (p < 0.05). Seventy-five percent of the instructors and 50% of the students reported a history of trauma to the head. A minority of the participants had deficits on cranial nerve, vestibular ataxia, and neurocognitive tests which did not change significantly postexposure. All the instructors and most of the students (90%) demonstrated postural stability deficits at baseline which did not change significantly postexposure. CONCLUSIONS: Studying the effects of blast exposure on the human brain in a controlled experimental setting is not possible. Forced explosive entry training courses afford an opportunity to begin examining this issue in real time in a controlled setting. This study underscores the importance of baseline testing of troops, of the consideration of subclinical implications of blast exposure, and of continued studies of the effects of blast exposures, including repeated exposures on the human brain.

The value of serum biomarkers in prediction models of outcome after mild traumatic brain injury.

BACKGROUND: To determine, using a civilian model of mild traumatic brain injury (TBI), the added value of biomarker sampling upon prognostication of outcome at 1 week and 6 weeks postinjury. METHODS: The Galveston Orientation and Amnesia test was administered, and blood samples for serum protein S100B and neuron-specific enolase (NSE) were collected from 141 emergency department patients within 4 hours of a suspected mild TBI (mTBI). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was administered via telephone 3 days postinjury. Patients were assessed by a physician at 1 week (n = 113; 80%) and 6 weeks (n = 95; 67%) postinjury. Neurocognitive and postural stability measures were also administered at these follow-ups. RESULTS: Levels of S100B and NSE were found to be abnormally elevated in 49% and 65% of patients with TBI, respectively. Sixty-eight percent and 38% of the patients were considered impaired at 1 week and 6 weeks postinjury, respectively. Stepwise logistic regression modeling identified admission Galveston Orientation and Amnesia test score, S100B level, and RPQ score at day 3 postinjury to be predictive of poor outcome at 1 week postinjury (c-statistic 0.877); female gender, loss of consciousness, NSE level, and RPQ score at day 3 postinjury were predictive of poor outcome at 6 weeks postinjury (c-statistic 0.895). The discriminative power of the biomarkers alone was limited. CONCLUSIONS: Biomarkers, in conjunction with other readily available determinants of outcome assessed in the acute period after injury, add value in the early prognostication of patients with mTBI. Our findings are consistent with the notion that S100B and NSE point to biological mechanisms underlying poor outcome after mTBI.

Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression.

PRIMARY OBJECTIVE: The most frequently reported psychiatric symptom after traumatic brain injury (TBI) is depression. This study examined whether internet-delivered cognitive behaviour therapy (CBT) could be appropriate and effective for patients with mild or moderate TBI and depression. METHODS AND PROCEDURES: Patients were recruited for an at-home, 6-week internet-based CBT program (MoodGYM). Participants were assessed during this period by weekly telephone calls and at 12 months post-enrolment. Intervention completion rates, predictors of adherence, user feedback and changes in scores on validated depression scales were assessed. MAIN OUTCOMES AND RESULTS: Twenty-one patients were recruited: 64% and 43% completed the 6-week intervention and the 12-month follow-up, respectively. Adherence rates were not predicted by demographic or injury characteristics in this small sample. Patients identified reading, memory and comprehension requirements as limitations of the program. Scores on the depression scales were significantly decreased upon completion of the intervention and at the 12-month follow-up. CONCLUSIONS: The MoodGYM program may be effective for treating symptoms of depression in patients with TBI. While adherence rates were not predicted by age, education level or injury severity, demands upon memory and concentration which may already be compromised in these patients need to be considered.

Randomized treatment trial in mild traumatic brain injury.

OBJECTIVE: To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury. METHODS: Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery). RESULTS: Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01). CONCLUSIONS: These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.

Treating Benign Paroxysmal Positional Vertigo in the Patient With Traumatic Brain Injury: Effectiveness of the Canalith Repositioning Procedure.

