Interventions for Postconcussion Symptoms 

(PCS)

Heather G. Belanger, PhD, ABPP-CN

James A. Haley Veterans Hospital

University of South Florida

Defense & Veterans Brain Injury Center

Tampa, FL
The views expressed in this presentation are those of 

the author and do not reflect the official policy of 

the Department of Veterans Affairs 

or 

the United States Government

This IRB approved work is in compliance with APA 

ethical standards in the treatment of research 

participants

Portion of this presentation funded by Department of 

Defense: W81XWH-10-1-0719
Objectives

• Briefly define and review mild traumatic brain

injury (mild TBI) and recovery

• Review non-medication treatment

approaches for Postconcussion Symptoms

(PCS)

• Preliminary Results of Web-Based Tx Study

• Conclusion and future directions
Poll Question #1

• My interest in mild TBI is as a: 

– Clinician

– Researcher 

– Clinician-researcher 

– Manager or policy-maker 

– Other 
What is a TBI?
Traumatic Brain Injury Definition

• TBI – any traumatically induced structural

injury and/or physiological disruption of brain

function as a result of an external force

• Concussion or mild TBI is one of the most

common forms of combat-related injury
DoD/DVA Consensus Criteria for TBI 

Severity 

Mild Moderate Severe

LOC < 30 min 

with 

normal CT &/or 

MRI

LOC >30 min 

and < 24 hours 

with normal or

abnormal CT 

&/or MRI

LOC > 24 

hours with 

normal or

abnormal CT 

&/or MRI

GCS 13-15 GCS 9-12 GCS < 9

PTA < 24hr PTA >1 day 

and < 7days

PTA > 7days

http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf
• Most individuals recover completely within 

days or weeks after a mild TBI (concussion)

• Yet, a subgroup experience postconcussive

symptoms (PCS sxs) in chronic stages

– Nonspecific symptoms 

 Postconcussion Symptoms

– Physical

• Headache, dizziness, fatigue, noise/light intolerance, insomnia 

– Cognitive

• Memory complaints, poor concentration

– Emotional

• Depression, anxiety, irritability, mood lability 

Mild TBI Sequelae
http://www.defense.gov/home/features/2012/0312_tbi/
Types of Mild TBI Interventions

• Symptom-based (e.g., headaches)

• Behavioral health

– sleep hygiene, diet, exercise, etc

– Cognitive-behavioral psychotherapy

• Education
Mild TBI Psychoeducation

• Brief Psychoeducational Interventions may

include:

– Defining the injury and what is expected

– Normalization of symptoms

– Reassurance of positive expectation of recovery

– Providing specific coping strategies

 “Recovering from Head Injury: A Guide for Patients” 

(Mittenberg et al., 1993)
PCS Intervention Review
First Author Year 

Published

Design Intervention(s) Tested Study Sample Tx and 

Control 

Groups

Follow-Up Tx Effect?

Alves 1993 RCT 1. Information + reassurance 

of recovery

2. Information only

3. Control 

Hospitalized 

after mild TBI

N=201

N=176

N=210

3, 6, 12 

months

Yes*

Bell 2008 RCT 1. Handout + telephone 

counsel (4-5 calls over 12 

weeks) providing education 

and reassurance and 

individualized plans for 

symptom management

2. Handout in ED

Within 48 hours 

of injury

N=146

N=166

6 months Yes

Minderhoud 1980 Retrospective 

comparison

Printed + verbal education + 

activity encouraged after 

week of bed rest.

Hospitalized 

after mild TBI

N=180

N=352

6 months Yes

Mittenberg 1996 RCT Printed manual + one-hour 

session

Hospitalized 

after mild TBI

N = 29

N = 29

6 months Yes

Ponsford 2002 Alternate 

assignment 

to group

Information booklet Hospital 

emergency 

room (within a 

week)

N=79

N=123

3 months Yes

Wade 1998 RCT Printed and verbal 

education + continued 

support as needed

7 to 10 days 

post-injury

N=132

N=86

6 months Yes

Positive Tx Effect – Educational Approaches

*For reassurance treatment group only, assuming that patients not seen at follow-up are asymptomatic
First Author Year 

Publish

ed

Design Intervention(s) 

Tested

Study Sample Tx and 

Control 

Groups

FollowUp Tx

Effect?

