Brain Injury, February 2012; 26(2): 183–187

Health-related quality-of-life after traumatic brain injury: A 2-yearfollow-up study in Wuhan, China

XUE-BIN HU1, ZHE FENG2, YU-CONG FAN1, ZHI-YONG XIONG1,& QI-WEI HUANG1

1Department of Neurosurgery, Wuhan Union Hospital, Tongji Medical College and 2School of Life Science and

Technology, Huazhong University of Science and Technology, Wuhan, Hubei, PR China

(Received 14 April 2011; revised 20 October 2011; accepted 5 December 2011)

AbstractObjective: To assess health-related quality-of-life (HRQoL) 2 years after traumatic brain injury (TBI) among a group ofChinese.Methods: A total of 358 adult patients with moderate-to-severe TBI based on Glasgow Coma Scale score were recruited in alarge trauma centre in Wuhan, China during May 2005 to April 2008. They were followed up for 2 years and the MedicalOutcome Short Form 36 was used to measure HRQoL.Results: After a 2-year follow-up, there were 312 (87.2%) survivors. All domains of HRQoL had the lowest scores atdischarge, greatly improved over the first 6 months and showed continued improvement. Patients with TBI still hadsignificantly lower scores in every domain than the reference group 2 years after discharge. Female patients had lower MCSscores than the males (OR¼ 1.8, 95% CI: 1.1–2.9). Patients older than 30 had lower scores in PCS (OR¼ 1.7, 95% CI:1.1–2.6). Patients with severe TBI had lower scores in both PCS (OR¼ 1.9, 95% CI: 1.2–3.1) and MCS (OR¼ 1.6, 95%CI: 1.0–2.6) compared with those with moderate TBI.Conclusions: HRQoL of a group of Chinese patients with TBI improved during 2 years after discharge. Age, sex and severityof TBI were significantly associated with physical or mental HRQoL after discharge.

Keywords: Health-related quality-of-life, traumatic brain injury, SF-36, follow-up

Introduction

Traumatic brain injury (TBI) is a leading cause ofdeath and long-term disability in the world, espe-cially in young adults [1]. In the US, it was estimatedthat an average of 1.7 million TBIs occurred eachyear [2]. In developing countries, TBI is also a majorpublic health problem [3]. A prospective study fromChina indicated that traumatic injury was the 5thleading cause of mortality in adults less than 40 yearsold, among which TBI was the leading cause oftraumatic injury [4].

Assessment and treatment of TBI have generallyfocused on physical and cognitive impairments

[5–8], emotional issues [9–11], as well as someobjective aspects such as return to work [12, 13].Over recent decades there has been increasingconcern about the importance of measuring health-related quality-of-life (HRQoL) for evaluation ofoutcomes after traumatic injuries [1, 14–18].HRQoL refers to the physical, psychological andsocial domains of health that are unique to eachindividual. The concept of HRQoL has evolved toencompass those aspects of overall quality-of-life(QoL) that can be clearly shown to affect physicaland mental health [19]. Patients with TBI have beenreported to have lower HRQoL than normal refer-ence individuals without TBI [15, 17, 20].

Correspondence: Xue-Bin Hu, Department of Neurosurgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science andTechnology, Wuhan, Hubei, 430032, PR China. Tel: þ86 27 83792304. Fax: þ86 27 83792352. E-mail: huxb7276@163.com

ISSN 0269–9052 print/ISSN 1362–301X online � 2012 Informa UK Ltd.DOI: 10.3109/02699052.2011.648707

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Some previous studies also examined the relation-ships between HRQoL and other variables, such asdemographics, injury severity and employment[14, 21]. However, due to the inconsistent findingsand heterogeneous study populations of previousstudies, more studies in different settings are stillneeded to further examine these previous findings.

To the authors’ knowledge, there was only onestudy assessing HRQoL after TBI in a Chinesepopulation, which was a longitudinal cohort study inTaiwan with 158 patients with TBI using the WorldHealth Organization Quality-of-Life scale as themeasurement tool for HRQoL [14]. Results of thisstudy indicated that HRQoL of patients with TBIgreatly improved over the first 6 months andcontinued improvement at 12 months after injury.Only Glasgow Outcome Scale level and depressivestatus were found to be significantly associated withlongitudinal changes in HRQoL over the 12-monthperiod after adjusting for baseline differences. Sinceevidence concerning HRQoL of patients with TBI inChinese populations is still lacking, the present studywas conducted to assess HRQoL among patientswith TBI 2 years after discharge from a neurosurgerydepartment in Wuhan, China. This study also aimedto investigate possible determinants of HRQoL ofthese patients, which may help identify patients whoare more subject to poor HRQoL after TBI. Thisstudy is hoped to help understanding the longitudi-nal changes in HRQoL of patients with TBI andprovide necessary information for further improve-ment of HRQoL after TBI.

