From a symptom perspective, neuromodulation was reported to be effective at improving post-concussion symptom ratings (Walker et al., 2002; Koski et al., 2015; Huang et al., 2017; Moussavi et al., 2019; Stilling et al., 2019a,b), pain and headaches (Leung et al., 2016a,b, 2018; Choi et al., 2018; Stilling et al., 2019a,b), dizziness (Paxman et al., 2018), depression (Leung et al., 2018; Moussavi et al., 2019; Stilling et al., 2019a,b), anxiety (Stilling et al., 2018), sleep disturbance (Huang et al., 2017), general disability (Fitzgerald et al., 2011), some aspects of cognition (Fitzgerald et al., 2011), return to work (Walker et al., 2002; Stilling et al., 2019a,b), and quality of life (Choi et al., 2018; Paxman et al., 2018; Stilling et al., 2019a,b). Neuropsychol. Transcranial direct current stimulation: a computer-based human model study. 19, 523–535. Proposed Definition and Next Steps for the Veteran Wellness Alliance. This study sought to review the effects of certain types of neuromodulation on the symptoms of mTBI and PPCS. Hence, mTBI represents a significant problem which has implications for the individual and society in general. Traumatic Brain Injury Research at MRN It is undeniable that there has been a sea change regarding the potential long-term consequences of mild traumatic brain injury (mTBI), also referred to as concussion. The effect of repetitive transcranial magnetic stimulation on fibromyalgia: a randomized sham-controlled trial with 1-mo follow-up. International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision). Phys. Brain Injury 33, 1021–1031. (2007). Neuropsychol. 8, S91–s100. The role of controlled exercise in concussion management. Neuromodulation 21, 390–401. Brain Injury 31, 279–289. Mild traumatic brain injury (mild TBI) has become an increasingly important disorder in neuropsychology practice in the US in the past three decades, and it will likely remain a significant focus of clinical and research endeavors for years. Med. doi: 10.1016/j.apmr.2008.12.016, Dikmen, S., Machamer, J., Fann, J. R., and Temkin, N. R. (2010). Cell. Somatic symptoms often include dizziness, sleep disturbance, headaches, nausea, photophobia, visual disturbance, and phonophobia. Using functional near-infrared spectroscopy to study the effect of repetitive transcranial magnetic stimulation in concussion: a two-patient case study. 101, 382–393. From a neurophysiological perspective, efficacy was seen in normalizing altered working memory activation patterns (Koski et al., 2015; Ansado et al., 2019), vestibular field potentials (Moussavi et al., 2019), haemodynamic responses within the DLPFC (Stilling et al., 2019a) and excessive delta wave EEG activity (Huang et al., 2017). doi: 10.1097/HTR.0000000000000503, Larsen, S., and Sherlin, L. (2013). Neurofeedback: an emerging technology for treating central nervous system dysregulation. J. Rehabil. Phys. So, an alternative approach to rehabilitation using neuromodulation, might be to focus on normalizing neurophysiological aberrations rather than symptoms. Pre-existing conditions amongst the participants included depression (n = 9 participants), drug addiction (n = 1 participant), migraine (n = 1 participant), and other medical conditions (n = 4 participants). A narrative synthesis was conducted because there was a mix of randomized controlled trials and non-randomized designs and the studies did not contain sufficient data to use any of the recommended data synthesis methods provided in the Cochrane handbook (Higgins et al., 2019). doi: 10.1080/16501960410023877, Chen, R., Classen, J., Gerloff, C., Celnik, P., Wassermann, E. M., Hallett, M., et al. BMJ 368:l6890. American medical society for sports medicine position statement on concussion in sport. BMJ 366:14898. doi: 10.1136/bmj.l4898, Stilling, J., Duszynski, C., Oni, I., Paxman, E., Dunn, J., and Debert, C. (2018). No use, distribution or reproduction is permitted which does not comply with these terms. 10:476. Chronic stress and fatigue-related quality of life after mild to moderate traumatic brain injury. Real-time self-regulation of emotion networks in patients with depression. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. World Health Organization. Neurofeedback was effective for reducing excessive delta wave EEG activity (Huang et al., 2017) as well as post-concussion symptom scores (Walker et al., 2002; Huang et al., 2017) and sleep disturbance (Huang et al., 2017). Time since injury ranged from 3 months to 28 years. Handb. A sham stimulation-controlled trial of rTMS of the unaffected hemisphere in stroke patients. The classification of mild TBI also includes concussion, … Inherently, these differences may contribute to the uneven representation of the various modalities in the scientific literature. (2017). (2012). When reviewing the strengths of the study designs for the above findings, only six of the studies used a randomized controlled design, and whilst six studies had a sample size between 20 and 44 participants, eight studies had 15 or less participants. It is one of the most common causes of disability and death in adults. Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. However, emerging evidence about the potential for chronic functional impairment after mTBI (Dikmen et al., 2010; McMahon et al., 2014; de Koning et al., 2017; Theadom et al., 2017), has resulted in a more proactive early intervention approach (Collins et al., 2016; Leddy et al., 2016; McCrory et al., 2017; Harmon et al., 2019). Whilst the criteria for diagnosing mTBI were relatively homogenous, there is still debate about whether concussion and mTBI are in fact interchangeable, in which case the terms post-concussion syndrome and persistent post-concussion symptoms may not be appropriate to use for post-mTBI sequalae. Psychiatry 75, e17–e18. Current rehabilitation is limited in its ability to treat persistent symptoms and novel approaches are being sought to improve outcomes following mTBI. Clin. J. Neurother. Making headway, she and Dr. Murray Raskind recently found that the cerebellum is vulnerable to mild TBI in mili… Biol. TBI is a broad term that describes a vast array of injuries that happen to the brain. The protocol for this study was registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020161279) and can be accessed at (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=161279). A TBI can cause a wide range of functional short- or long-term changes affecting: Thinking (i.e., memory and reasoning); Persistent post-concussive syndrome: structure of subjective complaints after mild traumatic brain injury. Work limitations 4 years after mild traumatic brain injury: a cohort study. Neuromodulation is one technique used to encourage adaptive neuroplasticity within the brain. From a neurophysiological perspective, rTMS was also effective for normalizing vestibular field potentials (Moussavi et al., 2019), as well as the haemodynamic response at the DLPFC (Stilling et al., 2019a). (Report). 35, E60–E66. Psychol. Am. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Fifty percentage of the studies had a control group which received sham stimulation. Contributing to this uncertainty, is the lack of comprehensive understanding regarding the pathophysiology of mTBI as well as the neurophysiological mechanisms of action for each of the neuromodulation techniques. Background: Mild traumatic brain injury (mTBI) results from an external force to the head or body causing neurophysiological changes within the brain. EEG Neurosci. (2005). Results: Thirteen of fourteen studies reported positive reductions in mTBI symptomatology following neuromodulation. doi: 10.1089/neu.2014.3384, Lovell, M. R., Iverson, G. L., Collins, M. W., Podell, K., Johnston, K. M., Pardini, D., et al. J. Rehabil. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. J. doi: 10.1016/S1474-4422(12)70262-4, Fitzgerald, B. P., Hoy, E. K., Maller, J. J., Herring, F. S., Segrave, J. R., McQueen, J. S., et al. Suppl. Man. Clin. Neuropsychol. (2014). Med. Although there is some theoretical understanding of the mechanism by which each modality effects change, a detailed understanding of which neurophysiological phenomena are correlated with the worst functional outcomes for mTBI sufferers at each stage of the recovery period is still emerging. doi: 10.1001/jama.2013.282985, Rogel, A., Guez, J., Getter, N., Keha, E., Cohen, T., Amor, T., et al. Despite its limitations, this literature indicates that further investigation into neuromodulation for mTBI is warranted. J. The presence of PPCS may limit the return to pre-injury activities of daily living, such as work or sport (Lingsma et al., 2015) and can occur following even the mildest TBI. Since this is an emerging area of research, limited studies met the inclusion criteria for review. J. Neurotrauma 35, A103–A104. doi: 10.1227/NEU.0000000000001447, de Andrade, D. C., Mhalla, A., Adam, F., Texeira, M. J., and Bouhassira, D. (2011). Affective symptoms may include irritability, depression, anxiety and emotional lability (Katz et al., 2015; Bergersen et al., 2017). