Approximately 10-15% of patients with mild traumatic brain injury (mTBI) report persistent, chronic symptoms more than one month later. Coping behaviors after mTBI can range from fear avoidance (FA), or a reluctance to return to activity because of the fear of symptom exaggeration, to endurance (END), or an overly aggressive return to activity. We evaluated how coping strategy relates to self-reported symptoms in patients with prolonged recovery from mTBI.

Participants were 72 individuals (age 37.8 + 18.4, 65% female) who sustained a mTBI at least one month prior to assessment (median (IQR) = 5.5 (2.0-11.3) months). Participants completed the Brain Injury Recovery Disposition Scale (BIRDS) to assess FA and END behaviors, and Sport Concussion Assessment Tool (SCAT5) Symptom Inventory. A BIRDS spectrum score was calculated as the difference between FA and END scores to determine individual coping behavior on a spectrum from extreme FA (more negative) to extreme END (more positive). SCAT5 symptoms were separated into four domain scores: somatic, cognitive, sleep, and emotion. Regressions were performed for each outcome examining their potential linear and quadratic associations to coping behavior (i.e., BIRDS spectrum score). Follow-up regressions were performed covarying for age and sex to explore the potential influence of these variables on each outcome.

The linear and quadratic components of the BIRDS spectrum score were not significantly related to total number of persisting concussive symptoms. For overall total symptom severity, the quadratic component of the relationship was significant (B = .24, p = 0.04). Visualization of the overall trend line suggested that symptom severity was highest on the extreme FA side of the BIRDS spectrum (highly negative BIRDS spectrum score), decreased as coping behavior become more balanced (BIRDS spectrum score surrounding “0"), plateaued, then increased abruptly on the extreme END side (highly positive BIRDS spectrum score). For cognitive symptoms, the linear component of the BIRDS spectrum score was significant (B = -.28, p = 0.02) and the quadratic component was marginally significant (B = .22, p = 0.06). The quadratic (but not linear) component was significantly related to both the severity of sleep (B = .31, p = 0.01) and emotion symptoms (B = .25, p = 0.03). Finally, neither the linear nor quadratic components were significantly related to the somatic symptom severity. After covarying for age and sex, the quadratic component remained significant for total symptom severity (p = 0.05) as well as the linear component for cognitive severity (p = 0.02).

Both extreme “fear avoidance” and “endurance” coping styles may be related to more severe chronic mTBI symptoms, especially in domains of sleep and emotion symptoms. Patients with balance of both fear avoidance and endurance behaviors may be more likely to experience less severe symptoms even among mTBI patients with persistent complaints. Identifying coping behavior styles early after mTBI could improve prognostication and help with developing personalized treatment plans to improve patient recovery. Future research with larger sample sizes should further examine the influence of age and sex on the relationship between coping behavior and symptom severity.