Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 1 , Pages 35-42, January 2010

Characteristics of a Mild Head Injury Subgroup With Extreme, Persisting Distress on the Rivermead Postconcussion Symptoms Questionnaire

  • Ned L. Kirsch, PhD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
    • Corresponding Author InformationCorrespondence to Ned L. Kirsch, PhD, Dept of Physical Medicine and Rehabilitation, University of Michigan Health Systems, 355 Briarwood Circle, Ann Arbor, MI 48109-5742
    • ,
  • Marita B. de Leon, PhD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
    • ,
  • Ronald F. Maio, DO

      Affiliations

    • Department of Emergency Medicine and the Injury Research Center, University of Michigan, Ann Arbor, MI
    • ,
  • Scott R. Millis, PhD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, MI
    • ,
  • Cheribeth U. Tan-Schriner, PhD

      Affiliations

    • Michigan Public Health Institute, Okemos, MI
    • ,
  • Shirley Frederiksen, RN, MS

      Affiliations

    • Department of Emergency Medicine, University of Michigan, Ann Arbor, MI

Article Outline

Abstract 

Kirsch NL, de Leon MB, Maio RF, Millis SR, Tan-Schriner CU, Frederiksen S. Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms Questionnaire.

Objective

To examine baseline variables and identify characteristics of participants with extremely high reports of symptoms (ie, outliers) 12 months after mild head injury (MHI).

Design

A prospective cohort study of MHI with and without loss of consciousness (LOC) and/or posttraumatic amnesia (PTA) recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months.

Setting

Level II community hospital ED.

Participants

Participants (n=58) with MHI and LOC less than or equal to 30 minutes and/or PTA less than 24 hours and participants (n=173) with MHI but no PTA/LOC. Inclusion criteria: age greater than or equal to 18 years, less than or equal to 24 hours after injury, Glasgow Coma Scale score greater than or equal to 13, and discharge from the ED. Fourteen (6%) participants had extremely high scores on the Rivermead Postconcussion Symptoms Questionnaire (RPQ).

Main Outcome Measures

RPQ and questions on health services use and litigation.

Results

Characterizing the outlier cases are prior head injury, preinjury disability, history of substance use, unemployment, and elevated somatic symptoms at the ED. At 12 months, outliers had higher use of health services and litigation.

Conclusions

The existence of a subgroup with a distinctive pattern of baseline characteristics in combination with elevated somatic symptoms at the time of presentation to the ED suggests that further taxonomic distinctions may be warranted for the MHI population, each requiring appropriately targeted interventions for addressing symptomatic complaints.

Key Words: Brain injuries, Rehabilitation

List of Abbreviations: ED, emergency department, GLM, General Linear Model, LOC, loss of consciousness, MHI, mild head injury, MTBI, mild traumatic brain injury, PTA, posttraumatic amnesia, RPQ, Rivermead Postconcussion Symptoms Questionnaire

 

ESTIMATES OF THE RATE of persisting symptoms after MHI range from 6%1 to 24% to 40%.2, 3, 4 These include (1) alterations in cognitive ability5, 6, 7; (2) changes in mood, personality, and behavior6, 8, 9, 10; (3) limitations of everyday functioning,11 such as disrupted work status3, 6, 12, 13; and (4) limited participation in social activities.9, 14, 15, 16

The persistence of these symptoms after MHI has remained a perplexing phenomenon,17, 18 because recovery patterns often appear inconsistent with the degree of known neurologic impairment or accident characteristics. For example, several studies have demonstrated a dose effect for MHI, such that increasing injury severity is associated with increasing symptom severity.19, 20, 21 However, others have been unable to demonstrate such an effect,5, 22, 23 or counterintuitively, report that patients having milder head injury also have worse outcomes.22, 24, 25, 26, 27, 28, 29, 30

As a result of these observations, it has become increasingly important to examine the clinical characteristics of various MHI subgroups, including those with and without neurologic changes. The purpose of this study is to examine preinjury (ie, baseline) and injury characteristics of a subgroup of outliers with highly elevated postconcussion complaints 1 year after MHI and to determine which of these characteristics differentiate the outlier subgroup from other MHI patients. In order to place this subgroup into perspective, we first briefly describe other proposed taxonomic subclassifications of the MHI population for whom persisting symptomatic complaints have been attributed to various causes. Factors associated with persisting symptoms after MHI include identifiable neuropathology, psychologic response to the injury or traumatic event, motivation, and specifically pertinent to this study, baseline characteristics.

