Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review.

BACKGROUND AND PURPOSE: Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI. METHODS: A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science. RESULTS: Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited. CONCLUSIONS: Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.

Attachment and Clinical Outcomes Among Treatment-Seeking Adults With Persistent Symptoms After Mild Traumatic Brain Injury.

OBJECTIVE: Interpersonal attachment influences the development and course of disease. Overreliance on insecure attachment strategies may increase risk for poor disease outcomes. This study aimed to investigate largely unexplored relationships between attachment strategies and clinical outcomes among adults with persistent symptoms after mild traumatic brain injury (mTBI). METHODS: Participants with persistent symptoms after mTBI (N=83) completed measures assessing dimensions of insecure attachment (Relationship Scales Questionnaire [RSQ]), persistent symptoms (Rivermead Post-Concussion Symptoms Questionnaire), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and health-related quality of life (HRQOL) (Quality of Life After Brain Injury-Overall Scale). Questionnaires were administered at clinic intake (mean=18.1 weeks postinjury) and again 3-4 months later (mean=32.2 weeks postinjury), except the RSQ, which was administered only in the follow-up assessment. Treatment response for each outcome was calculated as the difference between scores at clinic intake and follow-up. Generalized linear models were fitted for each clinical outcome, with RSQ variables as predictors. RESULTS: Higher attachment anxiety was associated with greater persistent symptom severity, greater depression and anxiety symptoms, and worse HRQOL at follow-up. Higher attachment anxiety was also associated with less improvement in depression and HRQOL over time. In contrast, attachment avoidance was unrelated to any of the clinical outcomes. CONCLUSIONS: Attachment anxiety, the fear that a significant other will not be available in stressful circumstances, may be a particularly important social factor associated with health among adults with persistent symptoms after mTBI. Greater consideration of the attachment system is warranted in mTBI care and research.

Post-concussion Syndrome Light Sensitivity: A Case Report and Review of the Literature.

Photophobia is considered the second most common symptom of both concussion and post-concussion syndrome. Soldiers on duty experience photophobia after blast-related concussions or mild traumatic brain injury in 60-75% of instances. In addition, soldiers report other symptoms, such as asthenopia, squinting, dry eyes and headaches, for which they are considered to be at high risk. According to the International Brain Injury Association, some concussed patients report indirect symptoms such as multi-tasking difficulties, dizziness, vertigo, and fatigue. Moreover, some concussed individuals experience photophobia for approximately 6 months or indefinitely. We present the case of a 23-year-old soldier who presented with severe photophobia after a mild traumatic head injury. His photophobia was alleviated after the administration of topical anaesthetic drops in the eyes in the absence of any ocular surface pathology. He was diagnosed with post-concussion syndrome light sensitivity and was managed successfully with rose-coloured special photophobia glasses tinted with FL-41. Photophobia is a common neurological symptom in military personnel that needs more attention as it affects body and mind. We have reported an uncommon pathway of photophobia, which may unveil an unrecognised mechanism that may play a role in post-concussion photophobia.

Rehabilitation Utilizing Controlled Aerobic Activity in Patients With a Concussion: A Critically Appraised Topic.

Clinical Scenario: A sport-related concussion is a common injury to the brain that may cause a variety of symptoms ranging in duration and severity. The mainstay of treatment for concussion has been rest, followed by a stepwise return to activity. This recovery process may be lengthy when symptoms persist. Aerobic exercise conducted at subsymptom and submaximal intensities has been proposed as a potential intervention for symptoms following a concussion. Therefore, the purpose of this critically appraised topic is to examine the safety of varying aerobic exercise intensities in patients with a concussion. Focused Clinical Question: Are subsymptom and submaximal exercise programs safe when implemented in a population with a symptomatic sports-related concussion when compared with traditional rest? Summary of Key Findings: Four randomized controlled trials were included for critical appraisal. The 4 studies investigated supervised and controlled aerobic exercise as early as within 1 week of with a concussion; all studies conclude that exercise is safe and may be of benefit to individuals with a concussion. Two studies support the use of submaximal exercise as a therapeutic intervention for adolescents with persistent concussion symptoms. Clinical Bottom Line: The authors conclude that controlled exercise performed within the symptom or exertion threshold of patients with concussion is safe compared with rest. It was noted that symptom changes may occur; however, the changes did not have a negative impact on long-term recovery. This research should ease concerns about prescribing physical activity when an athlete with concussion is still experiencing lingering symptoms. While specific parameters of the activity performed have not been described in detail, the individualization of each exercise program was stressed. Strength of Recommendation: Grade A.

