Effectiveness of personalized rehabilitation in adults suffering from persistent concussion symptoms as compared to usual care: a randomized control trial protocol.

BACKGROUND: Symptoms reported by patients who sustain a concussion are non-specific. As such, clinicians are better able to manage patients when a standardized clinical exam is performed to sub-type the driver(s) of symptoms. Aerobic exercise and multimodal rehabilitation have consistently shown to be a possibly effective means to manage this population; however, the optimal training prescription is unclear. Thus, there is a need to further examine the effectiveness of personalized rehabilitative treatments. Our primary aim is to evaluate the response to personalized therapy on recovery, as measured by The Rivermead Post-concussion Symptoms Questionnaire (RPQ) when compared to an active control. METHODS: We will conduct a multi-center 12-week case-crossover randomized controlled trial. 50 participants will be recruited from out-patient University Health Network clinics and community-based clinical practices around the greater Toronto area. Participants will be randomized at baseline to Group A: a personalized care program followed by an active control or Group B: an active control followed by a personalized care program. Participants will be included should they be 21 years of age and older and have symptoms that have persisted beyond 4 weeks but less than 1 year. Participants will undergo 6-weeks of care in their respective streams. After 6-weeks, participants will undergo a re-examination. They will then crossover and undertake the alternative treatment for 6 weeks. At the end of 12 weeks, participants will undertake the endpoint examinations. The primary outcome will be the Rivermead Postconcussion Questionnaire (RPQ). The secondary outcomes will be changes in standardized clinical examination, Neck Disability Index (NDI), Patient Health Questionnaire (PHQ-9) and an electroencephalography (EEG) via NeuroCatch™. The statistical analysis to be performed is composed of an adjusted model using an analysis of variance, specifically using an unpaired t-test to test for associations between variables and outcomes. DISCUSSION: Given the recommendations from reviews on the topic of rehabilitation for adults with persistent concussion symptoms, we are undertaking a controlled trial. The documented high costs for patients seeking care for persistent symptoms necessitate the need to evaluate the effectiveness of a personalized rehabilitative program compared to the current standard of care. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT06069700.

"I Wish I Had That!": A Qualitative Analysis of Psychosocial Treatment Preferences Among Young Adults With Recent Concussion and Anxiety.

OBJECTIVE: To assess psychosocial treatment preferences and factors that may affect treatment participation among young adults with a recent concussion and co-occurring anxiety. DESIGN: In-depth, semi-structured individual qualitative interviews, followed by thematic analysis using a hybrid deductive-inductive approach. SETTING: Academic medical center in the US Northeast. PARTICIPANTS: Seventeen young adults (18-24y) who sustained a concussion within the past 3-10 weeks and reported at least mild anxiety (≥5 on the Generalized Anxiety Disorder-7 questionnaire). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcomes include preferences for program content (eg, topics and skills), delivery modality, format, and barriers and facilitators to participation. RESULTS: We identified 4 domains characterizing participants' perceptions of and preferences for treatment. (1) Program content: Participants preferred a program early after injury that included psychoeducation and coping skills (eg, activity pacing, deep breathing, mindfulness). (2) Therapeutic processes: Participants preferred a person-centered approach in which clinicians normalized anxiety postconcussion and reassured them of recovery. (3) Program logistics: Participants endorsed that a brief, virtual program would be acceptable. They preferred access to program components through multiple modalities (eg, audio, video) and accommodations to manage concussion symptoms. (4) Barriers and facilitators to participation: Barriers included acute concussion symptoms (eg, screen sensitivity), time constraints, and forgetting sessions. Facilitators included a program that is flexible (format, scheduling), personalized (self-chosen mode for reminders, measure of accountability), and accessible (ie, advertising through health care professionals or social media). CONCLUSIONS: Participants need psychosocial support that normalizes their experiences and provides education and coping tools. Treatments should be accessible, flexible, and person centered. Psychosocial treatments meeting these preferences may help optimize the recovery of young adults with recent concussion and anxiety.