Neurologic changes after MHI, in particular white fiber changes that are detectable with diffusion tensor imaging,31, 32 and their resolution over time have been reported.33, 34 However, to the limits of our review, and as recently noted,35, 36 no prospective studies have as yet been published that demonstrate an association between changing symptom patterns and white fiber status.

Alternative nonphysiologic explanations for persisting symptoms have also been proposed. Depression,19, 37, 38 posttraumatic stress disorder,19, 39 limited social support,39 difficulties with social integration,15 expectations of poor outcomes,40, 41, 42 and misattribution of preinjury symptoms to a recent trauma43, 44, 45 all may individually contribute to protracted recovery. Decreased motivation associated with injury-related compensation has also often been identified as predictive of delayed recovery.9, 17, 46, 47, 48 Conversely, the role of motivation can be inferred from studies of sports-related MHI. In this cohort, the estimated recovery period is shorter, with symptoms returning to baseline within 7 to 14 days,49, 50, 51 in contrast with non–sports-related MHI, with estimated recovery often extending over 3 to 12 months.1, 4, 17, 52, 53

Last, baseline functioning has been reported to be related to poor outcomes after MHI. Preinjury physical health,54, 55 psychologic health,27, 56, 57 and social functioning14, 56 have been identified as predictors of persisting symptoms more so than, or instead of, head injury characteristics.

In our earlier work, we reported the predictive value of preinjury health status for persisting fatigue30 and postconcussion symptoms.54 We specifically found that a subgroup of patients with MHI without PTA or LOC had worse outcomes than a group with nonhead injuries and a group having sustained more severe MHI—that is, with PTA or LOC. This paradoxical finding, similar to those of several studies cited,22, 24, 25, 26, 27, 28, 29, 30 led us to explore possible differences between these MHI subgroups.

It should be noted that we use the term MHI rather than MTBI based on the distinction proposed by Kay et al.58 Additionally, we follow the recommendation of McLean and Clauw59 to use neutral and descriptive rather than definitive classification terms because of the uncertainty of pathogenesis of symptoms after head injuries. In this study, we use the descriptive terms “with or without PTA or LOC” to describe the 2 MHI groups. These descriptive terms are part of the criteria in the case definition of MTBI as proposed by the American Congress of Rehabilitation Medicine.60

In contrast with our earlier work, which reported outcomes for our entire MHI sample,30, 54 for this report, we focus analyses on a subsample of outlier participants (extracted from our larger, previously reported sample) who had extremely high scores on the RPQ 12 months after injury. We hypothesize that these outlier cases represent a coherent subgroup of persons with MHI. We specifically examine baseline (ie, preinjury and injury) variables to identify distinctive characteristics of this outlier group.

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Methods 

Data for this study were derived from a larger data set that prospectively investigated postconcussion symptoms and other outcomes.30, 54 The study protocol was approved by the institutional review boards of the University of Michigan Medical School, Saint Joseph Mercy Health System, and the Michigan Public Health Institute.