Diffusion kurtosis imaging in mild traumatic brain injury and postconcussional syndrome.

Aims of this study were to investigate white matter (WM) and thalamus microstructure 72 hr and 3 months after mild traumatic brain injury (TBI) with diffusion kurtosis imaging (DKI) and diffusion tensor imaging (DTI), and to relate DKI and DTI findings to postconcussional syndrome (PCS). Twenty-five patients (72 hr = 24; 3 months = 23) and 22 healthy controls were recruited, and DKI and DTI data were analyzed with Tract-Based Spatial Statistics (TBSS) and a region-of-interest (ROI) approach. Patients were categorized into PCS or non-PCS 3 months after injury according to the ICD-10 research criteria for PCS. In TBSS analysis, significant differences between patients and controls were seen in WM, both in the acute stage and 3 months after injury. Fractional anisotropy (FA) reductions were more widespread than kurtosis fractional anisotropy (KFA) reductions in the acute stage, while KFA reductions were more widespread than the FA reductions at 3 months, indicating the complementary roles of DKI and DTI. When comparing patients with PCS (n = 9), without PCS (n = 16), and healthy controls, in the ROI analyses, no differences were found in the acute DKI and DTI metrics. However, near-significant differences were observed for several DKI metrics obtained in WM and thalamus concurrently with symptom assessment (3 months after injury). Our findings indicate a combined utility of DKI and DTI in detecting WM microstructural alterations after mild TBI. Moreover, PCS may be associated with evolving alterations in brain microstructure, and DKI may be a promising tool to detect such changes.

Effectiveness of Vestibular Rehabilitation Therapy for Treatment of Concussed Adolescents With Persistent Symptoms of Dizziness and Imbalance.

CONTEXT: Adolescents who suffer sport concussion typically respond to a prescription of cognitive and physical rest in the acute phases of healing; however, some adolescents do not respond to rest alone. Dizziness, unsteadiness, and imbalance are impairments, which may linger longer than 30 days, leading to a diagnosis of postconcussion syndrome (PCS). Vestibular assessment and therapy may benefit adolescents suffering from these persistent symptoms. CLINICAL QUESTION: Does vestibular rehabilitation therapy (VRT) rather than continued prescription of rest (cognitive and physical) reduce recovery time and persistent symptoms of dizziness, unsteadiness, and imbalance in adolescents (12-18 y) who suffer PCS following a sports-related concussion? Summary of Key Findings: All 4 studies selected included adolescents suffering from PCS, specifically continued dizziness, unsteadiness, and imbalance. VRT was an effective intervention for this population. Adolescents presenting with this cluster of symptoms may also demonstrate verbal and visual memory loss linked to changes in the vestibular system postconcussion. Improved screening tools can help better understand vestibular system changes, identify adolescents who may benefit from VRT sooner, and decrease long-term impairments. Clinical Bottom Line: Moderate evidence supports that adolescents who suffer from persistent symptoms of dizziness, unsteadiness, and imbalance following sport concussion should be evaluated more specifically and earlier for vestibular dysfunction and can benefit from participation in individualized VRT. Early evaluation and treatment may result in a reduction of time lost from sport as well as a return to their premorbid condition. For these adolescents, VRT may be more beneficial than continued physical and cognitive rest when an adolescent's symptoms last longer than 30 days. Strength of Recommendation: Grade B evidence exists to support that VRT is more effective than continued cognitive and physical rest in reducing persistent symptoms of dizziness, unsteadiness, and imbalance in adolescents who suffer PCS.

A Systems Science Approach to Understanding Polytrauma and Blast-Related Injury: Bayesian Network Model of Data From a Survey of the Florida National Guard.

