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Student Perspectives: Interventions for Post-Concussion Syndrome Prevention Following ‎Mild Traumatic Brain Injury: Recommendations and Future Directions‎

Emmeline N. Taylor, BS

May 25, 2022

Approximately 2.5 million people present to an emergency department each year due to traumatic brain injury (TBI; Taylor et al., 2017). An estimated 75% of these cases involve mild TBI (mTBI; i.e., concussion) and do not require hospitalization (Centers for Disease Control and Prevention, National Center or Injury Prevention and Control, 2003). Thus, individuals are triaged and treated in the emergency department, released to rest at home, and receive outpatient follow-up care as needed. Following mTBI, it is not uncommon for people to experience some physical and sensory symptoms, such as headaches, blurred vision and nausea, and cognitive symptoms, such as difficulties with concentration, disorientation, and trouble sleeping. Most people fully recover from these symptoms within three months of the injury (Permenter et al., 2022). When concussion symptoms persist beyond what is expected in typical recovery (i.e., three months for mTBI), post-concussion syndrome (PCS) may be diagnosed (Permenter et al., 2022). Due to a lack of consensus around specific diagnostic criteria for PCS diagnosis, prevalence estimates vary between 11% to around 30% (Dean et al., 2012; Spinos et al., 2010; Voormolen et al., 2018).

Serious medical complications following mTBI are rare. However, posttraumatic stress disorder (PTSD) related to the mTBI injury event and PCS are unfavorable outcomes following mTBI that can occur (Bryant, 2011; King, 2008). Van Praag and colleagues (2019) estimated that around 13.5% of people who experience mTBI will develop PTSD associated with the mTBI injury event. Research suggests that PTSD, whether anchored to the mTBI event or a separate trauma, increases the risk for complications following mTBI, including PCS (Broshek et al., 2015; King, 2008). PTSD and PCS following mTBI take a toll both on individuals’ well-being as well as health care resources. In a study of over 80,000 individuals who had experienced mTBI, the mean follow-up health care costs associated with the condition were over $13,000 (Pavlov et al., 2019). It is likely that these costs were higher among individuals with PTSD and PCS. Additionally, individuals with co-occurring PCS-PTSD had lower rates of return to work and lower health-related quality of life (van der Vlegel et al., 2021).

PCS, as well as co-occurring PCS and PTSD, may be preventable in mTBI populations. A systematic review of nonsurgical interventions following mTBI identified early psychoeducation as beneficial (Nygren-de Boussard et al., 2014). Psychoeducation can help individuals who have experienced mTBI understand their symptoms and recovery timeline, develop fewer negative perceptions around mTBI and the effect of mTBI on their lives, and regain a sense of control related to their experience of mTBI (Caplain et al., 2019; Prince & Bruhns, 2017). However, the effectiveness of psychoeducation may depend on other factors. For example, implementation of psychoeducation in emergency medical settings has been variable and has lacked evaluation (Kempe et al., 2014; Prince & Bruhns, 2017). Additionally, psychoeducation may not be sufficient prevention for individuals at higher risk for PCS and PTSD (Al Sayegh et al., 2010).

A combination of psychoeducation, cognitive behavioral therapy (CBT), graduated physical activity, and cognitive rehabilitation may help to prevent PCS among those at greater risk (Al Sayegh et al., 2010; Broshek et al., 2015; Nygren-de Boussard et al., 2014). For example, a study of adults in France who experienced mTBI and were high risk for PCS found that participants who received 14 sessions of integrated psychoeducation and cognitive rehabilitation one month following injury had lower rates of PCS (6%) compared to the treatment as usual group (52%; in-person psychoeducation one, three, and six months following injury; Caplain et al., 2019). Silverberg and colleagues (2013) examined a brief (six-session) CBT protocol for mTBI among a sample of adults at high risk for PCS. They found that fewer participants in the treatment group developed PCS (54%) compared to treatment as usual (91%), as well as moderate effect sizes for post-concussive symptoms (Cohen d = 0.74).

Evidence suggests that PCS is preventable, even among those at higher risk. However, the evaluation of interventions aimed at prevention has been limited. Additionally, a lack of inclusion of other outcomes such as PTSD, as well as inconsistent implementation of psychoeducation protocols across emergency medical settings, limits our understanding of what may be most beneficial for preventing PCS and PTSD. Outlined below is a list of recommendations for the prevention of PCS and co-occurring PCS and PTSD, as well as the evaluation of prevention efforts.
  1. Development and implementation of an in-hospital screen for risk of PCS. Numerous psychosocial and medical risk factors for PCS have been identified including diagnosis of mental health conditions, chronic pain, older age, CT abnormalities associated with the mTBI, and negative illness perceptions (Voormolen et al., 2018; Whittaker et al., 2007). Developing a universal screening tool within hospitals to identify individuals at risk for PCS is crucial for tailoring prevention efforts and ensuring early intervention if needed. As PTSD, both historical and associated with the mTBI injury, is also a well-established risk factor for PCS (Broshek et al., 2015), screening for PTSD risk related to the mTBI injury event would also be important to include.
     
  2. Universal psychoeducation. Psychoeducation delivery within emergency medical settings is variable. Ensuring clear, concise, and consistent psychoeducation is delivered to every mTBI patient, regardless of PCS risk, may be a cost-effective and feasible way to prevent complications following mTBI (Prince & Bruhns, 2017). Development of guidelines for mTBI psychoeducation could help to reduce variability in content and quality of psychoeducation resources.
     
  3. Stepped-care approach to prevention. Psychoeducation may not be enough for individuals at higher risk for PCS and PTSD (Al Sayegh et al., 2010). Designing and implementing a stepped-care approach to PCS and PTSD prevention for those at greatest risk could serve to reduce economic burden on health care systems and improve quality of life for patients. An approach integrating psychoeducation, CBT, graduated physical activity, and cognitive rehabilitation may be effective. However, future research is needed to better understand the most effective approach to PCS and PTSD prevention (Al Sayegh et al., 2010; Broshek et al., 2015; Caplain et al., 2019; Nygren-de Boussard et al., 2014; Silverberg et al., 2013).
     
  4. Evaluate, evaluate, evaluate! Prevention of PCS and PTSD is an emerging area of research. Evaluation of PCS risk-screening tools and interventions aimed at prevention is needed to ensure that prevention approaches are being delivered effectively for different levels of risk. Evaluation of PCS prevention efforts should also include other psychological and health outcomes that may benefit from prevention interventions, such as health-related quality of life and perceptions around mTBI and recovery.

About the Author

Emmeline N. Taylor, BS, is a third-year clinical psychology doctorate student with an emphasis in trauma at the University of Colorado Colorado Springs. She works in collaboration with the Lyda Hill Institute for Human Resilience as a graduate research assistant and student clinician in a Level 1 Trauma Center. Emmeline’s research interests include intervention implementation, the role of emotion regulation in trauma recovery, and how complex systems strategies can help the field better understand the phenomena of resilience, co-occurring conditions, and trauma recovery. She also works part-time as a remote research assistant for the U.S. Department of Veterans Affairs Palo Alto’s Center for Innovation to Implementation. Please note that the opinions expressed in this piece are my own and do not necessarily reflect the positions of the University of Colorado Colorado Springs nor the U.S. Department of Veterans Affairs.

References

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