In de module Voorlichting en adviezen bij ontslag is de definitie van psycho–educatie besproken. Psycho-educatie betreft het verschaffen van relevante informatie aan patiënten (volwassenen en kinderen en hun ouders/verzorgers) over de medische en psychologische aspecten van de aandoening, en de specifieke factoren die bij de individuele patiënt een rol kunnen spelen. De vraag is of het geven van psycho-educatie aan de patiënt effectief is en in welke vorm dit gegeven moeten worden. Deze module richt zich op de informatie die in de acute fase na het ongeval aan de patiënt kan worden verstrekt.

Children

1. Posttraumatic symptoms

2. Resumption activities/work/school/sport

Adults

1. Posttraumatic symptoms

2. Resumption activities/work/school/sport

Description of studies

Children

Brooks (2017) performed a randomized controlled trial to assess the use and utility of a novel set of emergency department discharge instructions for concussion based on a child’s ongoing symptoms (symptom-guided discharge instructions) and to determine clinical outcomes. Children between 7 and 17 years of age who presented to an urban pediatric emergency department (ED) with a chief complaint of closed head injury or concussion were included. Other inclusion criteria were the presence of at least one symptom from the Graded Symptom Checklist (GSC), time of injury within 24 hours of ED visit, telephone availability for follow-up contact and one caregiver with the ability to communicate in English. Children with severe injury requiring hospital admission, intracranial hemorrhage or any previous concussion diagnosis were excluded. In total, 114 children were enrolled. Fifty-eight children received symptom discharge instructions, and 56 children received standard discharge instructions. The groups were comparable at baseline. Children were followed for 7 days.

Renaud (2020) performed a randomized controlled trial to assess the effectiveness of a psychoeducational intervention (Brains Ahead!) to prevent long-term problems with activities and participation in children after mTBI. Children between 6 and 18 years of age who presented with mTBI at the emergency department and their caregivers were included. Exclusion criteria were a previous head trauma confirmed by a neurologist, progressive neurological problems or disease, attending a day care center or school for cognitively impaired children and insufficient knowledge of the Dutch language (child or caregiver). In total, 124 children were included, and 60 children were allocated to the psychoeducation intervention and 64 children to the control group (usual care). The psychoeducational intervention consisted of two sessions administered by a health professional within 2 to 4 weeks and 6 to 8 weeks post-mTBI. The usual care consisted of a concise information brochure provided at discharge from the emergency department that contained recommendations to return to the general practitioner or hospital in case of increased symptoms during the first days after the injury. Lower levels of post-concussive symptoms were demonstrated at baseline. Follow-up occurred at 3- and 6 months post-mTBI.

Adults

Hoek (2021) performed a multicenter randomized controlled trial to assess the effect of video discharge instructions on post-concussion symptoms in patients with mTBI in the emergency department. Adult patients with mTBI who presented to the ED were included. Exclusion criteria were intracranial abnormalities on CT scan, a focal neurologic deficit, or insufficient command of the Dutch language and if informed consent could not be obtained. In total, 381 patients were randomized to the control group consisting of verbal and written discharge information, and 390 patients were randomized to the intervention group consisting of verbal, written and video discharge information. Patients were followed for 3 months.

Suffoletto (2013) performed a randomized controlled trial to assess whether patients with mTBI receiving text messaging-based education and behavioral support had fewer and less severe post-concussive symptoms than those not receiving text-message support. Inclusion criteria were > 18 years old, the ability to speak English, comply with the American College of Rehabilitation Medicine definition of mTBI, and having no other major confounding injuries. Participants who did not own a personal cellular phone equipped with text messaging were excluded. In total, 43 adult emergency department patients with mTBI were included, of which eighteen adults received the intervention and 25 adults were in the control group. Adults in the control group had usual ED standard of care with three daily text messages (for 14 days post-injury) assessing cognitive, somatic, and emotional symptom severity in the past 24 hours. Adults in the intervention group received the same text messages but patients who reported symptoms in the 3 to 4 score range received semi-individualized text messages focusing on symptom related education, reassurance, and management. The follow-up was 14 days.

