http://orcid.org/0000-0003-3151-4998
ABSTRACT
Objectives: This study, as part of the UPFRONT-study, aimed to study the patients that report zero complaints early after injury, a group that we named the ‘fortunate few’. We focused on their demographic, clinical and premorbid characteristics, and examined whether they would remain asymptomatic. Moreover, we investigated the influence of anxiety and depression (HADS), and determined outcome (GOS-E) and quality of life (WHOQOL-BREF) 1 year after injury.
Methods: Patients with MTBI (Glasgow Coma Scale score 13–15), without complaints 2 weeks after injury were included. Follow-up took place at 3, 6 and 12 months after injury.
Results: Of the entire UPFRONT-cohort (n = 1151), 10% (n = 119) reported zero complaints 2 weeks after injury. More than half of these patients (57%) developed complaints at a later stage (M = 2, p < .001). Patients with secondary complaints had higher anxiety (p = .004) and depression (p = .002) scores, leading to less favourable outcome (p = .014) and a lower quality of life (p = .006) 1 year after injury compared to patients that remained asymptomatic.
Conclusion: One in 10 patients with mTBI report zero complaints early after injury. Although they seem fully recovered early after injury, a substantial part may develop secondary complaints leading to less favourable outcome and lower quality of life, warranting further research of this interesting group.
Introduction
Research on mild traumatic brain injury (mTBI) particularly focuses on patients that show residual complaints or poor outcome (Citation1). Headache, fatigue, and poor concentration are examples of common complaints, which may be reported in the sub-acute phase after injury, but even up to several years post-injury. These complaints may interfere for instance with resumption of work and social activities. Multiple risk factors for poor outcome have been identified, and prevention of persistent complaints has become a major focus of mTBI research. However, no study so far has zoomed in on patients that report zero complaints at an early stage after injury. We argue that this is highly relevant, because these patients fall off the radar, with nothing known about their recovery trajectory. For example, it is not known whether these patients remain without complaints or whether secondary complaints (SC) develop. Therefore, this group could be one of the missing links in the search for factors leading to successful or unsuccessful recovery after mTBI.
It is uncommon to report no complaints after mTBI especially in the early stages of recovery (Citation2–Citation4). Interestingly, even healthy individuals without head injury often report similar complaints that are generally reported by patients with mTBI, because these posttraumatic complaints (e.g. headache, concentration problems) are unspecific to mTBI Citation(4). Although sparsely reported, frequencies of patients with zero complaints range from 6% within the first two weeks to 20% at one year post-injury (Citation1,Citation3). This implicates that this group is as big as the group reporting persistent complaints, sometimes referred to as the ‘miserable minority’ (Citation1).
Thus, this seemingly remarkable group deserves further scientific attention, which was the goal of this short report. In a large cohort of patients with mTBI, we selected the participants who reported zero complaints early after injury. Specifically, we questioned whether these patients would continue to report zero complaints throughout the first year, and examined the influence of anxiety and depression, that have been found to be related to chronic complaints. Secondly, we determined the rates of favourable outcome and quality of life at one year post injury.
Methods
Participants were selected from the UPFRONT-study cohort, a prospective multicentre study on mTBI outcome in the Netherlands. At the emergency departments of three participating Level-1 Trauma centres, all patients with mTBI aged 16 years or older were screened for inclusion. mTBI was defined as a head trauma resulting in a Glasgow Coma Scale score of 13–15 with loss of consciousness (<30 minutes) and/or post-traumatic amnesia <24 hours. Exclusion criteria were: chronic alcohol/drug abuse, previous TBI or psychiatric disorder requiring admission, major neurological disease or dementia, language barrier, no permanent home address. Written informed consent was obtained from all participants, in compliance with the ethical regulations of our institute. All participants of the UPFRONT-study received questionnaires at 2 weeks (T1), 3 (T2), 6 (T3) and 12 months (T4) after injury, measuring posttraumatic complaints, mood, and outcome. Questionnaires were sent either by mail, or a digital version by e-mail, depending on the patients’ preference. The following questionnaires were used for the current study:
Head Injury Symptom Checklist (HISC) Citation(5), administered T1–T4. The HISC comprises 21 common posttraumatic complaints, such as headache, dizziness, fatigue, and poor concentration. These complaints are rated on a pre-injury and post-injury level, by subtracting these scores, increase in complaints can be calculated. For the current study, all participants that reported no complaints (i.e. compared to pre-injury) 2 weeks after injury were selected. This no complaints group was divided into two groups: (1) Persistent no complaints (PnC): participants that reported no complaints throughout the follow-up (on all time measurements up to 12 months); (2) SC: participants that started to report complaints during follow-up.
Hospital Anxiety and Depression Scale (HADS) Citation(6) administered T1–T4. The HADS is a commonly applied measure to screen for anxiety and depression after head injury. It measures 2 subscales of 7 questions each, with scores ranging from 0 to 21, with the cut-off for anxiety or depression set on 8 or higher.
