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Traumatic brain injuries and whiplash injuries: epidemiology and long-term consequences
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

The incidence of traumatic brain injuries (TBI) is about 500 cases per 100,000 inhabitants per year, a majority of which are mild TBI (MTBI). The incidence of whiplash injuries is about 300/100,000/year. There are several similarities between MTBI and whiplash injuries with regard to the causes of injury (traffic crashes and falls), the demographic profile of the injured (mostly young persons), and the type of symptoms exhibited by some of the injured (for example head/neck pain, fatigue, irritability, impaired cognitive functioning, and depression). 

Main aim

To investigate the epidemiology and long-term consequences in terms of symptoms, disability, and life satisfaction in cases of TBI and whiplash injuries in a well-defined population.

Material and methods

Data on frequencies and characteristics of TBI and whiplash injuries were extracted from the injury database at the emergency department (ED) of Umeå University Hospital (UUH). The results were presented as descriptive epidemiology.

The 18-65 year-old persons who sustained an MTBI or whiplash injury in 2001, were provided a questionnaire three and five years after injury respectively, in which questions were asked about:

  • Symptoms; Rivermead Post Concussion Symptoms Questionnaire (RPQ)
  • Disability; Rivermead Head Injury Follow Up Questionnaire (RHFUQ)
  • Life satisfaction; LiSat-11

A local reference population was used for comparison of the RPQ. A national cohort was used as reference for LiSat-11. Data on sick leave for the cases of whiplash injuries were analysed to calculate the cost to society for loss of productivity.

Results

In 2001, the incidence of TBI was 354/100,000/year. The mean age was 23 and 55% were men. Ninety-seven percent of the injuries were classified as mild (Glasgow coma scale 13-15). The main causes were falls (55%) and traffic related injury events (30%). In 8% of the cases (17% of the elderly persons) an intracranial bleeding was detected by using CT.

The 3-year follow-up of the MTBI patients showed that women had more symptoms and disability (~50%) than men (~30%). Both women and men had more symptoms and lower life satisfaction compared with the reference population.

The incidence of traffic-related whiplash injuries in adults was 235/100,000/year and the annual incidences were relatively stable during 2000-2009. Combining the incidences with national insurance data showed that the proportion of insurance claims decreased during the period.

When looking at whiplash trauma following all causes of injury in 2001, traffic crashes caused 61% of the injuries and falls caused 14%. Neck fractures occurred in 3% of the cases.

Five years after whiplash injury, the injured persons had more symptoms and lower life satisfaction than the references. Sick leave ≥15 days was granted in 14% of the cases of whiplash injuries. The median number of sick days was 298 and the cost of loss of productivity during the follow-up was 5.6 million USD.

The frequencies of symptoms were relatively alike when comparing subjects with whiplash injuries to subjects with MTBI.

Conclusion

TBI and whiplash injuries are common, especially among young people, and the injuries render long-term symptoms, disability, and impaired life satisfaction in up to 50% of the cases. Symptoms exhibited are alike between the two types of injuries. The cost to society for loss of productivity is high, and there is a need for enhanced preventive measures aiming at reducing traffic-related injuries, sports injuries, alcohol-related injuries, and falls. Physical, mental, and social factors are important and should be addressed when examining and treating patients with persisting symptoms following TBI and whiplash injuries.

Abstract [sv]

Bakgrund

Skallskador utgör ett stort folkhälsoproblem, särskilt eftersom många som skadas är unga. Skallskador är också, parallellt med självmord, den vanligaste dödsorsaken hos ungdomar och unga vuxna. De flesta av skadorna klassas som ”lätta” i akutskedet men trots det så kommer en del av patienterna att drabbas av kvarstående besvär, t ex smärta, koncentrationssvårigheter, depression och nedsatt livstillfredsställelse.

Whiplashskador är nästan lika vanligt förekommande som skallskador och uppkommer framförallt i trafikolyckor. Även fall- och sportskador orsakar emellertid ett betydande antal whiplashskador. I normalfallet avtar de akuta symptomen inom några veckor men en del av patienterna anger att de får kvarstående besvär. Ett flertal skademekanismer i nackens vävnader är kända men tyvärr svåra att verifiera eller utesluta.

