Assessment of quality of life in patients with remote consequences of combat traumatic brain injury

The leading place in the structure of injuries in terms of the severity of consequences currently belongs to traumatic brain injuries (TBI), which are one of the leading causes of mortality, long-term temporary disability and disability of the population.

The constant equipping of armies with modern types of weapons with new high explosive properties causes a significant increase in mine-explosive and explosive injuries to the central nervous system. In this regard, there is a constant need to improve the diagnostics and treatment tactics of combat injuries to the nervous system. If we compare the frequency of explosive injuries to the skull and brain in the overall structure of craniocerebral injuries during participation in various armed conflicts, then in the wars of the early 20th century they constituted only 6.7%, during the Great Patriotic War - 56.2%, and during the war in Afghanistan - 70%.

The proportion of damage to the nervous system in the structure of sanitary losses due to combined trauma received as a result of an explosion is 25-70% of the total number of injuries.

Modern developments in resuscitation, surgery, neurosurgery, pharmacology, improvements in diagnostic capabilities and monitoring of basic physiological indicators have led to a decrease in the number of fatal outcomes and complications of craniocerebral injuries. Mortality due to combat TBI has decreased by 7.5%, but the number of people with severe consequences of such injuries has increased.

The consequences of traumatic brain injury are an evolutionarily predetermined and genetically fixed complex of processes in response to brain damage, which affect the social status of victims and their quality of life. Psychoneurological disorders in the late period of TBI disrupt the vital functions of patients and require the development of new principles of treatment and medical rehabilitation.

Patients with consequences of craniocerebral trauma are socially maladapted for a long time, and often for life, have serious neurological and psychological dysfunctions, and are recognized as disabled. It should be noted that medical and social examination of patients with consequences of combat trauma is of particular importance due to the importance of not only medical but also social aspects. In a number of cases, difficulties of a methodological nature arise, especially when post-traumatic neuropsychiatric or other complex defect predominates in the clinical structure.

Thus, combat traumatic brain injury and its consequences in former military personnel of working age in modern conditions are an important medical and social problem. Improving the quality of medical care in the late period of combat traumatic brain injuries, assessing the limitations of life activity caused by them, developing an individual rehabilitation program taking into account the rehabilitation potential of this contingent of patients will help improve the quality of life (QOL) of victims and reduce the economic costs of their maintenance.

Limitation of life activity in the ability to move independently, as a rule, was not taken into account when making an expert decision due to its insignificant frequency in this category of patients. The main deviations were observed in the ability to control one's behavior, to carry out work activities. A significant obstacle to rehabilitation was the low motivation of the patient to restore work activity and, in general, to the maximum possible restoration of impaired functions. This situation was often explained by the presence in the clinical picture of the consequences of combat craniocerebral trauma - long-standing psychoorganic and asthenic or astheno-neurotic syndromes.

One of the new criteria for the effectiveness of treatment and rehabilitation measures, which has become widespread in recent years in countries with a high level of medical development, is the assessment of quality of life.

QOL is an integral characteristic of the patient's physical, psychological, emotional and social functioning, based on his subjective perception. Remote consequences, as well as the fact of combat traumatic brain injury itself, lead to pronounced functional disorders, psychological problems and social limitations, which significantly worsens the patients' QOL.

QOL, being an integral characteristic of various spheres of human functioning, allows for the analysis of components of life activity in accordance with WHO criteria. The concept of QOL research in medicine is based on unified methodological approaches, including three main principles: multidimensionality of assessment, variability of QOL parameters over time, and patient participation in assessing their condition.

QOL assessment tools (general and specific questionnaires) developed by experts from leading global clinical centers in accordance with the principles of evidence-based medicine and the requirements of Good Clinical Practices have created the opportunity to quantitatively assess the main areas of human life. Their use together with other generally accepted clinical, laboratory and instrumental research methods allows the physician to expand his understanding of the patient's condition as a whole.

