The Rivermead Post-Concussion Questionnaire score is associated with disability and self-reported recovery six months after mild traumatic brain injury in older adults.

Background/Objectives: Post-concussion syndrome refers to the adverse group of symptoms following a mild traumatic brain injury (mTBI). The Rivermead post-concussion syndrome questionnaire (RPQ) is a common clinical tool for assessing baseline post-concussion syndrome symptomology; however, it is unknown if scores on this questionnaire are associated with future disability. Therefore, the goal of this study was to determine the association between baseline RPQ scores and future disability in older adults with mTBI.Methods and Findings: This study used a prospective cohort design, using the RPQ to measure baseline post-concussion syndrome symptomatology. Disability at 6 months was measured using the Glasgow Outcome Scale-Extended (GOSE; disability), short-form 12 (SF-12; physical and mental quality of life), and self-reported recovery. Linear and logistic models adjusted for confounding factors were estimated using 200 bootstrapped samples. Individuals with higher levels of baseline symptomatology were more likely to have poor GOSE scores (RR = 2.13, 95% CI [1.51, 2.31]) and self-reported recovery (RR = 2.64, 95% CI [1.31, 8.98]) 6 months later.Conclusions: High levels of baseline symptomatology may be associated with overall disability and individual perceptions of recovery 6 months post-MTBI. While the RPQ is valid in assessing a patient's post-concussive symptoms following mTBI, it may not predict long-term physical or mental health in older adults.

Disability Severity, Leader-Member Exchange, and Attitudinal Outcomes: Considering the Employee and Supervisor Perspectives.

Purpose Although the effects of disability on employee work outcomes are well-documented, the mechanism that explain these relationship remains unclear. We propose that the quality of relationships employees with disabilities develop with their supervisors explains the link between disability severity and employee work outcomes. More specifically, we examine the mediating role of leader-member exchange (LMX) in the relationship between employee disability severity and presenteeism, job accommodation, supervisor-rated performance, job satisfaction, and resilience. We test this proposition from two perspectives: employees with disabilities and supervisors who had supervised employees with disabilities. Method We collected data from employees with musculoskeletal disabilities (Sample 1, N = 264) and supervisors who had supervised employees with musculoskeletal disabilities in the past two years (Sample 2, N = 224). Results From the perspective of employees with disabilities (Sample 1), disability severity was negatively related to LMX quality (R2 = .28). Contrary to our hypothesis, we found a positive relationship between supervisor perceptions of employee disability severity and LMX in Sample 2 (R2 = .27). After adjusting for disability severity, LMX quality was related to improved outcomes in both samples: higher employee job satisfaction (Sample 1: R2 = .36), provision of job accommodations (Sample 1: R2 = .16; Sample 2: R2= .15), resilience (Sample 1: R2 = .18), lower levels of presenteeism (Sample 1: R2 = .20), and higher performance evaluations for employees with disabilities (Sample 2: R2 = .49). Conclusion By collecting two separate samples, we revealed similarities and differences in employee and supervisor perspectives. Our findings demonstrated the need for including both perspectives when considering implications of employee disability severity.

A multi-faceted community intervention is associated with knowledge and standards of workplace mental health: the Superior Mental Wellness @ Work study.