Huvudsyfte

Att undersöka förekomsten av skallskador och whiplashskador i en väldefinierad population samt beskriva restsymptom, funktions-nedsättningar och livstillfredsställelse hos de drabbade tre till fem år efter skadan.

Material och metod

Förekomsten av skadorna (Studie I, III och IV)

Studierna baseras på skadedatabasen vid Norrlands Universitetssjukhus i Umeå (NUS). I skadedatabasen registreras alla patienter som söker till akutmottagningen efter en skadehändelse, ca 10 000 fall per år. När patienterna anmäler sig i receptionen tilldelas de en skadejournal som de själva fyller i i väntan på att bli undersökta. När patienter inkommer med svårare skador får anhöriga i möjligaste mån fylla i journalen. Primärvårdens jour har under åren för studiens genomförande varit belägen på akutmottagningen under kvällar, nätter och helger vilket inneburit att de få skadefall som konsekvent missats har varit lättare skador som behandlats dagtid på vårdcentralerna i upptagningsområdet.

 

Långtidsuppföljning (Studie II, III och V)

En uppföljande enkätundersökning bestående av ett antal validerade frågeformulär skickades till alla skall- och whiplashskadade patienter i arbetsför ålder tre respektive fem år efter skadehändelsen. De frågeformulär som analyserades var:

  • För symptom: Rivermead Post Concussion Symptoms Questionnaire (RPQ)
  • För funktionsnedsättning: Rivermead Head Injury Follow Up Questionnaire (RHFUQ)
  • För livstillfredsställelse: Life Satisfaction-11 (LiSat-11)
  • För smärta (hos de whiplashskadade): Visual Analogue Scale (VAS)

 Resultaten från RPQ och LiSat-11 jämfördes med sedan tidigare tillgängligt material från åldersmatchade referenspopulationer.

När det gäller de whiplashskadade genomfördes en femårsuppföljning avseende sjukskrivning. Data från Försäkringskassan analyserades och samhällskostnaden för produktionsbortfall beräknades baserat på den genomsnittliga kostnaden för en årsarbetare.

Resultat

Förekomsten av skallskador vid NUS under 2001 var 354 skadade per 100 000 invånare. Medelåldern på de skadade var 23 år och 55% var män. Andelen lätta skallskador var 97%. Fallolyckor orsakade flest skador (55%) och trafikolyckor var näst vanligast (30%). Minst 17% av patienterna (ofta medelålders personer) var alkoholpåverkade. Hos 8% av patienterna (17% av personer över 65 år) upptäcktes blödningar i hjärnan.

I uppföljningen efter tre år noterades att de skallskadade patienterna i arbetsför ålder hade högre symptomfrekvens och lägre livstillfredsställelse än referenspopulationerna. Kvinnorna rapporterade högre förekomst av symptom och funktionsnedsättning än männen. Funktionsnedsättning av varierande grad samt så kallat postkommotionellt syndrom (med förekomst av minst tre specificerade symptom) fanns hos ca 50% av kvinnorna och hos ca 30% av männen.

Medelförekomsten av whiplashskador till följd av trafikolyckor var under 2000-2009 235 fall per 100 000 invånare och år. Sammantaget var förekomsten relativt stabil under perioden; en ökning med 1% per år noterades. När siffrorna matchades mot data från Försäkringsförbundet noterades en minskning av andelen försäkringsärenden under perioden.

2001 års incidens av akuta whiplashskador efter alla typer av skadehändelser var 383 skadade per 100 000 invånare. Könsfördelningen var 56% män / 44% kvinnor och medelåldern var 32 år. Trafikolyckor orsakade 61% av whiplashskadorna medan fallolyckor stod för 14%. Frakturer i nacken var ovanliga och hittades hos 3% av patienterna.

I femårsuppföljningen av whiplashpatienter i arbetsför ålder noterades att de hade högre frekvens (ca 50%) av symptom samt lägre livstillfredsställelse än referenspopulationerna. Funktionsnedsättning av varierande grad fanns hos ca 50% av patienterna. Kvinnorna skattade sin smärta högre än männen men i övrigt fanns ingen könsskillnad beträffande förekomsten av symptom, funktionsnedsättning och livstillfredsställelse. Vid jämförelse mellan whiplashskadade och skallskadade noterades att förekomsten av symptom med några få undantag inte skilde sig åt mellan grupperna.

