TREATMENT
OF MINOR HEAD INJURIES
J. M. Minderhoud*,
M. E. M. BoelenP, J. Huizenga* and R. J. Saan*
SUMMARY The results of various forms of treatment of patients with minor head injuries have been examined. The number and frequency of post-concussional sequelae was markedly reduced by treatment which included information, explanation and encouragement. Dizziness, loss of hearing and loss of balance were related to external lesions to the vestibular system caused by injuries to the parieto-temporal region of the skull. PTA proved to be a reliable indicator of the severity of cerebral concussion and correlated with post-concussional sequelae and periods of disability. Other factors which increased the number and frequency of post-traumatic sequelae. especially those related to stress before the accident, could be counteracted by better treatment of the patient. The results bear out the hypothesis that post-concussional sequelae start off on an organic basis (PTA) and that persistent sequelae after minor head injuries are also caused by psychogenic, and especially by iatrogenic factors.
In contrast to the statement of Miller (1961 and 1966) that long lasting sequelae of minor head injuries (the post-concussional syndrome) result from the need of financial compensation, it is now more generally held that the aetiology of these sequelae is multifactorial (LIDVALL et al., 1974). For some reason Miller’s statement has been used with respect to all kinds of patients who continue to have complaints after minor head injuries for a period of time longer than was expected, and ‘it has been quoted by doctors as an excuse for inactivity and by lawyers in the courts as though it is the gospel according to Saint Henry’ (KELLY, 1972). Miller examined selected patients who were referred to him by insurance companies after an average period of fourteen months between the accident and the referral, his statement applied to a different group of patients as those presented by others. Even before 1961 the observation was made that individuals displaying neurotic symptoms before the accident were over-represented among cases developing post-concussional symptoms (ADLER, 1945; KOZOL, 1945; DENCKER, 1958; GRWSTAD et al., 1958). Also fears and panics related to the accident as such, as described by ADLER (1945) may contribute to the appearance of post-concussional symptoms. KAY et al. (197 1) and also LIDVALL et al. (1974) made clear that complaints caused by external lesions to cranial nerves, especially those related to the vestibular system, increased the possibility of long lasting sequelae of all kinds. CARTLIDGE (1978), however, found that the majority of patients who still had a positional nystagmus on * Department Clin. Neural.
of Neurology, Neurosurg.,
University 1980, Vol. 82-2
Hospital,
Groningen,
The Netherlands
128 discharge showed progressive improvement later. On the other hand the observation by OPPENHEIMER (1968) that even in minor head injuries microscopical lesions of the brain can be found, as well as the results of the studies of UNTERHARNSCHEIDT (1975) on boxers, would seem to support the theory that the postconcussional symptoms start off from an organic basis, Transformation into long lasting complaints would appear to be caused by psychogenic factors and iatrogenic influences (SLATER and ROTH, 1969: KELLY, 1975). This hypothesis was supported by RUTHERFORD ef al.(1978). As regards iatrogenic factors KELLY (1975) reported that symptom rates were much higher when patients were given no explanation of their symptoms, no encouragement and no treatment. In this study the results of two kinds of treatment will be examined: one of a group of patients who received the head injury in 1974-1975 and whose treatment was not well programmed, and of a second group of patients who received the head injury in 1977. The second group was treated with strict instructions regarding the period they should remain in bed and was given as much information and encouragement as was possible in the given circumstances.