Methods

Participants and procedures

The study was performed in Wuhan Union Hospitalwhich houses one of the largest trauma centres inWuhan, China. Wuhan is a largest city in CentralChina and is also the capital of Hubei Province. Thistrauma centre from which the subjects wererecruited locates in the urban central area of thecity and principally served residents in this district.Eligible subjects were patients aged 18 or over whowere admitted to this hospital with TBI during May2005 to April 2008. Because of the diagnosticunreliability, those with mild TBI were excludedbased on the lowest score of Glasgow Coma Scale(GCS) score (GCS¼ 13–15) within 24 hours afteradmission [22]. Patients with blood alcohol levelexceeding 199 mg dL�1 were also excluded becauseGCS score could be decreased by alcohol intoxica-tion [23]. Patients with spinal cord injury were alsoexcluded. A total of 436 patients were invited toparticipate on the day of discharge and 379 (87%)agreed to participate. This study was approved by

the ethics committee of the hospital and all partic-ipants signed informed consents beforeparticipation.

Clinical characteristics abstracted from medicalrecords included cause of injury, length of stay in thehospital and GCS score. On the day of discharge, allparticipants were asked to provide their and theirnext of kin’s telephone numbers and mailingaddresses to enable follow-up. Face-to-face inter-views were also conducted to collect information ondemographic characteristics and HRQoL. Collecteddemographic variables mainly included age, educa-tion level, marital status and employment status. At6 months, 1 year and 2 years after discharge, theparticipants finished three separate follow-up assess-ments of HRQoL via telephone interview.

A reference sample was recruited from people whorequested general health examinations in the samehospital during the same period. The referencegroup was required to be without any previous TBIand frequency matched to patients with TBI by age(within 5 years) and sex. Face-to-face interviewswere conducted to collect information on demo-graphic characteristics and HRQoL from the refer-ence group. A total of 453 people were invited,among which 381 (84.1%) completed theinterviews.

Health-related quality-of-life

The Medical Outcome Short Form 36 (SF-36) wasemployed to measure HRQoL. The SF-36 is a well-validated HRQoL measuring instrument amongindividuals with TBI and has been widely usedamong trauma survivors [16, 20]. This 36-itemquestionnaire consists of eight HRQoL domains thatcomprise two summary measures: the physicalcomponent summary (PCS) and the mental com-ponent summary (MCS).

Statistical analysis

The Statistical Package for the Social Sciences(SPSS), version 12.0 (SPSS Inc., Chicago, IL) wasused for data analysis. A p-value less than 0.05 wasconsidered as statistically significant. Mann-WhitneyU-tests and Wilcoxon’s rank sum tests wereemployed to compare unpaired and paired quanti-tative variables, respectively. Chi-square tests wereused to compare categorical variables. ANOVA wereused for repeated measures to assess the overall timeeffect on HRQoL of patients with TBI. Non-conditional logistic regression was also performedto estimate odds ratios (ORs) and 95% confidenceintervals (CIs) of potential affecting factors for lowHRQoL 2 years after discharge. Median values ofdependent variables were chosen as cut-points. Theinclusion of variables into the model was based on

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biological and statistical considerations. Potentialconfounders were entered into the multivariatemodels if they changed the effect estimates by 10%or more. Variables selected to appear in the finalmodel include: sex, age at admission (�30, >30years), education level (less than high school, higherschool or above), days of stay in the hospital (�14,>14) and GCS score (3–8, 9–12). Inclusion ofadditional variables did not substantially change theresults.

Results

Twenty-one patients with TBI were lost to follow-upmainly because of change of telephone number orrefusal. There were 337 (94.1%) and 312 (87.2%)survivors out of the remaining 358 participants aftera 1-year and a 2-year follow-up, respectively.Baseline demographic and clinical characteristics ofthe trauma patients and the reference group werepresented in Table I. The mean age of patients whowere followed up at admission was 32.7 (12.2) years.Traffic accident, fall and assault were the majorcauses of injuries. The baseline characteristics ofpatients who were followed up were similar to the

characteristics of those who were lost to follow-up(data not shown).

Results of HRQoL assessments at discharge, 6months, 1 year and 2 years after discharge of the 312survivors are listed in Table II. All eight domains ofthe HRQoL had the lowest scores at discharge,greatly improved over the first 6 months and showedcontinued improvement 1 year and 2 years afterdischarge. At 6 months after discharge, there wasstatistically significant improvement of HRQoL in allfour physical health domains and two mental healthdomains (social function and mental health). After 1year from discharge, all eight domains had signifi-cant improvements compared with measurements atdischarge. Statistically significant time effects wereobserved from ANOVA for repeated measures in alleight domains. However, patients with TBI still hadsignificant lower scores in every domain than thereference group even 2 years after discharge.

