Mild traumatic brain injury (mTBI) is an important public health problem, due to its high incidence and the failure of at least 20% of patients to successfully recover from injury. Cognitive symptoms, in particular, are an important area of research in mTBI, due to their association with return to work and referral to neuropsychological services. Understanding the predictors of cognitive symptoms may help to improve outcomes after mTBI. This study explored female sex, psychological distress, coping style and illness perceptions as potential predictors of cognitive symptoms following adult civilian mTBI.

Sixty-nine premorbidly healthy adults with mTBI (mean age = 36.7, SD = 14.7, range = 18-60; 15 females) were recruited from trauma wards at two public hospitals in Australia and assessed 6-12 weeks following injury. Cognitive complaint was measured using a comprehensive 30-item scale (CCAMCHI) assessing mTBI-specific symptoms in the domains of processing speed, attention, memory and executive function. Participants additionally completed the following measures: Brief-COPE, Illness Perceptions Questionnaire-Revised, Inventory of Depressive Symptomatology, Beck Anxiety Inventory, and PTSD Checklist for DSM-5. The latter three measures were combined to create an index of psychological distress.

Bivariate nonparametric correlational analyses indicated that female sex (r[67] = .26, 95% CI [.14, .55], p = .03) and psychological distress (r[66] = .54, 95% CI [.40, .72], p < .001) were each significantly associated with cognitive symptom reporting following mTBI. Additionally, while none of the three coping style factors were associated with cognitive symptom reporting, seven of the eight dimensions of illness perceptions were associated with symptom reporting (|r| = .25 - .58, p < 0.05). In a linear regression model assessing the combined effects of each variable, female sex, greater psychological distress, and overall negative illness perceptions were each significant independent predictors of increased cognitive complaint (adj. R2 = .47, F[4,63] = 15.59, p < .001).

These findings implicate female sex, psychological distress, and illness perceptions as key factors associated with cognitive symptom reporting after mTBI. This research suggests that these factors may be useful in clinical practice when considering early identification of individuals at risk of poor recovery. Specifically, this research implicates females, individuals with high psychological distress, and individuals with negative illness perceptions as important to subgroups to consider for potential intervention after mTBI. Additionally, as psychological distress and illness perceptions are both potentially modifiable, this research suggests that these factors may be useful targets for intervention.

To examine relationships between history of mild traumatic brain injury (mTBI), neuropsychological measures of executive function, and lifetime history of criminal justice (CJ) involvement among combat-exposed Veterans and Service Members (V/SM).

Participants were combat-exposed V/SM who completed a baseline assessment for the multicenter Long-term Impact of Military-Relevant Brain Injury Consortium - Chronic Effects of Neurotrauma Consortium study (N=1,341) and had adequate engagement/symptom reporting on measures of performance and symptom validity (i.e., Medical Symptom Validity Test and Mild Brain Injury Atypical Symptoms Scale). Neuropsychological battery included the Trail Making Test (A and B), Wechsler Adult Intelligence Scale-IV (WAIS-IV) Digit Span subtest, and the National Institute of Health (NIH) Toolbox Flanker subtest. Lifetime history of brain injury, criminal justice involvement, and demographics were collected. Participants were 87% male, 72% white, with a mean age of 40 years (SD=9.67). Eighty-one percent had at least some college education. Nineteen percent were active duty. Eighty percent of Veterans and 86% of Service Members reported a history of >1 mTBI, and of these 31% and 47% respectively experienced 3+ mTBIs.

Three groups were composed based on level of involvement with the CJ system: 1.) No history of arrests or incarcerations (3+ mTBIs: 64%), 2.) A lifetime history of arrest but no felony incarceration (3+ mTBIs: 34%), and 3.) A lifetime history of felony incarceration (3+ mTBIs: 2%). Ordinal regression analyses revealed that performance on a working memory task (Digit Span; b= 0.024, p= .041; OR= 1.024) was significantly associated with increased CJ involvement after adjusting for age, education, service status, and mTBIs. Performance on measures of processing speed (Trails A), set-shifting (Trails B), and inhibition (Flanker) were not significantly associated with CJ involvement. Number of mTBIs was significantly and positively associated with level of CJ involvement in all four models; Digit Span (p= .016), Trails A (p= .016), Trails B (p= .020), and Flanker (p= .008).

Performance on most measures of executive functioning was not significantly associated with CJ involvement in this large, representative sample of V/SM who served in combat. Although performance on a working memory task was significantly associated with CJ involvement, the size of the effect was small and the association was in the opposite direction as expected. Number of mTBIs was significantly associated with level of CJ involvement, indicating that sustaining multiple mTBI may be linked to greater risk of CJ involvement. These findings suggest that social and psychological factors beyond executive dysfunction may better explain the relationship between history mTBIs and CJ involvement. Some aspects of military service and veteran status, such as interdisciplinary treatment for brain injury and physical, mental, and psychosocial health needs, may be protective against previously identified risk factors for arrest (e.g., deficits in executive functioning). Contextualizing mTBI within the larger behavioral health profile of V/SM, with emphasis placed on intervention for related co-morbidities, may reduce the impact of previous arrest on wellbeing and/or reduce the risk of future CJ involvement.

Investigate the relationship of chronic neurobehavioral and cognitive symptoms in military personnel with history of blast-related mild TBI and compare to a well-matched group of combat-deployed controls.

274 participants (mean age=34 years; mean education=14.75 years; 91.2% male) enrolled in the EVOLVE longitudinal study of combat-deployed military personnel were subdivided into those with history of blast TBI (n=165) and controls without history of blast exposure and TBI (n=109). As part of a larger study, we conducted a sub-analysis of 5-year follow up data. We focused on group differences (Mann-Whitney U) and correlational relationships between self-report neurobehavioral symptoms via the Frontal Systems Behavior Scale (FrSBE) and cognitive performances on measures of attention, working memory, processing speed, and executive functioning including D-KEFS Color Word Interference (CWI), Trailmaking A and B, and the Conners Continuous Performance Test (CPT).

