doi: 10.1176/jnp.6.1.15, 24. Illness perceptions and outcome in mild head injury: a longitudinal study. The recent clinical practice guidelines for mild traumatic brain injury supports multi-modal rehabilitation10,11 and physical therapy models of care for protracted concussion recovery have included cervical dysfunction and vestibular-ocular care and exertional activity without specific intervention sequence.40 The results of this study suggest that the intervention sequence27 addressing cervical dysfunction and BPPV within the three weeks post-injury before initiating vision and vestibular rehabilitation at more than three weeks post-injury may yield positive outcomes. (2001) 189:54851. See Table 2. New York, NY: Demos Medical Publishing (2012). Med Exp Int J Exp Med. Many have suggested that the etiology of persistent symptoms is due to the biological effects of a MTBI, psychological factors, psychosocial factors (broadly defined), chronic pain, depression, or a combination of factors (2230). Am J Psychiatry. Arlington, VA: American Psychiatric Publishing (2013). Developing exercise tolerance thereafter would precede a return to sport.40 In total, the inter-relationships among the musculoskeletal, vision and vestibular systems, with respect to both function and treatment, make screening for and addressing cervical dysfunction a logical first step even before the three-week post-injury timeframe for starting vision and vestibular rehabilitation. However, this term has been the subject of debate since the . Neuropsychological complaint base rates of 170 personal injury claimants. doi: 10.1177/1948550617709827, 103. Pre-injury mental health problems, such as depression and anxiety, are a risk factor for persistent symptoms following MTBI (21, 36, 109112). National Library of Medicine Near point of convergence after a sport-related concussion: Measurement reliability and relationship to neurocognitive impairment and symptoms. doi: 10.1371/journal.pone.0060188, 98. Mild traumatic brain injury (mTBI), commonly called concussion, affects millions of Americans each year. doi: 10.1016/0020-1383(81)90161-3, 33. FOIA (2018) 9:1113. doi: 10.3389/fneur.2018.01113, 20. The average number of sessions addressing cervical dysfunction was 4.03.8, vision and vestibular dysfunction 4.83.0, and combined symptoms 1.70.8. (2005) 193:54050. Injury. (2015) 72:121926. Kenzie ES, Parks EL, Bigler ED, Lim MM, Chesnutt JC, Wakeland W. Concussion as a multi-scale complex system: an interdisciplinary synthesis of current knowledge. Symptom centrality is an important concept in the network analysis. The authors have no conflicts to disclose. Bay E, de-Leon MB. Kristman VL, Cote P, Yang X, Hogg-Johnson S, Vidmar M, Rezai M. Health care utilization of workers' compensation claimants associated with mild traumatic brain injury: a historical population-based cohort study of workers injured in 19971998. Adaptive Personality Characteristics: resilience, grit (passion and perseverance toward long-term goals), and psychological hardiness (personality characteristic consisting of three psychological attitudes and beliefs: commitment, challenge, and control). (2018) 227:31322. doi: 10.1016/j.janxdis.2016.11.008, 154. 2004 Oct. 35(4):198-209. Cramer AO, Waldorp LJ, van der Maas HL, Borsboom D. Comorbidity: a network perspective. Common post-concussion symptoms include: Headache and sometimes neck pain. Mittenberg W, DiGiulio DV, Perrin S, Bass AE. It has long been believed by some researchers that no central underlying disease mechanism for the post-concussion syndrome has ever been found because it does not exist. government site. Ericsson M, Poston WS, Linder J, Taylor JE, Haddock CK, Foreyt JP. J Neurotrauma. Accessibility doi: 10.1093/arclin/13.5.415, 46. This involves three basic steps: 3. Symptoms can be causally connected through diverse biopsychosocial mechanisms. PTSD and Mild Traumatic Brain Injury. (2006) 26:2632. (2002) 7:1206. (1993) 16:1617. Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence. Bristol, PA: Swets & Zeitlinger (1999). Price M, Legrand AC, Brier ZMF, Hebert-Dufresne L. The symptoms at the center: examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Brain Inj. Arch Clin Neuropsychol. Cao X, Wang L, Cao C, Fang R, Chen C, Hall BJ, et al. (2002) 24:33440. In many cases, the therapies described are off-label. Silverberg ND, Iverson GL. Federal government websites often end in .gov or .mil. J Neurotrauma. Eur J Neurol. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. doi: 10.1111/acer.13914, 109. Postconcussional symptoms in chronic back pain. Bexander CSM, Hodges PW. The results of this retrospective cohort study showed that patients receiving physical therapy, consisting of manual therapy and exercise for cervical dysfunction and BPPV in the first three weeks post-concussion followed by vision and vestibular rehabilitation therapy beyond three weeks post injury, demonstrated clinical and patient-reported benefits in multiple systems. Pediatrics. King NS, Kirwilliam S. Permanent post-concussion symptoms after mild head injury. 157. Cramer AO, Borsboom D, Aggen SH, Kendler KS. Iverson GL, McCracken LM. The usefulness of quantitative EEG (QEEG) and neurotherapy in the assessment and treatment of post-concussion syndrome. Reid MW, Cooper DB, Lu LH, Iverson GL, Kennedy JE. (1992) 17:12731. doi: 10.1227/NEU.0000000000001447, Keywords: concussion, traumatic brain injury, rehabilitation, post-concussional syndrome, depression, Citation: Iverson GL (2019) Network Analysis and Precision Rehabilitation for the Post-concussion Syndrome. Examination of postconcussion-like symptoms in a healthy sample. It is a complication of concussion. The controversial post-concussion syndrome. This content does not have an English version. 