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Journal ArticleDOI

Persistent impairment based symptoms post mild traumatic brain injury: Does a standard symptom scale detect them?

TL;DR: Symptoms indicative of persisting impairments beyond the expected recovery period were apparent in a substantial proportion of individuals post mTBI, and findings suggest that a standard post-mTBI self-report symptom scale may often not detect the presence of Persisting symptoms.
Abstract: Aim To further explore symptoms in patients beyond the expected recovery period post mild Traumatic Brain Injury (mTBI) that are potentially indicative of impairment. Methods Ninety-four individuals (62 diagnosed with mTBI within the previous 4–24 weeks and 32 healthy controls) participated in the study. Participants in the mTBI group were further grouped as symptomatic (n = 33) or asymptomatic (n = 29) based on their spontaneous report of symptoms at the time of screening. Measures included a demographic questionnaire, 8 impairment specific self-report clinical tools, and a standard post-mTBI self-report symptom scale (Head Injury Scale (HIS)). Results Compared to the control group, scores for all instruments (including the HIS) were higher in the symptomatic mTBI group (P 0.093). Overall 94% of the symptomatic and 62% of the asymptomatic participants post-mTBI, recorded scores considered to be clinically relevant on at least one impairment screening tool. In contrast, only 28% of the asymptomatic mTBI group recorded a clinically relevant score for the HIS. Conclusion Symptoms indicative of persisting impairments beyond the expected recovery period were apparent in a substantial proportion of individuals post mTBI. Furthermore, a high percentage of individuals initially reporting as symptom free demonstrated clinically relevant scores on at least one impairment screening tool. Findings also suggest that a standard post-mTBI self-report symptom scale may often not detect the presence of persisting symptoms.

Summary (3 min read)

INTRODUCTION

  • Self-reported symptom resolution following a Mild Traumatic Brain Injury (mTBI) is thought to occur within the first 10 to 14 days post-injury in adults (1-5).
  • Studies have demonstrated persistent multi-system impairments, particularly sensorimotor and physiological disturbances, following mTBI, beyond expected recovery times (8-17) and following self-reported symptom abatement (8, 11, 13, 14).
  • Which were reported as absent in 5 studies, while the remaining 4 identified symptoms using impairment specific self-report clinical tools related to psychological distress and sleep quality, not standard post mTBI self-report symptom scales (18).
  • Potentially a battery of validated impairment specific self-report clinical tools may be more appropriate.
  • The authors hypothesised that scores from these impairment specific tools would be elevated (to a clinically relevant level) in a substantial proportion of individuals post-mTBI (Hypothesis 1) compared to healthy controls.

Participants

  • Participants included 62 individuals diagnosed with mTBI and 32 healthy controls aged between 18-60 years who had never sustained a mTBI.
  • Participants were recruited via the M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 4 institutions greater community, social media advertising, and the Emergency Department (ED) of a nearby teaching tertiary hospital.
  • Data collection for this study took place between October 2016 and July 2018.
  • Participants in the mTBI group were included if they had received a diagnosis of mTBI or concussion from a medical specialist.
  • Measures M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 5 Measures including demographic information and three levels of self-report symptom measures were completed by all participants in the mTBI group 4 weeks to 6 months postinjury, and at a time of convenience for the healthy control group using an online tool (Checkbox Survey Inc.).

Demographic Measures

  • Demographic measures were utilised for descriptive purposes and to pre-evaluate group comparability.
  • All participants reported age, gender, and activity level (measured by the International Physical Activity Questionnaire short form (35)).
  • Participants in the mTBI group also reported mechanism of their current mTBI, as well as total number of diagnosed mTBI’s (including current).

Spontaneous Self-Reported Symptoms Measure

  • A spontaneous self-reported symptom measure was taken at the time of assessment for participants in the mTBI group prior to the other self-reported symptom measures for the purposes of subgrouping to either the symptomatic or asymptomatic mTBI groups.
  • The term concussion was used instead of “mild traumatic brain injury” since it is more widely utilised and understood with respect to the clinical manifestations of mTBI.

