A prospective investigation of postconcussional symptoms after mild traumatic brain injury

Abstract

Objective: Traumatic brain injury (TBI) is the leading cause of disability under the age of 45. However, the majority of cases 85% are actually mild. Because of the delay in seeking medical attention and difficulty in detecting early invisible symptoms, mild traumatic brain injury (MTBI) remains a major, unrecognized public health issue and has been called a “silent epidemic”. A significant proportion (15-30%) of MTBI patients are at risk of developing Post Concussional Syndrome (PCS). Based on the model we developed for PCS, the aim of this study was to investigate the contributions of cognitive, emotional and behavioural factors to the development of PCS after MTBI, particularly the role of attentional bias (AB).

Methods: A prospective cohort design was employed. Patients meeting diagnostic criteria for MTBI were recruited from the A&E department. Data were collected at admission, 1-2 weeks (baseline), and 3 months after injury. 80 patients completed all the baseline questionnaire assessments and 39 completed computer tasks. 42 patients completed the follow-up assessments. A series of self-report measures including the Brief Illness Perceptions Questionnaire, the Impact of Events Scale, the Anxiety Sensitivity Index, the Behavioural Responses to Illness Questionnaire, and the Hospital Anxiety and Depression Score questionnaire were used to assess cognitive, behavioural and emotional responses, and the visual probe task was adopt to measure reaction time (RT) and assess attentional bias (AB) for health-threat information. We measured RT to both word and picture stimuli presented for 500ms and 1250ms. The main outcomes were measured by the Rivermead Postconcussion Symptoms Questionnaire (RPQ) to assess the severity of PCS, and the Diagnosis of PCS was based on the ICD-10 Code F07.2. Results: A number of PCS symptoms were evident at baseline and 3 months after injury: headache, fatigue and sleep disturbance were the most commonly reported symptoms at baseline whereas fatigue, forgetfulness and poor concentration were most commonly reported at 3 months. 9 out of 42 (21.43%) MTBI patients developed PCS at 3 months. PCS symptoms at 3 months were positively correlated with measures of stress response (r=0.397, p=0.011), particularly stress AVOIDANCE (r=0.497, p=0.001), anxiety (r=0.33, p=0.035), illness perception (r=0.528, p=0.000), and all or nothing behaviour (r=0.422, p=0.006). There were also significant correlations between PCS symptoms and Mean RT (r=0.507, p=0.012) and total AB (r=-0.425, p=0.039). The positive correlations between PCS and RT symptoms indicates that PCS symptoms may be associated with slow information processing, whereas the negative correlation between AB and PCS symptoms may reflect that PCS symptoms are associated with threat avoidance.

Conclusions: There were significant correlations between PCS symptoms and a number of cognitive, emotional and behavioral factors as we expected, which is consistent with the proposed cognitive behavioral model. The significant correlations between PCS symptoms and RT and AB reflect that PCS symptoms may be associated with slow information processing and trauma-related threat avoidance. This study provide a cognitive behavioural approach to a better understanding of the development of PCS.

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Identifiers

ORCID for Ruihua Hou: orcid.org/0000-0001-6127-1478

ORCID for Robert Peveler: orcid.org/0000-0001-5596-9394

ORCID for Brendan P. Bradley: orcid.org/0000-0003-2801-4271

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