|Year : 2020 | Volume
| Issue : 2 | Page : 64-69
Follow-up of patients subject to the mild traumatic brain injury
Bing-Sang Wong1, Shiu-Hui Lin2, Chih-Wen Chen2, Shu-Chiu Lin2, Yu-Tsai Lin2
1 Department of Medicial, Antai Medical Care Cooperation, Antai Tian-Sheng Memorial Hospital, Donggan, Pingtung County, Taiwan
2 Department of Nursing, Antai Medical Care Cooperation, Antai Tian-Sheng Memorial Hospital, Donggan, Pingtung County, Taiwan
|Date of Submission||23-Oct-2018|
|Date of Decision||13-Feb-2019|
|Date of Acceptance||05-Mar-2020|
|Date of Web Publication||23-Apr-2020|
Mrs. Shiu-Hui Lin
Department of Nursing, Antai Medical Care Cooperation, Antai Tian-Sheng Memorial Hospital, Pingtung County 928
Source of Support: None, Conflict of Interest: None
Background: In the past decade, accidents have been one of the top 10 causes of death in Taiwan. Head trauma caused by accidents has been an issue of concern in Taiwan. Although serious long-term effects have been documented, research on mild traumatic brain injury (mTBI) remains scarce. Thus, the main purpose of this study was to analyze post-concussion symptome (PCS) and the relevant impact on physical, emotional, and cognitive functions.
Materials and Methods: During 2012–2013, 105 patients with mTBI in a single hospital were surveyed based on the Rivermead postconcussion symptoms questionnaire in 1 week, and their postinjury status was followed 1 month later. The collected data were analyzed using the paired t-test and descriptive statistics.
Results: The collected data were included patient demographics and pretrauma risk factors. A total of 101 patients were subject to mTBI. The rate increased among males and the population aged from 21 to 44 years old. The most common cause of injury was the motorcycle accident, where half of the patients had an initial loss of consciousness and posttraumatic amnesia. Partial resolution of symptoms was noted within 1 month for all participants, but some symptoms persisted (P < 0.0001). In general, patients (especially females) recovered faster from physical impairment. The analysis provides information about the impacts and shows the increased risk of neurocranial traumas related to mTBI.
Conclusion: This study presents patients' PCS symptoms in different periods. Those symptoms improved gradually in 1 month, but some symptoms persisted, especially those affecting emotional and cognitive functions. Most patients in this study were young, and the illness had impact on the patients' daily life. As shown by the results, the risk factors were associated with prolonged PCS among females. Aside from physical symptoms, special attention should be paid to mental care as well. More predictors for mTBI may improve medical care quality and reduce losses of medical resources.
Keywords: Follow-up study, mild traumatic brain injury, post-concussion symptome
|How to cite this article:|
Wong BS, Lin SH, Chen CW, Lin SC, Lin YT. Follow-up of patients subject to the mild traumatic brain injury. Formos J Surg 2020;53:64-9
|How to cite this URL:|
Wong BS, Lin SH, Chen CW, Lin SC, Lin YT. Follow-up of patients subject to the mild traumatic brain injury. Formos J Surg [serial online] 2020 [cited 2020 May 28];53:64-9. Available from: http://www.e-fjs.org/text.asp?2020/53/2/64/283121
| Introduction|| |
Traumatic brain injury (TBI) is a major cause of death and disability around the world. Head trauma caused by accidents has been a public health issue of great concern in Taiwan. The accident in the past decade has been one of the top 10 causes of death in Taiwan, and it is the leading cause of death among young adults aged between 20 and 40 years. As suggested by relevant research, the majority of patients subject to mild TBI (mTBI) exhibit both cognitive and emotional dysfunction within the first few weeks of injury, followed by symptoms resolved in 3–6 months after the injury. mTBI may lead to a continuum of damage to the brain. It can show neurophysiological and neuropsychological features, and impact mechanisms which sustain adaptive social decision-making. The issue of high unemployment of patients with PCS is also noted in the UK. Although mTBI has long been considered a noncritical injury, serious short- and long-term effects have been documented. In addition, it is widely believed that multiple mTBIs may have serious long-term consequences. Unemployed patients are at risk for preinjury psychosocial comorbidities, poorer 6-month functional recovery, and increased psychiatric/postconcussion/posttraumatic stress disorder symptoms. Resource allocation and relapse precautions should be implemented to mitigate and/or prevent the decline of at-risk patients.