MATERIALANDMETHODS
This study deals with all patients with minor head injuries referred to the University Hospital in Groningen between July 1974 and July 1975 and in the second half of 1977. It includes patients with or without a cerebral concussion. A cerebral concussion was diagnosed if the patient had been unconscious for less than half an hour and evinced a post-traumatic amnesia (PTA). Not included in the study were patients with more severe head injuries, that is to say patients with clinical signs of local or diffuse contusion, skull fractures, penetrating brain lesions, CSF leakages etc., as well as patients with major lesions in other parts of the body, with lesions of the cranial nerves, and patients suffering from severe alcohol-intoxication. Patients, included in this study, with or without a cerebral concussion. were not hospitalised but referred to their genera1 practioner. Those with a cerebral concussion, according to the criteria described above, were advised to remain in bed for some period and received an appointment for the out-patients department a week after completion of the period of rest, for a check-up and if necessary, further treatment. Patients in whom no cerebral concussion was diagnosed were not advised to remain in bed and were in general not required to come to the out-patients department for a check-up. Until the second half of 1976 advice to remain in bed was given rather haphazardly and varied from ‘as long as necessary’ to three weeks, depending on how serious the injury was judged to be on first examination shortly after the accident (the majority of patients were seen within one hour after the accident). No special measures were taken to inform the patient as to the nature of the diagnosis. At the end of 1976 the programme was changed. An attempt was then made to inform the patient clearly as to the diagnosis, the reasons why rest in bed was advocated and the cause of possible complaints. This information was given verbally at the end of the first examination in the first-aid department, but also in
129 writing. Patients with a cerebral concussion, according to the above mentioned criteria, were advised to observe a week of rest in bed followed by a week of gradually increased mobility. Three weeks after the accident the patients were seen at the neurological out-patient department. A second examination was performed, focused on the post-traumatic complaints, and if no abnormalities were found, the patient was advised not to worry about these complaints as it might be expected that they would soon decrease and disappear. The patients were encouraged to resume work, school etc. PTA was established during the check-up-visit (three weeks after the accident) from patients memory of what had happened after the accident. Data on all patients regarding the accident, their complaints and the results of the neurological examinations were registered carefully in both study periods. At about 6 months after the accident a questionnaire was sent to all patients with minor head injuries. The same questionnaire was used for all patients in both study periods. Questions were asked regarding length of time spent in bed, length of time before work could be resumed, post traumatic sequelae, PTA etc. In both groups over 70% of the patients provided sufficient information to be used in this study. In this study data will thus be used which were obtained shortly after the accident, as to type of accident, external lesions, patient’s occupation etc., as well as data obtained from the questionnaire about 6 months post-trauma. All data were scored according to occurrence or non occurence or according to duration of occurrence (PTA etc.). In the second part of the study, in which the relationship between individual data, periods of confinement to bed or disability and sequelae were examined, a different score was employed. Data on three groups of patients with minor head injuries will be examined: Group 0: Patients without a cerebral concussion in both periods (1974-1975 and 1977); n = 193. Group 1: Patients with a cerebral concussion in 1974-1975 who were treated rather without a strict program; n = 352. Group 2: Patients with a cerebral concussion in 1977 who were treated according to a strict program: n = 180.
RESULTS
Since no clear differences were found between patients without a cerebral concussion in 1974-1975 and in 1977 these groups were taken together as a controlgroup to examine the influence of concussion per se on posttraumatic sequelae. Some data on the groups of patients are presented in Table 1. Differences between group 1 and 2 regarding the percentage of injuries occurring under the influence of alcohol seem to be caused by changes of life-style, resulting in an increased use of alcohol in social life as well as in traffic. Taken from the moment of accident until1 the moment continuous memory was regained, the periods of PTA in group 2 are in general longer than in group 1. This difference was evidently not caused by the influence of alcohol since severely intoxicated patients had been hospitalised and
130 TABLE 1. Some data about the groups
Age groups:
Accident:
< 2oy 20 - 60v > 60; traffic work at home elsewhere
Alcoholintoxication 0 < 5 min. 6- 30min. 31 - 120 min. > 120min.
P.T.A.:
Other
minor lesions
n
of patients.
I
0 no concussion 1914/ 1975 1977
concussion 1974-1975
2 concussion 1977
42.2% 41.6% 16.2%
32.0% 55.2% 12.8%
32.1% 54.0% 13.9%
61.8% 6.5% 14.6% 17.1%
80.4% 5.0% 6.4% 8.2%
73.3% 5.9% 5.2% 15.6% 32.3%
8.8%
18.0%
100% _ -
35.6% 30.3% 18.9% 15.2%
37.6%
35.6%
65.7%
193
352
180
_ (36.0%) (28.7%) (16.1%) (19.2%)
24.6% (28.0%) 20.3% (19.88) 27.1 %a (20.9%) 28.0% (30.5%)
I ( )
Percentages
in patients
where alcohol
did not play a role.
