Prediction of outcome following mild traumatic brain injury:From care to recovery

In Nederland worden jaarlijks zo’n 85.000 mensen op de spoedeisende hulp gezien met een traumatisch hersenletsel. De meerderheid hiervan betreft patiënten met een licht traumatisch hersenletsel. De meeste patiënten herstellen vlot en zonder restproblemen, maar een deel kan nog jarenlang klachten ervaren. In dit proefschrift werd een grote groep patiënten met licht traumatisch hersenletsel onderzocht. Hieruit bleek onder andere dat dat de ernst van het ongeval niet alleen bepalend is hoe patiënten herstellen. Ook de manier waarop patiënten omgaan met en zich aanpassen aan de gevolgen van het trauma zijn van belang voor het herstel. In het proefschrift wordt bepleit dat de huidige selectie voor nazorg op de polikliniek onafhankelijk moet zijn de ziekenhuisopname van een patiënt, zodat de patiënt die niet werden opgenomen niet uit het oog worden verloren. Er werd ook in het bijzonder gekeken naar de patiënten tussen 18-65 jaar, om de factoren die van invloed zijn op de werkhervatting te onderzoeken. Hieruit bleek dat er door het jaar heen een verandering in het patroon van werkhervatting ontstaat, en dat patiënten het werk hervatten ondanks het rapporteren van klachten. Deze klachten, samen met tekenen van psychologische belasting kunnen helpen voorspellen welke patiënten meer risico lopen op een problematische werkhervatting.Om een adequate nazorg voor alle patiënten te garanderen is het dan ook van essentieel belang mogelijke problemen in de omgang met de gevolgen van het ongeval vroeg te signaleren.Millions of people sustain a mild traumatic brain injury (mTBI) each year. Most patients recover quickly without, however a subgroup continues to experience complaints interfering with for instance work resumption. In this dissertation we studied factors influencing general outcome and specifically return to work following mTBI. By investigating posttraumatic complaints, psychological distress and aftercare, and accounting for pre-injury adaptive capacities and occupational factors we contributed to the current body of work on the specifics of recovery after mTBI. Our findings indicate that adaptive disorders could and should be signaled early after injury,to ensure proper aftercare for the broad spectrum of mTBI patients that the heterogenic disorder entails

Prediction of outcome following mild traumatic brain injury:From care to recovery

In Nederland worden jaarlijks zo’n 85.000 mensen op de spoedeisende hulp gezien met een traumatisch hersenletsel. De meerderheid hiervan betreft patiënten met een licht traumatisch hersenletsel. De meeste patiënten herstellen vlot en zonder restproblemen, maar een deel kan nog jarenlang klachten ervaren. In dit proefschrift werd een grote groep patiënten met licht traumatisch hersenletsel onderzocht. Hieruit bleek onder andere dat dat de ernst van het ongeval niet alleen bepalend is hoe patiënten herstellen. Ook de manier waarop patiënten omgaan met en zich aanpassen aan de gevolgen van het trauma zijn van belang voor het herstel. In het proefschrift wordt bepleit dat de huidige selectie voor nazorg op de polikliniek onafhankelijk moet zijn de ziekenhuisopname van een patiënt, zodat de patiënt die niet werden opgenomen niet uit het oog worden verloren. Er werd ook in het bijzonder gekeken naar de patiënten tussen 18-65 jaar, om de factoren die van invloed zijn op de werkhervatting te onderzoeken. Hieruit bleek dat er door het jaar heen een verandering in het patroon van werkhervatting ontstaat, en dat patiënten het werk hervatten ondanks het rapporteren van klachten. Deze klachten, samen met tekenen van psychologische belasting kunnen helpen voorspellen welke patiënten meer risico lopen op een problematische werkhervatting. Om een adequate nazorg voor alle patiënten te garanderen is het dan ook van essentieel belang mogelijke problemen in de omgang met de gevolgen van het ongeval vroeg te signaleren

Stability of coping and the role of self-efficacy in the first year following mild traumatic brain injury