Participants 

Procedures regarding recruitment and data collection are comprehensively presented in our earlier work.30, 54 To summarize, participants comprised an inception cohort of patients with minor head and nonhead injury evaluated and discharged directly from the ED. Inclusion criteria were age greater than or equal to 18 years, Glasgow Coma Scale score greater than or equal to 13, not meeting the institution's criteria for activation of the adult trauma team, presentation to the ED within 24 hours of injury, and direct discharge from the ED. Exclusion criteria were transfer from another hospital and inability to speak English. Participants were classified as having had a head injury based on evidence in the medical record and patient responses to multiple questions regarding indicators of an injury to the head, altered consciousness, or accident characteristics that indicate a blow to the head. All discrepancies were resolved by attending medical staff. LOC and PTA were likewise determined through the medical record and self-report, and patients were excluded if any of the following were true: LOC greater than 30 minutes, LOC not attributable to head trauma, PTA greater than 24 hours, or patient still in state of PTA at the time of interview (Galveston Orientation and Amnesia Test score <76). When PTA length could not be determined, it was estimated to be less than 24 hours if the patient was interviewed and clear of PTA within 24 hours of the presenting injury. The rigorous procedures of determining group membership are illustrated in a previous article (fig 1).30 From the larger cohort, we derived 2 MHI subgroups: a group with LOC less than or equal to 30 minutes and/or PTA less than or equal to 24 hours (head injury with PTA and/or LOC) and a group without any PTA or LOC (head injury only).

The sample size at the ED was 339 participants with MHI (head injury with PTA and/or LOC, n=94; head injury only, n=245). Retention rates at 12 months postinjury were 62% for the head injury with PTA and/or LOC group (n=58) and 71% for the head injury only group (n=173).

Identification of outliers 

From this data set, an outlier subsample was extracted. A conservative criterion of 2.0 SDs above the RPQ study sample mean at 12 months (mean ± SD, 12.0±15.2; cut-off RPQ score=42) was established for determining outlier status. Fourteen outlier cases were thus identified from the total sample of 231 (6%), with 13 (8%) of 173 participants with head injury only and 1 (2%) of 58 participants with head injury with PTA and/or LOC.

Measures 

Demographics and injury characteristics 

Demographic variables were obtained from a structured patient interview, adapted from the Colorado Traumatic Brain Injury Registry and Follow-up System61 and verified against the medical record where possible. These included age, sex, education, marital status, and employment status. Information related to the MHI was obtained from the medical record and included cause of injury and any computerized tomography findings. LOC was also assessed through the patient structured interview. PTA was assessed with the Galveston Orientation and Amnesia Test. All medical variables were verified by attending staff, if necessary.

Baseline functioning 

Measures of baseline status, also obtained from the structured interview, included dichotomous questions about medical history, mental health issues needing counseling, drug/alcohol problems needing treatment, prior head injuries (characterized by being “dazed or disoriented” or having lost consciousness), having a prior disability, involuntary unemployment because of termination (independent of disability status), and prior need for assistance. Need for assistance was assessed with dichotomous items about whether the participant had received any help one month prior to injury in various areas that are additionally indicative of 3 of the conditions mentioned (disability, mental health, substance use). These items were chosen as indicators of baseline functioning specifically because their dichotomous format appeared to be less subject to potential stress-induced response bias, given the participant's circumstance at the time of study interview (ie, being concurrently examined in an ED).

Outcome measures 

Severity of symptomatic complaints at 12 months postinjury was determined with the RPQ.62 Also included were additional questions regarding health-related services received “due to [the] injury” in the previous 9 months (ie, from the third month to twelfth month after injury) through various service settings such as EDs, hospital departments or clinics, physicians, or other rehabilitation and mental health care providers. Finally, litigation status was included in the analyses as another possible characteristic of the outlier group, broadly determined as positive if any of the following were true: the participant was actively involved in litigation, had received services from a lawyer or a paralegal, had consulted with an attorney, or was considering consulting an attorney regarding the injury.

Procedure 

Recruitment and consent procedures were completed in the ED. Participants were interviewed for baseline information between other examinations and treatments. Follow-up telephone interviews were conducted at 1, 3, and 12 months. For this study, only the baseline and 12-month follow-up data are reported. At each of the follow-up time points, a maximum of 10 attempts was made to contact each participant. They were given $25 after completion of the ED interview and $75 at 12 months to maximize retention rates.

