Network Analysis and Precision Rehabilitation for the Post-concussion Syndrome

Abstract

Some people experience persistent symptoms following a mild traumatic brain injury (MTBI), and the etiology of those symptoms has been debated for generations. Post-concussion-like symptoms are caused by many factors both before and after MTBI, and this non-specificity is the bedrock of the conundrum regarding the existence of the post-concussion syndrome. A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. It is the thesis of this paper that adopting a network perspective for persistent symptoms following MTBI, including the post-concussion syndrome, could lead to new insights and targeted treatment and rehabilitation strategies. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. This approach requires a conceptual shift away from thinking that symptoms reflect an underlying disease or disorder toward viewing inter-related symptoms as constituting the syndrome or disorder. The symptoms do not arise from an underlying syndrome—the symptoms are the syndrome. A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation.

Person-Specific Methods for Characterizing the Course and Temporal Dynamics of Concussion Symptomatology: A Pilot Study

“…There is a growing appreciation that post-concussion symptomatology is best conceptualized according to a bio-psychosocial model-wherein evolving pathophysiological processes interact with pre-injury vulnerabilities, environmental stressors, and psychological factors to produce symptoms. The underlying pathophysiology is itself complex, unfolding across the levels of cellular changes, brain network disruption, and perturbation of patients' experiences and social environments 7,8 . Heterogeneity at each of these levels leads to symptom profiles that are both complex and idiosyncratic.…”

“…This assumption underlies the common practice of using the sum total of symptom-checklist items as an index of severity, which treats symptoms as though they (i) represent the same underlying process across individuals, (ii) are interchangeable indicators of injury severity, and (iii) are relatively stable over time. A recent review by Iverson (2019) argues that a latent disease or common cause theory is particularly inappropriate in the case of prolonged symptoms-or symptoms that persist beyond the typical recovery window over which neurometabolic changes in the brain return to baseline-and proposes adopting a network model of concussion symptoms instead 7 .…”

“…Instead, networks are complex, with causality distributed across the self-reinforcing connections among nodes. This approach is particularly appropriate for syndromes, like post-concussion syndrome 7 , comprised of inter-related symptoms that are mutually reinforcing. Time series data collected from a single patient can be subject to network modeling, allowing characterization of the dynamic inter-relationships among symptoms on the individual-patient level.…”

Is the Rivermead Post-Concussion Symptoms Questionnaire a Reliable and Valid Measure to Assess Long-Term Symptoms in Traumatic Brain Injury and Orthopedic Injury Patients? A Novel Investigation Using Rasch Analysis

“…38 Aside from these theoretical debates on the misclassification of PCS, the evidence nevertheless points to the commonality in symptoms with non-TBI individuals. This evidence needs to be explored further by methods such as network analysis, 39 and should include further validation of PCS symptom scales for their potential use in other populations, which is currently lacking.…”

Architecture of Physical, Cognitive, and Emotional Symptoms at Preseason Baseline in Adolescent Student Athletes With a History of Mental Health Problems

“…Some features are core symptoms (e.g., sadness and anhedonia), whereas others are not (e.g., anxiety and sympathetic arousal) (12). Depression and anxiety commonly co-occur, and cross-sectional network analysis studies have illustrated how the symptoms of major depressive disorder and generalized anxiety disorder are interconnected and mutually amplifying (15)(16)(17).…”