Traumatic brain injury (TBI) is a leading cause of death, and in a recent analysis it was found that nearly one-third of all injury-related deaths in the US have at least one diagnosis of TBI (CDC-Quickstats, 2010). This chapter presents the burden of TBI as regards age group, gender, costs, race, emergency department (ED) visits, hospitalizations, and deaths. Injury trends over a 15 year period are examined. Rehabilitation estimates and disability estimates are also available. Through good epidemiology we can better understand the causes of TBI and design more effective intervention programs to reduce injury. Important sources of evidence for this chapter include mostly studies from the US because of their leading work in the epidemiology of this important injury.

Epidemiology of traumatic brain injury

Results: Major depressive disorder was observed in 30 (33%) of 91 patients during the first year after sustaining a TBI Major depressive disorder was significantly more frequent among patients with TBI than among the controls Patients with TBI who had major depression were more likely to have a personal history of mood and anxiety disorders than patients who did not have major depression Patients with major depression exhibited comorbid anxiety (767%) and aggressive behavior (567%) Patients with major depression had significantly greater impairment in executive functions than their nondepressed counterparts Major depression was also associated with poorer social functioning at the 6-and 12month follow-up, as well as significantly reduced left prefrontal gray matter volumes, particularly in the ventrolateral and dorsolateral regions Conclusions: Major depression is a frequent complication of TBI that hinders a patient’s recovery It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms The neuropathological changes produced by TBI may lead to deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala Arch Gen Psychiatry 2004;61:42-50

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/481944/YOA30059.pdf

Major depression following traumatic brain injury.

BACKGROUND: Much disagreement exists as to whether postconcussion syndrome (PCS) is attributable to brain injury or to other factors such as trauma alone, preexisting psychosocial problems, or medicolegal issues. We investigated the epidemiology and natural history of PCS symptoms in a large cohort of children with a mild traumatic brain injury (mTBI) and compared them with children with an extracranial injury (ECI). METHODS: This investigation was a prospective, consecutive controlled-cohort study of 670 children who presented to a tertiary referral emergency department with mTBI and 197 children who presented with ECI. For all participants, data were collected by use of a telephone interview of a parent 7 to 10 days after injury. If a change from preinjury symptoms was reported by a parent, follow-up continued monthly until symptom resolution. Outcomes were measured by using the Post Concussion Symptom Inventory, Rivermead Postconcussion Symptom Questionnaire, Brief Symptom Inventory, and Family Assessment Device. RESULTS: There was a significant difference between the mTBI and ECI groups in their survival curves for time to symptom resolution (log rank [Mantel-Cox] 11.15, P CONCLUSIONS: Among school-aged children with mTBI, 13.7% were symptomatic 3 months after injury. This finding could not be explained by trauma, family dysfunction, or maternal psychological adjustment. The results of this study provide clear support for the validity of the diagnosis of PCS in children.

Epidemiology of Postconcussion Syndrome in Pediatric Mild Traumatic Brain Injury

Mild Traumatic Brain Injury (mTBI), or concussion, is a major public health concern. There is controversy in the literature regarding the true incidence of postconcussion syndrome (PCS), with the constellation of physical, cognitive, emotional, and sleep symptoms after mTBI. In the current study, we report on the incidence and evolution of PCS symptoms and patient outcomes after mTBI at 3, 6, and 12 months in a large, prospective cohort of mTBI patients. Participants were identified as part of the prospective, multi-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. The study population was mTBI patients (Glasgow Coma Scale score of 13-15) presenting to the emergency department, including patients with a negative head computed tomography discharged to home without admission to hospital; 375 mTBI subjects were included in the analysis. At both 6 and 12 months after mTBI, 82% (n=250 of 305 and n=163 of 199, respectively) of patients reported at least one PCS symptom. Further, 44.5 and 40.3% of patients had significantly reduced Satisfaction With Life scores at 6 and 12 months, respectively. At 3 months after injury, 33% of the mTBI subjects were functionally impaired (Glasgow Outcome Scale-Extended score ≤6); 22.4% of the mTBI subjects available for follow-up were still below full functional status at 1 year after injury. The term "mild" continues to be a misnomer for this patient population and underscores the critical need for evolving classification strategies for TBI for targeted therapy.

/pdf/symptomatology-and-functional-outcome-in-mild-traumatic-47v76pd839.pdf

Symptomatology and Functional Outcome in Mild Traumatic Brain Injury: Results from the Prospective TRACK-TBI Study

Recommendations for the use of common outcome measures in traumatic brain injury research

Objectives: To provide further evidence of reliability and internal and external construct validity of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), which measures severity of postconcussion symptoms following head injury.Design and setting: A cross-sectional study of consecutive patients presenting with a head injury in two urban teaching hospitals and a community trust.Patients: Three hundred and sixty-nine patients returned a questionnaire from 1689 consecutive adult patients (18 years and above) referred to radiology for a skull X-ray following a head injury, and those who were currently under the care of a community-based multidisciplinary head injury team.Method: Internal construct validity tested by fit to the Rasch Measurement model; external construct validity tested by correlations with Rivermead Head Injury Follow-up Questionnaire (RHFUQ); test-retest reliability tested by correlations at two-week intervals.Outcome measures: Rivermead Post-Concussion Symptoms Questionnaire and Riv...