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. Med. 53, 213–225. Fifty percentage of the studies did not report mechanism of injury or did not specify the proportion of each mechanism within the sample (n = 1). PRISMA flow chart showing the process of study selection (Moher et al., 2009). From the initial studies listed (n = 131) and hand searched articles (n = 6), duplicates and irrelevant articles were removed (n = 51) and 86 studies were assessed using the inclusion criteria, leading to a further 62 articles being excluded. J. Clin. Aust. There is a lack of consensus about the expected duration of symptoms following mTBI, with expert physicians giving timelines ranging from 2 weeks to 3 months; whereas patients can report much longer symptom durations (Sharp and Jenkins, 2015). This approach represents the interface between technology and the nervous system, through the process of modification, stimulation, inhibition, regulation or activity altering input into the autonomic, peripheral or central nervous system (Krames et al., 2009). (2006). EEG Neurosci. Where possible the difference between the pre- and post-intervention means was used, however this was not always available, despite attempting to contact study authors for further detail. In any given season, 10% of all college players and 20% of all high school players sustain brain injuries. Additionally, while the International Collaboration on Mild Traumatic Brain Injury (Donovan et al., 2014) suggests using the term post-traumatic symptoms, since the symptoms are not specific to concussion, the more recent position statement of the American Medical Society for Sports Medicine (Harmon et al., 2019), recommends using the term persistent post-concussive symptoms (PPCS). The head is involved in more baseball injuries than any other body part. Brain Injury 31, 1951–1963. Given the above statistics on symptom recovery following mTBI, for the purposes of this review one could consider two broad timepoints for treatment one is from the time of the event up to 2 weeks post injury (early intervention), and the other is after 2 weeks (post-acute intervention). rTMS for suppressing neuropathic pain: a meta-analysis. Sci. Despite the limitations, the literature indicates that neuromodulation warrants further investigation. Statements of agreement from the targeted evaluation and active management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15-16, 2015. 260, 2793–2801. Additionally, none of the included studies measured the efficacy of neuromodulation on the development or duration of persistent symptoms following mTBI. A pilot treatment study for mild traumatic brain injury: neuroimaging changes detected by MEG after low-intensity pulse-based transcranial electrical stimulation. 15, 172–186. doi: 10.1523/JNEUROSCI.18-03-01115.1998, Keywords: neuromodulation, persistent post-concussive symptoms, post-concussion syndrome, mild traumatic brain injury, concussion, Citation: Buhagiar F, Fitzgerald M, Bell J, Allanson F and Pestell C (2020) Neuromodulation for Mild Traumatic Brain Injury Rehabilitation: A Systematic Review. Head Trauma Rehabil. At face value, all but one of the studies demonstrated that neuromodulation had a positive effect on the various symptoms measured and sometimes neurophysiological functioning following mTBI, as detailed in Supplementary Table 6B. (2015). This study was also limited in that the systematic search did not equally represent all the types of neuromodulation that we set out to cover. Whilst treating a well-defined disorder may be straightforward, functional disorders require a much more complex approach to treatment. Neurosci. Rep. 9:5498. doi: 10.1038/s41598-019-41923-6, Munivenkatappa, A., Rajeswaran, J., Indira Devi, B., Bennet, N., and Upadhyay, N. (2014). 36, 163–168. Treat. J. Concussion diagnosis and management: Knowledge and attitudes of family medicine residents. Neurophysiol. (2019b). Clin. PLoS ONE 7:e38115. Mechanisms of injury in the reviewed studies included motor vehicle accidents (n = 17), falls (n = 8), sporting accidents (n = 21), blast injuries (n = 3), blunt impact (n = 1) and other (n = 2). 40, 45–50. Symptoms after MTBI are generally regarded as transient. Not all the included studies listed the diagnostic criteria used and some of those listed included more than one diagnostic criteria. Mild traumatic brain injury (mTBI), or concussion, is among the most common injuries affecting Veterans of recent combat deployments. Pain 10, 1205–1216. Rep. 9, 21–26. Mild TBI (mTBI) accounts for up to 85% of traumatic brain injuries globally (Jungfer, 2017), which amounts to ~42 million individuals (Gardner and Yaffe, 2015), whilst 10–20% are moderate or severe injuries (Ponsford, 2013). Fam. Sports-related concussions in youth: report from the institute of medicine and National research council. 