The Blast TBI group reported higher levels of neurobehavioral symptoms on the FrSBE (p<.001), including domains of apathy (p<.001), disinhibition (p<.001), and executive dysfunction (p<.001), compared to Controls. On cognitive measures, group differences were observed on CWI Inhibition/Switching (p=.008), Trails B time (p=.010), and CPT commission errors (p=.014), such that the Blast TBI group performed worse than Controls. No significant group differences were observed for CPT omission errors or CPT hit rate (p’s>.05). After adjustment for multiple comparisons, greater FrSBE apathy correlated with slower performance on Trails A for Blast TBI (r=0.22, p=.014) but not Controls. Apathy endorsement was not significantly related to CPT omission errors for either group (p’s>.05). Higher endorsement of disinhibition symptoms was associated with worse performance on CWI Inhibition (Blast TBI: r=-0.19, p=.036; Controls: r=-0.28, p=.012) and Inhibition/Switching (Blast TBI: r=-0.23, p=.010; Controls: r=-0.29, p=.010) conditions for both groups, whereas only the Blast TBI group showed significant relationships between disinhibition symptoms and Trails B-A time (r=0.20, p=.025) and CPT commission errors (r=.18, p=.038). Higher endorsement of executive dysfunction correlated with poorer performance for Trails B-A for both groups (Blast TBI: r=.24, p=.009; Controls: r=.24, p=.030).

Our findings reveal that at 5-year follow up, military personnel with history of blast-related mild TBI reported significantly greater neurobehavioral symptoms and performed lower on standardized measures of executive functioning, relative to combat-deployed controls without TBI or blast exposure. Significant relationships between neurobehavioral symptoms and cognitive performance were present in both groups. However, these relationships were more pronounced in the Blast TBI group, including greater apathy associated with slower visual tracking as well as greater endorsement of disinhibition associated with set-switching. Objective measures of response inhibition were related to disinhibition endorsement for both groups, though impulsive errors were more pronounced for the Blast TBI group. Our results suggest chronic cognitive and neurobehavioral symptoms are present in military personnel with history of blast TBI exposure, and also discrepant from a well-matched control group of combat deployed military personnel. Future studies of this population should explore models to predict cognitive performance from neurobehavioral symptoms in military personnel, as this could inform treatment approaches for those at greatest risk of cognitive change.

Individuals who have experienced a mild traumatic brain injury, or concussion, often experience a variety of cognitive and emotional sequelae. Specifically, concussions can place individuals at increased risk for experiencing symptoms of depression. It is important to understand if loss of consciousness (LOC) is related to higher rates of depression in order to improve care and cognitive functioning by appropriately monitoring for mood-related symptoms post-concussion. The current study sought to examine the relationship between depressive symptoms (measured using the PHQ-9), working memory (WM; measured using RBANS Digit Span subtest), and presence of LOC in individuals who have sustained a head injury. The relationships between presence of LOC, depressive symptoms, and WM performance were examined, as it was expected LOC would result in greater depressive symptoms and negatively impact WM performance. Finally, the relationship between depressive symptoms and WM performance, while controlling for LOC, was also assessed.

Data was drawn from archival medical records of 40 patients who underwent brief neuropsychological screening in an outpatient, community clinic after being referred following a head injury. Patients ranged in ages from14 to 75, with a mean age of 39.1. The average years of education amongst patients was 14.62. Twenty-five (62%) of the patients were women. Ten individuals endorsed LOC secondary to their head injury.

The average PHQ-9 score was 9.68 (SD=7.69). LOC did not impact reported depressive symptoms (p >.05). The correlation between LOC and WM performance was also nonsignificant (p >.05). While it was predicted there would be an inverse relationship between PHQ-9 scores and WM performance, there was no statistical significance (p >.05). Similarly, there was no significant relationship between PHQ-9 and WM performance when controlling for LOC (p >.05).

While the relationships between LOC, depressive symptoms, and WM performance were found to be nonsignificant, understanding the course and best supports of cognitive and emotional sequelae of head injuries is of paramount importance. Future research exploring these relationships with larger, diverse populations would likely prove beneficial.

Utilization of an objective measure to evaluate history of head trauma has been demonstrated to have a significant effect on the amount of sustained trauma reported by the individual, in athletic male populations. The ability to generalize this definition across a more diverse population remains an opportunity; a report from the World Health Organization recognized that 93% of current research on mild traumatic brain injuries omitted gender specific data. Further, relative to reports in young adults, research on the effects of concussions in midlife remain sparse. Researchers hypothesized that women between the ages of 30 and 50 from a general population would report additional head injuries when provided with an objective definition similar to those previously used in male athletes.

Highly educated (M=16.7 years, SD=2.1 years) women between the ages of 30 and 50 (M=40.3, SD= 5.1) completed an online web-based survey. The survey probed for demographic information tied to participation in sports & related activities, individual history of head trauma, as well as a series of objective measures. Participants were first asked to provide a history of head trauma, in absence of an objective definition; they were then provided with an objective definition similar to what was previously documented to be effective in the literature, and then asked to provide a reassessment of sustained trauma.

A Wilcoxen Signed Rank test indicated a significant change in number of reported head injuries, pre and post definition (z= 4.06, p<.0001). The number of head injuries reported increased for 42% of the population, for this portion of the sample the median increased fourfold. To better understand the differences between those who reported an increase, and those who didn’t, researchers performed an examination of commonalities between those groups. A Chi-Square Test of Independence indicated a significant relationship (chi=7.03, p<.01) between participation in sports (recreational, organized) and change in reported head injuries: 21% of individuals without a sport history increased the number of reported head injuries, in contrast 58% of individuals with a sport history increased the number of head injuries reported.

Consistent with the literature in male athletes, providing a definition of a head injury significantly increased the number of reported head injuries in women, between 30 and 50 years of age. This finding indicates that providing a definition can improve reported concussion history within a more diverse population. This fourfold increase for 42% of our population could bear significant implications for those receiving clinical care. Further, given that the definition utilized was especially effective at correcting history of reported head injury in those who participated in sports, it’s adoption within clinical communities evaluating athletic populations seems especially promising.

Mild traumatic brain injury (mTBI) remains one of the most prevalent brain injuries, affecting approximately one-in-sixty Americans. Previous studies have shown an association between white matter integrity and aggression at chronic stages (either 6-months or 12 months post-mTBI) however, the association between white matter axonal damage, neuropsychological outcomes, and elevated aggression in multiple stages since time-since-injury (TSI) is unclear. We hypothesized that functional connectivity between the default mode network (DMN), a key brain network involved in cognitive, self-reflective, and emotional processes, and other cortical regions would predict elevated aggression and emotional disturbances across multiples stages of recovery in mild TBI.

Participants healthy controls (HC: n=35 total [15 male, 20 female], age M=24.40, SD=5.95; mTBI: n=121 total [43 male; 78 female], age M = 24.76, SD=7.48). Participants completed a cross-sectional study design at specific post-injury time points ranging from (2W, 1M,3M,6M,12M). Participants completed a comprehensive neuropsychological battery and a neuroimaging session, including resting state functional connectivity (FC). Here, we focus on the FC outcomes for the DMN. During the neuropsychological assessment, participants completed tests that measured learning and memory, speed of information processing, executive function, and attention. To predict neuropsychological performance from brain connectivity, we conducted a series of stepwise linear regression analyses with the 11 functional brain connections (extracted as Fisher’s z-transformed correlations between regions) as predictors and each of the 13 neurocognitive factor scores separately.

