Perceived Recovery and Self-Reported Functioning in Adolescents with Mild Traumatic Brain Injury: The Role of Sleep, Mood, and Physical Symptoms.

Purpose: To determine the contributions of anxiety, depressive, and concussion symptoms and sleep quality to self-perceived recovery in adolescents with concussion.Method: Adolescents aged 12-20 (n = 298) completed anxiety, depression, concussion symptoms, and sleep measures at an initial concussion clinic visit and three-month follow-up. At follow-up, they reported self-perceived recovery as percent back to normal.Results: Injury-related factors alone did not predict self-perceived recovery (R2Adj =.017, p =.074). More concurrent physical, mental health, and sleep symptoms explained 18.8% additional variance in poorer self-perceived recovery (R2Adj Change =.188, p <.05). Physical symptoms (Bstand = -.292) and anxiety (Bstand = -.260) accounted for the most variance in self-perceived recovery.Conclusion: Post-concussive symptoms, in particular anxiety and self-reported physical symptoms, seem to characterize protracted recovery. Self-perceived recovery as an outcome measure may provide a more holistic understanding of adolescents' experiences after concussion.

Neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

BACKGROUND: Persistent Sport-Related Post-Concussion Syndrome is often diagnosed with any type of prolonged PCS symptoms. However, there are not specific diagnostic criteria for PPCS such that misdiagnosis often occurs. Further, the signs and symptoms of PCS overlap with other common illnesses such as depression, anxiety, migraines, ADHD and others. Misdiagnosis may lead to less than efficacious treatment, resulting in prolonged symptoms. OBJECTIVE: This article will review relevant evidence-based literature on PCS, pointing out the lack of a systemic diagnostic framework. It will also provide evidence that highlights the multiple conflicting findings in the literature. This article will posit the BioPsychoSocial framework as the best diagnostic framework for understanding the impact of concussions on the person and to generate individualized and personal interventions. METHODS: A narrative review of sport concussion-related articles was conducted, after extensive searches of relevant and non-relevant literature by each author, as well as articles recommended by colleagues. Articles varied from American Academy of Neurology Class I to IV for evaluation and critique. Class IV articles were reviewed, as there is much public misconception regarding sport and other concussion treatment that needed identification and discussion. RESULTS: Articles reviewed varied by quality of research design and methodology. Multiple symptoms, recovery patterns and rehabilitation treatment approaches are purported in the sport-related concussion literature. Current consensus data as well as the mixed and contradictory findings were explored. CONCLUSIONS: Persistent Sport-Related Post-Concussion Syndrome is a topic of great interest to both professionals and the general public. There is much misunderstanding about the etiology, causation, diagnostic formulations, symptom presentation, prolonging factors and treatment involved in this syndrome. This article posits an individualized multi-system diagnostic formulation, examining all relevant factors, as generating the best interventions for neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

Physical Activity and Intermittent Postconcussion Symptoms After a Period of Symptom-Limited Physical and Cognitive Rest.

