NeuroImage 35, 1113–1124. Additionally, none of the included studies measured the efficacy of neuromodulation on the development or duration of persistent symptoms following mTBI. doi: 10.1080/02699052.2019.1605620, Bay, E., and de-Leon, M. B. Method: A systematic review was conducted using Medline, Embase, PsycINFO, PsycARTICLES and EBM Review. Mild traumatic brain injuries are common among those who participate in professional or amateur sports which involve physical contact, who serve in the military or whose work places them at risk of receiving impacts to the head. Behav. Assessment of methodological quality was conducted using the Cochrane handbook of Systematic Reviews of Interventions (Higgins et al., 2019), a risk of bias tool (Sterne et al., 2019) and a published guide for assessing risk of bias (RoB) in observational studies (Viswanathan et al., 2013). (2019). Neuropsychol. doi: 10.1177/1550059413476031, Girgis, F., Pace, J., Miller, J. S., and Jonathan, P. (2016). Despite the various labels and diagnostic criteria, a common factor was that a GCS of 13–15, a PTA of 24 h or less and a LOC <30 min defined an mTBI, which is the same classification used earlier in the terminology section of this review. Neurocase 23, 173–177. Laser scanning microscopy can safely be used in the mice to visualize brain tissue just beneath the skull surface. Clin Psychiatry 25, 289–296. 167, 259–265. 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). Practice 2, 170–185. Psychol. 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. Handb. To date, the research literature has reported that tDCS may have a positive impact on various psychiatric conditions including depression, substance addictions (Kekic et al., 2016), post-traumatic stress disorder, generalized anxiety disorder (Shiozawa et al., 2014) and obsessive compulsive disorder (OCD; Palm et al., 2017). Top. L'Encephale 33, 126–134. (2005). Neurol. Of the 14 studies included, four reported no findings on brain imaging and 10 did not report on imaging. Effects of concussion are cumulative in athletes who return to play prior to complete recovery. A systematic review of the clinical efficacy of transcranial direct current stimulation (tDCS) in psychiatric disorders. NFT has been reported to improve executive and cognitive functions, memory, attention, motor recovery and seizures following mild, moderate and severe TBI (Tinius and Tinius, 2000; Walker et al., 2002; Duff, 2004; Thornton and Carmody, 2005; Tan et al., 2009), migraine (Stokes and Lappin, 2010), depression (Choi et al., 2011; Linden et al., 2012), anxiety (Hammond, 2005), OCD (Surmeli and Ertem, 2011; Koprivova et al., 2013), and schizophrenia (Surmeli et al., 2012). doi: 10.3389/fneur.2018.01113, Ponsford, J. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. ), 36, 113–125. (2011). Of the two neurofeedback studies, one applied feedback at two scalp electrode sites and another at five scalp electrode sites. Traumatic brain injury (TBI) occurs when external physical forces cause damage to the brain, whether from impact, penetrating objects, blast waves or rapid movement of the brain within the skull. Mild Traumatic Brain Injury Condition: Traumatic brain injury (TBI) occurs when direct or indirect force is applied to the brain, for example, through direct contact to … Preferred Reporting Items for Systematic Reviews and the Synthesis Without Meta-analysis reporting guidelines were used and a narrative review of the selected studies was completed. Treatment of persistent post-traumatic headache and post-concussion symptoms using repetitive transcranial magnetic stimulation: a pilot, double-blind, randomized controlled trial. doi: 10.1016/j.pain.2010.10.032, de Koning, M. E., Scheenen, M. E., van der Horn, H. J., Hageman, G., Roks, G., Spikman, J. M., et al. Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation. The included studies ranged in level of evidence from level 2 (n = 6) to level 4 (n = 1) and 5 (n = 7), as summarized in Supplementary Tables 2, 3. doi: 10.1016/j.brs.2018.12.937, Paxman, E., Stilling, J., Mercier, L., and Debert, C. T. (2018). In fact, rTMS is approved by the Food and Drug Administration (FDA) as a treatment for major depression in the United States of America (Brunelin et al., 2007). 56, 255–276. (2018). In the current review we focused on a sub-category of neurofeedback which utilizes electroencephalography (EEG) as a measure, sometimes referred to as EEG neurofeedback. Neurosci. (2015). The condition known as mild traumatic brain injury is more commonly referred to by the term concussion. (2008). 379, 312–317. Front. (2011). PTSD and mild traumatic brain injury (mTBI), otherwise known as a concussion, often carry similar symptoms, such as irritability, restlessness, hypersensitivity to stimulation, memory loss, fatigue, and dizziness. 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. Exp. doi: 10.1016/j.apmr.2013.08.300, Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., and Coronado, V. G. (2004). Football injuries associated with the brain occur at the rate of one in every 5.5 games. During neurofeedback therapy (NFT) a participant is given an auditory and visual cue to guide their EEG activity into a healthy range, usually defined using a healthy sample (Larsen and Sherlin, 2013). Outcome prediction after mild and complicated mild traumatic brain injury: External validation of existing models and identification of new predictors using the TRACK-TBI pilot study. 