Team-based rehabilitation after mild traumatic brain injury - description of the clinical pathway.

PURPOSE: Describe clinical practice, inter-disciplinary clinical pathway and core principles of care within a mild traumatic brain injury (mTBI) rehabilitation team. METHODS: An observational study examined inter-disciplinary practice, nested within an observational trial investigating team-based mTBI rehabilitation. Data were collected to describe clinical service over 12 months. Activity data quantified clinical sessions per participant, mode of service delivery and content of sessions using custom-designed codes. The clinical team gathered narrative data to confirm the inter-disciplinary clinical pathway and individual discipline practice. RESULTS: 168 participants entered the rehabilitation program during the 12 months. A single Allied Health Screening Assessment identified patient priorities. Occupational Therapy (OT) and Physiotherapy (PT) provided the majority of clinical sessions; the team also comprised Social Work, Rehabilitation Medicine, Speech Pathology and Clinical Psychology. Telehealth was the most common service delivery mode (54%). Median session numbers per participant ranged 1-4 for all disciplines; mean/maximum occasions of service were highest for PT (6.9/44) and OT (6.8/39). CONCLUSION: A small proportion of participants received much higher number of sessions, consistent with intractable issues after mTBI. High attendance rates indicate the predominantly telehealth-delivered model was feasible. The clinical approach included early prioritizing of discipline input and follow-up after discharge.

Occupational Therapy's Role in Return to Occupations Post-Concussion in High School Athletes.

AIM: This study was designed to explore experiences of high school athletes in order to understand their occupational engagement after sustaining a sports-related concussion. The study explored the role occupational therapists (OTs) can play in post-concussion care while supporting adolescents in returning to meaningful occupations. METHODS: The study utilized a qualitative, phenomenological approach by conducting interviews with high school athletes to understand their participation in occupations during recovery. Six student-athletes from 14-18 years of age were interviewed. RESULTS: The five identified themes from the study included impacts on ADL performance, school performance, sleep, mental health, and driver safety. Student-athletes reported feelings of loneliness and loss of identity. Dressing, showering, grooming, and driving were disturbed due to balance deficits, headaches, and nausea. Participants reported decreased participation in social, sports, and leisure occupations due to heightened symptoms. CONCLUSIONS: Due to the considerable variability of disturbance in occupational participation post-concussion, occupational therapists can assist in creating and implementing individualized treatment plans to support high school athletes while recovering from a sports-related concussion.

Changes in Outpatient Healthcare Utilization and Costs Following Mild Traumatic Brain Injury Among Service Members in the Military Health System by Preexisting Behavioral Health Condition Status.

OBJECTIVE: To evaluate changes in healthcare utilization and cost following an index mild traumatic brain injury (mTBI) diagnosis among service members (SMs). We hypothesized that differences in utilization and cost will be observed by preexisting behavioral health (BH) diagnosis status. SETTING: Direct care outpatient healthcare facilities within the Military Health System. PARTICIPANTS: A total of 21 984 active-duty SMs diagnosed with an index mTBI diagnosis between 2017 and 2018. DESIGN: This retrospective study analyzed changes in healthcare utilization and cost in military treatment facilities among SMs with an index mTBI diagnosis. Encounter records 1 year before and after mTBI were assessed; preexisting BH conditions were identified in the year before mTBI. MAIN MEASURES: Ordinary least squares regressions evaluated difference in the average change of total outpatient encounters and costs among SMs with and with no preexisting BH conditions (eg, posttraumatic stress disorder, adjustment disorder). Additional regressions explored changes in utilization and cost within clinic types (eg, mental health, physical rehabilitation). RESULTS: There was a 39.5% increase in overall healthcare utilization during the following year, representing a 34.8% increase in total expenditures. Those with preexisting BH conditions exhibited smaller changes in overall utilization (ß, -4.9; [95% confidence interval (CI), -6.1 to -3.8]) and cost (ß, $-1873; [95% CI, $-2722 to $-1024]), compared with those with no BH condition. The greatest differences were observed in primary care clinics, in which those with prior BH conditions exhibited an average decreased change of 3.2 encounters (95% CI, -3.5 to -3) and reduced cost of $544 (95% CI, $-599 to $-490) compared with those with no prior BH conditions. CONCLUSION: Despite being higher utilizers of healthcare services both pre- and post-mTBI diagnosis, those with preexisting BH conditions exhibited smaller changes in overall cost and utilization. This highlights the importance of considering prior utilization and cost when evaluating the impact of mTBI and other injury events on the Military Health System.

