When a minor head injury results in enduring symptoms: A prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury

Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
Journal of neurology, neurosurgery, and psychiatry (Impact Factor: 6.81). 02/2012; 83(2):217-23. DOI: 10.1136/jnnp-2011-300767
Source: PubMed


A significant proportion (15-30%) of patients with mild traumatic brain injury (MTBI) are at risk of developing postconcussional syndrome (PCS). The aim of this study was to investigate the contributions of cognitive, emotional, behavioural and social factors to the development of PCS and identify early predictors.
A prospective cohort design was employed. 126 MTBI patients completed baseline questionnaire assessments within 2 weeks of the injury and 107 completed follow-up questionnaire assessments at 3 and 6 months. A series of self-report measures were used to assess cognitive, behavioural and emotional responses to MTBI. The primary outcome was the ICD-10 diagnosis for PCS. Demographic and clinical characteristic variables were compared between PCS cases and non-cases using independent sample t tests and χ(2) tests. Individual and multivariate logistic regression analyses were used to detect predictors of PCS.
Of 107 MTBI patients, 24 (22%) met the criteria for PCS at 3 months and 22 (21%) at 6 months. Individual logistic regression analysis indicated that negative MTBI perceptions, stress, anxiety, depression and all-or-nothing behaviour were associated with the risk of PCS. Multivariate analysis revealed that all-or-nothing behaviour was the key predictor for the onset of PCS at 3 months while negative MTBI perceptions predicted PCS at 6 months.
The study provides good support for the proposed cognitive behavioural model. Patients' perceptions of their head injury and their behavioural responses play important roles in the development of PCS, indicating that cognitive and behavioural factors may be potential targets for early preventive interventions.

16 Reads
  • Source
    • "95% CI, 1.1e8.9) Hou et al, 26 2012; "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective To update the mild traumatic brain injury (MTBI) prognosis review published by the World Health Organization Task Force in 2004. Data Sources MEDLINE, PsycINFO, Embase, CINAHL, and SPORTDiscus were searched from 2001 to 2012. We included published, peer-reviewed studies with more than 30 adult cases. Study Selection Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess subjective, self-reported outcomes. After 77,914 titles and abstracts were screened, 299 articles were eligible and reviewed for scientific quality. This includes 3 original International Collaboration on MTBI Prognosis (ICoMP) research studies. Data Extraction Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed each study and tabled data from accepted articles. A third reviewer was consulted for disagreements. Data Synthesis Evidence from accepted studies was synthesized qualitatively into key findings, and prognostic information was prioritized according to design as exploratory or confirmatory. Of 299 reviewed studies, 101 (34%) were accepted and form our evidence base of prognostic studies. Of these, 23 addressed self-reported outcomes in adults, including 2 of the 3 original ICoMP research studies. These studies show that common postconcussion symptoms are not specific to MTBI/concussion and occur after other injuries as well. Poor recovery after MTBI is associated with poorer premorbid mental and physical health status and with more injury-related stress. Most recover over 1 year, but persistent symptoms are more likely in those with more acute symptoms and more emotional stress. Conclusions Common subjective symptoms after MTBI are not necessarily caused by brain injury per se, but they can be persistent in some patients. Those with more initial complaints and psychological distress recover slower. We need more high-quality research on these issues.
    Archives of physical medicine and rehabilitation 03/2014; 95(3):S132–S151. DOI:10.1016/j.apmr.2013.08.299 · 2.57 Impact Factor
  • Source
    • "Activities that have a high exposure risk to another mTBI are to be avoided in the acute recovery period (Guskiewicz et al., 2004; McCrea et al., 2012). If somatic, emotional, or cognitive symptoms persist beyond 3 months, they are often not related to the neurological effects of the mTBI or concussion (Hou et al., 2012; Ponsford et al., 2012). Rather, other factors have been implicated, such as baseline characteristics (e.g., prior psychopathology; de Leon et al., 2009), headache and pain (Iverson & McCracken, 1997), vestibular dysfunction (Iverson et al., 2009), unrealistic appraisal of pre-injury status (Gunstad & Suhr, 2001; Iverson et al., 2010), inaccurate self-report (Barsky, 2002), inaccurate illness perception (Whittaker, Kemp, & House, 2007), and the non-specific nature of mTBI and concussion symptoms, leading to misattribution of symptoms (Lees-Haley, Fox, & Courtney, 2001). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Traumatic brain injury (TBI) occurs at a high incidence, involving millions of individuals in the U.S. alone. Related to this, there are large numbers of litigants and claimants who are referred annually for forensic evaluation. In formulating opinions regarding claimed injuries, the present review advises experts to rely on two sets of information: TBI outcome and neuropsychological dose-response studies of non-litigants and non-claimants, and response bias literature that has demonstrated the relatively high risk of invalid responding among examinees referred within a secondary gain context, which in turn has resulted in the development of specific assessment methods. Regarding prospective methods for detecting possible response bias, both symptom validity tests, for measuring over-reporting of symptoms on inventories and questionnaires, and performance validity tests, for measuring insufficient effort on ability tests, are considered essential. Copyright © 2013 John Wiley & Sons, Ltd.
    Behavioral Sciences & the Law 11/2013; 31(6). DOI:10.1002/bsl.2088 · 0.96 Impact Factor
  • Source
    • "In the present study, about a third of mTBI patients developed a PCS, a number which is in the upper limit of the reported prevalence of PCS after brain trauma, which is estimated at 15 to 30% [56]. Previous studies investigating brain networks following mild TBI have revealed alterations of network properties including reduced number and strength of connections in the default mode network and increased connections between the default mode network and the prefrontal cortex [25], [27], [28], [31], reduced interhemispheric connectivity in the primary visual cortex, hippocampus and dorsolateral prefrontal cortex networks [26], as well as increased overall strength [30]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Post-concussion syndrome has been related to axonal damage in patients with mild traumatic brain injury, but little is known about the consequences of injury on brain networks. In the present study, our aim was to characterize changes in functional brain networks following mild traumatic brain injury in patients with post-concussion syndrome using resting-state functional magnetic resonance imaging data. We investigated 17 injured patients with persistent post-concussion syndrome (under the DSM-IV criteria) at 6 months post-injury compared with 38 mild traumatic brain injury patients with no post-concussion syndrome and 34 healthy controls. All patients underwent magnetic resonance imaging examinations at the subacute (1-3 weeks) and late (6 months) phases after injury. Group-wise differences in functional brain networks were analyzed using graph theory measures. Patterns of long-range functional networks alterations were found in all mild traumatic brain injury patients. Mild traumatic brain injury patients with post-concussion syndrome had greater alterations than patients without post-concussion syndrome. In patients with post-concussion syndrome, changes specifically affected temporal and thalamic regions predominantly at the subacute stage and frontal regions at the late phase. Our results suggest that the post-concussion syndrome is associated with specific abnormalities in functional brain network that may contribute to explain deficits typically observed in PCS patients.
    PLoS ONE 10/2013; 8(6):e65470. DOI:10.1371/journal.pone.0065470 · 3.23 Impact Factor
Show more