Gronwall 

 

1986 Not 

randomized

Information 

booklet

Within 2 

weeks of 

injury

N=34

N=54

 

3 

months

No

Hinkle 1986 RCT 1. Information

2. Information + 

reassurance

3.Control (return 

to normal activity)

Hospitalized 

after mild TBI 

(10% had 

positive 

imaging)

N=166

N=75

3 

months

No***

Matuseviciene 2013 RCT 1. Assessment + 

verbal education + 

printed education 

+ gradual return to 

activity

2. Printed 

information

 

Recruited in 

ED and 

symptomatic 

at 10 days; 

intervention 

at 14-21 days 

post-injury

N=39

N=41

3 

months

No

No Tx Effect – Educational Approaches

***Tx groups returned to daily/social fx sooner
First Author Year 

Published

Design Intervention(s) Tested Study Sample Tx and 

Control 

Groups

Follow-Up Tx Effect?

Bryant 2003 RCT 1.CBT 

2.Supportive 

Counseling

Within 2 weeks 

of injury

N=12

N=12

6 months Yes**

Cicerone 2002 Prospective case 

comparison

Attention strategy 

training hourly for 11 to 

27 weeks

Average of 7.6 

months postinjury with 

cognitive 

impairment

N=4

N=4

Posttreatment 

(roughly 16 

weeks)

Yes

Ferguson as 

reported in 

Miller

 

1995 Pre-Post 12-session manualized 

cognitive-behavioral 

treatment

Referrals to 

outpatient clinic

N=4 12 weeks Yes

Hanna-Pladdy

 

2001 RCT Relaxation Less than 1 to 

multiple years 

post-injury

N=44

N=44

Post-stress 

induction 

or none

Yes

Leddy

 

2013 Quasi-random 

assignment with 

matched control

1. Exercise

2. Stretching 

3. Healthy Control

Average of 117 

days post-injury 

with PCS

N=4

N=4

N=4

Posttreatment 

(roughly 17 

weeks)

Yes

Leonard 2004 RCT 1. Group CBT

2. Group 

Education/Support

3. Control

? N=15

N=16

N=9

? Yes

Silverberg 2013 RCT 1.CBT 

2.Printed education + 3 

hour educational 

session

Less than 6 

weeks post-injury 

(average of 24 

days); 

symptomatic

N=13

N=11

3 months 

post-injury

Yes

Tiersky 2005 RCT with 

multiple 

baselines 

CBT+cognitive 

treatment for 11 weeks

 

Average of 5 

years post-injury

N=7 

(milds)

N=9

1 and 3 

months

Yes

Positive Tx Effect – Other Approaches
First Author Year 

Published

Design Intervention(s) 

Tested

Study Sample Tx and 

Control 

Groups

Follow-Up Tx Effect?

Azulay 2013 Pre-Post Mindfulness training 7 to 36 months 

post-injury

N=22 PosttreatmentNo

Elgmark

 

2007 RCT Information, support 

by multiple 

disciplines (mostly 

OT)

 

Median of 3 

weeks postinjury

N=264

N=131

12 months No

Ghaffar 2006 RCT Multidisciplinary 

treatment

Within 1 week 

of injury

N=97

N=94

6 months No

Paniak 1998, 2000 RCT 1. Assessment and 

feedback+treatment 

as needed for 

symptoms

2. Single session 

education + brochure 

Hospital 

emergency 

room (12 days 

post-injury)

N=53

N=58

3 to 4 

months, 

12 months

No

Relander 1972 RCT Seen daily at hospital 

+ encouragement to 

get out of bed + 

Physical Therapy

Within 36 

hours of 

hospital 

admission (not 

all milds)

N=82

N=96

12 

months 

postinjury

No***

No Tx Effect – Other Approaches

***Tx group returned to work sooner
• The 4 psychoeducational studies with prospective 

RCT’s conducted within one week of injury all 

demonstrated significantly reduced PCS at followup following psychoeducational interventions

administered in acute phase

• Hard to draw many other conclusions due to 

different treatment approaches, participants 

(e.g., time since injury).