BACKGROUND: Poor psychosocial work environments, such as those with low psychological support and high demands, can be harmful to the mental health of workers. In Canada, the National Standard for Psychological Health and Safety in the Workplace (the Standard) provides a comprehensive framework for organizations to identify hazards that may contribute to the psychological harm of employees. This study examines the association between a multi-faceted community intervention, the Superior Mental Wellness @ Work program designed to increase awareness of mental health and the National Standard, and outcomes assessing increased awareness and response to the Standard. These outcomes included the 1) prioritization of workplace mental health; 2) familiarity with the Standard; and 3) knowledge of mental health. METHODS: A quasi-experimental design was used to assess the associations of interest. Surveys were sent to two random samples of employer representatives pre-and post-intervention. Intervention participants were also compared to non-participants at the post-intervention stage. T-tests and chi-square tests were used to compare differences between pre- and post-intervention outcomes and also between intervention participants and non-participants identified at the post-intervention survey. RESULTS: The multi-faceted community intervention was associated with increased familiarity of the Standard, and increased knowledge of mental health challenges, mental health promotion, and existing resources at a community-level. When comparing those companies who participated in the intervention versus those who did not, participants were more likely to prioritize mental health in the workplace. Participants reported a greater need for support to address workplace mental health, poorer perceived mental health of employees, and greater stigma than non-participants. However, participants were more likely to be familiar with the Standard, have an action plan to implement the Standard, and be prepared to champion mental health in the workplace. Participants also had greater knowledge of workplace mental health in general compared to non-participants. CONCLUSIONS: The multi-faceted community intervention, the Superior Mental Wellness @ Work project, was associated with increased familiarity of the Standard, and increased knowledge of mental health challenges, mental health promotion, and existing resources at a community-level. Such a multi-faceted intervention has the capacity to improve mental health literacy and awareness of the Standard.

The association between a lifetime history of low back injury in a motor vehicle collision and future low back pain: a population-based cohort study.

PURPOSE: This population-based cohort study investigated the association between a lifetime history of a low back injury in a motor vehicle collision (MVC) and future troublesome low back pain. Participants with a history of a low back injury in a motor vehicle collision who had recovered (no or mild low back pain) were compared to those without a history of injury. Current evidence from two cross-sectional and one prospective study suggests that individuals with a history of a low back injury in a MVC are more likely to experience future LBP. There is a need to test this association prospectively in population-based cohorts with adequate control of known confounders. METHODS: We formed a cohort of 789 randomly sampled Saskatchewan adults with no or mild LBP. At baseline, participants were asked if they had ever injured their low back in a MVC. Six and 12 months later, participants were asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate the association while controlling for known confounders. RESULTS: The follow-up rate was 74.8% (590/789) at 6 months and 64.5% (509/789) at 12 months. There was a positive crude association between a history of low back injury in a MVC and the development of troublesome LBP over a 12-month period (HRR = 2.76; 95% CI 1.42-5.39). Controlling for arthritis reduced this association (HRR = 2.25; 95% CI 1.11-4.56). Adding confounders that may be on the casual pathway (baseline LBP, depression and HRQoL) to the multivariable model further reduced the association (HRR = 2.20; 95% CI 1.04-4.68). CONCLUSION: Our analysis suggests that a history of low back injury in a MVC is a risk factor for developing future troublesome LBP. The consequences of a low back injury in a MVC can predispose individuals to experience recurrent episodes of low back pain.

Supervisor and Organizational Factors Associated with Supervisor Support of Job Accommodations for Low Back Injured Workers.

Purpose Temporary job accommodations contribute to the prevention of chronic work disability due to low back pain (LBP) through the facilitation of early return to work; yet, workplace dimensions of job accommodation are poorly understood. The objective of this study was to determine supervisor and organizational factors associated with supervisors' support for temporary job accommodations for LBP injured workers. Methods Supervisors were recruited from 19 workplaces in the USA and Canada and completed an online survey regarding job accommodation practices and potential associated factors with respect to a case vignette of a worker with LBP. Multivariable linear regression was used to identify the most parsimonious set of factors associated with supervisors' support for accommodations. Results A total of 804 supervisors participated with 796 eligible for inclusion in the analysis. The final set of factors explained 21 % of the variance in supervisors' support for temporary job accommodations. Considerate leadership style (ß = 0.261; 95 % CI 0.212, 0.310), workplace disability management policies and practices (ß = 0.243; 95 % CI 0.188, 0.298), and supervisor autonomy for designing and providing workplace accommodations (ß = 0.156; 95 % CI 0.071, 0.241) had the largest effect on supervisor support for accommodations. Conclusion Factors predicting supervisors' likelihood to accommodate LBP injured workers include use of considerate leadership style, workplace disability management policies and practices, and supervisor autonomy. Workplace interventions targeting these factors should be developed and evaluated for their ability to improve work disability prevention outcomes.

