Jeno E. Marosszeky

Mild traumatic brain injury does not predict acute postconcussion syndrome

Background: The aetiology of postconcussion syndrome (PCS) following mild traumatic brain injury (mTBI) remains controversial. Identifying acute PCS (within the first 14 days after injury) may optimise initial recovery and rehabilitation, identify those at risk and increase understanding of PCS. Objective: To examine predictors of acute outcome by investigating the relationship between preinjury psychiatric disorder, demographic factors, injury related characteristics, neuropsychological and psychological variables and acute PCS. Methods: Prospective study of consecutive trauma admissions to a level 1 trauma hospital. The final sample comprised 90 patients with mTBI and 85 non-brain injured trauma controls. Individuals were administered a PCS checklist, and neuropsychological and psychological measures. Multiple imputation of missing data in multivariable logistic regression and bivariate logistic regressions were used to predict acute PCS at a mean of 4.90 days after injury. Results: Diagnosis of acute PCS was not specific to mTBI (mTBI 43.3%; controls 43.5%). Pain was associated with acute PCS in mTBI. The strongest effect for acute PCS was a previous affective or anxiety disorder (OR 5.76, 95% CI 2.19 to 15.0). Females were 3.33 times more likely than males to have acute PCS (95% CI 1.20 to 9.21). The effect of acute post-traumatic stress and neuropsychological function on acute PCS was relatively small. Higher IQ was associated with acute PCS. Conclusions: There is a high rate of acute PCS in both mTBI and non-brain injured trauma patients. PCS was not found to be specific to mTBI. The use of the term PCS may be misleading as it incorrectly suggests that the basis of PCS is a brain injury.

The prospective course of postconcussion syndrome: The role of mild traumatic brain injury.

OBJECTIVE To investigate whether postconcussion syndrome (PCS) represents long-term sequelae associated with mild traumatic brain injury (mTBI). METHODS Prospective consecutive admissions to a Level 1 trauma hospital were assessed a mean 4.9 days and again 106.2 days post-injury. The final sample comprised 62 mTBI and 58 nonbrain injured trauma controls (TC). Change or lack of change in individual PCS-like symptoms and PCS was examined. Multilevel logistic regression was used to analyze whether mTBI predicts 3-month PCS (Time 2; T2); whether predictors of PCS (within 14 days of injury, Time 1; T1) predict 3-month PCS, and how change in these predictors from T1 to T2 were associated with change in PCS status. Variables included demographic, injury-related, financial incentives, neuropsychological, and psychiatric disorder. RESULTS MTBI did not predict PCS. PCS was comparable (T1: mTBI: 40.3%, TC: 50.0%; T2: mTBI: 46.8%, TC: 48.3%). At T2, 38.6% were new cases of PCS; between 30.8% and 86.2% reported either a new or more frequent symptom. A pre-injury depressive or anxiety disorder (OR = 2.99, 95% CI [1.38, 6.45]), and acute posttraumatic stress (OR = 1.05, 95% CI [1.00, 1.00]) were early markers of PCS, regardless of mTBI. An interaction between time and posttraumatic stress disorder (PTSD) suggested the relationship between the severity of PTSD symptoms and PCS strengthened over time (OR = 2.66, 95% CI [1.08, 6.55]). Pain was related to PCS. Females were more likely than males to have PCS. CONCLUSION The data suggest the phenomenon of PCS in trauma patients does not show an association with mTBI.

Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury.

OBJECTIVE To investigate the association between posttraumatic stress disorder (PTSD) and chronic pain in patients who had sustained a severe traumatic brain injury (TBI). DESIGN Correlational relationships between pain variables and PTSD measures were examined in a cohort study. SETTING An adult tertiary care center brain injury clinic. PATIENTS Ninety-six persons with severe TBI. OUTCOME MEASURES The Posttraumatic Stress Disorder Interview (PTSD-I), a modified McGill Pain Questionnaire, the Beck Depression Inventory (BDI), the General Health Questionnaire (GHQ), the Community Integration Questionnaire (CIQ), the Satisfaction with Life Scale (SWL), and the Coping Style Questionnaire (CSQ). RESULTS More persons with chronic pain reported PTSD than did those without pain. The relationship between pain severity and depression, functional adjustment, and satisfaction with life was mediated by severity of PTSD. Pain severity was significantly associated with an avoidant coping style. CONCLUSIONS Effective rehabilitation of persons with chronic pain following severe TBI should recognize the role of posttraumatic stress in the maintenance of dysfunctional reactions. Specific interventions that address adaptive coping mechanisms to reduce PTSD may enhance rehabilitation for persons with TBI who suffer chronic pain.