Standard Self-Reported Symptoms Measure

  • The Head Impact Scale (9- items) (20) was included as a standard post-concussion selfreported symptom measure.
  • This tool lists commonly reported post-concussion symptoms and contains separate subscales for frequency (hours per day) and severity.
  • Scores range from 0 to 6 with increasing frequency or severity indicated by higher scores then summed to provide a cumulative score for each scale.
  • The HIS was selected based on its higher psychometric properties when compared to other available tools (19).
  • In the absence of a published threshold, the authors used the averaged score of the frequency (3.87/54) and severity M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 6 (4.96/54) subscales previously reported in healthy individuals (22) as a clinically relevant score (>4) for the HIS.

Impairment Specific Self-report Clinical Tools

  • The following impairment specific tools were used to quantify impairments within specific system domains previously identified to potentially demonstrate impairment post mTBI (eg. sensorimotor, musculoskeletal, physiological, psychological) based on their established validity (24, 26-28, 36-41).
  • Item scores are summed, then divided by nine for a final score out of 7.
  • Minimal clinically relevant scores are 9, 7 and 14 for depression, anxiety and stress respectively (45, 46).
  • A Shapiro-Wilk test investigated distribution of data overall and by group.
  • Test was used to identify significant proportional differences between groups of individuals scoring clinically relevant thresholds on one or more impairment specific tool, or the HIS.

RESULTS

  • Overall 94 (32 Healthy controls, 29 asymptomatic and 33 symptomatic) participants were included in the current study.
  • There were no age or gender group differences.
  • Thirty one (94%), 18(62%), and 4 (13%) individuals in the symptomatic mTBI, asymptomatic mTBI, and healthy control groups respectively, returned scores above the clinically relevant thresholds for one or more of the impairment specific tools.
  • One individual in the symptomatic group, two in the asymptomatic group and two in the healthy control group recorded clinically relevant scores for the HIS but not for any impairment specific tool.

DISCUSSION

  • Findings support their first study hypothesis of significantly elevated impairment specific symptom scores in those in the subacute phase (both symptomatic and asymptomatic) postmTBI compared to healthy controls.
  • In support of their second hypothesis, 18 (62%) asymptomatic mTBI participants also recorded clinically relevant scores on at least one impairment specific tool.
  • These findings are consistent with that of Reneker et al (2018) (32) who observed evidence of cervical musculoskeletal impairment in 81.6% of mTBI cases, as well as studies associating neck pain and dysfunction with initial injury or long term outcome (47, 48).
  • Elevated levels of hyperarousal symptoms may be relevant with regard to observed evidence of altered heart rate variability (HRV) and persistent ANS dysregulation post mTBI (8, 9, 44, 55).
  • Multiple previous sleep studies (10, 58) including those using the PSQI (10, 59) have identified disturbed sleep patterns post mTBI.

Limitations

  • Scores derived from the impairment specific tools used in this study can only infer potential of underlying physical impairment; they are not diagnostic of impairment.
  • Therefore, findings need to be taken in light of the need for further research to explore relationships between persisting symptoms and physical impairments.
  • Additionally, since study inception a tool specifically for brain injury related vision symptoms has been developed (73).
  • Thus, use of this tool may have identified differing results respecting presence of vision related symptoms, particularly among asymptomatic individuals.
  • Furthermore, only the HIS was used in this study and therefore the utility of other self-reported symptoms scales remains unknown.

CONCLUSION

  • A diverse range of symptoms potentially indicative of persisting impairments (eg. cervical, vestibular, physiological) may be present in individuals following mTBI beyond expected recovery time.
  • Symptoms may also be present in individuals who overall consider M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 16 themselves symptom-free.
  • Potentially generic self-reported symptom scales may not detect symptoms in these apparently asymptomatic individuals, questioning their appropriateness in determining recovery and ability to return to activity post-mTBI.
  • Studies exploring the relationships between symptoms and system impairments in this patient group is urgently needed.
  • M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 17.