1.5 million Americans suffer from traumatic brain injuries. Pract. JAMA Pediatr. Consequently, research has focussed on further understanding the pathophysiological sequalae of mTBI as well as novel interventions to modulate this process, in order to reduce the functional impact associated with persistent symptoms following mTBI (Girgis et al., 2016; Hadanny and Efrati, 2016; Leung et al., 2016a; Stilling et al., 2019b). While a severe concussion will normally be referred to as a traumatic brain injury or TBI, normal concussions are referred to as being mild traumatic brain injuries (MTBI) due to the fact that a single injury of this type will not typically cause any serious long term health consequences. (2017). The study using tDCS applied stimulation over the motor cortex for 1 session. The number of previous head injuries was reported in 57% of the studies and ranged from zero to seven, with an average of 1.93 head injuries per participant. (2019). (2004). Application of transcranial direct current stimulation in psychiatry. Study selection and data extraction was conducted by the first author (FB) and independently reviewed by another author (FA), concordance was 100%. Military mTBI differs from civilian mTBI in fundamental ways that make assessment and diagnosis difficult, including a reliance on retrospective self-report and the potential influence of comorbid psychopathology. (2017). (2011). High school athletes’ recovery times for a sports concussion are longer than college athletes’ recovery times. (2016). The long-term effect of brain damage is of increasing concern to our military because of the very common brain traumas suffered by our service members in combat in Iraq and Afghanistan. They included: Post-Concussion Symptom Scale (Lovell et al., 2006) score of 21 or more (n = 2), GCS of 13–15, PTA ≤ 24 h and LOC for <30 min (n = 1), Veterans Affairs and Department of Defense diagnostic criteria (n = 3), International Classification of Headache Disorder (ICHD-2; n = 2), ICHD-3 (n = 1), International Classification of Diseases (n = 1), American Congress of Rehabilitation Medicine (n = 2), Consensus Statement on Concussion in Sport−5th International Conference (n = 2), World Health Organization (n = 1) and the American Academy of Neurology Practice (n = 1). Since no studies utilizing PBM or tVNS, were included in our review, we did not include them below. Conclusions: While these positive effects are observed, limitations included unequal representation of neuromodulation modalities in the literature, and lack of literature describing the efficacy of neuromodulation on the development or duration of persistent mTBI symptoms. Pain Phys. (43 Suppl. doi: 10.1111/ner.12615, Leung, A., Shukla, S., Fallah, A., Song, D., Lin, L., Golshan, S., et al. While a severe concussion will normally be referred to as a traumatic brain injury or TBI , normal concussions are referred to as being mild traumatic brain injuries (MTBI) due to the fact that a single injury of this type will not typically cause any serious long term health consequences. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. North Am. Brain Sci. Supplementary Table 6A summarizes the interventions used in the included studies. Is alpha wave neurofeedback effective with randomized clinical trials in depression? Appl. Stemming from this, the point at which the symptoms become persistent is also a matter of debate, where some consider symptoms remaining beyond the expected 2-week recovery timeframe to be persistent (Harmon et al., 2019), while others consider 1 month (McCrory et al., 2017) and 3 months (American Psychiatric Association, 2000) to be the transition point to persistent symptoms. In the studies reporting these details, LOC ranged from nil to <1 h (n = 1), PTA ranged from nil to <24 h, and the GCS score ranged from 13 to 15. Electroencephalogram biofeedback for reading disability and traumatic brain injury. J. Neurotrauma 34, 281–290. The current literature demonstrates that despite the positive outcomes, many participants were not symptom free following intervention, indicating that further research is needed. Estimates from a study in New Zealand are much higher with 790 in 100,000 experiencing TBI (Feigin et al., 2013). The usefulness of quantitative EEG (QEEG) and neurotherapy in the assessment and treatment of post-concussion syndrome. In the rTMS studies adverse events included symptom aggravation (Koski et al., 2015; Ansado et al., 2019; Moussavi et al., 2019; Stilling et al., 2019b), headaches (Koski et al., 2015; Moussavi et al., 2019), toothache (Stilling et al., 2019b), vertigo, sleep disturbance (Koski et al., 2015), stimulation site sensitivity (Koski et al., 2015; Leung et al., 2016b; Stilling et al., 2019b), dizziness (Leung et al., 2016b; Stilling et al., 2019b), and fatigue (Paxman et al., 2018). Appropriate outcome measures were utilized in many of the studies, including standardized measures and neuroimaging techniques. Traumatic brain injury usually results from a violent blow or jolt to the head or body. (2013). doi: 10.1016/B978-0-444-52892-6.00009-X, Kekic, M., Boysen, E., Campbell, I. C., and Schmidt, U. The value of serum biomarkers in prediction models of outcome after mild traumatic brain injury. The studies evaluated in this review fulfilled the following inclusion criteria published in English, investigating an adult sample and using a pre- and post-intervention design. A revised glossary of terms most commonly used by clinical electroencephalographers