Kathleen R. Bell

Journal of Head Trauma Rehabilitation: Preface

T BRAIN INJURY can often be associated with long-lasting symptoms and effects on function in a wide variety of areas. Expertise in the assessment and management of chronic physical, cognitive, and behavioral complaints is limited in many geographic areas, especially in rural America. Even in urban and suburban areas, the ability to fund treatment and education may be limited over the long course of recovery from and living with a chronic disorder. However, alternatives to face-to-face visits and therapy may be found through the blossoming of communication technologies. Few are without access to good reliable telephone services these days and, increasingly, Internet access is available through cable and wireless services. Audio and visual contact is possible with individuals and groups through various means. Facebook, Wikis, and Twitter, all new and innovative means of communication, are potentially available to extend the reach of the healthcare provider. Reaching out electronically to provide treatment and education to patients and caregivers is the focus of this issue of The Journal of Head Trauma Rehabilitation. Dr Bombardier and colleagues report on the results of a telephone-based counseling intervention aimed at educating and improving problem-solving skills of persons with moderate to severe traumatic brain injury with a range of depressive symptoms. Dr Wade and her group present their findings on using Web-based education and therapy to improve outcomes among children, adolescents, and their families. Finally, focusing on caregiver support and education, Dr Sander and her fellow investigators describe the use of videoconferencing technology to provide access to those living at a distance from the brain injury rehabilitation site. Many pilot research and clinical uses of Web-based communication technology can be found, particularly in the military (eg, www.afterdeployment.org) and veterans healthcare worlds. Little is currently known about how and who accesses these resources, how effective they are in terms of education and outcome, or how these electronic resources compare with more traditional avenues of education and treatment. Experience gained in other fields of healthcare will need to be evaluated in light of the special cognitive challenges our patients bring to the process, for both education and therapy. Definitions and measures of “dosing” for interventions delivered by telecommunication methods will require further explication. With respect to currently available funding, only face-to-face education and treatment are generally covered by insurers and healthcare intermediaries, funded by government. As these techniques are researched and further developed, the means of financing electronically mediated interventions will need to be resolved. We could not present these papers without stretching our own avenues of education and dissemination as well. We will be presenting a Webinar on this JHTR Telerehabilitation issue at 3 PM ET on August 6, 2009. Registration for the Webinar, part of the Mitch Rosenthal Memorial Lecture series, will be available in the bookstore of the Brain Injury Association of America in early July. The path is www.biausa.org. Click on Bookstore, and then click on Strauss and Rosenthal Lecture Series to register. More information can be obtained by contacting Marianna Abashian at mabashian@biausa.org.

Accuracy of Mild Traumatic Brain Injury Diagnosis

OBJECTIVE To determine how often emergency department (ED) patients meeting the Centers for Disease Control and Prevention (CDC) mild traumatic brain injury (TBI) criteria were diagnosed with a mild TBI by the ED physician. DESIGN Prospective identification of cases of mild TBI in the ED by study personnel using scripted interviews and medical record data was compared with retrospective review of ED medical record documentation of mild TBI. SETTING EDs of a level I trauma center and an academic nontrauma hospital. PARTICIPANTS Prospective cohort of subjects (N=197; mean age, 32.6 y; 70% men) with arrival at the ED within 48 hours of injury, Glasgow Coma Scale score of 13 to 15, and injury circumstances, alteration of consciousness, and memory dysfunction consistent with the CDC mild TBI definition. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE ED medical record documentation of mild TBI. RESULTS Fifty-six percent of mild TBI cases identified by study personnel did not have a documented mild TBI-related diagnosis in the ED record. The greatest agreement between study personnel and ED physicians for positive mild TBI-related findings was for loss of consciousness (72% vs 65%) with the greatest discrepancy for confusion (94% vs 28%). CONCLUSIONS The diagnosis of mild TBI was frequently absent from ED medical records despite patients reporting findings consistent with a mild TBI diagnosis when interviewed by study personnel. Asking a few targeted questions of ED patients with likely mechanisms of injury that could result in mild TBI could begin to improve diagnosis and, in turn, begin to improve patient management and the accuracy of estimates of mild TBI incidence.

