A Cross-Sectional Investigation of Trait Mindfulness,Concussion Symptom Severity,and Quality of Life in Adults with Persisting Symptoms Postconcussion

Abstract

Individual differences in mindfulness may impact quality of life after concussion. In a cross-sectional analysis, the moderating effect of mindfulness was tested on the association between symptom severity and quality of life in adults with persisting postconcussion symptoms (N = 85). Mindfulness and symptom severity were independently associated with quality of life; however, mindfulness did not moderate this association. “Nonreactivity” was independently associated with quality of life; however, it was not a significant moderator. Taking a nonreactive stance, or allowing experiences to come and go without effort to change them, may be relevant to quality-of-life outcomes after concussion.

Introduction

Concussion is a major public health concern, affecting 600–1100 per 100,000 adults each year.^1,2 Although symptoms typically resolve within 1 month, recovery is prolonged in ∼30% of adults.³ Persisting symptoms after concussion are associated with worse quality of life,^4
–6 including lower work productivity,⁷ reduced social participation,⁸ and increased mental health problems.⁹ Little is known about the factors that contribute to quality of life for adults with persisting symptoms after concussion. Identifying such factors could help inform interventions, which is particularly important given the relative paucity of research on effective behavioral interventions for this patient group.¹⁰

Mindfulness, defined as paying attention on purpose, in the present moment, and nonjudgmentally,¹¹ could impact quality of life postconcussion.¹² In several pilot studies, mindfulness-based interventions improved quality of life¹³ and related psychological outcomes such as depression¹⁴ and post-traumatic stress¹⁵ after traumatic brain injury (i.e., mild and moderate traumatic brain injury). However, mindfulness is not a unidimensional construct. Trait mindfulness is composed of a number of facets, including observing one's experiences, describing one's experiences, acting with awareness, nonreactivity, and nonjudgment.¹⁶

In chronic pain, mindfulness facets differentially impact pain outcomes and quality of life. For example, acting with awareness and nonjudgement is associated with pain-related disability, anxiety, and depression;^17,18 however, nonreactivity is predictive of mental health-related quality of life.¹⁷

This suggests that focusing attention on the present moment and with a nonjudgemental stance may be particularly important in predicting psychological outcomes, whereas nonreactivity (i.e., allowing experiences, such as emotions, to come and go without effort to change them) may best predict how people perceive the impact of their symptoms on their life. It is also possible that these differences are related to population characteristics (e.g., orofacial pain vs. chronic neuropathic pain after cancer treatment). In adults with a remote history of concussion, lower scores on two facets of mindfulness—nonjudgement and nonreactivity—predicted more postconcussion symptoms.¹⁹

This study aims to determine whether the association between postconcussion symptom severity and quality of life is moderated by trait mindfulness. The authors hypothesized that mindfulness would moderate the association between symptom severity and quality of life, such that those higher in trait mindfulness would report better quality of life postconcussion, regardless of symptom severity. The authors also explored whether different facets of mindfulness were stronger moderators of this association.

Materials and Methods

Study design and participants

This study is a secondary data analysis from a parallel-group randomized feasibility trial for adults with maladaptive coping styles postconcussion.²⁰ Reporting follows the STROBE Statement guidelines (Supplementary Data) for reporting observational studies—cross-sectional studies extension.²¹ A total of 92 adults with concussion were enrolled from two specialized concussion clinics in the Greater Vancouver Area from May 2019 to April 2020. The sample size for the larger feasibility trial was pragmatic. In efforts to reduce selection bias, the study was introduced to all new patients at the clinics. Median time between the concussion and baseline assessment was 15 weeks.

Participants were eligible to participate if they met the following criteria: (1) age 18–70 years; (2) sustained a concussion according to the World Health Organization Neurotrauma Task Force definition²² between 1 and 12 months ago; (3) fluent in English; (4) had access to a computer, tablet, or smartphone with internet capability; (5) ≥3 moderate–severe symptoms on the Rivermead Post-Concussion Symptom Questionnaire (RPQ);²³ and (6) reported high avoidance behavior (>25 on an avoidance behavior short form scale²⁴); and/or endurance behavior (>18 on the All-or-Nothing subscale²⁵).

