emotional, neuropsychological, and organic factors: their use in the

J7ournal ofNeurology, Neurosurgery, and Psychiatry 1996;61:75-81

Emotional, neuropsychological, and organicfactors: their use in the prediction of persistingpostconcussion symptoms after moderate andmild head injuries

Nigel S King

AbstractBackground-After mild and moderatehead injuries a range of postconcussionsymptoms (PCS) are often reported bypatients. Both organic and psychogenicfactors can contribute to these. Fullrecovery from PCS usually occurs withinthree months of the injury. A significantminority, however, continue to experi-ence symptoms beyond this time. Todate, no means of identifying thesepatients early after injury has beenreported. This study investigates whethera combination of neuropsychological,emotional, and traditional measures ofseverity of head injury taken early afterthe injury can help predict severity ofPCS three months after injury.Methods-50 patients with mild or mod-erate head injury had a range ofmeasuresadministered at 7-10 days after injury.These included three tests of dividedattention, a PCS rating scale-theRivermead postconcussion symptomsquestionnaire (RPQ), the hospital anxietyand depression scale (HADS), the impactof event scale (IES), and post-traumaticamnesia. An RPQ was then completed byall patients three months after injury.Results-Stepwise multiple regressionanalysis was performed with the RPQscore at three months as the dependentmeasure. A combination of eight of thescores from the early measures gave amultiple correlation coefficient of R =086 accounting for 74%/o of the variance inRPQ scores. The most predictive individ-ual measures were the HADS and IES.Regression analysis with RPQ score at7-10 days as dependent measure showedthat 10 of the scores gave a coefficient ofR = 0-84 accounting for 71% of the vari-ance.Conclusions-A combination ofmeasuresmay significantly aid the prediction ofpersistent PCS. Five measures: HADS,post-traumatic amnesia, SOMC, PASAT,and RPQ are recommended for their pre-dictive value and clinical utility.Independent cross validation studies arerequired before these results can be gen-erally applied. They do, however, providevaluable indications regarding those mea-sures that are most likely to demonstrateutility.

(7 Neurol Neurosurg Psychiatry 1996;61:75-81)

Keywords: postconcussion symptoms; predictors ofmild head injury; head injury

Uncomplicated head injuries resulting in post-traumatic amnesia of less than 24 hours areusually described as being of mild or moderateseverity.'2 A range of postconcussion symp-toms (PCS) are often reported after suchinjuries. These include headaches, dizziness,fatigue, irritability, reduced concentration,sleep disturbance, memory dysfunction, anxi-ety, sensitivity to noise, double or blurredvision, sensitivity to light, and depression.3 7These symptoms certainly exist8-"I althoughthere is still debate as to whether they are bestthought of as a syndrome.35

Patients with mild or moderate headinjuries usually report the resolution of most oftheir symptoms within three months of theirinjury.5711-13 Prospective studies, however,indicate that a significant number still reportsymptoms at three months after injury and afew at 12 months.51014 Being able to predictthose patients likely to experience persistingsymptoms is important as PCS can signifi-cantly impair return to work and psychosocialfunctioning.3 15No neuropsychological or phenomenologi-

cal measure has consistently shown a capacityto make this prediction soon after injury-thatis, within the first four weeks. Traditionalmeasures of severity of head injury such asduration of post-traumatic amnesia have sig-nificant limitations in moderate and mild headinjuries16 and have been inconclusive whenused as predictors of patients with persistentPCS. For example, Middelboe et al 14 found nosignificant relation between post-traumaticamnesia and PCS, Jakobsen et al17 showed aninverse relation, and Minderhoud et al18reported direct positive correlations. Neuro-psychologial measures such as paragraph recalltests have similarly shown little correlationwith PCS'9 and reaction time tasks haveshown both no relation20 and positive correla-tion. 17 More consistent findings have comefrom measures of divided attention. Thepaced auditory serial addition test (PASAT)21and Stroop test22 have both been shown todirectly mirror the level of PCS reported duringthe recovery period.2'25 Neither of these tests,however, was able to predict early on those