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Citations
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Journal ArticleDOI
TL;DR: For example, this article found that cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mild traumatic brain injury (mTBI) compared to healthy controls.
Abstract: Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report to be recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mTBI.To determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls (HC).Observational cohort study.Participants aged 18-60 years consisting of 39 HC, and 72 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test (SPNT) and balance.Individuals in the Symp mTBI group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance and movement accuracy as well as increased postural sway and a higher percentage had positive cervical joint dysfunction (p < 0.01]. The mTBI group who considered themselves recovered (Asymp)demonstrated significantly lower rotation range, flexor endurance, and a higher percentage had positive cervical joint dysfunction and positive SPNT (p < 0.05) compared to HCs.Individuals reporting symptoms post mTBI demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.

3 citations

Journal ArticleDOI
TL;DR: In this paper, the authors found that individuals reporting symptoms post mild traumatic brain injury demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times, while those not reporting symptoms had fewer but some cervical impairments.
Abstract: BACKGROUND Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report to be recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mTBI. OBJECTIVE To determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls (HC). STUDY DESIGN Observational cohort study. METHODS Participants aged 18-60 years consisting of 39 HC, and 72 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test (SPNT) and balance. RESULTS Individuals in the Symp mTBI group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance and movement accuracy as well as increased postural sway and a higher percentage had positive cervical joint dysfunction (p < 0.01]. The mTBI group who considered themselves recovered (Asymp)demonstrated significantly lower rotation range, flexor endurance, and a higher percentage had positive cervical joint dysfunction and positive SPNT (p < 0.05) compared to HCs. CONCLUSION Individuals reporting symptoms post mTBI demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.