Procedures

Procedures are described in detail elsewhere.²⁰ In brief, patients who consented to be contacted about the study were screened for eligibility by telephone. Those eligible and interested provided consent and completed a baseline assessment on a secure online platform.²⁶ Only baseline questionnaire data from the feasibility trial are analyzed. The University of British Columbia's Behavioural Research Ethics Board approved all study procedures.

Measures

Demographics and clinical characteristics

Participants reported demographic information (e.g., age, gender) and clinical characteristics (e.g., mechanisms of injury, time since injury) on forms designed for the parent study.

Mindfulness

The Five Facet Mindfulness Questionnaires (FFMQ)²⁷ is a 39-item Likert scale self-report measure that assesses five facets of mindfulness: observing, describing, acting with awareness, nonjudging, and nonreactivity. Items are scored from 1 (never or very rarely true) to 5 (very often or always true). Higher scores reflect more self-reported mindfulness. In this study, the FFMQ total score (Cronbach's α = 0.90) and subscales (Cronbach's α = 0.80–0.91) had good to excellent internal consistency.

Quality of life

The Quality of Life After Brain Injury Scale (QOLBRI)²⁸—overall scale is a validated and reliable six-item scale that assess health-related quality of life (i.e., physical health, cognition, emotions, functioning in daily life, personal and social life, and current situations/future prospects).^28,29 Reponses are provided on a scale from 1 (not at all) to 5 (very). The sum of the items is converted to a percentage with higher scores reflecting better health-related quality of life. In this study, the QOLBRI had good internal consistency (Cronbach's α = 0.84).

Postconcussion symptom severity

The RPQ²³ was used to measure postconcussion symptom severity. Compared with preinjury functioning, participants rate how much of a problem 16 symptoms have been over the previous 24 h, on a scale from 0 (no problem) to 4 (severe problem). Total scores range from 0 to 64. Item scores of 1 (no more of a problem compared with preinjury) do not count toward the total. In this study, the RPQ had excellent internal consistency (Cronbach's α = 0.93).

Statistical analysis

Moderation analyses were conducted using Hayes' statistical macro for SPSS, Process, Model 1³⁰ to determine whether self-reported mindfulness (total score) and its facets moderated the association between postconcussion symptoms and quality of life. The β value, standard error, significance testing, and confidence interval were reported for the effect of symptom burden and mindfulness on quality of life, as well as their interaction (i.e., moderation). If the 95% confidence interval of the interaction term includes 0, this suggests that there is no moderation effect of mindfulness on symptom burden and quality of life.

Post hoc linear regression analyses were conducted to determine whether the proposed moderators (mindfulness and its facets) were independently associated with quality of life above and beyond symptom burden. The F statistic was used to assess model fit and R ² was reported as a measure of variance explained (i.e., how much variation in quality of life can be explained by variation in mindfulness, its facets, and symptom burden). Listwise deletion was used to handle missing data. All analyses were conducted in IBM Statistics SPSS 26.

Results

Participant characteristics are detailed in Table 1. Of the 92 eligible participants, 7 had missing data on the FFMQ, QOLBRI, or RPQ, and were excluded from analysis. Mindfulness did not moderate the association between concussion symptoms and quality of life [t(82) = 0.58, p = 0.56]. In a post hoc regression analysis, the independent associations of concussion symptoms and mindfulness with quality of life were tested. Both concussion symptoms (β = −0.60, p < 0.001) and mindfulness (β = 0.16, p = 0.01) were independently associated with quality of life. Together, they explained 47% of the variance in quality of life scores [R ² = 0.47, F(2,82) = 37.0, p < 0.001].

Table 1.