Coping style and post-traumatic stress disorder following severe traumatic brain injury

There is increasing evidence that a proportion of severe traumatically brain injured (TBI) patients do suffer post-traumatic stress disorder (PTSD). The aim of this study was to investigate the predictors of PTSD following severe TBI in a sample of 96 patients who sustained a severe TBI, of whom 27% satisfied diagnostic criteria for PTSD. The Post-traumatic Stress Disorder Interview, the Coping Style Questionnaire, and the Functional Assessment Measure was administered to these patients 6 months after hospital discharge. Avoidant coping style, behavioural coping style, and a history of prior unemployment were the significant predictors of PTSD severity. These findings indicate that reduction of PTSD and management of severe TBI may be facilitated by teaching patients more adaptive coping strategies.There is increasing evidence that a proportion of severe traumatically brain injured (TBI) patients do suffer post-traumatic stress disorder (PTSD). The aim of this study was to investigate the predictors of PTSD following severe TBI in a sample of 96 patients who sustained a severe TBI, of whom 27% satisfied diagnostic criteria for PTSD. The Post-traumatic Stress Disorder Interview, the Coping Style Questionnaire, and the Functional Assessment Measure was administered to these patients 6 months after hospital discharge. Avoidant coping style, behavioural coping style, and a history of prior unemployment were the significant predictors of PTSD severity. These findings indicate that reduction of PTSD and management of severe TBI may be facilitated by teaching patients more adaptive coping strategies.

Pharmacological management of Dysautonomia following traumatic brain injury

Primary objective: To document and critically evaluate the likely effectiveness of pharmacological treatments used in a sample of patients with Dysautonomia and to link these findings to previously published literature. Research design: Retrospective case control chart review. Methods and procedures: Data were collected on age, sex and GCS matched subjects with and without Dysautonomia (35 cases and 35 controls). Data included demographic and injury details, physiological parameters, medication usage, clinical progress and rehabilitation outcome. Descriptive analyses were undertaken to characterize the timing and frequency of CNS active medications. Main outcomes and results: Dysautonomic patients were significantly more likely to receive neurologically active medications. A wide variety of drugs were utilised with the most frequent being morphine/midazolam and chlorpromazine. Cessation of morphine/midazolam produced significant increases in heart rate and respiratory rate but not temperature. Chlorpromazine may have modified respiratory rate responses, but not temperature or heart rate. Conclusions: The features of Dysautonomia are similar to a number of conditions treated as medical emergencies. Despite this, no definitive treatment paradigm exists. The best available evidence is for morphine (especially intravenously), benzodiazepines, propanolol, bromocriptine and possibly intrathecal baclofen. Barriers to improving management include the lack of a standardized nomenclature, formal definition or accepted diagnostic test. Future research needs to be conducted to improve understanding of Dysautonomia with a view to minimizing disability.

Posttraumatic stress disorder and psychosocial functioning after severe traumatic brain injury.

The aim of this study was to investigate the influence of posttraumatic stress disorder (PTSD) on rehabilitation after severe traumatic brain injury (TBI). Ninety-six patients with severe TBI patients were assessed 6 months after hospital discharge with the Posttraumatic Stress Disorder Interview, the Functional Assessment Measure (FAM), the Community Integration Questionnaire (CIQ), the Overt Aggression Scale (OAS), the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), and the Satisfaction with Life Scale (SWL). PTSD was diagnosed in 27% of patients. Patients with PTSD reported higher scores on the GHQ and BDI, and lower scores on the FAM, CIQ, OAS, and SWLS than those without PTSD. Effective rehabilitation after severe TBI may be enhanced by management of PTSD.