RivermeadRehabilitation Centre,Abingdon Road,Oxford OX1 4XD, UKand ClinicalPsychologyDepartment,University ofBirmingham,Edgbaston,Birmingham B15 2TT,UKN S KingCorrespondence to:Dr N S King, RivermeadRehabilitation Centre,Abingdon Road, OxfordOXI 4XD, UK.Received 19 June 1995and in final revised form16 February 1996Accepted 23 February 1996

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patients likely to experience persisting symp-toms three months after injury.One factor in the variable nature of these

results is likely to be their use of relativelyunstandardised measures of the severity ofPCS. Most studies have relied on the reportedpresence or absence of symptoms from achecklist5 8 1() 26 or on self reports of the absoluteor relative increase in symptoms aftertrauma.42927 Others have used unvalidatednumerical rating scales." 21 However, arecently developed questionnaire, theRivermead postconcussion symptom question-naire (RPQ) (appendix 1) has been shown tomeasure reliably the severity of PCS (bothtest-retest and interrater reliability weredemonstrated).28 The RPQ also generates avery reliable total symptom score, whichpotentially provides a single numerical gaugeof severity of PCS. A second factor in theinconsistent results regarding the prediction ofpersistent PCS is that emotional and psy-chogenic problems seem to play a significantpart in postconcussion sequelae. Post-traumatic stress'4 and pre-existing emotionalproblems4 have both been shown to correlatepositively with persistent PCS. Indeed, someargue that postconcussion sequelae generallystart off on an organic basis but that psy-chogenic factors are pertinent when the PCSpersist.'1 Such variables need, therefore, to betaken into consideration when attempting toidentify patients likely to experience ongoingPCS.

This report investigates whether a combina-tion of neuropsychological, emotional, andtraditional measures of severity of head injurytaken 7-10 days after trauma can predict thoselikely to have persistent PCS three monthslater. The RPQ, the hospital anxiety anddepression scale (HADS),29 the impact ofevents scale (IES),40 duration of post-trau-matic amnesia, and three tests of dividedattention were used to assess patients withmild or moderate head injuries at 7-10 daysafter trauma. Results from all these measureswere then correlated with scores from theRPQ readministered three months after injury.

MethodsPATIENTSThe patients were 50 adults (23 men and 27women) with a mean age of 33 (SD 12 7),range 17-65 years. They had a mean post-traumatic amnesia of seven hours (SD 10-2),ranging from 0 to 44 hours. Two of thepatients had post-traumatic amnesia of morethan 24 hours (36 and 44 hours). They wereincluded because conventional definitions ofseverity of injury based on post-traumaticamnesia are known to have a large degree ofvariability, particularly when cut off points inthe definitions occur. The causes of headinjury were 20 road traffic accidents, 13 falls,five assaults, five horse riding accidents, andseven other. They were consecutive consent-ing patients registered with the Oxford HeadInjury Service (OXHIS) who had post-trau-matic amnesia of less than 48 hours.

MEASURES AND PROCEDUREPatients were visited in their homes 7-10 daysafter injury. During this visit a brief structuredinterview was conducted to ascertain basic epi-demiological information including durationof post-traumatic amnesia. Patients also com-pleted an RPQ (a measure of PCS severity), aHADS (a measure of symptoms relating toanxiety and depression), and an IES (a mea-sure of subjective stress in relation to a specificlife event; appendix 2). The RPQ presents 16of the most common published PCS symp-toms and asks the patient to rate the degree towhich they are any more of a problem com-pared with premorbid levels using values of0-4. A total symptom score can be calculatedfrom the sum of all scores (excluding 1) forwhich good reliability and adequate validityhave been demonstrated.28 4' Two scores werederived from the HADS; a depression scalescore and an anxiety scale score and twoscores were derived from the IES; an intrusionscale score (a measure of the extent to whichthe person experiences intrusive thoughts andfeelings about the life event) and an avoidancescale score (a measure of the extent to whichthe person avoids situations which elicit theaforementioned intrusions). Patients alsocompleted the short orientation memory andconcentration test (SOMC)'2 (appendix 3) asthis was already part of the normal OXHISassessment of patients. This is a short assess-ment of the person's ability to give basic orien-tation information and to perform three brieftests of verbal attention and short term mem-ory.

