Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

doi:10.1136/bmjopen-2019-035527

Randomized Controlled Trial

. 2020 Oct 20;10(10):e035527.

doi: 10.1136/bmjopen-2019-035527.

Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

Noah D Silverberg^{1

2

3}, William J Panenka^{4

5

6}, Pierre-Paul Lizotte⁷, Mark T Bayley^{8

9}, Derry Dance^{2

10}, Linda C Li^{11

12}

Affiliations

¹ Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada noah.silverberg@ubc.ca.
² Division of Physical Medicine and Rehabilitation, The University of British Columbia, Vancouver, British Columbia, Canada.
³ Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
⁴ Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada.
⁵ British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada.
⁶ BC Neuropsychiatry Program, Vancouver, British Columbia, Canada.
⁷ Department of Family Medicine, Providence Health Care, Vancouver, British Columbia, Canada.
⁸ Hull-Ellis Concussion Research Center, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
⁹ Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.
¹⁰ Acquired Brain Injury Program, GF Strong Rehabilitation Hospital, Vancouver, British Columbia, Canada.
¹¹ Arthritis Research Canada, Richmond, British Columbia, Canada.
¹² Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada.

PMID: 33082178
PMCID: PMC7577038
DOI: 10.1136/bmjopen-2019-035527

Randomized Controlled Trial

Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

Noah D Silverberg et al. BMJ Open. 2020.

. 2020 Oct 20;10(10):e035527.

doi: 10.1136/bmjopen-2019-035527.

Authors

Noah D Silverberg^{1

2

3}, William J Panenka^{4

5

6}, Pierre-Paul Lizotte⁷, Mark T Bayley^{8

9}, Derry Dance^{2

10}, Linda C Li^{11

12}

Affiliations

¹ Department of Psychology, The University of British Columbia, Vancouver, British Columbia, Canada noah.silverberg@ubc.ca.
² Division of Physical Medicine and Rehabilitation, The University of British Columbia, Vancouver, British Columbia, Canada.
³ Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
⁴ Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada.
⁵ British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, British Columbia, Canada.
⁶ BC Neuropsychiatry Program, Vancouver, British Columbia, Canada.
⁷ Department of Family Medicine, Providence Health Care, Vancouver, British Columbia, Canada.
⁸ Hull-Ellis Concussion Research Center, Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
⁹ Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.
¹⁰ Acquired Brain Injury Program, GF Strong Rehabilitation Hospital, Vancouver, British Columbia, Canada.
¹¹ Arthritis Research Canada, Richmond, British Columbia, Canada.
¹² Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada.

PMID: 33082178
PMCID: PMC7577038
DOI: 10.1136/bmjopen-2019-035527

Abstract

Objectives: New clinical practice guidelines for the management of mild traumatic brain injury (mTBI) emphasise that family physicians should proactively screen and initiate treatment for depression/anxiety, insomnia and headaches. This study aimed to evaluate the feasibility of delivering an implementation intervention to family physicians.

Design: Pilot cluster randomised controlled trial.

Setting: Specialty outpatient clinic (recruitment) and primary care (implementation).

Participants: 114 primary care clinics were randomised. These clinics were associated with 137 unique family physicians caring for 148 adult patients who sustained an mTBI within the previous 3 months and were seeking care for persistent symptoms.

Interventions: Patients completed self-report screening measures for depression/anxiety, insomnia and headaches. A tailored letter that incorporates the patient's screening test results and associated treatment algorithms was sent to their family physician (or walk-in clinic). Physicians at clinics assigned to the control condition received a generic letter, without the screening test results.

Primary outcome measures: Feasibility outcomes included the frequency of primary care follow-up, retention rates and reliability of patient recall of their physicians' actions (primary mechanistic outcome). The primary efficacy outcome was the Rivermead Post-Concussion Symptom Questionnaire (RPQ).

Results: Most patients (97.8%; 128 of 131) followed up at the primary care clinic they planned to. Retention rates were 88% (131 of 148) and 78% (116 of 148) at the 1-month and 3-month assessments, respectively. Agreement between patient recall of their physicians' actions and medical chart audits was moderate (intraclass correlation coefficient=0.48-0.65). Patients in the experimental group reported fewer symptoms on the RPQ compared with those in the control group, whose physician received a general letter (B=-4.0, 95% CI: -7.3 to -0.7).

