Rehabilitation and Management

## **Chapter 5** Concussion Rehabilitation

*Valentina Vanessa Re*

#### **Abstract**

Concussion represents one of modern medicine's biggest challenges. As we are gaining more and more information on pathophysiology, diagnosis, and treatment, a lot is still to be cleared. On the side of pharmacology, rehabilitation is the leading treatment for concussion signs and symptoms. From acute to the chronic phase of brain dysfunction, rehabilitation is nowadays providing help to people recover faster and better. In this chapter, we will analyze in depth the key information and evidence supporting current concussion rehabilitation methods and protocols. Through this chapter, we are exploring how aerobic training, vestibular rehabilitation, and oculomotor exercises are working together with the treatment of migraine and neck pain. We also aim to provide the basis and relevance of cognitive rehabilitation and double-task-multifunctional training and the importance of fatigue and mood problem management.

**Keywords:** concussion, rehabilitation, concussion subtypes, vestibular rehabilitation, ocular-motor rehabilitation, neck pain rehabilitation, post-concussion migraine, persistent post-concussion symptoms

#### **1. Introduction**

A concussion is a mild traumatic brain injury caused by a direct blow to the head, neck, or elsewhere in the body, resulting in an impulsive force being transmitted to the brain. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change, and inflammation affecting the brain [1]. This leads to a brain functional impairment that provokes signs and symptoms, such as headache, neck pain, nausea, balance problems, gait impairment, dizziness, fatigue, sleep disturbances, mood changes, cognitive and focus impairment, less tolerance to cognitive and physical exercise, blurred vision, and visual problems. This is a reversible condition that usually resolves within 2 to 4 weeks, but it can last months or longer [2, 3]. Experiments on rats demonstrate that, during this period of time, brain cells undergo an energy crisis and are more vulnerable to new traumas because of blood flow changes [4–7]. Advanced neuroimaging studies on humans seem to validate these findings [3]. During brain vulnerability period, any additional concussions can lead to an acute more aggressive brain injury, known as diffuse cerebral swelling, or to a progressive subclinical injury summation until massive cell death and encephalopathy, best known as chronic traumatic encephalopathy [8]. United States Centers for Disease Control and Prevention (CDC) have labeled concussion a major public health

issue due to acute and potential long-term effects associated with this injury [9]. Nowadays, many concussions still remain undiagnosed, and above all sport-related concussions [10], but the trend is positive. Over the past decade, knowledge about concussion has increased significantly, with increasing hospital consultations [11] and medical attention.

On actual knowledge, avoiding second-impact exposure and treating concussion with clinical and objective recovery are the key in preventing brain traumatic encephalopathy. That is why it is so important to know how to manage and treat concussions.

#### **2. How concussion evaluation is important for rehabilitation**

A concussion is a complex heterogeneous injury that presents with a variety of symptoms and clinical findings. The primary goal in concussion evaluation is to characterize the clinical presentation, identify factors of possible prolonged recovery and prescribe a specific treatment plan.

Clinical presentation is different in every concussion by symptom types, intensity, and duration. Researchers have attempted to classify concussions into specific clinical profiles, to help clinicians with prescription and follow-up. Clinical profiles are supported by intuitive evidence, but to date, they are not empirically validated. Nevertheless, they are useful for educational purposes and help in clustering and focusing on current concussion rehabilitation indications. Moreover, it can help in drawing a tailored rehabilitation protocol, which seems promising in concussion recovery, instead of a one-size fits all approach.

Here, we report the main clinical profile classification proposed by the literature.

Collins et al. [12] categorized concussion into five clinical profiles and two modifying factors. It is based on symptoms evaluation and physical examination only; it can be applied from the first week following injury and profiles are not mutually exclusive as the overlap is possible:

1.Vestibular

2.Ocular-motor

3.Cognitive/fatigue

4.Post-traumatic migraine

5.Anxiety/mood

Modifying factors are:

1.Cervical

2. Sleep disturbances

Ellis et al. [13] proposed a classification into three post-concussion disorders and two modifying factors, which can be applied after 3 weeks from injury and it is based on symptoms evaluation, physical examination, and aerobic treadmill testing.

1.Physiological

2.Vestibular-ocular

3.Cervicogenic

Modifying factors are:

1.Mood disorders

#### 2.Migraine

In other studies, even if a classification is not proposed, researchers identify the necessity to have a targeted evaluation and rehabilitation protocols for symptoms, such as headache, insomnia, cognition, mood, balance, vision, and fatigue, if symptoms last more than a month, which recall symptoms identified in the previous classifications.

Clustering patients'symptoms into this clinical profile are helpful for tailored treatment prescription, which we will describe soon in this chapter. A recent review states that individually tailored multimodal interventions have a worthwhile effect in providing a faster return to sport and clinical improvement, specifically in those with persistent symptoms [9, 14, 15]. Collecting a good clinical history is also fundamental. Identification of existing pre-injuries factors that can influence recovery is mandatory.

It has been demonstrated that the natural history of concussion, from 70% up to 85% of cases, is a spontaneous recovery within 2 weeks for adults and 4 weeks for children and adolescents. Patients will experiment with a natural reduction in symptoms by number and gravity through days, without any particular intervention [16, 17]. This means that, after diagnosing a concussion, an observational approach could be part of the treatment process, as Nature is working on its own to promote spontaneous recovery. Nevertheless, it is crucial to know that symptoms and clinical recovery could happen in a shorter time than brain complete function recovery. Preliminary studies have shown that brain normal functioning recovery could last longer than the symptoms perceived [3, 18].

Moreover, we should remember that 15–30% of concussions are going to have a prolonged recovery, and they will need a different approach and treatment. Thus, it is really important for a clinician, to draw up a precise clinical history to help understand if a wait-and-see approach is actionable, or close surveillance and a more active treatment is necessary.

Prolonged post-concussion symptoms (PPCS) and post-concussion syndrome (PCS) are labels used to identify symptoms lasting more than 4 weeks. Researchers are trying to understand recovery trajectories and predict prolonged recovery time as a way to stratify patients for a tailored rehabilitation and treatment protocol.

Nowadays, there are no objective measures to predict prolonged recovery: salivary biomarkers and advanced MRI spectroscopic imaging are promising fields of research, but more studies need to be done before application in clinical settings [3, 19]. Nevertheless, some factors on clinical presentation and history seem, on actual knowledge, to predict recovery time.

Symptoms severity score and overall symptom burden seem to be the most significant predictor of prolonged recovery [10, 20–22], history of previous concussions, sleep disturbances [23], vision and vestibular problem and a history of motion

sickness seems to predict prolonged recovery in children [24], prior diagnosis of mental health problem, as depression, anxiety, bipolar and personality disorder are predictive for prolonged recovery [25], prolonged rest and delay in search for medical attention relate to a longer recovery time too [26].

Physical examination and objective tests are also important to determine a patient's actual impairments and to discover new emerging factors that could predict a longer recovery. For example, cognitive impairment, such as reaction time and visual motor speed performance in neurocognitive testing, relates to prolonged recovery [20, 27].

Once collected all the information, clinicians are ready to give treatment indications and prescribe rehabilitation.

Part of concussion treatment is based on medication, but it will not be discussed, as it goes beyond the aim of this chapter.

#### **3. Treatment indication and tailored rehabilitation**

#### **3.1 Do not harm: avoiding a second impact**

First do not harm, state the Hippocratic Oath. Protecting a patient from a second brain impact, especially if close to the one he/she is suffering, is mandatory. As said before after a brain injury, even if mild, the brain lays in a state of vulnerability [1], and a second impact could lead to a Second Impact Syndrome (SIS) or diffuse cerebral edema, with the greatest risk occurring in the first 10 days post-injury [16]. It is particularly true in sport-related concussion because of possible repetitive traumatic events [28], related to sports characteristics. Returning an athlete to play with persistent symptoms may predispose the athlete to a higher risk of a new brain impact injury as concussion decreases the cognitive ability and reaction time, which theoretically diminished an athlete's ability to respond to the demands of the sport. Attention should be paid also to other environments, thus reducing risk exposure to driving, home accidents, or work accidents is recommended until medical clearance.

#### **3.2 Observation as the first step of concussion treatment**

If clinical history and physical examination are not suggestive of prolonged recovery, an observational approach could be part of the treatment process, as Nature is working on its own to promote spontaneous recovery. As said before, 70–85% of concussions will recover spontaneously, and follow-up could be a good managing decision. Nevertheless, we should also remember that medicine is not an exact science, so follow-up is always recommended.