Three tests of divided attention were thenadministered.

Information processing subtest of the adultmemory and information processing battery(AMIPB) 33One hundred and five sets of numbers are pre-sented. Each set consists of five two-figurenumbers. The second highest number in eachset is cancelled out by the subject as quicklyand accurately as possible. The total numberof correct responses in four minutes isrecorded. A motor speed test is also con-ducted. This allows an adjusted informationprocessing score to be calculated accountingfor the speed taken to cancel out figures.Standardised percentile scores accounting forage are then obtained for (a) the percentage oferrors made (error score), (b) the motor speedscore (speed score), and (c) the total scoreadjusted for motor speed (adjusted score).

Stroop test22A list of 112 words of colours (red, green,blue, and tan) printed in different colouredinks (red, green, blue, and tan) is presented tothe subject. In subtask 1 the subject reads thewords as quickly and accurately as possible.The number of correct responses in two min-utes is recorded. In subtask 2 the subjectnames the ink colour of each of the words asquickly and accurately as possible and thenumber of correct responses in two minutes isrecorded. A third subtask was also given,

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Emotional, neuropsychological, and organic factors: their use in the prediction ofpersisting postconcussion symptom

Table 1 Simple Pearson correlation coefficients (r) for allindependent measures. Dependent measures: RPQ score atthree months after injury and RPQ score at 7-10 daysafter injury

Dependent measure

RPQ Score RPQ Scoreat 3 months at 7-10 days

Independent measure r r

HADS Anxiety score 0-57* 0-60*HADS Depression score 0-54* 0-65*IES Intrusions score 0-64* 0.69*IES Avoidance score 0-53* 0-60*SOMC score -0-38* -0-26PASAT1 2 seconds score -0-12 -0-15PASAT1 6 seconds score -0-06 - 0-06PASAT2-0 seconds score -0-06 -0-08PASAT2-4 seconds score 0-07 0-01AMIPB Error percentile score -0-18 0-01AMIPB Adjusted percentile score -0-13 -0 10AMIPB Speed percentile score -0-17 -0-29Stroop 1 score 0-15 0-12Stroop 2 score -0-18 -0-10Stroop 3 score -0-15 -0-05Post-traumatic amnesia (hours) 0-12 -0-01RPQ (7-10 days) score 0-48*

*P < 0-01.

which was similar to that used by Bohnen etal15 and which has been found to be particu-larly sensitive to PCS. Twenty two of thecolour words were randomly selected and hadsmall rectangles drawn around them.Instructions were the same as for subtask 2except that the words in rectangles were readrather than the ink colour named. The num-ber of correct responses in two minutes wasrecorded.

Paced auditory serial addition task (PASA T)Four series of 61 digits are presented to thesubject verbally. Each series is presented atincreasingly quicker rates (one digit every 2-4,2-0, 1-6, and 1-2 seconds). The subject is

Table 2 Increase in multiple correlation coefficients (R and R2) when individualindependent measures are added to the regression analysis. Dependent measure RPQ scoreat three months after injury (n = 45)

Independent measures R R2 (B)

HADS Anxiety score 0.55 0 30 1.28*Post-traumatic amnesia (hours) 0-72 0-53 0.42*SOMC score 0-76 0-58 - 1.79*PASAT2-4 seconds score 0-78 0-61 0.44*PASAT1 6 seconds score 0-83 0-68 -0-25Stroop 1 score 0-84 0-71 0 17PASAT1 2 seconds score 0-85 0-72 -0-21AMIPB Adjusted percentile score 0-86 0-74 0-06

(B) weights are used to predict values of the dependent measure from the raw scores.(multiple regression equation constant was 23 08).*p < 0 05.