• Other approaches (in particular CBT in post-acute 

and chronic phases) have demonstrated efficacy

Intervention Review Conclusions
Gaps in the Treatment Literature

 Additional information is needed about 

potential impact of education in more chronic 

populations

 May be reluctant to seek out traditional care or 

not have access 

 Need for alternative delivery system
Pilot Study Results – Desktop 

Prototype 

0

5

10

15

20

25

30

35

40

Baseline Follow-Up

PCS (NSI Total)

VA Chronic TBI

Civilian Acute TBI

King, E.G, Kretzmer, T., Vanderploeg, 

R.D., Asmussen, S., Clement, V.L., & 

Belanger, H.G. (2013). Pilot of a novel 

intervention for postconcussive 

symptoms in active duty, veteran, and 

civilians. Rehabilitation Psychology, 58, 

272-279. doi: 10.1037/a0033116. 
Current Study

• Randomized Control Trial

– Examine changes in PCS from baseline (Pre-Tx) to 7 

Days and 6 Months Post-Tx

– Self-administered, interactive web-based 

intervention

• Adapted from Mittenberg et al. (1993) material

• Relevant post-combat material added
Co-Authors & Collaborators

Heather Belanger, PhD, Principal Investigator

Rodney Vanderploeg, PhD

Fiona Barwick, PhD

Tracy Kretzmer, PhD

Kevin Kip, PhD

Marc Silva, PhD

Emily King, PhD

Sarah Asmussen, PhD

John Neff, MD

Kendra Wagers, PhD
Setting and Participants 

 Inclusion Criteria:

 History of Mild TBI

 Aged 18-55

 Access to internet

 English-speaking

 Willing to be randomized
Setting and Participants 

 Exclusion Criteria:

 History of Moderate-Severe TBI

 Comorbid CNS disease (MS, seizures, 

encephalitis)

 Major Psychiatric Disorder (other than PTSD or 

Depression)

 Did not experience any sxs at injury and/or are 

not currently reporting any sxs

 Suicidal/homicidal
Recruitment 

• Subset (~30%) recruited in person to verify 

diagnosis through medical record review and 

structured interview

• All others recruited on-line through various 

means

– TBI, Deployment, and other list serves

– Flyers 

– Outreach 
Eligibility 

• Eligibility Screening 

Baseline 

• Baseline Assessment 

Randomized 

• Randomized 

Intervention 

for 

Treatment 

Group 

• Intervention for Tx Group 

• Wait List for Control Group 

7-Day Follow-Up 

Assessment 

• 7-Day Follow-Up Assessment 

6-Month 

Follow-Up 

Assessment 

• 6-Month Follow-Up Assessment 

Control Group 

Offered Treatment 

• Control Group Offered Treatment 
Outcome Measure

 A Priori Primary Outcome Measure = 

Neurobehavioral Symptom Inventory (NSI)

 22 symptoms, each rated on 5 point severity scale

 cognitive, somatic, psychological symptoms

 Also created an “Attribution Scale” by asking 

whether they believed each symptom was due to 

concussion (0-22) 
Other Measures

 Self-Efficacy

 Self Efficacy for Symptom Management Scale (SEsx) 

 Quiz 

 19 questions about typical recovery, injury severity indices, and 

symptoms based on educational content provided in Mittenberg 

et al. 1993

 Brief Symptom Inventory (BSI) 

 18-item shortened version of the Symptom Checklist 90-Revised 

 Depression 

 CESD

 Posttraumatic Stress Disorder

 PCL
Intervention


N=659

Total screened

N=203

Met criteria and 

completed baseline

N=138

Sample used in current analysis 

(completed all time points) N = 70 Control 

N = 68 Treatment

Study Flow 

Chart

N = 102 Control

N = 101 Treatment
Age (N=138) 