Consistent with our hypothesis, one predictor materialized as significant (R = .187, R2 = .035, F = 5.55, p = .020) for the Total Sample. Largely, positive connectivity between Right Inferior Frontal Gyrus and the PCC (seed) was associated with increased aggression in the Total Sample of all participants (ß = .187, t = 2.36, p = .020). One predictor materialized as significant in Individuals the 2W group, (R = .719, R2 = .518, F = 8.58, p = .019). In general, greater negative (anticorrelated) connectivity between the Left Lateral Occipital Cortex (ß = -.719, t = -2.93, p = .019) and the PCC (seed) and was associated with greater aggression at 2W, but no predictors emerged at 1M or 3M. Individuals in the 6M group showed one significant predictor (R = .675, R2 = .455, F = 16.71, p = .001). Specifically, greater positive connectivity between the Right Lateral Occipital Cortex (/? = .675, t = 4.09, p = .001) and PCC (seed) was associated with greater aggression at 6M. No associations were evident at 12M.

Overall, these findings suggest functional connectivity between the posterior hub of the DMN and cortical regions within the occipital cortex was predictive of higher aggression in individuals with mTBI. However, the direction of this connectivity differed at 2W versus 6M, suggesting a complex process of recovery that may contribute differentially to aggression in patients with mTBI. As these regions are involved in self-consciousness and visual perception, this may point toward future avenues for aiding in functional recovery of emotional dysregulation in patients with persistent post-concussion syndrome.

Mild traumatic brain injury (mTBI) remains one of the most silent recurrent head injuries reported in the United States. mTBI accounts for nearly 75 percent of all traumatic brain injuries in the American population. Brain injury is often associated with impulsivity, but the association between resting state functional connectivity (rsFC) and impulsivity at multiple stages since time-since-injury (TSI) is unclear. We hypothesized that rsFC within the default mode network (DMN) would predict impulsivity across multiples stages of recovery in mild TBI.

Participants healthy controls (HC: n=35 total [15 male, 20 female], age M=24.40, SD=5.95; mTBI: n=121 total [43 male; 78 female], age M=24.76, SD=7.48). Participants completed a cross-sectional study design at various post-injury time points ranging from (2W, 1M,3M,6M,12M). Participants a neuroimaging session and behavioral tasks including a psychomotor vigilance task. Impulsivity was assessed as a combination of false starts and impulsive responses on behavioral tasks. The neuroimaging session included a rsFC scan. To predict impulsivity from brain connectivity, we conducted a series of stepwise linear regression analyses with the 11 functional brain connections (extracted as Fisher’s z-transformed correlations between regions) as predictors and each of the 13 neurocognitive factor scores separately. We focus here on the outcomes for the impulsivity factor.

Results showed greater positive connectivity between the and Right Frontal Pole and the anterior cingulate cortex (ACC; seed) (ß = .158, t = 1.98, p = .049) which was associated with greater impulsivity. Individuals in the 2W group demonstrated one significant predictor (R = .632, R2 = .399, F = 5.32, p = .050). Largely, there was greater positive connectivity between the Right Frontal Pole and the ACC (seed) and (ß = .632, t = 2.31, p = .050) which was associated with higher impulsivity at the 2W time-since-injury. No predictors emerged for the 1M, 3M, or 6M conditions. However, individuals in the 12M group demonstrated two significant predictor connections (R = .497, R2 = .247, F = 5.73, p = .007). Overall, a linear combination of greater negative (anticorrelated) connectivity between the Right Frontal Pole and the mPFC (seed) (/? = -.576, t = -3.53, p = .002) and greater positive connectivity between the Paracingulate Cortex (seed) and the Left Lateral Prefrontal Cortex (ß = .368, t = 2.14, p = .039) was also associated with greater impulsivity in individuals with mTBI at 12M.

These findings suggest functional connectivity between the anterior node of the DMN and prefrontal cortex regions involved in behavioral control was predictive of higher impulsivity in individuals with mTBI at 2W and 12M post injury, but not at other time frames. Interestingly, these connections differed at the two time points. Acutely, greater impulsivity was associated with greater connectivity among regions involved in error detection, exploration, and emotion. At one year, the connections involve regions associated with error monitoring and inhibitory processes. This may reflect compensatory strategy development during recovery.

Veterans with a history of mild traumatic brain injury (mTBI) often endorse enduring postconcussive symptoms (PCS) including cognitive and neuropsychiatric complaints. However, although several studies have shown associations between these complaints and brain structure and cerebrovascular function, few studies have examined relationships between structural and functional brain alterations and PCS in the context of remote mTBI. We therefore examined whether PCS were associated with cortical thickness and cerebral blood flow (CBF) in a well-characterized sample of Veterans with a history of mTBI.

116 Veterans underwent structural neuroimaging and a clinical interview to obtain detailed TBI history and injury-related information. Participants also completed the following self-report measures: the Neurobehavioral Symptom Inventory (NSI) for ratings of cognitive, emotional, somatic-sensory, and vestibular symptoms, and the Posttraumatic Stress Disorder (PTSD) Checklist for PTSD symptom severity. Regional brain thickness was indexed using FreeSurfer-derived cortical parcellations of frontal and temporal regions of interest (ROIs) including the superior frontal gyrus (SFG), middle frontal gyrus (MFG), inferior frontal gyrus (IFG), orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), medial temporal lobe (MTL), and lateral temporal lobe (LTL). A subset of Veterans (n=50) also underwent multi-phase pseudo-continuous arterial spin labeling (MPPCASL) to obtain resting CBF. T1-weighted structural and MPPCASL scans were co-registered and CBF estimates were extracted from the 7 bilateral parcellations of ROIs. To assess the relationship between NSI total and subscale scores and ROI thickness and CBF, multiple regression analyses were conducted adjusting for age, sex, and PTSD symptom severity. False Discovery Rate was used to correct for multiple comparisons.

NSI total and subscale scores were not associated with cortical thickness of any ROI. However, higher NSI scores were associated with increased ROI CBF of the SFG (q=.014) and MFG CBF (q=.014). With respect to symptom subscales, higher affective subscale scores were associated with increased SFG (q=.001), MFG (q=.001), IFG (q=.039), ACC (q=.026), and LTL CBF (q=.026); higher cognitive subscale scores were associated with increased SFG (q=.014) and MFG CBF (q=.032); and higher vestibular subscale scores were associated with increased ACC CBF (q=.021). NSI somatic-sensory subscale scores were not associated with ROI CBF.