Table 3 Increase in multiple correlation coefficients (R and R2) when individualindependent measures are added to the regression analysis. Dependent measure RPQ scoreat 7-10 days after injury (n = 50)

Independent measures R R2 (B)

IES Intrusions score 0 70 0 50 1.04*SOMC score 0-74 0-55 -0-84Stroop 1 score 0 76 0-57 -0-46*PASAT2-4 seconds score 0 78 0-61 -0 24PASAT2-0 seconds score 0 80 0-64 0-24Stroop 2 score 0 81 0-66 -0 34PASAT1 2 seconds score 0 82 0-67 -0-35HADS Depression score 0-83 0-68 0-63Stroop 3 score 0-83 0-69 0-08PASAT1 6 seconds score 0-83 0 70 0-18AMIPB Adjusted percentile score 0-84 0-71 0-04

(B) weights are used to predict values of the dependent measure from the raw scores.(multiple regression equation constant was 86-95).*P < 0-05.

required to add each digit to the one immedi-ately preceding it and the answer is givenaloud. The percentage number of correctresponses was recorded for each of the fourpresentation speeds.

At three months after injury, patients wereposted a letter asking them to complete anenclosed RPQ. The completed questionnairewas returned using a stamped addressed enve-lope (also enclosed). If a patient failed toreturn the questionnaire within three weeksthey were contacted by telephone and an RPQwas administered verbally. At three monthsafter injury five patients were uncontactablehaving failed to return the RPQ. Data werethus collected on 45 patients; 36 of these com-pleted the RPQ by post and nine verbally. Itshould be noted that the original validationstudy of the RPQ included the questionnairesbeing completed by post.28

Stepwise regression analysis was used toevaluate the combined ability of the measurestaken 7-10 days after injury to predict theseverity of PCS at three months. It was alsoused to determine the contribution these mea-sures made to the severity of PCS at 7-10days. Dependent measures were thereforetotal RPQ score at three months after injuryand total RPQ score at 7-10 days. Regressionanalysis determines the group of predictorvariables that best predict the dependent mea-sure. Simple Pearson correlation coefficients(r) were calculated for all independent mea-sures (predictor variables). All independentmeasures were then entered into regressionanalysis using SPSSPC (stepwise regressioncommand). Independent measures remainedin the regression analysis only if they increasedthe explained variance by at least 1% (as indi-cated by the value of R2). The final regressionequation gives a parsimonious prediction ofthe dependent measure.

Results and discussionTable 1 shows the simple Pearson correlationcoefficients (r) for each independent measurewhen the dependent measures were the totalRPQ score at three months after injury and thetotal RPQ score at 7-10 days after injury.

Table 2 gives the stepwise multiple regres-sion analysis with the total RPQ score at threemonths after injury as the dependent measure.It shows the increase in the multiple regressioncoefficient (R) and R2 when each independentmeasure is added to the regression analysis. Italso displays the unstandardised regressioncoefficients (B) for each independent measurein the analysis. These can be used to calculatethe regression equation and thus to predictvalues of the dependent measure from the rawscores of the independent measures.

Table 3 shows stepwise multiple regressionanalysis with the total RPQ score at 7-10 daysas the dependent measure. It shows theincrease in R and R2 when each independentmeasure is added to the regression analysis.Unstandardised regression coefficients (B) foreach independent measure are also given.

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King

Table 4 Distribution ofRPQ total scores at 7-10 days and three months after injury

RPQ Total Scores

0 1-10 11-20 21-30 31-40 41+

7-10 days (n = 50) (n (%)) 3 (6) 15 (30) 13 (26) 10 (20) 5 (10) 4 (8)3 months (n = 45) (n (%)) 16 (36) 16 (36) 3 (7) 5 (11) 4 (9) 1 (2)

Table 4 summarises the distribution of totalRPQ scores at 7-10 days and three monthsafter injury. It shows that 6% of the patientswere asymptomatic at 7-10 days and 36% hadscores of 10 or less. At three months improve-ment in symptoms was such that 36% were

asymptomatic and 72% had scores of 10 or

less.Table 1 shows that the independent mea-

sures which had the strongest relations withthe total RPQ score at three months afterinjury were the scores from the HADS andIES measures. Each of them correlated mod-erately well with the RPQ scores (at threemonths). It would therefore seem that themeasures of emotional factors rather than theneuropsychological or traditional measures

were the best individual predictors of severityof PCS at three months.