Glasgow Outcome Scale Extended (GOS-E) Citation(7) administered T4. The GOS-E was administered as a measure of general functional outcome. The GOS-E defines outcome on an 8-point scale, ranging from dead (1) to complete recovery (8). Scores were dichotomised into incomplete recovery (scores 1–7) and complete recovery (8).
World Health Organization Quality of Life scale abbreviated version (WHOQOL-BREF), administered T4. Quality of life was measured with the Dutch version of the WHOQOL-BREF Citation(8). It contains 26 items, with scores ranging from 1 to 5 each. An overall Quality of Life score is calculated by summing up the first two items (overall quality of life and general health facet). The overall score, ranging from 2 to 10, was used as a general measure of quality of life.
Data were analysed with the Statistical Package for the Social Sciences (SPSS 22.0, IBM SPSS Statistics, SPSS Inc, Chicago, IL). PnC and SC groups were compared using parametric (Student’s t-test) and nonparametric tests (χ2, Mann–Whitney U). To investigate changes in HADS scores over time, a repeated measures ANOVA was performed on raw scores per subscale. Post-hoc mean comparisons were performed using univariate tests under the Bonferroni criterion. Alpha was set at 0.05, two-sided.
Results
A total of 119 patients with mTBI, 10% of the entire population (n = 1151), reported no complaints 2-weeks post-injury (total). Thirty patients remained without complaints over the course of 1 year after injury (PnC), while 40 patients (57%) developed SC over time (M = 2, range 0–10, p < .001 at 3, 6 and 12 months). shows a comparison of the PnC group with the SC group. The groups differed with respect to gender and educational level. Patients in the PnC group were significantly younger in comparison to those in the SC group (46.3 vs. 58.2). They also had a higher educational level than the SC group (5.7 vs. 4.9). No differences were found between groups with regard to gender, psychiatric history and measures of injury severity (GCS, ISS and CT-abnormalities).
Table 1. Patient demographic, clinical and premorbid characteristics.
We lost 49 patients (41%) to follow-up over the year. Patients that dropped out were comparable to patients that filled out all their questionnaires on characteristics as gender and injury severity. However, patients that dropped out were significantly younger than patients that filled out all their questionnaires (39.7 vs. 53.1, p < .001).
Anxiety and depression
Patients in the PnC group had significantly lower HADS-A (p = .004) and HADS-D (p = .002) scores than the SC group (). Post-hoc tests showed significant group differences at every time point. No significant effect was found for time or time × group interaction.
Figure 1. Anxiety and depression scores over time in the PnC and SC groups.
Outcome and quality of life
At 1 year post-injury, 93% (n = 26) of the PnC group showed favourable outcome compared to 68% (n = 25) of the SC group (χ2=6.03, p = .014). Quality of life was also significantly higher in the PnC group compared to the SC group at 1 year post-injury (median: 9 vs. 8; U = 343, p = .006).
Discussion
This is the first study that describes the 10% of patients with mTBI that report zero complaints early after injury, a group that we named the ‘fortunate few’. In current literature, it is generally assumed that these patients will remain without complaints and are therefore not followed-up. However, we observed that there exists considerable heterogeneity within this group, as more than half of these patients develop some complaints at a later stage. These SC were related to higher levels of anxiety and depression, leading to less favourable outcome and a lower quality of life one year after injury. The patients that remained without complaints were younger and had a higher educational level when compared to the group that developed SC.
The far right end of the mTBI spectrum is constituted by the miserable minority, which is a group with persistent complaints and poor outcome Citation(9). This group is extensively studied (Citation10–Citation12); however, little to nothing is known about the other end of the spectrum. This is a remarkable gap in knowledge, considering that it may be just as atypical to report no complaints at all Citation(1). Moreover, the belief that these patients are fully recovered early after injury and will remain complaint free is presumptuous and incorrect. We found that no less than 50% of this group develops complaints at a later stage. Remarkably, this subgroup already showed signs of psychological distress, reflected by higher scores of anxiety and depression, at two weeks post-injury. Although the differences in scores of anxiety and depression between the two groups is clear, it should be noted that even in the group developing SC, scores are well below the cut-off score of eight, which questions the meaning of these scores. We propose that future research should be aimed to identify patients at-risk for developing SC, by incorporating the signs of psychological distress in an early phase after injury.
The finding that the group that remained without complaints was younger than the group that developed SC can be explained by the robust finding that a younger age is associated with good recovery after mTBI Citation(13). The group with SC also had a higher educational level, an effect which has been shown to be of influence on recovery of mTBI in earlier studies. Interestingly, a previous publication of our group has shown that higher education was related to a better outcome in patients <20 and >64 years Citation(14). It might be the case that patients who are educated on a lower level are involved in more physical demanding tasks, which are putting more stress on a person with increasing age. It has also been proposed that higher educated patients may be better able to utilise adaptive coping strategies that prevent the secondary development of complaints (Citation15,Citation16). Finally, regarding the total fortunate few group, none of the patients had a psychiatric history. This in accordance with the literature, which reports psychiatric history to be a common risk factor for developing persisting complaints Citation(9).
