Traumatic brain injury and long-term associations with work, divorce and academic achievement.

OBJECTIVE: Traumatic brain injuries (TBI), irrespective of severity, may have long-term social implications. This study explores the relationships between TBI severity and outcomes related to work stability, divorce, and academic achievement. METHODS: Using a Danish nationwide sample of persons with and without TBI, we employed case-control and longitudinal cohort designs. The case-control design utilized individuals aged 18 to 60 years and examined work stability. Each case, employed at time of TBI, was compared with 10 matched controls. The cohort design utilized individuals alive from 1980 to 2016 with and without TBI and assessed the likelihood of 1) divorce and 2) higher-level education. TBI exposures included concussion, skull fractures, or confirmed TBI. RESULTS: TBI cases exhibited higher odds ratios (OR) for work instability at all follow-ups compared to controls. Increased TBI severity was associated with a higher risk of work instability at 2-year follow-up (concussion: OR = 1.83; skull fracture: OR = 2.22; confirmed TBI: OR = 4.55), and with a higher risk of not working at 10-year follow-up (confirmed TBI: OR = 2.82; concussion: OR = 1.63). The divorce incidence rate ratio (IRR) was elevated in individuals with TBI (males: IRR = 1.52; females: IRR = 1.48) compared to those without TBI. Individuals with childhood TBI had reduced chances of attaining high school degree or higher (males: IRR = 0.79; females: IRR = 0.85) compared to those without TBI. CONCLUSION: TBI is associated with an increased long-term risk of social consequences, including work instability, divorce, and diminished chances of higher education, even in cases with concussion.

Return to work in persons with persistent postconcussion symptoms: a survey study examining the perspectives of employees and managers.

OBJECTIVE: To examine challenges in return to work (RTW) for persons with persistent postconcussion symptoms (PPCS) experienced by the affected employees and their managers. METHODS: A survey of employees (S-E) and two surveys of managers (S-M1, S-M2) executed 4 months apart to capture the time perspective. Inclusion: Adults aged 18-66 with PPCS > 4 weeks, employed at the time of mTBI who returned to work within the previous year. Managers involved in their RTW process. OUTCOME MEASURES: Work status, working hours, work functioning (Work Role Functioning Questionnaire, WRFQ), work productivity. RESULTS: Ninety-two employees and 66 managers were recruited. Three-fourths of the employees had returned to work but only one-third worked under similar conditions. Weekly working hours decreased from 36,3 hours (SD = 10,5) before mTBI to 17,6 hours (SD = 9,7). Employees had difficulties with tasks 43% of time (WRFQ). They needed more breaks, struggled with multitasking and work speed. About 65.9% experienced affected work productivity. Managers reported lack of knowledge and difficulties assessing the number of working hours and suitable tasks. CONCLUSIONS: Most employees returned to work but only a minority worked under similar conditions as before mTBI. Employees and managers struggled to estimate workload. The affected employees and their workplaces need a long-term RTW support.

Labour market attachment dynamics in patients with concussion: a Danish nationwide register-based cohort study.

BACKGROUND: Concussion may lead to persisting post-concussive symptoms affecting work ability and employment. This study examined the transitions between labour market states an individual can experience after the acute phase of concussion. The aim was to describe the incidence of favourable and adverse transitions between different labour market states (e.g., employment, sick leave) in relation to socioeconomic and health characteristics in individuals with concussion relative to matched controls. METHODS: This Danish nationwide register-based cohort study extracted 18-60-year-old individuals between 2003-2007 with concussion from the Danish National Patient Register (ICD-10 S06.0). Controls were matched on age, sex, and municipality. Patients and controls were followed for 5 years starting three months after injury. Exclusion criteria were neurological injuries and unavailability to the labour market in the inclusion period (2003-2007) and 5-years before injury (1998-2002). Labour market states were defined from transfer income data in the Danish Register for Evaluation of Marginalization. Incidence rates of transitions between these labour market states were analysed in multistate models. Transitions were bundled in favourable and adverse transitions between labour market states and the difference in incidence rates between individuals with concussion relative to matched controls were assessed with hazard ratios from Cox regression models. RESULTS: Persons with concussion (n = 15.580) had a lower incidence of favourable transitions (HR 0.88, CI 0.86-0.90) and a higher incidence of adverse transitions (HR 1.30, CI 1.27-1.35), relative to matched controls (n = 16.377). The effect of concussion differed depending on health and socioeconomic characteristics. Notably, individuals between 30-39 years (HR 0.83, CI 0.79-0.87), individuals with high-income (200.000-300.000 DKK) (HR 0.83, CI 0.80-0.87), and wage earners with management experience (HR 0.60, CI 0.44-0.81) had a markedly lower incidence of favourable transitions compared to controls. Additionally, individuals with high income also had a higher incidence of adverse transitions (HR 1.46, CI 1.34-1.58) compared to controls. CONCLUSIONS: Concussion was associated with enhanced risk of adverse transitions between labour market states and lower occurrence of favourable transitions, indicating work disability, potentially due to persistent post-concussive symptoms. Some age groups, individuals with high income, and employees with management experience may be more affected.

Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis.

Individuals with mild traumatic brain injury (mTBI) may experience protracted symptoms affecting their ability to work. Several actors may facilitate or act as a barrier to a successful return to work (RTW). This qualitative study used semi-structured in-depth interviews with 22 adults with mTBI at 2-5 years post injury, targeting experiences of how different actors facilitated or acted as a barrier in the RTW process, and encompassed the mTBI trajectory from the acute phase to the post-acute phase. A thematic analysis with a hermeneutical phenomenological approach was used to analyse data. Three main themes emerged. (1) Worker-employer relationship: Workplace accommodations such as decreased working hours, modified working conditions, and support from co-workers were lacking. (2) The role of the general practitioner: The general practitioner was lacking treatment and referral opportunities and failed to provide the patient with relevant and individualized guidance. (3) Municipal case management: Participants perceived being met with distrust by social workers, follow-up assessments were too frequent, unnecessary, and did not target concussion, and rehabilitation was referred too late. Clinical practice guidelines to improve referral to relevant concussion rehabilitation in case of persistent symptoms are needed to inform clinicians, employers, and public institutions to facilitate a successful RTW.

Five-Year Trends in Marital Stability, Academic Achievement, and Socioeconomic Indicators After Concussion: A National Register Study.

OBJECTIVE: To examine long-term trends in marital stability, academic achievement, income, and socioeconomic status in patients with concussion. DESIGN AND SETTING: Danish national register-based cohort study with 5 years of follow-up. PARTICIPANTS: A total of 23 549 hospital-admitted or emergency-treated patients between 18 and 60 years of age with concussion (International Classification of Diseases, Tenth Revision [ICD-10] diagnosis S06.0) and 22 228 matching controls. MAIN MEASURES: Outcomes were the differences between patients with concussion and controls in the change from injury date to 5 years postinjury in the dichotomized outcomes-martial stability, academic achievement, income, and socioeconomic status. RESULTS: Fewer patients had high education (19.43%) compared with controls (23.96%) and the adjusted odds ratio (OR) of high education beyond the difference in prevalence at baseline became even lower at 5 years of follow-up (OR: 0.93, 95% confidence interval [CI]: 0.90-0.95). Patients were to a lesser extent gainfully employed (67.05%) compared with controls (77.32%) and had lower odds of being gainfully employed (OR: 0.83, 95% CI: 0.79-0.88), self-employed, leaders, or managers (OR: 0.89, 95% CI: 0.84-0.95) at 5 years postinjury, beyond differences at baseline. CONCLUSIONS: Academic achievement and socioeconomic status are affected by concussion. There is no evidence that marital stability and income are affected. Supporting interventions should be considered those at risk of persistent symptoms.

Specialized interdisciplinary rehabilitation reduces persistent post-concussive symptoms: a randomized clinical trial.