3 citations

Dissertation
31 Mar 2020
TL;DR: VMLD and touch-control treatments exhibited symptom improvements in both groups based upon questionnaire scores, suggesting these treatments may be beneficial in post-concussion syndrome rehabilitation.
Abstract: Fourteen to thirty-five percent of people with concussions develop post-concussion symptoms that last 30 days or more; a condition termed Post-Concussion Syndrome (PCS). Symptoms include headaches, vestibular, visual emotional and psychological changes. Rehabilitation includes physical and eye exercises, manual pharmacological therapies. We propose an additional treatment called Vodder Manual Lymphatic Drainage Massage (VMLD) that treats inflammation and lymphedema. It is hypothesized that a VMLD protocol will decrease PCS symptoms compared to a touch control treatment. Twenty-three adolescents were recruited and nineteen were randomly divided into VMLD (n=10; 16.1 ± 1.4 years) and touch control (n=9; 16.1 ± 1.3 years) groups. Time from the last concussion was 590.2± 476.7 days for the VMLD group and 468.9 ± 542.9 days for the touch control group. Participants received 15 x 1-hour interventions over 54 ± 14.8 days. On appointments 1, 7 and 15, participants were evaluated using the Rivermead Post-Concussion Syndrome Questionnaire (RPQ) and the SCAT-5 5-word and 10-word recall, Number Concentration Test, Months in Reverse and Delayed Word Recall Test. A 2x3 ANOVA (GenStat statistical software) was used to test for treatment and time effect. There was no statistical difference between the groups. Both groups showed a significant time effect (p<0.05) for the RPQ, SCAT5 Number Concentration, and Delayed Word Recall Tests. VMLD and touch-control treatments exhibited symptom improvements in both groups based upon questionnaire scores. These treatments may be beneficial in post-concussion syndrome rehabilitation. More research needs to be conducted to assess the effectiveness of these treatments.
Journal ArticleDOI
TL;DR: Individuals post-mTBI demonstrated PSI impairment subacutely in some individuals despite an initially reported absence of symptoms, and some preliminary evidence that BCTT duration and HR responses may be additionally informative post- mTBI is shown.
Abstract: Objective: The Buffalo Concussion Treadmill Test (BCTT) was developed to identify potential physiological system impairment (PSI) underlying persistent symptoms post-mild traumatic brain injury (mTBI). This study evaluates PSI in individuals 4 weeks to 6 months post-mTBI using the BCTT “failure” criteria, and additional exploratory measures of test duration and heart rate (HR) response. Setting: Tertiary hospital and university. Participants: Participants included 73 individuals 4 weeks to 6 months post-mTBI and a comparison group of 39 healthy controls (HCs). The mTBI group was further subgrouped at screening into those considering themselves asymptomatic (Asymp mTBI) (n = 35) or symptomatic (Symp mTBI) (n = 36). Design: Observational cohort study. Main Measures: BCTT; failure rate (%), test duration (minutes), HR responses. Results: : Thirty percent of the mTBI group (including 50% of the Symp and 9% of the Asymp subgroups) failed the BCTT. BCTT duration and associated overall HR change was significantly lower in the mTBI group and Symp subgroup compared with HCs. Compared with HCs maximal HR percentage was higher for the first 4 minutes of the test in the mTBI group, and for the first 2 minutes of the test for the Symp subgroup. Conclusions: Individuals post-mTBI demonstrated PSI impairment subacutely. In some individuals this was despite an initially reported absence of symptoms. The study also showed some preliminary evidence that BCTT duration and HR responses may be additionally informative post-mTBI.
Journal ArticleDOI
TL;DR: The Buffalo Concussion Treadmill Test (BCTT) was developed to identify potential physiological system impairment (PSI) underlying persistent symptoms post-mild traumatic brain injury (mTBI) as discussed by the authors .
Abstract: Objective: The Buffalo Concussion Treadmill Test (BCTT) was developed to identify potential physiological system impairment (PSI) underlying persistent symptoms post-mild traumatic brain injury (mTBI). This study evaluates PSI in individuals 4 weeks to 6 months post-mTBI using the BCTT “failure” criteria, and additional exploratory measures of test duration and heart rate (HR) response. Setting: Tertiary hospital and university. Participants: Participants included 73 individuals 4 weeks to 6 months post-mTBI and a comparison group of 39 healthy controls (HCs). The mTBI group was further subgrouped at screening into those considering themselves asymptomatic (Asymp mTBI) (n = 35) or symptomatic (Symp mTBI) (n = 36). Design: Observational cohort study. Main Measures: BCTT; failure rate (%), test duration (minutes), HR responses. Results: Thirty percent of the mTBI group (including 50% of the Symp and 9% of the Asymp subgroups) failed the BCTT. BCTT duration and associated overall HR change was significantly lower in the mTBI group and Symp subgroup compared with HCs. Compared with HCs maximal HR percentage was higher for the first 4 minutes of the test in the mTBI group, and for the first 2 minutes of the test for the Symp subgroup. Conclusions: Individuals post-mTBI demonstrated PSI impairment subacutely. In some individuals this was despite an initially reported absence of symptoms. The study also showed some preliminary evidence that BCTT duration and HR responses may be additionally informative post-mTBI.
References
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TL;DR: The clinimetric and clinical properties of the PSQI suggest its utility both in psychiatric clinical practice and research activities.
Abstract: Despite the prevalence of sleep complaints among psychiatric patients, few questionnaires have been specifically designed to measure sleep quality in clinical populations. The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire which assesses sleep quality and disturbances over a 1-month time interval. Nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of scores for these seven components yields one global score. Clinical and clinimetric properties of the PSQI were assessed over an 18-month period with "good" sleepers (healthy subjects, n = 52) and "poor" sleepers (depressed patients, n = 54; sleep-disorder patients, n = 62). Acceptable measures of internal homogeneity, consistency (test-retest reliability), and validity were obtained. A global PSQI score greater than 5 yielded a diagnostic sensitivity of 89.6% and specificity of 86.5% (kappa = 0.75, p less than 0.001) in distinguishing good and poor sleepers. The clinimetric and clinical properties of the PSQI suggest its utility both in psychiatric clinical practice and research activities.