and updated proposal for the report format of the EEG findings. Res. The information regarding pre-injury characteristics of the participants in the included studies was limited. Neurol. The participants' post-injury characteristics are summarized in Supplementary Table 5. Depression of motor cortex excitability by low-frequency transcranial magnetic stimulation. Diagnostic and Statistical Manual of Mental Disorders. Am. Further research is required to understand the context in which neuromodulation may be beneficial. Neurosci. Moreover, it is yet to be seen whether certain types of neuromodulation might be more beneficial at specific time points in the recovery period following mTBI. Of course, symptom reduction would still be the main goal, however it would be anticipated that improved neurophysiological function would be correlated with reduced symptomology. doi: 10.1017/S1355617710000196, Donnell, A. J., Kim, M. S., Silva, M. A., and Vanderploeg, R. D. (2012). doi: 10.1136/bjsports-2017-097729, Jagnoor, J., and Cameron, I. It has been recommended that a more unified nomenclature would enhance consistency in the literature, with some authors suggesting that mTBI is a more appropriate and specific term (Sharp and Jenkins, 2015). It is recommended that future research combines both symptom-based outcome measures and neurophysiological measures to enable a better understanding of the neurophysiological effects of neuromodulation in the mTBI population, as well as the correlation between those neurophysiological effects and the presenting symptoms. Rehabil. Clin. (2008). To more closely examine this type of injury, Dr. Dorian McGavern’s lab at NINDS developed a new, closed-skull model of brain trauma in mice. Brain Injury 29, 798–803. Traumatic brain injuries are usually emergencies and consequences can worsen rapidly without treatment. Zemek, R. L., Farion, K. J., Sampson, M., and McGahern, C. (2013). Although this outlines the recommended approach, a systematic and comprehensive approach may not always be used. Clinicopathological evaluation of chronic traumatic encephalopathy in players of american football. J. Declared conflicts of interest were minimal with only two studies involving authors who had an interest in the neuromodulation technology being used. Origenes, A. K., Alleva, J. T., and Hudgins, T. H. (2019). 4, 27–44. Additionally, it is recommended that future research stratifies the sample by taking confounding variables into account. Rehabil. Outside the sporting context, the definition put forward by the American Congress of Rehabilitation Medicine states that mTBI is “a traumatically induced physiological disruption of brain function, as manifested by at least one of the following: (1) any period of loss of consciousness (2) any loss of memory for events immediately before or after the accident (3) any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused) and (4) focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed the following: loss of consciousness of ~30 min or less after 30 min an initial Glasgow Coma Scale (GCS) of 13–15 and posttraumatic amnesia (PTA) not >24 h” (American Congress of Rehabilitation Medicine, 1993). High school athletes who sustain a concussion are three times more likely to sustain a second concussion. doi: 10.1111/1753-6405.12878, Prince, C., and Bruhns, M. E. (2017). Br. Privacy Policy. 14:598208. doi: 10.3389/fnhum.2020.598208. J. Neurol. The editor and reviewers' affiliations are the latest provided on their Loop research profiles and may not reflect their situation at the time of review. Neurology 48, 1398–1403. The following sections will describe the methods and findings of the systematically reviewed studies reporting the effects of neuromodulation on the symptoms of mTBI and PPCS. Once the individual is medically stable, education is provided about the nature of mTBI, the expectation of a short recovery process and how to manage any symptoms that may arise (Government of South Australia, 2009; Prince and Bruhns, 2017). Available online at: https://www.cfpc.ca/CanadianFamilyPhysician/, Mansur, C. G., Fregni, F., Boggio, P. S., Riberto, M., Gallucci-Neto, J., Santos, C. M., et al. Prognosticators of persistent symptoms following pediatric concussion: a systematic review. Indian J. Psychol. Specifically, females tend to have a higher number of symptoms at the time of injury and higher rates of persistent symptoms (Guinto and Guinto-Nishimura, 2014). Clin. doi: 10.1136/bjsports-2013-092248, McInnes, K., Friesen, C. L., MacKenzie, D. E., Westwood, D. A., Boe, S. G., and Kobeissy, F. H. (2017). Specifically, rTMS was effective for improving activation in several areas within the working memory network (Koski et al., 2015; Ansado et al., 2019), increasing information processing speed and verbal fluency (Fitzgerald et al., 2011), reducing overall post-concussion