General questionnaires measure a wide range of health perception functions and are used to compare QOL of patients suffering from various diseases, as well as to assess it in the population, while specific instruments are focused to a greater extent on problems associated with certain diseases. Since the original questionnaires were created in English, researchers in the post-Soviet countries face problems with cultural and linguistic adaptation, testing of psychometric properties (assessment of reliability, validity and sensitivity). Russian versions of the EuroQpl-5D (EQ-5D) are registered by the International Society for Quality of Life Research (ISOQOL), but their psychometric properties have not been studied.

Quantitative determination of the functional state of patients with the consequences of combat traumatic brain injury is a rather complex task, since it is assessed by the patient's attitude to the performance of not only professional and non-professional duties, but also to social adaptation. Nevertheless, in this case, the assessment of the patient's functional activity is schematic and not expressed quantitatively, which makes it very difficult to analyze changes in the functional status of patients over time, especially in short-term studies. One of the principles of studying QOL is based on the variability of its indicators over time, which allows monitoring the patient's condition.

Thus, the concept and methodology of QOL research have created opportunities to study various aspects of the patient's life. The traditional medical opinion made by the doctor and the QOL assessment given by the patient himself constitute an objective characteristic of the patient's health, which provides a real opportunity to find ways to improve prevention, treatment effectiveness and develop new rehabilitation programs.

Taking into account the set tasks, 108 men who suffered combat traumatic brain injury of varying severity (cerebral contusion) were examined - participants in military operations in the Democratic Republic of Afghanistan, who undergo annual courses of inpatient treatment at the Kharkiv Regional Hospital for War Disabled after suffering a mine-explosive or explosive injury.

The age of the patients ranged from 40 to 50 years, the time of injury was from 22 to 28 years. Patients over 55 years old were not included in the analysis due to the possibility of ambiguous judgments about the nature of cerebral changes (post-traumatic, vascular or mixed). Persons who had any somatic diseases before craniocerebral injuries, severe enough to cause pathological changes in the central nervous system, were also not included in the examination.

All patients were divided into groups depending on the severity of the injury:

• Group I consisted of 40 people who had suffered combat traumatic brain injury with mild concussion (12 of them repeated),
• Group II - 38 people with moderate concussion (5 of them with repeated) and
• Group III - 30 people who suffered severe concussion.

In addition to the results of clinical observation, neurological examination and additional (laboratory and instrumental) examination methods, we used data from the EQ-5D scale questionnaires, including an assessment of mobility, self-care, usual daily activities, pain/discomfort, anxiety/depression, which were filled out by patients themselves.

Patients with the consequences of mild combat traumatic brain injury did not have any significant impairments in walking or self-care; only 1 patient had significant impairments in performing activities in everyday life, and 5 patients had severe pain syndrome and anxiety.

In patients with consequences of combat traumatic brain injury of moderate severity, moderate functional impairments prevailed on all scales, the percentage of patients with no impairments was significantly reduced compared to patients with a history of mild combat traumatic brain injury. Severe impairments were observed in individual patients, 21.3% noted obvious pain. In general, the QOL of patients with consequences of moderate severity was worse compared to patients in Group I (p < 0.001).

Most patients with the consequences of severe combat TBI showed moderate impairments in walking, self-care and performing activities of daily living, anxiety or depression. There was not a single patient in this group without pain syndrome. The quality of life for all EQ-5D indicators was lower than in patients of other groups (p < 0.001).

Thus, the conducted regression analysis showed that the EQ-5D profile adequately assessed the QOL of patients with late consequences depending on the severity of the TBI suffered (p < 0.001). The obtained data confirmed that the QOL of this category of patients worsens from a mild degree of combat traumatic brain injury to severe according to all scales of the E0,-5B profile.

Prof. V. A. Yavorskaya, I. I. Chernenko, Ph.D. Yu. G. Fedchenko. Assessment of the quality of life in patients with remote consequences of combat traumatic brain injury // International Medical Journal No. 4 2012

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