83. (2016) 7:156. doi: 10.3389/fneur.2016.00156, 168. Intention to change drinking behaviour in general practice patients with problematic drinking and comorbid depression or anxiety. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, J Child Psychol Psychiatry. This injury can lead to short- or long-term problems affecting how a person thinks, acts, and feels. J Neurosurg Pediatr. Larrabee GJ. doi: 10.1007/s12529-018-9754-8, 146. Anderson JFI, Fitzgerald P. Associations between coping style, illness perceptions and self-reported symptoms after mild traumatic brain injury in prospectively studied pre-morbidly healthy individuals. Identify treatments of concussion and approach differences when tr. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). (2000) 15:18. Sullivan CP, Smith AJ, Lewis M, Jones RT. An official website of the United States government. Boschloo L, Schoevers RA, van Borkulo CD, Borsboom D, Oldehinkel AJ. ROM was either normal, denoted in the clinical notes as normal, within normal or within functional limits, or limited, defined as any limitation recorded in degrees, percentage, or qualitative term. Brain Injury. Varatharajan S, Ferguson B, Chrobak K, et al. World Health Organization. Drinking water helps the brain, too. Problems with concentration, attention, memory, and cognition (thinking) (2017) 16:513. (1996) 153:710. Major depression and insomnia in chronic pain. For example, medications have had minimal success (20%), and in many cases (up to 35%) have exacerbated the primary symptom of visual snow [ 4 ]. Before doi: 10.1097/HTR.0b013e3181e50ef1, 149. Youngjohn JR, Burrows L, Erdal K. Brain damage or compensation neurosis? doi: 10.3109/02699052.2011.635352, 152. It is essential to appreciate that these diverse symptoms and problems occur within a personal biopsychosocial context, as seen in Figure 1. A network analysis of depressive symptoms in individuals seeking treatment for chronic pain. Am J Phys Med Rehabil. doi: 10.1037/abn0000150, 104. The concept of critical slowing is applicable to a pathway by which a person might develop persistent symptoms following an MTBI. doi: 10.1080/02699052.2017.1366551. After 10.44.8 sessions over 57.634.0 days, general symptoms improved on the PCSS (p=0.001, 95%CI=12.4-30.6); and specific symptoms on the DHI (p<0.001, 95%CI=14.5-33.2), CISS (p<0.002, 95%CI=7.1-18.3), ABC (p<0.024, 95%CI=-.3 - -.1), and BIVSS (p<0.001, 95%CI=13.4-28.0). Russell JD, Neill EL, Carrion VG, Weems CF. Patients received treatment integrating cervical, vision and vestibular dysfunction as indicated by individual impairment and determined pragmatically by the trained concussion clinic treatment specialist, as previously outlined in a treatment algorithm.27 Patients evaluated within the three-week post-injury recovery window began treatment for cervical dysfunction and symptoms. diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of mTBI/concussion. 66. Moreover, post-injury worry, stress, and anxiety are thought to be central features of long-term symptom reporting (17, 27, 41, 61). Wijenberg MLM, Stapert SZ, Verbunt JA, Ponsford JL, Van Heugten CM. Deidentified coded data was received for analysis from the participating concussion clinic in accordance with the protocol approved by the Columbia University Irving Medical Center Institutional Review Board of the participating University Medical Center. Gunstad J, Suhr JA. doi: 10.1097/00001199-199510030-00002. Additional vestibular screening assessments included vestibular ocular reflex, visual motion sensitivity and the Balance Error Scoring System (BESS), which has been shown to be a reliable measure in athletes post-concussion.21. J Am Acad Child Adolesc Psychiatry. Bryant RA, Creamer M, O'Donnell M, Forbes D, McFarlane AC, Silove D, et al. The replicability of ICD-11 complex post-traumatic stress disorder symptom networks in adults. This is an open access article distributed under the terms of the, vestibular rehabilitation, vision therapy, manual therapy, cervicogenic headache, concussion. doi: 10.1016/j.jad.2016.02.001, 147. van de Leemput IA, Wichers M, Cramer AO, Borsboom D, Tuerlinckx F, Kuppens P, et al. Headache. Borsboom D, Rhemtulla M, Cramer AO, van der Maas HL, Scheffer M, Dolan CV. Bethesda, MD 20894, Web Policies He has a clinical practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including athletes). Patients with missing re-evaluation data could not be included in the pre-post analysis, thus although effect size changes were large, results should be viewed with caution given unknown outcomes in at least 35.6%. Patient-reported outcomes included five scales that collectively provide insight on the potential symptoms that stem from deficits in the cervical spine, vestibular and visual systems.2226 The Post-Concussion Symptom Scale (PCSS) assesses general post-concussion symptoms with specific symptom indices for associated sequelae including headache, with variable reliability for the different indices.22 The Dizziness Handicap Inventory (DHI) assesses the impact of dizziness on functional, emotional, and physical quality of life with excellent reliability and internal consistency.23 Visual impairment was assessed with the Convergence Insufficiency Symptom Survey (CISS), which has excellent reliability,24 and the Acquired Traumatic Brain Injury Vision Symptom Questionnaire, since adapted and renamed the Brain Injury Vision Symptom Survey (BIVSS).25 Finally, the Activities-specific Balance Confidence (ABC) scale assesses individual sense of balance and correlates with cognitive measures after concussion.26 See Table 2. (2017) 33:899904. McWilliams LA, Sarty G, Kowal J, Wilson KG. Greene T, Gelkopf M, Epskamp S, Fried E. Dynamic networks of PTSD symptoms during conflict. Received 2020 Feb 29; Accepted 2021 Jul 24. (2000) 15:110312. Campbell LC, Clauw DJ, Keefe FJ. Iverson GL, Silverberg ND, Mannix R, Maxwell BA, Atkins JE, Zafonte R, et al. This is a tricky balance to achieve and usually requires advice from a concussion therapist. (2004) 291:188796. Careers, Unable to load your collection due to an error. J Clin Exp Neuropsychol. The average time from injury to initial evaluation was 31.6 50.4 days, with 17 reporting protracted symptoms beyond 21 days. Arch Clin Neuropsychol. (2018) 10:5866. It is believed that better understanding of which symptoms of traumatic stress are more central and strongly interconnected than others may have implications for targeting clinical interventions. In post-concussion syndrome (PCS), a patient with a mild traumatic brain injury (mTBI) experiences persistent symptoms from the injury. Brain Injury. Delis DC, Wetter SR. Cogniform disorder and cogniform condition: proposed diagnoses for excessive cognitive symptoms. 