Table 2 shows that a combination of emo-tional, neuropsychological, and traditionalmeasures taken early after injury predictedseverity of PCS well at three months. Eight ofthese measures together accounted for 74% ofthe variance in total RPQ scores. This com-

pares with 30% of the variance accounted forby the HADS anxiety score alone and 3% ofthe variance that would be expected to beaccounted for by random data alone (using the"R for random data equation" from Howell3).The predictive ability of the independent mea-

sures is therefore significantly enhanced byusing a combination of different types of mea-sure together.

Table 1 indicates that all four scores fromthe HADS and IES had moderately high cor-

relations with the total RPQ score (threemonths). By contrast, however, table 2 showsthat only one of these scores was eventuallyentered in the stepwise multiple regressionanalysis. This suggests that a significant degreeof collinearity exists between these measures.

This is consistent with the finding that it is a

combination of different types of measures

which maximises the predictive ability of theindependent measures.

It should be noted that table 1 shows a veryweak correlation between post-traumaticamnesia and total RPQ score at three months.Table 2, however, shows that when post-trau-matic amnesia was added to the regressionanalysis it accounted for an additional 23% ofthe variance in RPQ scores. It is therefore pos-sible that post-traumatic amnesia makes a rela-tively unique contribution to the ability of theindependent measures to predict severity ofPCS at three months.

Table 1 also shows that the correlationbetween RPQ score at 7-10 days and threemonths was significant but not substantial

(+0A48). This might be expected from thosetheories of PCS development which emphasiseboth organic and emotional factors. Someconsistency in relative severity of PCS overtime would be expected with organic factorsbeing a feature of the sequelae but high corre-lations would not necessarily be expectedbecause of the variation in the emotionalimpact of the event which caused the headinjury and the PCS themselves.A close examination of table 2 shows that

only five scores accounted for 68% of thevariance in RPQ scores (three months). Thesewere the HADS anxiety, post-traumaticamnesia, SOMC, PASAT 2 4, and PASAT1 6. The other three scores accounted foronly an additional 6% of the variance. From aclinical viewpoint these results might haveimportant implications. For clinicians wishingto identify early after head injury thosepatients likely to have persistent PCS it ispossible that a screening battery of just fourmeasures (HADS, PTA, SOMC, andPASAT) might be of significant help. TheRPQ would also be recommended so thata measure of current PCS is included. Patientscould then be targeted for ongoing specialistintervention. At the very least such abattery might help clinicians in the difficulttask of advising patients with mild and moder-ate head injuries when they should expect tobe able to return to premorbid levels of workand leisure activities. A regression formulaspecifying the relative weights that should begiven to these measures would help cliniciansin these tasks. This is not appropriate,however, with the present data as cross valida-tion via an independent sample is required. It ishoped that this will be possible with futureresearch.

For RPQ score at 7-10 days after injury,table 1 shows that the measures which hadthe strongest individual correlations with RPQscore (7-10 days) were scores from theIES and HADS-that is, measures ofemotional factors. It also shows that therewas almost a zero correlation coefficientbetween post-traumatic amnesia and totalRPQ score (7-10 days). This suggests thatthere is no significant relation between post-traumatic amnesia and severity of PCS andlends some support to the findings ofMiddelboe et al. 4

It is also interesting to note from table 1that the total RPQ score at 7-10 days wasnot significantly correlated with any of theneuropsychological tests of divided attention(Stroop, PASAT, and AMIPB subtests).This superficially seems to be in directcontrast wiith the findings of Bohnen et al 25 onthe Stroop test and Gronwall's2' on thePASAT. Both found positive relationsbetween PCS and tests of divided attention.On close examination, however, Bohnen et alreported that no significant relation existed at10 days after head injury and that the Strooptest only mirrored PCS change between fiveweeks and three months after injury. Similarly,Gronwall reports a correlation between PCSand PASAT performance only for subjects

