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Article 10 Cognitive-Behavioral Prevention of Post-Concussion Syndrome in At-Risk Patients: A Pilot Randomized Controlled Trial
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2012 ACRM–ASNR Annual Conference Abstracts
(University of Washington, Seattle, WA), Jeanne M. Hoffman, Sylvia Lucas, Sureyya Dikmen, Kathleen R. Bell. Disclosure: None disclosed. Objective: Examine neuroimaging abnormalities and association with headache characteristics after traumatic brain injury (TBI). Design: Prospective Observational Study. Setting: Inpatient rehabilitation (IR) and post discharge. Participants: 452 consecutive patients with TBI admitted to 7 TBI Model Systems IR units between February 2008 and June 2009. Interventions: Not applicable. Main Outcome Measures: Structured headache interview at IR, 3, 6 and 12 months post TBI. Acute injury head CT (computed tomography) inventoried for 10 abnormalities (focal cortical/parenchymal contusion, focal non-cortical contusion, intraventricular hemorrhage (IVH), subarachnoid hemorrhage, skull, facial, or spine fracture, extra-axial hematoma/hygroma (fluid), cistern compression/midline shift ⬎5mm. Imaging abnormalities at time of injury, early headache severity, and persistent headache (at 3, 6 and 12 months post-TBI). Results: IVH was the most frequent abnormality (70%) on CT scans followed by focal contusions and extra-axial fluid (both 60%). While skull fracture was less frequent (N⫽175), 41% of these subjects reported moderate to severe headache during IR. Those with mid-line shift (38%) and/or extra-axial fluid (34%) also reported higher rates of moderate to severe headache at IR. Complete headache information at all time points was available for 273 subjects and sixty-three (30%) of those had headache at all time points. Of those with complete headache information, 32% with midline shift and 32% with skull fracture had persistent headaches at all time points. Conclusions: Early moderate to severe headache was associated with skull fracture, as well as mid-line shift, and extra-axial fluid. Persistent headache was associated with midline shift and skull fracture. Further analysis of relationship between neuroimaging and headache is warranted. Key Words: Brain injury; Health and wellness; Epidemiology; Outcomes research; Rehabilitation.
Arch Phys Med Rehabil Vol 93, October 2012
Article 10 Cognitive-Behavioral Prevention of Post-Concussion Syndrome in At-Risk Patients: A Pilot Randomized Controlled Trial. Noah Silverberg (Vancouver Coastal Health, Vancouver, BC, Canada). Disclosure: None disclosed. Objective: To examine the tolerability and estimate the treatment effect of early cognitive-behavioral therapy (CBT) for patients who are at risk for poor outcome from mild traumatic brain injury (MTBI). Design: Open label randomized controlled trial with blinded assessor. Setting: Concussion clinic in a tertiary rehabilitation center. Participants: Of consecutive referrals, 28 patients with uncomplicated MTBI were at-risk for poor outcome based on a published algorithm that incorporates post-concussion symptoms and illness beliefs (recovery expectations and perceived consequences). Participants were enrolled within six weeks post-injury. Four participants (2:2) withdrew. Interventions: The control group received standard care – education, reassurance, and symptom management strategies. The experimental group received standard care plus a six-session CBT protocol designed to target modifiable risk factors for poor MTBI outcome. Main Outcome Measures: Rivermead Post Concussion Symptoms Questionnaire (primary), modified Illness Perception Questionnaire (secondary). Results: ANCOVA revealed a moderate intervention effect on postconcussion symptom reporting at three-month follow-up (Cohen’s d ⫽ 0.68, p ⫽ 0.11), controlling for baseline differences on this variable. Compared to the standard care only group, participants in the standard care ⫹ CBT group also developed more optimistic expectations for recovery, perceived less threatening consequences from MTBI, attributed fewer symptoms to MTBI, rated higher personal control over symptoms, and reported less emotional distress at follow-up (d ⫽ 0.80 to 1.67, all p ⬍ .10). Conclusions: Our preliminary data suggests that early CBT is well-tolerated and may modify the recovery trajectory from MTBI in patients who are at-risk for poor outcome. A definitive clinical trial is warranted. Key Words: Brain injury; Concussion; Mental health; Clinical practice; Rehabilitation.