OBJECTIVE: To compare the effectiveness of a specialized, interdisciplinary rehabilitation (S-REHAB) with standard care (STAND) for people with persistent post-concussive symptoms (PPCS > 6 month). DESIGN: Randomized controlled trial. PARTICIPANTS: Eighty-nine adults. INTERVENTIONS: 22-week programme combining individual and group-based neuropsychological treatment with exercise therapy and physiotherapeutic coaching (S-REHAB), and the usual treatment offered by the public municipality services (STAND). OUTCOME MEASURES: The Rivermead Postconcussion Symptoms Questionnaire (RPSQ) (primary), The Headache Impact Test (HIT-6), Major Depression Inventory (MDI), Multidimensional Fatigue Inventory (MFI-20) and The Short Form (36) Health Survey (SF-36); all collected at baseline, post-treatment, and at 6-month follow-up. RESULTS: The S-REHAB group showed a significant reduction in symptoms measured by RPSQ compared to the STAND immediately post-treatment (effect size [ES] = 0.28) and at follow-up (ES = 0.26). The S-REHAB groups also showed significant improvements regarding HIT-6 post-treatment (ES = 0.38) and at follow-up (ES = 0.68), MFI-20 - dimension 'mental fatigue' post-treatment (ES = 0.42), MFI-20 - dimension 'reduced activities' at follow-up (ES = 0.74) and SF-36 - dimension 'social functioning' post-treatment (ES = 0.31). CONCLUSIONS: The S-REHAB is more effective than the STAND in reducing the PPCS affecting physical, cognitive and emotional domains. This symptom reduction was associated with experienced improvement in social functioning, increased levels of activity, a decrease in mental fatigue and increased life satisfaction.

The diagnosing and treatment of concussions.

Mild traumatic brain injury, such as concussion, was once considered self-resolving. However, over the past decade, increased understanding of the short- and long-term impact has led to new guidelines for active management. In this review, we summarise recent findings, covering diagnostic criteria, and management for early and persistent symptoms. Many of the postconcussive symptoms can be treated and an individualised approach from a biopsychosocial perspective is recommended. Overall, the new knowledge will significantly impact patient care and future research.

Predictive Validity of Motor Assessment Scale on Poststroke Discharge Destination.

Background: Stroke frequently leads to hospital admission and subsequent rehabilitation in order to overcome poststroke sequelae, such as motor impairments. Efficient planning of the steps following hospital admission includes early prediction of whether the patient can be discharged home or not. Early assessment of motor performance in patients with stroke-induced motor deficits may be able to function as a predictor of discharge destination but is less explored. Objective: The primary objective was to assess the predictive validity of the Motor Assessment Scale (MAS) on discharge destination both regarding total score and regarding subscores (transfer-mobility items and upper extremity items). Design: The study was designed as a prospective cohort study. Subjects: Thirty-seven consecutively recruited patients with stroke are the subjects of the study. Methods: Logistic regression model was used to calculate the odds of being discharged to own home upon hospital admittance. The predictive ability was examined with a receiving operator characteristic (ROC) curve, and cut-points from the curve were employed in Cox regression. Results: A one-unit higher score on the total MAS significantly increased the odds of being discharged home upon hospital admittance (odds ratio (OR) 1.14, 95% CI 1.04-1.25). The same pattern was observed with the summed items of 1-5 and 6-8. The total MAS showed sensitivity of 91.7% and specificity of 68.0%. Patients having a total MAS score ≥ 24 were 17 times more likely to be discharged home (HR 17.64, 95% CI 2.23-139.57) compared to patients with a lower score. Conclusion: Motor function measured by the MAS can be applied as a predictor of discharge destination upon hospital admission after stroke in Danish setting.

Dissociating spatial strategies in animal research: Critical methodological review with focus on egocentric navigation and the hippocampus.

One major challenge in animal research on spatial learning and memory pertains to designing methods to dissociate spatial strategies (allocentric vs. egocentric). This is crucial for understanding the underlying cognitive processes and neural circuits that are recruited in navigational tasks. Taking the egocentric reference frames as a starting point, this review argues that in many extensively used spatial paradigms, multiple spatial reference frames are often available to the animals but remain unaccounted for. We discuss the implications this has for the inferences that can be made and propose a decision-algorithm to construct spatial learning paradigms that can reduce the influence of these confounding variables. Furthermore, with these considerations in mind, we review the role of the hippocampus in egocentric navigation forms, i.e. in response learning, egocentric sequential learning and path integration. This choice is based on the controversy surrounding the role of hippocampus in these spatial paradigms. We discuss the possible methodological confounders that may explain the inconclusive results.

Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation.

Importance: Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. Objective: To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. Data Sources: Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. Study Selection: A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury. Data Extraction and Synthesis: Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Main Outcomes and Measures: All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). Results: Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus. Conclusions and Relevance: Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.