Data Analysis 

Statistical analyses were performed with SPSS version 17.a Two-tailed tests of significance with alpha level of .05 were used.

Differences between outliers' and nonoutliers' baseline characteristics and service use were assessed with Pearson chi-square tests of independence with Yates correction, because of the small sample size of the outlier group, and with t tests for continuous variables. GLM repeated-measures analysis was done to assess differences in RPQ scores of the head injury only and head injury with PTA and/or LOC groups at the ED and at 12 months, and also to determine significance of changes in scores over time for each of the groups. This analysis was done first with the entire MHI sample, and then with outliers removed to determine whether the outlier sample was accounting for our earlier reported paradoxical finding of worse outcomes for the head injury only group.

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Results 

Baseline Characteristics 

Analyses were based on 14 identified outlier cases. Visual inspection of the data revealed a pattern of distinctive preinjury characteristics. To identify which of these characteristics significantly differentiated between the groups, we compared endorsement percentages for the outlier and nonoutlier groups (table 1). The groups differed significantly for several characteristics, with outliers more frequently reporting preinjury disability, history of services for drug/alcohol use, unemployment because of job termination, and prior head injury. We additionally examined the outliers' reports of symptoms at time of ED presentation. More of these cases also had outlier RPQ scores at the time of injury (6 of 14) than those who were not outliers at 12 months (5 of 217). The 2 groups did not significantly differ in regard to sex, marital status, education, motor vehicle collision as cause of injury, having PTA or LOC (see table 1), and age (mean age ± SD for the outlier and nonoutlier groups were, respectively, 41.4±13.4 and 41.2±18.8; t=.04; P=.968).

Table 1. Baseline Characteristics of the Outlier and Nonoutlier Groups
Baseline CharacteristicsOutliers (n=14)Nonoutliers (n=217)Total (N=231)P⁎φ Coefficient
With a disability8(57)31(14)39(17).000.27
Prior mental health counseling9(64)79(36)88(38).072†.14
History of drug/alcohol services7(50)36(17)43(19).006.21
Unemployment because of job termination4(29)5(2)9(4).000.32
Prior head injury with LOC or was “dazed or disoriented”9(64)39(18)48(21).000.27
Female9(64)125(58)134(58).832.03
Married8(57)90(42)98(42).384.08
High school or less education7(50)66(31)73‡(32).223.10
With PTA or LOC1(7)57(26)58(25).200.11
Motor vehicle collision3(21)77(36)80(35).435.07
RPQ outlier score at ED§6(43)5(2)11(5).000.45

NOTE. Values are n (%) unless otherwise indicated.

⁎Yates correction.

†Fisher exact test, P=.045; other variables with similar P using Fisher exact test.

‡One case with missing data.

§RPQ score >2 SD above study group mean (mean ± SD, 10.2±10.1; cut-off score=30).

Outcomes at 12 Months After Injury 

Change in Rivermead Postconcussion Symptoms Questionnaire scores 

The outlier group had, by definition, extremely high scores on the RPQ at 12 months. We therefore explored the possibility that outliers account for previously reported paradoxically worse outcomes for participants with MHI without LOC or PTA.30

We first compared RPQ scores that had been obtained at the ED and at 12 months from our entire sample (ie, with outliers included), comparing the head injury only group and head injury with PTA and/or LOC group. We then repeated this analysis with all outliers removed from either group. The GLM repeated-measures analysis for the entire sample (see fig 1) revealed a significant interaction effect of time by group (F1,229=5.71; P=.018; partial η2=.02) and a significant increase in RPQ scores over time for the head injury only group (P=.003; partial η2=.04). However, with the outliers removed (fig 2), there were no significant changes in RPQ scores over time for either injury group, while RPQ scores for the extracted outliers increased dramatically (F1,228=62.72; P=.000; partial η2=.22).