Usually, behavioral modifications are suggested:


If the clinician is an expert in managing concussion, an active and individualized approach is always recommended, but if patient history and symptoms do not depict a serious clinical presentation, remember that sometimes wrong prescriptions are worse than no prescription.

#### **3.3 Rest: is it useful in concussion treatment?**

During the acute post-injury period, patients who suffered from concussion usually experience intense symptoms that are worsened by cognitive or physical activity, and assuming that vigorous activity could magnify the underlying energy crisis is reasonable [9, 29, 30]. Moreover, as said before, a second impact during the period of brain vulnerability could lead to more aggressive injury and CTE [31–34]. Literature also demonstrates that delayed reporting and removal from athletic activity following a sports concussion, predicts prolonged recovery [35], meaning that early physical activity could relate to a longer recovery period. These are the main reasons why most clinicians prescribe rest until symptoms improve, and in the previous decade, rest was highly recommended [9].

Nevertheless, it is important to notice that *avoiding contact* during this period and *rest* are two different strategies. If the first one is always recommended as far as the patient remains symptomatic or until medical clearance, the second one is open to different management.

Researchers noted that patients with the highest and lowest levels of activity had worse outcomes and took longer to recover, suggesting that too much or too little physical and cognitive activity could be detrimental to recovery [31].

Strict and prolonged rest in medicine is demonstrated to be of no benefit. It exacerbates symptoms and prolongs recovery [36], and the same thing applies to brain injury [37].

In addition, we should also state that strict rest, meaning no physical or cognitive activity during the time prescribed, forces people who suffer from concussion to avoid sports, social life, and school or work. This has a big impact both on the patient's psychology and on the society [9].

In contrast, there is increasing evidence that early mild noncontact, such as physical activity, does not appear to worsen or cause additional injury and indeed seems to help recovery [9, 17, 37, 38].

So, how is rest beneficial? How much and how long should rest be prescribed?

Evidence from the last 10 years showed that strict rest beyond 2 days will prolong recovery from concussion [37, 39–41], and that symptoms are of greater magnitude.

In agreement with that, the concussion consensus in the sports group set an average rest period of 24–48 hours after a concussion trauma, before starting rehabilitation and progressive return to physical and cognitive activity [2]. During the first few days, rest should not be strict avoidance of physical and cognitive activity [31], but should be dosed, based on the patient's sensitivity to symptom exacerbation. Physical and cognitive activities of daily living are permitted if they do not exacerbate symptoms, absence from school or work is recommended. A patient could sleep and take naps if needed.

#### **3.4 Physical activity as a medicine for concussion**

Many studies demonstrate that physical activity is the principal intervention in concussion management as it helps in recovering faster and lowering symptoms

intensity [26]. Thus, it is indicated in any concussion case, even if prolonged recovery is not suspected.

If we consider "physical activity" as a medicine, it is important to understand what is the "active ingredient" and how to dose it. "Physical activity" may include aerobic exercise, resistance training, full body exercise, sport-specific exercise, balance and vestibular exercise, visual ocular-motor exercise, postural exercise, multitasking exercise … and so on.

What is known nowadays is that aerobic exercise and full body exercise, in general, are good interventions for concussion recovery, a sort of "one size fits all" approach, while other types of physical exercise are more specific for concussion clinical subtype profiles. So, in this chapter "physical activity" will be synonymous with "aerobic exercise, resistance training, full body exercise, and sport-specific exercise," while vestibular rehabilitation, balance exercise, motor-ocular exercise, visual rehabilitation, and cervical rehabilitation will be deeply investigated later in this chapter.

It is well established that concussion leads to an altered ionic and cellular homeostasis, that requires more ATP usage to restore the physiological environment. This energy requirement crashes with a setting of reduced cerebral blood flow, resulting in a mismatch between energy supply and demand [32]. The autonomic nervous system is also altered in the concussed patient, and this condition leads to an altered modulation of cardiac function and cerebral perfusion [42, 43].

Introducing aerobic exercise in this setting of the energy crisis is not so straightforward, but at the same time it is well-known that aerobic training could help in autonomic dysfunction recovery [44].

As said before, an average rest period of 24–48 hours after a concussion is recommended, then an initial light aerobic exercise could be initiated, even if symptomatic. The main warning lights that we have in a concussed patient are symptoms. Thus, it is mandatory to count on personal patients'symptoms and feelings and it is important to establish good cooperation with the patient. The active training could be done independently, but it is recommended to be followed by a personal trainer or physiotherapist, who is trained in concussion rehabilitation.

Based on literature findings, here we provide guidance on validated physical exercises for concussion.

#### *3.4.1 The graduated return to play protocol (GRTP)*

The fifth consensus statement on concussion in sports creates an easy graduated protocol to return to sport participation [2]. It is based on the progressive introduction of aerobic and resistance training, mixed with sport-specific exercises. For contact sports, returning to full contact practice is permitted after medical clearance. This approach could be applied to any sport.

The characteristics of this approach are based on progressive physical stimulation and evaluation of symptom exacerbation. Every step should last at least 24 hours and if symptoms worsen with the exercise, the athlete should go back to the previous step.

#### *3.4.2 GRTP*

• Stage 1. Symptoms-limited activity: Daily activities that do not provoke symptoms and gradual reintroduction of work/school activity.


Dosing exercise based on symptoms provocation only is a useful method if no assessment tools are disposable. It can be applied to everyone, athletes or not, helping them to increase physical activity. The graduated return to play protocol is obviously particularly indicated for sports concussion, but the underlying symptoms-based approach could be applied also for people who are not athletes, as a "sub-symptoms threshold method" (see below).

For example, we can use the same protocol by using only aerobic exercises, such as walking, running, and cycling. Every step should last at least 24 hours and exercises should be done on a daily basis or 6 days/week and stay at a sub-symptoms' threshold level. On a scale from 0 to10, any new symptoms or symptoms worsening of 3 points out of 10 is considered an "exercise symptoms provocation," and the patient should set his exercise to a lower level, or stop.

The patient should start at a light perceived level of exercise and monitor his symptoms. If no symptoms are provoked, the patient can increase activity level by duration and/or intensity or exercise type and, again, monitor his symptoms. If the exercise provokes symptoms, the patient should set the training at a previous level of exercise for the next 24 hours.

The same pattern could be applied to resistance training.

#### *3.4.3 The concussion sub-symptoms threshold approach*

This method is based on the physical activity below the symptoms threshold, which is similar to the previous approach. Nevertheless, it is based on aerobic exercises and a more objective setting and progression.

An initial test should be done to evaluate patient tolerance to aerobic exercise, which has been demonstrated to be lower in concussed patients because of the autonomic dysregulations mentioned before. It is important to set each patient's threshold for symptom exacerbation because the following physical activity is set on a subthreshold level, and then a new test for progression will follow.

The most popular and validated test is the Buffalo Concussion test. It is done on a treadmill (BCTT) [45] with a progressive increase of aerobic loading, measuring heart rate and symptom exacerbation. In particular, the patient is asked to wear a heart rate monitor and to step on a treadmill. To increase heart rate, the treadmill is tilted progressively, similar to the Balke treadmill test, until aerobic intolerance. The aerobic threshold is set if the maximum heart rate is reached or new symptoms appear or symptoms are worsened by 3 points on a scale out of 10. The patient is then instructed to perform aerobic exercise at 80% of the heart rate threshold for 20 minutes on a daily basis. If the patient is an athlete, it is recommended to exercise at 90% of the heart rate threshold for 20 minutes twice a day. If patients feel

symptomatic while exercising at home, they have to stop and rest and continue the next day at a lower exercise intensity. If not, patients may extend the duration of exercise from 20 to 30 minutes or more, keeping the heart rate steady. A daily symptom diary is recommended to track symptoms exacerbation and exercise progression.

After 1 week a patient could increase heart rate exercise by 5–10% or, if possible, the Buffalo Concussion test should be repeated to set a new symptoms threshold [46, 47].

The test could be performed also on a stationary bike (BCBT) [45].

During the last years, aerobic exercise prescriptions were made easier even in case of a lack of aerobic test or heart rate monitor availability, for more practical use. Test explanations, preset modules, and preset exercise prescriptions are available online, see link below for more information.

