Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study

John K Yue, Maryse C Cnossen, Ethan A Winkler, Hansen Deng, Ryan R L Phelps, Nathan A Coss, Sourabh Sharma, Caitlin K Robinson, Catherine G Suen, Mary J Vassar, David M Schnyer, Ava M Puccio, Raquel C Gardner, Esther L Yuh, Pratik Mukherjee, Alex B Valadka, David O Okonkwo, Hester F Lingsma, Geoffrey T Manley, TRACK-TBI Investigators, Shelly R Cooper, Kristen Dams-O'Connor, Wayne A Gordon, Allison J Hricik, Andrew I R Maas, David K Menon, Diane J Morabito, John K Yue, Maryse C Cnossen, Ethan A Winkler, Hansen Deng, Ryan R L Phelps, Nathan A Coss, Sourabh Sharma, Caitlin K Robinson, Catherine G Suen, Mary J Vassar, David M Schnyer, Ava M Puccio, Raquel C Gardner, Esther L Yuh, Pratik Mukherjee, Alex B Valadka, David O Okonkwo, Hester F Lingsma, Geoffrey T Manley, TRACK-TBI Investigators, Shelly R Cooper, Kristen Dams-O'Connor, Wayne A Gordon, Allison J Hricik, Andrew I R Maas, David K Menon, Diane J Morabito

Abstract

Introduction: Over 70% of traumatic brain injuries (TBI) are classified as mild (mTBI), which present heterogeneously. Associations between pre-injury comorbidities and outcomes are not well-understood, and understanding their status as risk factors may improve mTBI management and prognostication. Methods: mTBI subjects (GCS 13-15) from TRACK-TBI Pilot completing 3- and 6-month functional [Glasgow Outcome Scale-Extended (GOSE)] and post-concussive outcomes [Acute Concussion Evaluation (ACE) physical/cognitive/sleep/emotional subdomains] were extracted. Pre-injury comorbidities >10% incidence were included in regressions for functional disability (GOSE ≤ 6) and post-concussive symptoms by subdomain. Odds ratios (OR) and mean differences (B) were reported. Significance was assessed at p < 0.0083 (Bonferroni correction). Results: In 260 subjects sustaining blunt mTBI, mean age was 44.0-years and 70.4% were male. Baseline comorbidities >10% incidence included psychiatric-30.0%, cardiac (hypertension)-23.8%, cardiac (structural/valvular/ischemic)-20.4%, gastrointestinal-15.8%, pulmonary-15.0%, and headache/migraine-11.5%. At 3- and 6-months separately, 30.8% had GOSE ≤ 6. At 3-months, psychiatric (GOSE ≤ 6: OR = 2.75, 95% CI [1.44-5.27]; ACE-physical: B = 1.06 [0.38-1.73]; ACE-cognitive: B = 0.72 [0.26-1.17]; ACE-sleep: B = 0.46 [0.17-0.75]; ACE-emotional: B = 0.64 [0.25-1.03]), headache/migraine (GOSE ≤ 6: OR = 4.10 [1.67-10.07]; ACE-sleep: B = 0.57 [0.15-1.00]; ACE-emotional: B = 0.92 [0.35-1.49]), and gastrointestinal history (ACE-physical: B = 1.25 [0.41-2.10]) were multivariable predictors of worse outcomes. At 6-months, psychiatric (GOSE ≤ 6: OR = 2.57 [1.38-4.77]; ACE-physical: B = 1.38 [0.68-2.09]; ACE-cognitive: B = 0.74 [0.28-1.20]; ACE-sleep: B = 0.51 [0.20-0.83]; ACE-emotional: B = 0.93 [0.53-1.33]), and headache/migraine history (ACE-physical: B = 1.81 [0.79-2.84]) predicted worse outcomes. Conclusions: Pre-injury psychiatric and pre-injury headache/migraine symptoms are risk factors for worse functional and post-concussive outcomes at 3- and 6-months post-mTBI. mTBI patients presenting to acute care should be evaluated for psychiatric and headache/migraine history, with lower thresholds for providing TBI education/resources, surveillance, and follow-up/referrals. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01565551.

Keywords: functional impairment; mild traumatic brain injury; post-concussive symptoms; pre-injury comorbidities; prognosis.

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