Results demonstrate that in TBI-susceptible anterior ROIs, alterations in CBF but not cortical thickness are associated with postconcussive symptomatology in Veterans with a history of mTBI. Specifically, postconcussive total symptoms as well as affective, cognitive, and vestibular subscale symptoms were strongly linked primarily to CBF of frontal regions. Remarkably, these results indicate that enduring symptoms in generally younger samples of Veterans with head injury histories may be closely tied to cerebrovascular function rather than brain structure changes. These findings may provide a neurological basis for negative clinical outcomes (e.g., enduring PCS and poor quality of life) that is frequently reported by many individuals following mTBI. Future work is needed to examine unique effects of blast exposure as well as associations with repeated injury on brain-behavior relationships.

The objective of the study was to examine longitudinal changes in the white matter tracts with diffusion tensor imaging (DTI), neuropsychological performance, and the associate between the two in adults with a mild traumatic brain injury (mTBI).

Sixteen adult patients (age = 38.5(12.8); 75% female) seeking medical care at an emergency department for their first mTBI and 15 healthy adults (age = 30.5(11.3); 33% female) from the community were recruited. DTI and the neuropsychological evaluation were performed at 7 days and 4-months post-injury. The neuropsychological evaluation consisted of the CNS Vital Signs computerized neurocognitive test battery and 2 trials of the Paced Auditory Serial-Addition Test.

Results showed a significant decrease in fractional anisotropy (FA) and an increase in radial diffusivity (RD) of the right uncinate fasciculus as well as a significant decrease in FA and axial diffusivity (AD) of the right inferior fronto-occipital fasciculus over the 4-month follow-up period in the mTBI group compared to the Control group.

The FA of multiple white matter tracts at baseline were positively associated with working memory, sustained attention, and complex attention at baseline in the mTBI group but not the Control group. The global mean cerebral diffusivity for FA at baseline was positively associated with working memory and sustained attention at 4-months post-injury.

The current findings of abnormal white matter suggest an oxidative stress reaction as a result of mTBI altering the diffusivity of some white matter tracts. Furthermore, the disruption of the white matter tracts at baseline may serve as a biomarker for identifying mTBI and those who may have prolonged cognitive difficulties in working memory and attention as a result of the mTBI.

Few concussion studies have investigated the psychological domain of concussions. Of the 22 postconcussion symptoms assessed on the Graded Symptom Checklist of the SCAT-5, five do not overlap with core symptoms of anxiety and depression. 43% of patients report at least one psychiatric symptom, the median is four after injury. Previous studies focus on total scores and not individual items; furthermore, few consider resilience as part of psychological factors that impact recovery. This research aims to describe general and specific characteristics of psychological functioning in males/females ages 12-18 after concussion to help guide treatment. We compared total scores for each measure between males/females and looked at the differences between the genders for individual items in each measure.

Participants were evaluated at an outpatient concussion clinic participating in the North Texas Concussion Registry (ConTex; N=1238, 53% female, mean age=15.4 years, SD=1.16 years). The Generalized Anxiety Disorder 7-item Scale (GAD-7, the Patient Health Questionnaire-8 (PHQ-8), the Brief Resilience Scale (BRS), and the Pittsburgh Sleep Quality Index (PSQI) were used to determine levels of anxiety, depression, resilience, and sleep quality.

Utilizing Mann-Whitney U tests (median, interquartile range) to examine group distributions for the GAD-7, PHQ-8, and BRS, females had significantly higher scores than males for the GAD (p<0.001; Female: 4, 1-9 v. Male: 2, 0-5) and PHQ (p<0.001; Female: 5, 210 v. Male: 3, 1-7). For the BRS, total scores for females were significantly lower than males (p<0.001; Female: 3.67, 3-4 v. Male: 3.83, 3.214.33). The PSQI media score was significantly different between males and females: item 2, p=.016 and item 4 p=.007 using an exact sampling distribution for U. Pearson Chi square tests were used to examine sex differences for each item of the psychological measures. Items 1-7 within the GAD-7 were significant between sexes (i.e. male or female). The seven items assess (1) Feelings of nervousness, (2) Inability to stop/control worry, (3) Worrying too much about different things, (4) Trouble relaxing, (5) Inability to sit still due to restlessness, (6) Irritability, and (7) Feeling afraid. Items 2-8 within the PHQ were significant between sexes. The items assess (2) Feeling down/depressed/hopeless, (3) Trouble falling/staying asleep, (4) Feeling tired/no energy, (5) Appetite changes, (6) Lowered/poor self-esteem, (7) Concentration issues, and (8) Feeling slowed down or unable to be still. There was a statistically significant difference between genders and Items 2 and 4 within the BRS were significant between sexes. The items assess (2) Difficulty surviving hard times and (4) Difficulty snapping back from something bad.

Like other studies, this study found females have higher levels of negative affect (i.e., depressive and anxious symptoms). Females displayed lower resilience and reported poorer sleep. By analyzing psychiatric measures, treatment protocols can be tailored to address specific problems, and mental health difficulties can be mitigated by teaching specific coping techniques. These results suggest clinicians should consistently be providing education on depression, anxiety, sleep, and resilience, particularly to female patients, who appear at greater risk for psychological distress.

There is growing evidence to indicate that blast exposure military personnel experience throughout their career can have a negative impact on their brain health. The majority of research in the area of blast related neurotrauma has been focused on traumatic brain injury (TBI); however, the blast exposure may often be independent of TBI. It is common in both active duty military and veterans to report years of blast exposure from combat and training. The objective of this study was to explore the relationship between blast exposure and cognitive functioning in military personnel seeking treatment for a mild TBI.

Participants were recruited from a military hospital while enrolled in a multidisciplinary treatment program for TBI. All patients had at least one diagnosed mTBI as well as persistent cognitive complaints. Exclusion criteria included invalid performance on a performance validity test and a symptom validity test. 97 participants were included in the analysis with an average age of 34.0 (SD = 7.9) and average 4.0 combat deployments (SD = 3.6). Blast exposure history was measured by the overall score from the Blast Exposure Threshold Survey (BETS) which assessed the frequency and duration of use of various blast sources. Outcomes included the Neurobehavioral Symptom Inventory (NSI) and the Global Deficit Scale (GDS) an objective measure of cognitive deficiency. GDS was calculated from seven measures: Hopkins Verbal Learning Test-Revised Total and Delayed Recall (HVLT-TR and HVLT-DR); DKEFS System Color-Word Condition 3 Inhibition (CW3), Color-Word Condition 4 Switching (CW4) and Trail Making Condition 3 Letter Sequencing (TM3), Paced Auditory Serial Addition Test (PASAT), and the Symbol Digit Modality Test (SDMT). Demographically corrected t-scores (M=50, SD = 10) were converted to deficit scores and averaged to calculate GDS. To adjust for nonnormal distributions, non-parametric statistics were examined.