BCTT: https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_ 19-313\_sdc1.pdf

BCBT: https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_ 19-313\_sdc2.pdf

Aerobic exercise prescription after BCTT or BCBT:

https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_19-313\_ sdc3.pdf

Aerobic exercise if HR monitor is not available:

https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_19-313\_ sdc4.pdf;

https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_19-313\_ sdc5.pdf

Aerobic exercise prescription if no threshold test is performed:

https://cdn-links.lww.com/permalink/jsm/a/jsm\_2020\_01\_28\_haider\_19-313\_ sdc6.pdf

#### **3.5 Vestibular rehabilitation**

If vestibular symptoms are present and a vestibular clinical profile is recognized, a vestibular evaluation and rehabilitation are recommended. Studies evidence that an intervention before 30 days from the injury is indicated [48], but it can be started sooner.

The vestibular system is a complex circuit that detects the motion of the head in time and space and helps to regulate postural stability and balance (vestibulo-spinal reflex), and stabilizes vision (vestibulo-ocular reflex). Disruptions to this system due to concussion are frequent [49], in fact from 23% up to 81% of concussed patients experience dizziness [50].

The reason is likely due to a complex and massive interaction of neurons engaging long pathways, including cortex, brainstem and reticular formation, cranial nerves, and peripheral organs.

Symptoms reported are vertigo, dizziness, impairment in balance, in gait and visual motion sensitivity. Visual motion sensitivity refers to an inability to centrally integrate visual and vestibular information, in particular, in busy environments, such as shopping malls. To make the pathology more complex, this dysfunction may be accompanied by anxiety [51]. Alteration in visual and spatial orientation is identified as a cognitive component of vestibular impairment, as the system is also connected to cortical areas.

#### *Concussion Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.109856*

Usually, these symptoms are recalled under the term "post-concussion dizziness" or "post-traumatic dizziness," as part of the post-concussion syndrome. It is unclear, to our knowledge, if it is due to functional microstructural abnormalities from the trauma or whether there is an unrecognized labyrinthine cause, or both of them. Autonomic dysfunction could be a potential contributor to post-concussive dizziness, too.

Thus, the necessity of a specific evaluation of the vestibular system, before setting up the rehabilitation program, is mandatory.

If the patient reports spinning vertigo, a labyrinthine cause should be evaluated with specific testing as caloric testing, postural testing, audiometry, and VEMPs, to ensure the correct function of the semicircular canal and otolith organs [49].

If a labyrinthine cause is identified, the treatment aims to resolve the underlying cause. For example, benign paroxysmal positional vertigo (BPPV) should be identified and treated as soon as possible, while possible ruptures of portions of the membranous labyrinth, bleeding, traumatic ischemia, utricular and saccular injuries, and perilymphatic fistula should be addressed to a specialized ENT doctor [49].

If a labyrinthine injury is not identified, the hypothesis of microstructural dysfunction of the brain is reasonable, and symptoms are due to the inability to integrate visual, proprioceptive, and vestibular information. In this latter case, the literature provides some easy and practical tests to assess vestibular and oculomotor function as the Vestibular-Ocular-Motor Screening test [51–53].

Therapies for vestibular impairment are a group of active treatments, including dynamic movements involving head and eye coordination, balance and gaze stabilization exercises. These therapies are based on an expose-recover model involving exercises that stress specific impairments and make symptoms arise in a controlled way to promote recovery.

Rehabilitation interventions were designed to work on vestibular-ocular reflex impairment improving gaze stability and eye-head coordination, thus promoting habituation and adaptation to dizziness symptoms.

Different vestibular rehabilitation techniques may be used based on the symptoms and impairments. Here, we list the main group of clinical impairments and symptoms and the type of physical interventions [50, 54, 55]. Vestibular-ocular reflex (VOR) impairment contributes to dizziness, vertigo, disequilibrium, visual motion sensitivity, unstable sensations, oscillopsia, impaired fixation, visual tracking, instability, and blurred vision [56]. It can be improved by targeted eye-head coordination and gazestability training.


Many studies have shown that vestibular rehabilitation is effective [57–61]. If post-traumatic dizziness is persistent despite rehabilitation, other causes should be examined as, for example, cervicogenic dizziness, anxiety-related dizziness, post-traumatic migrainous-related dizziness, or a more serious underlying diffuse axonal injury (DAI). DAI is usually reported in more severe traumatic brain injury, but it has to be taken into account as central nervous dizziness is possible and, if clinically suspected, a diffusion tensor imaging or advanced fiber tract MRI has to be considered [49].

#### **3.6 Visual and ocular-motor rehabilitation**

As for every specific rehabilitation protocol, it is important to collect a good clinical anamnesis and physical examination. It will not be discussed as it is not the aim of this chapter, but abnormal findings will guide in the correct rehabilitation approach. Clinicians should remember that particular abnormal findings in vision and ocular movement, such as visual field loss, cranial nerve palsy, and diplopia, should be investigated with brain MRI, unless made before, to exclude the diagnosis of a major brain injury, instead of a concussion [62]. Especially in patients with prolonged symptoms and recovery.

The visual system is particularly vulnerable to brain traumas because of the numerous brain pathways, cortical areas, and cranial nerves involved in vision. In fact, usually monocular (nuclear and infranuclear) eye movement, best known as ductions, is normal, while binocular (supranuclear) eye movement, such as smooth pursuit, saccades, and optokinetic nystagmus, has pathologic findings. The reason is supposed to be due to a longer neurologic pathway of control, as said before. The alteration could be found also in vestibular-ocular reflex and vergence movements.

Given the fact that concussion is not related to anatomical damages, visual problems are identified as visual dysfunction that could lead to symptoms, such as blurry vision, difficulty in reading, and light sensitivity, which are a common complaints

#### *Concussion Rehabilitation DOI: http://dx.doi.org/10.5772/intechopen.109856*

(35–65%) in post-concussion patients. Visual information processing could also be altered, and thus should be investigated as cognitive impairment [63, 64].

In 2015, a "see to play" protocol was released to help clinicians in rehabilitation prescription for prescription ocular dysfunction, it is based on evaluation and a sort of "one size fits all" treatment, that you can find in the references at the bottom of the page [65].

Below, we report the main pathological findings in visual/oculomotor function in concussed patients and rehabilitation indications for recovery.

	- Convergence insufficiency could be treated with specific exercises. There is a magnitude of exercises in literature, but what seems to be more effective is a combination of office-based exercises and home reinforcement. In particular, office-based exercises should be done by an expert optometrist. The specific indication could be found in the CITT protocol [69] and is based on gross convergence exercises, positive fusional vergence exercises, rump fusional exercises, and jump fusional exercises [69, 70].
	- **Photophobia** is related to pupillary dysfunction in a suspected imbalance between the parasympathetic and sympathetic systems. It should be treated with a reduction to light exposure (hat or glasses with low-density (20% light reduction) achromatic tint, and neutral gray. Physical exercise is also recommended for a better autonomic balance.
	- **Accommodation dysfunction** could be treated with exercises that enhance accommodation. It could be driven by blurry vision, using various magnitudes of positive/negative lenses in a repetitive manner (flippers) and based on the subject's task performance, the difficulty could be altered by increasing the dioptric power of the lens. Or it could be driven by vergence and proximity. In this case, the exercises could be done monocular or binocular, and progression is made by bringing closer and closer an object asking to focus on it [71].
	- Saccades are usually treated by a workout on rapid eye movements, usually, binocular exercises triggering horizontal, vertical, and near-far saccades are

used. Hart chart, visual scanning exercises, reading, or computerized exercises, for example, Sanet Vision integrator or similar are some of the known interventions [70].

	- Smooth pursuit could be worked out by different monocular or binocular exercises, such as thumb rotation, rotating pegboard, tracking objects, or using a computerized approach, such as Sanet Vision Integrator or similar, in sports field strobe glasses could be used [70].
	- Treatment of these symptoms is frequently connected to vestibular rehabilitation discussed before and it is based on an "expose and recover" approach. In-office treatment is usually made in a room free from points of reference and the visual stimulus should reproduce the appearance of the optokinetic disk (optokinetic rotatory disk, or confounding background movements while gaze is maintained on a fixed dot or figure). Usually, real-life exposure to environments with complex visual stimuli is also performed [75].
	- Its rehabilitation has been deeply analyzed in the previous paragraph [56].