Background and aims: Coping, the psychological adaptation to stressors and serious life events, has been found to have a great influence on the development and persistence of posttraumatic complaints. Coping has received much attention for having been found to be modifiable in treatment following mild traumatic brain injury (mTBI) and for its potential to identify the Patients who are at risk of suffering from long-term complaints. Currently, coping styles are assumed to be stable over time. Although interventions to facilitate adaptive coping are given at different time intervals after the injury, little is known about spontaneous changes in preferred strategies over time following mTBI. This study aimed to investigate the stability of different coping styles over a one-year period following mTBI (at two weeks', six and twelve months' post-injury) and to investigate the relation between coping styles and feelings of self-efficacy.Methods: We included 425 mTBI patients (Glasgow Coma Scale [GCS] score 13-15) admitted to three Level-1 trauma centers in the Netherlands as part of a prospective follow-up study. All participants filled out The Utrecht Coping List (UCL) to determine their position on seven coping subscales.Results: Most coping styles showed a decrease over time, except for positive reframing, which showed a decrease and then increased. Interestingly, the passive coping style was found to stabilize over time within the year after injury. High feelings of self-efficacy were related to a high active coping style (r = 0.36), and low feelings of self-efficacy with passive coping (r =-032).Conclusions: These results hold important possibilities for the use of the passive coping strategy as an inclusion criterion for intervention studies and an entry point for treatment itself. Considering the intertwinement of coping with self-efficacy, improving feelings of self-efficacy could form an effective part of an intervention to improve outcome. (C) 2017 Elsevier Ltd. All rights reserved.</p

Graph Analysis of Functional Brain Networks in Patients with Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is one of the most common neurological disorders worldwide. Posttraumatic complaints are frequently reported, interfering with outcome. However, a consistent neural substrate has not yet been found. We used graph analysis to further unravel the complex interactions between functional brain networks, complaints, anxiety and depression in the sub-acute stage after mTBI. This study included 54 patients with uncomplicated mTBI and 20 matched healthy controls. Posttraumatic complaints, anxiety and depression were measured at two weeks post-injury. Patients were selected based on presence (n = 34) or absence (n = 20) of complaints. Resting-state fMRI scans were made approximately four weeks post-injury. High order independent component analysis resulted in 89 neural components that were included in subsequent graph analyses. No differences in graph measures were found between patients with mTBI and healthy controls. Regarding the two patient subgroups, degree, strength, local efficiency and eigenvector centrality of the bilateral posterior cingulate/precuneus and bilateral parahippocampal gyrus were higher, and eigenvector centrality of the frontal pole/bilateral middle & superior frontal gyrus was lower in patients with complaints compared to patients without complaints. In patients with mTBI, higher degree, strength and eigenvector centrality of default mode network components were related to higher depression scores, and higher degree and eigenvector centrality of executive network components were related to lower depression scores. In patients without complaints, one extra module was found compared to patients with complaints and healthy controls, consisting of the cingulate areas. In conclusion, this research extends the knowledge of functional network connectivity after mTBI. Specifically, our results suggest that an imbalance in the function of the default mode-and executive network plays a central role in the interaction between emotion regulation and the persistence of posttraumatic complaints

Trajectories of Fatigue, Psychological Distress, and Coping Styles After Mild Traumatic Brain Injury:A 6-Month Prospective Cohort Study

Objective: To analyze fatigue after mild traumatic brain injury (TBI) with latent class growth analysis (LCGA) to determine distinct recovery trajectories and investigate influencing factors, including emotional distress and coping styles. Design: An observational cohort study design with validated questionnaires assessing fatigue, anxiety, depression, posttraumatic stress, and coping at 2 weeks and 3 and 6 months postinjury. Setting: Three level 1 trauma centers. Participants: Patients with mild TBI (N=456). Interventions: Not applicable. Main Outcome Measures: Fatigue was measured with the fatigue severity subscale of the Checklist Individual Strength, including 8 items (sum score, 8-56). Subsequently, 3 clinical categories were created: high (score, 40-56), moderate (score, 26-38), and low (score, 8-25). Results: From the entire mild TBI group, 4 patient clusters with distinct patterns for fatigue, emotional distress, and coping styles were found with LCGA. Clusters 1 and 2 showed favorable recovery from fatigue over time, with low emotional distress and the predominant use of active coping in cluster 1 (30%) and low emotional distress and decreasing passive coping in cluster 2 (25%). Clusters 3 and 4 showed unfavorable recovery, with persistent high fatigue and increasing passive coping together with low emotional distress in cluster 3 (27%) and high emotional distress in cluster 4 (18%). Patients with adverse trajectories were more often women and more often experiencing sleep disturbances and pain. Conclusions: The prognosis for recovery from posttraumatic fatigue is favorable for 55% of mild TBI patients. Patients at risk for chronic fatigue can be signaled in the acute phase postinjury based on the presence of high fatigue, high passive coping, and, for a subgroup of patients, high emotional distress. LCGA proved to be a highly valuable and multipurpose statistical method to map distinct courses of disease-related processes over time

Patients with mild traumatic brain injury and acute neck pain at the emergency department are a distinct category within the mTBI spectrum:a prospective multicentre cohort study

