Missed Emergency Department Diagnosis of Mild Traumatic Brain Injury in Patients with Chronic Pain After Motor Vehicle Collision.

BACKGROUND: Mild traumatic brain injury (mTBI), or concussion, is the most common presentation of TBI in the emergency department (ED), but a diagnosis of mTBI may be missed in patients presenting with other acute injuries after a motor vehicle collision (MVC). OBJECTIVE: To estimate the frequency of missed diagnoses of mTBI in patients seen in the ED after MVC who later developed chronic pain syndromes. STUDY DESIGN: Retrospective cohort study. SETTING: An interventional pain management clinic. METHODS: Data were drawn from information collected during standardized intake assessments completed by 33 patients involved in an MVC referred to a community-based clinic for chronic pain management. The prevalence of missed mTBI and postconcussion syndrome (PCS) were estimated based on the clinical diagnosis, which included reviewing acute care medical records, the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) scores, and patient-reported injury history. RESULTS: There was a high prevalence of presumed mTBI in this sample (69.7%) of patients involved in an MVC, but an acute care diagnosis was made in only 39.1% of cases. Patients diagnosed with mTBI at acute care had significantly lower PCS symptom scores than patients whose diagnosis was missed (P < 0.05). Diagnostic brain imaging (magnetic resonance imaging [MRI] or computed tomography [CT]) was more frequently ordered (P < 0.05) in patients diagnosed with mTBI. Using a modified RPQ developed for use with chronic pain patients, 54.5% of the sample met criteria for PCS. Loss of consciousness, meeting established criteria for mTBI, postinjury headache, and meeting criteria for posttraumatic stress disorder were significantly correlated with the development of PCS. LIMITATIONS: Data may be subject to recall and selection bias. Additional research with a larger study sample is needed to investigate correlations between individual symptoms and the development of PCS following an MVC. CONCLUSION: Patients presenting to the ED following an MVC have a high prevalence of mTBI. Patients whose diagnosis of mTBI is missed end up with significantly more severe postconcussion symptoms. While all patients included in this study were either referred or being treated for chronic pain after an MVC, they all also went on to develop PCS and disability following their accident, suggesting that better screening for mTBI after an MVC might identify those who may require more follow-up or rehabilitation therapy. In particular, those presenting with loss of consciousness, an altered mental state, posttraumatic amnesia, or postinjury headache are at increased risk of PCS.

Acceptability of transcranial direct current stimulation in children and adolescents with ADHD: The point of view of parents.

Transcranial direct current stimulation (tDCS) is a novel treatment option for attention deficit hyperactivity disorder. To facilitate translation into clinical practice, we interviewed parents of children who have experienced experimental tDCS. A grounded theory approach using open, axial, and selective coding provided seven emergent themes for acceptability: tDCS provides hope for parents, safety tolerability and side effects of tDCS versus medication, burden of treatment, education and trust with care providers, cost and coverage, unestablished tDCS efficacy versus established medication effectiveness, perceived compliance of tDCS versus medication. Results suggest tDCS is acceptable but depends on evidence of effectiveness and regular availability.

Elevated and Slowed EEG Oscillations in Patients with Post-Concussive Syndrome and Chronic Pain Following a Motor Vehicle Collision.

(1) Background: Mild traumatic brain injury produces significant changes in neurotransmission including brain oscillations. We investigated potential quantitative electroencephalography biomarkers in 57 patients with post-concussive syndrome and chronic pain following motor vehicle collision, and 54 healthy nearly age- and sex-matched controls. (2) Methods: Electroencephalography processing was completed in MATLAB, statistical modeling in SPSS, and machine learning modeling in Rapid Miner. Group differences were calculated using current-source density estimation, yielding whole-brain topographical distributions of absolute power, relative power and phase-locking functional connectivity. Groups were compared using independent sample Mann-Whitney U tests. Effect sizes and Pearson correlations were also computed. Machine learning analysis leveraged a post hoc supervised learning support vector non-probabilistic binary linear kernel classification to generate predictive models from the derived EEG signatures. (3) Results: Patients displayed significantly elevated and slowed power compared to controls: delta (p = 0.000000, r = 0.6) and theta power (p < 0.0001, r = 0.4), and relative delta power (p < 0.00001) and decreased relative alpha power (p < 0.001). Absolute delta and theta power together yielded the strongest machine learning classification accuracy (87.6%). Changes in absolute power were moderately correlated with duration and persistence of symptoms in the slow wave frequency spectrum (<15 Hz). (4) Conclusions: Distributed increases in slow wave oscillatory power are concurrent with post-concussive syndrome and chronic pain.