We understand that there is questionable applicability of GLM repeated-measures analysis to this comparison because of the small sample size, different distribution, and variability of the outlier group. However, the notably distinct RPQ score patterns over time for the outlier and nonoutlier groups are compelling. Specifically, RPQ scores for the MHI subgroups without the outliers were stable, while the RPQ scores at 12 months for the outliers reflected a substantial worsening of reported symptoms.

Use of health and litigation services 

At 12 months, participants were asked how many times they had received various health care services “due to [the] injury” over the prior 9 months (ie, from the time of the last study interview at 3 months). Table 2 compares the percentages of outlier and nonoutlier participants according to total number of health care visits. Of the outlier group, 79% reported at least 3 visits, while 77% of the nonoutlier group reported no visits of any kind (χ2=32.34; P=.000; φ coefficient=.398). Additionally, at 12 months, 43% of the outliers were in some stage of the litigation process, compared with only 13% of the nonoutlier group (χ2=6.75; P=.009; φ coefficient=.196).

Table 2. Percentages of Outliers and Nonoutliers by Number of Health-Related Visits
Number of Health-Related VisitsOutliers (n=14)Nonoutliers (n=217)Total (N=231)
02(14)167(77)169(73)
11(7)8(4)9(4)
20(0)11(5)11(5)
3ormore11(79)31(14)42(18)

NOTE. Value are n (%). Yates correction and Fisher exact test P=.000, φ coefficient=.40. For statistical analysis, categories were collapsed into 2 categories of “3 or more” and “2 or less” to adjust for cells that did not meet minimum cell size requirements.

Predicting Outlier Status at the Time of Emergency Department Presentation: A Post Hoc Analysis 

As additional analyses, we explored the data presented in table 1 to determine which preinjury characteristics and symptomatic concerns (as measured by the RPQ in the ED) would optimally classify participants into outlier and nonoutlier groups. Prior head injury, disability, and unemployment had comparable effect sizes in distinguishing between these 2 groups.

However, prior head injury identified the largest percentage of outlier cases (9 of 14) relative to any of the other baseline characteristic. Prior head injury was still not an acceptable sole classification criterion because it resulted in 18% (39) being falsely classified as at risk for outlier status.

When all 4 preinjury characteristics are considered, a criterion of any 2 out of the 4 distinctive characteristics correctly classified 10 (71%) of 14 of the outliers and incorrectly classified 20 (9%) 217 of the nonoutliers (table 3). The absolute number of false positives based on this criterion may also be considered unacceptably high in many clinical settings, because the health care costs associated with provision of services to so many false-positive cases may be prohibitive. We therefore additionally explored whether any other baseline variables would maximize the percentage of correct identification to the 2 groups. However, no significant differences were found for any demographics or injury characteristics (having had PTA/LOC and motor vehicle accident as cause of injury).

Table 3. Percentages of Outliers and Nonoutliers Positive for Baseline Characteristics and RPQ Symptoms
Criteria at EDTotal Sample
Outliers (n=14)Nonoutliers (n=217)Total (N=231)
Baseline characteristics
With prior head injury9(64)39(18)48(21)
With prior head injury and 1 other baseline characteristic8(57)16(7)24(10)
With 2 or more baseline characteristics⁎10(71)20(9)30(13)
RPQ symptoms
RPQ outlier at the ED†6(43)5(2)11(5)
At least 1 somatic symptom‡13(93)88(41)101(44)
Baseline characteristics and somatic symptoms
With 2+ baseline characteristics and at least 1 somatic symptom10(71)8(4)18(8)
With prior head injury and at least 1 somatic symptom9(64%)16(7)25(11)

NOTE. Values are n (%). All differences are significant at P=.000.

⁎Any 2 of 4 baseline characteristics: prior head injury, disability, unemployment, services for drug/alcohol use.

