Preliminary efficacy and predictors of response to a remotely-delivered symptom self-management program for persistent symptoms after concussion

Figures & data

Table 1. CESM protocol.

Week	General content
1	General information about concussion; acute effects
2	Prolonged symptoms: why symptoms persist, the importance of treating symptoms, risk factors for prolonged symptoms, synergistic amplification of symptoms. Introduction to self-care/self-management, and to mindfulness principles.
3	Prolonged physical symptoms (e.g., post-traumatic headache, sleep-wake disturbances, vestibular symptoms, vision issues, deconditioning) including tools and self-management strategies (e.g., headache diary, sleep hygiene, exercise as medicine). Introduction to gratitude journaling.
4	Prolonged cognitive symptoms, including strategies for maximizing cognitive function in the context of ongoing physical and emotional symptoms (e.g., energy conservation). The causal role of reduced attentional resources for other cognitive symptoms.
5 and 6	Management of emotional symptoms, including self-care and activity planning (e.g., nourishing vs. depleting activities), concepts and tools from cognitive behavior therapy (e.g., the role of thoughts in contributing to mood; coping plans for dealing with anxiety). Introduction to acceptance and self-compassion.

Table 2. Outcome measures.

Scale	Domain and description
Primary outcome
Perceived Medical Condition Self-Management Scale (38; PMCSMS)	Confidence to self-manage symptoms is an important construct in the maintenance of self-care behaviors and for patient satisfaction (38). The PMCSMS is a reliable and valid way of measuring perceived competence for self-management behaviors in patients with chronic disease (39–41). Eight items are scored on a 6-point Likert scale (strongly disagree to strongly agree), assessing confidence to self-manage (e.g., It is difficult for me to find effective solutions for problems that occur in managing my medical condition; I am generally able to accomplish my goals with respect to managing my medical condition).
Secondary outcomes
Depression, Anxiety, and Stress Scale (39; DASS-21)	A widely used self-report measure indexing symptoms of stress, anxiety and depression over the previous week, with separate sub-scales for each plus a total score. The DASS-21 has previously been shown to be valid as a screening tool for anxiety and mood disorders in TBI samples (42,43). The questionnaire is designed to measure the severity of a range of symptoms common to depression, anxiety, and stress. In completing the DASS-21, the individual is required to indicate the presence of a symptom over the previous week. Each item is scored from 0 (did not apply to me at all over the last week) to 3 (applied to me very much or most of the time over the past week).
Quality of Life Enjoyment and Satisfaction Questionnaire (40, 41; Q-LES-Q)	Quality of life; participants are asked to rate their satisfaction over the prior week (on a 6-point Likert scale ranging from very poor to very good) with a number of different life domains (e.g., physical health, mood, work, social relationships, family relationships, living/housing situation, etc.)
CESM Feedback Questionnaire	Participants rated seven statements according to the scale: agree/neutral/disagree: 1) The program met my expectations; 2) I am glad that I participated in this program; 3) The content of the program met my needs; 4) The content of the program was relevant and appropriate; 5) The information presented was clear and understandable; 6) The length of the program was just right; 7) The length of the program was too long.Participants also had the opportunity to answer the following, open-ended questions: 1) Have you noticed any overall benefits or improvements as a result of your participation in the Concussion Education and Symptom Management Module? 2) Is there anything you would have liked to hear more about, or is there anything we didn’t discuss that you feel would be helpful for future sessions? 3) Is there anything else you can think of that would help us improve future Concussion Education and Symptom Management groups? Participants also had the opportunity to answer the following, open-ended questions: 1) Have you noticed any overall benefits or improvements as a result of your participation in the Concussion Education and Symptom Management Module? 2) Is there anything you would have liked to hear more about, or is there anything we didn’t discuss that you feel would be helpful for future sessions? 3) Is there anything else you can think of that would help us improve future Concussion Education and Symptom Management groups?

Only participants who began the program in 2020 (and ongoing) completed the PMCSMS. Completion of home practice recommendations was not formally assessed.

Table 3. Demographic and clinical information.

Demographics	N = 80
Age (years) M(SD)	41.9 (12.0)
Education (years) M(SD)	15.3 (1.7)
Time post-injury (months) M(SD)	30.7 (33.8)
Single vs. multiple concussions (based on self-report only)	51:29
Areas of cognitive difficulty reported at intake M(range)	4 (0–9)
Physical symptoms reported at intake M(range)	5 (0–11)
Areas of emotional difficulty described at intake M(range)	2 (0–4)
Index injury type:
MVA	36
Bicycle accident	4
Fall	21
Sports-related	6
Assault	2
Other blows to head	11

Table 4. Change on clinical outcome variables in full sample and enriched sample with clinical elevations on DASS21.