26. In theory, and of particular relevance to sequenced care following MTBI, targeting one or two symptoms with a high degree of strength of centrality might dampen or even ameliorate other symptoms in the acute or subacute period following injury, potentially preventing entrenchment and persistence of symptoms. 40. Frisher M, Crome I, Macleod J, Millson D, Croft P. Substance misuse and psychiatric illness: prospective observational study using the general practice research database. Columbia University Irving Medical Center, 2 Post concussion syndrome is where the symptoms related to a concussion have persisted past the initial 7-10 day period of time. (2014) 31:2633. doi: 10.1007/s00127-016-1319-z, 96. J Neurol Neurosurg Psychiatry. (2018) 48:240917. (2004) 11:4119. Rates of symptom reporting following traumatic brain injury. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: A multicenter randomized clinical trial. Iverson GL. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. (2018) doi: 10.1080/09602011.2018.1556706. J Psychosom Res. Br J Psychiatry. Major depression as a complex dynamic system. An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. As such, an individual's symptoms and problems (from Figure 1) occur within a unique personal context. Iverson GL, Silverberg N, Lange RT, Zasler N. Conceptualizing outcome from mild traumatic brain injury. While clinical practice guidelines outline treatments to address the symptoms that arise from the multiple involved systems, no preferred treatment sequence for post-concussion syndrome has emerged. Symptoms can form amplification and self-sustaining feedback loops. A network of symptoms is represented graphically, in a two-dimensional figure, by having circles representing symptoms and lines connecting circles representing the association (i.e., correlation) between the symptoms. The nocebo phenomenon: concept, evidence, and implications for public health. J Int Neuropsychol Soc. In fact, network analysis has been used to simultaneously study 12 major psychiatric diagnoses in a sample of more than 34,000 adults, with the resulting network illustrating differential associations between symptoms within the same diagnosis and strong connections with symptoms from other diagnoses, illuminating the complexity of psychopathology and psychiatric comorbidity (100). Arch Phys Med Rehabil. doi: 10.1093/alcalc/agh182, 129. p. 47097. J Head Trauma Rehabil. Park City Hospital, Intermountain Healthcare, 3 J Anxiety Disord. (1995) 9:8992. (2004) 18:113553. (1991) 45:11121. Wood RL. In this systematic review, the authors aimed to evaluate the potential efficacy of cognitive behavioural . Brain Injury. For the 5th Edition (i.e., the DSM-5), published in 2013 (43), the post-concussional disorder was dropped and problems relating to MTBI can be coded as mild neurocognitive disorder, but this diagnosis does not include post-concussion symptomsit is based on objective evidence of a decline in cognitive functioning. Brain Injury. (2016) 11:e0167490. Traumatic stress is fairly common in both civilians and military personnel who sustain MTBIs (148, 149). A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. Dizziness. It might also help us better understand complex comorbidities, such as depression, anxiety, PTSD, chronic pain, peripheral vestibular problems, and substance abuse, how they are inter-related, and how they might bridge and amplify post-concussion-like symptoms. Pain Res Manag. doi: 10.1080/13854049508401593, 27. (2017) 34:21416. Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis. doi: 10.1111/j.1468-2982.2005.00985.x, 121. Numbness or tingling in arms or legs. doi: 10.1207/S15324826AN1003_02, 47. Soc Psychiatry Psychiatr Epidemiol. doi: 10.1097/HTR.0b013e3181fc5e1e, 70. Relationship between cognitive assessment and balance measures in adolescents referred for vestibular physical therapy after concussion. Brain Inj. Hoorelbeke K, Marchetti I, De Schryver M, Koster EH. (2005) 20:23956. Cervicovestibular rehabilitation in sport-related concussion: A randomised controlled trial. [Epub ahead of print]. Management of concussion and PPCS relies on identifying underlying symptom generators. Pain. Demographic, medical, and psychiatric factors in work and marital status after mild head injury. Persistent post-traumatic headache, postconcussion syndrome, and whiplash injuries: the evidence for a non-traumatic basis with an historical review. These graphic depictions arise from statistical psychometric analyses of large databases, not from theory. Background and aim: Postconcussion syndrome (PCS) is a term used to describe the complex, and controversial, constellation of physical, cognitive and emotional symptoms associated with mild brain injury. Non-hospitalized patients with mild traumatic brain injury: the forgotten minority. doi: 10.1017/S003329171100211X, 140. He has received honorariums for serving on research panels that provide scientific peer review of programs. 