The Buffalo Concussion Treadmill and Bike Tests in People With Mild-to-Moderate Traumatic Brain Injury: An Exploratory Clinical Audit.

OBJECTIVE: To assess the performance on the Buffalo Concussion Treadmill and Bike Tests in nonathletic people following a mild-to-moderate traumatic brain injury. SETTING: An outpatient rehabilitation clinic. PARTICIPANTS: Forty-nine patients with mild-to-moderate traumatic brain injury who underwent the Buffalo Concussion Treadmill or Bike Test as usual clinical care. DESIGN: A retrospective clinical audit. MAIN MEASURES: Demographics and brain injury-specific clinical data, Depression Anxiety Stress Scale; Rivermead Post-Concussion Symptom Questionnaire, and performance outcomes on the Buffalo Concussion Treadmill or Bike Test. RESULTS: Forty-nine patients (mean age: 33.7 ± 13.0 years), on average 56.2 ± 36.4 days post-injury, completed the Buffalo Concussion Treadmill or Bike Test. Fourteen patients stopped the test due to symptom exacerbation with a mean test duration of 8.1 ± 4.5 minutes, reaching an age-predicted maximum heart rate of 72.9% ± 12.4% and reporting a rating of perceived exertion of 13.4 ± 2.2. Those who terminated the test for other reasons had a significantly longer test duration (14.0 ± 4.7 minutes, P = .01), with a higher age-predicted maximum heart rate (83.3% ± 12.8%, P = .01) and rating of perceived exertion (17.0 ± 2.5, P = .01). Within the group who stopped for other reasons, 10 were due to symptoms deemed unrelated to the injury at the time of the test and 2 were stopped by the therapist for safety reasons. A significant but weak correlation between heart rate and rating of perceived exertion existed only for those who terminated the test for other reasons ( r = 0.38, P = .02). Overall, a shorter test duration was associated with higher scores of both self-reported depression ( r = -0.41, P < .01) and late postconcussion symptoms ( r = -0.40, P < .01). CONCLUSION: The Buffalo Concussion Treadmill or Bike Test can be used in the nonathletic mild-to-moderate traumatic brain injury population to differentiate between those who experience symptom exacerbation during exercise and those who do not based on symptom exacerbation, test duration, and poor perception of exertion. Further research is required to determine whether other reasons for test termination are related to the injury.

Effectiveness of interventions for the improvement of mental health and well-being post-concussion: a systematic review.

OBJECTIVE: To identify and assess the effectiveness and quality of interventions targeted at improving mental health, well-being, and psychosocial impairments post-concussion. DATA SOURCES: EBSCOHost, SPORTSDiscus, PsychINFO, Medline (Web of Science), PubMed, and Embase databases. REVIEW METHODS: This systematic review is reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement in exercise, rehabilitation, sport medicine and sports science (PERSiST). Articles were included if they: (1) were randomized controlled trials or repeated measures pre-posttest study designs, (2) reported mild traumatic brain injury (mTBI) or concussion injury, and (3) evaluated interventions targeting mental health, well-being, and psychosocial impairments post-injury. RESULTS: Twenty-three studies were included which evaluated interventions targeting mental health, well-being, and psychosocial impairments post-concussion. Interventions included cognitive rehabilitation (n = 7), psychotherapy (n = 7), psychoeducational (n = 3), neurocognitive training (n = 4), neurocognitive training combined with cognitive rehabilitation (n = 1), and psychotherapy combined with cognitive rehabilitation (n = 1). The seven (100%) cognitive rehabilitation intervention studies and four of the five (80%) neurocognitive training intervention studies observed significant improvements in mental health and well-being outcomes. CONCLUSIONS: Cognitive rehabilitation and neurocognitive training may be the most effective interventions for mental health and well-being impairments post-concussion. Researchers and clinicians should continue to explore the effectiveness of these interventions, specifically in populations most impacted by concussion (i.e. athletes).