We sought to further define the epidemiology of the complex, multiple injuries collectively known as polytrauma/blast-related injury (PT/BRI). Using a systems science approach, we performed Bayesian network modeling to find the most accurate representation of the complex system of PT/BRI and identify key variables for understanding the subsequent effects of blast exposure in a sample of Florida National Guard members (1,443 deployed to Operation Enduring Freedom/Operation Iraqi Freedom and 1,655 not deployed) who completed an online survey during the period from 2009 to 2010. We found that postdeployment symptoms reported as present at the time of the survey were largely independent of deployment per se. Blast exposure, not mild traumatic brain injury (TBI), acted as the primary military deployment-related driver of PT/BRI symptoms. Blast exposure was indirectly linked to mild TBI via other deployment-related traumas and was a significant risk for a high level of posttraumatic stress disorder (PTSD) arousal symptoms. PTSD arousal symptoms and tinnitus were directly dependent upon blast exposure, with both acting as bridge symptoms to other postdeployment mental health and physical symptoms, respectively. Neurobehavioral or postconcussion-like symptoms had no significant dependence relationship with mild TBI, but they were synergistic with blast exposure in influencing PTSD arousal symptoms. A replication of this analysis using a larger PT/BRI database is warranted.

Adolescents with Mild Traumatic Brain Injury Get SMART: An Analysis of a Novel Web-Based Intervention.

BACKGROUND: There have been few trials of interventions to facilitate recovery following mild traumatic brain injury (mTBI) in adolescence. To address this gap, we developed and piloted a novel Web-based intervention, entitled Self-Management Activity Restriction and Relaxation Training (SMART), and examined its impact on symptom burden, functional disability, and executive functioning during the month following mTBI in adolescents. MATERIALS AND METHODS: Open-label, single arm study. Adolescents with recent mTBI and a parent were recruited from the emergency department and provided access upon discharge to SMART-a Web-based program designed to facilitate recovery via self-management and education about symptoms and sequelae associated with mTBI. Symptom burden, functional disability, and executive functioning were rated by both the adolescent and the parent initially and at assessments at 1-, 2- and 4-weeks postinjury. Mixed models analyses were used to examine trajectories on these outcomes. RESULTS: Of the 21 adolescent/parent dyads enrolled, 13 engaged in the program and reported significant improvement in symptoms over the 4-week program (adolescent, p = 0.0005; parent, p = 0.004). Adolescents spent a median of 35.5 min (range 1.1-107.6) using the program. Parent ratings of the adolescent's functional disability and executive functioning significantly improved over the 4-week period from baseline (p = 0.009 and p = 0.03, respectively), whereas adolescents themselves did not report significant changes in either outcome. All participants improved and there were no adverse outcomes. CONCLUSION: The SMART program, a novel Web-based intervention, may serve as a self-management tool for adolescents and their parents to assist with the recovery following a recent mTBI.

Characterization of bilateral frontal lobe cerebral oxygen saturation in patients with mild traumatic brain injury.

BACKGROUND: There is clear evidence of the potential for long-term neuro behavioral and cognitive sequelae following a mild traumatic brain injury (mTBI). Although the source of these persistent behavioral and cognitive issues is unclear, several studies have suggested a cerebral vascular disorder is a likely contributor. PURPOSE: Measure and compare cerebral blood oxygen saturation values in frontal brain lobes of subjects with and without a history of mTBI. METHODS: Bilateral frontal brain lobe blood oxygen saturation was measured using near-infrared spectroscopy in mTBI and non-brain injured subjects while alternately breathing room air and a mildly hypoxic gas mixture. RESULTS: Subjects with a history of mTBI displayed a significantly different trajectory of change in their cerebral oxygen saturation values during exposure to mild hypoxia compared to controls. DISCUSSION: The finding confirms and adds to previous research that indicates there is likely a vascular component to this mild form of brain injury.

Chronic Traumatic Encephalopathy and Movement Disorders: Update.

Association of repetitive brain trauma with progressive neurological deterioration has been described since the 1920s. Punch drunk syndrome and dementia pugilistica (DP) were introduced first to explain symptoms in boxers, and more recently, chronic traumatic encephalopathy (CTE) has been used to describe a neurodegenerative disease in athletes and military personal with a history of multiple concussions. Although there are many similarities between DP and CTE, a number of key differences are apparent especially when comparing movement impairments. The aim of this review is to compare clinical and pathological aspects of DP and CTE with a focus on disorders of movement.