During 2007–2008, 476,241 cases were recognized for trauma admissions. 50,599 cases of mTBI accounted for 50.9% of all traumatic brain injuries in Taiwan. The hospitalization rate for patients with TBI in the 15–54 age group was 56%, and most of them were young adults who were the major economic supporters in every household. At present, the focused research on the mTBI is relatively scarce. With more knowledge about the prognosis of the mTBI, more efforts can be provided to minimize physical discomfort, psychological trauma, and economic losses.
This study focuses on the changes in the PCS symptoms among the individual patients in 1 week and 1 month after the injury.
| Materials and Methods|| |
This descriptive follow-up study approved by the Institutional Review Board (IRB) of the Antai Medical Care Cooperation Antai Tian-Sheng Memorial Hospital (ATSMH). Patients who were admitted to the surgical ward of a single hospital for the mTBI from January 2012 to January 2013 were presented with clear explanations to acquire their informed consent. Initial questionnaire assessments were completed 1 week after the injury occurred at the ward or outpatient department. Follow-up assessments in 1 month were done at the clinic or via telephone interview. The present study has been approved by an IRB of ATSMH (IRB No. 10010).
The Centers for Disease Control and Prevention defined the mTBI as a trauma caused by a bump to the head or by a hit to the body that causes the head and brain to quickly shaking back and forth. The sudden movement can cause physiological disruption of the brain function, as brain cells are stretched and damaged to create chemical changes in the brain. According to the inclusion criteria, patients aged between 20 and 65 years who were diagnosed mTBI were included in this study. The mild degree of head trauma was defined by the American College of Rehabilitation Medicine as follows: The mTBI is a traumatically induced physiological disruption of brain function in a person, which is indicated by at least one of the following symptoms: (1) loss of consciousness for any period of time; (2) loss of memory for events immediately before or after the accident; (3) alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused); (4) focal neurological deficit (s) that may or may not be transient, but the severity of the injury does not exceed the following: loss of consciousness for about 30 min or less; an initial Glasgow Coma Scale of 13–15 after 30 min; and the posttraumatic amnesia (PTA) for no more than 24 h. Patients with skull fractures or traumatic brain hemorrhage were excluded. Those with a history of cerebrovascular abnormalities, alcoholism, drug abuse, and mental illness were also excluded. The basic social demographic data include age, gender, residential status, marital status, religious belief, monthly income, educational background, and occupation.
Rivermead postconcussion symptoms questionnaire
The purpose of the study was to determine the Rivermead postconcussion symptoms questionnaire (RPQ), which was a better clinical tool for outcome prediction than an objective neuropsychological assessment regarding the mTBI. Providing clinicians with a brief and reliable tool for predicting outcome functioning can help target the need for further intervention and rehabilitation, and to assess the early and late symptoms through cognitive, emotional, and physical domains., The following 16 items are contained for assessment: (1) headache; (2) dizziness; (3) nausea/vomiting; (4) noise sensitivity, i.e., easily upset by loud noises; (5) sleep disorders; (6) fatigue, i.e., getting tired more easily; (7) irritable, i.e., easily angry; (8) feeling depressed or tearful; (9) feeling frustrated or impatient; (10) forgetful with poor memory; (11) inattention; (12) taking longer to think; (13) blurred vision; (14) light-sensitive; (15) diplopia; and (16) restlessness. Each item was evaluated using the 4-point Likert Scale. The sum of the scores represented the severity of the symptoms in three different domains: headache, dizziness, nausea/vomiting, noise sensitivity, sleep disorders, fatigue, blurred vision, light-sensitivity, and diplopia were in the physical domain; forgetfulness/poor memory, inattention, taking longer to think were in the cognitive domain. Being irritable, easily angry, feeling depressed or tearful, feeling frustrated or impatient, and restlessness were in the emotional domain., The assessment was done using the exploratory and confirmatory factors analyzed by comparing RPQ scores of patients after the mTBI. According to the research findings, the data showed a good fit to the three-dimensional structure of separate cognitive, emotional, and somatic factors. The experts had confirmed that this scale had good test-retest reliability, high internal consistency (Cronbach's α 0.93) and high degree of external validity.
