Mild traumatic brain injury (mTBI) or concussions are relatively common events, especially among young adults. While many recover completely from concussions, 44%-64% of people with concussions develop persistent symptoms that can be difficult to manage and may have a significant impact on functioning and quality of life.
Anxiety has been identified as one factor contributing to the progression from acute to persistent mTBI symptoms. In order to address anxiety in the acute setting, with the ultimate goal of preventing persistent symptoms, Jonathan Greenberg, PhD and colleagues from the Center for Health Outcomes and Interdisciplinary Research (CHOIR) at Massachusetts General Hospital have developed a Toolkit for Optimal Recovery after Concussions (TOR-C), an innovative mind-body program aimed at preventing persistent symptoms among young adults with mTBI and comorbid anxiety.
Toolkit for Optimal Recovery after Concussions (TOR-C)
The TOR-C program was adapted from the Toolkit for Optimal Recovery after Orthopedic Injury (TOR) developed by Dr. Ana-Maria Vranceanu to address the needs of adults ages 18-35 with a recent concussion and comorbid mild to severe anxiety. The ultimate goal of TOR-C is to prevent persistent concussion symptoms using a combination of:
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- Mind-body skills (e.g., body scan, deep breathing, mindfulness)
- Cognitive-behavioral strategies (e.g., reframing)
- Acceptance and commitment skills
- Skills to pace returning to activity
- Psychoeducation on concussion recovery
The intervention consists of four 45-minute 1:1 sessions with a clinician over Zoom.
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- Session 1 focuses on concussion education, debunking concussion myths, setting recovery goals, introducing mind-body concepts, and practicing deep breathing and the body scan.
- Session 2 introduces the “disability spiral” and “recovery path”, introduces mindfulness, mindful breathing, and mindful STOP (Stop, Take a breath, Observe, Proceed mindfully).
- Session 3 Focuses on mindfulness of pain and discomfort, working with challenging unhelpful thoughts about concussion symptoms, and re-engaging in physical, social and cognitively engaging activities.
- Session 4 focuses on Acceptance, problem-solving, skills review and plan for recovery.
Between sessions, participants may elect to receive text messages with daily encouragement to practice the TOR-C skills via skill recordings on the study website.
Testing the Feasibility and Acceptability of TOR-C
In a pilot randomized controlled trial, Greenberg and colleagues examined the feasibility and acceptability of the live video TOR-C and an active comparison intervention (Health Enhancement after Concussion – HE-C). For this study, 50 young adults (ages 18-35) with a recent concussion (within 3-10 weeks) and comorbid anxiety were recruited through provider and self-referrals. Referring providers were based in the Massachusetts General Hospital (MGH) Emergency Department and concussion clinics.
Both interventions met a-priori set benchmarks for feasibility of recruitment, credibility, expectancy, acceptability, safety, feasibility of assessments, fidelity, and satisfaction.
Participants in TOR-C noted significant improvements of large effect size in post-concussion symptoms, physical function, and pain during activity. They also exhibited significant improvements of medium to large effect in anxiety and significant improvements of medium effect size in depressive symptoms
Participants in TOR-C exhibited significant improvements of large effect size in fear avoidance behavior and limiting behavior, significant improvements of medium to large effect size in mindfulness and pain catastrophizing and significant improvement of medium effect size for all-or-nothing behavior.
Participants in the active comparison group receiving HE-C experienced improvements. In line with recommendations for pilot trials, authors refrain from conducting between group comparisons in this feasibility study.
Next Steps
The Toolkit for Optimal Recovery after Concussions (TOR-C) intervention focuses on the specific needs of a population at risk for persistent symptoms after concussion: young adults with comorbid anxiety. The findings of the current study provide strong evidence that TOR-C, as well as the comparison HE-C intervention, are feasible, acceptable, credible, and result in high satisfaction.