Prognostic Markers for Poor Recovery After Mild Traumatic Brain Injury in Older Adults: A Pilot Cohort Study.

OBJECTIVE: To identify prognostic markers associated with poor recovery from mild traumatic brain injury (MTBI) in older adults. SETTING: Three Ontario emergency departments. PARTICIPANTS: Forty-nine participants aged 65 years and older that visited an emergency department for MTBI. DESIGN: Pilot prospective cohort study. MAIN MEASURES: Recovery from MTBI determined using the Rivermead Postconcussion symptom Questionnaire, the Glasgow Outcomes Scale-Extended, physical and mental health functioning (SF-12), and a single question on self-rated recovery assessed by telephone shortly after emergency department visit (baseline) and again 6 months later. Predictors were measured at baseline. RESULTS: Markers potentially associated with poor recovery included reporting worse health 1 year before the injury, poor expectations for recovery, depression, and fatigue. CONCLUSION: Recovery after MTBI in older adults may be associated more with psychosocial than with biomedical or injury-related factors.

The association between a lifetime history of work-related low back injury and future low back pain: a population-based cohort study.

PURPOSE: This population-based cohort study investigated the association between a lifetime history of a work-related low back injury, in those who had recovered to have no or mild low back pain, and the development of troublesome low back pain (LBP). A secondary analysis explored the possible effects of misclassification of the exposure by examining the association between a lifetime history of having taken time off work or performed light duties at work because of a work-related low back injury. Current evidence from cross-sectional studies suggests that individuals with a history of a work-related low back injury are more likely to experience future LBP. However, there is a need to examine this association prospectively in a large population-based cohort with adequate control of known confounders. METHODS: We formed a cohort of 810 randomly sampled Saskatchewan adults with no or mild LBP in September 1995. At baseline, participants were asked if they had ever injured their low back at work. The secondary analysis asked if they had ever had to take time off work or perform light duties at work because of a work-related low back injury. Prospective follow-up 6 and 12 months later, asked about the presence of troublesome LBP (grade II-IV) on the Chronic Pain Grade Questionnaire. Multivariable Cox proportional hazards regression analysis was used to estimate these associations while controlling for known confounders. RESULTS: The proportion followed up at 6 and 12 months was 76 and 65%, respectively. We found an association between a history of work-related low back injury and the onset of troublesome LBP after controlling for gender (adjusted HRR = 2.24; 95% CI 1.41-3.56). When covariates that may also be mediators of the association were added to the model, the effect estimate was attenuated (adjusted HRR = 1.37; 95% CI 1.41-3.56). We found a similar association between a lifetime history of having taken time off work or had to work light duties at work because of a work-related low back injury, adjusted for gender (adjusted HRR = 2.31; 95% CI 1.39-3.85) which was also diluted by the further adjustment for covariates that may also be mediators of the association (adjusted HRR = 1.80; 95% CI 1.08-3.01). CONCLUSION: Our study suggests that a history of work-related low back injury or taking time off work or having to perform light duties at work due to a work-related low back injury may be a risk factor for the development of troublesome LBP. Residual confounding may account for some of the observed associations, but this was less in the group who took time off work or had to work light duties due to a work-related low back injury.

Researching Complex and Multi-Level Workplace Factors Affecting Disability and Prolonged Sickness Absence.