29. Miserable minority: emotional risk factors that influence the outcome of a mild traumatic brain injury. Arch Clin Neuropsychol. (1997) 11:7919. (2010) 25:44250. Psychol Assessment. However, none have emerged as a latent common cause, and most in the field accept that post-concussion symptoms are multifactorial in causation. As seen in Figure 1, a diverse array of physical, psychological, and cognitive symptoms and problems can be amplifying and mutually reinforcing in people who have experienced a mild TBI. (2019) 36:5548. Posttraumatic stress disorder in the National Comorbidity Survey. Dunning JR, Cleland JA, Waldrop MA, et al. Sullivan MJ, Hall E, Bartolacci R, Sullivan ME, Adams H. Perceived cognitive deficits, emotional distress and disability following whiplash injury. Clinical measure of abnormal saccades did not change for patients post-treatment, consistent with past research.35 Missing data precluded analysis of other visual deficits common after minor traumatic brain injury such as smooth pursuits, and eye alignment.16 Also consistent with previous findings, patient-reported outcomes for vision symptoms improved significantly on the CISS and BIVSS.25,34,36 The oculomotor and vestibular systems are highly interconnected with integrated roles in maintaining balance, postural control and gaze stabilization,16 and patients exhibited benefits in both systems. PLoS ONE. 7 Headache is the most common postconcussion symptom, with a prevalence of 86% to 96%. Response bias in plaintiffs' histories. Iverson GL, Lange RT, Brooks BL, Rennison VL. doi: 10.1080/01688638608401325, 23. Brown SJ, Fann JR, Grant I. Postconcussional disorder: time to acknowledge a common source of neurobehavioral morbidity. Ruff RM, Camenzuli L, Mueller J. Curr Opin Psychiatry. To minimize variation among different clinicians for patients who had limited cervical ROM at the initial evaluation, the cervical ROM measure was reduced for analysis in this study to a simple dichotomous outcome. Bartels L, Berliner L, Holt T, Jensen T, Jungbluth N, Plener P, et al. A network analysis of DSM-5 posttraumatic stress disorder symptoms and correlates in U.S. military veterans. Iverson GL. Eur J Neurol. J Clin Psychol. Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from iraq. Neuropsychology. Franklin CL, Zimmerman M. Posttraumatic stress disorder and major depressive disorder: investigating the role of overlapping symptoms in diagnostic comorbidity. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Iverson GL, Terry DP, Karr JE, Panenka WJ, Silverberg ND. Central symptoms are those that are most important in the network, and there are several was to measure centrality including the degree, strength, expected influence, closeness, and betweenness. Musculoskeletal, vision, and vestibular system functions were assessed after pragmatic treatment including early cervical manual therapy and canalith repositioning treatmentwhen indicatedintegrated with advanced vision and vestibular rehabilitation. Most subjects regained full cervical ROM by re-evaluation, though data for some patients was missing, the measurement method was unreported, and the definition for full ROM can vary.7 Direct comparison of the study results with past reports that have shown that manual therapies improve cervical ROM with thrust or mobilization with movement31,32 was not possible because the retrospective data did not include specific manual techniques. Specific sport involvement was not consistently recorded, although at least 10 concussions were due to skiing; and return to sport outcomes were not available. Persistent post-concussive symptoms (Post-concussion syndrome) - Diagnosis and treatment - Mayo Clinic Find out what to do when symptoms such as headache, fatigue and dizziness last longer than expected after an injury causes a concussion. Geneva: World Health Organization (1992). (2014) 111:8792. Improved cervical dysfunction such as limited ROM and headache following head injury, as well as other causes of post-concussion symptoms, can be contributed to by concomitant whiplash injury suffered at the time of the concussion.16 Changes in neck muscle activity during cervical rotation and cervico-ocular coordination may underlie clinical symptoms reported by people with visual deficits and changes in function, such as postural control, during cervical rotation.17 Regardless, whether cervicogenic headaches include pain, dizziness, and/or oculomotor dysfunction,8 restoring cervical ROM may well be one factor affecting multiple systems.31 Findings in the current study for the musculoskeletal, vision, and vestibular systems were consistent with past literature for select recommendation of the most recent clinical practice guidelines.10,11. Table 1. Patient-reported outcomes included the Post-Concussion Symptom Scale (PCSS) for general symptoms; and for specific symptoms, the Dizziness Handicap Index (DHI), Convergence Insufficiency Symptom Scale (CISS), Activities-specific Balance Confidence scale (ABC), and the Brain Injury Vision Symptom Survey (BIVSS). official website and that any information you provide is encrypted A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. Dunn JT, Lees-Haley PR, Brown RS, Williams CW, English LT. Neurotoxic complaint base rates of personal injury claimants: implications for neuropsychological assessment. (2016) 66:e1623. INTRODUCTION Postconcussion syndrome (PCS) is a common sequelae of traumatic brain injury (TBI) and describes a symptom complex that includes headache, dizziness, neuropsychiatric symptoms, and cognitive impairment [ 1 ]. (1995) doi: 10.1002/1097-4679(199507)51:4<;577::AID-JCLP2270510418>3.0.CO;2-E, 55. Evans RW. (2011) 25:46270. The network structure of psychopathology in a community sample of preadolescents. Psychol Methods. (2009) 24:34454. Paired t-tests with Bonferroni correction to minimize familywise error (p<0.05) were used to analyze the clinical and patient-reported outcomes. Soc Psychol Personal Sci. Hung CI, Liu CY, Fuh JL, Juang YY, Wang SJ. doi: 10.1016/j.jpsychores.2007.06.023, 91. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. doi: 10.1037/met0000167, 102. A network analysis of anger, shame, proposed ICD-11 post-traumatic stress disorder, and different types of childhood trauma in foster care settings in a sample of adult survivors. Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Patients with PCS can experience concussion-like symptoms in response to too much physical activity, screen time, or focus/attention, often impacting their ability to work or study. Psychol Med. A network, graphically represented, is comprised of nodes and edges. (1988) 153:4609. Neuropsychological outcome, post concussion symptoms, and forensic considerations in mild closed head trauma. Prev Med. Afzali MH, Sunderland M, Batterham PJ, Carragher N, Calear A, Slade T. Network approach to the symptom-level association between alcohol use disorder and posttraumatic stress disorder. Argaet EC, Bradshaw AP, Welgampola MS. Benign positional vertigo, its diagnosis, treatment and mimics. Post concussion syndrome. Tinnitus. 65. Clin EEG Neurosci. Diagnostic and Statistical Manual of Mental Disorders. It is well established in psychiatry that depression and anxiety are comorbid in many people (140), and cross-sectional network analysis studies have illustrated how major depressive disorder and generalized anxiety disorder are interconnected, entangled, and amplifying (141143). Arch Clin Neuropsychol. Boschloo L, van Borkulo CD, Rhemtulla M, Keyes KM, Borsboom D, Schoevers RA. Diagnostic and Statistical Manual of Mental Disorders. 84. Semin Clin Neuropsychiatry. Rutherford WH, Merrett JD, McDonald JR. (1998) 155:6307. Physical therapy evaluation and treatment after concussion/mild traumatic brain injury. J Neurotrauma. doi: 10.1080/02699050701209980, 92. 17 Articles, This article is part of the Research Topic, Network Analysis and Persistent Post-Concussion Symptoms, Network Analysis in Psychiatry and Psychology, Conclusions and Directions for Future Research, Creative Commons Attribution License (CC BY). Clin J Pain. Post-concussion syndrome is a collection of symptoms that some people develop after they have had concussion. He has received grant funding from the National Football League and salary support from the Harvard Integrated Program to Protect and Improve the Health of NFLPA Members. Neck pain. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation. (1997) 26:60711. The lines can be unweighted, which means that all statistically significant correlations are shown with the same thickness of lines, or they can be weighted, meaning that thicker lines represent stronger correlations. doi: 10.1080/13854040903190797, 79. doi: 10.1073/pnas.1312114110, 148. Scheiman MM, Talasan H, Mitchell GL, Alvarez TL. Borsboom D, Cramer AO. (2003) 60:130812. J Head Trauma Rehabil. Mood disturbances, including irritability, mood swings, and anxiety. For most patients, having PCS (or wondering if you have PCS) can mean confusion, questions, and anxiety. Network analysis of PTSD symptoms following mass violence. Network theory and analysis (95100) posits that mental disorders can be viewed as a set of interacting symptoms. Forensic Neuropsychology: Fundamentals and Practice Studies on Neuropsychology, Development, and Cognition. Front Psychiatry. doi: 10.1016/j.apmr.2009.09.019. It is important to appreciate that a limitation of network analysis diagrams is that they can lead to the impression that inter-related and interacting between symptoms are static, when in fact they might be temporally sequenced and dynamic. Evidence Acquisition: MEDLINE and PubMed searches were conducted for the years 1966 to 2011 using the search terms brain concussion/complications OR brain concussion/diagnosis OR brain concussion/therapy AND sports OR athletic injuries.Secondary search terms included post-concussion syndrome, trauma, symptoms, metabolic, sports medicine, cognitive behavioral therapy, treatment and rehabilitation. A comparison of complaints by mild brain injury claimants and other claimants describing subjective experiences immediately following their injury. Sleep problems. Post-concussion syndrome can develop after recovery from a concussion and last for weeks, months, or years after the initial injury. State University of New York at Stony Brook designates this live activity for a maximum of . J Head Trauma Rehabil. In: Zasler ND, Katz RD, Zafonte RD, editors. Ingebrigtsen T, Waterloo K, Marup-Jensen S, Attner E, Romner B. Quantification of post-concussion symptoms 3 months after minor head injury in 100 consecutive patients. Hoffman JM, Dikmen S, Temkin N, Bell KR. Persisting symptoms after mild head injury: a review of the postconcussive syndrome. Postconcussive' symptoms in persons with chronic pain. See Table 2. doi: 10.1016/0304-3959(91)90175-W, 117. doi: 10.1080/02699050902926309, PubMed Abstract | CrossRef Full Text | Google Scholar, 2. Robust symptom networks in recurrent major depression across different levels of genetic and environmental risk. The prospective course of postconcussion syndrome: the role of mild traumatic brain injury. Appl Neuropsychol. Avocados, blueberries, and dark chocolate are also considered to be good for the brain. Biol Psychiatry. 