†RPQ score >2 SD above study group mean (mean ± SD, 10.2±10.1; cut-off score=30).

‡Somatic symptoms include headache, blurred vision, and light sensitivity.

Because total-score RPQ outlier status at the ED only correctly classified 43% (6 of 14) of the outliers, as final exploratory analyses, we examined the possibility that a specific pattern of elevated symptoms, as reported on the RPQ, might yield better predictions of group membership. Specifically, we examined scores for 3 RPQ subscales (somatic, cognitive, affective) adopting the method used by Smith-Seemiller et al.63 The outlier group had significantly higher scores only on the somatic subscale (mean score ± SD for the outlier and nonoutlier groups were, respectively, 17.0±9.0 and 8.5±6.4; t=3.00; P=.006). Examination of each of the 9 RPQ somatic symptoms revealed that more outliers than nonoutliers reported the following symptoms as moderate or severe: headache (90% vs 37%; P=.019), blurred vision (50% vs 0%; P=.004), and light sensitivity (70% vs 15%; P=.009). Using the criterion of having at least 1 of these 3 somatic symptoms in the ED, in combination with having 2 or more baseline characteristics, substantially reduced the percentage of nonoutliers incorrectly classified as outliers, without reducing the number of those correctly classified as true outliers.

Table 3 summarizes percentages of true positives (correct identification of outliers) and false positives (incorrect classification of nonoutliers) applying all of these exploratory combinations of variables to the entire sample. All combinations are presented in the table because their application in regard to case management and clinical decision-making may be critically dependent on clinical setting, purpose of evaluation, and availability of resources.

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Discussion 

We extracted and analyzed outlier cases with extremely high RPQ scores at 12 months after an MHI that had initially been evaluated in an ED. The outlier group is distinctively different from the rest of the sample in baseline characteristics (including prior head injury, disability, history of substance use, unemployment) and elevated somatic symptoms at the ED. Having brief PTA or LOC as an injury characteristic did not significantly distinguish between the outlier and nonoutlier groups. This finding is consistent with our earlier reports that preinjury physical and mental health status, rather than head injury severity, are predictive of postconcussion syndrome54 and fatigue30 at 12 months.

Poor outcomes are evident for the present outlier subsample. There are significantly higher rates of health care service use and pursuit of litigation over the first year postinjury compared with our substantially larger nonoutlier group. Additionally, the high symptom reporting at the ED not only remained unresolved but also actually worsened significantly over time, contrary to typical symptom resolution patterns reported in other studies of MHI1, 49, 64 or for our nonoutlier group.

We further present exploratory findings suggesting that extreme symptom reporting at 12 months may be determined at the time of injury, to varying degrees, by different combinations of variables. Of the preinjury variables that significantly differentiated the outlier and nonoutlier groups, prior head injury is the most predominant characteristic of the outlier group. The effect of multiple head injuries is an important factor in determining risk of persisting problems, as has been described in previous studies.55, 64 However, prior head injury is not a sufficient condition alone in risk assessment for outlier status, because 39 of 45 participants with prior head injury did not convert to outlier status and reported good recovery at 12 months. Assessment of risk for future problems is enhanced by examining multiple factors. The combination of having 2 or more baseline characteristics (prior disability, history of services for drug/alcohol use, prior head injury, unemployment) and moderate to severe somatic symptoms (headache, light sensitivity, blurred vision) characterize those who would be extremely symptomatic at 12 months and eliminates most of those who are not symptomatic. However, because of the exploratory and post hoc nature of these analyses, this finding warrants further prospective verification. Studies on identification and further refinement of prediction algorithms would enable clinicians to accurately assess, at the time of injury, relative risk for developing persisting problems, independent of the recent MHI reported in the ED.