Background: Acute neck pain (ANP) has recently been demonstrated to be a predictor of persistent posttraumatic complaints after mild traumatic brain injury (mTBI). The aim of this study was to determine specific characteristics of patients with ANP following mTBI, their posttraumatic complaints and relationship with functional outcome. Methods: Data from a prospective follow-up study of 922 mTBI patients admitted to the emergency department (ED) in three level-one trauma centres were analysed. Patients were divided into two groups: 156 ANP patients and 766 no acute neck pain (nANP) patients. Posttraumatic complaints were evaluated 2 weeks and 6 months post-injury using standardized questionnaires and functional outcome was evaluated at 6 months with the Glasgow Outcome Scale Extended (GOSE). Results: ANP patients were more often female (p < 0.01), younger (38 vs. 47 years, p < 0.01) with more associated acute symptoms at the ED (p < 0.05) compared to nANP patients. More motor vehicle accidents (12% vs. 6%, p = 0.01) and less head wounds (58% vs. 73%, p < 0.01) in ANP patients indicated 'high-energy low-impact' trauma mechanisms. ANP patients showed more posttraumatic complaints 2 weeks and 6 months post-injury (p < 0.05) and more often incomplete recovery (GOSE < 8) was present after 6 months (56% vs. 40%, p = 0.01). Conclusions: MTBI patients with acute neck pain at the ED constitute a distinct group within the mTBI spectrum with specific injury and demographic characteristics. Early identification of this at risk group already at the ED might allow specific and timely treatment to avoid development of incomplete recovery

Rating of pre-injury symptoms over time in patients with mild traumatic brain injury:The good-old-days-bias revisited

Objective Post-concussion syndrome (PCS) occurs following mild traumatic brain injury (mTBI). Patients with mTBI are often assessed using self-report instruments that rely on perception of current symptoms compared to how they felt and functioned pre-injury. The objective was to examine reliability of patients’ post-injury reporting of their pre-injury symptoms. Methods We included two control groups (trauma patients without brain injury history and healthy controls) who were recruited at an outpatient surgical clinic and among the working and social environment of the researchers, respectively. The Head Injury Symptom Checklist (HISC) was used to assess pre-injury and current symptoms at four time points post injury. We included 836 patients with mTBIs, 191 trauma patients without brain injury history, and 100 healthy controls. Results Patients with mTBI reported significantly more pre-injury symptoms than both control groups (p < .001). Forty-five percent of patients with mTBI were inconsistent in their pre-injury ratings across four assessments. Patients with post-injury PCS reported much greater pre-injury symptoms and were more often inconsistent. Conclusion Accurately assessing PCS by comparing pre with post-injury complaints is difficult, and may have implications for diagnosis when using self-report instruments. Therefore, post-injury PCS diagnosis should be interpreted with caution and PCS should ideally be examined using clinical examination

Neurophysiological signatures of mild traumatic brain injury in the acute and subacute phase

Background: Mild traumatic brain injury (mTBI) affects 48 million people annually, with up to 30% experiencing long-term complaints such as fatigue, blurred vision, and poor concentration. Assessing neurophysiological features related to visual attention and outcome measures aids in understanding clinical symptoms and prognostication. Methods: We recorded EEG and eye movements in mTBI patients during a computerized task performed in the acute (&lt; 24 h, TBI-A) and subacute phase (4–6 weeks thereafter). We estimated the posterior dominant rhythm, reaction times (RTs), fixation duration, and event-related potentials (ERPs). Clinical outcome measures were assessed using the Head Injury Symptom Checklist (HISC) and the Extended Glasgow Outcome Scale (GOSE) at 6 months post-injury. Similar analyses were performed in an age-matched control group (measured once). Linear mixed effect modeling was used to examine group differences and temporal changes within the mTBI group. Results: Twenty-nine patients were included in the acute phase, 30 in the subacute phase, and 19 controls. RTs and fixation duration were longer in mTBI patients compared to controls (p &lt; 0.05), but not between TBI-A and TBI-S (p &lt; 0.05). The frequency of the posterior dominant rhythm was significantly slower in TBI-A (0.6 Hz, p &lt; 0.05) than TBI-S. ERP mean amplitude was significantly lower in mTBI patients than in controls. Neurophysiological features did not significantly relate to clinical outcome measures. Conclusion: mTBI patients demonstrate impaired processing speed and stimulus evaluation compared to controls, persisting up to 6 weeks after injury. Neurophysiological features in mTBI can assist in determining the extent and temporal progression of recovery.</p