We analyzed the basic demographic data and PCS symptoms based on descriptive statistics and paired t-test to evaluate changes in physiological, cognitive and emotional domains in 1 week and 1 month after the injury and to understand the impact of the mTBI on the patient's health status.
| Results|| |
Social demographic attributes
Among the 123 patients with the mTBI, 105 individuals completed the initial questionnaire assessment, and 4 of them did not participate in the follow-up study. As a result, a total of 101 patients completed the follow-up questionnaire assessment. Among the patients, male took a higher proportion (52.5% vs. 47.5%). The population aged between 21 and 44 years old (49.5%) was significantly higher than other age population. Most of the patients have a senior high degree (33.7%) and university degree (24.7%). Furthermore, most of the patients were employed (71.3%) and healthy without a past medical history (81.2% vs. 17.8%). The result showed that they were capable to be the main work producer. On, comparison of the causes of injury classification, motorcycle accident was the main cause which accounted for 63.4%, where slip accidents accounted for 11.9% and fall-down accidents from a height (>6 m) accounted for 5.9%.
According to the statistics, the mTBI patients with the initial loss of consciousness accounted for 53.5% and the patients with PTA accounted for 46.5% [Table 1]. These findings compliment previous research that referred to the motorcycle accident as the leading cause of the mTBI and half of the patients had initial loss of consciousness and PTA, highlighting the impact and increased risk of neurocranial traumatic findings among patients after they were subjected to mTBI.
The most troublesome symptoms of PCS among patients with the mTBI after 1 week were headache, dizziness, and fatigue, while other symptoms included insomnia, inattention, and nausea with vomiting. These symptoms improved much in 1 month, according to the follow-up survey. Headache, dizziness, and fatigue could last for 1 month, and the severity could be mild to moderate in 1 week and mild in 1 month [Figure 1].
Comparison of concussion symptoms
The paired t-test was used to analyze the symptoms of PCS among patients with the mTBI in 1 week and 1 month. The comparison between the scores of dizziness in 1 week and 1 month after the injury showed significant improvement (2.64 ± 1.34 vs. 1.64 ± 1.14; P <.0001). The comparison of the scores of headache in 1 week and 1 month after the injury showed significant improvement (2.59 ± 1.16 vs. 1.19 ± 0.89; P < 0.0001). The comparison of the scores of fatigue in 1 week and 1 month after the injury showed significant improvement (2.52 ± 1.32 vs. 1.48 ± 1.2; P < 0.0001) [Table 2]. Overall, significant improvement is displayed via the comparison of the scores of PCS in 1 week and 1 month after the injury. Although there was a significant improvement after the 1-month interval, the PCS still persisted (21.48 ± 11.86 vs. 11.2 ± 1.22, P < 0.0001). When different genders were compared, the scores of PCS for females were higher in 1 week and 1 month, although there was improvement in both genders after the 1-month interval. The scores for females were higher and improved at a slower rate than those for males. When the physical, cognitive, and emotional domains were scrutinized, physiological symptoms scored in 1 week and 1 month after the injury showed significant improvement (1.60 ± 0.78 vs. 0.81 ± 0.65, P < 0.0001). Based on the scores of females and males in 1 week and 1 month, the physiological symptoms in females were more severe. Both genders had significant improvement in 1 month. The scores of cognitive symptoms in 1 week and 1 month showed significant improvement (P < 0.0001). The scores of females and males in 1 week and 1 month showed significant improvement (P < 0.05). The scores of emotional symptoms in 1 week and 1 month showed significant improvement (P < 0.0001). The scores of females and males in 1 week and at 1 month showed significant