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TL;DR: Considering the diverse samples in this study, IPAQ has reasonable measurement properties for monitoring population levels of physical activity among 18- to 65-yr-old adults in diverse settings.
Abstract: CRAIG, C. L., A. L. MARSHALL, M. SJOSTROM, A. E. BAUMAN, M. L. BOOTH, B. E. AINSWORTH, M. PRATT, U. EKELUND, A. YNGVE, J. F. SALLIS, and P. OJA. International Physical Activity Questionnaire: 12-Country Reliability and Validity. Med. Sci. Sports Exerc., Vol. 35, No. 8, pp. 1381-1395, 2003. Background: Physical inactivity is a global concern, but diverse physical activity measures in use prevent international comparisons. The International Physical Activity Questionnaire (IPAQ) was developed as an instrument for cross-national monitoring of physical activity and inactivity. Methods: Between 1997 and 1998, an International Consensus Group developed four long and four short forms of the IPAQ instruments (administered by telephone interview or self-administration, with two alternate reference periods, either the "last 7 d" or a "usual week" of recalled physical activity). During 2000, 14 centers from 12 countries collected reliability and/or validity data on at least two of the eight IPAQ instruments. Test-retest repeatability was assessed within the same week. Concurrent (inter-method) validity was assessed at the same administration, and criterion IPAQ validity was assessed against the CSA (now MTI) accelerometer. Spearman's correlation coefficients are reported, based on the total reported physical activity. Results: Overall, the IPAQ questionnaires produced repeatable data (Spearman's clustered around 0.8), with comparable data from short and long forms. Criterion validity had a median of about 0.30, which was comparable to most other self-report validation studies. The "usual week" and "last 7 d" reference periods performed similarly, and the reliability of telephone administration was similar to the self-administered mode. Conclusions: The IPAQ instruments have acceptable measurement properties, at least as good as other established self-reports. Considering the diverse samples in this study, IPAQ has reasonable measurement properties for monitoring population levels of physical activity among 18- to 65-yr-old adults in diverse settings. The short IPAQ form "last 7 d recall" is recommended for national monitoring and the long form for research requiring more detailed assessment. Key Words: MEASUREMENT, SURVEILLANCE, EPIDEMIOLOGY

15,345 citations

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TL;DR: The factor structure of the combined BDI and BAI items was virtually identical to that reported by Beck for a sample of diagnosed depressed and anxious patients, supporting the view that these clinical states are more severe expressions of the same states that may be discerned in normals.

9,443 citations

Related Papers (5)
Frequently Asked Questions (2)
Q1. What are the contributions in "Persistent impairment based symptoms post mild traumatic brain injury: does a standard symptom scale detect them?" ?

Methods Ninety-four individuals ( 62 diagnosed with mTBI within the previous 4-24 weeks and 32 healthy controls ) participated in the study. Participants in the mTBI group were further grouped as symptomatic ( n=33 ) or asymptomatic ( n=29 ) based on their spontaneous report of symptoms at the time of screening. Furthermore, a high percentage of individuals initially reporting as symptom free demonstrated clinically relevant scores on at least one impairment screening tool. Findings also suggest that a standard post-mTBI self-report symptom scale may often not detect the presence of persisting symptoms. 

These findings now warrant further mechanistic research to identify the impairments associated with these symptoms that may include factors such as vestibular ( peripheral or central ) ( 51, 52 ), and or cervical musculoskeletal or sensorimotor impairments ( 53, 54 ). Nevertheless, further investigation of the relationship between sleep and specific impairments post-mTBI is warranted given the impact of sleep quality on health and recovery following TBI ( 60 ). The findings suggest that for some individuals, standard self-report symptom scales such as the HIS may be inadequate to detect potentially relevant symptoms post-mTBI. Hence, items in standard self-reported symptom scales ( such as the HIS ) may be too limited to identify those with potentially ongoing impairments.