Demographic and Clinical Characteristics of the Sample

Demographic variables	N	n (%)
Age, mean (SD)	85	41.1 (11.4)
Sex ( female)	85	54 (63.5)
Education level	85
High school		3 (3.5)
Some college		17 (10.0)
Diploma		19 (22.4)
Bachelor's		24 (28.2)
Graduate		22 (25.8)
Ethnicity (%)^a	85
White		65 (76.5)
Asian		13 (15.3)
Other		3 (3.6)

Clinical variables	N	n (%)
Weeks postinjury at enrollment, mean (SD)	85	18.7 (10.5)
Mechanism of injury	85
Motor vehicle crash		30 (35.3)
Fall		15 (17.6)
Sport and recreation		22 (25.9)
Other		17 (20.0)
Loss of consciousness	85	9 (10.6)
Post-traumatic amnesia	85	39 (45.9)
Co-occurring orthopedic injury	85	21 (24.7)
Receiving compensation	85	55 (65.5)
Litigating	85	20 (23.5)
On leave from school/work	85	26 (30.6)
Previous concussion (yes)	82	32 (37.6)
Number of previous concussions	32
1		14 (43.8)
2		7 (21.9)
3 or more		11 (34.4)

Baseline characteristics		Mean (SD)
RPQ		33.8 (14.4)
QOLTBI		42.2 (13.7)
FFMQ		125.9 (18.9)

Not mutually exclusive.

FFMQ, Five Facet Mindfulness Questionnaire; QOLIBRI, Quality of Life after Brain Injury; RPQ, Rivermead Post-Concussion Symptoms Questionnaire; SD, standard deviation.

In exploratory analysis for the FFMQ subscales, no individual facets of mindfulness moderated the association between symptom severity and quality of life. In a post hoc regression analysis, the independent association of concussion symptoms and mindfulness facets with quality of life was tested. Concussion symptoms and mindfulness facets explained 50% of the total variance in quality of life [R ² = 0.50, F(6,78) = 12.78, p < 0.001]. However, concussion symptoms (β = −0.58, p < 0.001) and the facet nonreactivity (β = 0.63, p = 0.03) were the only variables independently associated with quality of life. See Table 2 for moderation results.

Table 2.

Moderation Analysis with Quality of Life Predicted by Symptom Severity Moderated by Mindfulness and Mindfulness Facets

Model	β	SE	t	p	95% CI
Model	β	SE	t	p	Lower	Upper
FFMQ total
RPQ	−0.71	0.10	−6.83	<0.001	−0.91	−0.50
FFMQ total	0.19	0.08	2.45	0.02	0.04	0.35
RPQ × FFMQ	−0.003	0.01	−0.58	0.56	−0.014	0.01
FFMQ observing
RPQ	−0.76	0.10	−7.23	<0.001	−0.97	−0.55
FFMQ observing	0.24	0.28	0.88	0.38	−0.31	0.80
RPQ × FFMQ	−0.02	0.02	1.03	0.31	−0.05	0.02
FFMQ awareness
RPQ	−0.72	0.10	−7.22	<0.001	−0.92	−0.52
FFMQ awareness	0.41	0.23	1.77	0.08	−0.05	0.87
RPQ × FFMQ	0.01	0.02	0.54	0.59	−0.02	0.05
FFMQ describing
RPQ	−0.72	0.10	−7.13	<0.001	−0.92	−0.52
FFMQ describing	0.42	0.25	1.65	0.10	−0.09	0.92
RPQ × FFMQ	−0.00	0.02	−0.01	0.99	−0.04	0.04
FFMQ nonjudgment
RPQ	−0.73	0.11	−6.93	<0.001	−0.94	−0.52
FFMQ nonjudgment	0.25	0.22	1.14	0.25	−0.18	0.68
RPQ × FFMQ	−0.00	0.02	−0.16	0.87	−0.03	0.23
FFMQ nonreactivity
RPQ	−0.72	0.10	−7.53	<0.001	−0.92	−0.53
FFMQ nonreactivity	1.09	0.31	3.47	<0.001	0.47	1.71
RPQ × FFMQ	−0.03	0.02	−1.44	0.15	−0.07	0.01

CI, confidence interval; FFMQ, Five Facet Mindfulness Questionnaire; RPQ, Rivermead Post-Concussion Symptoms Questionnaire; SE, standard error.