Usually, in concussed patients, multimodal exercises are proposed and the result is a mixture of the previously listed exercises, such as saccadic eye movements, visual pursuit, tracking tasks, alternating monocular and binocular tasks, and reading tasks. In addition, visual attention tasks, such as visual-field scanning, attentional grid, and near-far-vision focal shifting, may also be used. Often these tasks involve the use of prisms, special optical lenses, eye cover-ups, penlights, and mirrors. The effectiveness seems to be higher if multiple domain exercises are prescribed [51, 76].

#### **3.7 Cervical rehabilitation**

Cervical or neck injury can be defined as persistent impairments caused by dysfunction of the somatosensory system of the cervical spine likely caused by strain on the soft tissue.

Most cervicogenic symptoms have been attributed to injury or impairment of the upper cervical spine. The reason is that afferents from the upper cervical spine (C1-C3) are widely interconnected. They carry somatosensory information of head and neck position to the brainstem and the cerebellum, useful for adaptive postural and oculomotor regulation, and to the thalamus and the primary somatosensory cortex, useful for the perception of head and body position.

In fact, their direct interactions with the vestibular nuclei, superior colliculi, and central cervical nuclei help coordinate important reflexes (cervico-ocular reflex and vestibulo-ocular reflex) required for gaze stabilization during functional head and neck movements, and for postural stability (cervicocollic reflex and vestibulocollic reflexes). In addition, interactions with the spinal tract contribute to postural tone regulation (cervicospinal and vestibulospinal reflexes).

During concussion, especially if caused by a whiplash movement, abnormal somatosensory afferents arising from the muscle spindles, nerve roots, and joint and pain receptors of the cervical spine could determine cervicogenic pain, dizziness, disorientation, blurred vision, and balance problems. Aberrant cervical somatosensory information may directly affect the cervical and vestibular reflexes and ocular responses, or may indirectly affect the system by creating mismatched information between abnormal somatosensory cervical information and normal vestibular and visual information. Moreover, cervical afferents interact with the trigeminal sensory afferents through the lesser and greater occipital nerves and could lead to hemicranial pain [77–80].

Cervical spine physiotherapy intervention has been demonstrated to be effective in concussion rehabilitation and symptom improvement [81, 82].

Rehabilitation intervention included manual therapy of the cervical and thoracic spines, cervical neuromotor training exercises, and sensorimotor training exercises. It is important that such a program does not produce an increase in pain or headache, but that some temporary exacerbation of dizziness, nausea, unsteadiness, and/or visual disturbances is acceptable [82].

It is important to perform a good physical examination in order to understand if pain originators, muscle hyperactivation, and nerve sensitization are present and to address rehabilitation. If dizziness is present, it is important to understand if it is originated from the cervical spine by performing specific tests, for example, cervical joint-reposition error test, smooth-pursuit neck-torsion test, head-neck differentiation test, cervical flexion-rotation test, and motor-control assessment of deep cervical flexors and extensors [78].

Cervical pain could be discogenic or due to muscle contraction and nerve sensitization. Manual therapy of the cervical and thoracic spines should be addressed based on physical examination and include a set of manipulative therapy for pain, muscle de-contracture, decreasing unwanted muscle activity, and range of movement improvement and relaxation, which are demonstrated to improve patients'symptoms and joint position sense and dizziness [82, 83].

• Cervical neuromotor training exercises and cervical muscle training have been suggested to improve balance proprioceptive neuromuscular facilitation, for example, activating the deep cervical flexors and scapula stabilizers [82, 84].

• Sensorimotor retraining exercises are a set of specific neuromuscular control exercises to improve cervical joint position sense, head relocation accuracy, and movement sense. It could be trained by using exercises with auditory or visible feedback as a laser fastened to the head to trace patterns on a wall, such as a figure-of-eight. It is important to work also with posture, in particular, by giving ergonomic and postural advice for work sitting position [82].

The best evidence of concussion rehabilitation programs is performing a mixture of vestibular, ocular, and cervical exercises, as they are strictly interconnected [51].

#### **3.8 Post-traumatic headache: non-pharmacological treatment**

Post-traumatic headache (PTH) is one of the most common sequelae of traumatic brain injury. It is considered a secondary headache defined by the onset of a headache within 7 days following trauma or injury. If the headache persists beyond 3 months, is it defined as a persistent post-traumatic headache. PTH could be associated with somatic symptoms, for example, nausea, vomiting, photophobia and phonophobia, and cognitive and psychological symptoms.

Possible mechanisms of PTH include trauma-induced impairment in descending modulation of pain-modulating systems, neurometabolic changes, and activation of the trigeminal sensory system. We should also remember that Nociceptive input from upper cervical afferents might also converge on the trigeminocervical complex.

It is important to understand if PTH is a tension-type headache, cervicogenic headache, or a migraine, because treatment interventions could differ. ICHD-3 criteria for diagnosing tension-type or migraine are clear. In the diagnosis of PTH, it is also fundamental to reveal the possibility of co-occurring medication-overuse headaches (MOH), which are frequent and have to be addressed.

The heterogeneity of the headache phenotype in PTH might partially be explained by genetic predisposition and a history of headaches [85, 86].

If a headache or migraine clinical profile is suspected then setting a specific treatment is important in concussion rehabilitation.

The approach to the treatment of post-traumatic headache is both pharmacological and non-pharmacological approaches. In this paragraph, we will list the nonpharmacological intervention, as pharmacological treatment is not the aim of this chapter.


• Cervical rehabilitation is beneficial in tension-type headache, but also in cervicogenic headache and migraine that have a hyperactivation of the trigeminal system triggered by afferents from the upper cervical spine [89].

#### **3.9 Cognitive impairment: indication for rehabilitation**

Cognitive complaints following a concussion are frequent and include mental fogginess, feeling to be mentally slow down, difficulties with attention and concentration, and memory problems. They may also be exacerbated by emotional symptoms, such as anxiety, irritability or depression, sleep disturbances, and pain.

Cognitive functions are a group of brain superior functions, including memory, visuospatial orientation, attention, learning, information processing capacity, and reaction time. The most frequently affected domains after a concussion are memory, attention, and visuospatial functions [90, 91].

Cognitive impairments are due to the well-known energy crisis of the brain, which is incapable of providing good interaction between complex neural circuits from different brain areas. In literature, there is also evidence in support of a diffuse axonal injury as an anatomical substrate underlying cognitive dysfunction [90], and depending on the extent and distribution of damage multiple sensory, motor, emotional, and cognitive systems can be affected [92].

Even if most of the studies demonstrate that cognitive impairments are acutely associated with concussion, there is also evidence that usually they improve 2 weeks post-injury. Nevertheless, there is less agreement in the literature on when these deficits completely resolve, and there is evidence that some cognitive deficits can last more than 6 months [93]. Moreover, studies conducted on long-term sequelae in concussed patients reveal that cognitive impairment could arise as a summation of multiple concussions [94].

It is mandatory to remember that during the acute phase of concussion, cognitive symptoms may be due to other concomitant causes, such as visual ocular-motor deficits, which could lead to blurred vision and difficulty in reading and focusing; post-traumatic headache that could be triggered by visual stimuli and so pushing the patient to avoid cognitive activity as a way to reduce pain; vestibular and visual vertigo lead the patient to avoid crowded places and has a high relationship with anxiety, which could arise cognitive issues; vestibular impairments are also related directly to visual and spatial orientation; and finally, autonomic dysfunction could provoke fatigue and difficulty in concentrating.

Knowing this interaction between neurological systems is important to address rehabilitation.

In the acute phase and initial cognitive rest is recommended for 48 hours, then an active approach could be initiated.

Cognitive rest includes reducing reading, computer use, texting, watching television or movies, playing video games, and similar mental activities. Complete cognitive rest is impractical and is not advised [95].

Then, a progressive return to the activity of daily living, return to school and work is recommended, it has to be taken as an "expose and recover" mental exercise, so accommodation could be necessary (see below). Treatment should also focus on the ocular, vestibular, cervical, and autonomic system to reduce cognitive cross-linked symptoms.

#### *Concussion – State-of-the-Art*

If cognitive impairments last longer than 2–4 weeks, a specific cognitive rehabilitation should be activated. If psychological health disorders are coexisting, adding cognitive behavioral therapy is suggested.

• Progressive return to learn and work:

Following a concussion, the active return to school and work is recommended to improve cognitive impairments and thus is a major priority for the recovering patient. Moreover, prolonged absence from school or work environments must be avoided to reduce the risk of secondary adverse social and emotional effects, for example, anxiety and depression [9].