A new agent for the control of spasticity

In a preliminary controlled trial, CIBA 34,647-Ba, a gamma aminobutyric acid derivative, was found to be more effective than placebo in reducing spasticity due to spinal injuries. In an uncontrolled trial, 34,647-Ba also appeared more effective than diazepam. The intensity of spasticity was measured electromyographically by the amplitude of the stretch reflex at various velocities, and the results were correlated with those obtained by clinical assessment. 34,647-Ba was effective in both complete and incomplete spinal cord lesions and it is suggested that it has an action at the spinal level. No significant side-effects were encountered.

The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury

The relationship of psychological and cognitive factors in the development of the postconcussion syndrome (PCS) following mild uncomplicated traumatic brain injury (mTBI) has received little study. This may be because of the widely held belief that neurological factors are the cause of early PCS symptoms, whereas psychological factors are responsible for enduring symptoms. To further understand these relationships, the association between PCS and neuropsychological and psychological outcome was investigated in 122 general trauma patients, many of whom had orthopedic injuries, around 5 days following mTBI. Apart from verbal fluency, participants with a PCS did not differ in their performances on neuropsychological measures compared to those without a PCS. Individuals with a PCS reported significantly more psychological symptoms. Large effect sizes present on the psychological measures showed that the difference between participants with a PCS and without was greater on psychological than on neuropsychological measures. Analyses also revealed a relationship between opioid analgesia and depression, anxiety and stress, and opioids and reduced learning. The results suggest that psychological factors are present much earlier than has previously been considered in the development of the PCS.

Utility of the functional assessment measure after discharge from inpatient rehabilitation.

OBJECTIVE To assess the relationship between the Functional Independence Measure (FIM) and the Functional Assessment Measure (FAM), and community integration and return to work in patients with severe traumatic brain injuries (TBI). DESIGN A cross-sectional, prospective design was used to collect data at 6 and 24 months postdischarge. The Return to Work Scale (RTW) and Community Integration Questionnaire (CIQ) were selected to assess return to work and community functioning. Predictor variables included the motor and cognitive subscales of the FIM and the FAM. SETTING Follow-up database of an inpatient and community TBI Rehabilitation Unit. PARTICIPANTS All consenting patients with TBI admitted to the unit, aged 16 or above. There were 88 patients at 6 and 79 patients at 24 month follow-up. RESULTS At 6 months follow-up, the FAM and the FIM were roughly equivalent in their ability to predict RTW and CIQ scores. At 24 months, FAM motor was the only significant predictor of CIQ, and FAM cognitive scores displayed an advantage over the FIM in predicting employment status. CONCLUSIONS The FAM subscales produced only modest gains in prediction of employment status and community integration at 24 months postdischarge. This may reflect ceiling effects on the functional measures, a limited range on the RTW measure, poor ecologic validity of functional disability measures in assessing handicap, or a combination of these factors.

Elevated resting heart rate as a predictor of posttraumatic stress disorder after severe traumatic brain injury.

Objective: This study indexed the relationship between resting heart rates (HRs) after injury and subsequent posttraumatic stress disorder (PTSD) in patients who sustained severe traumatic brain injury (TBI). Methods: Patients who sustained a severe TBI (N = 68) had their resting HR assessed 1 week and 1 month after injury, and they were assessed for PTSD 6 months after injury with the PTSD Interview, a structured clinical interview based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Results: PTSD was diagnosed in 23% of patients. PTSD participants had higher HRs at 1 week but not at 1 month after trauma than non-PTSD participants. This difference remained significant when the effect of posttraumatic amnesia was controlled, but it was not significant when the effect of Glasgow Coma Scale was controlled. Conclusion: These findings accord with the proposal that fear conditioning can occur outside the level of awareness and contribute to PTSD development. PTSD = posttraumatic stress disorder; HR = heart rate; TBI = traumatic brain injury; PTA = posttraumatic amnesia; GCS = Glasgow Coma Scale; PTSD-I = Posttraumatic Stress Disorder Interview; SD = standard deviation.