Reference: Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307. CLINICAL QUESTION: After concussion and a period of symptom-limited physical and cognitive rest, do athletes who experience intermittent symptoms return to asymptomatic condition more quickly with physical activity than with prolonged physical rest? DATA SOURCES: One investigator performed an individual search for each research question using the following databases: CINAHL, Cochrane Controlled Trials Registers, EMBASE, HealthSTAR, ProQuest, PsychInfo, PubMed, SPORTDiscus, and Web of Science. Search terms for rest were brain concussion, cognitive rest, mild traumatic brain injury, physical exertion, postconcussive syndrome, rehabilitation, sport-related concussion, therapy, treatment, and treatment outcome. Search terms for treatment were the same terms as for rest, as well as brain training, cervical spine, cognitive therapy, dizziness, exercise, headache, neck, pharmacotherapy, postural balance, and vertigo. The authors included peer-reviewed, published articles and abstracts and performed a citation search. STUDY SELECTION: Studies were included based on the following criteria as determined before searching: classified as original research, symptoms resulted after sport-related concussion, and investigation of the effects of either rest or treatment on symptoms. Abstracts that were excluded failed to evaluate rest, omitted sport-related concussion as the cause of symptoms, failed to evaluate a treatment's effect on sport-related concussion, or did not present original research. DATA EXTRACTION: The following data were extracted from each study that fit the selection criteria: study design; sample size; participants' demographic information (age and sex); type, duration, and intensity of treatment; key findings including effect sizes and means with 95% confidence intervals (calculated when possible using the data provided in the original study, even if not presented in the original study); and relevant comments. MAIN RESULTS: The search revealed 749 articles evaluating the effects of rest and 1175 articles evaluating the effects of treatment. Of the 749 articles evaluating the effects of rest, only 2 met all the inclusion criteria. Of the 1175 articles evaluating the effects of treatment, only 10 met all the inclusion criteria. Ultimately, the authors were able to identify additional treatment articles that met the inclusion criteria, for a total of 12. The nature of the treatments and the participants differed enough that meta-analysis was not possible. One of the 2 articles that evaluated rest was a retrospective analysis of athletes that showed those who were prescribed a period of cognitive rest had a longer duration of symptoms. The other study followed athletes postconcussion who were retrospectively assigned to groups based on self-reported activity level after injury. Those who reported moderate levels of cognitive and physical exertion over the first month postinjury appeared to demonstrate improved outcomes compared with those who pursued small or large amounts of activity. Twelve studies evaluated the effects of treatment on symptoms after sport-related concussion. Various interventions were reviewed, including pharmacotherapy, light aerobic activity, graded exercise treadmill test, hyperbaric oxygen therapy, vestibular physiotherapy, and cervical spine manual therapy. Unfortunately, the authors did not report effect sizes for specific interventions, and due to the varied nature of each study and its respective treatment approach, no pooled data could be analyzed. However, a group of adolescents treated with submaximal aerobic and coordination exercises, visualization, and imagery returned to full normal physical activity at a mean duration of 4.4 weeks (95% confidence interval = 3.1, 5.7 weeks). Furthermore, a randomized controlled trial of patients experiencing persistent neck pain, dizziness, and headaches who underwent manual and physical therapy showed they were more likely to return to sport after 8 weeks of treatment. Despite the inability to pool data, the authors concluded that each treatment appeared to positively influence specific aspects of certain patients' symptoms. CONCLUSIONS: Little high-quality evidence has addressed the effects of rest and treatment after sport-related concussion. Current evidence suggests that an initial period of rest appears to be beneficial. Further research is needed to evaluate the long-term outcomes of rest (including the quality and quantity of the rest). Low levels of exercise may benefit the athlete postinjury, but additional study is required to determine the optimal timing for initiation of treatment postinjury. Patients with cervical spine or vestibular dysfunction may benefit from rehabilitation techniques targeted at their individual symptom profile to facilitate recovery. Overall, we need high-quality studies evaluating resting period, pharmacologic interventions, rehabilitative techniques, and exercise and their effects on patients slow to recover from concussion symptoms.

Neuropsychological and psychological rehabilitation interventions in refractory sport-related post-concussive syndrome.

BACKGROUND: The neuropsychological, physical, vestibular and oculomotor sequelae of sports-related concussion are extremely well documented. However, there is a paucity of interventions for these symptoms in refractory sports-related concussions. AIM: The intent of this article is to review the known and emerging neuropsychological and psychological rehabilitation interventions for reducing morbidity in refractory sports-related concussions (SRCs). METHODS: The authors openly acknowledge the limited amount of empirical data available for review, as did the Zurich consensus papers, but posit a mindful and ethical approach towards rehabilitation interventions in the absence of evidence-based guidelines. Further, rehabilitation interventions proven useful with similar injuries or illnesses, particularly non-sports-related mild TBI, will be reviewed for applicability. Such interventions include Cognitive-Behavioural psychotherapy, biofeedback, cranial electrical stimulation, neurofeedback and cognitive rehabilitation. RESULTS AND CONCLUSIONS: Modified approaches for rehabilitation with young children within family and school systems are provided. Recommendations for further research are offered.

EEG Neurofeedback therapy: Can it attenuate brain changes in TBI?