Study Limitations 

In regard to study limitations, the results and their implications are restricted to those MHI cases with the very mildest of injuries. The sample characteristics of such mild injuries were no LOC or PTA (our head injury only group), or at most very brief LOC or PTA (our head injury with PTA and/or LOC group) and direct discharge from the ED. Additionally, computerized tomography scans were most often not prescribed, or if prescribed (38% of our sample) revealed no accident-related neurologic changes. In the absence of comprehensive and sensitive neuroimaging data, we cannot be certain of our participants' neurologic status.

Another limitation is that we did not specifically inquire about preinjury health care use. Although we know that outliers' symptomatic complaints after injury increase significantly over time, we are uncertain whether their associated reports of greater health care visits (compared with nonoutliers) represent a change subsequent to injury or a continuation of a preinjury health care use pattern. It is possible that for some persons, both their reported concerns after MHI and the health care sought for those concerns may be misattributed to the injury, even if use rates do not change. Clearly, this can only be clarified with subsequent prospective studies.

These findings raise several important issues. In regard to the characterization of MHI samples, in general, the data indicate that the effect of an outlier group can be so extreme that erroneous conclusions may be reached about MHI population mean symptom characteristics. One such erroneous conclusion may be that there are paradoxical differences between patients who do and do not sustain brief loss of consciousness (ie, that less severely injured patients report greater impairment). Our data suggest that this is only the case if outliers are not accounted for.

Another potentially erroneous conclusion would be that symptomatic complaints for persons with MHI either do not resolve over time or intensify. Our findings indicate that this is not characteristic of the general MHI population but does occur for a very small outlier group potentially identifiable at the time of injury.

More generally, our data support the impression that the MHI population is, as a whole, comprised of several subgroups, each having distinct clinical presentations at the time of initial evaluation and distinct patterns of symptom evolution over time. This, in turn, suggests that when patients present to the ED, it is critical to identify the subgroup to which they can be predominantly assigned and that evaluation and disposition protocols be implemented that specifically address the characteristics of those group members.

For all of those who at the time of ED evaluation do not have the characteristics of the outlier subgroup, prophylactic discharge and disposition protocols do appear worth consideration.65, 66 In contrast, for those patients who, at the time of ED presentation, have characteristics of the outlier group, careful monitoring of nonresolving or increasing symptomatic complaints is warranted during the first year after injury, particularly because, based on our data, members of the outlier group appear to use relatively expensive health care resources that may not be directly pertinent. For these persons, services may be most appropriate that specifically address symptomatic complaints, combined with a careful consideration of their preinjury history. While such interventions may require the reallocation of health care resources, the costs may, over longer periods, be less than those associated with the use of more standard clinical services (eg, doctor visits) that do not specifically address the underlying medical and psychosocial distress faced by these patients. Clearly, this is a hypothesis requiring further investigation.

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Conclusions 

We were able to identify 1 subgroup of persons with unusually high RPQ scores indicative of persisting—that is, unresolved and even worsening—symptomatic complaints. This group has distinctive characteristics, including prior disability, unemployment, a history of drug or alcohol use, prior head injury, and moderate to severe somatic symptoms at the time of injury. The existence of this subgroup suggests that further taxonomic distinctions may be warranted for the larger population of persons with MHI. In addition to those who have sustained demonstrable neuropathology, there may be other, yet to be determined subgroups with distinctive psychological, psychosocial, or neuropsychologic characteristics that also require appropriately designed and targeted interventions. As a model for this approach, the International Mission on Prognosis and Analysis of Clinical Trials in traumatic brain injury presents prognostic models for moderate to severe traumatic brain injuries.67 Such models are also needed for MHI, even for those subgroups for whom full recovery is an expectation.

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 Supported by the Centers for Disease Control (grant no. R49/CCR523223-01), the National Institutes of Health, the National Institute of Child Health and Human Development, and the National Center for Medical Rehabilitation Research (grant no. 5-T32-HD007422-17).

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

 Reprints are not available from the author.

PII: S0003-9993(09)00848-X

doi:10.1016/j.apmr.2009.09.019

Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 1 , Pages 35-42, January 2010

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