Discussion

In this cohort of adults with persisting symptoms after concussion, mindfulness did not moderate the relationship between symptom burden and quality of life. However, higher mindfulness and lower symptom burden were independently associated with better quality of life. No specific facets of mindfulness were identified as moderators of symptom burden and quality of life. However, nonreactivity was independently associated with quality of life in this sample.

Contrary to the hypotheses, mindfulness did not reduce the strength of the relationship between postconcussion symptom severity and quality of life. Several explanations are possible. The effect of mindfulness and symptom severity on quality of life might depend on a third confounding variable. For example, people high on pain catastrophizing benefit more from mindfulness than distraction during experimental pain induction, whereas those low on pain catastrophizing benefit more from distraction.³¹

The relationship between mindfulness, symptom severity, and clinical outcomes, such as quality of life, may, therefore, vary due to individual differences. Other factors, such as pre-existing comorbidities, age, and sex that were not adjusted for in this study, may interact with symptom burden, mindfulness, and quality of life.^32,33 In contrast, there may be no moderating effect in this population.

Mindfulness may contribute independently to quality of life, without impacting the strength of the relationship between symptom severity and quality of life. Specifically, nonreactivity, or allowing thoughts and emotions to come and go without effort to change them, may promote quality of life in those with persisting symptoms after concussion. To provide a more comprehensive understanding of this relationship, future research should consider exploring other variables and factors that might impact the association between postconcussion symptoms and quality of life.

The exploratory findings align with previous research in meditators with chronic pain,^17,34 demonstrating that different facets of mindfulness can have differential effects on pain outcomes and quality of life. The findings suggest that nonreactivity may be particularly relevant to the well-being of individuals with persisting symptoms after concussion. This highlights the nuanced nature of mindfulness and emphasizes the need for a comprehensive understanding of its various facets.

Limitations

Limitations of this study should be noted. The cross-sectional design precludes making causal inferences or examining longitudinal changes in mindfulness, symptom severity, and quality of life over time. Furthermore, a larger sample size would enhance statistical power and permit us to adjust for confounding and extraneous variables to better understand the unique effects of mindfulness on postconcussion symptoms and quality of life. Some research suggests that higher mindfulness is associated with better clinical outcomes for individuals with lower levels of distress.^35,36 Therefore, the use of a treatment seeking sample who endorsed maladaptive coping and overall poor quality of life may have contributed to null findings and restrict the generalizability to the broader population. However, such a sample is relevant given these individuals have high need for effective treatments.

Conclusions

In conclusion, mindfulness was not a significant moderator of the relationship between persisting symptoms after concussion and quality of life in this sample. Yet, mindfulness and nonreactivity, specifically, demonstrated independent associations with quality of life in adults with persisting symptoms after concussion. Mindfulness may be an important factor to consider in interventions aiming to improve the well-being of individuals with prolonged concussion recovery. More research is needed to explore these underlying mechanisms in order to develop effective mindfulness-based interventions for this population.

Footnotes

Authors' Contributions

M.C. conceived of this substudy, conducted statistical analysis, wrote the first draft of the article, and critically reviewed the article. A.A.L. conceived of this substudy, contributed to the interpretation of statistical analyses, wrote portions of the article, and critically reviewed the article. J.G. conceived of this substudy, contributed to the interpretation of statistical analyses, and critically reviewed the article. N.D.S. conceptualized and designed the larger parent study, contributed to the interpretation of statistical analyses, and critically reviewed the article.

Author Disclosure Statement

The authors have no disclosures to make.

Funding Information

J.G.'s contribution to this study is supported by the National Center for Complementary and Integrative Health (Grant No. K23AT01065301A1).