Purpose There is growing research evidence that workplace factors influence disability outcomes, but these variables reflect a variety of stakeholder perspectives, measurement tools, and methodologies. The goal of this article is to summarize existing research of workplace factors in relation to disability, compare this with employer discourse in the grey literature, and recommend future research priorities. Methods The authors participated in a year-long collaboration that ultimately led to an invited 3-day conference, "Improving Research of Employer Practices to Prevent Disability, held October 14-16, 2015, in Hopkinton, Massachusetts, USA. The collaboration included a topical review of the literature, group conference calls to identify key areas and challenges, drafting of initial documents, review of industry publications, and a conference presentation that included feedback from peer researchers and a question/answer session with a special panel of knowledge experts with direct employer experience. Results Predominant factors in the scientific literature were categorized as physical or psychosocial job demands, work organization and support, and workplace beliefs and attitudes. Employees experiencing musculoskeletal disorders in large organizations were the most frequently studied population. Research varied with respect to the basic unit of assessment (e.g., worker, supervisor, policy level) and whether assessments should be based on worker perceptions, written policies, or observable practices. The grey literature suggested that employers focus primarily on defining roles and responsibilities, standardizing management tools and procedures, being prompt and proactive, and attending to the individualized needs of workers. Industry publications reflected a high reliance of employers on a strict biomedical model in contrast to the more psychosocial framework that appears to guide research designs. Conclusion Assessing workplace factors at multiple levels, within small and medium-sized organizations, and at a more granular level may help to clarify generalizable concepts of organizational support that can be translated to specific employer strategies involving personnel, tools, and practices.

Is low back pain associated with worse health-related quality of life 6 months later?

PURPOSE: The purpose of this study was to investigate the impact of low back pain (LBP) on future health-related quality of life (HRQoL). Current evidence suggests that individuals with LBP have poorer HRQoL than those without LBP. However, most of the evidence comes from cross-sectional studies where LBP and HRQoL are determined at the same time. One prospective study examined the association between days with LBP and HRQoL but did not account for the intensity of LBP. Therefore, this association needs to be tested in a large prospective population-based sample with a valid measure of LBP and adequate control of known confounders. METHODS: We formed a cohort of 1,110 randomly sampled Saskatchewan adults in September 1995. LBP at baseline was measured with the chronic pain questionnaire. The SF-36 questionnaire was used to measure physical and mental HRQoL at 6 months follow-up. Multivariable linear regression was used to estimate the association between graded LBP at baseline and HRQoL at 6 months while controlling for the effects of confounding. RESULTS: The 6-month follow-up rate was 70.7 % (785/1,110). LBP had a dose-response relationship with worsening physical HRQoL at 6 months, after controlling for age, income, arthritis, neck pain, and kidney disorders: grade III-IV LBP (ß = -10.23; 95 % CI -12.46, -7.99), grade II LBP (ß = -6.72, 95 % CI -8.79, -4.65), and grade I LBP (ß = -1.77; 95 % CI -3.18, -0.36). There was no dose-response relationship between LBP and mental HRQoL at 6 months. CONCLUSIONS: Low back pain has an impact on future physical HRQoL. Strategies for reducing the effects of LBP on HRQoL should be an important focus for clinicians, researchers, and health policy makers.

Supervisor Autonomy and Considerate Leadership Style are Associated with Supervisors' Likelihood to Accommodate Back Injured Workers.

PURPOSE: To determine the association between supervisors' leadership style and autonomy and supervisors' likelihood of supporting job accommodations for back-injured workers. METHODS: A cross-sectional study of supervisors from Canadian and US employers was conducted using a web-based, self-report questionnaire that included a case vignette of a back-injured worker. Autonomy and two dimensions of leadership style (considerate and initiating structure) were included as exposures. The outcome, supervisors' likeliness to support job accommodation, was measured with the Job Accommodation Scale (JAS). We conducted univariate analyses of all variables and bivariate analyses of the JAS score with each exposure and potential confounding factor. We used multivariable generalized linear models to control for confounding factors. RESULTS: A total of 796 supervisors participated. Considerate leadership style (ß = .012; 95% CI .009-.016) and autonomy (ß = .066; 95% CI .025-.11) were positively associated with supervisors' likelihood to accommodate after adjusting for appropriate confounding factors. An initiating structure leadership style was not significantly associated with supervisors' likelihood to accommodate (ß = .0018; 95% CI -.0026 to .0061) after adjusting for appropriate confounders. CONCLUSIONS: Autonomy and a considerate leadership style were positively associated with supervisors' likelihood to accommodate a back-injured worker. Providing supervisors with more autonomy over decisions of accommodation and developing their considerate leadership style may aid in increasing work accommodation for back-injured workers and preventing prolonged work disability.