Fig. 1. Cumulative frequencies of periods of stay in bed in the age-groups cerebral concussion: group I: patients with cerebral concussion cerebral concussion in 1977).
of patients (group 0: patients with no in 1974-1975: group 2: patients with
0
Owk
q
lor2wk
q
3or4wk >4wk
< 20
20-60
0
>bO
< 20
20-M)
1
>60
< 20
20-M)
2
>bO
131
had thus been excluded from this study. Moreover a similar difference was found in groups of patients who where not under influence of alcohol at the time of injury (Table 1).
PERIODS
OF CONFINEMENT
TO BED AND
DISABILITY
In Fig. 1 the cumulative frequencies of the periods of confinement to bed are presented. The time spent in bed was found to be related to age, even when no concussion was present (group 0). The median of the periods of confinement to bed among patients with a cerebral concussion in groups 1 and 2 did not differ significantly. In group 1 in 1974-1975 only small differences were encountered between patients with a cerebral concussion in different age-groups. In group 2, in 1977 a different pattern was found among patients with cerebral concussion. Very few patients did not remain in bed at all and among patients under 60 years of age only a few had remained in bed for more than 4 weeks. This would appear to have been a consequence of instructions received. In group 2 however, among older patients the period spent in bed had increased by comparison with group 1. It might be supposed that the clear information regarding the cerebral concussion had exerted more influence on these patients than in younger ones while they had less belief in the benefits of a short period of confinement to bed. Similar results were obtained with respect to the length of time before work or school was resumed. (Fig. 2.). Again the median of the periods of disability in the two groups with a cerebral concussion did not differ. In 1977 (group 2) only a small percentage of patients had Fig. 2. Cumulative
frequencies
of periods
of disability
in the groups of patients.
% 100
III q q
90 80 70
d 2 wk 3or4wk 5-12wk >12wk
60 50 40 30 20 10 0 <20
20-60
0
>60
<
20
20-60
1
>60
<20
20-60
2
>60
132 resumed
pre-traumatic
than in group older
patients,
activities
within
1, at least as regards treatment
given
two weeks, but after this, results were better
patients
under
in 1977 would
60 years of age. In the group
appear
to have exerted
influence. In both groups of patients a small percentage pre-traumatic activities after three months.
POST-TRAUMATIC
of
a negative
had still not yet resumed
SEQUELAE
The questionnaire sent to all patients about 6 months after trauma also contained questions as to sequelae. Sequelae were classified into two groups: of short duration, namely lasting for more than four weeks but less than six months; or more lasting sequelae, namely those persisting more than six months after trauma. In Table 2a the frequencies of these sequelae in the three groups of patients are given. In both groups of patients with a cerebral concussion (1 and 2) the frequencies at 4 weeks after trauma are markedly higher than in the control group of patients with no cerebral concussion (group 0). In general frequencies in group 2 are lower than in group 1. Six month after trauma similar differences between group 1 and the control group are present, but in group 2 none of the frequencies of sequelae differed
TABLE 2a. Frequencies of sequelae 4 weeks or 6 months after trauma. The levels of difference between the control group (0) and the concussion groups (I and 2) are given (Chi-square test; O: (Y< 0.05; 0: a < 0.005); as well as the levels of difference over the whole post-trauma period between group 1 and 2. 4 weeks after trauma
6 months
difference between I-2
after trauma
0
1
2
0
I
2
Headache Dizziness Neck pains Hearing defect Visual defect Loss of balance Anosmia
17.6% 12.4% 13.0% 5.2% 5.7% 6.7%
31.3%” 21.9%’ 21.0% 6.3% 13.9%” 9.7% 4.0%
29.4%’ 21.7%’ 18.9% 7.2% 13.9%” 8.3% 5.6%
9.8% 8.3% 7.8% 3.1% 4.7% 4.7%
21.6%’ 13.1% 15.9%” 5.4% 10.2% 6.0% 3.7%
16.1% 13.3% 12.2% 5.6% 7.8% 6.1%’ 3.9%
Irritability Loss of memory Fatigue Apathy Loss of concentration
12.4% 5.7% 14.5% 7.3% 8.8%
24.7%” 18.8%* 29.3%” 19.O%O 20.7%”
19.4% 13.9%” 26.7%” 15.0%” 16.7%
8.8% 4.1% 10.9% 6.2% 7.3%
19.6%” 15.3%” 22.7%” 15.6%” 17.6%”
13.9% 10.0% 18.9% 11.1% 11.7%
15.9%
20.0%
7.8%
13.9%
17.8%
Other sequelae
I .O%
8.8%
I .O%
2b. The average number of sequelae per patient. The levels of difference between (0) and group 1 or 2 are given (Student’s_t-test; two-sided; ’ : p < 0.05; : p < 0.005).
