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Follow-up care for mild brain injury lacking, study shows
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Patients with mild traumatic brain injury may not receive adequate follow up-care in spite of experiencing debilitating postconcussive symptoms, according to a study.
The TRACK-TBI study surveyed patients with mild traumatic brain injury (mTBI), Glasgow Coma Scale Score (GCS) of 13 to 15 and diagnosed by head computed tomography at one of 11 level I U.S. trauma centers. A total of 1,316 patients were evaluated, and 831 completed the 2-week and 3-month follow-up, which included questions on the care received after discharge. They also completed questionnaires on physical and psychological symptoms associated with postconcussion syndrome (PCS).
Less than half of the patients reported seeing a medical practitioner at 2 weeks and 3 months or receiving TBI educational material at discharge. There was a wide site-specific variation, with better rates in sites with specialty TBI clinics. Of the 273 patients who saw a physician at 3 months, 218 saw a general practitioner, and 38% saw a neurologist. Only 15% reported visiting specialized TBI clinics.
More frequent follow-up care was associated with injury severity and with some demographic characteristics, such as female gender and non-Hispanic white ethnicity, while no association was found with age, income and insurance status.
The authors expressed concern about the low rates and inconsistency of follow-up care provided to these patients. Many patients reported persistent PCS symptoms, such as headache, dizziness, nausea and sleep disturbances, as well as symptoms of psychological distress such as depression and anxiety.
“Despite the classification of mild, mTBI can lead to persistent physical, neuropsychiatric and cognitive symptoms that have a major impact on function and quality of life of the injured patient,” the authors noted. “The finding that 48% of patients with significant postconcussive symptoms (134 of 279) were not seen by a medical practitioner by 3 months underscores the need to improve the system of care for mTBI and concussion,” they wrote. – by Michela Cimberle
Disclosure: Seabury reported grants from the National Institute of Neurological Disorders and Stroke and grants from Research to Prevent Blindness during the conduct of the study and personal fees from Precision Health Economics outside the submitted work. Please see the study for the other authors’ financial disclosures.
Perspective
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Shirley Ha, HBSc, OD, FCOVD, LBM
CT scans are tools used for differential diagnosis and may help rule out structural problems. However, as this study clearly highlights, even if the results are negative, patients should be followed up on the functional deficits that are often invisible on imaging because symptomology-wise, they are detrimental to the patients.
Vision may also be involved. In this study specifically, patients were assessed with the Rivermead Post Concussion Questionnaire (RPQ) and the Brief Symptom Inventory-18 at 3 months. These tools measure severity of several physical symptoms associated with post-concussion syndrome but do not include queries about the visual system.
Previous studies showed that 90% of TBI patients suffer from visual dysfunctions, such as, but not limited to, blurred vision, sensitivity to light, reading difficulty, headaches with visual tasks, reduction or loss of visual field, and difficulties with eye movements. As optometrists, we are well aware that, left untreated, visual system disorders can have serious consequences, such as the ability to organize and make sense of visual information, poor depth perception, and difficulties concerning balance and posture.
This study also found that that less than half of patients with mTBI self-reported receiving TBI educational material at discharge or seeing a medical practitioner within 3 months of the injury. Patients with persistent symptoms often are not aware of what to expect in their road to recovery and assume their symptoms will pass over time.
Members of the Neuro-Optometric Rehabilitation Association (NORA) provide patients with brain injury-related disabilities with a complete ocular health evaluation and visual rehabilitation program. We are a group of professionals with specific training and clinical experience in this area. Because no brain injury is like the other, we use an interdisciplinary, integrated team approach to tailor our rehabilitation programs to the patient’s individual needs.
NORA is also in the process of updating its website and working on the development of educational resources to help patients, caregivers and health care professionals. We welcome the opportunity to partner with other professional organizations within and outside of eye care who play a vital role in the rehabilitation of patients with concussions, stroke or other neurological deficits.
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