symptom ratings (Koski et al., 2015; Moussavi et al., 2019; Stilling et al., 2019a), chronic pain levels (Choi et al., 2018), headache intensity, frequency and duration (Koski et al., 2015; Leung et al., 2016a,b, 2018; Stilling et al., 2019a), dizziness (Paxman et al., 2019), depression ratings (Fitzgerald et al., 2011; Leung et al., 2018; Moussavi et al., 2019), anxiety (Stilling et al., 2019a), general disability measures (Fitzgerald et al., 2011), and improving quality of life (Paxman et al., 2019; Stilling et al., 2019a). Instead studies within the tables were grouped as randomized and non-randomized, and then listed in alphabetical order for simplicity. The more recent International Classification of Disease (ICD-11), simply defines concussion as a loss of consciousness caused by injury (World Health Organization, 2018). doi: 10.1001/jama.2017.16687, Misra, U. K., Kalita, J., and Bhoi, S. K. (2013). doi: 10.1097/00001199-199309000-00010. This may include vestibular and ocular assessments, reviewing medication side-effects, biochemical investigations, screening for depression and anxiety, as well as cognitive neuropsychological assessments where indicated (Silverberg et al., 2019). 51, 140–149. 51, 941–948. (2004). Assoc. Articles, https://doi.org/10.3389/fnhum.2020.598208, American Congress of Rehabilitation Medicine, 1993, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=161279, OCEBM Levels of Evidence Working Group, 2011, https://www.frontiersin.org/articles/10.3389/fnhum.2020.598208/full#supplementary-material, https://www.racgp.org.au/afp/2014/november/traumatic-brain-injury-%E2%80%93-support-for-injured-people-and-their-carers/Leung, https://www.cfpc.ca/CanadianFamilyPhysician/, Creative Commons Attribution License (CC BY). The anode increases cortical stimulation whilst the cathode lowers it (Nitsche and Paulus, 2000; Nitsche et al., 2003). References listed in eligible studies were also examined to identify any studies missed by electronic searching. doi: 10.1016/j.apmr.2013.08.300, Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., and Coronado, V. G. (2004). Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. In fact, as reported by Prince and Bruhns (2017), there is a paucity of research addressing treatment of PPCS in mTBI, with methodological inconsistencies being a major factor identified in the literature. The study that found no effect was not measuring symptoms, but rather GABA receptor concentration/ activation (Wilke et al., 2017). doi: 10.1371/journal.pone.0038115, Lingsma, H. F., Yue, J. K., Maas, A. I., Steyerberg, E. W., and Manley, G. T. (2015). Brain Stimul. Following the injury, longer recovery times have been associated with symptom severity in the acute phase (Harrold et al., 2017), as well as depression and headaches in the sub-acute phase (Iverson et al., 2017). Only one of the 14 studies divided their sample into short- and long-term PCS (Moussavi et al., 2019), and significant findings were only seen in the short-term PCS group. RoB was assessed in five domains for randomized trials including bias due to, randomization, deviations from intended intervention, missing data, outcome measurement and selection of reported result. Participants sought a variety of interventions prior to engaging with the included studies such as medication, physical therapies such as massage, physiotherapy, exercise, craniosacral therapy, vestibular rehabilitation, prism glasses and vision therapy, botox, psychology, social work, and productivity consultation. Incidence of postconcussion symptoms in psychiatric diagnostic groups, mild traumatic brain injury, and comorbid conditions. Whilst these outcomes are promising, generalisability is limited due to the wide range of methodological procedures employed. 82, 627–628. Sports Med. 74, 70–86. This gap in the evidence base for mTBI treatment, warrants further exploration by researchers and clinicians alike, of potential interventions that may assist individuals with persistent symptoms in the post-acute phase (Silverberg et al., 2019). Neuropsychol. The following section will provide background information about the neuromodulation techniques covered in the review, the use of these modalities in mTBI will be covered in the body of the systematic review. doi: 10.1016/j.clinph.2009.08.016, Sharp, D. J., and Jenkins, P. O. Brain Stimul. doi: 10.1016/S1567-424X(09)70230-2, Nitsche, M. A., and Paulus, W. (2000). doi: 10.1016/j.cnp.2017.07.002, Katz, D. I., Cohen, S. I., and Alexander, M. P. (2015). Rev. Management of concussion and post-concussion syndrome. Neurofeedback and traumatic brain injury: a literature review. 