TABLE
l
at 4 weeks after trauma 0 I Neurophysicai sequelae Mental sequelae
0.62 0.49
1.08. 1.13.
2 I.050 0.92.
at 6 months 0 0.30 0.37
after trauma 2 1 0.760 0.91.
0.65’ 0.66
< 0.1 < 0.05
< 0.05
the controlgroup
133 significantly from those of the control group. In some instances the frequencies in group 2 differed significantly from those in group 1. In Table 2b the average number (per patient) of physical sequelae (headache, dizziness, neckpain, hearing defects, visual defects, loss of balance and anosmia) and mental sequelae (irritability, loss of memory, fatigue, apthy, loss of concentration) is given. The number of physical as well as the number of mental sequelae at four weeks after trauma was found to be markedly higher in patients with a cerebral concussion than in the control group of patients with no cerebral concussion. Six months after trauma the average number of physical as well as mental sequelae had decreased, especially in group 2, in which the number of mental sequelae did not differ significantly from the control group. Thus one may conclude that especially with respect to mental sequelae caused by a cerebral concussion, the prognosis was better if treatment was according to the strict regimen of 1977. Since differences with respect to duration of confinement to bed and disabilities were found to exist between different age groups it seemed worthwhile also to compare the number of sequelae present in these age-groups. In Table 3a the average number (per patient) of the combined physical sequelae and mental sequelae are compared according to age group. There is again a marked difference between groups 0 and 1 with respect to results in patients under 60 years of age, while in many instances the differences between the control group and group 2 are small and not significant. In older patients however the mean number of sequelae are much higher in group 2 than in group 0 or group 1, the difference being in many comparisons statistically significant (Student’s_t-test; two-sided: p < 0.05). To determine whether results were influenced by other minor lesions of the body or limbs or slight alcohol-intoxication at the moment of the accident, the mean number of sequelae in groups of patients ofworking age in whom these factors did not play a role were compared. The influence of slight alcohol-intoxication could erroneously have placed patients in the cerebral-concussion group because of amnesia caused by alcohol rather than by the presence of cerebral concussion. The number of patients over 60 years of age was too small to make a similar comparison
TABLE 3a. Comparison of the average numberofsequelae in groups ofpatients and with a cerebral concussion (Student’s_t-test: two-sided; * : p < 0.05 :
l
Number
of sequelae
per person
4 weeks after trauma 0 1 2
Age 0.19y
Neurophysical sequelae Mental sequelae Total
0.23 0.25 0.53
0.56* 0.62* 1.28=
0.60* 0.45 1.12
*Se 20-60 y
Neurophysical sequelae Mental sequelae Total
0.94 0.73 1.79
1.44* 1.48. 3.12.
1.13 1.10 2.47
*Se >6Oy
Neurophysical sequelae Mental sequelae Total
0.83 0.53 1.47
0.96 0.98 2.08
1.95* l.38* 3.71*
1-2
with no cerebral
concussion
: p < 0.005). 6 months 0
after trauma 2
I
l-2
0.16 0.22 0.43
0.35* 0.50* 0.91*
0.25 0.17 0.48
to. I
0.54 0.53 I.17
1.02* 1.18. 2.38.
0.73 0.86 1.79
to.
to.05
0.67 0.40 1.17
0.76 0.88 1.78
1.43* 1.10* 2.90*
to.05
co.05
to.05 I
134 VIABLE 3b. Comparison which the patient Table 3a). Number
of the average number of all sequelae in patients between 20 and 60 years of age in had not been under influence of alcohol or did not suffer other lesions (statistics see
of sequelae Accidents alcohol Accidents lesions
Age 20-60 y
TABLE 3c. Percentages
Number
of sequelae
Age 20-60 y
per person not influenced without
by
other
of patients
4 weeks after trauma 1 1-2 2
0
1.72
3.439
2.38
2.00
3.06*
1.96
in the three groups
per person
Percentages of patients with no sequelae Neurophysical Mental
to.05
6 months after trauma 1-2 0 I 2 1.10
2.65*
1.70
1.27 2.40*
1.46
<0.05
aged 20-60 years with no sequelae.