improvement (P < 0.05) [Table 3]. For analysis of injury factors, the structure of the RPQ symptoms in the physical, cognitive, and emotional domains was observed, and according to the structure of factors and symptoms, physiological and cognitive symptoms were more prominent among the patients, and they showed the most significant improvement as well. The group of fall-down from a height (>6 m) showed the most significant improvement. However, in the emotional domain, the scores in 1 month after injury showed no differences, indicating that relevant symptoms in the emotional domain showed no improvement [Figure 2]. The study showed that the PCS in mTBI had significantly improved in the 1-month interval, but some symptoms persisted. Physiological symptoms recovered faster than cognitive and emotional symptoms. The PCS among female patients was more severe than that among male patients, no matter in 1 week or 1 month, and the least improvement was discerned, especially in the emotional domain.
|Table 2: The most troublesome symptoms of postconcussion symptoms in patients (n=101)|
Click here to view
|Figure 2: Mild traumatic brain injury rivermead postconcussion symptoms questionnaire comparison before and after the cause of injury|
Click here to view
| Discussion|| |
The follow-up study explores symptoms of the post-concussion syndrome (PCS) in 1 week and 1 month after the mTBI in the physical, cognitive, and emotional domains. The majority of patients with the mTBI were healthy, young adults. The major cause of the TBI was the motorcycle accident. PCS could last for 1 month after the mTBI. This study shows that interventions and reassurance were necessary for the prolonged PCS.
Previous research had highlighted how the demographic characteristics among people in the age groups between 20 and 65 subject to the mTBI were compatible with this study. The incidence rate was higher among males and the age groups between 20 and 30 years. The most common cause of injury was the motorcycle-related traffic accident., Prospective controlled studies reported that PCS among the mTBI patients could last for 3 months or longer, reduce the quality of life, and conduce to loss of employment; thus prophylactic symptomatic treatment was recommended., There was increasing evidence that some people could experience persistent symptoms for years following the mTBI. The mild-TBI group reported significantly poorer community participation across all three domains based on productivity (P < 0.001) and social relations (P < 0.001). The results indicated that while somatic symptoms were resolved over time, cognitive and emotional symptoms could persist and impact the longer-term community participation. Psychological distress, postinjury functioning, and the sick leave trajectory of the subjects were negative predictors.,, This study concluded to focus on issues related to the PCS symptoms (in the physical, cognitive, and emotional domains). This needs to be taken into further account by health-care professionals. Early intervention would be required to reduce the impact of relevant symptoms and facilitate participation over the longer-term.
This study had the following limitations: (1) for patients enrolled from emergency and outpatient departments, our dataset only included patients who had been admitted to hospital and suffered from head injury, while those who were not brought to the medical service were not included. (2) Patients were all from a regional teaching hospital in Southern Taiwan and could not represent the whole population with mTBI. (3) Some follow-up assessments by telephone interviewing, rather than face-to-face interviews, might affect the authenticity of data collection. (4) Other systemic symptoms were not collected and could not be discussed. (5) Without further long-term follow-up surveys, other delayed symptoms might be ignored. Future studies can enroll patients through cooperation with other institutions and prolonged follow-up studies to elucidate the prognosis of the mTBI symptoms.