	Mean at PRE ±SD	Mean at POST ± SD	Change from PRE-POST	Standard error	Degrees of freedom	t-value	p-value
PMCSMS	26.09 ± 7.68	27.86 ± 7.61	1.78	0.79	57	2.24	0.03
Q-LES-Q	0.46 ± 0.16	0.51 ± 0.15	0.06	0.01	78	4.49	<0.001
Full Sample
DASS-21 Depression	9.10 ± 5.48	7.35 ± 5.24	−1.75	0.47	79	−3.70	<0.001
DASS-21 Anxiety	6.88 ± 4.76	6.16 ± 4.67	−0.71	0.37	79	−1.92	0.06
DASS-21 Stress	11.35 ± 5.08	9.84 ± 5.27	−1.51	0.41	79	−3.68	<0.001
DASS-21 Total	27.33 ± 13.45	23.35 ± 13.32	−3.98	1.03	79	−3.86	<0.001
Enriched Sample
DASS-21 Depression	11.08 ± 4.53	8.74 ± 4.94	−2.34	0.57	61	−4.13	<0.001
DASS-21 Anxiety	9.18 ± 3.89	7.60 ± 4.61	−1.58	0.43	54	−3.69	<0.001
DASS-21 Stress	13.76 ± 3.63	11.53 ± 4.85	−2.22	0.48	57	−4.61	<0.001

DASS-21 = Depression, Anxiety, and Stress Scale-21; Depression, Anxiety and Stress refer to sub-scale scores on DASS-21. PMCSMS = Perceived Medical Condition Self-Management Scale. Q-LES-Q = Quality of Life Enjoyment and Satisfaction Questionnaire.

Table 5. Change in confidence to self-manage by symptom burden.

		Change from PRE-POST	Standard error	Degrees of freedom	t-value	p-value
PMCSMS	Main effect: time (pre-post)	9.98	2.35	56	4.25	0.0001
	Main effect: group (low vs. high cognitive symptom burden)	2.53	2.01	56	1.26	0.21
	Time by Group Interaction	−5.29	1.44	56	−3.67	0.0005
	Main effect: time (pre-post)	8.86	2.86	56	3.10	0.003
	Main effect: group (low vs. high physical symptom burden)	0.21	2.16	56	0.10	0.92
	Time by Group Interaction	−4.19	1.63	56	−2.57	0.01
	Main effect: time (pre-post)	3.80	2.57	56	1.48	0.14
	Main effect: group (low vs. high emotional symptom burden)	−2.13	1.99	56	−1.07	0.29
	Time by Group Interaction	−1.32	1.59	56	−0.83	0.41

PMCSMS = Perceived Medical Condition Self-Management Scale.

Wallston KA, Rothman RL, Cherrington A. Psychometric properties of the Perceived Diabetes Self-Management Scale (PDSMS). J Behav Med. 2007;30(5):395–401. doi: 10.1007/s10865-007-9110-y.

 PubMed Web of Science ®Google Scholar

Dahm J, Wong D, Ponsford J. Validity of the depression anxiety stress scales in assessing depression and anxiety following traumatic brain injury. J Affect Disord. 2013;151(1):392–96. doi: 10.1016/j.jad.2013.06.011.

 PubMed Web of Science ®Google Scholar

Randall D, Thomas M, Whiting D, McGrath A. Depression Anxiety Stress Scales (DASS-21): factor structure in traumatic brain injury rehabilitation. J Head Trauma Rehabil. 2017;32(2):134–44. doi: 10.1097/HTR.0000000000000250.

 PubMed Web of Science ®Google Scholar

Wallston KA, Osborn CY, Wagner LJ, Hilker K. The perceived medical condition self-management scale applied to persons with HIV/AIDS. J Health Psychol. 2010;16(1):109–15. doi: 10.1177/1359105310367832.

 PubMed Web of Science ®Google Scholar

Wild MG, Wallston KA, Green JA, Beach LB, Umeukeje E, Nunes JA, Ikizler TA, Steed J, Cavanaugh KL. The perceived medical condition self-management scale can be applied to patients with chronic kidney disease. Kidney Int. 2017;92(4):972–78. doi: 10.1016/j.kint.2017.03.018.

 PubMed Web of Science ®Google Scholar