4 weeks after trauma I 0 2
6 months 0
62.5% 73.6%
75.0% 83.3%
38.7% 49.7%
50.0% 63.5%
after trauma 2
1
58.7% 62.6%
71.6% 71.6%
reliable. The comparison of the groups of patients aged 20-60 years who were not under the influence of alcohol at the time of injury or of those without other lesions gave similar results as the whole group of the same ages (Table 3b). In Table 3c the percentages of patients with no physical or mental sequelae in the three groups are presented. Differences between the groups are also shown. The relation between age and the average number of sequelae in patients between 20 and 60 years of age is also presented in Fig. 3. No clear explanation can be given for the reverse pattern in patients older than 60 years of age, except for the influence of treatment given to these patients in 1977. The better results obtained in 1977 (group 2) in patients under 60 years of age and especially in patients of working age could also be illustrated by the anwers given to the query in the questionnaire as to whether after work had been resumed, further
absenteism
had been necessitated
by post-traumatic
sequelae
(Table 4). The
Fig. 3. Average number of sequelae in different age-groups at four weeks (left) and six months (right) after trauma 0. I and 2: the groups of patients without or with a cerebral concussion; ordinate: average number of sequelae 40
4.0
3.0
3.0
2.0
2.0
1.0
1.0
O-20
21-40
41-60
>60
yr
O-20
21-40
AI-60
>60
yr
TABLE
4. Absentensm after resuming work etc. because of post-traumatic sequelae.
all patients patients without other lesions idem and between 20 - 60 years
0
1
2
4.1% 3.4% 5.4%
11.8% 11.7% 14.3%
6.2% 3.7% 0%
percentages of affirmative answers in group 2 are markedly lower than in group 1 and are similar to percentages of group 0 or even lower. Summarising the results obtained: It was found that the treatment given in 1977 did not alter the average periods of confinement to bed or disability, though differences were found in the number of patients who did not remain in bed at all and those who remained in bed for longer periods and suffered from disabilities. The number of sequelae present in groups of patients with a cerebral concussion, as compared with the control group indicate that the majority of these sequelae were caused by the cerebral concussion. A clear reduction in sequelae was obtained by the strict regimen employed in 1977, especially as far as mental sequelae in patients under 60 years of age are concerned. Poor results were obtained in older patients.
RELATIONSHIP BETWEEN INDIVIDUAL DATA, PERIODS OF REST IN BED, DISABILITY AND SEQUELAE 1. Periods of resl in bed, disability and number of sequelae versus individual data (Tuble 5). The periods of rest in bed were categorised into a period of four weeks or iess, and a period of over four weeks; the periods of disability were divided into disabilities of two months duration or less and disabilities lasting more than two months, while the number of sequelae were classified as being less than a quarter of the maximum or greater in number (sequelae present for 4 weeks were scored I and those still present after 6 months were scored 2; so the total score of sequelae ranged from 0 to 24, divided into 0 - 5 and 6 - 24. The item ‘other sequelae’ was excluded). Since a number of individual data regarded situations at work, these comparisons were confined to patients between 20 and 60 years, The results are presented in Table 5 as far as significant relations were found. It was found that periods of rest in TABLE 5. Relationship between periods spent in bed. disabilities and the number of sequelae and other data in patients aged 20-60 years ~Student’s-t-test; two-sided; NS: p > 0.05).
older ages physically heavy job pre-traumatic diseases pre-traumatic stress PTA other minor lesions long period of rest in bed long period of disability
long period of rest in bed 197411975 1977
long period of disability 1974/1975
1977
1974f 1975
1977
NS CO.02 NS NS NS CO.005
<0.005 NS NS NS NS
to.05 NS <0.0005 NS < 0.0005 < 0.05 ‘Co.0005 < 0.0005
to.02 to.02 NS NS to.05 CO.005
many sequeiae
136 bed, periods
of disability
both study periods. in this limited as regards
PTA was related
of sequelae
are significantly
to these data especially
related
of confinement
diseases
to bed, disabilities
and stress exerted
an influence
in
in the 1977 group. Even
age group (20-60 years) age was again found to be an important
duration
Pre-traumatic only.