A randomized clinical trial of plasticity-based cognitive training in mild traumatic brain injury.

Clinical practice guidelines support cognitive rehabilitation for people with a history of mild traumatic brain injury (mTBI) and cognitive impairment, but no class I randomized clinical trials have evaluated the efficacy of self-administered computerized cognitive training. The goal of this study was to evaluate the efficacy of a self-administered computerized plasticity-based cognitive training programmes in primarily military/veteran participants with a history of mTBI and cognitive impairment. A multisite randomized double-blind clinical trial of a behavioural intervention with an active control was conducted from September 2013 to February 2017 including assessments at baseline, post-training, and after a 3-month follow-up period. Participants self-administered cognitive training (experimental and active control) programmes at home, remotely supervised by a healthcare coach, with an intended training schedule of 5 days per week, 1 h per day, for 13 weeks. Participants (149 contacted, 83 intent-to-treat) were confirmed to have a history of mTBI (mean of 7.2 years post-injury) through medical history/clinician interview and persistent cognitive impairment through neuropsychological testing and/or quantitative participant reported measure. The experimental intervention was a brain plasticity-based computerized cognitive training programme targeting speed/accuracy of information processing, and the active control was composed of computer games. The primary cognitive function measure was a composite of nine standardized neuropsychological assessments, and the primary directly observed functional measure a timed instrumental activities of daily living assessment. Secondary outcome measures included participant-reported assessments of cognitive and mental health. The treatment group showed an improvement in the composite cognitive measure significantly larger than that of the active control group at both the post-training [+6.9 points, confidence interval (CI) +1.0 to +12.7, P = 0.025, d = 0.555] and the follow-up visit (+7.4 points, CI +0.6 to +14.3, P = 0.039, d = 0.591). Both large and small cognitive function improvements were seen twice as frequently in the treatment group than in the active control group. No significant between-group effects were seen on other measures, including the directly-observed functional and symptom measures. Statistically equivalent improvements in both groups were seen in depressive and cognitive symptoms.

Feasibility of Concussion Rehabilitation Approaches Tailored to Psychological Coping Styles: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could affect selective change on targeted coping outcomes. DESIGN: Randomized controlled trial. SETTING: Outpatient concussion clinics. PARTICIPANTS: Adults (N=73, mean age=42.5y) who had persistent postconcussion symptoms and high avoidance or endurance behavior were enrolled at a mean of 12.9 weeks post injury. Ten participants did not complete treatment. INTERVENTIONS: Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy [GET]) or endurance coping (operant condition-based pacing strategies plus mindfulness training [Pacing+]). MAIN OUTCOME MEASURES: Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire. RESULTS: Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275 of 618). A total of 65.8% (73 of 111) of eligible patients were randomized (37 to GET, 36 to Pacing+), meeting accrual targets; 91.7% (55 of 60) of participants perceived treatment as credible. Therapists covered a mean of 96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47 of 66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater posttreatment reductions in avoidance behavior compared with Pacing+ (Cohen's drepeated measures, 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's drepeated measures, 0.39). CONCLUSIONS: These findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.

Adolescent and parent experiences with Tele-Active Rehabilitation for concussion: an exploratory qualitative study.