Fjorton procent av de whiplashskadade blev sjukskrivna i mer än 14 dagar. Sjukskrivningens medianlängd var 298 dagar och i 3% av fallen fortskred sjukskrivningen under hela 5-årsperioden. Trafikskadade sjukskrevs oftare än fallskadade och noterbart är också att nackfrakturer ej resulterade i längre sjukskrivningar än mjukdelsskador. Samhällskostnaden för produktionsbortfall var i snitt ca 600 000 kr per sjukskrivning.

Konklusion

Avhandlingen bidrar med nya grunddata som ytterligare förstärker bilden av att skallskador och whiplashskador är vanliga och att det framförallt är unga personer som drabbas. Grad och typ av kvarstående besvär är likartade efter båda skadetyper. Samhällskostnaden för skadorna är hög och lämpliga områden för skadepreventivt arbete tycks vara fallskadeprevention, trafikskadeprevention, skadeprevention inom hästsport, fotboll och ishockey samt prevention av alkoholrelaterade skador.

Både fysiska, psykologiska och sociala faktorer inverkar på läkningsförloppet och symptombilden efter skadorna och det är viktigt att utvärdera och behandla patienterna med utgångspunkt från detta.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2012. , 49 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1526
Keyword [en]
Traumatic Brain Injuries, Whiplash Injuries;, Epidemiology;, Follow-up Studies, Cohort Studies
National Category
Surgery
Research subject
Epidemiology; Surgery; Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:umu:diva-61412ISBN: 978-91-7459-495-9 (print)OAI: oai:DiVA.org:umu-61412DiVA: diva2:567969
Public defence
2012-12-07, Hörsal B, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2012-11-16 Created: 2012-11-13 Last updated: 2012-11-16Bibliographically approved
List of papers
1. Traumatic brain injuries in a well-defined population: epidemiological aspects and severity
Open this publication in new window or tab >>Traumatic brain injuries in a well-defined population: epidemiological aspects and severity
2007 (English)In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 24, no 9, 1425-1436 p.Article in journal (Refereed) Published
Abstract [en]

The aim was to describe epidemiological and medical aspects of 449 cases of traumatic brain injury (TBI) from a well-defined geographical area with a population of 137,000 inhabitants. An episode of disturbed consciousness was a prerequisite for inclusion in the study. The incidence of TBI was 354/100,000 inhabitants. Median age was 23 years, range 0–91 years; 55% were men and 45% were women; 33% children 0–14 years, 50% adults 15–64 years, and 17% elderly persons 65–91 years old. Severity classification was based on Glasgow Coma Scale (GCS) on arrival; mild TBI 97% (GCS 13–15), moderate 1% (GCS 9–12), and severe 2% (GCS 3–8). The most common injury events were falls (55%) and vehicle-related events (30%). The percentage of falls was high among children and elderly persons but among adults vehicle-related injury events were also prominent. At least 17% of all patients were under the influence of alcohol, especially adult male bicyclists. CT was performed on 163 cases (36%) revealing 34 cases with intracranial hemorrhage (ICH) which is 21% of the examined or 8% of all the injured. The rate of ICH increased with increasing age (from 3% among children to 17% among the elderly persons) and also increased with decreasing GCS from 6% in the group of mild TBI to 60% among those with severe TBI. Attention should be directed to acute management of mild TBI in order to detect potentially dangerous ICH as well as to preventive actions against falls and vehicle related accidents.

Place, publisher, year, edition, pages
New York, NY, USA: Mary Ann Liebert, Inc., 2007
Keyword
Epidemiology, Head trauma, Traumatic brain injury
National Category
Surgery
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-5956 (URN)10.1089/neu.2007.0266 (DOI)17892405 (PubMedID)
Available from: 2012-11-15 Created: 2008-01-28 Last updated: 2017-12-14Bibliographically approved
2. Sex-differences in symptoms, disability, and life satisfaction three years after mild traumatic brain injury: a population-based cohort study
Open this publication in new window or tab >>Sex-differences in symptoms, disability, and life satisfaction three years after mild traumatic brain injury: a population-based cohort study
Show others...
2013 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 45, no 8, 749-757 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To investigate sex differences in symptoms, structure of symptoms, disability and life satisfaction 3 years after mild traumatic brain injury. Secondary aims were to find risk factors for adverse outcome.

