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  • Research article
  • Open Access

Post-concussion syndrome among patients experiencing head injury attending emergency department of Hawassa University Comprehensive specialized hospital, Hawassa, southern Ethiopia

The Journal of Headache and PainOfficial Journal of the "European Headache Federation" and of "Lifting The Burden - The Global Campaign against Headache"201819:112

https://doi.org/10.1186/s10194-018-0945-0

  • Received: 17 October 2018
  • Accepted: 8 November 2018
  • Published:

Abstract

Introduction

Post-concussion syndrome (PCS) is defined as the presence of 3 or more of the following signs and symptoms after experiencing head injury such as headache, dizziness, fatigue, irritability, insomnia, difficulty of concentration or memory difficulty. In Ethiopia, even though there was no research conducted on post-concussion syndrome, it is common health problems after experiencing head trauma that affect the productive age group, which directly or indirectly influences the development of the country.

Objective

To assess the prevalence and determinants of post-concussion syndrome among patients experiencing head injury attending emergency department of Hawassa University Comprehensive Specialized hospital, Hawassa, Southern Ethiopia.

Methods

Institution based cross sectional study was conducted from November 1, 2017 to March 30, 2018, in Hawassa University Comprehensive Specialized Hospital emergency department, Hawassa, Southern Ethiopia.

Result

A total of 275 cases were interviewed during data collection period with response rate of 95.2%. More than half (55.7%) of patients were within age range of 25–34 and Majorities (55.6%) of patients were married. About two-fifths of study participants (41.5%) had at least three symptoms of post-concussion syndrome components. Headache and restlessness were the most symptoms occurring in varying severity while double vision and fatigue were less severe among others. Occupation, cause of injury and location of injury were significant determinants of post-concussion syndrome.

Conclusion

About 41.5% of study participants had at least three symptoms of PCS. Occupation, cause of injury and location of injury were significantly associated with the occurrence of PCS.

Keywords

  • Post-concussion syndrome
  • Mild traumatic brain injury
  • Head injury
  • Hawassa

Introduction

According to World Health Organization (WHO) Post-concussion syndrome (PCS) is defined as the presence of 3 or more of the following signs and symptoms after experiencing head injury such as headache, dizziness, fatigue, irritability, insomnia, difficulty of concentration, or memory difficulty [1].The diagnosis of PCS is made in people who have suffered with a head trauma when persistent post-traumatic amnesia, loss of consciousness, or post-traumatic seizures and neuropsychological impairment must be present for three months after the injury which must have been absent or less severe before the injury [2].

PCS is one of the commonest neuropsychiatric consequence after having traumatic brain injury (TBI) [3] and its onset is more often for the period of the first month after trauma, but it may continue for months even years or more after head trauma [1, 3]. The magnitude of PCS differs, however most studies reported that about 15% of individuals with a history of a single concussion develop persistent symptoms associated with the injury and these symptoms may continue last for more than three months after the head injury [4]. However, there is substantial risk of misdiagnosis of PCS, because most of the symptoms related to PCS are common or may be worsen by other disorders. For example; headaches that occur after a concussion may feel like migraine or tension-type headaches [5].

Some of the risk factors that have been associated with PCS are pre-existing medical or psychological conditions, expectations of disability, being female and older age. Physiological and psychological factors present before, during, and after the injury are all thought to be involved in the development of PCS [6] and the questions of the cause or causes of PCS have been a lot debated for many years and remain controversial [7]. Some experts found out that post-concussion symptoms are caused by structural damage to the brain or disruption of neurotransmitter systems [8]. Though, about 38% of people who experience a head injury with symptoms of concussion had no radiological evidence of brain lesions [9].

In addition, about 10% of people with PCS develop sensitivity to light or noise, about 5% experience a decreased sense of taste or smell, and about 14% report blurred vision [10] and some people may also have double vision or ringing in the ears [11].

Post-concussion syndrome (PCS), the most common entity to be diagnosed in people who have experienced TBI, is a constellation of physical, cognitive, emotional, and behavioral symptoms and its prevalence varies from 11% to 64% [12]. The prevalence of persistent symptoms at 1 year is not known, but is estimated to be 5%. There is limited information on the prevalence and incidence of PCS in children. Despite the prevalence of PCS, uncertainty exists about the validity of this diagnosis because behavioral disturbances frequently occur in children after any injury and because factors present before injury and medico legal concerns after injury may influence recovery [13]. Up to 60% of patients with minor traumatic brain injury (MTBI) will suffer from post-concussion syndrome (PCS) characterized by persistence of symptoms such as headache, fatigue, memory difficulties and emotional liability [14].