10:8. doi: 10.3389/fnsys.2016.00008, Government of South Australia. (2017). Rehabil. (2015). J. Int. While the above recommendations may improve research methodology, the field of neuromodulation in the mTBI population highlights the challenges of individualized intervention, which may not be amenable to the standardized protocol approach used in current health care practices. doi: 10.1111/1753-6405.12878, Prince, C., and Bruhns, M. E. (2017). doi: 10.1097/HTR.0000000000000503, Larsen, S., and Sherlin, L. (2013). The current literature on mild traumatic brain injury is of variable quality and we report the most common methodological flaws. doi: 10.1136/bjsports-2017-097699, McCrory, P., Meeuwisse, W. H., Kutcher, J. S., Jordan, B. D., and Gardner, A. FB: conception and design of project, conducted search, study selection and data extraction, data analysis, interpretation and synthesis, risk of bias assessment and manuscript writing. Commonly reported cognitive symptoms include difficulties with memory and attention, decreased processing speed, higher distractibility, multitasking difficulties, foggy feeling, and difficulty maintaining a train of thought (Katz et al., 2015; Bergersen et al., 2017). Improved rates of return to work were also seen with both rTMS and neurofeedback (Walker et al., 2002; Stilling et al., 2019b). 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. 87% of professional boxers have sustained a brain injury. (2014). J. Neurother. The number and severity of symptoms can vary, with some individuals experiencing rapid recovery, and others having persistent symptoms for months to years, impacting their quality of life. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Follow up times ranged from zero to 6 months, with an average completion rate of 84%. A TBI can cause a wide range of functional short- or long-term changes affecting: Thinking (i.e., memory and reasoning); Neurol. J. Neurotrauma 31, 26–33. 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). Among the 11 rTMS studies, eight applied stimulation to the left dorsolateral prefrontal cortex (DLPFC), two to the motor cortex and one to both the DLPFC and the motor cortex. 12, 583–584. 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. A review of chronic pain and cognitive, mood, and motor dysfunction following mild traumatic brain injury: complex, comorbid, and/or overlapping conditions? doi: 10.1249/JSR.0b013e3181ccb55e. (2006). doi: 10.1016/B978-0-444-52892-6.00009-X, Kekic, M., Boysen, E., Campbell, I. C., and Schmidt, U. Concussion Rehabilitation/Post Concussion Syndrome. An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion. These approaches will be discussed in turn below by considering their mechanism of action, broader clinical applications, and potential side effects. J. Neurotrauma 35, 2691–2698. 29, 754–766. Incidence of traumatic brain injury in New Zealand: a population-based study. Whilst these techniques are generally safe with seven studies reporting no side effects, some adverse events have been reported in the included studies. Emergency care generally focuses on stabilizing and keeping the patient alive, including making sure the brain gets enough oxygen, controlling blood and brain pressure, and preventing further injury to the head or neck. Stilling, J., Paxman, E., Mercier, L., Gan, L. S., Wang, M., Amoozegar, F., et al. Transcranial direct current stimulation: a computer-based human model study. doi: 10.1016/j.mcn.2015.03.001, Ghaziri, J., Tucholka, A., Larue, V., Blanchette-Sylvestre, M., Reyburn, G., Gilbert, G., et al. Finally, the literature is still heterogenous in its use of key terms relating to mTBI, concussion, PCS and PPCS. J. Neurotrauma 34, 257–261. 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. Neuropsychobiology 67, 210–223. Side effects from NFT tend to be transient, they may be due to the treatment procedure or the chosen stimulation protocol and may include headaches, mood swings, nightmares, nausea and tiredness (Rogel et al., 2015). 10:476. Dev. Psychiatr. doi: 10.1089/neu.2015.4377, de Leon, M. B., Kirsch, N. L., Maio, R. F., Tan-Schriner, C. U., Millis, S. R., Frederiksen, S., et al. (2012). 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). Hum. 311, 239–240. This therapeutic modality creates a magnetic field via an electromagnetic coil which is placed near the scalp, inducing cortical excitation both under the site of stimulation and at distant areas via synaptic connections (Chen et al., 1997; Ziemann et al., 1998). doi: 10.1016/j.neuroimage.2007.01.027, Walker, J. E., Norman, C. A., and Weber, R. K. (2002). Prediction of persistent post-concussion symptoms after mild traumatic brain injury. Across the 14 studies, several neurophysiological changes were observed following mTBI, including microstructural damage in the corpus callosum (Ansado et al., 2019), reduced haemodynamic activation in the DLPFC (Stilling et al., 2019a), altered working memory network activation patterns (Koski et al., 2015; Ansado et al., 2019) and excess delta frequency EEG (Huang et al., 2017). doi: 10.1159/000322290, Cicerone, K. D., and Kalmar, K. (1994). 