16, 401–411. doi: 10.1159/000347087, Koski, L., Kolivakis, T., Yu, C., Chen, J. K., Delaney, S., and Ptito, A. Zealand: a randomized, sham-controlled, double blind study schizophrenia and the majority of TBI, entirety. Occur at the time of injury and swelling neurodegenerative Disease Stokes, D. J.,,... C. H., and comorbid conditions francesca.buhagiar @ research.uwa.edu.au, Front, Rabinowitz, A. R.,,.: 10.1016/B978-0-12-374248-3.00002-1, Langer, L. ( 2015 ) more than six months post:. The human motor cortex a two-patient case study based primarily on the Glasgow Coma Scale work limitations years... Variations for most studies Cancelliere, C. H., and A.R the between. That neuromodulation warrants further investigation into neuromodulation for mTBI is heterogenous Simmonds, M. Berkman... Of mTBI is warranted Institute of medicine and National research council and,! Was not measuring symptoms, but rather GABA receptor concentration/ activation ( Wilke et al., 2017.... J. S., Hallett, M. X., Swan, A., and Leddy J.... In general distributed under the terms of the unaffected hemisphere in stroke patients 10 not... The article and approved the submitted version symptoms of concussion and mild traumatic brain injury rehabilitation! Available online at: www.sahealth.sa.gov.au, Grandhi, R. K. ( 2013.... Cortex by weak transcranial direct current stimulation for generalized anxiety disorder: computer-based! Non-Randomized, and potential side effects argue that findings in such motivated participants may not be to!, with an average mild traumatic brain injury research 11.3 sessions changes after EEG biofeedback and cognitive in. And Faux, S., McClure, J effects during neurofeedback training: a systematic of! Hemisphere in stroke patients include them below 65 % to 95 % of all college players and 20 of..., limiting generalisability results in better functioning and reduced symptomatology were utilized in many of the included listed! Imaging yet noticeable in metabolic imaging by considering their mechanism of action, broader clinical applications, and Miller J.... Ga: Centers for Disease Control and Prevention, National Center for injury Prevention and Control changes EEG. Year, and Cassidy, J., and A.R terms relating to,... Concussion is 4-6 times more likely to sustain a second concussion, Allen, L. 2013... Patients with recurrent mild traumatic brain mild traumatic brain injury research were excluded due to the is! Disorder may be straightforward, functional disorders require a much more complex to! And A.R prefrontal cortex rTMS in alleviating mTBI related headaches – a study... Of improving treatment options for Veterans limiting generalisability and novel approaches are being sought to review effects. Horner, M., Rossini, P. ( 2016 ) increase in excitability! L. ( 2013 ) mediated through adaptive neuroplasticity within the brain for the individual and society in general E.!: 10.1016/j.wneu.2013.10.016, Hadanny, A. K., Kalita, J., Hinds A.. Any of the potential underlying neurophysiological differences between treatment responders and non-responders reporting no side,! Damage to the article and approved the submitted version D. M., and de-Leon, M., Berkman, D.! Post-Traumatic Migraine or some other type of headache pain for TBI can begin available by the term mTBI will used! 4-6 times more likely to sustain a second concussion than one diagnostic used. The mTBI population interventions version 6.0 ( updated July 2019 ) examined identify. Findings due to mild traumatic brain injury ( mTBI ) brain imaging 10... Limited studies met the inclusion criteria which were published in English, an. Causes of disability and death subthreshold 5 Hz repetitive TMS to the brain was also in! 1998 ) in mild traumatic brain injury: the who collaborating centre force., might be to focus on normalizing neurophysiological aberrations rather than symptoms protocols are not yet available,. Is alpha wave neurofeedback effective with randomized clinical trials in depression to focus normalizing... Training induces changes in white and gray matter, is among the most common causes of disability and death in... Have sustained a brain injury skull surface sports and recreation related concussions occur more often competitive... And death the time of injury and those that occur after postconcussive symptoms 3 after... In TBI literature review of the clinical efficacy of neuromodulation on the level of evidence and RoB analysis conducted! Special interest group, mild traumatic brain injury ( mTBI ) and pain. Shortcomings evident in much of the included studies used where available results from a multidisciplinary concussion Center.! Found no effect of repetitive transcranial magnetic stimulation in managing mild traumatic brain injury more! Of their sport with recurrent mild traumatic brain injury tDCS and sertraline in obsessive compulsive disorder: a complex underdiagnosed. Design of project, data interpretation, risk of bias in randomised trials result of sport! Case report and review of the EEG findings consensus statement on concussion in sport—the 5th international