PURPOSE: To explore the experiences of adolescents with concussion and their parents who participated in a novel remotely delivered Tele-Active Rehabilitation (Tele-AR) intervention involving sub-symptom threshold exercise, education, and support. Specifically, we aimed to elicit perspectives regarding the remote delivery approach, valued aspects of the program, and perceived benefits of the intervention. METHODS: This qualitative study took place within the context of a larger mixed-methods project exploring the feasibility of the Tele-AR intervention. A descriptive qualitative design was utilized. Semi-structured interviews were conducted with adolescents (n = 3; ages 14-17 years) with concussion and one of their parents (n = 3) within one week of completing the six-week Tele-AR intervention. Data were analyzed using thematic analysis. RESULTS: Four themes were identified that capture participant experiences in the intervention: (1) Enabling access to active rehabilitation; (2) Focusing on individual needs; (3) Learning to take responsibility for recovery; and (4) Convenience and comfort of engaging in rehabilitation from home. CONCLUSIONS: A small sample of 3 adolescents with concussion and their parents were satisfied with the Tele-AR intervention and appreciated the convenience and comfort of engaging in rehabilitation from home, which facilitated adolescents taking responsibility for their own recovery. Findings support continued study of Tele-AR, which may be an accessible intervention to facilitate recovery in adolescents with concussion.

Exploring the value of the SCHOOLFirst return-to-school resource: Evaluating usability and satisfaction.

OBJECTIVE: To cocreate an evidence-based resource to enable educators to support students returning to school after concussion; evaluate the usability of and users' satisfaction with the resource; understand the role of the resource in supporting students' return to school; and describe changes in concussion knowledge following a concussion education and training workshop. DESIGN: Survey during a concussion education and training workshop. SETTING: Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ont, and York Region District School Board in Richmond Hill, Ont. PARTICIPANTS: Fifty-six educators, of whom 64% were teachers, 11% were school administrators, 23% fulfilled other roles (eg, child and youth worker), and 2% fulfilled unspecified roles. MAIN OUTCOME MEASURES: The survey collected demographic information, usability data via the System Usability Scale, and satisfaction data. Thematic analysis was used for open-ended questions. RESULTS: Participants reported the resource to be easy to use (69.6%), not complex (62.5%), and most felt confident using this resource (83.9%). Participants indicated they were satisfied with the resource (73.2%) and would use it in the future (87.5%). Some found the resource overwhelming and recommended it be summarized in a reference guide. Participants found the links, videos, and classroom accommodations or academic supports to be helpful. CONCLUSION: SCHOOLFirst is an evidence-based, user-driven resource that was created for educators to support students returning to school following concussion. Educators, health care providers, youth, and families collaborated on developing SCHOOLFirst to improve students' successful return to school following concussion. Educators were satisfied with the resource and saw opportunities to use it to support their students.

Vision Therapy: Ocular Motor Training in Mild Traumatic Brain Injury.

Vision therapy in the form of ocular motor training is increasingly used to treat visual complaints, particularly in the setting of persistent symptoms after mild traumatic brain injury (mTBI). In this review, we discuss the rationale behind this intervention and the evidence for its utility. Although the efficacy of exercises for primary convergence insufficiency is plausible and supported by data, there is not yet strong evidence of benefit for the post-traumatic variant. It is not established that abnormalities in fixation, pursuit, and saccades in mTBI are the cause of post-concussive symptoms, or that these abnormalities arise from ocular motor damage rather than being secondary effects of cognitive problems with attention or executive control. The few studies to date have significant methodological weaknesses. More substantial evidence is required before vision therapy can be accepted as a useful tool in the rehabilitation of patients with brain trauma. ANN NEUROL 2020;88:453-461.

Increased Microglial Exosomal miR-124-3p Alleviates Neurodegeneration and Improves Cognitive Outcome after rmTBI.