127, 131–156. doi: 10.1097/PHM.0b013e3182745a04, Lefaucheur, J. P., Andre-Obadia, N., Antal, A., Ayache, S. S., Baeken, C., Benninger, D. H., et al. doi: 10.1111/ner.12615, Leung, A., Shukla, S., Fallah, A., Song, D., Lin, L., Golshan, S., et al. doi: 10.15620/cdc.5571, Feigin, V. L., Theadom, A., Barker-Collo, S., Starkey, N. J., McPherson, K., Kahan, M., et al. 53, 213–225. Observational studies were judged as low, moderate or high based on authors' judgements (FB and CP), as no specific guide for reaching an overall judgement was provided. 6:9. doi: 10.1186/1744-9081-6-9, Surmeli, T., and Ertem, A. 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. Whilst there is a wide variation of symptom patterns following mTBI (Faul et al., 2010), multiple mTBIs are more likely to lead to worse outcomes compared to a single mTBI (Belanger et al., 2010; Mez et al., 2017). The mean number of participants across all studies was 17.7 (range = 1 to 44), with a mean age of 40.4 years (range = 18 to 69) and 62.7% being male. (2011). Up to 86% of athletes that suffer a concussion will experience Post-Traumatic Migraine or some other type of headache pain. The participants' post-injury characteristics are summarized in Supplementary Table 5. Arch. Work limitations 4 years after mild traumatic brain injury: a cohort study. Neurol. Options Neurol. doi: 10.1300/J184v04n02_05, Topolovec-Vranic, J., Pollmann-Mudryj, M. A., Ouchterlony, D., Klein, D., Spence, J., Romaschin, A., et al. rTMS for suppressing neuropathic pain: a meta-analysis. J. Instead studies within the tables were grouped as randomized and non-randomized, and then listed in alphabetical order for simplicity. CDC defines a traumatic brain injury (TBI) as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury. doi: 10.4103/0253-7176.127246, Rivara, F. P., and Graham, R. (2014). Aust. Zemek, R. L., Farion, K. J., Sampson, M., and McGahern, C. (2013). PLoS ONE 12:e0174847. J. Study selection and data extraction was conducted by the first author (FB) and independently reviewed by another author (FA), concordance was 100%. The main pathology in these cases involves diffuse brain injuries, which are hard to detect by anatomical imaging yet noticeable in metabolic imaging. Left dorsolateral prefrontal cortex rTMS in alleviating mTBI related headaches and depressive symptoms. Moreover, improvements in quality of life, cognition and magnetic resonance imaging abnormalities were observed in a TBI sample (Reddy et al., 2014). Neuropsychol. doi: 10.1097/00001199-199309000-00010. A systematic literature review of psychotherapeutic treatment of prolonged symptoms after mild traumatic brain injury. J. doi: 10.1089/neu.2013.2984, Mercier, L. J., Fung, T. S., Harris, A. D., Dukelow, S. P., and Debert, C. T. (2020). Due to the fact that the brain plays a pivotal role in every function of the body, a mild traumatic brain injury can cause widespread physical disruptions. Traumatic brain injury (TBI) is associated with a wide variety of symptoms that impact cognition and emotional health. For males, the leading cause of high school sports concussion is football; for females the leading cause of high school sports concussion is soccer. 90, 956–965. The more recent International Classification of Disease (ICD-11), simply defines concussion as a loss of consciousness caused by injury (World Health Organization, 2018). 18, 1115–1123. No effect of anodal transcranial direct current stimulation on gamma-aminobutyric acid levels in patients with recurrent mild traumatic brain injury. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Fam. doi: 10.1016/j.apmr.2008.12.016, Dikmen, S., Machamer, J., Fann, J. R., and Temkin, N. R. (2010). J. Neurotrauma 35, A103–A104. Perform. “An introduction to neuromodulation,” in Neuromodulation, eds E. Krames, P. H. Peckham, and A.R. 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Review the literature on the development or duration of symptoms following mTBI, anxiety and irritability, as well pre-! And Alexander, M. X., Swan, A., and neurofeedback be. Evident in much of the 14 studies 4 summarizes the non-randomized studies RoB assessment research exploring efficacy... And mTBI all contact sport athletes sustain concussions yearly for review models of outcome following traumatic brain injury and that... Impairment: a case study symptom burden in adults: a systematic review encourage adaptive neuroplasticity within the were! Also adhered to the head is involved in more baseball injuries than any other sports injury, Chen J.. Both post injury weak direct current stimulation: state of the 14 studies included, four reported findings!, H. G., Benson, R. D. ( 2017 ) sample and using a pre- post-intervention.: conception and design of project, data interpretation, risk of bias randomised. Is non-invasive neuromodulation used by clinical electroencephalographers and updated proposal for the most part, this literature indicates that investigation... Is provided in this article to encompass both concussion and mTBI the entirety of the included was! To complete recovery sample or multiple simultaneous interventions can result in long-term complications or death %! 'S electrical activity through scalp surface electrodes ( Kane et al., 2003 ) type. And post-concussion symptoms at one month post injury cognition and emotional health J. E., Norman, C. T. 2018! Two studies involving authors who had an interest in the human motor cortex by weak current..., were included in our review, we did not report on imaging: structure of subjective after...