Teo (2020) evaluated the effects of cognitive and psychological interventions, among which psychoeducation, for the reduction of post-concussion symptoms (PCS) in patients with mTBI in a systematic review. A literature search was performed in six databases (CINAHL, Medline, PubMed, PsychINFO, Web of Science, and the Cochrane Database of Systematic Reviews) from January 1998 to December 2017. English RCTs were included if 1) these reported on cognitive and/or psychological interventions that focus on the reduction of post-concussion symptoms; 2) the interventions were performed on patients with mTBI (age ≥ 18 years); 3) these included an assessment of PCS using the Rivermead Post-concussion Symptoms Questionnaire (RPQ) as primary outcome at three and six months. Articles were excluded if the researched interventions were not of cognitive and/or psychological nature (e.g., visual rehabilitation, transcranial magnetic stimulation, exercise). Teo (2020)’s review included 17 studies. The review’s authors assessed the quality of included studies through the use of the Physiotherapy Evidence Database (PEDro) scale (score 0-10), classifying a study with a score of 6 or higher as “high quality”.

To answer the PICO of this module, only five RCTs were eligible, since six RCTs reported also on chronic mild TBI patients (more than two months after mTBI) (Belanger 2015; Bell 2008; Bell 2017; Kjeldgaard 2014; Vikane 2017 and Vuletic 2016). Another three RCTs were excluded for studying the wrong population (including patients with moderate TBI) (Bomyea 2017; Twamley 2014 and Wade 1998), and in three studies the intervention went further than psychoeducation, offering patients cognitive behavioural therapy (Potter 2016; Scheenen 2017; Silverberg 2013). Characteristics of the included studies are shown in Table 1.

Table 1. Overview of the RCTs from the review by Teo (2020)

Abbreviations (alphabetical): FU: follow-up, PCS: post-concussion symptoms, TBI: traumatic Brain Injury

Results

Children

1. Posttraumatic symptoms
   Brooks (2017) assessed the number and type of symptoms with the Graded Symptom Checklist. No significant differences in the frequency of any of the symptoms between children who received symptom discharge instructions and children who received standard discharge instructions were reported. The most common symptoms were dizziness, drowsiness, fatigue, and headaches. Because only the statistical significance of the results was presented and no absolute values were reported, no interpretation can be given for the clinical relevance of these results.
   
   Renaud (2020) reported post-concussive symptoms (PCSs) with the Health and Behaviour Inventory (HBI). This is a 50-item questionnaire that measures the experience of PCSs on a 4-point scale ranging from never (1), seldom (2), sometimes (3) and often (4). Lower total score represents fewer PCSs. At 6 months post-mTBI, children who received the psychoeducation intervention Brains Ahead! had a mean HBI score of 82.04 (SD=3.26), as compared to a mean HBI score of 92.05 (SD=3.39) for children who received usual care (MD=-10.01, 95%CI -11.18 to -8.84). This difference was clinically relevant.

2. Resumption activities/work/school/sport
   Brooks (2017) reported the median time to return to school. For children receiving symptom discharge instructions, the median time was 2 days as compared to 3 days for children receiving standard discharge instruction. Besides, Brooks (2017) reported that 53% of the children receiving symptom discharge instructions had no sports participation for 7 or more days as compared to 80% of children who received standard discharge instructions (p<0.01). These differences were clinically relevant.
   
   Renaud (2020) reported activities and participation with the Child and Adolescent Scale of Participation-Dutch language version (CASP-DLV). This is a 20-item questionnaire categorized according to the following settings: at home, in the community, at school, and in the environment. Each item can be scored on a 4-point scale with age-appropriate (1), slightly impaired (2), heavily impaired (3), and not capable (4). Higher total score represents better outcome. The CASP scores were dichotomized because of its ceiling effect. A score of 0 represent deviant functioning/any score less than 100 and a score of 1 represents full functioning/a score of 100, in comparison with their healthy/noninjured age-related peers.
   
   For the total self-reported CASP score assessed by children between 10 and 18 years old 3 months after mTBI, 20 children (48.8%) who received the psychoeducation Brains Ahead! had full functioning as compared to 11 children (26.2%) who received usual care (RR=1.86, 95%CI 1.03 to 3.38). At 6 months post-mTBI, still 20 children (48.8%) who received the psychoeducation Brains Ahead! had full functioning as compared to 10 children (23.8%) who received usual care (RR=2.05, 95%CI 1.10 to 3.38). These differences were clinically relevant.