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Emotional, neuropsychological, and organic factors: their use in the prediction ofpersisting postconcussionsymptoM7

with post-traumatic amnesia of less than onehour. She found that for her patients withmore severe head injury (post-traumaticamnesia of over one hour) PCS and post-trau-matic amnesia were not correlated. The mean

post-traumatic amnesia for patients in the pre-sent study was seven hours which suggests a

population more akin to Gronwall's more

severely injured sample. The results from thisstudy on closer analysis therefore, tend toconfirm previous studies on PCS and tests ofdivided attention.The results in table 1 concerning RPQ

scores at 7-10 days may have some implica-tions for current models of the causes anddevelopment of PCS. Some theorists assertthat organic factors play a greater part in PCSearly on after injury and emotional ones play a

greater role when PCS persist. The resultscannot shed any light on the role of organicfactors in PCS as no valid measure of organic-

ity in mild head injuries has been identified.The results do, however, show that all signifi-cant correlations with severity of PCS came

from IES and HADS scores. This suggeststhat emotional factors play an important partin the early development of PCS. This in no

way infers that emotional factors cause PCS as

such an inference cannot be made from corre-

lational statistics. It does suggest, however,that emotional factors should possibly beconsidered as part of the early developmentof PCS. Such a suggestion is consistentwith the finding that emotional factors, includ-ing stress, are common mediating factors inthe exacerbation of PCS soon after headinjury. 3

Table 3 shows that a combination of 11 ofthe independent measures predicted PCSseverity at 7-10 days moderately well.Together they accounted for 71% (R = 0 84)of the variance in total RPQ scores (7-10days). Table 3 also shows that the IESintrusion scale score alone accounted for50% of the variance. In other words theremaining 10 measures accounted foronly an additional 21% of the variance. Thiscould be interpreted as further supportfor the assertion that emotional factors may

play some part in PCS early after headinjury.The results provide further evidence for

the validity of the RPQ as a measure of severityof PCS. Tables 2 and 3 show that the totalPCS score at both 7-10 days and threemonths was best predicted by a combinationof emotional, cognitive, and traditionalmeasures. This is precisely what would bepredicted from current models of PCSwhich acknowledge psychological, neuro-

psychological, and organic factors in thedevelopment of such symptoms. In addition,Table 1 indicates a significant correlationbetween RPQ scores at 7-10 days and threemonths. This too would be the expected resultwith the RPQ reliably measuring severity ofPCS.Two limitations should be highlighted for

this study. Firstly, the single outcome measure

(total RPQ score) relies on postal administra-

tion. Secondly, the validity of the total RPQscore as a measure of severity of PCS has yetto be fully demonstrated. Although havingsome validity, these facts should be set against(a) the high proportion of PCS follow upstudies which rely on postally administeredoutcome measures,0'1"18 (b) the validationstudy of the RPQ which showed good test-retest reliability when the measure was admin-istered postally,28 and (c) a recent studyshowing a moderately good correlation(r = +0 67) between the total RPQ scoreand a recently developed measure designedto assess psychosocial outcome six monthsafter injury."T The latter is a particularly usefulmeasure against which the RPQ has beenvalidated. It assesses common difficultiesin everyday functioning which can beaffected by PCS and as such may be a uniquemeasure. It therefore goes some waytowards establishing the ecological validity ofthe RPQ. A fuller account of how the RPQ'svalidity can be assessed can be found inKing et al.21

It should be noted that the study useda relatively large number of variables (n = 17)with a moderate size sample (n = 50) andthat all generalised conclusions drawn fromthe regression analysis of a single set ofdata should be treated with caution. Forboth these reasons it is necessary that theresults are confirmed by cross validationstudies on independent samples beforeconclusions from this study can be con-sidered as ones entirely pertinent to allpatients with head injury. The study does,however, provide valuable guidance regardingthose measures most likely to be clinicallyuseful.

In conclusion, the results show that mea-sures of emotional factors taken early afterinjury were the best individual predictors ofseverity of PCS three months after headinjury. These measures, however, seem tohave a significant degree of collinearity.When used together with neuropsychologicaland traditional measures of severity of headinjury, their combined ability to predict theseverity of PCS at three months is goodalthough cross validation studies are requiredto confirm this. Together such measuresmay significantly help a clinician identifyearly on patients likely to require ongoingspecialist intervention. A brief screening bat-tery made up of the HADS, post-traumaticamnesia, PASAT, SOMC, and RPQ is recom-mended both for its combined predictivepower and its clinical utility.