Systematic Review on the Safety and Tolerability of Transcranial Direct Current Stimulation in Children and Adolescents.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a safe, tolerable, and acceptable technique in adults. However, there is limited evidence for its safety in youth. Although limited, there are a handful of important empirical articles that have evaluated safety and tolerability outcomes in youth. However, a synthesis of pediatric safety studies is not currently available. OBJECTIVE: To synthesize objective evidence regarding the safety and tolerability of pediatric tDCS based on the current state of the literature. METHODS: Our search and report used PRISMA guidelines. Our method systematically examined investigations purposefully designed to evaluate the safety, tolerability, and acceptability of tDCS in healthy and atypical youth that were submitted to three databases, from the beginning of the database to November 2019. Safety considerations were evaluated by studies utilizing neuroimaging, physiological changes, performance on tasks, and by analyzing reported and objective side effects; tolerability via rate of adverse events; and acceptability via rate of dropouts. RESULTS: We report on 203 sham sessions, 864 active sessions up to 2 mA, and 303 active hours of stimulation in 156 children. A total of 4.4% of the active sessions were in neurotypical controls, with the other 95.6% in clinical subjects. CONCLUSION: In spite of the fact that the current evidence is sporadic and scarce, the presently reviewed literature provides support for the safety, tolerability, and acceptability, of tDCS in youth for 1-20 sessions of 20 min up to 2 mA. Future pediatric tDCS research is encouraged.

What Do We Know about Transcranial Direct Current Stimulation for Major Depression?

The interest in using non-invasive brain stimulation (NIBS) for the treatment of major depression (MD), including treatment resistant depression, is growing rapidly. The paper by Bennabi and Haffen (Brain Sci. 2018, 8) was an important step towards the formal acceptance of transcranial direct current stimulation (tDCS) as a possible form of therapy. Their review demonstrated favourable support for the beneficial effects of tDCS for MD, coupled with necessary practical considerations, such as its relatively low cost, portability/ease of use in clinical settings, non-invasiveness, and good tolerability. Here, we provide a follow-up to their review and sketch a current update. Means for optimizing tDCS efficacy and potential limitations of current studies are discussed.

The polytrauma clinical triad in patients with chronic pain after motor vehicle collision.

BACKGROUND: The polytrauma clinical triad (PCT) is a complex disorder composed of three comorbid diagnoses of chronic pain, post-traumatic stress disorder (PTSD), and postconcussion syndrome (PCS). PCT has been documented in veterans returning from deployment, but this is the first report on PCT prevalence in nonmilitary personnel after a motor vehicle collision (MVC). METHODS: Data were drawn from routine intake assessments completed by 71 patients referred to a community-based clinic for chronic pain management. All patients completed the post-traumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PCL-5), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) during a standardized intake assessment. An additional modified RPQ score was derived to address previously reported symptom overlap between PCS and chronic pain. RESULTS: Standard and modified RPQ scores yielded PCS prevalence rates of 100% and 54.9% in our sample, respectively. Results suggest that a modified RPQ score, limited to visual and vestibular symptoms, may be more useful PCS screening criteria in patients with chronic pain. PTSD screening criteria on the PCL-5 were met by 85.9% of the patients. More than half of the patients referred for chronic pain after MVC met criteria for PCT (52.1%). Patients who met PCT criteria reported worse headache, overall pain, and sleep quality outcomes. CONCLUSION: Among patients in our sample with chronic pain after MVC, more than half met criteria for PCT. A modified approach to RPQ scoring limited to visual and vestibular symptoms may be required to screen for PCS in these patients.