According to different researches which were done worldwide, head injuries are common health problems of the world which affects mainly productive age groups of the world and contributes strongly to costs in the health care system. In Africa, head injuries are the common health problems and are substantial causes for morbidity and mortality which mostly affects productive age group of the population and brings economic consequences for both individuals and society of the continent [15].

In Ethiopia, even though there was no research conducted on post-concussion syndrome, it is a common health problem that affect the productive age group, which directly or indirectly influences the development of the country [16]. So, since the problem affects the productive age group of the country, paying attention to carry out this study assessing the magnitude and determinants of post-concussion syndrome is most crucial.

Methods

Study design, study area and study period

Institutional based cross-sectional study was conducted in Emergency department of Hawassa University Comprehensive and Specialized Hospital (HUCSH), from November 1, 2017 to March 30, 2018 which is found in Hawassa city 273 Km far south from Addis Ababa. HUCSH started giving service since 2005 and serves for more than 18 million people of the catchment area, from the southern region and the surrounding Oromia zones. The hospital had 400 beds for inpatient service and also gives different outpatient services.

Population

All patients presented to adult emergency department of HUCSH with head trauma were the source population and all head injury patients presented to adult emergency department in HUCSH during the study period were the study population.

Inclusion and exclusion criteria

All patients experiencing head injury whose age 18 year or above were included in the study and patients who were severely ill or unconscious were excluded from the study.

Sample size and sampling technique

The sample size was determined using single population proportion formula considering the following assumptions: confidence interval (CI) of 95% (Z = 1.96), absolute precision or tolerable margin of error (d = 0.05), and anticipated proportion of patients who experience PCS =50% (P). Since the source population was < 10,000, we used a correction formula, adding 10% non-response rate the final sample size was 289. Consecutive sampling technique was used to select the respondents for interview.

Data collection instrument

In order to assess symptoms after experiencing head injury, a number of measures have been described. One commonly used tool is the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), which has demonstrated reliability and validity [17, 18]. This questionnaire takes into account the high background prevalence of symptoms by asking the patients not only if symptoms are present, but also to rate the intensity of each of 16 symptoms as compared to before the Mild Traumatic Brain injury (MTBI).

Data quality control measures

The data was collected by trained nurse professionals and supervised by two emergency and critical care nurse specialists. The questionnaire was pre tested on 5% of the study participant prior to the actual data collection period for its clarity, understandability and completeness. The data collected during the pre-test was not included in the final analysis.

Data processing and analysis

The collected data were checked cleaned, coded and entered and analyzed using SPSS version 21. Descriptive statistical analysis was used to estimate the frequencies and percentages of the variables. Bivariate and multivariate logistic regression analysis was used to see the association between outcome and explanatory variables. The strength of the association was measured by odds ratio with 95% CI and P-value less than 0.05 was considered as statistically significant.

Results

A total of 275 cases were interviewed over five months data collection period with final response rate of 95.2%. More than half (55.7%) of patients were in age range of 25–34. Majorities (55.6%) of patients were married and 74.9% were living with family (Table 1).
Table 1

Socio-demographic characteristics of study participants attending emergency outpatient department of HUCSH, Hawassa, Southern Ethiopia (n = 289)

Characteristics

Categories

Number

Percent

Age

18–24

61

22.2

25–29

100

36.4

30–34

53

19.3

35–39

38

13.8

40+

23

8.4

Sex

Male

161

58.5

Female

114

41.5

Religion

Orthodox

99

36.0

Muslim

64

23.3

Protestant

89

32.4

Catholic

22

8.4

Other

1

0.4

Marital status

Single

105

38.2

Married

153

55.6

Divorced

6

2.2

Widowed

11

4.0

Occupation

Government employee

84

30.5

Merchant

72

26.2

Farmer

34

12.4

Student

44

16.

Daily labor

15

5.5

House wife

26

9.5

Educational status

Unable to read and write

43

15.6

Able to read and write

39

14.2

Primary

31

11.3

Secondary

141

51.3

College and above

21

7.6

Ethnicity

Sidama

104

37.8

Wolaita

35

12.7

Amhara

39

14.2

Oromo

62

22.5

Tigre

2

0.7

Gurage

19

6.9

Others

14

5.1

Living condition

With family

206

74.9

Alone

69

25.1

Social support and causes of injury

From the total study participants 31.6% of respondents have very good social support (Additional file 1).43.6% of study participants get injured due to motor bicycle accident (Additional file 2).