DESIGN: Population-based cohort study.Patients: The cohort comprised 137,000 inhabitants at risk in a defined population served by a single hospital in northern Sweden. Patients attending the emergency department following a mild traumatic brain injury in 2001 were included.

METHODS: Of 214 patients aged 18–64 years, 163 answered a questionnaire on symptoms, disability, and life-satisfaction 3 years post-injury. The instruments were analysed with descriptive statistics. A principal component analysis of the Rivermead Post-Concussion Symptoms Questionnaire was conducted. Risk factors were identified using logistic regression.

RESULTS: Post-concussion syndrome was found in 50% of the women and 30% of the men. Disability was found in 52% of the women and 37% of the men, and 57% of the women and 56% of the men were satisfied with their lives. For both genders, high frequency of symptoms was a risk factor for disability and low life satisfaction. Back pain was a risk factor for disability. Living alone was a risk factor for low levels of life satisfaction. The principal component analysis revealed differences between the sexes.

CONCLUSION: There are sex differences in outcome 3 years after mild traumatic brain injury. Women and men should be analysed separately.

Place, publisher, year, edition, pages
Stiftelsen Rehabiliteringsinformation, 2013
Keyword
traumatic brain injury, minor head injury, sex differences, post-concussion syndrome, follow-up studies, quality of life, principal component analysis, odds ratio
National Category
Surgery
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:umu:diva-61422 (URN)10.2340/16501977-1215 (DOI)000326357500009 ()24002310 (PubMedID)
Available from: 2012-11-13 Created: 2012-11-13 Last updated: 2017-12-07Bibliographically approved
3. A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in Northern Sweden
Open this publication in new window or tab >>A 10-year incidence of acute whiplash injuries after road traffic crashes in a defined population in Northern Sweden
Show others...
2012 (English)In: PM&R, ISSN 1934-1482, E-ISSN 1934-1563, Vol. 4, no 10, 739-747 p.Article in journal (Refereed) Published
Abstract [en]

Objective

To examine the annual incidence of acute whiplash injuries after road traffic crashes in a geographic catchment area in Northern Sweden during the period 2000-2009.

Design

Descriptive epidemiology determined by prospectively collected data from a defined population.

Setting

The study was conducted at a public hospital in Sweden.

Participants

The population of the hospital's catchment area (136,600 inhabitants in 1999 and 144,500 in 2009).

Methods

At the emergency department, all injured persons (approximately 11,000 per year) were asked to answer a questionnaire about the injury incident. Data from the medical records also were analyzed. From 2000-2009, 15,506 persons were injured in vehicle crashes. Persons who were subject to an acute neck injury within whiplash-associated disorder grades 1-3 were included. The overall and annual incidences were calculated as incidence. Age, gender, type of injury event, and direction of impact were described. The incidences were compared with national statistics on insurance claims from 2003, 2007, and 2008 to detect changes in the proportions of claims.

Main Outcome Measures

The annual incidence of acute whiplash injuries. Secondary outcome measures were types of injury events, age and gender distribution, changes in the proportion of rear-end crashes during 2000-2009, and changes in the proportion of insurance claims during 2003-2008.

Results

During 2000-2009, 3297 cases of acute whiplash injury were encountered. The overall incidence was 235/100,000/year. The average yearly increase in incidence was 1.0%. Women comprised 51.9% and men 48.1% of the injured. Car occupants (86.4%) and bicycle riders (6.1%) were most frequently injured. The proportion of rear-end crashes decreased from 55% to 45% from 2000-2009. The proportion of insurance claims significantly decreased between 2003 and 2008 (P < .0001, χ2 test).

Conclusion

The incidence of emergency department visits attributable to acute whiplash injuries after road traffic crashes have been relatively stable during the past decade in our area, except in 2007 and 2008, when a peak occurred.