Health care utilization of workers' compensation claimants associated with mild traumatic brain injury: a historical population-based cohort study of workers injured in 1997-1998.

OBJECTIVE: To compare the health care use of workers with an injury before and after making a workers' compensation claim for mild traumatic brain injury (MTBI). DESIGN: Cohort study of workers with an MTBI who received workers' compensation benefits. SETTING: Workers' compensation system in Ontario, Canada. PARTICIPANTS: Workers (N=728) who made an incident claim involving MTBI to the Ontario Workplace Safety and Insurance Board between 1997 and 1998. We linked workers' compensation and Ontario Health Insurance Plan files and collected all health care services accrued during the year before and 2 years after the claim was initiated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We report our results as a 7-day simple moving average of health care services per 1000 claimants per day. We stratified our analysis by age, sex, the preclaim level of health care utilization, diagnostic category, and health care specialty. RESULTS: Over the 2 years, 728 claims related to MTBI were filed by workers with an injury. The majority of the claims (65.8%) were filed by men, and 28.3% were filed by those aged between 25 and 34 years. The cumulative rate of health care utilization was stable (mean=67.6 visits/1000 claimants per day; 95% confidence interval [CI], 65.0-70.2) throughout the year before claim initiation. Health care utilization peaked during the first 4 weeks following the initiation of the claim (mean=274.3 visits/1000 claimants per day; 95% CI, 172.2-376.4) and remained on average 182% higher than that at baseline throughout the 5th to 12th week postclaim. Two years after the initiation of the claim, utilization remained 9.5% higher than the preclaim level. The increase was more pronounced (125% higher) for workers with less than the median preclaim utilization level. CONCLUSIONS: Making a workers' compensation claim involving MTBI is associated with a long-term increase in health care use.

Systematic review of the risk of Parkinson's disease after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on the risk of Parkinson's disease (PD) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (1990-2012) with terms including "craniocerebral trauma" and "parkinsonian disorders." Reference lists of eligible articles and relevant systematic reviews and meta-analyses were also searched. STUDY SELECTION: Controlled clinical trials, cohort studies, and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria. Sixty-five studies were eligible and reviewed, and 5 of these with a low risk of bias were accepted as scientifically admissible and form the basis of our findings. Among these admissible studies, the definitions of MTBI were highly heterogeneous. One study found a significant positive association between MTBI and PD (odds ratio, 1.5; 95% confidence interval, 1.4-1.7). The estimated odds ratio decreased with increasing latency between MTBI and PD diagnosis, which suggests reverse causality. The other 4 studies did not find a significant association. CONCLUSIONS: The best available evidence argues against an important causal association between MTBI and PD. There are few high-quality studies on this topic. Prospective studies of long duration would address the limitations of recall of head injury and the possibility of reverse causation.

Systematic review of the risk of dementia and chronic cognitive impairment after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence regarding the risk of dementia and chronic cognitive impairment (CCI) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) using a previously published search strategy and predefined criteria. Peer-reviewed reports in 6 languages were considered. STUDY SELECTION: Systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies, with a minimum of 30 MTBI cases in subjects of any age, assessing the risk of dementia or CCI after MTBI were selected. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (ie, with a low risk of bias) into evidence tables. DATA SYNTHESIS: Evidence from accepted studies was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria, and prognostic information was prioritized as exploratory or confirmatory according to design. Of 77,914 records screened, 299 articles were eligible and reviewed. Methodological quality was acceptable for 101 (34%) articles, of which 1 article considered dementia and 7 articles considered CCI. The study examining the risk of dementia after MTBI did not find an association. One randomized controlled trial found that being informed about possible cognitive dysfunction after MTBI was associated with worse cognitive performance on standard tests. Children with MTBI and intracranial pathology ("complicated" MTBI) performed worse than did children without intracranial pathology. Children showed higher rates of cognitive symptoms a year after MTBI than did a control group. CONCLUSIONS: There is a lack of evidence of an increased risk of dementia after MTBI. In children, objective evidence of CCI exists only for complicated MTBI. More definitive studies are needed to inform clinical decisions, assessment of prognosis, and public health policy.

Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To update the mild traumatic brain injury (MTBI) prognosis review published by the World Health Organization Task Force in 2004. DATA SOURCES: MEDLINE, PsycINFO, Embase, CINAHL, and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed studies with more than 30 adult cases. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess subjective, self-reported outcomes. After 77,914 titles and abstracts were screened, 299 articles were eligible and reviewed for scientific quality. This includes 3 original International Collaboration on MTBI Prognosis (ICoMP) research studies. DATA EXTRACTION: Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and tabled data from accepted articles. A third reviewer was consulted for disagreements. DATA SYNTHESIS: Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including 2 of the 3 original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer premorbid mental and physical health status and with more injury-related stress. Most recover over 1 year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. CONCLUSIONS: Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues.

Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on objective outcomes after adult mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) for studies related to MTBI. Inclusion criteria included published, peer-reviewed articles in English and other languages. References were also identified from the bibliographies of eligible articles. STUDY SELECTION: Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 MTBI cases and assess objective outcomes in adults. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 299 were found to be relevant and critically reviewed, and 101 were deemed scientifically admissible. Of these, 21 studies that were related to the objective outcomes form the basis of this review. Most evidence indicates the presence of cognitive deficits in the first 2 weeks post-MTBI, and some evidence suggests that complete recovery may take 6 months or a year. A small number of studies indicate that MTBI increases the risk of psychiatric illnesses and suicide. CONCLUSIONS: Early cognitive deficits are common, and complete recovery may be prolonged. Conclusions about mortality post-MTBI are limited. This review has implications for expected recovery after MTBI and MTBI-related health sequelae. Well-designed confirmatory studies are needed to understand the medium- to long-term consequences of MTBI and to further evaluate the effect of prior MTBI and injury severity on recovery.

Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on return to work (RTW) after mild traumatic brain injury (MTBI). DATA SOURCES: MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "employment." Reference lists of eligible articles were also searched. STUDY SELECTION: Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess RTW or employment outcomes in at least 30 MTBI cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria and prioritized according to design as exploratory or confirmatory. After 77,914 records were screened, 299 articles were found eligible and reviewed; 101 (34%) of these with a low risk of bias were accepted as scientifically admissible, and 4 of these had RTW or employment outcomes. This evidence is preliminary and suggests that most workers RTW within 3 to 6 months after MTBI; MTBI is not a significant risk factor for long-term work disability; and predictors of delayed RTW include a lower level of education (<11y of formal education), nausea or vomiting on hospital admission, extracranial injuries, severe head/bodily pain early after injury, and limited job independence and decision-making latitude. CONCLUSIONS: Our findings are based on preliminary evidence with varied patient characteristics and MTBI definitions, thus limiting firm conclusions. More well-designed studies are required to understand RTW and sustained employment after MTBI in the longer term (≥2y post-MTBI).

Systematic review of prognosis and return to play after sport concussion: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

OBJECTIVE: To synthesize the best available evidence on prognosis after sport concussion. DATA SOURCES: MEDLINE and other databases were searched (2001-2012) with terms including "craniocerebral trauma" and "sports." Reference lists of eligible articles were also searched. STUDY SELECTION: Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases. DATA EXTRACTION: Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables. DATA SYNTHESIS: Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing 19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms. CONCLUSIONS: The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis. Our findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports.

Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.

The International Collaboration on Mild Traumatic Brain Injury (MTBI) Prognosis performed a comprehensive search and critical review of the literature from 2001 to 2012 to update the 2002 best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force on the prognosis of MTBI. Of 299 relevant studies, 101 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. Here we report and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, we discuss issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children, and an account for reverse causality and differential recall bias. Well-conducted studies in these areas will aid our understanding of MTBI prognosis and assist clinicians in educating and treating their patients with MTBI.