Odds ratios with confidence intervals for lowHRQoL 2 years after discharge from logistic regres-sion were shown by summary measurement inTable III. Female patients were found to be withlower MCS scores than the males (OR¼ 1.8, 95%CI: 1.1–2.9). Patients older than 30 had lower scoresin PCS (OR¼ 1.7, 95% CI: 1.1–2.6). Patients withlength of stay in the hospital longer than 14 days hadlower PCS and MCS scores than those who stayed inthe hospital no more than 14 days, but the associa-tions were not statistically significant. Patients withsevere TBI (GCS score 3–8) had lower scores in bothPCS (OR¼ 1.9, 95% CI: 1.2–3.1) and MCS(OR¼ 1.6, 95% CI: 1.0–2.6) compared with thosewith moderate TBI (GCS score 9–12).

Discussion

The present study was the first longitudinal cohortstudy to investigate the HRQoL of patients with TBIafter discharge in a Chinese population using SF-36as the measuring tool. The study observed animprovement in HRQoL of patients with TBIduring 2 years after discharge. Such a change ofHRQoL over time was consistent with previousfindings [14, 24]. However, in keeping with findingsfrom previous studies [15, 17, 20], the HRQoLscores of patients with TBI were still lower thanthose of the general population in all domains, even2 years after discharge.

A difference of HRQoL was found in MCSbetween the two genders, indicating female traumapatients after discharge may be in poorer mentalhealth status, which was in line with some previousreports [21, 25]. In the present study, older patientswere found to have lower HRQoL 2 years afterdischarge on the physical health aspect. This may be

Table I. Baseline demographic and clinical characteristics ofpatients with traumatic brain injury and the reference group.

VariablesPatients with TBI

(n¼ 358)Reference group

(n¼ 381)

Sex, n (%)Male 257 (71.8) 275 (72.2)Female 101 (28.2) 106 (27.8)

Age at admission, yearsMean (SD) 32.7 (12.2) 32.1 (11.6)Range 18–56 17–57

Education, n (%)Less than high school 137 (38.3) 156 (40.9)High school or above 221 (61.7) 225 (59.1)

Marital status, n (%)Married or cohabitant 261 (72.9) 282 (74.0)Single or divorced 97 (27.1) 99 (26.0)

Employment, n (%)Employed 331 (92.5) 360 (94.5)Unemployed 27 (7.5) 21 (5.5)

Cause of injury, n (%)Traffic accidents 181 (50.6)Fall 74 (20.7)Assault 71 (19.8)Others 32 (8.9)

Length of stay in hospitalMean (SD) 15.7 (9.4)Range 1–37

GCS score, n (%)3–8 147 (41.1)9–12 211 (58.9)

GCS, Glasgow Coma Scale; TBI, Traumatic Brain Injury.

HRQoL after TBI 185

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partly explained by slower recovery of older patients.However, lowered HRQoL of older patients may notnecessarily be the effect of the trauma or the receivedtreatment because, even in the general population,the older also have lower HRQoL than the younger[26]. As expected, it was found that trauma severitywas significantly associated with low HRQoL onboth physical and mental health aspects. Similarresults were also found in some but not all previousstudies [15, 20, 27]. Such inconsistent findingscould be explained by the differences in time pointsfor data collection, measuring tools for HRQoL,trauma severity and ethnic/cultural background ofthe patients and also by chance. In any case, the

present study confirmed the impact of TBI onindividuals’ HRQoL and the importance of measur-ing HRQoL in evaluating prognosis following TBI.The results suggest female, older or severe patientsare more subject to impaired HRQoL after TBI.These groups of patients need additional attentionand care during their rehabilitation process, whichmay depend on corporate efforts of health workers,family members and even the patients themselves.

The present study had several limitations. First,only patients with moderate-to-severe TBI wererecruited and, thus, this study was unable to evaluateHRQoL of patients with mild TBI. Secondly, thisstudy was conducted in a single trauma centre,although this unit is one of the largest trauma centresin this city. The participants included might not berepresentative of all patients with TBI in this city andthe results may not be generalized to the wholepopulation in this city or other populations in China.Thirdly, because of practical difficulties, the follow-up was only 2 years, which was not long enough toassess long-term HRQoL of patients with TBI afterdischarge. In addition, this study did not addresssome variables that may potentially affectingHRQoL, such as existence of comorbidity, employ-ment after injury and social support [14, 20, 21].Overall, all these limitations should be taken intoconsideration in future studies.