The BETS was not related to GDS (rho = -.055); however, there was a significant correlation between higher levels on the BETS and better performance on measures of selective attention (PASAT rho = .307) and processing speed (SDMT rho = .218). The correlation between BETS and the other neuropsychological measures were not meaningful (all rho’s <.10). Those with an impaired GDS, did not differ from others on the BETS. BETS was also not associated with neurobehavioral symptoms (rho = .125). BETS had moderate correlations with number of combat deployments (rho =.483), severity of combat exposure (rho =.556). It was not related to education (rho = .004) or pre-morbid intelligence (rho =-.029).

The BETS was not related to GDS (rho = -.055); however, there was a significant correlation between higher levels on the BETS and better performance on measures of selective attention (PASAT rho = .307) and processing speed (SDMT rho = .218). The correlation between BETS and the other neuropsychological measures were not meaningful (all rho’s <.10). Those with an impaired GDS, did not differ from others on the BETS. BETS was also not associated with neurobehavioral symptoms (rho = .125). BETS had moderate correlations with number of combat deployments (rho =.483), severity of combat exposure (rho =.556). It was not related to education (rho = .004) or pre-morbid intelligence (rho =-.029).

Pre- and post-morbid mental health conditions can prolong recovery from concussion and are generally detrimental to athletic performance and quality of life. If psychiatric conditions can be identified in athletes at the time of baseline testing, psychological/psychiatric intervention can be implemented to prevent these complications. Given the time constraints on neuropsychological baseline testing, it is important to have time-efficient screening measures. As such, the purpose of this study was to develop and calibrate a psychiatric screening measure within the Post-Concussion Symptom Scale (PCSS) from the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), which is commonly administered to athletes at baseline, thereby “killing two birds with one stone”: (1) screening for psychiatric conditions and (2) obtaining a baseline measurement of concussion-like symptoms.

Participants were 278 undergraduate students from a Canadian university with a mean age of 21.87 years (SD=4.87, range=18 to 52) and a sex composition of 64% females (n=179, Age: M=21.29 years-old, SD=4.34, range: 18 to 52) and 36% males (n=179, Age: M=22.93 years-old, SD=5.57, range: 18 to 50). Participants were a convenience sample collected via online survey platform in exchange for bonus points toward courses through a participant pool system between January and July 2021. The psychiatric screener consisted of the affective subscale from the PCSS (irritability, sadness, feeling more emotional, nervousness) and the criterion measure was the Depression, Anxiety, and Stress Scales (DASS-42). Statistical analyses were conducted in R v.4.3 and included confirmatory factor analysis and receiver operating characteristic (ROC) curve analyses. Although a balance was sought between sensitivity and specificity, the former was prioritized given that this is intended as a screening measure. Males and females were analyzed separately as females tend to report more symptoms than males. Mild, moderate, and severe elevations were predicted for depression, anxiety, and stress, based on standard DASS cutoffs.

The CFA analyses revealed good fit for both the PCSS (CFI=.992; TLI=.991; RMSEA=.053; SRMR=.066) and DASS (CFI=.995; TLI=.995; RMSEA=.053; SRMR=.065) models. Cutoffs of >3, >4, and >8 (SENS= .77-.80, SPEC= .52-.83) optimally classified males as having mild, moderate, and severe depression, respectively; and cutoffs of >8, >8, and >9 (SENS= .79-.83, SPEC= .63-.67) optimally classified females as having mild, moderate, and severe depression, respectively. A cutoff of >2 (SENS= .78-.81, SPEC= .35-.39) optimally classified males as having both mild and moderate anxiety (insufficient n in severe group); and >7, >8, and >9 (SENS= .80-.85, SPEC= .63-.68) optimally classified females as having mild, moderate, and severe anxiety. Cutoffs of >5and >8(SENS= .80-.86, SPEC= .70-.85) were optimal for detecting mild and moderate stress in males (insufficient n in severe group); and >8, >8, and >9 (SENS= .80.89, SPEC= .60-.75) were optimal in females.

The affective subscale within the PCSS operates well as a psychiatric screening measure. In general, females had higher cutoffs and the cutoffs for mild and moderate levels of the conditions tended to be similar. Males were less onsistent, with cutoffs varying widely depending on the construct and severity.

Given that at least 75% of traumatic brain injuries in the U.S. are mild, concussions are a serious public health concern that cause significant neurological damage and negatively impact individuals’ quality of life. Due to the rotational forces that occur during a concussion, immediate damage to the corpus callosum is common, resulting in neurological and behavioral deficits. However, the longitudinal damage to the integrity of the corpus callosum is unclear and may differ across sections of the corpus callosum. Our primary aim was to compare the white matter integrity across eight corpus callosum tracts in concussed individuals to healthy controls 3-4 weeks after injury and at a 10-month follow-up.

Seventeen concussed participants completed a diffusion tensor imaging (DTI) scan 3-4 weeks after receiving a concussion and again 10 months after injury. Nineteen control participants completed a single DTI scan. DTI data were analyzed using the automated fiber quantification (AFQ) pipeline, which extracts fractional anisotropy (FA) values from 100 nodes in eight tracts of the corpus callosum (listed anterior to posterior): orbital frontal, anterior frontal, superior frontal, motor, superior parietal, posterior parietal, occipital, and temporal. Given the non-linearity, high multicollinearity, and large number of data points, a cubic smoothing spline was used to fit a penalized regression to the FA values in each tract, allowing us to compare the FA values of each node in each tract between groups and across time. To assess acute damage, a spline model for the concussed participants at 3-4 weeks was compared to a spline model for the control participants in each tract. To assess longitudinal damage, a spline model of the FA difference value (10-month minus acute visit) in concussed participants was compared to a spline model of the FA difference value for controls (zero, representative of a theoretical no change in FA values). Significant nodes were defined as p-values less than 0.006 (alpha of .05/8, given 8 tracts).

Acutely following injury, concussed participants showed lower FA values than controls in the anterior frontal, posterior parietal, occipital, and temporal tracts. In the orbital frontal tract, concussed participants had higher FA values on the left, but decreased FA values compared to controls in the middle. Longitudinally, concussed participants showed continued decreased white matter integrity in the orbital frontal, superior parietal, and occipital tracts, but improved white matter integrity in the anterior frontal and superior frontal tracts. The motor, posterior parietal, and temporal tracts showed mixed longitudinal results of decreased or improved white matter integrity within each tract.