25. (2002) 18:7783. Dizziness is the second most common symptom of concussion (mTBI) and predictive of a prolonged recovery from Post-Concussive Syndrome. doi: 10.1093/arclin/acq031, 78. Annu Rev Clin Psychol. Prospective study of posttraumatic stress disorder and depression following trauma. doi: 10.1001/jama.291.15.1887, 128. (2017) 52:110. There is a lack of objective markers and standard treatment . Int Rev Psychiatry. Reid SA, Callister R, Katekar MG, Rivett DA. Expectation as etiology versus the good old days: postconcussion syndrome symptom reporting in athletes, headache sufferers, and depressed individuals. A rehabilitation approach for post-concussion syndrome that sequenced cervical dysfunction and benign paroxysmal positional vertigo treatment within the first three weeks of injury followed by integrated vision and vestibular therapy improved clinical and patient-reported outcomes. Concussion etiology was varied with concussions occurring after sport (60.5%), fall (18.4%), motor vehicle accident (13.2%), and assaults (7.9%). doi: 10.1176/appi.books.9780890425596, 44. All statistics were run in Stata for Mac. doi: 10.1016/j.jpsychires.2018.11.016, 164. 67. After concussion, symptoms can arise from multiple systems with musculoskeletal, visual, and vestibular dysfunction. doi: 10.1111/j.1468-1331.2004.00816.x, 12. PCS Treatments: What you should know Here's the good news: Post-Concussion Syndrome (PCS) will get better with time and the right therapies. the contents by NLM or the National Institutes of Health. (2009) 23:48997. (2018) 23:61734. Arch Clin Neuropsychol. J Neuropsychiatry Clin Neurosci. Department of Rehabilitation & Regenerative Medicine (2018) 57:96473. (2010) 91:3542. J Head Trauma Rehabil. Network theory is agnostic with regard to how causal relations among symptoms are exemplified. It is the author's firm belief that pharmacologic treatment of sport-related concussions should be considered only if the following 3 conditions are met: 1. 158. and transmitted securely. New York, NY: Guilford Press (2012). Network analysis has been used to better understand the structure of emotional and behavioral problems in children (103), the central symptoms and syndromic pathways of traumatic stress in children and adolescents (104106), longitudinal developmental associations between symptoms of depression and anxiety (107), and the associations between internalizing and externalizing psychopathology in the transition from childhood to adolescence (107). (1995) 52:104860. doi: 10.1001/archpsyc.1995.03950240066012, 126. JAMA Psychiatry. Sawchyn JM, Brulot MM, Strauss E. Note on the use of the postconcussion syndrome checklist. (1998) 13:41524. Factors associated with postconcussion syndrome: neurological, psychological, or legal? (2019). Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. 1. Dizziness and difficulties with balance. [Epub ahead of print]. The 38 patients with follow-up data received an average of 10.44.8 treatment sessions over 57.634.0 days. Clinical measures improved including cervical range-of-motion (55.6% fully restored), benign paroxysmal positional vertigo symptoms (28/28, fully resolved), Brock string visual convergence (p<0.001, 95%CI=3.3-6.3), and score on the Balance Error Scoring System (p<0.001, 95%CI=5.5-11.6). (2017) 31:1597604. Does the fear avoidance model explain persistent symptoms after traumatic brain injury? Concussions that are more severe, or have several symptoms, are more likely to transition to post concussion syndrome, as can a lack of proper management of an initial concussion. Suhr JA, Gunstad J. The bottom figure illustrates the role of external factors, in the external field, that are amplifying the network of symptoms, such as social stress (E1) and academic stress (E2). Psychological . doi: 10.1016/j.jaac.2018.05.027, 108. The network perspective eschews the idea that a single latent dimension is the underlying cause of both symptom emergence and coherence. Evaluation of vertical and horizontal saccades using the developmental eye movement test compared to the King-Devick test. The top figure shows that anxiety (A8) has the greatest degree (eight connections to other symptoms) and strength (three heavier lines) of centrality, followed by headaches (H6) and sleep (S5). A network perspective makes it possible to study the architecture of persistent symptoms and problems following MTBI, allowing the identification of symptoms that are more central and strongly interconnected. Assessment of severity involves rating the scope and scale of symptoms. Stulemeijer M, Vos PE, Bleijenberg G, van der Werf SP. Persistent problems 1 year after mild traumatic brain injury: a longitudinal population study in New Zealand. (2017) 8:52837. Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Ziaks L, Giardina R, Kloos A. Front. J Head Trauma Rehabil. Collins MW, Kontos AP, Okonkwo DO, Almquist J, Bailes J, Barisa M, et al. Post-concussion symptoms after traumatic brain injury at 3 and 12 months post-injury: a prospective study. Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. J Anxiety Disord. J Int Neuropsychol Soc. Binder LM. Psychol Trauma. Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Symptoms of BPPV were fully resolved for all 28/28 (100%) diagnosed with BPPV. J Head Trauma Rehabil. Benfer N, Bardeen JR, Cero I, Kramer LB, Whiteman SE, Rogers TA, et al. J Neurotrauma. Losoi H, Silverberg ND, Waljas M, Turunen S, Rosti-Otajarvi E, Helminen M, et al. doi: 10.1080/09638280802532720, 4. A history of prior concussion was reported by 15 (39.5%). Arch Clin Neuropsychol. Non-parametric and parametric statistics were used as appropriate after assessment of normal distribution patterns. Epskamp S, Fried EI. (1994) 9:41125. Int J Behav Med. Figure 1. Mild traumatic brian injury. Some of those symptoms might be caused directly or indirectly by injuries to the brain, head, peripheral vestibular system, or body, and some symptoms might be caused, amplified, or maintained by a diverse range of other factors. (2012) 26:3647. Alcohol Clin Exp Res. 2013. Ryan LM, Warden DL. Wrightson P, Gronwall D. Time off work and symptoms after minor head injury. Self-perception in mild traumatic brain injury. doi: 10.1111/j.1526-4610.2010.01645.x, 