Repetitive mild traumatic brain injury (rmTBI) is considered to be an important risk factor for long-term neurodegenerative disorders such as Alzheimer's disease, which is characterized by ß-amyloid abnormalities and impaired cognitive function. Microglial exosomes have been reported to be involved in the transportation, distribution, and clearance of ß-amyloid in Alzheimer's disease. However, their impacts on the development of neurodegeneration after rmTBI are not yet known. The role of miRNAs in microglial exosomes on regulating post-traumatic neurodegeneration was investigated in the present study. We demonstrated that miR-124-3p level in microglial exosomes from injured brain was significantly altered in the acute, sub-acute, and chronic phases after rmTBI. In in vitro experiments, microglial exosomes with upregulated miR-124-3p (EXO-124) alleviated neurodegeneration in repetitive scratch-injured neurons. The effects were exerted by miR-124-3p targeting Rela, an inhibitory transcription factor of ApoE that promotes the ß-amyloid proteolytic breakdown, thereby inhibiting ß-amyloid abnormalities. In mice with rmTBI, the intravenously injected microglial exosomes were taken up by neurons in injured brain. Besides, miR-124-3p in the exosomes was transferred into hippocampal neurons and alleviated neurodegeneration by targeting the Rela/ApoE signaling pathway. Consequently, EXO-124 treatments improved the cognitive outcome after rmTBI, suggesting a promising therapeutic strategy for future clinical translation.

Predicting Concussion Recovery with PHQ-9 and GAD-7.

OBJECTIVE: To determine whether scores obtained from Patient Health Questionnaire-9 (PHQ-9) or the General Anxiety Disorder-7 (GAD-7) instruments administered following a concussion can be used to predict recovery time. METHOD: Retrospective cohort study in a university-based specialty concussion center of 502 concussed participants. Participants completed a PHQ-9 and GAD-7 during their initial visit and subsequent visits during the recovery period (ie, at 14, 28, 56, and 84 days). RESULTS: The median recovery time from a concussion was 21 days from the initial clinical evaluation; however, individuals with a PHQ-9 score ≤ 6 (n = 262) had a median recovery time of 17 (95% confidence interval [CI] 15-19) days, whereas those with PHQ-9 scores >6 (n = 240) had a median recovery time of 33 (95% CI 28-37) days and a hazard ratio of 0.525 (95% CI 0.438-0.629, P < 0.0001). For individuals with a GAD-7 score ≤ 4 (n = 259), the median recovery was 19 (95% CI 17-21), days whereas for those with a GAD-7 score > 4 (n = 243), the median recovery was 32 (95% CI 28-36) days with a hazard ratio of 0.554 (95% CI 0.462-0.664, P < 0.00). CONCLUSIONS: Scores obtained from PHQ-9 and GAD-7 screening tools appear to be predictive of an individual's recovery and may help identify those subjects who may benefit from early psychological interventions.

Scale-free functional brain dynamics during recovery from sport-related concussion.

Studies using blood-oxygenation-level-dependent functional magnetic resonance imaging (BOLD fMRI) have characterized how the resting brain is affected by concussion. The literature to date, however, has largely focused on measuring changes in the spatial organization of functional brain networks. In the present study, changes in the temporal dynamics of BOLD signals are examined throughout concussion recovery using scaling (or fractal) analysis. Imaging data were collected for 228 university-level athletes, 61 with concussion and 167 athletic controls. Concussed athletes were scanned at the acute phase of injury (1-7 days postinjury), the subacute phase (8-14 days postinjury), medical clearance to return to sport (RTS), 1 month post-RTS and 1 year post-RTS. The wavelet leader multifractal approach was used to assess scaling ( c1 ) and multifractal ( c2 ) behavior. Significant longitudinal changes were identified for c1 , which was lowest at acute injury, became significantly elevated at RTS, and returned near control levels by 1 year post-RTS. No longitudinal changes were identified for c2 . Secondary analyses showed that clinical measures of acute symptom severity and time to RTP were related to longitudinal changes in c1 . Athletes with both higher symptoms and prolonged recovery had elevated c1 values at RTS, while athletes with higher symptoms but rapid recovery had reduced c1 at acute injury. This study provides the first evidence for long-term recovery of BOLD scale-free brain dynamics after a concussion.

How Perceptions Impact Recovery from Concussion in Childhood and Adolescence: a Systematic Review.