Patients returning to school/work while recovering from concussion benefit from individualized management strategies, as concussion symptoms and cognitive impairments have an impact on academic learning and work performance [9]. Accommodative support and adjustments may be necessary to balance the goals of recovery and return to productivity, but it is also important to ensure that modifications are not prolonged when no longer necessary.

Accommodations for cognitive impairment for example are:


General accommodations, for example, are:


Literature proposed different return-to-learn and work strategies, for example the "return-to-learn protocol" proposed by Gioia [96], which is similar to the one used for return-to-play mentioned before in this chapter. Some organizations also released guidelines to help clinicians and school professionals with the management of their concussed students or workers [97, 98].

• Cognitive rehabilitation:

It refers to a set of interventions that aim to improve a person's ability to perform cognitive tasks by *retraining* previously learned skills and teaching *compensatory* strategies.

A neuropsychological assessment is fundamental to identify cognitive strengths and weaknesses and areas of treatment. The neuropsychological assessment is usually done by a neuropsychologist with paper and pencil battery tests. In recent years, many computerized neurocognitive testing, designed for concussed patients are at disposal and if specific training is present, they can be evaluated also by clinicians with different specialties [99, 100].


It is a talking therapy that can help patients in managing problems by changing the way they think and behave. It focuses on treating psychological health disorders, including mood, sleep, and anxiety [101].

#### **3.10 Fatigue, anxiety, and sleep disorder: how to manage**

*Fatigue* is defined as "the awareness of a decreased capacity for mental and/or physical activity, because of an imbalance in the availability, utilization, or restoration of resources needed to perform activities" [102].

In the acute phase post-concussion, more than 70% of patients report excessive fatigue, which can persist for years. It is significantly correlated with anxiety and depression and sleep disturbances [103].

Sleep–wake disturbance and fatigue have been linked also to reduced cognitive functioning [104]. Fatigue and autonomic dysfunction are also correlated [105].

	- Lifestyle modifications are recommended, for example, drinking enough fluids to stay well hydrated, healthy eating habits, getting enough sleep, avoiding known stressors, and avoid alcohol.
	- Physical exercise is helpful in reducing fatigue and sleep disturbances [106].

*Mood and anxiety disorders* are frequent in post-concussed patients. It could be related to previous psychiatric conditions or to other post-concussion impairments, such as vestibular dysfunction, visual motion sensitivity, migraine and isolation from school work, and social recreational activities.

	- Mild anxiety could be managed with psychological intervention to gain acknowledgment of the problem, cognitive-behavioral therapy, and behavioral intervention similar to exposure therapy for the treatment of phobias. If psychogenic vertigo is present, vestibular rehabilitation may be recommended.
	- Moderate-to-severe anxiety and particularly if panic attacks are frequent, a psychiatric intervention is also suggested.

*Sleep disorders* reported in post-traumatic brain injury patients include insomnia and hypersomnia syndromes, circadian rhythm disorders, and sleep-related breathing disorders [107, 108]. The pathophysiology may include disruption of neuronal networks involved in the regulation of the circadian rhythm, but it is also related to other post-concussion symptoms, such as pain, headache, or mood disturbances. Studies demonstrate that there is a decrease in melatonin as a possible cause for circadian rhythm alteration. A lack of good-quality sleep is related to fatigue and can affect mood and cognitive functions.

	- During the first 48 hours after concussion, sleep is permitted as needed.

After the first few days, avoiding naps and having sleep habits are suggested. For example, having regular bed and wake times and a bedtime routine, such as a warm bath, is helpful. Also, having a healthy sleeping place (dark, clean, tidy, and quiet) is useful. Patients should avoid other activities at bedtime, such as reading, watching TV, or using the computer.

Eating foods containing magnesium, iron, and B vitamins, which could help in producing melatonin, instead of exciting food such as sugar and caffeine 4 to 6 hours before bed, is recommended.

Physical aerobic exercise is suggested everyday, but patient should avoid exercising too close to bedtime.


#### **4. Conclusion**

A concussion is a heterogeneous and complex syndrome resulting from acute brain trauma. Most of the symptoms reported are related to a brain energy crisis and to disruption in neural circuits. It is considered a reversible condition, even if some

studies demonstrate concussion-related cognitive long-term effects and a suspicion of an underlying diffuse axonal injury is reasonable, as demonstrated in multiple research papers. The summation of a new concussion could lead to phosphorylated tau protein deposits and encephalopathy.

Symptoms usually recover in a brief period, from 2 weeks for adults to 4 weeks for children and adolescents, in almost 80% of cases, but they can last longer. Limiting cognitive and physical rest and setting an early active rehabilitation intervention is the key to a rapid recovery and limiting symptoms chronification.

Progressive cognitive and physical activity in a sub-symptoms threshold manner is the main effective intervention proposed nowadays. In recent years, more individualized rehabilitation is taking place with promising results in concussion management. Clustering patients in different clinical profiles based on individual symptoms lays the foundation for a specific rehabilitation: vestibular, visual ocular-motor, cervical spine, and cognitive rehabilitation are the cornerstone of a tailored intervention. Managing factors, such as mood and anxiety disorder, sleep disturbances, and fatigue, are also fundamental for the achievement of physical and mental well-being.

A concussion is an evolving burning issue and the world of research is moving faster to better understand the importance of concussion clinical profiles, the predictive power of biomarkers, and the effectiveness and timing of treatments.

#### **Conflict of interest**

The author has no conflict of interest.

#### **Author details**

Valentina Vanessa Re Istituto Auxologico Italiano, Milan, Italy

\*Address all correspondence to: valentinare.doc@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 6**

## The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison

*Christopher A. Veeh, Pamela K. Lattimore, Kristin Stainbrook, Arnie P. Aldridge and Carrie Pettus*

#### **Abstract**

Traumatic brain injury (TBI) is found at substantially higher rates among incarcerated individuals compared to the general adult population. Individuals with TBI report a higher likelihood to experience a range of deleterious outcomes including substance abuse, depression, post-traumatic stress disorder, aggressive behavior, and violence. Thus, a history of TBI is likely to lead to the types of behaviors that will significantly increase the odds of an individual returning to incarceration post-release, as supported by recent research with a cohort of state prisoners. TBI has largely gone unaddressed by prison reentry programs that are integral to rehabilitating individuals returning to the community. Relatively little is known, however, about the effects of TBI on the receipt of services post-release. Additionally, few studies have examined sex differences in the prevalence of TBI in reentry populations. This chapter uses data from a multi-state prisoner reentry program randomized control trial to examine whether individuals with TBI are significantly different than their peers without TBI with respect to a variety of demographic and psychological metrics and in expressions of needs for and participation in services and programming during the transition from incarceration to the community.

**Keywords:** traumatic brain injury, post-traumatic stress disorder, criminal recidivism, mental health, substance abuse

#### **1. Introduction**

Over the past decade, traumatic brain injury (TBI) has become more widely recognized as a risk factor for criminal justice involvement. While there is no research that provides a causal link between TBI and criminal offending, studies have found TBI among justice-involved individuals to be as high as 10 times that in the general population. Research indicates that between 23–86% of individuals who are incarcerated have a history of TBI [1–4], significantly larger than estimates of TBI in the general population of 8.5% [5]. Like has been observed in adult populations, research has also found large proportions of youth in juvenile justice settings have a history of TBI [6, 7].

TBI is a significant concern among both men and women who are incarcerated. In the general population, epidemiological studies have found TBI rates among men to be almost twice as high as women [8], while the rates of TBI among incarcerated women are the same or slightly higher than their male counterparts [4, 9]. Recent research review articles have pointed to the male bias in TBI research due in large part to the higher incidence of TBI among men in the general population [10–13]. Mollayeva et al.'s analysis of 58 TBI studies that included a focus on sex/gender, found that women were under-represented in most studies and few researchers made hypotheses specific to sex/gender effects [10, 11, 14]. The potential for similarly high rates of TBI among incarcerated individuals warrants attention to the sex differences in this population.