and the number
factor
and the number
of sequelae.
on the number
of sequelae
2. Relationship of PTA to periods of disability and number of sequelae. The relationship between PTA and the number of sequelae, the percentage of patients who suffered from these sequelae and the period of disability were examined in patients who had had the accident in 1977, and in whom PTA had been established three weeks after the accident during their check-up visit in the outpatients department. As shown in Table 6, high correlations were found, so that PTA would appear to be a good indicant of the severity of these minor head injuries. 3. Mutual relationship of sequelae and comparision with other data. In order to examine the background of sequelae, their pattern of correlation was analysed. It was found that in nearly each group of patients three syndromes of sequelae which correlated with each other (r > 0.50) were to be found. These syndromes are presented in Table 7. All so-called mental sequelae are present in syndrome A. These sequelae correlated in all groups of patients between 20 and 60 years of age (group 0, 1 and 2) four weeks after trauma as well as at six months after trauma. The second syndrome (B) including dizziness, loss of hearing and loss of balance was present in some groups four weeks after trauma and in all groups six months after trauma. The third syndrome (C) including headache, neckpains and fatigue was present in group 0 four weeks after trauma and in groups 1 and 2 six months after trauma. The frequencies in which the syndromes were slightly or clearly present (number of sequelae more than half of the maximum) and the mean number of sequelae of a syndrome present in each group of patients four weeks or six months
after trauma
IABLE6. Relationship sequelae
or the periods
are also presented
in Table
7. It was found
between PTA and the average number of sequelae, the frequency spent in bed and disabilities (r: correlation-coefficient).
24% 40% 46% 42% 48% 50% 56% 60%
5.04 w 5.14w 6.68 w 6.60 w 6.05 w 7.38 w 7.78 w 9.67 w
l.l9w 1.84 w 2.47 w 2.13 w I .63 w 2.00 w 3.00 w 2.57 w
0.80
0.93
0.63
percentage of patients with complaints
at 4 weeks
at 6 months
at 4 weeks
at 6 months
5min. 6 10 min. II -3Omin. 31 -6Omin. I-2h. 2-3h. more
I .07 1.35 1.69 1.45 2.14 2.25 2.56 2.77
0.6 I .02 0.94 0.96 0.97 I .63 2.33 2.67
39% 61% 73% 70% 76% 75% 77% 79%
r
0.90
0.97
0.58
0
with
mean period of rest in bed
of,
>O-
of patients
mean period of disability
mean number sequelae PTA
that as regards
I37 TABLE 7. Syndromes of correlatingseyuelae. The percentages of patients in whom these syndromes were present (anyway) or clearly present (more than half of the symptoms of the syndrome) is shown (* : difference with group 0: I_Y < 0.05; Chi-square), as well as the average number of sequelae (differences with group 0; Student’s_t-test; two-sided). Syndromes
A. Irritability Loss of memory Loss of concentration Fatigue Apathy B. Loss of hearing Loss of balance Dlzzrness
C. Headache Neck pains Fatigue
4 weeks after trauma
6 months after trauma 0 I
0
1
2
present clearly present
28.4% 9.9%
51.9%. 24.3%.
41.4% 15.6%
18.5% 6.2%
40.2%* 34.3%. 15.3% 8.1%
average (max. = 5)
0.73
1.50 <0.001
1.10 NS
0.53
1.18 <0.005
0.86 NS
present clearly present
22.2% 6.2%
35.4% 5.3%
25.3% 6.6%
13.68 2.5%
20.6% 4.2%
17.2% 6.1%
average (max. = 3)
0.36
0.46 NS
0.38 NS
0.20
0.29 NS
0.28 NS
present clearly present
37.0% 14.8%
58.7%~ 5 1.3% 26.7% 16.2%
19.8% 8.6%
42.9%. 20.4%.
