Fear Avoidance and Clinical Outcomes from Mild Traumatic Brain Injury

Address correspondence to:Noah D. Silverberg, PhDUniversity of British ColumbiaRehabilitation Research Program4255 Laurel StreetVancouver, British Columbia V5Z 2G9Canada [email protected]

Introduction

Asubstantial minority of patients who sustain a mild traumatic brain injury (MTBI) have persistent symptoms,^1–3 disability,^2,4 and high health care utilization^5,6 for more than three months post-injury. Psychological factors, when considered alongside demographic variables and clinical indicators of brain injury severity, are among the most robust predictors of unfavorable outcome from MTBI.^7–14 If psychological factors are prominently involved in the development and maintenance of chronic symptoms after MTBI, there is an opportunity for psychologically informed early intervention to mitigate the risk of poor outcome. Proof of concept for this strategy has been demonstrated.¹⁵ To fully translate the findings from prognostic studies into effective treatments for MTBI, however, it is essential to clarify the specific psychological processes that confer risk. Better characterizing treatment targets could help researchers and clinicians to identify individuals who can most benefit from early psychological intervention, match patient profiles to treatments, and reveal treatment components (i.e., active ingredients) that could be enhanced or eliminated to improve intervention potency or efficiency.^16–18

Cognitive-behavioral models have been developed for chronic pain after musculoskeletal injury,¹⁹ daily headache,²⁰ chronic fatigue syndrome,²¹ chronic subjective dizziness,²² and medically unexplained symptoms^23,24— all health conditions with clinical features that resemble chronic MTBI. Integral to each of these models is the role of fear-based activity avoidance. Patients tend to restrict what they do or modify how they do it to prevent physical or psychological discomfort. This fear avoidance predicts chronic disability.^25–27

Little is known about the role of avoidance behavior in recovery from MTBI....