Adults

1. Posttraumatic symptoms
   Posttraumatic symptoms measured with the Rivermead Post-concussion Symptoms Questionnaire (RPQ) were reported in four RCTs (Ghaffar, 2006; Hoek, 2021; Matuseviciene, 2013; Suffoletto, 2013) (table 7.2). The RPQ is a 16-item measure of the severity and impact of post-concussion symptoms. Each item can be scored from 0 to 4, resulting in a maximum score of 64. A higher score represents a higher symptom burden. 

Table 2. Posttraumatic symptoms measured with Rivermead Post-concussion Symptoms Questionnaire

*Median difference; IQR=interquartile range; NR=not reported

Ghaffar (2006) assessed the presence and severity of post-concussion symptoms 6 months after mTBI. For adults receiving psychoeducation, a mean RPQ score of 17 (SD=18) was found at 6 months post-mTBI, as compared to a mean RPQ score of 16.3 (SD=15.9) for adults receiving no follow-up visits or treatment (MD=0.70, 95%CI -5.40 to 6.80). This difference was not clinically relevant.

Hoek (2021) assessed the RPQ score 1 week and 3 months post-mTBI. At 1 week, the mean total RPQ score was 11.4 (SD=11.7) for patients receiving additional video information as compared to a mean total RPQ score of 11.6 (SD=12.9) for patients receiving usual care (MD=-0.20, 95%CI -1.82 to 1.42). Three months after mTBI, a mean total RPQ score of 8.7 (95% CI 7.6 to 9.8) and 9.0 (95% CI 7.9 to 10.2) were found for patients receiving additional video information and usual care, respectively (MD=-0.30, 95%CI -1.85 to 1.25). These differences were not clinically relevant.

Matuseviciene (2013) assessed symptoms with the RPQ score 3 months after mTBI. There were no significant differences between the early intervention visit and treatment as usual in changes of any of the separate symptoms at 3 months post-mTBI.

Suffoletto (2013) assessed the RPQ score at 14 days after mTBI. For patients who received text-message based support, a median RPQ score of 17 (IQR 6 to 34) was demonstrated as compared to a median RPQ score of 20 (IQR 10 to 31) for patients who had usual care (median difference=-3.0, 95%CI -4.0 to 3.0). This difference was not clinically relevant.

Fewer and less severe symptoms were found for patients who received text-message based support as compared to usual care. Patients receiving text-message based support trended to lower odds of reporting headaches (OR=0.38, 95%CI 0.07 to 1.99), concentration difficulties (OR=0.32, 95% CI 0.04 to 2.24) and irritability/anxiety symptoms (OR=0.33, 95%CI 0.05 to 2.35) as compared to patients who received usual care. Besides, patients who received text-message based support had significantly lower odds of reporting severe anxiety as compared to patients who received usual care (OR=0.09, 95% CI 0.02 to 0.31).

In addition, two RCTs reported posttraumatic symptoms with other questionnaires (Elgmark Andersson, 2007; Varner, 2017).

Elgmark Andersson (2007) reported post-concussion symptoms one year after injury with the Post-concussion Symptoms Questionnaire (PCSQ) including 21 items. For adults receiving psychoeducation, the mean number of symptoms was 5.2 (SD=5.3) as compared to 4.4 (SD=5.3) for adults receiving usual care (MD=0.80, 95%CI -0.44 to 2.04). This difference was not clinically relevant.

Headache (42%) and fatigue (41%) were the most reported post-concussion symptoms for adults receiving psychoeducation as compared to neck pain (42%) for adults receiving usual care. No significant (clinically important) differences in the frequency of the post-concussion symptoms were demonstrated between both groups, except for anosmia. Anosmia was reported in 15 of the 226 adults (7%) receiving psychoeducation and in 2 of the 101 adults (2%) who received usual care (p=0.035). This difference was clinically relevant.

Varner (2017) reported symptoms with the Post-Concussion Symptom Score (PCSS) including 22 items. At 2 weeks post-mTBI, patients who received graduated return to usual activity discharge instructions had a change in PCSS of -10.5 points as compared to -12.8 points for patients who received usual care discharge instructions (MD=-2.3, 95%CI -11.7 to 7.0). At 4 weeks post-mTBI, a change in PCSS of -21.1 points was found for patients who received graduated return to usual activity discharge instructions as compared to -18.3 points for patients who received usual care discharge instructions (MD=-2.8, 95%CI -6.9 to 12.7). These differences were not clinically relevant.