Concussed individuals show decreased white matter integrity across the corpus callosum acutely after injury. Longitudinally, the most anterior and posterior portions of the corpus callosum (i.e., genu and splenium) show continued damaged while the more medial sections of the corpus callosum may show some recovery. Results suggest the corpus callosum displays differential patterns of damage acutely and longitudinally following concussion, with some tracts improving while others continue to deteriorate.

Approximately 10-15% of patients with mild traumatic brain injury (mTBI) report persistent, chronic symptoms more than one month later. Coping behaviors after mTBI can range from fear avoidance (FA), or a reluctance to return to activity because of the fear of symptom exaggeration, to endurance (END), or an overly aggressive return to activity. We evaluated how coping strategy relates to self-reported symptoms in patients with prolonged recovery from mTBI.

Participants were 72 individuals (age 37.8 + 18.4, 65% female) who sustained a mTBI at least one month prior to assessment (median (IQR) = 5.5 (2.0-11.3) months). Participants completed the Brain Injury Recovery Disposition Scale (BIRDS) to assess FA and END behaviors, and Sport Concussion Assessment Tool (SCAT5) Symptom Inventory. A BIRDS spectrum score was calculated as the difference between FA and END scores to determine individual coping behavior on a spectrum from extreme FA (more negative) to extreme END (more positive). SCAT5 symptoms were separated into four domain scores: somatic, cognitive, sleep, and emotion. Regressions were performed for each outcome examining their potential linear and quadratic associations to coping behavior (i.e., BIRDS spectrum score). Follow-up regressions were performed covarying for age and sex to explore the potential influence of these variables on each outcome.

The linear and quadratic components of the BIRDS spectrum score were not significantly related to total number of persisting concussive symptoms. For overall total symptom severity, the quadratic component of the relationship was significant (B = .24, p = 0.04). Visualization of the overall trend line suggested that symptom severity was highest on the extreme FA side of the BIRDS spectrum (highly negative BIRDS spectrum score), decreased as coping behavior become more balanced (BIRDS spectrum score surrounding “0"), plateaued, then increased abruptly on the extreme END side (highly positive BIRDS spectrum score). For cognitive symptoms, the linear component of the BIRDS spectrum score was significant (B = -.28, p = 0.02) and the quadratic component was marginally significant (B = .22, p = 0.06). The quadratic (but not linear) component was significantly related to both the severity of sleep (B = .31, p = 0.01) and emotion symptoms (B = .25, p = 0.03). Finally, neither the linear nor quadratic components were significantly related to the somatic symptom severity. After covarying for age and sex, the quadratic component remained significant for total symptom severity (p = 0.05) as well as the linear component for cognitive severity (p = 0.02).

Both extreme “fear avoidance” and “endurance” coping styles may be related to more severe chronic mTBI symptoms, especially in domains of sleep and emotion symptoms. Patients with balance of both fear avoidance and endurance behaviors may be more likely to experience less severe symptoms even among mTBI patients with persistent complaints. Identifying coping behavior styles early after mTBI could improve prognostication and help with developing personalized treatment plans to improve patient recovery. Future research with larger sample sizes should further examine the influence of age and sex on the relationship between coping behavior and symptom severity.

There is rising concern over the potential cumulative and long-lasting effects of prior concussions in active and retired athletes. Previous studies suggest that there is an inverse relationship between concussion (or mild traumatic brain injury) and sleep, with increasing evidence of individuals reporting chronically disrupted sleep following remote concussion. The extent to which these effects are cumulative across repeat concussions is unknown. This project aimed to investigate the association between the number of prior concussions and subjective sleep quality in otherwise healthy collegiate-aged athletes. Furthermore, we investigated which aspects of sleep are most associated with prior concussion.

A total of 176 collegiate-aged athletes (Mage = 21.19, SD = 1.63; 65.9% men) completed off-season clinical visits, at least 6 months since their most recent concussion. Semi-structured interviews captured detailed sport and head injury history across the lifespan. The number of prior concussions for each participant was retrospectively assessed based on American Congress of Rehabilitation Medicine criteria. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). A general linear model tested the relationship between number of prior concussions and global PSQI score (i.e., overall sleep quality). Logistic regression models were fit to investigate the association of the number of prior concussions with individual subcomponents of the PSQI (i.e., quality, latency, duration, efficiency, disturbances, use of sleep medications, and daily dysfunction), which were binarized based on their distribution. Sex and total number of years of exposure to contact sports were included as covariates for all models.

The number of prior concussions was significantly associated with worse overall sleep quality as assessed by the global PSQI score, F(3,172)=6.92, p= <0.001, unstandardized beta[B](standard error[SE])=0.54(0.14). Investigation of sub-components showed that the number of prior concussions was significantly associated with multiple PSQI subcomponents, including: poorer sleep quality, odds ratio [OR]=1.35, 95% CI [1.05, 1.74], p=0.02; longer sleep latency, OR=1.35, 95% CI [1.08, 1.68], p=0.008; more sleep disturbances, OR=1.56, 95% CI [1.15, 2.12], p=0.004; and more sleep-related daily dysfunction, OR=1.46, 95% CI [1.16, 1.83], p=0.001. The number of prior concussions was not significantly associated with sleep duration, sleep efficiency, or the use of sleep medication (ps>0.05). There were no years of exposure effects (ps>0.05). Select sex-related effects on sleep quality were observed. Specifically, women reported significantly worse global sleep scores, F(3,172)=6.92, p=0.048, B(SE)=-0.99(0.50), and women reported significantly more sleep disturbances, B(SE)=1.47(0.70), p=0.04, OR=4.34 (95% CI [1.11, 16.98].

These results suggest a potential dose-effect of concussion history on poorer sleep quality ratings in otherwise healthy athletes. Specific facets of sleep that were adversely associated with prior concussion included sleep quality, latency, disturbances, and daily dysfunction, highlighting potential areas for sleep-related clinical interventions. Given the adverse effects of chronic sleep disturbance on mental health, future studies are needed to determine the role of concussion-related sleep problems in the adverse psychological outcomes observed in some athletes with multiple prior concussions.

Prior research has found that a greater history of concussion is associated with subtle increases in symptom endorsement. Recent work indicates that a family history of psychiatric disorder is a potential risk factor for prolonged recovery following a single injury. While greater symptom endorsement is observed among those with a personal psychiatric history, the potential role of family psychiatric history in elevated symptom endorsement in the context of repeated concussion has not been investigated. Therefore, the objective of this work was to determine whether family psychiatric history moderates the association of concussion history and elevated symptom endorsement in active collegiate athletes.

