Assessment and management of patients at risk for persisting disability after mild traumatic brain injury

Abstract: There is a lack of evidence-based interventions for patients with persisting problems after mild traumatic brain injury (mTBI). The interventions needed should focus on patients at particular risk for persisting disability after mTBI and target modifiable factors. After initial studies of an early educational intervention unexpectedly gave negative results (studies I, II), a renewed focus on possible targets for interventions was needed: studies III, IV explored associations with self-reported and objectively measured visual disturbances, self-rated and objectively measured fatigue, and correlations between fatigue, visual functions and attention. Study design and participants: Randomized controlled intervention study (studies I, II), and exploratory prospective observational study (studies III, IV). In studies I, II, patients with an estimated high risk for persisting disability were randomized to an early interventional visit (EIV) to physician or to Treatment as usual (TAU). All 173 patients, including the non-randomized group were followed up at 3 months after the injury. Studies III, IV, compared patients with mTBI to patients with minor orthopedic trauma and non-injured controls, with 15 in each group. Participants were assessed sub-acutely and after approximately 3 months. Outcome measures: Multimodal outcome measures related to the ICF-framework incorporating: 1.Self-reported data on symptoms (Rivermead Post Concussion Symptoms Questionnaire (RPQ)), activity and participation (Occupational Gap Questionnaire, Rivermead Head Injury Follow-up Questionnaire), and quality of life (SF-36) (studies I, II). 2. Findings from visual examination (accommodation, convergence, visual acuity, saccades), and visual symptoms (Convergence Insufficiency Symptoms Survey (CISS) and RPQ (study III). 3. Self- reported data on fatigue: acquired fatigue, (RPQ-f), and trait fatigue (Fatigue Severity Scale) and objectively measured cognitive fatigability (DSST-f) and saccades (study IV). Results: The intervention was not found to have an effect on symptoms, activity, participation or quality of life (studies I, II). Patients with few symptoms early after the mTBI continued to report few problems at follow-up. Visual findings showed that accommodative amplitude was lower in the mTBI group compared to non-injured controls at sub-acute stage; near point of convergence in the mTBI group was receded at sub-acute stage, but improved at follow-up; patients with mTBI reported a higher CISS score than persons in the control groups (study III). Acquired fatigue was present more often after mTBI and correlated to cognitive fatigability. Associations were found between acquired fatigue and some saccade measures, but not with other visual measures. Conclusions: An early intervention to patients at risk for persisting disability had no effect on symptoms, activity, participation or quality of life. Patients with few symptoms early after mTBI are likely to have a good outcome. Some transient measurable visual changes regarding convergence were found in patients with mTBI during the sub-acute period after the injury. Some support for the suggested value of assessing different aspects of fatigue have been found.