I thank Mrs Joanna McGrath, Clinical PsychologyDepartment, Rivermead Rehabilitation Centre, Oxford,Mr David Quinn, Clinical Psychology Department, NewtownRoad Hospital, Worcester, Professor Jim Orford, School ofPsychology, Birmingham University, Dr Derick Wade,Rivermead Rehabilitation Centre, Oxford, and Mrs SueCrawford, Oxford Head Injury Service, RivermeadRehabilitation Centre, Oxford for their comments andadvice on draft versions on this manuscript; Mrs Ann Whitefor her administrative and secretarial contribution; andthe Department of Health for funding the Oxford HeadInjury Service as part of their traumatic brain injuryinitiative.

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King

Appendix 1

pIVERMEAD4?EHABILITATIONLENTRE

Abingdon Road, OXFORD, OX I 4XD

Name/Identity

Copyright RRC June 29th 1993Reproduce freely, but acknowledge source

DATE:

After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would liketo know if you now suffer any of the symptoms given below. As many of these symptoms occur normally, wewould like you to compare yourself now with before the accident.

For each one please circle the number closest to your answer.

0 = Not experienced at all1 = no more of a problem

2 = a mild problem3 = a moderate problem

4 = a severe problem

Compared with before the accident,do you now (i.e. over the last 24 hours) sufferfrom:

HeadachesFeelings of dizzinessNausea and/or vomitingNoise sensitivity, easily upset by loud noiseSleep disturbanceFatigue, tiring more easilyBeing irritable, easily angeredFeeling depressed or tearfulFeeling frustrated or impatientForgetfulness, poor memoryPoor concentrationTaking longer to thinkBlurred visionLight sensitivity, easily upset by bright lightDouble visionRestlessness

Are you experiencing any other difficulties?Please specify, and rate as above:

1.2.

0 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 40 1 2 3 4

0 1 2 3 40 1 2 3 4

Appendix 2

r Date: Impact of Event Scale Case No:

Below is a list of comments made by people after stressful life events such as your recent accident. Please check eachitem, indicating how frequently these items were true for you during the past seven days. If they did not occur at all,please mark the 'not at all' column.

Comment1 I thought about it when I didn't mean to

2 I avoided letting myself get upset when I thought about it or

was reminded of it3 I tried to remove it from memory4 I had trouble falling asleep or staying asleep because of pictures

or thoughts about it that came into my mind5 I had a wave of strong feelings about it6 I had dreams about it7 I stayed away from reminders of it8 I felt as if it hadn't happened or wasn't real9 I tried not to talk about it

10 Pictures about it popped into my mind11 Other things kept making me think about it12 I was aware that I still had a lot of feelings about it but I didn't

deal with them13 I tried not to think about it14 Any reminder brought back feelings about it15 My feelings about it were kind of numb

SCORE: Intrusion ItemsAvoidance Items

Not Some-at all Rarely times Often

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Emotional, neuropsychological, and organic factors: their use in the prediction ofpersisting postconcussionsynptom8

Appendix 3

Date: f Orientation Memory Concentration Case No:

INSTRUCTION:Possible

Answer score

1. What year is it now?

2. What month is it now?

3. Repeat this address:Arthur/Jones OR Philip/Smith42/West Street 92/Columbia RoadWitney BanburyTry and remember this,I'll ask you at the end of the test to recall it.

4. About what time is it?(within one hour)

5. Count backwards 20 to 1

20 19 18 17 16 15 14 13 12 111098765432 1

6. Say months in reverse orderDec Nov Oct Sept Aug July June May April Mar Feb Jan

7. Repeat the address givenArthur/Jones OR Philip/Smith42/West Street 92/Columbia RoadWitney Banbury

TOTAL SCORE (/28)

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moderate and mild head injuries.persisting postconcussion symptoms afterfactors: their use in the prediction of Emotional, neuropsychological, and organic

N S King

doi: 10.1136/jnnp.61.1.751996 61: 75-81 J Neurol Neurosurg Psychiatry

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