2. Resumption activities/work/school/sport
   Matuseviciene (2016) reported the activity and participation 3 months after mTBI. No significant differences in the number of activities in which the patients have problems were found between patients who received an early intervention visit and patients who received usual care. Besides, no (clinically important) differences regarding occupational gaps or the number of gaps in leisure and social activities (such as sports, seeing relatives and friends, engaging in societies, clubs and unions) were demonstrated.
   
   Varner (2017) reported time off from work and school. Thirty-two patients (69.6%) who received graduated return to activity discharge instructions and 26 patients (59.1%) who received usual care discharge instructions missed days of work or school due to their symptoms (MD=10.5, 95%CI –9.1 to 29.0). The median number of days of work or school missed was 5 days (IQR 3 to 7 days) for patients who received graduated return to activity discharge instructions as compared to 4 days (IQR 3 to 10 days) for patients who received usual care discharge instructions (MD=1, 95% CI -2 to 3). These differences were not clinically relevant.

Level of evidence of the literature

According to GRADE, the level of evidence for systematic reviews of RCTs and individual RCTs start at a high GRADE.

Children

1. Posttraumatic symptoms
   The level of evidence regarding the outcome measure posttraumatic symptoms was downgraded by two levels to low because of lack of blinding and imbalance in relevant baseline characteristics between group (-1, risk of bias) and the optimal information size has not been reached (-1, imprecision).

2. Resumption activities/work/school/sport
   The level of evidence regarding the outcome measure resumption activities/work/school/sport was downgraded by two levels to low because of lack of blinding and imbalance in relevant baseline characteristics between group (-1, risk of bias) and the optimal information size has not been reached (-1, imprecision). 

Adults

1. Posttraumatic symptoms
   The level of evidence regarding the outcome measure posttraumatic symptoms was downgraded by three levels to very low because of fair methodological quality (-1, risk of bias), and differences in the direction of the effect and clinical heterogeneity because of different periods of follow-up and different interventions (-2, inconsistency).

2. Resumption activities/work/school/sport
   The level of evidence regarding the outcome measure resumption activities/work/school/sport was downgraded by three levels to very low because of fair methodological quality (-1, risk of bias), clinical heterogeneity because of different follow-up periods and different interventions (-1, inconsistency) and the optimal information size has not been reached (-1, imprecision). 

A systematic review of the literature was performed to answer the following question:

What is the effect of psychoeducation in patients in the acute phase after mild traumatic brain injury (mTBI) on functional outcome, posttraumatic symptoms and patient satisfaction?

P:           Patients within two months after mTBI

I:            Psycho education

C:           Usual care/placebo

O:          Posttraumatic symptoms, resumption activities /work /school /sport

Relevant outcome measures

The guideline development group considered posttraumatic symptoms and resumption activities/work/school/sport as critical outcome measures for decision making.

A priori, the working group defined posttraumatic symptoms as the score on the Rivermead Post-concussion Symptoms Questionnaire. In addition, resumption to activities/work/school/sport was defined as the score on productive employment (BICRO-39), the percentage of patients who returned to work, and functional impairment in work, social life and family life domains as measured with the Sheehan Disability Scale (SDS scale).

The working group defined a 10% difference for continuous outcome measures, 20% for dichotomous outcome measures informing on relative risk (0.8 ≤ RR ≥ 1.25), and 0.5 for Cohen’s d in standardized mean difference (-0.5 ≤ SMD ≥ 0.5) as minimal clinically (patient) important differences.

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms from 2000 until August 22^nd, 2022. The detailed search strategy can be found under the tab Methods. The systematic literature search resulted in 178 hits. Studies were selected based on the following criteria:

• Systematic review and/or meta-analysis, or randomized controlled trial (RCT);
• Included adults and children;
• Described any type of psychoeducation as an intervention;
• Described placebo or usual care as a comparison;
• Described at least one of the outcome measures as described in the PICO;
• Included at least 10 patients per treatment arm.

Twenty-three studies were initially selected based on title and abstract screening. After reading the full text, nineteen studies were excluded (see the table with reasons for exclusion under the tab Methods), and four studies were included. Besides, one additional study was included derived from the systematic review of Sullivan (2020).

Results

Five studies were included in the analysis of the literature. Two studies reported about psychoeducation for mTBI in children and three studies reported about adults. Important study characteristics and results are summarized in the evidence table and Table 7.1. The assessment of the risk of bias is summarized in the risk of bias table.