Early prediction of persisting post-concussion symptoms following mild and moderate head injuries.

OBJECTIVES: King (1996) reported that a combination of emotional, organic and neuropsychological measures taken at 7-10 days following mild and moderate head injury may significantly help predict patients most likely to suffer persisting post-concussion symptoms (PCS) at three months post-injury. This study investigated a cross-validation sample (N = 57) to determine whether the results would be replicated for the early prediction of longer-term sufferers (i.e. those with persisting symptoms at 6 months post-injury). DESIGN: Multiple regression analyses were used in which scores on the Hospital Anxiety and Depression Scale, Impact of Event Scale, Short Orientation Memory and Concentration Test, Rivermead Post-Concussion Symptoms Questionnaire and Post-Traumatic Amnesia taken at 7-10 days post-injury were the independent measures. Scoring on the Rivermead Post-Concussion Symptoms Questionnaire taken at 6 months post-injury was the dependent measure. METHODS: Sixty-six consecutive patients admitted to any trauma ward in Oxfordshire with a mild or moderate head injury were recruited from a largescale randomized controlled sample. The assessment measures were administered at 7-10 days post-injury and the Rivermead Post-Concussion Symptoms Questionnaire at 6 months post-injury. Nine patients were unable to be followed up, leaving an active sample of 57. RESULTS: The cross-validation data confirmed that a similar combination of measures to that found in the original study best predicted persisting PCS but that the strength of prediction diminished for the longer term prediction (i.e. 6 months post-injury). CONCLUSIONS: The Hospital Anxiety and Depression Scale, Impact of Even Scale and Post-Traumatic Amnesia in combination are recommended as useful prognostic screening instruments for predicting persisting PCS, but great caution is required if they are used to aid predictions beyond 3 months post-injury.

Routine follow up after head injury: a second randomised controlled trial.

OBJECTIVE: To confirm that patients admitted to hospital with a head injury benefit from a routinely offered early intervention service. PATIENTS AND METHODS: A mixed rural and urban Health District of 560000 people with two accident and emergency departments provided the setting. Existing routine services for most patients with head injury are minimal. All patients aged 16-65 years admitted to hospital after a head injury of any severity, with or without other injuries entered the trial. Prospective randomisation, with a block randomisation procedure was used to allocate all eligible patients to either: a group offered an additional service by a specialist team; or a group receiving existing standard services. Patients were assessed at follow up six months after injury. The primary outcome measure was the Rivermead head injury follow up questionnaire, a validated and reliable measure of social disability. The Rivermead post-concussion symptoms questionnaire was used to estimate severity of post-concussion symptoms. Each patient in the trial group was contacted 7-10 days after injury, and offered assessment and interventions as needed. These initially focused on the provision of information, support, and advice. Forty six per cent of patients in the trial group also received further outpatient intervention or additional support by telephone. RESULTS: 314 patients were registered: 184 were randomised into the trial group, 130 into the control group. For prognostic data, the groups were comparable at randomisation, and remained comparable when assessed at six months. 132 trial and 86 control patients were followed up at six months after injury. Patients' posttraumatic amnesia ranged from mild (n=79, 40%), and moderate (n=62, 32%), to severe (n=38, 19%) and very severe (n=17, 9%). The trial group patients had significantly less social disability (p=0.01) and significantly less severe post-concussion symptoms (p=0.02) at follow up at six months after injury than the control group patients. CONCLUSIONS: The early interventions offered by a specialist service significantly reduced social morbidity and severity of post-concussion symptoms in trial group patients at six months after head injury. Recommendations about how specialist services should be targeted are made both in the light of these results and those from a previous randomised controlled trial.

Measurement of post-traumatic amnesia: how reliable is it?

OBJECTIVE: To develop and test a clinical protocol for determining post-traumatic amnesia by retrospective questioning. To establish its limits and factors which influence reliability. DESIGN: Two independent assessments using the Rivermead post-traumatic amnesia protocol were undertaken by separate observers on various groups of patients at various time intervals. Analysis investigated the correlations between assessments, the percentage difference between assessments, the number of patients changing category, and the differences between these analyses in the different patient subgroups. Assessments were undertaken both in hospital and in the patients' homes. Four different patient groups were studied. These were group A: 12 inpatients with very severe head injury late after injury; Group B: 40 patients interviewed at home six months after injury; group C: 22 patients interviewed within a few weeks of injury at home; group D: 116 patients interviewed initially within a few weeks and then at six months, on both occasions at home. The Rivermead post-traumatic amnesia protocol involved clinical questioning of the patient to establish how long after injury (in hours/days/weeks) the patient regained continuous day to day memory. All periods of coma were included. Severity was categorised with standard criteria. RESULTS: Overall correlation was good (Spearman's r 0.79), but the correlation was lower for patients with post-traumatic amnesia < 24 hours and when there was a long delay between assessments. In all groups 19%-25% of patients changed categories between assessments, but only 2% changed by two categories. CONCLUSIONS: The assessment of post-traumatic amnesia with the Rivermead post-traumatic amnesia protocol is reasonably reliable. The misclassification rate however, is significant enough that some caution should be taken in individual cases. Other evidence does show post-traumatic amnesia to be valid, and it probably remains the best simple prognostic item available. In clinical practice one should avoid placing too much weight on post-traumatic amnesia alone.