Perceptions about the causes and consequences of concussion, and individual representations and interpretations of these factors, can influence the post-concussive recovery process. The goal of this project was to synthesize evidence on perceptions related to concussions as experienced by children, adolescents, and parents, and to evaluate how these perceptions impact post-concussive recovery in physical, behavioural, cognitive, and psychological domains. We undertook a systematic review based on the Cochrane Handbook, conducting a comprehensive search of six databases and Google Scholar. Duplicate, independent screening was employed and the quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). A total of 1552 unique records were identified, and six records (5 scientific articles and 1 thesis, published between 1990 and 2018; N = 26 to 412, age range from 2 to 18 years) were included. Perceptions about concussions were assessed differently between studies, with a range in types of measures and respondents. Some evidence suggested that perceptions could negatively impact concussion recovery, mostly post-concussive symptoms. However, results were not consistent between studies and the methodological quality was variable (and often low). There is limited evidence of the impact of perceptions of children, adolescents, and their parents on concussion recovery. Priorities for future research investigating concussion recovery should include recruiting representative samples, accounting for potential confounders, and measuring perceptions in children, adolescents and parents using validated measures. Higher quality studies are needed to better understand the role of perceptions in concussion recovery and to inform clinical care.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI.

OBJECTIVE: Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD: Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS: Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION: Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population.

OBJECTIVES: To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. DESIGN: Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. SETTING: Three military treatment facilities. PARTICIPANTS: Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. RESULTS: Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. CONCLUSIONS: Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Process evaluation of 'Brains Ahead!': an intervention for children and adolescents with mild traumatic brain injury within a randomized controlled trial.

OBJECTIVE: To investigate whether the 'Brains Ahead! Intervention for children and adolescents with mild traumatic brain injury' was implemented as intended. In addition, involvement in and satisfaction with the intervention among patients, caregivers and professionals delivering the intervention were studied. DESIGN: Mixed methods, prospective study. PARTICIPANTS: Children with mild traumatic brain injury and their caregivers, allocated to the intervention group of the randomized controlled trial in the 'Brains Ahead!' study, and the two professionals providing the intervention. INTERVENTION: The intervention consists of a standardized and individualized psychoeducational session with written take-home information, and follow-up telephone call(s). MAIN MEASURES: Registration forms, evaluation questionnaires for patients and caregivers and semi-structured interviews for professionals. DATA ANALYSIS: Qualitative data were categorized based on content. Quantitative data were reported as descriptive statistics. RESULTS: Fifty-five patients and caregivers out of 60 study-participants attended both sessions. All elements of the intervention were delivered to 53 study-participants. Evaluation questionnaires were completed by 21 of the 31 patients aged 12 years and older, and by 41 caregivers. Overall, the sessions were considered useful by 19 patients, 40 caregivers and both professionals. Reassurance, creating a better understanding and recognition of symptoms were rated as important aspects. On a scale from 1 to 10, the intervention was rated by children, caregivers and professionals with 7.6 (SD 1.2), 8.1 (SD .9) and 8.0 (SD .0), respectively. CONCLUSION: The 'Brains Ahead!' intervention was largely implemented as intended and the process evaluation revealed that it is considered feasible according to patients, caregivers and professionals.

The factor structure of the Quality of Life Inventory (QOLI) following traumatic brain injury.

Quality of life is a key indicator of outcome following traumatic brain injury (TBI). Research has reported several different factor structures for the Quality of Life Inventory (QOLI, Frisch, 1994). We compared the fit of existing factor models and examined the clinical utility of the QOLI's factors in a sample of Australian adults with TBI. Archival data from 901 participants were provided by the Neurotrauma Register of Tasmania. Participants were aged 16-80 years and 63% were male. Approximately 69% had mild TBI (PTA < 24 h), approximately 24% had moderate TBI (PTA >1 day, <7 days) and 7% had severe TBI. Both cross sectional and longitudinal analyses were utilized, as participants provided data at one or more of seven time-points, up to 3 years following injury. The results showed the data best fitted a three-factor model, comprising Self-functioning and activity, Self-actualization and Family and environment factors, and a second order Overall QOL factor. Differences in the trajectory of recovery were noted between the QOLI factor scores over time and in relation to demographic and injury variables. In conclusion, the three-factor structure of the QOLI provided useful clinical information about the recovery of patients' subjective quality of life following TBI.