Assessment & Intervention for Mild TBI
Assessment and Intervention for Patients with Mild Traumatic Brain Injury
Chief Investigator: Professor Jennie Ponsford
Associate Investigators: Professor Peter Cameron, Associate Professor Mark
Fitzgerald
Lead Organisation: Monash University
TAC Neurotrauma Funding: $229,955
Project Dates: 1 November 2006 - 28 February 2009
Background:
There is continuing debate as to the most appropriate methods of assessing and
managing patients with mild traumatic brain injury (mTBI). Scores on the Glasgow
Coma Scale (GCS) and duration of post-traumatic amnesia (PTA) are key indicators
of head injury severity. Most recently, the accuracy of screening for PTA in the
emergency department and the validity of using GCS scores has been called into
question.
Aims:
This study aimed to examine the validity and utility of the revised Westmead PTA
scale in identifying presence of post-traumatic amnesia (PTA) and/or cognitive
impairment in patients presenting to the Emergency Department (ED) with mild head
injury (mHI), as compared with trauma patients with no head injury (controls); to
examine the ability of this scale to predict outcome one week and three months postinjury; and to evaluate the impact of receiving an information booklet on symptoms
reported and anxiety and depression three months post-injury.
Method:
One hundred and twenty-three adults presenting with mHI and 100 controls with
minor injuries not involving the head were recruited from the ED of the Alfred
Hospital, assessed and followed up one week and three months later. Screening
measures included the Glasgow Coma Scale (GCS) and revised Westmead PTA
Scale, measures of post-concussive symptoms, cognitive performance, psychiatric
state, quality of life, pain and other life stressors. The mHI participants were
randomised to receive an information booklet describing common mHI symptoms and
suggested coping strategies one week post-injury.
Results:
The initial (at ED) Westmead score was not recorded correctly in many cases. At
baseline the scale differentiated patients with mHI from trauma controls, and was
correlated with GCS. However cognitive performance in the ED was a stronger
predictor of ongoing symptoms one week post-injury than scores on this scale,
estimated PTA duration or GCS. MHI patients reported many more post-concussional
symptoms than controls at one week post-injury, particularly headaches, fatigue,
concentration difficulties and sleeping more and showed visual memory impairment.
Three months post-injury both groups had improved significantly, with no group
differences in post-concussive symptoms, but persisting deficits in visual memory.
Those patients who received the information booklet showed a greater reduction in
symptoms three months post-injury. Both mHI and control groups showed high rates
of return to work (over 95%). The strongest predictors of post-concussive symptoms
at three months in BOTH groups were the presence of PTSD and pain and, for
controls, other life stressors.
Conclusion:
In conclusion, the revised Westmead PTA was not administered sufficiently
frequently or early to draw conclusions as to its predictive value in relation to
outcome. However cognitive performance in the ED did predict outcome. The
generally good outcomes in this cohort of uncomplicated mHI patients, discharged
when judged to have emerged from PTA if PTA was less than 24 hours, supports this
as an appropriate risk reduction strategy. Providing mHI patients with an information
booklet was effective in reducing post-concussive symptoms at three months.
It is recommended that the booklet be given out in the ED to maximise its therapeutic
effect. It appears that post-concussive symptoms are associated with mHI and
cognitive dysfunction at least within the first week after injury. Although some of
these uncomplicated mHI patients continued to experience subtle cognitive
difficulties at three months, psychological factors, including PTSD and pain
predominated in influencing their reporting of symptoms by three months post-injury
and predictors of ongoing problems did not differ from those of a trauma control
group. This suggests the importance of addressing these issues in those with persisting
problems.
Publications:
None
Presentations:
CAMERON, P. Minor Head Injuries - can we identify bad outcomes. Injury; 2007, Auckland, NZ.
PONSFORD J. Factors influencing outcome and return to work following mild traumatic brain injury.
Annual conference of the Australasian Faculty of Rehabilitation Medicine; 2008 May 7-9, Adelaide,
Australia.
PONSFORD J. Vocational re-entry following mild traumatic brain injury. Symposium on Mild
Traumatic Brain Injury, Seventh World Congress on Brain injury; 2008 April 8, Lisbon, Portugal.
GRANT M, PONSFORD J, CAMERON P, FITZGERALD M, MIKOCKA-WALUS A. Use of an
information booklet following mild traumatic brain injury. Trauma Melbourne Conference; 2009
November 20- 21, Melbourne, Australia.
PONSFORD J. Monitoring and prediction of outcome following mild traumatic brain injury. Trauma
Melbourne Conference; 2009 November 20-21, Melbourne, Australia.
CAMERON P. Update in Head Injury Management. Central European Emergency Medicine 2009, 3rd
International Congress of Polish Society for Emergency Medicine; 2009 June 17-20, Wroclaw, Poland.