21. Adopting a network perspective in clinical research might help us identify single, paired, or small clusters of strongly interconnected symptoms that could be initial targets for treatment and rehabilitation (168). Armour C, Fried EI, Deserno MK, Tsai J, Pietrzak RH. Money matters: a meta-analytic review of the effects of financial incentives on recovery after closed-head injury. (2019) 60:54554. Gasquoine PG. J Nerv Ment Dis. Network analysis of depression and anxiety symptom relationships in a psychiatric sample. Treatment outcomes for post-concussion syndrome can be complicated by the interconnectedness of the vestibular, visual, and musculoskeletal systems.16 For instance, vestibular therapy requires the ability to maintain visual fixation on a point while turning the head.9 Furthermore, deficits in cervical spine and oculomotor coordination can lead to dizziness and blurred vision.17 The function of the cervical spine, visual and vestibular systems are not isolated. The biopsychosocial heterogeneity and complexity associated with outcome from MTBI is illustrated further in an interesting review by Kenzie et al. doi: 10.1136/jnnp-2011-300767. (94). Herring SA, Cantu RC, Guskiewicz KM, et al. But it's important to set appropriate expectations for recovery. doi: 10.1371/journal.pone.0137621, 101. . Whether these symptoms represent a post-concussion syndrome has been controversial for generations. doi: 10.1080/10826080500294924, 132. Network models of posttraumatic stress symptoms across trauma types. The small sample size limited ability to analyze sub-groups or perform regression analysis of factors associated with the outcomes. Columbia University. (2001) 15:16270. doi: 10.1017/S0033291716002300, 143. doi: 10.1080/0269905021000030823, 57. Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury. (2011) 26:35563. The most common presentation was mixed cervical, vision and vestibular symptoms reported by 24 (63.2%); followed by 10 (26.3%) that had vision and vestibular symptoms; and 4 (10.5%) that reported only cervicogenic symptoms including headache. The records of 59 people with post-concussion symptoms were reviewed. Voormolen DC, Polinder S, von Steinbuechel N, Vos PE, Cnossen MC, Haagsma JA. (1995) 10:117. Arch Gen Psychiatry. Exercise. Bijur PE, Haslum M, Golding J. Cognitive and behavioral sequelae of mild head injury in children. However, participation of the one concussion clinic allowed consistent use of the established protocol that sequenced and integrated musculoskeletal, vision and vestibular system care. Arch Phys Med Rehabilit. (1998) 245:60912. doi: 10.1089/neu.2018.5873, 165. 93. doi: 10.1212/01.WNL.0000058907.41080.54, 123. p. 31538. Network analysis is leading to important new insights in depression (135139). In the hypothetical example set out in Figure 2, an aggressive treatment and rehabilitation strategy targeting the two most central symptoms, anxiety, and headaches, might dampen the amplifying inter-relations among multiple symptoms leading to improvement across the entire network of symptoms. Disrupted sleep, insomnia, or daytime sleepiness. Comparison of subjective cognitive complaints with neuropsychological tests in individuals with mild vs more severe traumatic brain injuries. Post-concussion syndrome (PCS) is when you have concussion symptoms that last months or even a year or more after your initial injury. doi: 10.1016/S0006-3223(03)00545-6, 118. Neurol. See Figure 2 for a hypothetical network of nine symptoms in slow to recover high school and college students with pre-existing anxiety problems. Because cervical ROM is a part of both the assessment and treatment of visual and vestibular dysfunction, cervical limitations can confound symptoms in both systems. Spine. (1992) 55:2004. Depression is also common in people with chronic pain (116119), chronic headaches (120123), PTSD (55, 124126), and substance abuse problems (127131). (2019) 60:21624. (2003) 84:17784. Fox DD, Lees-Haley PR, Ernest K, Dolezal-Wood S. Post-concussive symptoms: base rates and etiology in psychiatric patients. He is a co-investigator, collaborator, or consultant on grants relating to mild TBI funded by the federal government and other organizations. Protracted recovery from a concussion: A focus on gender and treatment interventions in an adolescent population. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. Reducing musculoskeletal limitation was an important early goal because of the importance of cervical ROM for vision and vestibular assessments and rehabilitation and the impact cervical dysfunction has on headaches, visual and vestibular function. (1997) 2:196206. Visual system outcome measures included the Brock string score for convergence and divergence distance,18 the cover-uncover test to screen for malalignment and strabismus that would require neuro-optometry referral,19 and clinical screening for quality and speed of smooth pursuits and saccades, and near point convergence.20 Vestibular measures included Dix-Hallpike and Supine Roll Tests for benign paroxysmal positional vertigo (BPPV). Comparison of premorbid and postinjury mmpi-2 profiles in late postconcussion claimants. Divergence and abnormal saccades did not change significantly (p>0.05). doi: 10.1097/01.yco.0000165601.29047.ae, 17. Brain Injury. Brady KT, Verduin ML. 9 Furthermore, deficits in cervical spine and oculomotor coordination can . Injury. Phillips RD, Wilson SM, Sun D, Workgroup VAM-AM, Morey R. Posttraumatic stress disorder symptom network analysis in U.S. Military Veterans: examining the impact of combat exposure. doi: 10.1097/HTR.0b013e3181e4622a, 64. (2018) 9:608. doi: 10.3389/fpsyt.2018.00608, 160. Grothues J, Bischof G, Reinhardt S, Hapke U, Meyer C, John U, et al. One common vision system dysfunction, convergence insufficiency, has been associated with other neurocognitive impairments and higher PCSS.33 After the study treatment, patient-reported symptoms on the PCSS had improved significantly as did clinical Brock string measures for near point convergence consistent with a five subject pilot study34 and a case-control study including 15 people with mild traumatic brain injury.35 Randomized controlled trials would be the next step to determine effect of vision therapy post-concussion compared to no treatment. Scand J Rehabil Med. (2004) 61:80716. The network approach, applied to the post-concussion syndrome, posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. Disabil Rehabil. (2011) 26:12737. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation | Vestibular Disorders | JAMA Network Open | JAMA Network Afzali MH, Sunderland M, Teesson M, Carragher N, Mills K, Slade T. A network approach to the comorbidity between posttraumatic stress disorder and major depressive disorder: the role of overlapping symptoms. Moreover, transitional states from being healthy to being depressed are not well-understood. Subjective vision symptoms assessed with the CISS also improved significantly (p<0.002, d=1.04). Researchers have used network analysis to examine (i) how specific combinations of symptoms might drive the development of PTSD in trauma-exposed adults (154); (ii) whether traumatic stress symptom presentations vary in association with different types of index traumas (158); (iii) the symptom connectivity and associations in combat veterans with PTSD and subthreshold PTSD (159, 160), and the interactions among traumatic stress symptoms, suicidal ideation, depression, and quality of life in veterans (153); (iv) the association between PTSD and alcohol use disorders (161); (v) the identification of central symptoms and bridging symptoms relating to the comorbidity of PTSD and major depressive disorder (162), and (vi) the comorbidity of GAD, depression, and PTSD (163). doi: 10.1093/arclin/16.5.435, 49. Lundblad M. A conceptual model for physical therapists treating athletes with protracted recovery following a concussion. Appl Neuropsychol. (2010) 17:17. A latent model or common cause theory for the syndrome is inconsistent with a biopsychosocial conceptualization (6466). J Abnorm Psychol. doi: 10.1016/j.acn.2005.12.008, 133. (1995) 9:11223. (1986) 8:32346. Hypothetical network of nine symptoms in slow to recover high school and college students with pre-existing anxiety problems. 73. Social Psychological Factors: maladaptive coping, catastrophizing, expectations, good-old-days bias (tendency to view oneself as healthier in the past and underestimate past problems), nocebo effect, diagnosis threat, cognitive hypochondriasis and preoccupation, lifestyle and family dynamics changes, avoidance behavior, cogniphobia (fear and avoidance of mental exertion out of concern for developing or exacerbating a headache), reinforced illness behavior, anger, bitterness, perceived injustice, justification/entitlement, or iatrogenesis. doi: 10.1001/jamapsychiatry.2015.2079, 139. Light sensitivity (L2) is connected to two other symptoms, and nausea (N1) and dizziness (D1) are connected to only one other symptom. doi: 10.1212/WNL.54.2.308, 122. (2002) 24:44857. Brain Injury Vision Symptom Survey (BIVSS) Questionnaire. Vision function significantly improved for convergence on Brock string score (p<0.001, d=1.20). A tutorial on regularized partial correlation networks. Significant improvements were observed at post-test for general post-concussion symptoms on the patient-reported PCSS (p=0.001, d=1.18). Neuropsychology. Sigurdardottir S, Andelic N, Roe C, Jerstad T, Schanke AK. HHS Vulnerability Disclosure, Help Persistent pain and depression: a biopsychosocial perspective. Understanding the miserable minority': a diasthesis-stress paradigm for post-concussional syndrome. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Clin Neuropsychol. Common symptoms of post-concussion syndrome can include headache, dizziness and memory and concentration problems. Common signs and symptoms are listed in Table 2. Fear avoidance and clinical outcomes from mild traumatic brain injury. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). (2009) 31:123543. (2002) 42:93444. Kennedy WP. Breslau N, Schultz LR, Stewart WF, Lipton RB, Lucia VC, Welch KM. (2000) 15:78391. Neurorehabilitation. doi: 10.1037/tra0000237, 156. How is a traumatic brain injury (TBI) diagnosed and treated? The four nested scales are cellular (e.g., axonal injury, neuroinflammation, and synaptic changes), network (e.g., intrinsic connectivity and neuronal population dynamics), experiential (e.g., physical, cognitive, and psychological symptoms), and social (e.g., access to healthcare, social support, work or school pressures)and each of these interacting scales can be influenced by a diverse range of personal characteristics and external environmental factors [see Figure 1 in Kenzie et al. doi: 10.1097/HTR.0b013e3181ae35fd, 5. doi: 10.1076/jcen.24.8.981.8372, 135. van Loo HM, Van Borkulo CD, Peterson RE, Fried EI, Aggen SH, Borsboom D, et al. doi: 10.1080/13854049508402064, 53. Jamora CW, Young A, Ruff RM. 4. doi: 10.3171/2018.3.PEDS1850, 113. Treleaven J. Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. Potentially Amplifying and Reinforcing Persistent Symptoms and Problems and Personal Biopsychosocial Context for Experiencing Persistent Symptoms and Problems. Brain Injury. J Affect Disord. Thompson EL, Broadbent J, Fuller-Tyszkiewicz M, Bertino MD, Staiger PK. (2001) 16:43545. Symptoms may be physical (headache, dizziness, sleep problems), cognitive (difficulty with memory or concentration), or behavioral (irritability, intolerance). Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migrainesystematic review and meta-analysis.
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