1. Non-pharmacological interventions to reduce psychological sequelae of mild traumatic brain injury: A systematic review Dr Nikola Creasey Paediatric Emergency Medicine, Bristol Royal Hospital for Children, UK

2. Clinical Context

3. Objectives To perform a review of the literature to answer the question: In ‘all age groups with minor Traumatic Brain Injury’ can ‘non-pharmacological interventions’ reduce the incidence of ‘post concussion syndrome’?

4. Records identified through database searching (n = 2722) Abstracts screened (n = 2722 ) Records excluded (n = 2619) Full-text articles assessed for eligibility (n = 114) Exclusions (total = 93) Chronic symptoms (n=36) Not mTBI (n=9) Reviews/editorials/ protocols/non RCTs (n=24) Abstract only/no published data (n=15) Duplicates (n=7) Not human (n=1) Unable to access (n=1 ) Studies included in qualitative synthesis (n = 21) Additional articles identified from screening references (n= 11) Flow chart showing identification of studies

5. Results – Children 3 studies

6. Results – Children – 3 studies Casey 1987 Discharge interview and follow up phone call next day No significant difference in symptoms, behaviour at 1 month Ponsford 2001 Booklet then face to face appointment within a week Reduced frequency of symptoms at 3 months Olsson 2015 Parent information booklet and educational website for the child No significant differences

7. Results – Adults 2

8. 2 5

9. 2 5 3

10. 2 5 3 1

11. 2 5 3 1 2

12. 2 5 3 1 2 3

13. Bed rest/admission to hospital Lowdon 1989 24 hour hospital stay with advice and reassurance at discharge Slight reduction in duration of symptoms (significant only for poor memory) De Kruijik 2002 Bed rest for 6 days then gradual return to activities vs gradual activity No significant difference

14. Information/Face to face Wade 1997 Face to face (or telephone) information and advice at 7-10 days including leaflet Ponsford 2002 Information booklet plus follow up at 5-7 days with neuropsych assessments Moore 2014 Verbal and written education, coping strategies delivered by a social worker in ED. Prevented functional decline. Heskestad 2010 Educational consultation with neurosurgeon at 2 weeks Matuseviciene 2013 Physician visit at 14-21 days assessing symptoms, giving information and reassurance. Included only those symptomatic at day 10

15. Information/Telephone contact Hinkle 1986 Information OR Information plus weekly phone calls Quicker return to work only if both groups combined (no difference in Sx) Alves 1993 Information OR Information plus weekly phone calls Reduced symptoms only in ‘best case’ scenario Bell 2008 Telephone counselling at 2 days, 2, 4, 8, 12 weeks & written information. Significantly less symptoms and better functioning in intervention group

16. Text messages Suffoletto 2013 Text messages to assess symptoms then with advice in response to symptom reporting Reduction in symptoms but not significant Pilot study

17. Cognitive Behavioural therapy Mittenburg 1996 Written information & 1 hour CBT session Shorter duration and fewer symptoms in intervention group Silverberg 2013 CBT VS face to face session with OT for advice and information Significantly lower rate of PCS in CBT group Patients included were assessed to be high risk for persistent symptoms

18. Treatment as needed Ghaffar 2006 MDT clinic then personalised treatment or follow up for 6 months Paniak 1998 & 2000 Single session with education then physical and psychotherapy as needed Elgmark-Andersson 2007 & 2011 Phone call 2-8 weeks – if symptomatic offered rehabilitation based on need

19. Results - Summary Limited evidence – extremes of age Methodological heterogeneity Variable quality Efficacy of interventions is questionable

20. Conclusions Providing information appears to reduce morbidity & no harm More intensive interventions yet to convincingly show benefit May be most useful for patients at higher risk of PCS More (and improved) research clearly needed Lack of research in young children

21. Thank you Any questions? Contact: nikolacreasey@nhs.net