Journal of Rehabilitation Medicine 51-1CompleteIssue | Page 36

Factors associated with persistent post-concussion symptoms
Limited evidence supports efficacy of interven-
tions to reduce PCS following mTBI. Some evidence
suggests provision of written information regarding
expected symptoms and suggested coping strategies
results in fewer reported PCS and lower anxiety 3
months post-injury (26–28).
The recently completed NET trial (29) examined
the effectiveness of an implementation intervention
to increase uptake of 3 recommendations for mana-
gement of mTBI patients in emergency departments
(ED): (i) prospective assessment of PTA using a vali-
dated tool; (ii) use of guideline-developed criteria to
determine use and timing of computed tomography
(CT) imaging; and (iii) provision of written patient
information upon discharge from the ED. Control sites
received access to an evidence-based clinical practice
guideline without further implementation support. The
present study utilized a cohort of patients participating
in a follow-up component of this study (NET-Plus);
first to describe long-term PCS symptoms, work/study
outcomes, anxiety levels and quality of life in mTBI
patients presenting to ED with GCS 14 or 15; and
secondly, to identify factors associated with persistent
PCS at follow-up, including the impact of receiving
mTBI information in ED. It was hypothesized that
persistent PCS would be reported in 20% of cases, and
symptom reporting associated with age, sex, pre-injury
mental health issues, concurrent anxiety, and recall of
receipt of written information regarding the nature of
expected symptoms.
METHODS
The NET trial was a cluster randomised trial (CRT) involving
31 Australian EDs. The NET protocol has previously been
published and this study only provides a brief overview of
procedures relevant to the NET-Plus component of the trial (29).
Recruitment
The trial had 2 levels of hospital participation, designated NET
and NET-Plus. EDs participating in NET measured clinical
practice outcomes only, whereas EDs participating in NET-Plus
assessed patient outcomes following discharge in a subgroup
of individuals who agreed to be followed up from the larger
cohort. This paper examines data from the NET-Plus cohort.
Of the 31 EDs in the NET study, 24 agreed to participate in the
NET-Plus trial and recruited participants. In this cohort, 10 EDs
were allocated to the intervention and 14 to the control group.
However, 7 control EDs reported receiving (limited) education
regarding the management of mTBI as part of standard clinical
education programmes or in-service training during the trial.
One control site had an existing validated PTA assessment tool,
administered by occupational therapists. For the current paper,
the NET-Plus cohort was analysed as a single group. Trained
chart auditors identified eligible candidates on the basis of 4
pre-defined inclusion criteria obtained from medical records: (i)
aged 18 years or older; (ii) presented to the ED within 24 h of
33
injury; (iii) sustained an acute blunt head trauma; and, (iv) do-
cumented a GCS score of 14 or 15 at presentation. Patients with
penetrating injuries or non-traumatic brain injuries (e.g. stroke)
were excluded. Eligible candidates were initially contacted by
an ED staff member and invited to participate in a follow-up
telephone interview. Exclusion criteria at this phase were: (i)
non-English speaking background; (ii) limited hearing ability;
(iii) cognitive impairment from intellectual disability and/or
other neurological syndrome; and, (iv) severe substance use
disorder and/or major psychiatric disorder requiring previous
hospitalization. Interested candidates were posted an informa-
tion sheet with a 2-week opt out option. After 2 weeks, consent
was presumed and contact details were provided to researchers
with clinical training and experience in conducting interviews
with a brain trauma population. Researchers further screened for
capacity to provide informed consent at interview commence-
ment and calls were terminated if participants were intoxicated,
distressed or impaired cognition was suspected. Overall, 343
participants were recruited into the study.
Procedures
Ethical approval for the study protocol was granted by Alfred
Health Human Research Ethics Committee (approval number
398/12). Local ethics was further obtained for each hospital site.
Four attempts were made to contact consenting participants.
Patient outcomes were collected through a structured telephone
interview. The interview took approximately 15 min to complete
and included questions on whether patient information was
received in the hospital (see the following website for a copy
of this information resource, which included information about
expected symptoms and suggested coping strategies: https://
www.monash.edu/medicine/psych/research-programs/merrc/
resources), healthcare utilization since discharge (i.e. whether
they visited healthcare facilities in the 4 weeks prior to the
assessment for the head injury or another reason, and whether
they had taken medication for headaches, anxiety, sleep issues
or nausea), and return to work/study (i.e. status prior and post-
injury). Pre-injury psychiatric history and substance use was
documented by asking participants to answer yes or no to the
following questions: “Have you ever had psychological/psychia-
tric problems?”, “Are you currently taking or have previously
taken illicit drugs?”, and, “Has drinking alcohol ever disrupted
your lifestyle?” The interview also included scales measuring
PCS, anxiety and quality of life, discussed below. Participant
responses were entered directly into the online database with
real-time checks to minimize risk of error and missing data.
Researchers conducting interviews received training and su-
pervision in initial interviews to ensure standardized protocol
delivery. Information regarding injuries (LOC, GCS, other
injuries) and whether information had been given to patients
was sought from medical records.
Measures
Primary outcome for current study. The Rivermead Post Con-
cussion Symptom Questionnaire (RPQ) (30) was used to assess
symptom experience. Participants rated on a 5-point scale their
experience of each of 16 symptoms at time of assessment (over
the last 24 h), with 0 = symptom not present, 1 = symptom no more
of a problem than pre-injury, and scores of 2, 3, and 4 reflecting
mild, moderate and severe post-injury symptoms, respectively.
Higher scores thus indicated greater severity of PCS. The overall
score was computed by summing scores for all 16 items (range
0–64). A total score represented the sum of scores only if scores
J Rehabil Med 51, 2019