Place, publisher, year, edition, pages
New York, NY, USA: Elsevier, 2012
Keyword
Whiplash Injuries, Epidemiology, Traffic accidents
National Category
Surgery
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-61413 (URN)10.1016/j.pmrj.2012.05.010 (DOI)
Available from: 2012-11-15 Created: 2012-11-13 Last updated: 2017-12-07Bibliographically approved
4. Whiplash trauma: epidemiology, long-term sick leave and its' costs
Open this publication in new window or tab >>Whiplash trauma: epidemiology, long-term sick leave and its' costs
Show others...
(English)Article in journal (Other academic) Submitted
Abstract [en]

Introduction

Neck injuries following whiplash trauma are common and primarily caused by traffic incidents but are also caused by fall incidents and sporting mishaps. The economic consequences to society for the consequent sick leave are significant. Original studies covering all types of cervical spine injuries (WAD-grade 1-4) following whiplash trauma and the following sick leave are rare. The aim of this study was to describe the epidemiology of neck injuries caused by whiplash trauma and the resulting long-term sick leave of patients in a well-defined area who sought medical attention within a one-year period and with a five-year follow-up. Possible risk factors for sick leave and the cost of loss of productivity were also studied.

Materials and Methods

From the ongoing injury registration of Umeå University Hospital, the only hospital in the area, we extracted the year 2001’s data set of neck injuries (acute WAD 1-4). Those injured by whiplash trauma were included. The Swedish Social Insurance Agency provided five-year post-injury data on sick leave because of the injury in question. This is a compulsory register of all Swedes. Epidemiological aspects were described and follow-up data were analysed to find risk factors for long-term sick leave.

Results

The incidence was 383/100,000/year for all ages. In 14% of 18-64 year olds, sick leave was granted for more than two weeks and the median number of sick days in this group was 298. Older age, having a WAD-grade of 1, being injured in traffic crashes and being injured at velocity exceeding 50 km/h were significant risk factors for being granted sick leave. A few (6%) had more serious cervical spine injuries (WAD 4). However, their average time on sick leave was not significantly longer than the sick leave of those with WAD 1-3. The cost to society for loss of productivity was estimated at 5.6 million USD during the 5-year follow-up.

Conclusion

Whiplash injuries affect many people including the young. The long-term periods of sick leave described in this paper indicate individual suffering as well as a societal economic burden. Finding preventive measures is of most importance.

Keyword
Neck injury, Whiplash injury, Sick leave, Epidemiology, Cost of illness
National Category
Surgery
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-61419 (URN)
Available from: 2012-11-13 Created: 2012-11-13 Last updated: 2012-11-16Bibliographically approved
5. Symptoms, disability, and life satisfaction five years after whiplash injuries: a population-based cohort study
Open this publication in new window or tab >>Symptoms, disability, and life satisfaction five years after whiplash injuries: a population-based cohort study
(English)Article in journal (Refereed) Submitted
Abstract [en]

Objective

To study symptoms and disabilities five years after participants sustained whiplash injuries using questionnaires designed for mild traumatic brain injury. A second aim was to study life satisfaction and a third aim was to investigate differences between women and men regarding these variables.

Design

Population-based cohort study

Methods

In total 186 persons (100 women and 86 men) aged 18-64 answered questionnaires on pain intensity (Visual Analogue Scale) symptoms (Rivermead Post Concussion Symptoms Questionnaire, RPQ), disabilities (Rivermead Head Injury Follow Up Questionnaire RHFUQ) and life satisfaction (LiSat-11) five years post injury.

Results

The most common symptoms reported on the RPQ were fatigue (41%), poor memory (39%), and headache (37%). The presence of three symptoms or more was reported by 54% of the women and 50% of the men. Inability to sustain previous workload (44%) and fatigue at work (43%) were the most frequently reported disabilities on the RHFUQ. Only 39% were satisfied with their somatic health and 60% with their mental health. Women reported significantly higher pain intensity than men. No significant differences between women and men regarding symptoms, disabilities, and life satisfaction were found.

Conclusion

These findings highlight the importance of assessing and quantifying symptoms in addition to neck pain in persons with long-term problems after whiplash injury and may provide a possibility to identify subgroups to tailor rehabilitation interventions. The high proportions of disability and low life satisfaction have to be taken into account when managing persons with chronic whiplash associated disorder. 

Keyword
Whiplash Injuries, Post-Concussion Symptoms, Life Satisfaction
National Category
Surgery
Research subject
Rehabilitation Medicine
Identifiers
urn:nbn:se:umu:diva-61421 (URN)
Available from: 2012-11-13 Created: 2012-11-13 Last updated: 2012-11-16Bibliographically approved

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