Supplementary Material

Supplementary Data

References

Cassidy

, Carroll

, Peloso

, et al. Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med, 2004; 36:28–60; doi: 10.1080/16501960410023732

Langer

, Levy

, Bayley

. Increasing incidence of concussion: True epidemic or better recognition?. J Head Trauma Rehabil, 2020; 35(1):E60–E66; doi: 10.1097/HTR.0000000000000503

Cancelliere

, Verville

, Stubbs

, et al. Post-concussion symptoms and disability in adults with mild traumatic brain injury: A systematic review and meta-analysis. J Neurotrauma, 2023; 40(11–12):1045–1059; doi: 10.1089/neu.2022.0185

Voormolen

, Polinder

, von Steinbuechel

, et al. The association between post-concussion symptoms and health-related quality of life in patients with mild traumatic brain injury. Injury, 2019; 50(5):1068–1074; doi: 10.1016/j.injury.2018.12.002

Yousefzadeh-Chabok

, Kapourchali

, Ramezani

. Determinants of long-term health-related quality of life in adult patients with mild traumatic brain injury. Eur J Trauma Emerg Surg, 2021; 47(3):839–846; doi: 10.1007/s00068-019-01252-9

van der Vlegel

, Polinder

, Toet

, et al. Prevalence of post-concussion-like symptoms in the general injury population and the association with health-related quality of life, health care use, and return to work. J Clin Med, 2021; 10(4):806; doi: 10.3390/jcm10040806

Silverberg

, Panenka

, Iverson

. Work productivity loss after mild traumatic brain injury. Arch Phys Med Rehabil, 2018; 99(2):250–256; doi: 10.1016/j.apmr.2017.07.006

Theadom

, Starkey

, Barker-collo

, et al. Population-based cohort study of the impacts of mild traumatic brain injury in adults four years post-injury. PLoS One, 2018; 13(1):e0191655; doi: 10.1371/journal.pone.0191655

Sheldrake

, Al-Hakeem

, Lam

, et al. Mental health outcomes across the lifespan in individuals with persistent post-concussion symptoms: A scoping review. Front Neurol, 2022; 13:850590; doi: 10.3389/fneur.2022.850590

10.

Polinder

, Cnossen

, Real

RGL

, et al. A multidimensional approach to post-concussion symptoms in mild traumatic brain injury. Front Neurol, 2018; 9:1113; doi: 10.3389/fneur.2018.01113

11.

Kabat-Zinn

Wherever You Go, There You Are: Mindfulness Meditation in Every-Day Life. Hyperion: New York, NY, USA; 1994.

12.

Lovette

, Kanaya

, Bannon

, et al. “Hidden Gains”? Measuring the impact of mindfulness-based interventions for people with mild traumatic brain injury: A scoping review. Brain Inj, 2022; 36(9):1059–1070; doi: 10.1080/02699052.2022.2109745

13.

Azulay

, Smart

, Mott

, et al. A pilot study examining the effect of mindfulness-based stress reduction on symptoms of chronic mild traumatic brain injury/postconcussive syndrome. J Head Trauma Rehabil, 2013; 28(4):323–331; doi: 10.1097/HTR.0b013e318250ebda

14.

Bédard

, Felteau

, Marshall

, et al. Mindfulness-based cognitive therapy: Benefits in reducing depression following a traumatic brain injury. Adv Mind Body Med, 2012; 26(1):14–20.

15.

Cole

, Muir

, Gans

, et al. Simultaneous treatment of neurocognitive and psychiatric symptoms in veterans with post-traumatic stress disorder and history of mild traumatic brain injury: A pilot study of mindfulness-based stress reduction. Mil Med, 2015; 180(9):956–963; doi: 10.7205/milmed-d-14-00581

16.

Baer

, Smith

, Lykins

, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 2008; 15(3):329–342; doi: 10.1177/1073191107313003

17.

Poulin

, Romanow

, Rahbari

, et al. The relationship between mindfulness, pain intensity, pain catastrophizing, depression, and quality of life among cancer survivors living with chronic neuropathic pain. Support Care Cancer, 2016; 24(10):4167–4175; doi: 10.1007/s00520-016-3243-x.

18.

Elvery

, Jensen

, Ehde

, et al. Pain catastrophizing, mindfulness, and pain acceptance: What's the difference?. Clin J Pain, 2017; 33(6):485–495; doi: 10.1097/AJP.0000000000000430

19.