A total of 176 (mean age = 21.19 ± 1.63; 116 male) collegiate athletes completed this study at the Medical College of Wisconsin. Participant’s family psychiatric history was collected through a modified Family History Screen (FHS) regarding the participant’s biological parents, siblings, and children, focusing on questions relating to major depressive disorder (MDD; 3 total questions) and general psychiatric history (5 total questions). Concussion history was assessed through a semi-structured interview using American College of Rehabilitation Medicine criteria for mild traumatic brain injury. Concussion symptoms were measured via the Sport Concussion Assessment Tool (SCAT-5) and psychological distress was assessed using the Brief Symptom Inventory-18 (BSI-18). General linear models tested the association of the number of prior concussions with log-transformed SCAT-5 and BSI-18 scores. Additional general linear models were fit to assess the effects of number of prior concussions, family psychiatric history (MDD family history and general family history, each coded as Yes/No), and the interaction of prior concussion and family psychiatric history on log-transformed SCAT-5 and BSI-18 scores. Sex was included as a covariate in all models.

More prior concussions were significantly associated with greater symptom severity scores on the SCAT-5 (x2=26.87, p<0.001, unstandardized beta[B](standard error[SE])=0.25(0.05)) and BSI-18 (x2=20.94, p<0.00, B(SE)=0.19(0.04)). For the models investigating the effects of family psychiatric history, neither the main effect of MDD family history nor the MDD family history by prior concussion interaction were significant for either the SCAT-5 (ps>0.05) or BSI-18 (ps>0.05). Similarly, for the general history model, neither the main effect of general family psychiatric history nor the interaction of general family psychiatric history and number of prior concussions were significant for either the SCAT-5 (ps>0.05) or BSI-18 (ps>0.05). For both the MDD family history and general psychiatric family history models, the number of prior concussions remained positively associated with subjective symptoms on both the SCAT-5 (X2=20.10, p<0.001, and x2=23.50, p<0.001) and BSI-18 (x2=16.46, p<0.001, and x2=20.68, p<0.001).

The results of the current study provide further evidence for a relationship between elevated sub-clinical symptom endorsement and the number of prior concussions in active, collegiate athletes. The results do not, however, support the hypothesis that the association between prior concussion and an athletes’ level of symptom endorsement are moderated by the family psychiatric history. Additional research is needed to determine what factors predispose some individuals to the adverse chronic effects of repeated concussion.

Olfaction is a critical sensory function and changes in the ability to detect smells could affect quality of life by diminishing appreciation of food, drink, and other aroma-based experiences, increase danger of hazardous exposures, and cause a loss of employment. Additionally, decrements in olfaction have been related to onset of some neurodegenerative conditions. Olfactory impairments in military populations are highly prevalent and often attributed to the long-term effects of mild traumatic brain injury (mTBI) and chronic psychiatric disorders. The main goal of this investigation was to examine olfactory function in a cohort of combat veterans using a quantitative smell test.

Participants underwent a neurological examination using a revised version of the Neurological Outcome Scale for Traumatic Brain Injury. Olfactory function was examined using a set of essential oil vials with common odors. Based on the number of correctly identified odors, the following grading system was employed: no deficit; mild; moderate; severe deficit; and absence of smell detection. All study assessments were performed prior to March of 2020 (onset of COVID-19 pandemic). In addition, participants completed performance validity testing (PVT) and screening for ongoing substance misuse using the Alcohol Use Disorders Identification Test and Drug Abuse Screening Test-10. Lifetime history of brain injury, combat-related extracranial injuries, and deployment characteristics were assessed using structured interview. All available medical records were reviewed.

Participants were 38 veterans with a deployment-related mTBI who passed the PVT and did not have ongoing substance misuse issues. Olfactory examination revealed normosmia in 20 participants and various degrees of deficit in 18 (11= mild; 4=moderate; and 3=severe). The groups did not differ in demographics, post-injury interval, or current clinical (non-psychiatric) conditions. Participants with hyposmia frequently reported being exposed to a higher number of blasts and being positioned closer to the nearest primary blast, and more often endorsed a period of loss of consciousness after the most serious mTBI. In addition, they more often reported tympanic membrane perforation, extracranial injuries, and histories of both blast and blunt force mTBI. Comorbid diagnoses of posttraumatic stress disorder (PTSD), depression, chronic headaches, and pain were more common among these participants as well.

Several blast exposure and specific injury-related characteristics increase the likelihood of long-term olfactory impairments, comorbid psychiatric conditions, and chronic pain among veterans with a history of deployment-related mTBI. Notably, none of the participants with hyposmia had a clinical diagnosis of olfactory dysfunction or were receiving service-connected disability for a loss of sense of smell at the time of their assessment. Multidisciplinary rehabilitation care provided to combat veterans with history of mTBI and/or PTSD should include olfactory examination using both quantitative and qualitative smell tests, education regarding the adversities related to loss of smell, management of current psychiatric symptoms, and follow-up assessments. The lack of a comparison group without a history of mTBI and the small sample size were the main limitations of this investigation.

mTBI is trauma to the brain due to a blow or other mechanical force affecting the head. Prior research has established that common symptoms of mTBI include decreased sleep quality and onset/worsening of emotional dysregulation. However, there is little published research investigating how sleep disruption and depressive symptoms are experienced at varying stages of mTBI. We hypothesized that sleep disruption would change with differing time since injury, and that depressive symptoms should accordingly. Additionally, since females tend to have higher rates of depression, we predicted that there would be a significant difference between the sexes at different stages post-mTBI.

This study included 145 healthy adults, split into six groups, comparing healthy controls consisting of 15 males (Mage=23.67, SD=5.066) and 17 females (Mage=25.35, SD=7.035) to individuals who had mTBI, 41 males (Mage=26.88, SD=8.509) and 72 females (Mage=23.79, SD=6.898) at five points post-mTBI: 2 weeks and 1, 3, 6, and 12 months. The Pittsburgh Sleep Quality Index (PSQI) global score was used to assess individual sleep quality and disturbances; higher scores indicated poorer sleep quality. The Beck Depression Index (BDI-II) was used to assess characteristics and symptoms of depression. We adjusted the score to exclude item 16, which measures changes in sleep. Higher scores indicate more severe depressive symptoms. We conducted a multivariate analysis of variance and Pearson correlation to examine whether there were significant differences in sleep and depression at different stages of mTBI for each sex.