2012 ACRM–ASNR Annual Conference Abstracts
(University of Washington, Seattle, WA), Jeanne M. Hoffman, Sylvia Lucas, Sureyya Dikmen, Kathleen R. Bell. Disclosure: None disclosed. Objective: Examine neuroimaging abnormalities and association with headache characteristics after traumatic brain injury (TBI). Design: Prospective Observational Study. Setting: Inpatient rehabilitation (IR) and post discharge. Participants: 452 consecutive patients with TBI admitted to 7 TBI Model Systems IR units between February 2008 and June 2009. Interventions: Not applicable. Main Outcome Measures: Structured headache interview at IR, 3, 6 and 12 months post TBI. Acute injury head CT (computed tomography) inventoried for 10 abnormalities (focal cortical/parenchymal contusion, focal non-cortical contusion, intraventricular hemorrhage (IVH), subarachnoid hemorrhage, skull, facial, or spine fracture, extra-axial hematoma/hygroma (fluid), cistern compression/midline shift ⬎5mm. Imaging abnormalities at time of injury, early headache severity, and persistent headache (at 3, 6 and 12 months post-TBI). Results: IVH was the most frequent abnormality (70%) on CT scans followed by focal contusions and extra-axial fluid (both 60%). While skull fracture was less frequent (N⫽175), 41% of these subjects reported moderate to severe headache during IR. Those with mid-line shift (38%) and/or extra-axial fluid (34%) also reported higher rates of moderate to severe headache at IR. Complete headache information at all time points was available for 273 subjects and sixty-three (30%) of those had headache at all time points. Of those with complete headache information, 32% with midline shift and 32% with skull fracture had persistent headaches at all time points. Conclusions: Early moderate to severe headache was associated with skull fracture, as well as mid-line shift, and extra-axial fluid. Persistent headache was associated with midline shift and skull fracture. Further analysis of relationship between neuroimaging and headache is warranted. Key Words: Brain injury; Health and wellness; Epidemiology; Outcomes research; Rehabilitation.
Arch Phys Med Rehabil Vol 93, October 2012
Article 10 Cognitive-Behavioral Prevention of Post-Concussion Syndrome in At-Risk Patients: A Pilot Randomized Controlled Trial. Noah Silverberg (Vancouver Coastal Health, Vancouver, BC, Canada). Disclosure: None disclosed. Objective: To examine the tolerability and estimate the treatment effect of early cognitive-behavioral therapy (CBT) for patients who are at risk for poor outcome from mild traumatic brain injury (MTBI). Design: Open label randomized controlled trial with blinded assessor. Setting: Concussion clinic in a tertiary rehabilitation center. Participants: Of consecutive referrals, 28 patients with uncomplicated MTBI were at-risk for poor outcome based on a published algorithm that incorporates post-concussion symptoms and illness beliefs (recovery expectations and perceived consequences). Participants were enrolled within six weeks post-injury. Four participants (2:2) withdrew. Interventions: The control group received standard care – education, reassurance, and symptom management strategies. The experimental group received standard care plus a six-session CBT protocol designed to target modifiable risk factors for poor MTBI outcome. Main Outcome Measures: Rivermead Post Concussion Symptoms Questionnaire (primary), modified Illness Perception Questionnaire (secondary). Results: ANCOVA revealed a moderate intervention effect on postconcussion symptom reporting at three-month follow-up (Cohen’s d ⫽ 0.68, p ⫽ 0.11), controlling for baseline differences on this variable. Compared to the standard care only group, participants in the standard care ⫹ CBT group also developed more optimistic expectations for recovery, perceived less threatening consequences from MTBI, attributed fewer symptoms to MTBI, rated higher personal control over symptoms, and reported less emotional distress at follow-up (d ⫽ 0.80 to 1.67, all p ⬍ .10). Conclusions: Our preliminary data suggests that early CBT is well-tolerated and may modify the recovery trajectory from MTBI in patients who are at-risk for poor outcome. A definitive clinical trial is warranted. Key Words: Brain injury; Concussion; Mental health; Clinical practice; Rehabilitation.