Identification of At-Risk Patients that need more Intensive Treatment Following mTBI: Post-Hoc Inisghts

Objective. To identify at-risk patients unresponsive to preventative treatment following mild traumatic brain injury (mTBI), by retrospectively studying demographics and several psychological measures two weeks after injury on their predictive value with regard to return to work (RTW) and functional outcome twelve months post-injury.

Participants and methods. The study is a post-hoc study of a RCT which was part of a larger prospective cohort-study on outcome following mTBI (UPFRONT-study). In this RCT, the effectiveness of an CBT intervention was compared to telephonic counseling in at-risk mTBI patients. In total, 84 patients were included and randomized. Of those 84 patients, 39 patients received five sessions of the CBT intervention and 45 patients received five sessions telephonic counseling (which included psycho-education). For this post-hoc analysis, we investigated the 84 patients as one at-risk group that received a form of psychological treatment (either CBT or telephonic counseling). A binomial logistic regression was performed to determine which variables at two weeks post-injury had the strongest contribution to the prediction of an unsuccessful RTW and an unfavorable outcome twelve months post-injury.

Results. Of the 84 patients, 43 (51.2%) showed a favorable functional outcome twelve months post-injury, and 56 (66.7%) of these patients had a full RTW twelve months post-injury. The patients with an unfavorable outcome and unsuccessful RTW had a higher age and higher levels of psychological complaints (i.e. higher reports of anxiety, depression, PTSD) at 2-weeks post-injury and 12 months post-injury. With regard to outcome (GOSE), the logistic regression model was statistically significant ((6)=28.08, p<.0001). Of the 6 predictor variables, 3 where significant: levels of anxiety, depression and the treatment condition. With RTW, the logistic regression model was statistically significant ((6)=20.69, p<.001), and 3 out of 6 predictor variables were significant: patients with higher levels of depression, posttraumatic stress and a higher use of a passive coping style at two-weeks had higher odds of an unsuccessful RTW.

Conclusions. This post-hoc study is one of the few studies that investigates the factors within an at-risk mTBI group that may predict patients being more or less likely to benefit from treatment. The main findings comprise several differences in demographic and psychological measures between the patients with a favorable outcome and an unfavorable outcome and between patients that have returned to work versus the patients that have not. Moreover, in both our prediction models of outcome and RTW, we found several psychological measures assessed at two weeks post-injury that greatly determined the likelihood of patients benefitting from the preventive treatment.
Our results seem to suggest that from the beginning there are some patients for whom a short preventive treatment is not sufficient and that selection and treatment of at-risk patients might be better based on psychological symptoms instead of general posttraumatic complaints.