18-25 

12% 

26-45 

82% 

46-55 

6% 
Gender (N=138)

Female

21%

Male

79%
Education Level (N=138)

55%

38%

7%

Less Than 4-

Year College

4-Year

College

Degree

PostGraduate
Acuity (Time Since Injury)

≤1 Month

40% 

2 or 

More 

Months 

Ago

33% 

1 Year or 

More

27% 
How Often Do You Use Internet?

Daily

88% 

Less Than 

Daily

12% 
Number of Concussions Reported

22%

50%

17%

11%

1

2

3

>3
Disability and/or Litigation Hx (N=138)

Yes

40%

No

58%
Those with >1 Concussion Report More 

PCS at Baseline Than Those with 1 (p < 

.001) 
Sample Characteristics

0

10

20

30

40

50

60

PCL (PTSD) CESD (Depression) NSI (Postconcussion

Symptoms)

Current Sample

Reference Group

Other Reference (VA)
Primary Analyses

• Treatment and Control Group did not differ on 

any outcome measure or demographic 

variables at baseline

• Complete case analysis

• Repeated Measures with the following time 

points:

– Baseline

– 7 Days post treatment

– 6 Months post treatment
No differential effect on symptom 

severity across time by group (p > .05)
No differential effect on attributions
No differential effect on 

Psychological Distress (BSI), p = .12
What is Related to Reduction of PCS 

from Baseline to 6 Months? 

Those who tended to show the most recovery (vis-àvis symptom severity) had:

– More symptoms at baseline (r=.52)

– Greater self-efficacy at baseline (r=.34) 

– Greater baseline satisfaction with social support 

(r=.25) 

– Greater perception that concussion adversely 

impacted life at baseline (r=.24)

– Fewer attributions to concussion over time 

(r=.35) 
Conclusion

• No impact of intervention at follow-up

• Some suggestion that symptom reduction

related to things like social support, selfefficacy, changing attributions or expectancies
If we only look at those in the tx group 

who showed change in expectancies....
Hamblen, Bernardy, Sayer, Nelson, 

Schnurr & Forshay (unpublished data)

• 1,236 Veterans screened for TBI:

– 1⁄2 received information handout on mild TBI

– 1⁄2 received no booklet
Hamblen et al. 

– Knowledge of mild TBI increased with handout
Hamblen et al. 

– Handout had no effect on expectations (but did

increase self-rating of understanding symptoms)
Final Thoughts

• We can increase knowledge with information

administered in more chronic phase postconcussion but effect on attributions/positive

expectancies less clear

– But “in person” administration not tested

 Some evidence for other approaches like CBT but 

the literature is currently somewhat sparse and 

heterogeneity across studies makes generalization 

difficult
Crosswords to Computers:

Review of Computer-based Cognitive 

Training Programs 

Amy Jak, Ph.D.

VA San Diego Healthcare

UCSD Department of Psychiatry
Crosswords to Computers

• Review of the empirical literature on popular and 

publically available computer-based cognitive 

training programs 

• Discuss applicability of these programs to those 

with a history of mild traumatic brain injury
Traditional Cognitive Rehabilitation

• Restoration, improvement or strengthening of 

cognitive skills

• Improvement in functioning

• Defined number of in-person sessions

• Led by a qualified professional

• Empirical support (Cicerone et al., 2011)
‘Analog’ Cognitive Enhancement

• Reading

• Board Games

• Musical Instruments

• Traveling

• Knitting

• Gardening

• Playing Bridge

• Crossword puzzles

• Juggling Clarkson-Smith and Hartley, 1990, 

Fabrigoule et al.; 1995; Verghese et 

al., 2003, Draganski et al., 2004, Pillai 

et al., 2011, Hambrick et al., 1999
Computer-Based Training

• Cognitive enhancement strategies have 

gained recent popularity - $300 million 

industry predicted to increase to $2-8 billion 

by 2015. 