Krzeczkowski

, Robb

, Good

. Trait mindfulness is associated with lower post-injury psychological symptoms following a mild head injury. Mindfulness, 2017; 8(6):1594–1602; doi: 10.1007/s12671-017-0731-0

20.

Silverberg

, Cairncross

, Brasher

PMA

, et al. Feasibility of concussion rehabilitation approaches tailored to psychological coping styles: A randomized controlled trial. Arch Phys Med Rehabil, 2022; 103(8):1565.e2–1573.e2; doi: 10.1016/j.apmr.2021.12.005

21.

von Elm

, Altman

, Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg, 2014; 12(12):1495–1499; doi: 10.1016/j.ijsu.2014.07.013

22.

Holm

, Cassidy

, Carroll

, et al. Summary of the WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury. J Rehabil Med, 2005; 37(3):137–141; doi: 10.1080/16501970510027321

23.

King

, Crawford

, Wenden

, et al. The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability. J Neurol, 1995; 242(9):587–592; doi: 10.1007/BF00868811

24.

Silverberg

, Panenka

, Iverson

. Fear avoidance and clinical outcomes from mild traumatic brain injury. J Neurotrauma, 2018; 35(16):1864–1873; doi: 10.1089/neu.2018.5662

25.

Spence

, Moss-Morris

, Chalder

. The Behavioural Responses to Illness Questionnaire (BRIQ): A new predictive measure of medically unexplained symptoms following acute infection. Psychol Med, 2005; 35(4):583–593; doi: 10.1017/S0033291704003484

26.

Harris

, Taylor

, Minor

, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform, 2019; 95:103208; doi: 10.1016/j.jbi.2019.103208

27.

Baer

, Smith

, Hopkins

, et al. Using self-report assessment methods to explore facets of mindfulness. Assessment, 2006; 13(1):27–45; doi: 10.1177/1073191105283504

28.

von Steinbuechel

, Wilson

, Gibbons

, et al. QOLIBRI Overall Scale: A brief index of health-related quality of life after traumatic brain injury. J Neurol Neurosurg Psychiatry, 2012; 83(11):1041–1047; doi: 10.1136/jnnp-2012-302361

29.

Kreitzer

, Jain

, Young

, et al. Comparing the Quality of Life after Brain Injury-Overall Scale and Satisfaction with Life Scale as Outcome Measures for Traumatic Brain Injury Research. J Neurotrauma, 2021; 38(23):3352–3363; doi: 10.1089/neu.2020.7546

30.

Bolin

. Hayes, Andrew F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. J Educ Meas, 2014; 51(3):335–337; doi: 10.1111/jedm.12050

31.

Prins

, Decuypere

, Van Damme

. Effects of mindfulness and distraction on pain depend upon individual differences in pain catastrophizing: An experimental study. Eur J Pain, 2014; 18(9):1307–1315; doi: 10.1002/j.1532-2149.2014.491.x

32.

Durish

, Yeates

, Brooks

. Psychological resilience as a predictor of persistent post-concussive symptoms in children with single and multiple concussion. J Int Neuropsychol Soc, 2018; 24(8):759–768; doi: 10.1017/S1355617718000437

33.

Iverson

, Gardner

, Terry

, et al. Predictors of clinical recovery from concussion: A systematic review. Br J Sports Med, 2017; 51(12):941–948; doi: 10.1136/bjsports-2017-097729

34.

Greenberg

, Spyropoulos

, Bakhshaie

, et al. Mindfulness facets associated with orofacial pain outcomes. J Integr Complement Med, 2022; 28(10):839–844; doi: 10.1089/jicm.2022.0479

35.

Bergmann

, Hahn

, Hahne

, et al. The relationship between mindfulness, depression, anxiety, and quality of life in individuals with schizophrenia spectrum disorders. Front Psychol, 2021; 12:708808; doi: 10.3389/fpsyg.2021.708808

36.

Verrier

, Day

. The moderating effects of mindfulness facets on psychological distress and emotional eating behaviour. Health Psychol Rep, 2022; 10(2):103–110; doi: 10.5114/hpr.2021.109921

Supplementary Material

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