Although there has been little attention devoted to addressing TBI as a risk factor for criminal behavior, there has been extensive focus in the United States since the late 1980s on identifying programs and approaches to assist those returning to the community from prisons and jails to achieve a pro-social future. Reentry services and programming can be characterized as those like cognitive behavior therapy (CBT) that are intended to promote individual change and those like employment services that are practical. To date, much of the evidence suggests that services that focus on individual change may be most effective at reducing recidivism [15–21]. Thus, although the high prevalence of TBI has not been explicitly addressed in reentry efforts, to the extent that programs and services focused on behavioral change and mental health have proven effective in improving outcomes for justice-involved individuals, it is reasonable that there is value in learning more explicitly about the relationships among TBI and service need and receipt during the reentry from incarceration.

After briefly reviewing relevant literature, this chapter describes the 265 individuals who were included in a randomized control trial to examine the impact of a wellness-based prisoner reentry program (5-Key Reentry Program) [22] and who participated in an interview 18-months after release from incarceration. The 18-month interview included the administration of the Ohio State University TBI Identification Method (OSU TBI-ID) [23, 24]. Information on the rate of TBI and a comparison of those with TBI to study participants without TBI on a variety of demographic characteristics is provided. The chapter then statistically examines self-reported receipt of mental health and substance use disorder services over time and whether the receipt of those services is differently impacted by either TBI or sex. The discussion and conclusions section summarizes the key findings and describes plans for future research.

#### **2. Literature review**

#### **2.1 Sex differences in acquiring TBI**

TBI results from a blow to the head from an assault, a fall, sporting accident, traffic accidents, or some sort of external force, and often leads to internal bleeding, bruising, and/or a reduced lack of oxygen flow to brain tissues. Men and women acquire TBI-related injuries in different ways. Men are more likely to receive their injuries from being struck by or against an object, interpersonal violence (i.e., fights), motor vehicle accidents, sports-related or workplace injuries, and in military combat; in contrast, women incur TBI more often in falls, concussive impacts, and in incidences of intimate partner violence (IPV) [11, 12, 25, 26].

*The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

Women who experience IPV are at great risk for TBI. According to the National Intimate Partner and Sexual Violence Survey, about 41% of women and 26% of men experience IPV in their lifetime [27]. IPV is defined as a pattern of physical violence, sexual violence, psychological aggression, and stalking behaviors inflicted by a current or former intimate [27]. The majority of IPV injuries sustained by women are to the neck, head, face, or strangulation [28]. While there are no epidemiological studies on the rates of TBI among IPV victims, one literature review on TBI from IPV found rates between 35–92% [29]. Jackson et al.'s study of women attending domestic violence support groups found that 92% reported a blow to the head or face and 44% reported loss of consciousness (LOC) [30]. Valera and Berenbaum found 74% of a shelter sample of women exposed to IPV sustained TBI and 50% had a history of multiple TBI [31].

Incarcerated women report high rates of violence and victimization. Threequarters of women in prison report experiencing IPV, and 70% report experiencing severe physical violence from a parent or caretaker [32]. Colantonio et al. found that incarcerated women with TBI experienced more physical and sexual abuse than those without TBI [33]. Some research also suggests that TBI history increases the odds of reoccurring victimization compared to non-victims and single-event victims [34].

#### **2.2 Impact of TBI**

While not all individuals who experience TBI will have negative long-term outcomes, many will experience a decline in their daily functioning [35]. TBI may cause problems with various brain functions that can lead to slowed information processing, diminished decision-making capacity, attention disorders and other executive functioning impairments [36–38]. TBI is associated with cognitive impacts, including memory and attention deficits, impulsive behavior, and slowed responses [35]. The long-term social–emotional effects of TBI make individuals vulnerable for the risk factors associated with justice involvement, including aggression, rule-breaking, violence, irritability and risk-taking [37–39].

Research finds that individuals with TBI have a significantly higher occurrence of mental illness, suicide attempts, and poorer quality of life compared to individuals without TBI [5]. TBI in youth is linked to violent behavior, substance use, and mental health problems [35, 40]. Petruccelli et al.'s meta-analysis of research on adverse child experiences (which may include TBI) found strong associations between exposure to childhood violence and poor behavioral health outcomes [41]. Even individuals experiencing mild-TBI are three times more likely to experience depression compared to those without a TBI history [42].

Many TBI injuries are sustained through traumatic events, and some research suggests that PTSD can develop after severe, and even mild TBI [43]. TBI and PTSD have many symptoms in common, including concentration and information processing difficulties, memory problems, irritability, depression, sleep disturbance, nausea, and headaches [44, 45]. Among a sample of female veterans who experienced IPV, those with current IPV-related TBI symptoms were 5.9 times more likely to meet criteria for PTSD symptoms [26]. Given the higher rates of traumatic and TBI experiences, rates of PTSD and TBI co-occurrence are higher among incarcerated populations. Harner found almost half (45%) of the incarcerated women in their sample met criteria for PTSD at the time of the interview, and 23% with severe symptoms [46]. In one of the few large studies examining the relationship between TBI, PTSD, and criminal reoffending, Lattimore et al. found that TBI and PTSD predicted violent offending

but not general criminal behavior [47]. These findings suggest the need for officials to identify individuals with a history of TBI and PTSD and to develop appropriate interventions that could be provided during and after incarceration to reduce the post-release likelihood of violence.

Rates of substance use disorder (SUD) among individuals with TBI is significantly higher than among the general population, with ranges for those with TBI from 37–66% compared to 11% among those without TBI [48, 49]. There is a high co-occurrence of TBI and risky substance use, and while the causal link is unclear, there is evidence that each increases the incidence of the other [50]. Fishbein et al.'s study of TBI and SUD co-occurrence among incarcerated individuals found early TBI predicted early on set and severity of drug use, and earlier drug use predicted greater aggression regardless of TBI [9].

#### **2.3 Sex differences in outcomes**

Most of the limited research on sex differences in TBI-related symptoms has found that women experience worse functioning symptoms than men [10, 13, 34, 51]. Farace et al.'s meta-analysis of sex differences found that women fare worse on 85% of outcomes, including higher rates of anxiety and depression, concussive syndrome such as dizziness, fatigue, irritability, impaired concentration, insomnia, headache, anxiety, and lower rate of returning to work [13]. Using the Glasgow Outcome Scale-Extended (GOSE), a widely known instrument tool for TBI, Kirkness et al. found that women aged 30 and older had poorer outcomes than younger women and men in all age groups 6 months following the injury, even when controlling for injury severity [51].

While research suggests that TBI is associated with problems during incarceration and post-release, including increasing the risk of reincarceration [1, 47, 52–54], there is limited research exploring sex differences. Wall et al. found women with a history of violence-related TBI were four-times more likely to have physical health problems than women without violence-related TBI [55]. However, they did not find differences in rates of mental health or substance abuse between the groups. Gorgens et al. found that women with TBI on probation have similar recidivism rates to men with TBI, though women without TBI had a lower risk of reoffending than men without TBI [1]. The authors also found that women with TBI were more likely than their male counterparts to have mental illness and substance use disorders [1].

#### **2.4 Service utilization by TBI and sex**

Research on the role of sex in treatment-seeking behavior is largely mixed. While many researchers have suggested that women are less likely to participate in substance use services than men [56, 57], other research suggests that women are at least as likely or more likely [58–60] to engage in these services. Similarly, some research finds women are more likely to use mental health services than men [61, 62]; while research on specialty psychiatric services shows higher utilization by men [63]. Coxe et al. found that mental service utilization among individuals with a head injury with loss of consciousness was higher for those with military service, a history of drug use, and moderate to severe depression, but no differences were observed by sex [64]. While there is limited research on post-release service utilization for TBI populations, Piccolino and Solberg's study of prison-based services found incarcerated men with high probable TBI used medical and psychological services at significantly higher rates than the low and moderate probable TBI groups and required more crisis services [53].

*The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

Overall, TBI is an important factor in the likelihood of success for individuals transitioning from incarceration to the community. However, there has been limited attention to how TBI can impact an individual's receipt of the services aimed at helping them reintegrate into the community. Given this current lack of knowledge, this paper provides an exploratory examination into whether services, specifically targeted for mental health and substance abuse, are impacted by an individual's history of TBI during the 18-months following incarceration, as well as the role of sex in service receipt.