Natural History of Headache after Traumatic Brain Injury

Headache is one of the most common persisting symptoms after traumatic brain injury (TBI). Yet there is a paucity of prospective longitudinal studies of the incidence and prevalence of headache in a sample with a range of injury severity. We sought to describe the natural history of headache in the first year after TBI, and to determine the roles of prior history of headache, sex, and severity of TBI as risk factors for post-traumatic headache. A cohort of 452 acute, consecutive patients admitted to inpatient rehabilitation services with TBI were enrolled during their inpatient rehabilitation from February 2008 to June 2009. Subjects were enrolled across 7 acute rehabilitation centers designated as TBI Model Systems centers. They were prospectively assessed by structured interviews prior to inpatient rehabilitation discharge, and at 3, 6, and 12 months after injury. Results of this natural history study suggest that 71% of participants reported headache during the first year after injury. The prevalence of headache remained high over the first year, with more than 41% of participants reporting headache at 3, 6, and 12 months post-injury. Persons with a pre-injury history of headache (p<0.001) and females (p<0.01) were significantly more likely to report headache. The incidence of headache had no relation to TBI severity (p=0.67). Overall, headache is common in the first year after TBI, independent of the severity of injury range examined in this study. Use of the International Classification of Headache Disorders criteria requiring onset of headache within 1 week of injury underestimates rates of post-traumatic headache. Better understanding of the natural history of headache including timing, type, and risk factors should aid in the design of treatment studies to prevent or reduce the chronicity of headache and its disruptive effects on quality of life.

The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: A randomised trial

Background: Mild traumatic brain injury (MTBI) is a significant public health problem affecting approximately 1 million people annually in the USA. A total of 10–15% of individuals are estimated to have persistent post-traumatic symptoms. This study aimed to determine whether focused, scheduled telephone counselling during the first 3 months after MTBI decreases symptoms and improves functioning at 6 months. Methods: This was a two-group, parallel, randomised clinical trial with the outcome assessed by blinded examiner at 6 months after injury. 366 of 389 eligible subjects aged 16 years or older with MTBI were enrolled in the emergency department, with an 85% follow-up completion rate. Five telephone calls were completed, individualised for patient concerns and scripted to address education, reassurance and reactivation. Two composites were analysed, one relating to post-traumatic symptoms that developed or worsened after injury and their impact on functioning, the other related to general health status. Results: The telephone counselling group had a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score, 95% confidence interval (CI) 1.2 to 12.0), but no difference in general health outcome (1.5 difference in adjusted mean functional score, 95% CI 2.2 to 5.2). A smaller proportion of the treatment group had each individual symptom (except anxiety) at assessment. Similarly, fewer of the treatment group had daily functioning negatively impacted by symptoms with the largest differences in work, leisure activities, memory and concentration and financial independence. Conclusions: Telephone counselling, focusing on symptom management, was successful in reducing chronic symptoms after MTBI. Trial registration number: ClinicalTrials.gov, #NCT00483444

A prospective study of prevalence and characterization of headache following mild traumatic brain injury

Background Headache is one of the most common and persistent symptoms following traumatic brain injury (TBI). The current study examines the prevalence and characteristics of headache following mild TBI (mTBI). Methods We prospectively enrolled 212 subjects within one week of mTBI who were hospitalized for observation or other system injuries in a single level 1 US trauma center and followed by telephone at three, six, and 12 months after injury for evaluation of headache. Headaches were classified according to ICHD-2 criteria as migraine, probable migraine, tension-type, cervicogenic, or unclassifiable headache. Results Subjects were 76% male and 75% white, and 58% were injured in vehicle-related crashes. A follow-up rate of 90% (190/212) occurred at 12 months post-injury. Eighteen percent (38/212) of subjects reported having a problem with headaches pre-injury while 54% (114/210) of subjects reported new or worse headaches compared to pre-injury immediately after injury, 62% (126/203) at three months, 69% (139/201) at six months, and 58% (109/189) at one year. Cumulative incidence was 91% (172/189) over one year. Up to 49% of headaches met criteria for migraine and probable migraine, followed by tension-type headaches (up to 40%). Age (≤ 60) was found to be a risk factor, but no significant difference was found in persistence of new or worse headache compared to pre-injury between males and females. More than one-third of the subjects reported persistent headache across all three follow-up time periods. Conclusions Headache after mTBI is very common and persistent across the first year after injury. Assertive, early treatment may be warranted to avoid chronicity and disability. Further research is needed to determine whether post-traumatic headache (PTH) responds to headache treatment used in the primary headache disorders and whether chronic PTH is preventable.

