“The most common form of traumatic brain injury (TBI) that we see in the ED—accounting for about 90% of the ED visits in the United States—occurs in patients who have a Glasgow Coma Scale (GCS) score of 15,” Debbie Y. Madhok, MD, explains. “This means that their consciousness is not altered at all, and they’re behaving normally. They’ve also had a CT scan that doesn’t show any evidence of intracranial injury.”

However, many of these patients “are not back to their baseline function by 6 or 12 months after their injury,” she continues.

For a study published in JAMA Network Open, Dr. Madhok and colleagues examined recovery outcomes in patients with mild TBI, a GCS score of 15, and a negative head CT at 2 weeks and 6 months. The Glasgow Outcome Scale-Extended (GOS-E) score, stratified by functional recovery (GOS-E score, 8) compared with incomplete recovery (GOS-E score, <8), at 2 weeks and 6 months after the injury, served as the primary outcome. The secondary outcome was TBI-related symptom severity assessed by the Rivermead Post Concussion Symptoms Questionnaire (RPQ) total score.

Incomplete Recovery Occurs in Half of Patients With Head Injury

The study included 991 participants (mean age, 38.5; 64% male) enrolled in the Transforming Research and Clinical Knowledge in TBI study, or TRACK-TBI, from January 2014 through December 2018.

Most participants (n=751) received follow-up care 2 weeks after the injury, of whom, 204 (27%) had a GOS-E score of 8, indicating functional recovery, and 547 (73%) had GOS-E scores of less than 8, indicating incomplete recovery (Table). For 659 participants (66%) who received follow-up care 6 months following the injury, 287 (44%) experienced functional recovery, while 372 (56%) experienced incomplete recovery.

Most participants (88%) with incomplete recovery indicated that they had not returned to baseline or pre-injury life. The mean RPQ score was 16 points lower at 2 weeks and 18 points lower at 6 months in participants with a GOS-E score of 8 compared with those with a GOS-E score less than 8.

“Most ED doctors, when they see a negative head CT and a GCS of 15, think that people will get better,” Dr. Madhok said. “It might take days or weeks, but a patient with that clinical profile most likely will get better. As a result, it was shocking to see that 73% of the cohort was not back to baseline at 2 weeks after the injury—and even more frightening that 56% of patients were not fully recovered 6 months after the injury.”

The researchers were also able to determine that 2-week outcomes predicted 6-month outcomes. “That means, if you see patients 2 weeks after the injury who are not doing well, those are likely the patients who will also not be doing well 6 months out,” she noted.

All Patients With Head Injury Need Follow-Up Care

An important takeaway from the study is that patients with a head injury, regardless of the type, “need follow-up care, ideally within 2 weeks of the injury,” Dr. Madhok says.

“Many patients are just not able to go back to work because they can’t focus. Some individuals suffer from debilitating headaches,” she continues. “Some patients may need referral to a neurologist, a therapist, or another specialist, but seeing a primary care doctor within 2 weeks would be a huge step forward.”

She also acknowledges that this concept “may be very difficult” to put into action, particularly in areas with limited resources or large groups of individuals who are traditionally underserved by healthcare.

“It’s very clear that we need more resources for patients with TBI,” Dr. Madhok concludes. “Our ongoing research aims to identify these patients who will have long-term issues in the ED so that we can assist patients right then and there, whether that’s by setting up a follow-up appointment or providing a prescription for pain medication.”