OBJECTIVE: The aim of this study was to determine the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) among patients after mild-to-moderate traumatic brain injury. METHODS: An unblinded, nonrandomized, case comparison interventional study with repeated measures (1, 5, 9, and 12 weeks postenrollment) of three groups of patients with traumatic brain injury (BPPV, n = 21; nonspecific dizziness, n = 23; no dizziness, n = 12) was conducted. Patients in the BPPV group received the CRP at baseline and repeatedly until a negative Dix-Hallpike Maneuver was observed. Participants in the other two groups did not receive the CRP. RESULTS: Symptom resolution at the 12-week follow-up was observed in 75% of patients in the BPPV group versus 8.3% in the nonspecific dizziness group (p = .0006). A significant Group × Time interaction was observed for the Dizziness Handicap Inventory (F = 4.2, p = .003) and 36-item Short Form Health Questionnaire physical component scores (F = 2.16, p = .035) with the BPPV group showing significantly improved scores by the 12-week follow-up. Although there were between-group differences on the 36-item Short Form Health Questionnaire mental health component scores (F = 4.06, p = .022), changes over time were not significant in the groups. CONCLUSIONS: Treatment with the CRP for posttraumatic BPPV resulted in significant symptom resolution and improvement in perceived physical health status.

Identification of hidden health utilization services and costs in adults awaiting tertiary care following mild traumatic brain injury in Toronto, Ontario, Canada.

AIM: The cognitive, emotional, behavioral and physical impairments experienced by adults after mild traumatic brain injury (mTBI) can produce substantial disability, with 15-20% requiring referral to tertiary care (TC) for persistent symptoms. METHODS: A convenience sample of 201 adult patients referred to TC as a result of mTBI was studied. Self-reported data were collected at first TC visit, on average 10 months postinjury. Patients reported the type and intensity of healthcare provider visit(s) undertaken while awaiting TC. RESULTS: On average males reported 37 and females 30 healthcare provider visits, resulting in over $500,000 Canadian dollars spent on potentially excess mTBI care over 1 year. DISCUSSION: Based on conservative estimate of 15% of mTBI patients receiving TC, this finding identifies a possible excess in care of $110 million for Ontario. Accurate diagnosis of mTBI and early coordination of follow-up care for those needing TC could increase cost-effectiveness.

Traumatic brain injury and cognitive impairment in men who are homeless.

PURPOSE: To examine cognitive performance among a sample of men in a residential unit of an urban homeless shelter and to compare cognitive performance between those with and without a history of traumatic brain injury (TBI). METHODS: An exploratory, quantitative study of participants recruited through convenience sampling. Participants were screened for TBI using the Brain Injury Screening Questionnaire, and cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Data were analyzed to examine associations between TBI status and cognitive performance. RESULTS: Thirty-four participants were recruited for the study: n = 12 with a positive and n = 22 with a negative screen for TBI. Both groups performed below norms in all cognitive domains measured by the RBANS. Those with a positive screen for TBI performed significantly worse on attention tasks than those with a negative screen for TBI (p = 0.026). RBANS scores were not associated with either mental health or substance abuse status. CONCLUSIONS: A history of TBI was associated with generally poorer cognitive performance in the study sample. An improved awareness of TBI and cognitive dysfunction among service providers and routine TBI screening could improve treatment and service delivery for this population.

Traumatic brain injury among men in an urban homeless shelter: observational study of rates and mechanisms of injury.

BACKGROUND: Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter. METHODS: We recruited participants from an urban men's shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group. RESULTS: A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27-81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse. INTERPRETATION: Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.

Posttraumatic amnesia and recall of a traumatic event following traumatic brain injury.

The relationship between posttraumatic amnesia (PTA) and symptoms of posttraumatic stress disorder (PTSD) was examined in 282 outpatients at a mean of 53 days after traumatic brain injury (TBI). Patients were assessed for TBI severity, intrusive and avoidant PTSD-type symptoms, and psychological distress, and were stratified into four comparison groups by duration of PTA. Levels of PTSD-type symptoms and psychological distress did not differ significantly between groups. Even patients with PTA >1 week reported intrusive and avoidant PTSD-type symptoms. However, when patients were stratified into those with PTA of <1 hour or >1 hour, the former were more likely to report such symptoms. TBI patients with brief PTA are more likely to experience PTSD-type reactions, but severe TBI with prolonged PTA is not incompatible with such reactions in a subset of patients. Possible mechanisms that could account for this finding are discussed.