We discovered that sleep quality was worse at chronic stages of mTBI (i.e, 12M, p=<.001), than at acute stages (2W, p=.049), and compared to healthy controls. There were also significant differences in depression scores compared to healthy controls at 2W, p=.008, 3M, p=<.001, and 6M, p=.012, but not 12M, p=.313, suggesting that depressive symptoms resolved by 12M in those with mTBI. To explain this, we investigated sex differences, as males tend to experience fewer depressive disorders than females. However, females reported fewer depressive symptoms than males at chronic stages of mTBI. This finding was not statistically significant as females had a Mbdi_total=6.84, SD=7.98 and males had a Mbdi_total=5.38, SD=6.078; still, this could be due to the low statistical power of the study, and with a larger sample size, could produce statistically significant differences between the sexes. Despite this, there is a statistically significant difference in the depression score for females between 2W and 12M post-mTBI (p=.046; effect size of d=.99). Comparatively, males showed no significant divergence between depression and sleep scores.

Sleep disruption and depressive symptoms were correlated in individuals with mTBI in both acute and chronic stages; however, at 12M, there was a decrease in this correlation due to females exhibiting fewer depressive symptoms in combination with greater sleep disruption in the chronic phase of mTBI. Further research investigating the relationship between depression and sleep quality by looking at females with a much larger sample size would be helpful in clarifying these associations.

There is a wide variability in the neuropsychiatric presentation of mild traumatic brain injury (mTBI), and accurate diagnosis and treatment is complicated by within-condition heterogeneity and overlapping symptoms of common comorbidities (e.g., PTSD). Such diagnostic complexities can obfuscate clinical decision-making and lead to suboptimal treatment response. In contrast to traditional diagnostic categories, person-centered analysis methods create data-derived groupings wherein individuals within a cluster are similar and individuals across clusters are different. The current study sought to apply clustering to dimensional emotional and neuropsychological features in treatment-seeking Veterans with mTBI, with the goal of identifying more precise, homogeneous clinical profiles.

Study participants were 190 Veterans with mTBI history participating in a clinical neuropsychological assessment of cognitive complaints (Mean age: 34.38, 89.6% male, average years of education: 13.14). Participants completed a diagnostic interview, neuropsychological tests, and symptom questionnaires (NBSI, PCL, BDI, BAI, AUDIT, PSQI). To identify clusters of similar neuropsychiatric presentations, we first conducted dimension reduction on data from the cognitive tests and self-report measures using principal components analysis. Second, cluster analysis and cluster validation was performed on the resultant principal components (R: kmeans, clusterboot, clusterValid) to find homogeneous subgroups of participants.

The clinical data was best represented by principal components reflecting anxious arousal, depressive cognitions, somatic post-concussive symptoms, reexperiencing and avoidance symptoms, and objective cognitive deficits. Cluster analysis using bootstrapping and cluster validity indices (e.g., Silhouette width, Dunn index) indicated that a 6-subgroup solution was optimal (subgroups were labeled Group A-Group F). Group A was characterized by moderate levels across all dimension scores. Group B was characterized by elevated somatic post-concussive symptoms and cognitive deficits. Group C was characterized by intact cognitive performance and low somatic post concussive symptoms. Group D was characterized by elevated depressive cognitions. Group E was characterized by high anxious arousal but low depressive cognitions and reexperiencing and avoidance. Group F was characterized by elevated reexperiencing and avoidance. The subgroups did not differ statistically on any demographic items, such as years of education, age, or gender. However, there were statistically significant differences across groups in performance validity failure (x2(10) = 27.17, p=.002); Group B showed the highest rate of failure.

Results demonstrate that phenotypically similar subgroups of individuals can be identified within treatment-seeking Veterans with mTBI. Data suggest that somatic post-concussive symptoms may be linked to cognitive deficits, however the rate of validity failure indicates that neuropsychological test scores may not reflect true cognitive ability. In contrast to prior studies that treat mTBI as a unitary construct that accounts for symptoms, our data suggest that a nuanced evaluation yields vastly diverse clinical presentations. Cluster analytic frameworks hold promise for better assessment and treatment planning for Veterans, as both patients and their treating clinicians would be greatly served by the ability to use common clinical assessment tools to better identify a given individual’s clinical needs. A critical next step is to validate subgroups using novel samples and data sources (e.g., neurobiology, genetics) and to determine if these subgroupings can be effectively utilized to personalize treatment assignment.

A non-negligeable proportion of individuals who have sustained a mild traumatic brain injury (TBI) are at risk of developing persistent symptoms. The impact of persistent post-mTBI symptoms can be profound, causing significant disruptions in well-being, functioning and quality of life (Agtarap, et al., 2021). Reduced social participation often extends beyond the acute recovery period and continues to be associated with lower quality of life for many months after mTBI (Voormolen et al., 2019). Coping was found to be essential in order to decrease physical symptoms, have better psychological health, as well as increase social participation (Vos et al., 2019). The variables of perceived stress and depression were also linked directly and indirectly to mild post-TBI adjustment in terms of their return-to-work status (Strom and Kosciulek, 2007). Furthermore, a greater percentage of individuals with mTBI report chronic pain as compared to individuals with more severe TBIs (Weyer Jamora, Schroeder & Ruff, 2013). Given these implications and the growing concern for mTBI as a potentially disabling and chronic medical condition, it is important to focus on identifying the processes that can lead to persistent symptoms and related preventive interventions that can be applied. This present study aimed to investigate the association between coping and social participation according to anxiety, depression, and pain symptomatology, before and after rehabilitation in a mild TBI population benefiting from an outpatient rehabilitation program.

A prospective longitudinal cohort study design was employed, with two-time points for outcome assessment (i.e., start and end of rehabilitation). This study included 70 adults aged between 18 and 78 who experienced a mTBI between February 2016 and January 2020 and received interdisciplinary outpatient rehabilitation services at a major rehabilitation centre in the Greater Montreal region.Measures administered pre and post rehabilitation included the Rehabilitation Survey of Problems and Coping (R-SOPAC), the Mayo-Portland Adaptability Inventory-4 (MPAI-4), the Depression Anxiety Stress Scales 21 (DASS-21), and the Brief Pain Inventory-Short Form (BPI-SF). Mediation analyses were carried out via PROCESS macro for SPSS, model 4 and 6 (Hayes, 2013).

Mediation analyses indicated a partial indirect link between coping, anxiety, and pain on the level of social participation at the pre-rehabilitation time point. Post-rehabilitation, a significant partial mediating relationship regarding the impact of pain on the link between coping and social participation, was found. In addition, a statistically significant mediation relationship was found, where anxiety mediated the relationship of coping and social participation. These relationships suggest that lower levels of coping appear to be linked to a higher self-reported level of psychological distress and pain, resulting in lower social participation.

This observational rehabilitation cohort study demonstrates how anxiety and pain are associated with coping and social participation outcome following mTBI. These results are quite pertinent for clinical purposes in that paying close attention to the level of anxiety and perceived impact of pain during rehabilitation, and applying targeted interventions at these levels, in particular to increase coping, may prove particularly beneficial to improve social participation outcome.