Characteristics of injury and symptoms of PCS

From the study participants 65.1% had < 1 week duration of illness and 30.9% faced injury on the right lateral part of their brain (Table 2). Among the study participants 227(82.5%) complains headache as a major symptom of PCS (Additional file 3).
Table 2

Characteristics of injures of study participants attending emergency outpatient department of Hawassa University compressive specialized hospital, Hawassa, Southern Ethiopia (n = 289)

Characteristics

Categories

Number

Percent

Duration of illness

< 1 week

179

65.1

1–2 weeks

55

20.0

34 weeks

32

11.6

> 1 month

9

3.3

Location of head injury

Right lateral

85

30.9

Left lateral

86

31.3

Frontal

75

27.3

Other site

29

10.5

Clinical presentation at time of admission

Shock

55

20.0

Unconscious

115

41.8

Bleeding

77

28.0

Other

28

10.2

Length of stay in hospital

< 5 days

108

39.3

1 week

87

31.6

2–4 weeks

61

22.2

5+ weeks

19

6.9

Duration of treatment

< 1 week

123

44.7

1–5 weeks

115

41.8

6–10 weeks

26

9.5

10+ weeks

11

4.0

Prevalence of post-concussion syndrome

We computed total score from 16 items, each measured from zero to four. All values were summed, with expected value from 0 to 64. The finding showed that mean of 7.57 with SD + 2.63. In this study the overall prevalence of post-concussion syndrome is 41.5%.

Factors associated with PCS

During Multivariate logistic regression being student (P = 0.04, CI [0.14, 0.95]), Motor bicycle as a cause of injury (P = 0.04, CI [0.30, 0.98]) and location of head injury (P = 0.02, CI [0.09, 0.83]) were significantly associated with post-concussion syndrome (Table 3).
Table 3

Factors Associated PCS (Bivariate and Multivariate logistic regression) of study participants attending emergency outpatient department of Hawassa university compressive specialized hospital, Hawassa, Southern Ethiopia (n = 289)

Variable

PCS

COR (95% CI)

AOR (95% CI)

P-Value

No

Yes

Age

 18–24

38

23

1

1

 

 25–29

64

36

0.9 (0.48–1.79)

0.61 (0.28–1.35)

0.22

 30–34

32

21

1.08 (0.51–2.31)

0.66 (0.26–1.70)

0.39

 35–39

19

19

1.65 (0.73–3.75)

1.02 (0.36–2.88)

0.97

  > 40

8

15

3.09 (1.14–8.44)

2.01 (0.57–7.09)

0.28

Sex

 M

86

75

1

  

 F

75

39

0.59(0.36–0.98)

0.62 (0.34–1.12)

0.11

Marital status

 Single

67

38

1

1

1

 Married

87

66

1.34(0.80–2.23)

1.03 (0.52–2.03)

0.93

 Divorced\widowed

7

10

2.53 (0.88–7.16)

1.94 (0.55–6.77)

0.30

Occupation

 Government employee

45

39

1

1

1

 Merchant

41

31

0.87(0.46–1.6)

0.62 (0.29–1.30)

0.21

Farmer

18

16

1.02 (0.46–2.2)

0.41 (0.13–1.26)

0.12

 Student

31

13

0.48(0.22–1.05)

0.36 (0.14–0.95)*

0.04*

 Day labor

10

5

0.57 (0.18–1.83)

0.25 (0.06–1.06)

0.06

 House wife

16

10

0.72 (0.29–1.77)

0.36 (0.10–1.28)

0.11

Education

 Unable to write & read

20

23

1

1

1

 Read & write only

23

16

0.61 (025–1.4)

0.61 (0.25–1.45)

0.26

 Primary

19

12

0.55 (0.22–1.4)

0.55 (0.22–1.40)

0.21

 Secondary

88

53

0.52 (0.26–1.04)

0.52 (0.26–1.04)

0.66

 College & above

11

10

0.79 (0.27–2.25)

0.79 (0.28–2.25)

0.66

Social support

 Excellent

54

32

1

1

 

 Very good

50

37

1.24(0.67–2.29)

1.28 (0.65–2.50)

0.48

 Good

41

27

1.11 (0.57–2.1)

1.13 (0.55–2.31)

0.74

 Fair & poor

16

18

2.03 (0.89–45)

1.58 (0.63–4.01)

