It was beyond the scope of this study to examine the mechanisms of the association of resilience and outcome from MTBI or to address interventions for resilience. However, conceptualizing resilience as an attribute that is modifiable, together with the findings about resilience being associated with outcome from MTBI, call for attention to the possibilities for its enhancement to improve recovery.
Results from resilience research could be used to identify individuals who may benefit from interventions early after injury (White et al., 2008). In this study, the patients with relatively low resilience had poorer outcome, suggesting that these patients could benefit from closer follow-up and interventions. This has been suggested by other researchers as well (Sullivan et al., 2015). In addition, the assessment of resilience has been considered useful in defining more individualized rehabilitation programs and in considering patients expectations of neurorehabilitation (Bertisch et al., 2014; Tonks et al., 2011).
Resilience could also be targeted by interventions to improve outcomes from MTBI. Resilience in rehabilitation can be conceptualized as part of the broader positive psychology paradigm that focuses on nurturing strengths instead of correcting weaknesses (Bertisch et al., 2014; Cui et al., 2010; Godwin & Kreutzer, 2013; Mak et al., 2011; Richardson, 2002). There are few interventions that have focused on resilience per se (Zautra et al., 2012), but based on a recent systematic review (Macedo et al., 2014) there is evidence of some degree of effectiveness of resilience promotion programs. Resilience enhancement or training has been considered useful in stress- management and stress-prevention programs for college students (Steinhardt & Dolbier, 2008), and for improving stress, anxiety, fatigue, and quality of life in cancer patients (Loprinzi et al., 2011). Mindfulness-based interventions might be useful for promoting resilience (McEwen et al., 2015; Neenan, 2009), and these approaches to managing stress have shown effectiveness in enhancing resilience in the workplace (Aikens et al., 2014) and for reducing anxiety (Feder et al., 2012).
An interesting and well-described example of a resilience training program is the one developed for use in the U.S. Army (Reivich et al., 2011). This program includes: (i) learning about resilience; (ii) building resilience competencies with techniques from
cognitive behavioral therapy (CBT), such as challenging negative thoughts, learning about explanatory styles and thinking traps (like over-generalizing), identifying deeply held beliefs and values, energy management (such as breathing and relaxation), problem solving skills, minimizing catastrophic thinking, and cultivating gratitude; (iii) identifying strengths; and (iv) strengthening relationships (Reivich et al., 2011). This training has been shown to improve the resilience and psychological health of soldiers (Lester et al., 2013). In addition, the positive psychotherapy developed by Seligman et al. (2006) focuses on targeting personal strengths and building positive emotions and meaning, and positive psychology exercises have been delivered successfully via the internet (Seligman et al., 2006). Others have considered the promotion of positive appraisal styles essential for developing resilience (Tugade & Fredrickson, 2004).
In addition to psychological interventions, social support and physical activity could enhance resilience (McEwen et al., 2015). In the context of MTBI, it is noteworthy, that physical activity and exercise has been shown to improve cerebral blood flow and executive function, increase hippocampal volume, and to be an effective antidepressant (McEwen et al., 2015). There is some evidence for both direct and indirect benefits of exercise after MTBI as well (Tan et al., 2014). It has also been suggested that as the understanding of the neurobiological underpinnings of resilience progresses, the pharmacological treatment options also will broaden (Feder et al., 2012).
A broader approach to enhancing resilience following MTBI encompasses related psychological constructs. For example, a belief in oneself and one's abilities, positive views, and high expectancy have been considered to be part of resilience (Mak et al., 2011). After MTBI, there is consistent evidence that expectations about injury/illness perceptions are associated with outcome (Pargament & Cummings, 2012; Snell et al., 2011; Suhr & Gunstad, 2002; Suhr & Gunstad, 2005; Trontel et al., 2013; Whittaker et al., 2007). These expectations could be targeted by patient education and reassurance of expected full recovery early after injury (Kraus et al., 2009; Management of Concussion/mTBI Working Group, 2009). It has also been suggested that in clinical work with patients with MTBI, words such as brain injury and brain damage should be avoided in favor of more neutral terms to lessen the distress of patients (Management of Concussion/mTBI Working Group, 2009; McLean et al., 2009). This literature suggests that patients who have stronger negative beliefs about the nature and consequences of
the injury are more at risk for poor outcome. Thus, the resilience perspective together with these findings about recovery expectations and illness perceptions supports the view of giving patients with MTBI realistic but hopeful information about the good prognosis of their injury. This could be delivered in person, by phone or mail, or via email or a web site (Kraus et al., 2009).
However, only providing information or education does not seem to be enough for some patients who are at risk for chronic symptoms (Silverberg et al., 2013). Adaptive health behavior is also part of resilience (Wagnild & Young, 1993), and maladaptive behavior, like all-or-nothing coping, is associated with risk for the post-concussion syndrome after MTBI (Hou et al., 2012). Thus, early interventions targeting coping skills have been widely suggested for patients with MTBI to improve outcome (Gregorio et al., 2014; Hou et al., 2012; Ponsford et al., 2012). Interventions may be especially beneficial for patients at risk for persistent symptoms (Cassidy et al., 2004) and a closer follow-up is recommended for those with pre-injury psychiatric disorders (Dagher et al., 2013). As mentioned above, one potential intervention is CBT. In patients with chronic fatigue syndrome, CBT has been shown to improve health, physical activity, and cognitive performance, and effective CBT was also associated with increased grey matter volume in the lateral prefrontal cortex (de Lange et al., 2008). CBT delivered soon after injury could be beneficial for supporting recovery from MTBI (Hou et al., 2012; Silverberg et al., 2013), especially for those with previous stressful life events (Veldhoven et al., 2011).
In summary, early interventions to enhance resilience and recovery from MTBI are both important and feasible. It has been noted however, that as the applications of positive psychology continue to grow, there is a need to develop clearer definitions and instruments to evaluate these constructs and the way they apply to patients with brain injury (Bertisch et al., 2014). More quality research is also needed on the associations between resilience and related concepts such as coping and illness perceptions in recovery from MTBI, and about the effectiveness of resilience promotion programs (Macedo et al., 2014).