Predictors of postconcussion syndrome in collegiate student-athletes.

OBJECTIVE Sport-related concussion (SRC) has emerged as a public health problem, especially among student-athletes. Whereas most concussions resolve by 2 weeks, a minority of patients experience postconcussion syndrome (PCS), in which symptoms persist for months. The objective of this study was to elucidate factors predictive of PCS among a sample of National Collegiate Athletic Association (NCAA) student-athletes in the academic years 2009-2010 to 2014-2015. METHODS The SRC data originated from the NCAA Injury Surveillance Program (ISP) in the 2009-2010 to 2014-2015 academic seasons. The NCAA ISP is a prospective database made up of a convenience sample of schools across all divisions. All SRCs are reported by certified athletic trainers. The PCS group consisted of concussed student-athletes with concussion-related symptoms that lasted ≥ 4 weeks. The non-PCS group consisted of concussed student-athletes with symptom resolution in ≤ 2 weeks. Those with symptoms that resolved in the intermediate area of 2-4 weeks were excluded. Odds ratios (ORs) were estimated using logistic regression. RESULTS During the 2009-2010 to 2014-2015 seasons, 1507 NCAA student-athletes sustained an SRC, 112 (7.4%) of whom developed PCS (i.e., concussion-related symptoms that lasted ≥ 4 weeks). Men's ice hockey contributed the largest proportion of concussions to the PCS group (28.6%), whereas men's football contributed the largest proportion of concussions in the non-PCS group (38.6%). In multivariate analysis, recurrent concussion was associated with increased odds of PCS (OR 2.08, 95% CI 1.28-3.36). Concussion symptoms that were also associated with increased odds of PCS included retrograde amnesia (OR 2.75, 95% CI 1.34-5.64), difficulty concentrating (OR 2.35, 95% CI 1.23-4.50), sensitivity to light (OR 1.97, 95% CI 1.09-3.57), and insomnia (OR 2.19, 95% CI 1.30-3.68). Contact level, sex, and loss of consciousness were not associated with PCS. CONCLUSIONS Postconcussion syndrome represents one of the most impactful sequelae of SRC. In this study of exclusively collegiate student-athletes, the authors found that recurrent concussions and various concussion-related symptoms were associated with PCS. The identification of initial risk factors for the development of PCS may assist sports medicine clinicians in providing timely interventions and treatments to prevent morbidity and shorten recovery time after SRC.

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis.

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.

Retirement-from-sport considerations following pediatric sports-related concussion: case illustrations and institutional approach.

The decision to advise an athlete to retire from sports following sports-related concussion (SRC) remains a persistent challenge for physicians. In the absence of strong empirical evidence to support recommendations, clinical decision making must be individualized and should involve a multidisciplinary team of experts in concussion and traumatic brain injury. Although previous authors have advocated for a more conservative approach to these issues in child and adolescent athletes, there are few reports outlining considerations for this process among this unique population. Here, the authors use multiple case illustrations to discuss 3 subgroups of clinical considerations for sports retirement among pediatric SRC patients including the following: those with structural brain abnormalities identified on neuroimaging, those presenting with focal neurological deficits and abnormalities on physical examination, and those in whom the cumulative or prolonged effects of concussion are suspected or demonstrated. The authors' evolving multidisciplinary institutional approach to return-to-play and retirement decision making in pediatric SRC is also presented.

Sports-related concussions: diagnosis, complications, and current management strategies.

Sports-related concussions (SRCs) are traumatic events that affect up to 3.8 million athletes per year. The initial diagnosis and management is often instituted on the field of play by coaches, athletic trainers, and team physicians. SRCs are usually transient episodes of neurological dysfunction following a traumatic impact, with most symptoms resolving in 7-10 days; however, a small percentage of patients will suffer protracted symptoms for years after the event and may develop chronic neurodegenerative disease. Rarely, SRCs are associated with complications, such as skull fractures, epidural or subdural hematomas, and edema requiring neurosurgical evaluation. Current standards of care are based on a paradigm of rest and gradual return to play, with decisions driven by subjective and objective information gleaned from a detailed history and physical examination. Advanced imaging techniques such as functional MRI, and detailed understanding of the complex pathophysiological process underlying SRCs and how they affect the athletes acutely and long-term, may change the way physicians treat athletes who suffer a concussion. It is hoped that these advances will allow a more accurate assessment of when an athlete is truly safe to return to play, decreasing the risk of secondary impact injuries, and provide avenues for therapeutic strategies targeting the complex biochemical cascade that results from a traumatic injury to the brain.