• Has the potential to benefit clinical and nonclinical populations.

• As computer-based cognitive training 

becomes more relevant it warrants greater 

scientific scrutiny.
Computer-based Cognitive 

Training/Enhancement 

• Game-like tasks

– Finding a target in an array of distractors

– List learning

• Repeated trials

• Speed/complexity of task increases as 

performance improves

• 3-5 days per week, 15-100 minutes a day, 

for 4-12 weeks

 
Examples of Popular Programs

• Brain HQ 

• Braintrain

• Cogmed

• Cognifit

• Lumosity

This presentation is not intended to endorse any particular entity or product.
Poll Question 

• Do you use any computer cognitive 

enhancement program with your patients?

• Yes

• No
Computer-based Training Outcomes

• Successful cognitive training programs will 

elicit effects that generalize to untrained, 

practical tasks for extended periods of time

• Converging evidence of significant 

improvements in trained cognitive tasks 

• More limited evidence of improvements in 

untrained tasks. 

Jak et al., 2013
Computer-based Training Outcomes

• Emerging evidence of maintenance of gains 

over extended follow-up intervals (Brehmer et al., 

2012; Johansson and Tournmalm, 2012; Lundqvist; et al, 2010; Rebok 

et al., 2014).

• Processing speed gains are a fairly robust 

finding with computer based training (Jak et al., 

2013) 
Computer-based Training Outcomes

• Studied predominantly in older adults 

(mostly healthy) 

• Some research to support use in HIV, postchemotherapy, other neurological and 

psychiatric populations 

• Limited data on efficacy with TBI, 

particularly mild TBI. However, populations 

studied have similar deficits to TBI –

attention, memory, processing speed. 
Feasibility

 70% reported no/little difficulty using program

 Non-”tech-savvy” older adults successfully used 

computer based training and reported a positive 

experience

 58 - 80% maintained average compliance 

 Side effects dissipated over time but included fatigue 

(80%), headaches (20%), and eyestrain (10%). 

Lebowitz et al.; 2012; 

Kueider et al.; 2012, Shatil

et al.; 2010
Additional Benefits to ComputerBased Training 

• Expands accessibility

• Require fewer resources

– Home computer

– Internet access

– Basic computer literacy

– Reduces personnel, space, and travel needs 

• May hold higher entertainment value and 

appeal more to younger cohorts

• Minimal negative side-effects 
Traditional vs. Modern

• Limited investigations of traditional approaches 

compared to newer computer-based programs. 

• Median effect sizes of traditional cognitive training in 

older adults range from .39 (executive functioning 

and visual spatial abilities) to 1.30 (processing 

speed). 

• Median effect sizes for computer training ranged 

from .36 (attention) to 4.0 (processing speed). (Kueider

et al., 2012) 
Limitations of Current Research

• Lack of an adequate control group 

• Limited independent peer-reviewed research 

• Long-term follow-up 

• Ecologically valid outcome measures 

• Small sample sizes

• Large variability in amount of training time

• Samples performing in normal range to begin with
Summary

• Processing speed is one of the domains most 

robustly impacted by computer based cognitive 

training; programs may hold promise for 

improving functioning in this cognitive domain in 

TBI. 

• Computer-based training may be a useful adjunct 

to formal cognitive rehabilitation and may be 

particularly applicable to a higher functioning mild 

TBI population

• Development of new products may have outpaced 

credible scientific investigation 
•Heather Belanger, PhD, ABPP 

Staff Neuropsychologist,

Asst. Training Director, James A Haley Veterans Hosp. 

Associate Professor, Dept. of Psychiatry and Behavioral 

Neurosciences, 

University of South Florida Medical School

•Amy Jak Ph.D. 

Staff Neuropsychologist, 

Director, TBI Cognitive Rehabilitation, VA San Diego 

Assistant Professor, Department of Psychiatry, University of 

California, San Diego