Evaluation of the quality of life in patients with long-term consequences of an armed craniocerebral trauma

The leading place in the structure of injuries due to the severity of the consequences now belongs to craniocerebral injury (TBI), which is one of the leading causes of death, prolonged temporary disability and disability of the population.

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

The specific gravity of damages of the nervous system in the structure of sanitary losses in a combined injury resulting from the explosion is 25-70% of the total number of injuries.

Modern development of resuscitation, surgery, neurosurgery, pharmacology, improvement of diagnostic capabilities and monitoring of basic physiological parameters led to a reduction in the number of deaths and complications of craniocereberal trauma. Mortality due to military CCT decreased by 7.5%, but the number of people with severe consequences of such injuries increased.

The consequences of craniocerebral trauma are an evolutionarily predetermined and genetically fixed complex of processes in response to brain damage that affect the social status of the victims and the quality of their life. Psychoneurological disorders in the late period of TBI disturb the life of patients and require the development of new principles of treatment and medical rehabilitation.

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

Thus, the combat craniocerebral trauma and its consequences for former servicemen of working age in modern conditions are an important medical and social problem. Improving the quality of medical care in the long-term period of combat craniocerebral trauma, assessing the life-cycle limitations caused by them, and developing an individual rehabilitation program, taking into account the rehabilitation potential of this patient population, will help improve the quality of life (QoL) of victims and reduce the economic costs of their maintenance.

Restriction of ability to move independently, as a rule, was not taken into account when making an expert decision because of its insignificant frequency in this category of patients. The basic deviations were observed in the ability to control one's behavior, to carry out labor activity. A significant obstacle in carrying out rehabilitation was the patient's low motivation to resume labor activity and, in general, the maximum possible restoration of disrupted functions. This situation was often explained by the presence in the clinical picture of the consequences of a war craniocerebral injury - a long-standing psycho-organic and asthenic or astheno-neurotic syndrome.

One of the new criteria for the effectiveness of treatment and the implementation of rehabilitation measures that have become widespread in recent years in countries with a high level of medical development is the assessment of QOL.

QOL is an integral characteristic of the patient's physical, psychological, emotional and social functioning, based on his subjective perception. Long-term consequences, like the very fact of a battle craniocerebral injury, lead to pronounced functional impairments, psychological problems and social limitations, which significantly worsens the QoL of patients.

QOL, being an integral characteristic of various spheres of human functioning, allows to analyze the components of vital activity in accordance with WHO criteria. The concept of QOL research in medicine is based on unified methodological approaches, including three main principles: multidimensional evaluation, the variability of QoL parameters in time, and the patient's participation in assessing his condition.

Tools for assessing QOL (general and specific questionnaires), developed by experts from the world's leading clinical centers in accordance with the principles of evidence-based medicine and the requirements of Good Clinical Practices, have created the possibility of quantifying the main areas of human life. Their application together with other generally accepted clinical, laboratory and instrumental methods of research allows to expand the doctor's views on 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 a population, while specific tools focus more on the problems associated with certain diseases. Due to the fact that the originals of the questionnaires were created in English, researchers in post-Soviet countries have problems of cultural and linguistic adaptation, testing of psychometric properties (reliability, validity, and sensitivity). Russian versions of EuroQpl-5D (EQ-5D) are registered by the International Society for the Study of QoL (ISOQOL), however, their psychometric properties have not been studied.

The quantitative determination of the functional state of patients with the consequences of an armed craniocerebral injury is a rather difficult task, as it is assessed in relation to the patient to perform not only professional and non-professional duties, but also to social adaptation. Nevertheless, in this case, evaluation of the patient's functional activity is schematic and not quantified, which makes it very difficult to analyze the changes in the functional status of patients in the dynamics, especially in short-term studies. One of the principles of the study of 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 for studying various aspects of the patient's life. The traditional medical conclusion made by the doctor and the assessment of QOL, given by the patient himself, constitute an objective description of the patient's health condition, which gives a real opportunity to find ways to increase the prevention, the effectiveness of treatment and the development of new rehabilitation programs.

In view of the tasks, 108 men who underwent craniocerebral trauma of various degrees of severity (cerebral contusion), combatants in the Democratic Republic of Afghanistan, who undergo annual inpatient treatment at the Kharkov Regional Hospital for the Disabled after the Mine explosive or explosive injury.

The age of the patients was from 40 to 50 years, the limitation period of the trauma is from 22 to 28 years. Patients older than 55 years in the analysis were not included because of the possibility of an ambiguous judgment about the nature of cerebral changes (posttraumatic, vascular or mixed). Persons who had had somatic illnesses prior to craniocerebral trauma, sufficiently pronounced to cause pathological changes in the central nervous system, were also not included in the survey.

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

• Group I comprised 40 people who underwent combat head injury with light concussion (12 of them repeated),
• Group II - 38 people with moderate-grade concussion (5 of them with repeated) and
• III group - 30 people who had a severe concussion.

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

Patients with sequelae of mild craniocerebral trauma did not show significant disorders in walking and caring for themselves, only 1 patient had marked deviations when performing actions in daily life, and 5 patients had pronounced pain syndrome and anxiety.

Moderate functional abnormalities prevailed in all patients with the consequences of a war craniocerebral trauma of moderate severity, the percentage of patients with no violations was significantly reduced in comparison with patients with a history of light war craniocerebral trauma. Expressed disorders were found in individual patients, 21.3% noted obvious pain. In general, QOL patients with consequences of moderate severity were worse compared with patients in Group I (p <0.001).

The majority of patients with the consequences of severe combat head injury were found to have mild disorders in walking, taking care of themselves and in performing activities in daily life, anxiety or depression. In this group there was no patient with no pain syndrome. QoL in all parameters of EQ-5D 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 long-term consequences depending on the severity of the CCT (p <0.001). The received data confirmed that QL of this category of patients worsens from mild degree of combat craniocerebral trauma to E0, -5V-profile, severe in all scales.

Prof. V. A. Yavorskaya, I. I. Chernenko, Cand. Honey. Yu. G. Fedchenko. Estimating the quality of life in patients with long-term consequences of combat craniocerebral trauma // International Medical Journal No. 4 2012

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