Type and occurrence of serious complications in patients after mild traumatic brain injury.

Traumatic brain injury (TBI) remains a major public health and socio-economic problem, and 70-90% of all TBIs are classified as mild. Mild TBIs and concussions are mostly considered to be non-serious conditions with symptoms subsiding within a few days or weeks. However in 10-15% of patients, the symptoms persist one year after concussion and mostly include headache, fatigue, irritability, and cognitive problems (e.g. memory, concentration). These persisting symptoms negatively influence patient daily activities as postconcussion syndrome (PCS). Second-impact syndrome (SIS) is a very rare but usually fatal condition and occurs when repeated brain injuries lead to a catastrophic diffuse brain swelling. There is no scientific evidence on the incidence and risk of SIS. Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease of the brain found in patients with a history of repetitive brain trauma. CTE presents with behavioural, cognitive, and motor symptoms. The literature to date lacks prospective epidemiological studies of the incidence of CTE. In recent medical literature, there is a description of 110 athletes with postmortem diagnosis of CTE (Tab. 1, Ref. 37).

Elevated C-reactive protein levels may be a predictor of persistent unfavourable symptoms in patients with mild traumatic brain injury: a preliminary study.

The pathogenesis of persistent unfavourable outcomes following mild traumatic brain injury (mTBI) are not fully understood. Low-grade systemic inflammation might contribute to the development of persistent unfavourable outcomes in patients with mTBI. We used plasma high-sensitivity C-reactive protein (CRP) levels as the biomarker of systemic inflammation to investigate whether elevated CRP levels were associated with persistent adverse outcomes in these patients. A total of 213 consecutive patients with mTBI were identified in our study. Plasma high-sensitivity CRP levels were measured at baseline, 1month, 2months and 3months after initial traumatic brain injury. The study endpoints included persistent postconcussion syndrome (PCS), persistent psychological problems (depression and anxiety), persistent physiological problems (frequent headache, nausea, insomnia, dizziness and fatigue) and persistent cognitive impairment, which were screened by International Classification of Diseases (ICD-10), diagnostic and statistical manual of mental disorders (DSM-IV), Beck anxiety inventory (BAI), Beck depression inventory (BDI) and montreal cognitive assessment (MoCA) 3months post-injury. The associations between baseline CRP levels and persistent unfavourable outcomes were estimated from multiple regression models adjusting for various confounding covariates. Elevated baseline CRP levels were associated with a significant increase in the incidence of persistent PCS (odds ratio [OR], 2.719; 95% confidence interval [CI], 1.609-4.594; p=0.000), persistent psychological problems (OR, 1.535; 95% CI, 1.063-2.216; p=0.022), and persistent cognitive impairment (OR, 1.687; 95% CI, 1.135-2.507; p=0.010). However, elevated CRP levels were not associated with persistent physiological problems (OR, 1.330; 95% CI, 0.905-1.956; p=0.146). Furthermore, three adjusted models did not essentially affect the OR of elevated CRP levels for these persistent unfavourable outcomes. Among patients with mTBI, baseline elevated CRP levels may be an independent predictor of persistent persistent PCS, psychological problems and cognitive impairment.

mTBI Biological Biomarkers as Predictors of Postconcussion Syndrome-Review.