Characterization of headache after traumatic brain injury

Background: Headache is a common and persistent symptom following traumatic brain injury (TBI). Headaches following TBI are defined primarily by their temporal association to injury, but have no defining clinical features. To provide a framework for treatment, primary headache symptoms were used to characterize headache. Methods: Three hundred and seventy-eight participants were prospectively enrolled during acute in-patient rehabilitation for TBI. Headaches were classified into migraine/probable migraine, tension-type, or cervicogenic headache at baseline and 3, 6, and 12 months following TBI. Results: Migraine was the most frequent headache type occurring in up to 38% of participants who reported headaches. Probable migraine occurred in up to 25%, tension-type headache in up to 21%, then cervicogenic headache in up to 10%. Females were more likely to have endorsed pre-injury migraine than males, and had migraine or probable migraine at all time points after injury. Those classified with migraine were more likely to have frequent headaches. Conclusions: Our data show that most headache after TBI may be classified using primary headache criteria. Migraine/probable migraine described the majority of headache after TBI across one year post-injury. Using symptom-based criteria for headache following TBI can serve as a framework from which to provide evidence-based treatment for these frequent, severe, and persistent headaches.

The efficacy of a scheduled telephone intervention for ameliorating depressive symptoms during the first year after traumatic brain injury

ObjectiveTo determine whether an intervention designed to improve functioning after traumatic brain injury (TBI) also ameliorates depressive symptoms. DesignSingle-blinded, randomized controlled trial comparing a scheduled telephone intervention to usual care. ParticipantsOne hundred seventy-one persons with TBI discharged from an inpatient rehabilitation unit. MethodsThe treatment group received up to 7 scheduled telephone sessions over 9 months designed to elicit current concerns, provide information, and facilitate problem solving in domains relevant to TBI recovery. Outcome MeasuresBrief Symptom Inventory-Depression (BSI-D) subscale, Neurobehavioral Functioning Inventory-Depression subscale, and Mental Health Index-5 from the Short-Form-36 Health Survey. ResultsBaseline BSI-D subscale and outcome data were available on 126 (74%) participants. Randomization was effective except for greater severity of depressive symptoms in the usual care (control) group at baseline. Outcome analyses were adjusted for these differences. Overall, control participants developed greater depressive symptom severity from baseline to 1 year than did the treatment group. The treated group reported significantly lower depression symptom severity on all outcome measures. For those more depressed at baseline, the treated group demonstrated greater improvement in symptoms than did the controls. ConclusionsTelephone-based interventions using problem-solving and behavioral activation approaches may be effective in ameliorating depressive symptoms following TBI. Proactive telephone calls, motivational interviewing, and including significant others in the intervention may have contributed to its effectiveness.

A Randomized Controlled Trial of Exercise to Improve Mood After Traumatic Brain Injury

To test the hypothesis that a structured aerobic exercise regimen would decrease the severity of depressive symptoms in people with traumatic brain injury (TBI) who reported at least mild depression severity at baseline.

Systematic Review of Interventions for Post-traumatic Headache

Headache is one of the most common physical symptoms after traumatic brain injury (TBI). The specific goals of this review include (1) determination of effective interventions for post‐traumatic headache (PTHA), (2) development of treatment recommendations, (3) identification of gaps in the current medical literature regarding PTHA treatment, and (4) suggestions for future directions in research to improve outcome for persons with PTHA.

Benefits of Exercise Maintenance After Traumatic Brain Injury

OBJECTIVE To examine the effect of exercise intervention on exercise maintenance, depression, quality of life, and mental health at 6 months for people with traumatic brain injury (TBI) with at least mild depression. DESIGN Treatment group participants were assessed at baseline, after a 10-week exercise intervention, and 6 months after completion of the intervention. SETTING Community. PARTICIPANTS Participants (N=40) with self-reported TBI from 6 months to 5 years prior to study enrollment and a score of 5 or greater on the Patient Health Questionnaire-9. INTERVENTIONS Ten-week exercise intervention program consisting of supervised weekly 60-minute sessions and unsupervised 30 minutes of aerobic exercises 4 times each week. Telephone follow-up was conducted every 2 weeks for an additional 6 months to promote exercise maintenance for individuals randomized to the intervention group. MAIN OUTCOME MEASURE Beck Depression Inventory (BDI) comparing participant outcomes over time. Post hoc analyses included comparison among those who exercised more or less than 90 minutes per week. RESULTS Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health. CONCLUSIONS Exercise may contribute to improvement in mood and quality of life for people with TBI and should be considered as part of the approach to depression treatment.