Conclusions: A larger trial will need to address minor feasibility challenges to evaluate the effectiveness of this guideline implementation tool for improving mTBI clinical outcomes and confirm the mechanism(s) of intervention benefit.

Trial registration number: NCT03221218.

Keywords: clinical trials; depression & mood disorders; neurological injury; primary care.

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Conflict of interest statement

Competing interests: None declared.

Figures

**Figure 1**
Consolidated Standards of Reporting Trials diagram. mTBI, mild traumatic brain injury.

**Figure 2**
Plot of recovery trajectories by group.

See this image and copyright information in PMC

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References

1. Cassidy JD, Carroll L, Peloso P, et al. . Incidence, risk factors and prevention of mild traumatic brain injury: results of the who collaborating centre Task force on mild traumatic brain injury. J Rehabil Med 2004;36:28–60. 10.1080/16501960410023732 - DOI - PubMed
1. Langer L, Levy C, Bayley M. Increasing incidence of concussion: true epidemic or better recognition? J Head Trauma Rehabil 2020;35:E60–6. 10.1097/HTR.0000000000000503 - DOI - PubMed
1. Taylor CA, Bell JM, Breiding MJ, et al. . Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1–16. 10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed
1. McCrea M, Iverson GL, McAllister TW, et al. . An integrated review of recovery after mild traumatic brain injury (MTBI): implications for clinical management. Clin Neuropsychol 2009;23:1368–90. 10.1080/13854040903074652 - DOI - PubMed
1. Cassidy JD, Cancelliere C, Carroll LJ, et al. . Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil 2014;95:S132–51. 10.1016/j.apmr.2013.08.299 - DOI - PubMed

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[1] Cassidy JD, Carroll L, Peloso P, et al. . Incidence, risk factors and prevention of mild traumatic brain injury: results of the who collaborating centre Task force on mild traumatic brain injury. J Rehabil Med 2004;36:28–60. 10.1080/16501960410023732 - DOI - PubMed

[2] Cassidy JD, Carroll L, Peloso P, et al. . Incidence, risk factors and prevention of mild traumatic brain injury: results of the who collaborating centre Task force on mild traumatic brain injury. J Rehabil Med 2004;36:28–60. 10.1080/16501960410023732 - DOI - PubMed

[3] Langer L, Levy C, Bayley M. Increasing incidence of concussion: true epidemic or better recognition? J Head Trauma Rehabil 2020;35:E60–6. 10.1097/HTR.0000000000000503 - DOI - PubMed

[4] Langer L, Levy C, Bayley M. Increasing incidence of concussion: true epidemic or better recognition? J Head Trauma Rehabil 2020;35:E60–6. 10.1097/HTR.0000000000000503 - DOI - PubMed

[5] Taylor CA, Bell JM, Breiding MJ, et al. . Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1–16. 10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed

[6] Taylor CA, Bell JM, Breiding MJ, et al. . Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1–16. 10.15585/mmwr.ss6609a1 - DOI - PMC - PubMed

[7] McCrea M, Iverson GL, McAllister TW, et al. . An integrated review of recovery after mild traumatic brain injury (MTBI): implications for clinical management. Clin Neuropsychol 2009;23:1368–90. 10.1080/13854040903074652 - DOI - PubMed

[8] McCrea M, Iverson GL, McAllister TW, et al. . An integrated review of recovery after mild traumatic brain injury (MTBI): implications for clinical management. Clin Neuropsychol 2009;23:1368–90. 10.1080/13854040903074652 - DOI - PubMed

[9] Cassidy JD, Cancelliere C, Carroll LJ, et al. . Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil 2014;95:S132–51. 10.1016/j.apmr.2013.08.299 - DOI - PubMed

[10] Cassidy JD, Cancelliere C, Carroll LJ, et al. . Systematic review of self-reported prognosis in adults after mild traumatic brain injury: results of the International collaboration on mild traumatic brain injury prognosis. Arch Phys Med Rehabil 2014;95:S132–51. 10.1016/j.apmr.2013.08.299 - DOI - PubMed

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Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

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Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

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