#### **3. Methods**

#### **3.1 Study overview**

Data were drawn from individuals recruited into a multistate randomized controlled trial of a behavioral health reentry intervention conducted in two Midwestern states and one southeastern state in the United States. Eligibility for study participation included being 18 years of age or older, incarcerated in a correctional facility study site, approximately 6 months from release from prison, and scheduled for release to a county study site. Upon providing informed consent into the study, participants completed the baseline research interview using computer-assisted interview software. Following completion of the baseline interview, participants were randomized into either a treatment group to receive the 5-Key behavioral health intervention [22] or a comparison group to receive services-as-usual both while incarcerated and following release from prison. Once individuals released into the community, research interviews were conducted with all study participants 1 week later. Additional interviews were conducted at months 8, 14 and 18. Participants received compensation of \$40 per follow-up research interview and \$5 to update location tracking monthly. No compensation was provided to participants who were incarcerated. Analyses presented here are for the 265 individuals who completed the fourth (T4) follow-up interview at 18 months following release.

#### **3.2 Measures**

#### *3.2.1 Ohio State University TBI identification method*

A modified version of the Ohio State University TBI Identification Method (OSU TBI-ID) [24] was used to determine history of exposure to TBI. A history of TBI was indicated if the participant endorsed having had a head or neck injury event on any one of the five screener questions from the OSU TBI-ID. If at least one screener question was endorsed, the participant was prompted to answer the question whether they were ever knocked or lost consciousness. If they responded affirmatively, participants were asked if they were knocked out or lost consciousness for 30 minutes or longer. Finally, participants were asked the age when they first injured their head or neck. This assessment was administered at the T4 18-month follow-up interview in the community.

#### *3.2.2 Service assessment for children and adults*

The Service Assessment for Children and Adults (SACA) is a modified version of the Service Assessment for Children and Adolescents [65] that was adapted to ask

about service needs relevant to an individual in the transition from prison to the community. The SACA asked respondents about services in the following nine domains: life skills, mental health, substance abuse, relationships, job readiness, education, physical health, housing, and cognitive. Within each of the service domains, participants were asked whether they needed help in that domain and whether they received help. When an individual endorsed receiving a service, they were asked how many times they received help and whether services were helpful. The domains of mental health and substance abuse were asked at both baseline and follow-up interviews; the remaining seven domains were only asked at follow-up. At baseline, the queries were for any prior need or receipt (i.e., lifetime); at follow-up, the queries were asked relative to the time since last interview.

#### *3.2.3 Mini neuropsychiatric interview*

Substance use disorder and mental health disorder were assessed with the Mini Neuropsychiatric Interview (MINI) [66]. Participants were assessed for symptoms consistent with major depressive episode, manic episode generalized anxiety disorder, alcohol use disorder, and substance use disorder. The MINI has good test–retest and inter-rater reliability [66] and the MINI has demonstrated effectiveness in correctional settings [67]. All domains of the MINI were administered at the baseline research interview, and alcohol use disorder and substance use disorder were also asked at follow-up.

#### *3.2.4 Traumatic history questionnaire*

The Trauma History Questionnaire (THQ ) is a 25-item measure of lifetime trauma that captures a variety of events, including forced robbery, home break-in, natural disaster, man-made disaster, military combat, close friend/family member murdered, life-threatening illness, intercourse against one's will, and attacked by family member [68]. For each traumatic event, the respondent who answered in the affirmative was asked the number of times the event occurred and the age of the individual at each event. This analysis used a total score from zero to 25 that summed the number of traumatic events endorsed by a participant.

#### *3.2.5 Childhood trauma questionnaire*

The Childhood Trauma Questionnaire is a 28-item measure of physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect the occurred during the individual's childhood. The total score of each subscale can range between with 5 to 25, with higher scores indicating a higher level of trauma exposure. Cutoffs for moderate–severe exposure are: > = 13 for emotional abuse; > = 10 for physical abuse; > = 8 for sexual abuse; > = 15 for emotional neglect; and > =10 for physical neglect. The CTQ has shown to have strong inter-rater reliability and criterion-related validity [69].

#### *3.2.6 Demographic information*

Participants were asked at the baseline interview about their race, sex, age, education level, and employment. Race was a three-category variable coded as Black, White, and other. Sex was also a three-category variable of man, woman, and *The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

non-binary. Age was computed based on the date of birth reported by the participant. Education captured an individual's current level achieved and was coded as less than a high school diploma/GED, high school diploma/GED completed, and post-secondary education. Finally, employment asked about the respondent's work situation prior to their incarceration and was coded as unemployed, working full/part-time, or other.

#### **3.3 Analytic methods**

Analyses focus on respondents who completed a T4 interview, the interview at which the OSU TBI-ID was collected. We first examined how the respondents to the T4 interview compared with the original sample of individuals enrolled at baseline but who did not complete the T4 interview. Bivariate statistics of independent t-tests for continuous measures and chi-square statistics for categorical measures were used to compare the two groups. Within the T4 sample, descriptive statistics are presented overall and stratified by sex and by TBI status. The same bivariate tests were used when comparing service use and need across the interview waves for the T4 sample.

Among respondents completing a T4 interview, fixed effects linear probability models (LPM) were used to estimate within-person changes in service receipt within the mental health and substance abuse domains of the SACA. The analysis sample was further constrained into two, but not mutually exclusive, samples to examine each outcome. For the mental health receipt outcome, analysis was focused on those who indicated a need for mental health services at the baseline interview; similarly, for the substance abuse receipt outcome, analysis only included those with an identified substance abuse need at baseline. Fixed effects LPM allow us to estimate the effects for the full analysis sample by including responders with no change over time in each respective outcome variable. The LPM is shown to have comparable statistical properties to logit models under certain conditions, such as for outcome variable proportions not close to 0 or 1 [70–74]. Moreover, the fixed effects LPM suffers little from the convergence challenges seen with conditional logit, and LPM produces estimates in natural, interpretable percentage point units. Because the fixed effects LPM tests the within-person change in the outcome variable (i.e., mental health or substance use service receipt), each participant effectively acts as their own comparison, which allows for the control of all observed (e.g., sex or race) as well as unobserved timeinvariant covariates (e.g., unmeasured health status). Moreover, to further test for between-group difference in within-person change (i.e., by TBI and by sex) we fitted separate models that included interaction terms between each time-invariant covariate and an indicator of time (i.e., 8 months, 14 months, and 18 months with the T1 interview serving as reference). All analysis were completed with Stata version 17.

#### **4. Results**

#### **4.1 Subject characteristics**

**Table 1** shows characteristics of the 265 participants who completed the T4 interview at 18-months post-release. Individuals who completed the T4 interview were majority Black (52.08%) and men (83.40%) and reported an average age of 37.79 years old at the baseline interview. Prior to incarceration a majority had been employed (59.25%) and achieved either a high school diploma or GED (72.83%).


#### **Table 1.**

*Means and percentages of subjects who completed the T4 interview compared to subjects who did not complete the T4 interview (\* = p < 0.05).*

#### *The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

The sub-sample of T4 responders comprises approximately 29.78% of the original sample of 890 individuals enrolled into the study at baseline. The T4 responders were shown to have significant differences (p < 0.05) compared with the sample of study participants who did not complete the T4 interview (**Table 1**) in some categories. Participants who completed the T4 interview reported a higher total score on the trauma history questionnaire (8.17 vs. 7.18) as well as higher scores on both emotional abuse (10.13 vs. 9.36) and emotional neglect (11.11 vs. 10.45) on the childhood trauma questionnaire. T4 responders were also more likely to indicate their race as Black (52.08 vs. 42.00%), and T4 responders reported higher level of major depression (41.13 vs. 32.80%), alcohol use disorder (46.42 vs. 38.88%), and generalized anxiety disorder (18.87 vs. 13.12%). Lastly, T4 responders showed higher levels of need for mental health services prior to incarceration (61.07 vs. 52.33%), and they reported being unemployed prior to incarceration at a statistically lower level (28.90 vs. 41.57%). For all remaining variables, the T4 responders were statistically similar to their counterparts who did not complete the T4 interview.

Members of the T4 sample reported at baseline high levels of lifetime need with help for emotional problems and substance use disorder. Fully 61.07% reported needing help in the past for emotional problems and 55.30% reported needing help for drug and alcohol problems. Most also reported having received help in the past with 56.06% reporting having received help with emotional problems and 56.44% receiving help for drug and alcohol problems.