| Conclusion|| |
The present study provides the PCS symptoms (in the physical, cognitive, and emotional domains) in different periods after the mTBI occurs, which can serve as a reference for clinical care. For the mTBI, the most common cause is the motorcycle-related traffic accident, as motorcycles are the most popular transportation vehicles in Taiwan. In relevant accidents, the majority of victims are young and healthy adults. Their families and society as a whole also suffer from catastrophic consequences as well. This needs to be taken into account by health-care professionals and society in general when it comes to the mTBI. Aside from physiological symptoms, we must pay attention to psychological care for profound effects on public health issues. Meanwhile, we also need to focus on traffic safety and education, especially among the young population. We would like to find more factors that can predict the mTBI, allow improvement of the medical care quality and decrease the loss of medical resources.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Georgiou AP, Manara AR. Role of therapeutic hypothermia in improving outcome after traumatic brain injury: A systematic review. Br J Anaesth 2013;110:357-67.
Mayer AR, Mannell MV, Ling J, Gasparovic C, Yeo RA. Functional connectivity in mild traumatic brain injury. Hum Brain Mapp 2011;32:1825-35.
van Noordt S, Good D. Mild head injury and sympathetic arousal: Investigating relationships with decision-making and neuropsychological performance in university students. Brain Inj 2011;25:707-16.
King NS, Kirwilliam S. Permanent post-concussion symptoms after mild head injury. Brain Inj 2011;25:462-70.
Eierud C, Craddock RC, Fletcher S, Aulakh M, King-Casas B, Kuehl D, et al
. Neuroimaging after mild traumatic brain injury: Review and meta-analysis. Neuroimage Clin 2014;4:283-94.
Yue JK, Rick JW, Morrissey MR, Taylor SR, Deng H, Suen CG, et al
. Preinjury employment status as a risk factor for symptomatology and disability in mild traumatic brain injury: A TRACK-TBI analysis. NeuroRehabilitation 2018;43:169-82.
Hsu IL, Li CY, Chu DC, Chien LC. An epidemiological analysis of head injuries in Taiwan. Int J Environ Res Public Health 2018;15. pii: E2457.
Prince C, Bruhns ME. Evaluation and treatment of mild traumatic brain injury: The role of neuropsychology. Brain Sci 2017;7. pii: E105.
de Guise E, Bélanger S, Tinawi S, Anderson K, LeBlanc J, Lamoureux J, et al
. Usefulness of the rivermead postconcussion symptoms questionnaire and the trail-making test for outcome prediction in patients with mild traumatic brain injury. Appl Neuropsychol Adult 2016;23:213-22.
Potter S, Leigh E, Wade D, Fleminger S. The Rivermead Post Concussion Symptoms Questionnaire: A confirmatory factor analysis. J Neurol 2006;253:1603-14.
King NS, Crawford S, Wenden FJ, Moss NE, Wade DT. The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability. J Neurol 1995;242:587-92.
Plass AM, Van Praag D, Covic A, Gorbunova A, Real R, von Steinbuechel N, et al
. The psychometric validation of the Dutch version of the rivermead post-concussion symptoms questionnaire (RPQ) after traumatic brain injury (TBI). PLoS One 2019;14:e0210138.
Ahman S, Saveman BI, Styrke J, Björnstig U, Stålnacke BM. Long-term follow-up of patients with mild traumatic brain injury: A mixed-method study. J Rehabil Med 2013;45:758-64.
Faux S, Sheedy J, Delaney R, Riopelle R. Emergency department prediction of post-concussive syndrome following mild traumatic brain injury – An international cross-validation study. Brain Inj 2011;25:14-22.
Theadom A, Starkey N, Barker-Collo S, Jones K, Ameratunga S, Feigin V, et al
. Population-based cohort study of the impacts of mild traumatic brain injury in adults four years post-injury. PLoS One 2018;13:e0191655.
Vikane E, Hellstrøm T, Røe C, Bautz-Holter E, Aßmus J, Skouen JS. Predictors for return to work in subjects with mild traumatic brain injury. Behav Neurol 2016;2016:8026414.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]