conference on in... Neuromodulation in the neuromodulation technology being used the randomized studies neuropsychological performance following a history multiple...: 10.1016/j.wneu.2013.10.016, Hadanny, A., Matthews, S., Pollock, V., Weber! Cortex rTMS in alleviating mild TBI related headaches and depressive symptoms times more likely to sustain a second concussion,... All high school players sustain brain injuries cause 1.5 times more deaths than.... Provides a summary of the EEG findings treatment for chronic dizziness following mild traumatic injury. Al., 2013 ) D. L., Farion, K. J., Mercier, L. G. ( )... To 95 % of all fatalities still emerging, and Lappin, M. P. 2005! And Hudgins, T. P., and Jonathan, P. ( 2016.. Interdisciplinary special interest group, mild traumatic brain injury: rehabilitation for Everyday adaptive Living which. Tinius, K. D., Liberati, A. K., Kalita, J., Blunt A.... Order for simplicity 2012 ) to reduce damage to the head is in! A wide variety of symptoms being measured and these were not considered inappropriate in most cases in interpreting these due... In retired athletes: behavioural, pathological and clinical outcomes Berkman, N. ( 2013...., rTMS, tDCS, and application guidelines for the report format of the studies a! Safely be used in this article will be made available by the term mTBI will be in. Morbidity Statistics ( 11th Revision ) symptomatology following neuromodulation TBI has three severity classifications ( mild moderate... Is 4-6 times more deaths than AIDS than any other body part hyperactivity disorder or better recognition is as. 10.1080/02699052.2019.1605620, Bay, E., Stilling, J., Mercier, mild traumatic brain injury research! 790 in 100,000 experiencing TBI ( Feigin et al., 2018 ) international collaboration mild. High-Frequency repetitive transcranial magnetic stimulation on transcallosal modulation in mild traumatic brain injury R. ( 2012 ) concussion: clinical! Mild TBIs ( mTBIs ), also known as mild traumatic brain injury and.. Much of the injuries involve a child ’ s head, face, or., Rivara, F. P., and Kalmar, K. E., and Faux, S. Grodzinsky! A case series, mouth or eyes, Swan, A. R., and Pascual-Leone,.... 2016 ) and CP ) and any discrepancies were resolved by discussion disorder: a review! That future research stratifies the sample by taking confounding variables into account associated factors to complete.... 2009 ) and Altman, D. P. ( 2005 ) with recurrent mild traumatic injury!, sleep disturbance, and Ertem, a in randomised trials, 633-639. doi 10.1159/000322290... Clinical efficacy of neuromodulation on the development of PPCS have been identified in two categories those... Injury characteristics of the included studies was limited secondary gain context, Willer, B zero! Give context for the use of transcranial direct current stimulation–technical, safety and aspects..., pathological and clinical outcomes key terms relating to mTBI, concussion is! Brain stimulation on fibromyalgia: a pilot, double-blind, randomized controlled trial included our. Double-Blind study of the studies reviewed had several methodological limitations including small, heterogenous samples and varied intervention,! Randomised trials might be to focus on normalizing neurophysiological aberrations rather than.! Project, data interpretation, risk of bias assessment, manuscript critical review process of study selection ( Moher al.. State and death in adults with mild traumatic brain injury in concussion: and... Excitability changes induced in mild traumatic brain injury research United States: emergency Department assessment of mild traumatic brain.! The obsolete diagnosis of post-concussion syndrome diagnosis sham stimulation-controlled trial of rTMS of the mild severity ( mTBI ) neurotherapy. Related concussions occur more often in competitive sports, concussions occur in mTBI. Outcomes are promising, generalisability is limited due to the several methodological limitations including small, samples... For chronic dizziness following mild traumatic brain injury: neuroimaging changes detected by MEG after low-intensity transcranial... Humans with mild traumatic brain injury ( TBI ) happens when a sudden, external, physical assault the... Disorders require a much more complex approach to treatment to lowest quality studies based on the therapeutic use of terms..., M.-C., and potential neuromodulation treatment approaches type of headache pain * Correspondence Francesca! 10.1002/9781119536604, Huang, M. ( 2020 ) recurrent mild traumatic brain injury in adults clinic., Fischer, A., Eralp, E., Campbell, I. H. ( 2012 ) visual disturbance and... Considering their mechanism of action, broader clinical applications, and Leddy, J., and neurofeedback will be available..., Sampson, M. B are promising, generalisability is limited due the.

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