Nearly one-third (30.2%) of the sample reported having experienced PTSD. The TBI-ID scale wasn't administered at baseline, but individuals reported high levels of physical and emotional trauma. **Table 2** shows the responses to the OSU TBI-ID by sex. Nearly 40% of the respondents reported having been hospitalized following a head or neck injury, with no significant difference between the men and women. Large numbers also reported having head or neck injuries as a result of an accident (35.43%), from a fall or playing sports (39.53%), and from being in a fight or being shot (32.81%)—again the differences in reporting by men and women were not significant. Men were more likely than women to report having been exposed to an explosion or blast (19.91 v. 7.14%; *p* < .05). Of the 146 who reported sustaining head or neck injuries, 88 (60.27%) reported losing consciousness and 39 of those 88 (49.37%) reported losing consciousness for more than 30 minutes. Although women were somewhat more likely to report losing consciousness (68.00 v. 58.68%) and men


#### **Table 2.**

*Numbers and percentages of subjects reporting ever experiencing the TBI event by sex (\* = p < 0.05).*


#### **Table 3.**

*Numbers and percentages of subjects reporting ever experiencing selected traumatic events by sex (\* = p < 0.05).*

were somewhat more likely to report losing consciousness for more than 30 minutes (51.52 v. 38.46%), these differences were not statistically significant.

Select items from the THQ also indicate high levels of lifetime trauma. **Table 3** provides information on the percentage of respondents at baseline who reported ever experiencing specific events. Women reported higher rates of traumatic events for more categories than did men. Women were shown to be exposed to more direct personal crime, such as being beaten (47.73 v. 24.89%) or having their home broken into (29.55 v. 15.38%). Additionally, women reported significantly higher levels of sexual abuse (47.73 v. 10.86%) then did male respondents and experienced more non-violent death within their immediate family and friends (40.91 v. 29.42%). On the flip side, male respondents also reported high levels of lifetime trauma, but it was concentrated in interpersonal violence; particularly, seeing someone killed or injured (78.28 v. 54.55%) as well as having a family member or friend murdered (74.66 v. 59.09%).

#### **4.2 Demographic comparison of respondents with TBI versus No TBI at baseline**

Among the 265 respondents to the T4 interview, a majority (55.47%) endorsed at least one of the five screener questions for TBI. When comparing those who indicated a lifetime TBI to those participants who did not, significant differences are found (**Table 4**). Individuals with TBI were found to have higher levels of trauma


*The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

#### **Table 4.**

*Means and percentages of subjects with TBI compared to subjects without TBI (\* = p < 0.05).*

as indicated by the THQ total score (9.17 v. 6.90) as well as were more likely to score as having a substance use disorder (76.19 v. 64.41%) and/or a generalized anxiety disorder (23.13 13.56%). Given these reported symptoms by individuals with TBI, it is expected they would also report a higher level of need for mental health services

(68.28 v. 52.14%). Nevertheless, no differences were found in self-reported need for substance use services nor the receipt of either mental health or substance use services. Individuals who screened positive for TBI were more likely to describe themselves as White than individuals without TBI (43.54 v. 22.88%). Employment prior to incarceration was significantly higher for those with TBI compared to their T4 counterparts who did not report TBI (62.59 v. 56.03%).

**Table 5** provides information on the individuals who reported the need for mental health and substance abuse services at baseline. A participant was identified as receiving either mental health or substance abuse services in **Table 5** if they received the service at any point during the 18-month follow-up period. Looking at the results, there is a higher rate of receipt for mental health service (49.38%) among those with a mental health need compared to the rate of receipt for substance abuse service (41.78%) among those with a substance abuse need. Within the TBI subgroup, respondents with TBI reported a higher rate of service receipt for both mental health (51.52 v. 45.90%) and substance abuse (43.68 v. 38.98%) compared to those without TBI. Men with TBI identified a need for substance abuse services at a higher rate (60.53%) than did women with TBI (56.25%); a similar difference is not seen for mental health services. Lastly, women reported a higher rate of receipt than men for both types of services, and the difference was most notable for mental health services versus substance use services (54.29 v. 48.00%).

#### **4.3 Impact of TBI and sex on service receipt**

Estimation of the fixed effects models began by estimating with a base model that included only the indicators of time to show the average service receipt path over time up to 18 months following reentry. Then, two separate models were estimated that used interactions with time indicators to show how the service receipt path differed by TBI status (Model 2) and sex (Model 3).

Results are presented in **Table 6**. For the models focused on mental health services receipt, no direct effect of time or any of the interaction effects were found to be significant. For the models examining substance use services receipt, there was a


#### **Table 5.**

*Service receipt by those expressing need at T4 follow-up by TBI and sex.*

*The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*


#### **Table 6.**

*Fixed effects linear probability models: Within-person change in service receipt and time interactions by TBI and sex (\* = p < 0.05).*

negative effect of time on the receipt of substance use services. As the follow-up timeperiod increased, the receipt of substance abuse services decreased and at 18 months was 13 percentage points lower compared to the T1 interview at one-week post-release (*b* = −0.13, *p* < 0.05). None of the interaction terms were significantly associated with substance abuse service receipt in models 2 and 3. However, the decrease in receipt at 18 months remained negative and similar in magnitude to the base model estimates.

#### **5. Discussion and conclusions**

Research focused on understanding the influence of lifetime experiences of TBI on incarceration and post-incarceration outcomes is in its infancy. However, scientific discoveries related to the deleterious effects of TBI on lifetime outcomes among athletes and war veterans underscore the importance of this burgeoning body of inquiry. Within a criminal justice involved population, the influence of TBI on individual behavior has high stakes implications for the health and safety of those beyond the justice-involved individual with TBI because criminal behavior frequently impacts the lives of the public. Findings from the current study suggest that additional inquiry is needed into the post incarceration experiences and outcomes for persons with a history of TBI.

The current study results are preliminary yet highly relevant. Rather than assessing TBI during incarceration and at every subsequent time point during post incarceration follow up, we screened for TBI 18 months after release. The screening occurred at that time point not because TBI was a primary focus of the clinical trial, but rather because the participant reports during the study suggested that this additional data point was imperative to understanding reentry results. Because TBI was examined posteriori, we were only able to speak to TBI among those participants retained in the study a year and a half post release. Importantly however, those participants who remained in the study were not the highest functioning, rather statistical analyses indicated that these participants displayed comparatively high needs — suggesting that the study findings reflect the realities of those facing complex issues post incarceration.

Reentry to communities from incarceration is a lengthy experience and the social and behavioral supports needed to fully assimilate into societal expectations of positive and productive living can take a substantial amount of time. Yet, the results from the current study show that the receipt of supportive services declines over time for all reentering participants. And, although the study did not identify statistically significant differences for those who screened positive for a TBI and those who did not at 18-months post-release, this research finding needs further testing because the current study cannot tease out the cumulative impact of TBI because of attrition and the binary (yes/no) nature of the data on service receipt. Most importantly, the research supports what other studies have consistently found – services are needed and important to reentry success and these same services are difficult to access and that the limitations to access are exacerbated overtime.

Future research that is longitudinal in nature that utilizes more detailed measures of cognitive deficits like executive dysfunction can help to pinpoint which symptoms of TBI persist, and the myriad of ways those symptoms may impact how a person progresses through services provided during and after incarceration. Foundational research describing the prevalence and patterns of TBI of formerly incarcerated individuals in the community is still needed as is more causal research that can help to identify treatment targets and intervention components post-release. In turn, reentry services providers can screen for TBI and provide more tailored approaches to individual care with the expectation that such tailored approaches could improve the relatively limited impact that generic reentry approaches have accomplished to date.

#### **Acknowledgements**

Funding for the original 5-Key Reentry Program randomized control trial and the collection of the data analyzed herein was provided by the Charles Koch Foundation to the lead researcher who was at the Institute for Justice Research and Development at Florida State University. Additional funding to support the long-term follow-up of

*The Impact of Traumatic Brain Injury on the Receipt of Services Following Release from Prison DOI: http://dx.doi.org/10.5772/intechopen.109467*

the original study participants has been provided by the National Institute of Justice grant number 15PNIJ-21-GG-00140-NIJB. Conclusions are those of the authors and do not necessarily represent the views of the Charles Koch Foundation or the United States Department of Justice.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Christopher A. Veeh1 , Pamela K. Lattimore2 \*, Kristin Stainbrook<sup>2</sup> , Arnie P. Aldridge2 and Carrie Pettus3

1 University of Iowa, Iowa, United States

2 RTI International, Research Triangle Park, North Carolina, United States

3 Justice System Partners, Boston, United States

\*Address all correspondence to: lattimore@rti.org

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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