Outcome after mild to moderate traumatic brain injury: The role of dizziness

OBJECTIVE

To assess the specific effect of dizziness on psychosocial outcome after mild to moderate traumatic brain injury (TBI).

DESIGN

Six-month cross-sectional study. Setting An outpatient TBI clinic in a tertiary care referral center. Participants A consecutive sample of 207 adults with mild to moderate TBI, 138 (66.7%) of whom had subjective complaint of posttraumatic dizziness.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Psychosocial indices (Glasgow Outcome Scale [GOS], General Health Questionnaire [GHQ], Rivermead Head Injury Follow-Up Questionnaire [RHFUQ], return to work status) were collected from dizzy and nondizzy patients.

RESULTS

Despite similar demographic, TBI, and global disability (GOS) profiles of both groups, psychosocial functioning (GHQ, RHFUQ, return to work) was significantly worse in dizzy subjects ( P <.01 for all indices). A logistic regression analysis identified dizziness ( P =.006), total GHQ ( P =.001), and psychotropic and analgesic use ( P =.05) as significant independent predictors of reemployment.

CONCLUSIONS

Although dizziness was closely linked to psychologic distress at 6 months after head injury, it also emerged as an independent predictor of failure to return to work, suggesting that not all its adverse effects on outcome are psychologically mediated. Clinicians need to be alert to the presence of dizziness as an adverse prognostic indicator after mild to moderate TBI.

Occipital Nerve Blocks in Postconcussive Headaches

Headaches are common following traumatic brain injuries of all severities. Pain generators may be in the head itself or the neck. Headache assessment is discussed. Diagnosis and treatment of cervical headaches syndromes and, in particular, occipital neuralgia are reviewed. Finally, a retrospective study of 10 postconcussive patients with headaches who were treated with greater occipital nerve blocks is presented. Following the injection(s), 80% had a "good" response and 20% had a "partial" response. Occipital nerve block is a useful diagnostic and treatment modality in the setting of postconcussive headaches.

Contemporary issues in mild traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To determine (1) minimum criteria in adults for clinical diagnosis of mild traumatic brain injury (TBI) and (2) whether persistent postconcussive syndrome exists as a nosologic entity.

DATA SOURCES

PubMed search by MEDLINE of head injuries from January 1977 to July 2002.

STUDY SELECTION

All reviews and studies of mild TBI with special reference to those on persistent postconcussive syndrome having a general trauma cohort as a control comparison.

DATA EXTRACTION

Review of design and other methodologic issues. Studies dependent on superior strength of evidence (as defined by the American Academy of Neurology) concerning the biologic nature of persistent postconcussive syndrome.

DATA SYNTHESIS

A period of altered awareness with amnesia brought on by a direct craniofacial blow is the starting point in determining whether diffuse mild TBI has occurred. An amnestic scale is more helpful than Glasgow Coma Scale score in grading mild injury and in formulating minimum inclusion criteria for mild TBI. Neuropsychologic test results coupled with self-reported symptoms should not be taken as the primary source of evidence for mild TBI. Prolonged cognitive impairment after injury is not unique to brain trauma.

CONCLUSIONS

Persistent postconcussive syndrome after mild brain trauma, uncomplicated by focal injury, is biologically inseparable from other examples of the posttraumatic syndrome. To account for the persistent cognitive and behavioral sequelae of posttraumatic states, including persistent postconcussive syndrome, we need further studies on the emerging concept of limbic neuronal attrition occurring as a maladaptive response to pain and stress.

Quality of life and post-concussion symptoms in adults after mild traumatic brain injury: a population-based study in western Sweden

OBJECTIVES

To study quality of life and subjective post-concussion symptoms in adults (16-60 years) with a mild traumatic brain injury (MTBI) 3 months and 1 year after injury.

METHODS

Of a total of 489 patients 173 responded to questionnaires at 3 months and at 1 year, including the SF-36 health-related quality of life survey, which is a standardized measure validated for Swedish conditions. Post-concussion symptoms were rated as either existing or non-existing in a 21-item checklist [a modified version of Comprehensive Psychopathological Rating Scale (CPRS)].

RESULTS

SF-36 showed impaired scores in all dimensions. Existing post-concussion symptoms were reported by 1545%. Significantly, more symptoms were present at 3 months than at 3 weeks after injury. Furthermore, a significant correlation between higher rates of post-concussion symptoms and lower SF-36 scores was found.

CONCLUSIONS

The SF-36 results were significantly impaired compared with an age- and gender-matched normative control group and the rate of post-concussion symptoms was significantly higher at 3 months than at 3 weeks after injury. As a significant correlation between higher rates of symptoms and low SF-36 scores was also found we assume SF-36 to be a sensitive enough measure of MTBI-related effects.

Psychological aspects of serious head injury in the competitive athlete

In addition to the physical aspects of athletic injury, there are psychological aspects to consider. These are important during all phases of injury management: the acute injury, the rehabilitative process, and the return-to-play progression. Emotional disturbances are often associated with mild traumatic brain injury (mTBI) both directly and indirectly. Evaluating the athlete with mTBI can be made more difficult by the need to distinguish the physical and the emotional effects of injury and to differentiate the emotional factors directly related to the brain injury from those that arise indirectly (eg, reaction to being held out of play). This article discusses some of the psychological issues related to evaluating the head injured athlete.

Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury

PRIMARY OBJECTIVE

Post-concussion syndrome (PCS) is a controversial diagnosis, in part because many symptoms may be present in other conditions, such as chronic pain (CP). However, direct comparisons between people with CP and mild traumatic brain injury (MTBI) are limited. The purpose of this study was to compare people with CP and MTBI on a measure of PCS symptoms.

DESIGN

Group comparison between patients with CP and MTBI on the Rivermead Post-Concussion Questionnaire (RPCQ).

METHODS

Sixty-three patients with CP and 32 with MTBI were evaluated at the authors' institutions. Patients completed the RPCQ as part of their initial evaluation.

RESULTS

No group differences were found for total RPCQ scores. There were some differences in the proportion of patients endorsing specific symptoms. However, most people with CP endorsed symptoms consistent with PCS.

CONCLUSIONS

PCS symptoms are not unique to MTBI, and may be seen in conditions such as CP.