Departments of Neurology and Population Health, NYU Langone Medical Center, New York, NY, USA.
Barnard College, Columbia University, New York, NY, USA.
Headache. 2019 Feb;59(2):151-163. doi: 10.1111/head.13455. Epub 2018 Dec 1.
BACKGROUND: There are no clear guidelines on how to treat posttraumatic headache (PTH) or post-concussive symptoms (PCS). However, behavioral interventions such as cognitive behavioral therapy, biofeedback, and relaxation are Level-A evidence-based treatments for headache prevention. To understand how to develop and study further mind-body interventions (MBIs) and behavioral therapies for PTH and PCS, we developed the following question using the PICO framework: Are behavioral therapies and MBIs effective for treating PTH and PCS? METHODS: We conducted a systematic search of 3 databases (Medline, PsycINFO, and EMBASE) for behavioral interventions and MBIs with the subject headings and keywords for PTH, concussion, and traumatic brain injury (TBI). Inclusion criteria were (1) randomized controlled trials, (2) the majority of the intervention had to be behavioral or mind-body therapy focused, (3) the majority of the participants (>50%) had to have had a mild TBI (not a moderate or severe TBI), (4) published in a peer-reviewed publication, and (5) meeting pre-specified primary and/or secondary outcomes. Primary outcome(s): whether there was a significant change in concussion symptom severity (yes/no) based on the symptom severity checklist/scale used, whether there was a 50% reduction in headache days and/or disability; secondary outcome(s): sleep variables, cognitive complaints, depression, and anxiety. The search identified 917 individual studies. Two independent reviewers screened citations and full-text articles independently. Nineteen articles were pulled for full article review. Seven articles met the final inclusion criteria. The systematic review was registered in Prospero (CRD42017070072). RESULTS: Overall, there was vast heterogeneity across the studies, making it difficult to fully assess efficacy. The heterogeneity ranged from differences in patient populations, the timing of when the interventions were initiated, the types of intervention implemented, and the measures used to assess outcomes. Seven studies were identified as meeting final inclusion criteria, resulting in a total of 1108 adult participants ranging from 18 to 80. Sixty-nine percent were male. Of the 7 studies, 3 were focused on military staff (retired and active). Time post-injury for inclusion into the studies varied from 48 hours post-injury to more than 2 years post-injury. One of the 7 studies did not include time post-TBI in the inclusion criteria. Two studies recruited patients who had visited their emergency departments, 4 of the studies recruited subjects through outpatient referrals, and 1 study recruited patients who had been in a prior traffic accident with resulting chronic PTH directly from a headache center. Group cognitive behavioral therapy (CBT) sessions and telephonic counseling or communication were common intervention methods used in the studies, with group CBT being used in 2 of the studies and telephonic counseling being used in 3. Other intervention methods used included individual CBT, cognitive training, psychoeducation, and computer-based and/or therapist-directed cognitive rehabilitation. CONCLUSIONS: Many of the interventions offered vastly different methods of delivery of intervention and doses of intervention. Many of the negative studies were done after an extended duration post-injury (>1-year posttraumatic brain injury [TBI]). In addition, the participants were lumped together regardless of their pre-concussion comorbidities, their mechanism of injury, their symptoms, and the duration from injury to the start of the intervention. The mass heterogeneity found between the studies led to inconclusive findings. Thus, there are various considerations for the design of the intervention for future behavioral/MBI studies for PTH and concussion that must be addressed before the leading question of this review may be effectively answered.
背景:目前尚无明确的指南来治疗创伤后头痛(PTH)或脑震荡后症状(PCS)。然而,认知行为疗法、生物反馈和放松等行为干预措施是预防头痛的一级循证治疗方法。为了了解如何为 PTH 和 PCS 开发和进一步研究身心干预(MBI)和行为疗法,我们使用 PICO 框架提出了以下问题:行为疗法和 MBI 是否对治疗 PTH 和 PCS 有效?
方法:我们对 3 个数据库(Medline、PsycINFO 和 EMBASE)进行了系统搜索,以查找针对 PTH、脑震荡和创伤性脑损伤(TBI)的行为干预和 MBI 的主题词和关键词。纳入标准为:(1)随机对照试验,(2)干预措施大部分必须为行为或身心治疗,(3)大部分参与者(>50%)必须患有轻度 TBI(非中度或重度 TBI),(4)在同行评审出版物中发表,(5)符合预先指定的主要和/或次要结局。主要结局:是否根据使用的症状严重程度检查表/量表,出现了 concussion 症状严重程度的显著变化(是/否),头痛天数和/或残疾是否减少了 50%;次要结局:睡眠变量、认知主诉、抑郁和焦虑。搜索共确定了 917 项单独的研究。两名独立评审员独立筛选引文和全文文章。抽取了 19 篇文章进行全文审查。有 7 篇文章符合最终纳入标准。该系统评价已在 Prospero(CRD42017070072)中注册。
结果:总体而言,研究之间存在很大的异质性,难以全面评估疗效。异质性范围从患者人群的差异、干预开始的时间、实施的干预类型以及用于评估结果的措施等方面。有 7 项研究被确定为最终纳入标准,共纳入 1108 名成年参与者,年龄从 18 岁到 80 岁不等。69%为男性。在 7 项研究中,有 3 项针对军事人员(退休和现役)。纳入研究的时间从受伤后 48 小时到受伤后 2 年以上不等。其中 1 项研究的纳入标准中不包括 TBI 后的时间。有 2 项研究招募了曾去过急诊室的患者,4 项研究通过门诊转介招募受试者,1 项研究从头痛中心直接招募了曾发生过慢性 PTH 的交通事故患者。小组认知行为疗法(CBT)会议和电话咨询或沟通是研究中常用的干预方法,其中 2 项研究使用了小组 CBT,3 项研究使用了电话咨询。其他干预方法包括个体 CBT、认知训练、心理教育以及基于计算机和/或治疗师指导的认知康复。
结论:许多干预措施提供了截然不同的干预方法和干预剂量。许多负面研究是在受伤后较长时间(>1 年)后进行的。此外,参与者被不分青红皂白地聚集在一起,无论他们是否有预先存在的共病、损伤机制、症状以及从受伤到开始干预的时间。研究之间存在大量的异质性,导致研究结果不一致。因此,在这个综述的主要问题得到有效回答之前,针对 PTH 和脑震荡的身心干预/MBI 研究,需要考虑各种干预设计的考虑因素。
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