Symptoms, return to school, physical activity take longer with pre-existing anxiety

Children and adolescents who were anxious prior to mild traumatic brain injury (mTBI) had almost 50% more symptoms at baseline and took almost twice as long to return to school as those without pre-injury anxiety, a retrospective cohort study found.

Anxiety pre-dating mTBI was associated with an additional 2.64 (95% CI 1.84-3.44) concussion symptoms throughout recovery in age- and sex-adjusted findings, reported Amy Linabery, PhD, MS, of the Children’s Minnesota Neuroscience Institute in Minneapolis, and co-authors, in the Journal of Neurology Neurosurgery & Psychiatry.

Prolonged recovery in those with pre-existing anxiety was seen in:

  • Time to reach symptom resolution: median 86 versus 36 days (P<0.001); adjusted HR 3.34, 95% CI 2.18-5.12.
  • Return to academics: 83 versus 46 days (P<0.001); adjusted HR 2.01, 95% CI 1.59-2.53.
  • Return to physical activity: 90 versus 47 days (P<0.001); adjusted HR 1.88, 95% CI 1.49-2.37.

“Pre-existing anxiety disorders are associated with more symptomatic and prolonged recovery in children and adolescents following concussion,” Linabery and colleagues wrote. “From a clinical perspective, the provision of accurate recovery estimates to patients and families at the time of the initial clinic visit may normalize longer recovery expectations and the timely administration of targeted therapies may promote more efficient recovery in these patients.”

“There was no evidence that concussion or vision symptom trajectories varied over time between those with/without anxiety after accounting for baseline dissimilarities in symptom scores (all P interaction >0.05),” they added.

In an accompanying editorial, Simon Fleminger, MD, of Kings College in London, England, pointed out that a larger study of pediatric mTBI did not find that pre-injury anxiety predicted outcome. That study recruited children in emergency departments within 2 days of injury and measured outcome at 28 days post-injury, whereas in the present study, children were recruited from specialist tertiary concussion clinics up to 90 days post-injury with follow-up until 180 days.

“The difference in the findings of these two studies is therefore consistent with the hypothesis that the longer symptoms persist after an mTBI the more likely it is that psychological factors are at play,” he wrote.

Pediatric mTBI recovery stretches beyond 4 weeks or so (as seen in the majority), to months or years in 25%–40% of patients. Risk factors for prolonged recovery include psychiatric disorders in addition to age, sex, and injury mechanism and severity.

The prevalence of anxiety— as high as 24% — and paucity of mixed-result findings in its role in pediatric mTBI motivated the authors to explore the relationship further.

Linabery and colleagues studied 637 participants ages 5–17 presenting to three tertiary concussion clinics within 90 days of injury between April 2018 and March 2019. Patients were followed from initial visit until they were discharged from clinic with recovery of symptoms, or when providers attributed remaining symptoms to non-injury causes or patients chose to end visits. Anxiety as well symptoms were judged present/absent. Overall, 24% of the cohort reported pre-existing anxiety.

Females made up 50% of those without and 63% of those with pre-existing anxiety. Participants ages 5-11 made up 36% of those without a history of anxiety and 21% of those with a history of anxiety, while those ages 12-17 accounted for 64% of those without and 79% of those with a history of anxiety.

Median acute symptom score (number of 28 queried symptoms experienced immediately following injury) was 9 (range 0-14) for those without and 12 (range 5-17) for those with a history of anxiety.

“These increased symptom loads in patients with anxiety disorders persisted throughout follow-up such that no between-group differences in concussion or vision symptom trajectories were observed,” the authors noted. “In both groups, concussion symptoms decreased over the first 7 days (−0.006 symptoms per day, 95% CI −0.10 to 0.09), and this reduction progressed at a faster rate thereafter (−0.09, 95% CI −0.10 to −0.06).”

For vision symptoms, they added, the trend was reversed with a steeper negative slope in the first 7 days (−1.14, 95% CI −1.77 to −0.52) followed by a less steep but still negative slope thereafter (−0.14, 95% CI −0.17 to −0.11).

“Somewhat unusually, [the authors] selected visual symptoms after mTBI for special consideration,” the editorialist noted. “Blurred vision, photophobia, and double vision are not uncommonly described early after mTBI.” The authors “found that visual symptoms were as likely as the generality of post-injury symptoms to be associated with pre-injury anxiety.”

Limitations of this study include anxiety exposure measures based on clinician interviews and medical record confirmation, so misclassification is possible. The study cohort may be subject to selection bias and the population may differ from non-tertiary center cohorts, potentially affecting generalizability.

“Additional studies that incorporate baseline anxiety screening are needed to better characterize the role of anxiety disorder severity and management in mTBI recovery,” Linabery and co-authors observed. “Further work is also required to determine the underlying biological and psychosocial mechanisms driving the increased symptomology and protracted recovery observed in children and adolescents with anxiety disorders.”

  1. Children and adolescents who had pre-existing anxiety prior to mild traumatic brain injury (mTBI) had almost 50% more symptoms at baseline as those without pre-injury anxiety, a retrospective cohort study found.

  2. Those with a history of anxiety had longer times to symptom resolution (median of 86 versus 36 days), return to academics (83 versus 46 days), and return to physical activity (90 versus 47 days) than those without history of anxiety.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Linabery’s work is in support of the Neuroscience Institute’s research. She reported no competing interests.

Fleminger reported no competing interests.

Cat ID: 474

Topic ID: 82,474,474,138,192,52,925