35.4%. 9.6%
average (max. = 3)
0.67
1.12 <0.005
0.38
0.84 0.55
0.84 NS
2
frequencies as well as average severity of syndrome B, only slight and insigni~cant differences were present between groups of patients with a cerebral concussion (1 and 2) and the control group. The presence and intensity of this syndrome was thus not clearly related to cerebral concussion. With respect to syndromes A and C the differences between frequencies and intensities of group I and the control group were more marked, and either after 4 weeks or after 6 months differences were significant. Similar differences between the control group (0) and group 2 (with concussion in 1977) were also present though these differences were not significant. A relationship was thus found to exist in both groups between syndrome A and C and cerebral concussion but only in.the group of patients with cerebral concussion in 1974/ 1975 was this relationship significant. The presence of the syndromes was now compared with individual data and the duration of confinement to bed and disabilities (Table 8). It was found that syndrome B was not related to PTA, age etc., but clearly to external lesions of skin and skull in the parieto-temporal regions. In 1974/1975 as well as in 1977 syndrome A and C were found to be reIated to PTA, length of time spent in bed and disabilities but the significant relationship between the presence of these syndromes and age, self employment, private insurance and stress before the accident present in 1974, was not encountered in 1977 (Chi-square; NS: (Y:> 0.05). It might be argued that the relationship between the presence of these syndromes and PTA expresses the same relationship as that shown in Table 7 between concussion and frequency and severity of these syndromes (although not
138 TABLE 8. Relationship
between
the presence
of syndromes
of sequelae
and other data (Chi-square;
NS: (Y
> 0.05).
age level of education heavy work self employment private insurance stress before accident PTA other minor lesions lesions L/R par. temp. period of rest in bed period of disability
Syndrome 1974
A 1977
Syndrome 1974
B 1977
Syndrome 1974
C 1977
<0.005 NS NS to.02 to.02 <0.05 <0.02 NS NS to.05 <0.05
NS NS <0.05 NS NS NS <0.05 <0.05 NS to.005 <0.05
NS NS NS NS NS to.05 NS NS to.05 NS NS
NS NS NS NS NS NS NS NS to.02 to.05 NS
<0.005 NS NS NS NS NS
NS to.02 NS NS NS NS CO.02 NS NS
significantly in 1977). The influence of age, stress, self exployment or private insurance which were important factors in evoking sequelae in 1974/ 1975, did not play an important role in 1977. This would appear to be the result of the difference in treatment given in the two periods.
DISCUSSION
In this study on patients with minor head injuries the results of two kinds of treatment were examined and compared. Treatment given to patients in 1974-1975 was rather unsystematic and no special effort was made to give information and encouragement, while patients whose accident occurred in 1977 were treated according to a strict programme, which included rest in bed for a week and gradual recovery during another week, while as much information was given as was possible in the given circumstances and patients were encouraged to resume pretraumatic activities. None of the patients were hospitalised. It was found that the majority of patients observed the period of rest in bed prescribed. In general no differences were found in the average period spent in bed. Results in older patients were poor. The strict regime in 1977 resulted in a longer period of confinement to bed and more disabilities than had been present in this group in 1974/ 1975. It was concluded that being told they had a cerebral concussion possibly resulting in temporary complaints had had a greater impact in these patients than simply advocating a short period of rest in bed. The best results in 1977 were obtained with respect to post-traumatic sequelae, except in the group of patients over 60 years of age. The number of sequelae and the average frequencies of sequelae was less in 1977 by comparision with the other group with cerebral concussion. In the youngest age group as well as in the group of ‘working age’ the number of neurophysical and mental sequelae in patients with a cerebral concussion in many instances did not differ significantly from the number of sequelae in patients with no cerebral concussion. In 197411975 the majority of these ratios differed significantly. Further study of the kinds and intensities of posttraumatic sequelae resulted in three syndromes. One of these (B) was found not to be related to cerebral concussion