A limitation that needs to be addressed is the relatively large group of patients that was lost to follow-up, despite our repeated attempts to obtain these data. Although our dropout rate was comparable to other follow-up studies, we believe that the dropout of younger patients might have biased our results. It could be true that the percentage of patients that continue to have no complaints is larger than reflected by our results. Nevertheless, the fact that already 10% of patients with mTBI have zero complaints in an early phase after injury warrants future research on this remarkable group.
In conclusion, we demonstrated that some of the fortunate few, who seem fully recovered early after injury, may develop SC leading to poorer outcome and lower quality of life. Therefore, the truly fortunate are in even fewer numbers than expected. We plead that more future mTBI research should be focused on early signs of psychological distress. This may be a better criterion to discern patients with optimal and non-optimal recovery than the presence of posttraumatic complaints, which holds important implications for clinical practise.
Declaration of Interest
No conflicts of interest are present.
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References
- Ruff RM, Camenzuli L, Mueller J. Miserable minority: emotional risk factors that influence the outcome of a mild traumatic brain injury. Brain Inj. 1996;10:551–65.
- McMahon P, Hricik A, Yue JK, Puccio AM, Inoue T, Lingsma HF, Beers SR, Gordon WA, Valadka AB, Manley GT, et al. Symptomatology and functional outcome in mild traumatic brain injury: results from the prospective TRACK-TBI study. Journal of Neurotrauma. 2014;31(1):26–33. doi: 10.1089/neu.2013.2984.
- Wäljas M, Iverson GL, Lange RT, Hakulinen U, Dastidar P, Huhtala H, Liimatainen S, Hartikainen K, Öhman J. A prospective biopsychosocial study of the persistent post-concussion symptoms following mild traumatic brain injury. Journal of Neurotrauma. 2015;32(8):534–47.
- King NS. Emotional, neuropsychological, and organic factors: their use in the prediction of persisting postconcussion symptoms after moderate and mild head injuries. J Neurol Neurosurg Psychiatry. 1996;61(1):75–81. doi: 10.1136/jnnp.61.1.75.
- De Koning ME, Gareb B, El Moumni M, Scheenen ME, Van Der Horn HJ, Timmerman ME, Spikman JM. van der Naalt J. Subacute posttraumatic complaints and psychological distress in trauma patients with or without mild traumatic brain injury. Injury. 2016;47(9):20417. doi: 10.1016/j.injury.2016.04.036.
- Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica. 1983;67(6):361–70.
- Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the glasgow outcome scale and the extended glasgow outcome scale: guidelines for their use. Journal of Neurotrauma. 1998;15(8):573–85. doi: 10.1089/neu.1998.15.573.
- De Vries J, Van Heck GL. The world health organization quality of life assessment instrument (WHOQOL-100): validation study with the dutch version. European Journal of Psychological Assessment. 1997;13(3):164–78. doi: 10.1027/1015-5759.13.3.164.
- Ruff RM, Camenzuli L, Mueller J. Miserable minority: emotional risk factors that influence the outcome of a mild traumatic brain injury. Brain Injury. 1996;10(8):551–66. doi: 10.1080/026990596124124.
- Lundin A, De Boussard C, Edman G, Borg J. Symptoms and disability until 3 months after mild TBI. Brain Injury. 2006;20(8):799–806.
- Dischinger PC, Ryb GE, Kufera JA, Auman KM. Early predictors of postconcussive syndrome in a population of trauma patients with mild traumatic brain injury. The Journal of Trauma. 2009;66(2):287–89. doi: 10.1097/TA.0b013e3181961da2.
- Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A. Long-term outcomes after uncomplicated mild traumatic brain injury: a comparison with trauma controls. Journal of Neurotrauma. 2011;28(6):937–46. doi: 10.1089/neu.2010.1516.
- Jacobs B, Beems T, Stulemeijer M, Van Vugt AB, Tm VDV, Gf B, Pe V. Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities. Journal of Neurotrauma. 2010;27(4):655–68. http://online.liebertpub.com/doi/abs/10.1089/neu.2009.1059 doi: 10.1089/neu.2009.1059.
- Van Der Naalt J, Timmerman ME, De Koning ME, Van Der Horn HJ, Scheenen ME, Jacobs B, Hageman G, Yilmaz T, Roks G, Spikman JM. Early predictors of outcome after mild traumatic brain injury (UPFRONT): an observational cohort study. Lancet. Neurol. 2017;16(7):532–40. doi: 10.1016/S1474-4422(17)30117-5.
- Lingsma HF, Yue JK, Maas AIR, Steyerberg EW, Manley GT, Cooper SR, Dams-O’Connor K, Gordon WA, Menon DK, Mukherjee P, et al. Outcome prediction after mild and complicated mild traumatic brain injury: external validation of existing models and identification of new predictors using the TRACK-TBI pilot study. Journal of Neurotrauma. 2015;32(2):83–94.
- Stulemeijer M, Van Der Werf S, Borm GF, Vos PE. Early prediction of favourable recovery 6 months after mild traumatic brain injury. J Neurology Neurosurg Psychiatry. 2008;79(8):936–42. doi: 10.1136/jnnp.2007.131250.