Construct validity and reliability of the Rivermead Post-Concussion Symptoms Questionnaire

Objective: t o investigate factors that predict walking with a prosthesis after lower limb amputation. Design: Systematic literature review. Methods: A computer-aided literature search of MeDliNe, eMBASe, ciNAHl and the cochrane library was per formed to identify studies published up to August 2007 that investigated factors that predicted walking ability after lower limb amputation. Results: A total of 57 studies were selected. Predictors of good walking ability following lower limb amputation include cognition, fitness, ability to stand on one leg, independence in activities of daily living and pre-operative mobility. longer time from surgery to rehabilitation and stump problems are predictors of poor outcome. the impact of the cause of amputation on walking varies between studies. in gener al, unilateral and distal amputation levels, and younger age were predictive of better walking ability. Sex probably does not have a significant influence on walking ability. Conclusion: the heterogeneity of methods and outcome measures used in the identified studies make comparison difficult and, in part, explains conflicting conclusions in relation to predictive factors. Further investigation of predictive factors is needed to estimate walking potential more accurately and guide targeting of modifiable factors to optimize outcome after lower limb amputation.

/pdf/predicting-walking-ability-following-lower-limb-amputation-a-1m51puwvc0.pdf

Predicting walking ability following lower limb amputation: a systematic review of the literature.

The extent of mood disorders following traumatic brain injury (TBI), and the possible risk factors, are investigated. New data are presented from a prospective study of consecutive hospital admissions. Six months post-TBI, 99 adults completed a standardized assessment of emotional state, the Wimbledon Self-Report Scale. Cognitive performance and the impact of the injury on everyday functioning were also assessed. The rate of clinically significant mood disorders (caseness) was 38%. Of the demographic or injury characteristics, only pre-injury occupational status predicted post-injury caseness. Those unoccupied pre-injury were more likely to report mood disturbances post-injury. In contrast, post injury occupational status was not related to caseness either for the whole group or the subgroup of those previously occupied, despite the adverse effects on occupational functioning for a significant proportion of subjects. Associations were found between emotional state and cognitive and everyday functioning 6 ...

Mood disorders following traumatic brain injury: identifying the extent of the problem and the people at risk

Objective: The objective of this study was to explore the concept of work instability (a mis-match between an individual's functional and cognitive abilities and the demands of their job) following traumatic brain injury (TBI) and develop a work instability scale specific to this population.Method: Work instability (WI) following TBI was explored through qualitative interviews which were then used to generate items for a work instability scale (WIS). Rasch analysis was used to examine the scaling properties of the TBI-WIS which was then validated against a gold standard of expert vocational assessment by occupational psychologists.Results and conclusion: The resulting measure is a 36 item, self-administered scale which can be scored in three bands indicating low, medium and high risk of job retention problems. The scale meets modern psychometric requirements for measurement and presents an opportunity in routine clinical practice to take positive action to prevent job loss.

Screening for job loss: Development of a work instability scale for traumatic brain injury

The study investigated whether the frequency of mood disorders following traumatic brain injury (TBI) increased with time. Consecutive hospital admissions completed the Wimbledon Self-Report Scale at 6 and 12 months post-injury. Scores in the 'borderline/case' range were deemed clinically significant. Seventy-seven of those assessed at 6 months completed the 12 month follow-up. Those lost to follow-up (22) were not more likely to have been classified 'borderline/case' at 6 months. They were more likely to have been 'unoccupied' pre-injury (p=0.002). The frequency of clinically significant disorders did not change significantly, being 39% at 6 months and 35% 1 year post-injury. The majority of subjects (58) maintained the same clinical classification at both assessments. Eight of the 47 (17%) classified 'normal' at 6 months changed to 'borderline/case' at 12 months. However, 11 of the 30 (37%) classified 'borderline/case' at 6 months were 'normal' at 12 months. The direction of change was not statistically significant (p=0.5). These findings are consistent with previous research. However, the present study examined a larger sample and included a wider range of injury severity, thereby increasing the generalizability of the findings. Also, a broader spectrum of mood disorders was investigated which adds to previous work specifically on depression.

Vera Neumann

Papers

Construct validity and reliability of the Rivermead Post-Concussion Symptoms Questionnaire

Predicting walking ability following lower limb amputation: a systematic review of the literature.

Mood disorders following traumatic brain injury: identifying the extent of the problem and the people at risk

Screening for job loss: Development of a work instability scale for traumatic brain injury

The persistence of mood disorders following traumatic brain injury: a 1 year follow-up