139 at all, but to external lesions in the parieto-temporal region. This external lesion to the region of the vestibular system had caused complaints of dizziness, loss of hearing and loss of balance in some patients with or without cerebral concussion. The presence of the syndrome as a whole correlated with the presence of other syndromes (A and C) which were related to cerebral concussion. This coincides with the findings of KAY et al. (1971) and LIDVALL et al. (1974) that external lesions to cranial nerves, especially those related to the vestibular system increased the possibility of prolonged sequelae of all kinds. However CARTLIDGE (1978) reported that patients who still suffered from a positional nystagmus, headache and dizziness on discharge often showed progressive improvement, by contrast with the group of patients without these signs and symptoms on discharge who developed symptoms later on. The other syndromes, one involving all mental sequelae and the other involving headache, neckpain and fatigue, were related to age, PTA, periods of confinement to bed and periods of disability. PTA was shown clearly to correlate with the number of sequelae, the number of patients who had them and the period of disability, indicating that PTA is a reliable indicator of the severity of cerebral lesions, even in these minor head injuries. This finding also indicated that, as was proposed by SLATER and ROTH ( 1969) KELLY (1975) and RUTHERFORD et al. (1978) post-concussional symptoms start off on an organic basis. On the other hand the frequency and intensity of the syndromes of sequelae, as found in this study, were less and not clearly related to cerebral concussion in patients treated with the strict regime, and who were provided with information and encouragement (1977) than in the other group ( 1974/ 1975). Similarly the relationship between some pre-traumatic events such as age, self employment, and stress before the accident and the presence of posttraumatic syndromes of sequelae which were clearly present in 197411975, had disappeared in the group of patients treated in 1977. It might be concluded that the treatment given in 1977 counteracted influences not directly related to the injury. It may be concluded also that it are not so much patients in need of financial compensation (MILLER; 1961, 1966) who are subject to a post-concussional syndrome, but those who are in situations of stress. It may be proposed that these patients are similar to the group of patients described by CARTLIDGE (1978) who develop symptoms only after discharge. In such instances depression and claims for compensation are frequent. The results of this study indicate that possible claims for compensation are often secondary to iatrogenic factors such as lacking information and encouragement. As was proposed by ADLER (1945) and KELLY (1975) symptom-rates could decrease if fear and panic regarding post-traumatic sequelae are treated with better information as to the type of injury, explanation of the symptoms and encouragement to resume pre-traumatic activities. In general the results of this study bear out these proposals. The approach employed with regards to patients in 1977, namely a week in bed followed by a week of gradually increased mobility was based on the experience gained with former patients. When asked whether this period had been too long or too short, the majority of patients expressed the opinion that they considered it of suitable length. It would, however, be
140 interesting to examine results after advising other periods of confinement with the same amount of information and encouragement provided.
to bed
REFERENCES ADLER, A. (1945) Mental
symptoms following head injury. A statistical analysis of two hundred cases. Arch. 53: 34. CARTLIDGE, N. E.F.(19%) Post-concussional syndrome. Scott. med. J. 23: 103. DENCKER, s.J.(1958) A follow-up study of 128 closed head injuries in twins using co-twins as controls. Acta Psychiat. neurol. Stand. 33, suppl. 12. GRUVSTAD, M., L. KEBBON and s. GRUVSTAD (1958) Social and psychiatric aspects of pretraumatic personality and posttraumatic insufficiency reactions in traumatic headinjuries. Acta Sot. Med. Upsal 63: 103. KELLY, R. (1972) The posttraumatic syndrome. Proceedings of the 4th Pahlave International Congress. Pahlave Med. J. 3: 530. KELLY, R. (1975) The posttraumatic syndrome: an iatrogenic disease. Forensic. Sci. 6: 17. KAY, D. w., T. A. KERR and L. P. LOSSMAN (1971) Brain trauma and the postconcussional syndrome. Lancet ii: 1052. KOZOL, H. L. (1946) Pretraumatic personality and psychiatric sequelae of head injury. Arch. Neurol. Psychiat. 56: 245. LIDVAL, H. F.,B. LINDEROTH and B. NORLIN (1974) Causes of the post-concussional syndrome. Acta neural. Stand. 50, suppl. 56. MILLER, H. (1961) Accident neurosis. Brit. med. J. I: 919. MILLER, H. (1966) Mental sequelae of head injury. Proc. Roy. sot. Med. 59: 257. OPPENHEIMER, R. D. (1968) Microscopic lesions in the brain following head injury. J. Neural. Neurosurg. Psychiat. 4: 229. RUTHERFORD, w. H.,J.D. MERRETT and J.R. MCDONALD (1978) Symptoms at one year following concussion from minor head injuries. Injury 10: 225. SLATER, E. and M. ROTH (1969) Mayer-Gross Clinical Psychiatry, Bailhere, Tindall and Carssell, Eds. London: 507. UNTERHARNSCHEIDT, F.J.(1972) Die traumatischen Hirnschaden Mechanogenese, Pathomorphologie und Klinik. Z. Rechtsmedizin 71: 153. Neurol.
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