BACKGROUND: Electroencephalogram Neurofeedback therapy (EEG-NFT) has several potential beneficial effects in terms of improving cognition and electrophysiological regulation among patients with brain injury. However, in vivo structural and functional changes remain less explored. OBJECTIVE: The aim of the present study is to explore EEG-NFT induced in vivo changes in traumatic brain injury (TBI) patients. METHOD: Two patients with mean age of 15 years with moderate head injury who had more than seven post concussion symptoms and poor cognitive performances (<5 percentile) were subjected to 20 sessions of EEG-NFT. The neuropsychological test scores, post concussion symptoms and MRI scan of the brain were recorded pre-post to EEG-NFT. RESULTS: During EEG-NFT the cognitive scores and concussion symptoms improved significantly (p < 0.05). The EEG-NFT has shown significant increase in cortical grey matter (GM) volumes (p < 0.0001) and fractional anisotropy (FA) of cortical white matter (WM) tracts (p < 0.0001, voxel max 60 and above). There was a significant decrease in global, local efficiency, cost and clustering coefficient of functional connectivity (Wilcoxon Sign Rank Test p < 0.05). Interestingly there was a significant increase in thalamo-cortical connection (increase FA value) after EEG-NFT. CONCLUSION: The EEG-NFT therapy has shown significant changes in structural and functional connectivity among young moderately injured TBI patients.

The effect of hyperbaric oxygen on persistent postconcussion symptoms.

BACKGROUND: The high incidence of persistent postconcussion symptoms in service members with combat-related mild traumatic brain injury has prompted research in the use of hyperbaric oxygen (HBO2) for management. OBJECTIVE: The effects of HBO2 on persistent postconcussion symptoms in 60 military service members with at least 1 combat-related mild traumatic brain injury were examined in a single-center, double-blind, randomized, sham-controlled, prospective trial at the Naval Medicine Operational Training Center at Naval Air Station Pensacola. METHODS: Over a 10-week period, subjects received a series of 40, once-daily, hyperbaric chamber compressions at 2.0 atmospheres absolute (ATA). During each session, subjects breathed 1 of 3 preassigned oxygen fractions (10.5%, 75%, or 100%) for 60 minutes, resulting in an oxygen exposure equivalent to breathing surface air, 100% oxygen at 1.5 ATA, or 100% oxygen at 2.0 ATA, respectively. Individual, subscale and total item responses on the Rivermead Postconcussion Symptom Questionnaire and individual and total Posttraumatic Disorder Checklist-Military Version were measured just prior to intervention and immediately postintervention. RESULTS: Between-group testing of pre- and postintervention means revealed no significant differences on individual or total scores on the Posttraumatic Disorder Checklist-Military Version or Rivermead Postconcussion Symptom Questionnaire, demonstrating a successful randomization and no significant main effect for HBO2 at 1.5 or 2.0 ATA equivalent compared with the sham compression. Within-group testing of pre- and postintervention means revealed significant differences on several individual items for each group and difference in the Posttraumatic Disorder Checklist-Military Version total score for the 2.0 ATA HBO2 group. DISCUSSION: The primary analyses of between group differences found no evidence of efficacy for HBO2. The scattered within group differences are threatened by Type 2 errors and could be explained by nonspecific effects. CONCLUSION: This study demonstrated that HBO2 at either 1.5 or 2.0 ATA equivalent had no effect on postconcussion symptoms after mild traumatic brain injury when compared with sham compression.

Psychological approaches to treatment of postconcussion syndrome: a systematic review.

BACKGROUND AND AIM: Postconcussion syndrome (PCS) is a term used to describe the complex, and controversial, constellation of physical, cognitive and emotional symptoms associated with mild brain injury. At the current time, there is a lack of clear, evidence-based treatment strategies. In this systematic review, the authors aimed to evaluate the potential efficacy of cognitive behavioural therapy (CBT) and other psychological treatments in postconcussion symptoms. METHODS: Four electronic databases were searched up to November 2008 for studies of psychological approaches to treatment or prevention of postconcussion syndrome or symptoms. RESULTS: The search identified 7763 citations, and 42 studies were included. This paper reports the results of 17 randomised controlled trials for psychological interventions which fell into four categories: CBT for PCS or specific PCS symptoms; information, reassurance and education; rehabilitation with a psychotherapeutic element and mindfulness/relaxation. Due to heterogeneity of methodology and outcome measures, a meta-analysis was not possible. The largest limitation to our findings was the lack of high-quality studies. CONCLUSION: There was evidence that CBT may be effective in the treatment of PCS. Information, education and reassurance alone may not be as beneficial as previously thought. There was limited evidence that multifaceted rehabilitation programmes that include a psychotherapeutic element or mindfulness/relaxation benefit those with persisting symptoms. Further, more rigorous trials of CBT for postconcussion symptoms are required.