Postconcussion syndrome (PCS) is one of the leading complications that may appear in patients after mild head trauma. Every day, thousands of people, regardless of age, gender, and race, are diagnosed in emergency departments due to head injuries. Traumatic Brain Injury (TBI) is a significant public health problem, impacting an estimated 1.5 million people in the United States and up to 69 million people worldwide each year, with 80% of these cases being mild. An analysis of the available research and a systematic review were conducted to search for a solution to predicting the occurrence of postconcussion syndrome. Particular biomarkers that can be examined upon admission to the emergency department after head injury were found as possible predictive factors of PCS development. Setting one unequivocal definition of PCS is still a challenge that causes inconsistent results. Neuron Specific Enolase (NSE), Glial Fibrillary Acidic Protein (GFAP), Ubiquitin C-terminal Hydrolase-L1 (UCH-L1), Serum Protein 100 B (s100B), and tau protein are found to be the best predictors of PCS development. The presence of all mentioned biomarkers is confirmed in severe TBI. All mentioned biomarkers are used as predictors of PCS. A combined examination of NSE, GFAP, UCH-1, S100B, and tau protein should be performed to detect mTBI and predict the development of PCS.

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes.

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

Subclinical brain manifestations of repeated mild traumatic brain injury are changed by chronic exposure to sleep loss, caffeine, and sleep aids.

INTRODUCTION: After mild traumatic brain injury (mTBI), the brain is labile for weeks and months and vulnerable to repeated concussions. During this time, patients are exposed to everyday circumstances that, in themselves, affect brain metabolism and blood flow and neural processing. How commonplace activities interact with the injured brain is unknown. The present study in an animal model investigated the extent to which three commonly experienced exposures-daily caffeine usage, chronic sleep loss, and chronic sleep aid medication-affect the injured brain in the chronic phase. METHODS: Subclinical trauma by repeated mTBIs was produced by our head rotational acceleration injury model, which causes brain injury consistent with the mechanism of concussion in humans. Forty-eight hours after a third mTBI, chronic administrations of caffeine, sleep restriction, or zolpidem (sedative hypnotic) began and were continued for 70 days. On Days 30 and 60 post injury, resting state functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) were performed. RESULTS: Chronic caffeine, sleep restriction, and zolpidem each changed the subclinical brain characteristics of mTBI at both 30 and 60 days post injury, detected by different MRI modalities. Each treatment caused microstructural alterations in DTI metrics in the insular cortex and retrosplenial cortex compared with mTBI, but also uniquely affected other gray and white matter regions. Zolpidem administration affected the largest number of individual structures in mTBI at both 30 and 60 days, and not necessarily toward normalization (sham treatment). Chronic sleep restriction changed local functional connectivity at 30 days in diametrical opposition to chronic caffeine ingestion, and both treatment outcomes were different from sham, mTBI-only and zolpidem comparisons. The results indicate that commonly encountered exposures modify subclinical brain activity and structure long after healing is expected to be complete. CONCLUSIONS: Changes in activity and structure detected by fMRI are widely understood to reflect changes in the functions of the affected region which conceivably underlie mTBI neuropathology and symptomatology in the chronic phase after injury.

Multidisciplinary interventions increase weekly working hours and quality of life in persons with post-concussion syndrome.

OBJECTIVES: To improve labor market attachment, general health and quality of life in persons suffering from post-concussion syndrome. Labor market attachment often changes after mTBI, and especially in persons suffering from post-concussion syndrome, and constitutes a huge societal burden. METHODS: Eighty-two adults with persistent post-concussion syndrome participated in this single-center and uncontrolled interventional efficacy open-label investigation. The primary endpoint was to increase weekly working hours. Outcome measures ranged from self-reported cognitive symptoms to objective performance testing. Multidisciplinary interventions were used to reduce symptoms of fatigue, stress, pain, oculomotor malfunction, and sensitivity to both sound and light. RESULTS: Workhours improved from median 0 to 6 hours (p = 0.00002). Several significant improvements were observed in quality of life measured by the SF-36. General fatigue measured by the MFI-20 was reduced (p < 0.0001), and symptoms of depression were reduced (p < 0.0001). The COPM results were improved for task completion satisfaction and for ability to perform a task (p < 0.0001). Reading speed, and performances in the Groffman Visual Tracing Test and the King-Devick Test, all improved (p < 0.01). The intervention did not reduce perception of pain intensity (p = 0.11). CONCLUSION: After the intervention, participants increased weekly workhours and improved in many aspects of life - including quality of life, performance in everyday activities, fatigue and depression. Perception of pain intensity was not improved.