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Invited Commentary
Emergency Medicine
May 25, 2018

Mild Traumatic Brain Injury: A Clarion Call for Care of the Postconcussive Spectrum

Author Affiliations
  • 1Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, Boston
  • 2Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
JAMA Netw Open. 2018;1(1):e180211. doi:10.1001/jamanetworkopen.2018.0211

Although a large portion of those with so-called mild injury recover in the period proximal to their injury, a significant portion do not.1 While recent media has focused on the important issue of repetitive brain injury among professional athletes, the cohort of individuals with mild traumatic brain injury (mTBI) who have been evaluated in the emergency department remains underappreciated.

The concept that all will be well in everyone is likely naive. In this important longitudinal survey study by Seabury et al,2 we learn of the stunning lack of follow-up care for those with mTBI, even those with significant postconcussive symptoms or positive results on computed tomographic neuroimaging. It should be noted that this cohort represented a potentially more severe part of the spectrum of mTBI, those with enough clinical concern to be evaluated in the emergency department and to require computed tomographic neuroimaging. Despite this, the authors report that fewer than half of the patients received educational materials or saw a clinician in follow-up. The study also illustrates the wide variability in care for such patients even in recognized academic centers of excellence.

While postconcussive symptoms may be best described as a spectrum rather than a defined syndrome, they nonetheless produce a constellation of clinical challenges that are often difficult to treat and can result in longer-lasting symptoms.1 A critical factor to appreciate is that time lost for those who may remain symptomatic may be of consequence. In a study by Hiploylee et al3 that excluded those with symptom amplification and potential secondary gain, few persons with chronic symptoms recovered within 1 year and no patients with postconcussion syndrome lasting at least 3 years had permanent recovery. It appears likely that a series of biopsychosocial issues contribute to the heterogenic phenotype that produces the persistent postconcussive spectrum of symptoms.4 Such factors could be premorbid psychologic status, cognitive reserve, prior injury pattern, genetics, sex, and care path, all of which have some support in the literature. The TRACK-TBI study by Seabury and colleagues2 has begun the process of biologically phenotyping those with a broad spectrum of TBI severity. This large study has sought to characterize the heterogeneity of the injury pattern as well as define the premorbid and postmorbid issues associated with outcome.

Expectations often influence reality in such cases. Without education and follow-up, the role of social isolation, misinformation, and nocebo-based responses could become significant.5 Prior work has suggested that preinjury depression and resilience may be associated with symptom manifestation for those with mTBI.6

In this population, early education and symptom-based treatment may be the best approach.7 For example, a recent study has suggested that an aggressive program of rest may not be helpful, and there is some evidence that activity-based therapies addressing symptom complexes offer benefit.8,9 In addition, multidisciplinary care seems to shine as a theme toward success.

While Seabury and colleagues did not find insurance-based bias to care, the clinical reality is that required follow-up and multidisciplinary care programs are often regionally specific in their ability to address the needs of such patients in an economically prudent manner.

Limitations of this study include the small sample size, the heterogeneity of the sites, and the lack of multiyear longitudinal follow-up. Thus, the benefits of follow-up care and education on outcomes can only be inferred. The lack of cost data is also a limitation and is inherently difficult to investigate in studies based in the United States. In the era of value-based medicine, the comorbid costs of mTBI should be considered and evaluated. Early education and symptom-based interventions may mitigate costly secondary comorbid issues, and they deserve further clinical and economic evaluation.

Despite these limitations, this work is an important notation for next steps in understanding care needs and defining the phenotype of individuals who would most benefit from further education and integrated medical care. Future work will be served by approaches that study individuals who are ill and those who are well, defining specific biopsychosocial links to their phenotypic characteristics and furthering the understanding of long-term implications of mTBI.10 In this manner, we may better define individuals at greatest risk and use meaningful strategies to mitigate injury symptoms and foster recovery.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Iaccarino M. JAMA Network Open.

Corresponding Author: Mary Iaccarino, MD, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Massachusetts General Hospital, 300 First Ave, Charlestown, MA 02129 (miaccarino@partners.org).

Conflict of Interest Disclosures: None reported.

References
1.
McMahon  P, Hricik  A, Yue  JK,  et al; TRACK-TBI Investigators.  Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study.  J Neurotrauma. 2014;31(1):26-33. doi:10.1089/neu.2013.2984PubMedGoogle ScholarCrossref
2.
Seabury  SA, Guadette  É, Goldman  DP,  et al; TRACK-TBI Investigators.  Assessment of follow-up care after emergency department presentation for mild traumatic brain injury and concussion: results from the TRACK-TBI study.  JAMA Netw Open. 2018;1(1):e180210. doi:10.1001/jamanetworkopen.2018.0210Google ScholarCrossref
3.
Hiploylee  C, Dufort  PA, Davis  HS,  et al.  Longitudinal study of postconcussion syndrome: not everyone recovers.  J Neurotrauma. 2017;34(8):1511-1523. doi:10.1089/neu.2016.4677PubMedGoogle ScholarCrossref
4.
Iverson  GL, Silverberg  ND, Mannix  R,  et al.  Factors associated with concussion-like symptom reporting in high school athletes.  JAMA Pediatr. 2015;169(12):1132-1140. doi:10.1001/jamapediatrics.2015.2374PubMedGoogle ScholarCrossref
5.
Polich  G, Iaccarino  MA, Kaptchuk  TJ, Morales-Quezada  L, Zafonte  R.  Placebo effects in traumatic brain injury  [published online January 17, 2018].  J Neurotrauma. doi:10.1089/neu.2017.5506PubMedGoogle Scholar
6.
Marwitz  JH, Sima  AP, Kreutzer  JS,  et al.  Longitudinal examination of resilience after traumatic brain injury: a traumatic brain injury model systems study.  Arch Phys Med Rehabil. 2018;99(2):264-271. doi:10.1016/j.apmr.2017.06.013PubMedGoogle ScholarCrossref
7.
Ponsford  J, Willmott  C, Rothwell  A,  et al.  Impact of early intervention on outcome after mild traumatic brain injury in children.  Pediatrics. 2001;108(6):1297-1303.PubMedGoogle ScholarCrossref
8.
Thomas  DG, Apps  JN, Hoffmann  RG, McCrea  M, Hammeke  T.  Benefits of strict rest after acute concussion: a randomized controlled trial.  Pediatrics. 2015;135(2):213-223. doi:10.1542/peds.2014-0966PubMedGoogle ScholarCrossref
9.
Schneider  KJ, Leddy  JJ, Guskiewicz  KM,  et al.  Rest and treatment/rehabilitation following sport-related concussion: a systematic review.  Br J Sports Med. 2017;51(12):930-934. doi:10.1136/bjsports-2016-097475PubMedGoogle ScholarCrossref
10.
Zafonte  RD.  Traumatic brain injury: an enduring challenge.  Lancet Neurol. 2017;16(10):766-768. doi:10.1016/S1474-4422(17)30300-9PubMedGoogle ScholarCrossref
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