0.33

Cause of head injury

 Car

56

52

1

1

1

 Motor bicycle

77

43

0.6 (0.35–1.02)

0.54 (0.30–0.98)

0.04*

 Fall accident

23

14

0.66 (0.31–1.4)

0.94 (0.39–2.27)

0.90

 Other

5

5

1.07 (029–0.9)

1.98 (0.47–8.37)

0.35

Location of head injury

 Rt Lateral

48

37

1

1

1

 Lt Lateral

48

38

1.03 (0.561–1.8)

1.01 (0.52–1.96)

0.97

 Frontal

42

33

1.02 (0.55–1.9)

1.02 (0.51–2.05)

0.95

 Other site**

23

6

0.34 (0.12–0.9)

0.28 (0.09–0.83)

0.02*

* P value < 0.05 (Significant Association), ** Back, occipital and parietal area

Discussion

This study was designed to assess prevalence of PCS and its associated factors among patients experiencing head injury and attending emergency department in Hawassa university comprehensive specialized hospital in 2018.

The Overall prevalence of PCS among patients experiencing head injury and attending emergency department in Hawassa university comprehensive specialized hospital was 41.5%. The finding of this study was higher than study done in New Zealand where more than 30% of participants reported PCS symptoms [19]. In addition it was significantly higher as compared to Malaysian [20] and Swedish [21] study which was 8.1% and 34%of patients survived from mild TBI developed PCS, respectively. The variation between the current study and the study mentioned above might be due to the difference in sample size, studies area and socioeconomic difference among study participants.

Students were 36% less likely to develop PCS compared to government employee. As it was evidenced, among study participants who experience head injury 30.5% and 16% were government employee and students by occupation respectively. This implies those who experienced head injury are more likely to develop PCS. Also, as it was commonly observed in the study area government employees uses motor bicycle compared with students, which will increase risk of road traffic accident.

Patients injured by motor bicycle were 54% less likely to develop PCS compared with those injured due to car accident. This might be due to the fact that it is obligatory to use helmets by motor bicycle drivers which protect them from head injury.

Patients who injured occipital area of the brain were 28% less likely to develop PCS compared to with those who injured on right lateral. This finding is also supported by the follow up study conducted in USA, study participants who injured on fronto temporal and parietal area were severely affected and atrophied because of head injury compared with injuries on the different part of the brain [22].

Conclusion

About 41.5% of study participants had at least three symptoms of PCS. Occupation, cause of injury and location of injury were significantly associated with the occurrence of PCS.

Recommendation

Future studies better to consider imaging finding of individuals with head injury as supportive data in addition to assessing symptoms included in the PCS tool.

Limitation

Since the study design is cross-sectional, it does not allow inferring causation.

Abbreviations

ACRM: 

American congruent of rehabilitation medicine

CDC: 

Center for disease control

CI: 

Confidence Interval

DHS: 

Demographic and Health Survey

DSM: 

Diagnostic and statistical manual

ED: 

Emergency department

GCS: 

Glasgow coma scale

HUCSH: 

Hawassa University compressive specialized hospital

ICD: 

International classification of diseases

ICU: 

Intensive care unite

MTBI: 

Mild traumatic brain injuries

NGO’s: 

Non-Governmental Organization

NICU: 

Neonatal intensive care unit

PCD: 

Post-concessional disorder

PCS: 

Post-concussion syndrome

PCSS: 

Post-concussion syndrome scale

PTA: 

Post traumatic amnesia

RTA: 

Rode traffic accident

SD: 

Standard deviation

TBI: 

Traumatic brain injuries

US: 

United state

Declarations

Acknowledgements

We would like to forward our gratitude to study participants and staffs from Hawassa University Comprehensive specialized hospital for devoting their time to contribute their idea during data collection.

Funding

No Funding was received for this research work.

Availability of data and materials

All generated data are included in this article and its supporting information.

Authors’ contributions

AB and EG participated in the conception, design of the study, reviewing the proposal, data analysis and report writing. AB, EG, MA, BD and ZO were participated in data analysis and report writing. AB prepared the manuscript for publication. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical clearance was obtained from Hawassa University College of medicine and health sciences, Institutional review board. Written consent was obtained from of each study participants. The purpose of this study was explained and confidentiality of the interview results and Anonymity was maintained.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interest.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
College of Medicine and Health Sciences, School of Nursing, Hawassa University, P.O.BOX: 1560 Hawassa, Ethiopia

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Copyright

© The Author(s). 2018

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