Both interventions were associated with improvements in outcomes (concussion symptoms, physical function, anxiety, depression and pain) and resulted in significant changes in behaviors associated with symptom persistence (pain catastrophizing, mindfulness, fear-avoidance, and limiting behavior).
The study demonstrated high participant support and engagement. Importantly, the high rates of participation and retention suggest that while some patients experience light and screen sensitivity after concussion, this did not pose a significant barrier to the live-video delivery of the intervention.
While the current study was not intended or adequately powered to measure the efficacy of the two interventions, the findings provide preliminary support for improvements in target behaviors and outcomes and support a future fully powered randomized controlled trial comparing TOR-C with HE-C in order to establish the efficacy of these interventions and to explore how they differ in terms of mechanisms of change.
Read More
Greenberg J, Levey NS, Becker M, Yeh GY, Giacino JT, Iverson G, Silverberg ND, Parker RA, Vranceanu AM. A Feasibility Randomized Controlled Trial of the Toolkit for Optimal Recovery after Concussion: A Live Video Program to Prevent Persistent Concussion Symptoms in Young Adults with Anxiety. Arch Phys Med Rehabil. 2024 Nov 4:S0003-9993(24)01317-0.
Greenberg J, Singh T, Iverson GL, Silverberg ND, Macklin EA, Parker RA, Giacino JT, Yeh GY, Vranceanu AM. A Live Video Mind-Body Treatment to Prevent Persistent Symptoms Following Mild Traumatic Brain Injury: Protocol for a Mixed Methods Study. JMIR Res Protoc. 2021 Jan 14;10(1):e25746.
Lovette BC, Kanaya MR, Grunberg VA, McKinnon E, Vranceanu AM, Greenberg J. “Alone in the dark”: A qualitative study of treatment experiences among young adults with a recent concussion and anxiety. Neuropsychol Rehabil. 2024 Jul;34(6):781-801.
Greenberg J, Kanaya MR, Bannon SM, McKinnon E, Iverson GL, Silverberg ND, Parker RA, Giacino JT, Yeh GY, Vranceanu AM. The Impact of a Recent Concussion on College-Aged Individuals with Co-Occurring Anxiety: A Qualitative Investigation. Int J Environ Res Public Health. 2023 Jan 21;20(3):1988.
Vranceanu AM et al. Results of a feasibility randomized controlled trial (RCT) of the Toolkit for Optimal Recovery (TOR): a live video program to prevent chronic pain in at-risk adults with orthopedic injuries. Pilot Feasibility Stud 5, (2019).
Jonathan Greenberg, PhD is a research staff psychologist in the Center for Health Outcomes and Interdisciplinary Research (CHOIR) at Massachusetts General Hospital and an Assistant Professor of Psychology in the Department of Psychiatry at Harvard Medical School. His work focuses primarily on cognitive, affective and neural effects of mindfulness practice. Dr. Greenberg’s research primarily focuses on developing and testing mind-body and mindfulness-based interventions for various clinical populations, with an emphasis on chronic musculoskeletal pain, orofacial pain, and mild traumatic brain injury.
Dr. Ana-Maria Vranceanu is a clinical health psychologist, Associate Professor of Psychology at Harvard Medical School, and Founding Director of the Center for Health Outcomes and Interdisciplinary Research (CHOIR). She is also the James and Elizabeth Gamble Endowed Chair Co-Director (Psychiatry) for MassGeneral Neurosciences, and Co-director for Grants Consultation and Support within the Department of Psychiatry. She is an expert in mind-body and lifestyle intervention development and testing. Dr. Vranceanu has served as Principal Investigator for over 20 research grants and has published more than 200 peer-reviewed articles. She is currently PI on several federally funded projects including: Active Brains Digital (NIA R01); Doorstep (NCCIH 34 with Cale Jacobs); Resilient Youth with Neurofibromatosis (DoD R01); Resiliency in Adults with Neurofibromatosis (DoD Ro1); Recovering Together (NINR R01); and Toolkit for Optimal Recovery (NCCIH R01).