Conclusion

In conclusion, the HRQoL of a group of Chinesepatients with TBI improved during 2 years afterdischarge. Age, sex and GCS score were significantlyassociated with physical or mental HRQoL afterdischarge. Further studies in Chinese populationsare still warranted.

Table II. Health-related quality-of-life among patients with traumatic brain injury and the reference group.

Dimensions

Patients with traumatic brain injuries (n¼ 312)

Referencegroup (n¼ 381)At discharge

6 monthsafter discharge

1 year afterdischarge

2 years afterdischarge

Physical function# 52.1 (23.7) 58.8 (26.8)* 63.0 (27.9)* 65.8 (29.2)* 81.7 (20.5)Role physical# 49.4 (27.1) 53.7 (24.7)* 57.5 (23.1)* 62.7 (24.2)* 80.4 (27.3)Bodily pain# 51.3 (28.6) 59.1 (26.6)* 63.2 (27.8)* 63.7 (28.4)* 82.1 (22.7)General health# 44.1 (25.4) 48.9 (23.3)* 52.1 (21.3)* 54.8 (21.8)* 60.4 (20.8)Vitality# 38.9 (22.8) 41.3 (21.6) 46.8 (22.6)* 49.9 (21.7)* 57.9 (21.6)Social function# 52.4 (27.3) 59.5 (27.6)* 64.6 (29.2)* 71.5 (28.3)* 81.5 (25.8)Role emotional# 58.8 (27.0) 60.7 (22.7) 65.8 (23.4)* 71.9 (23.6)* 79.6 (22.4)Mental health# 47.8 (21.6) 52.8 (21.4)* 57.1 (22.5)* 59.2 (24.4)* 69.7 (21.5)

Data are presented as means and standard deviation (SD).*p< 0.05 under Wilcoxon’s rank sum test compared with measurements at discharge; #p< 0.05 for time effect under ANOVA for repeatedmeasures.

Table III. Logistic regression for low health-related quality-of-life 2 years after discharge among 312 patients with traumaticbrain injury.

PCSa MCSb

VariablesOdds ratio(95% CI)c

Odds ratio(95% CI)c

SexMale 1.0 (referent) 1.0 (referent)Female 1.3 (0.7–2.4) 1.8 (1.1–2.9)*

Age at admission, years�30 1.0 (referent) 1.0 (referent)>30 1.7 (1.1–2.6)* 1.3 (0.6–2.8)

EducationLess than high school 1.0 (referent) 1.0 (referent)High school or above 1.1 (0.5–2.4) 0.8 (0.3–2.1)

Stay in the hospital, days�14 1.0 (referent) 1.0 (referent)>14 1.5 (0.8–2.8) 1.2 (0.6–2.4)

GCS score9–12 1.0 (referent) 1.0 (referent)3–8 1.9 (1.2–3.1)* 1.6 (1.0–2.6)*

PCS, Physical Component Summary; MCS, Mental ComponentSummary; GCS, Glasgow Coma Scale.aCut-point: 43.7 (median); bCut-point: 46.3 (median); cAdjustedfor all the listed variables; *p< 0.05.

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Declaration of interest: The authors report noconflicts of interest. The authors alone are respon-sible for the content and writing of the paper.

References

1. Nichol AD, Higgins AM, Gabbe BJ, Murray LJ, Cooper DJ,Cameron PA. Measuring functional and quality of lifeoutcomes following major head injury: Common scales andchecklists. Injury 2011;42:281–287.

2. Faul M, Xu L, Wald MM, Coronado VG. Traumatic braininjury in the United States: Emergency department visits,hospitalizations, and deaths 2002–2006. Atlanta, GA:Centers of Disease Control and Prevention, NationalCenter for Injury Prevention and Control; 2010.

3. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G,Kobusingye OC. The impact of traumatic brain injuries: Aglobal perspective. NeuroRehabilitation 2007;22:341–353.

4. Wu X, Hu J, Zhuo L, Fu C, Hui G, Wang Y, Yang W,Teng L, Lu S, Xu G. Epidemiology of traumatic brain injuryin eastern China, 2004: A prospective large case study. TheJournal of Trauma 2008;64:1313–1319.

5. Bercaw EL, Hanks RA, Millis SR, Gola TJ. Changes inneuropsychological performance after traumatic brain injuryfrom inpatient rehabilitation to 1-year follow-up in predicting2-year functional outcomes. The Clinical Neuropsychologist2010;25:72–89.

6. Arango-Lasprilla JC, Rosenthal M, Deluca J, Komaroff E,Sherer M, Cifu D, Hanks R. Traumatic brain injury andfunctional outcomes: Does minority status matter? BrainInjury 2007;21:701–708.

7. Arango-Lasprilla JC, Rosenthal M, Deluca J, Cifu DX,Hanks R, Komaroff E. Functional outcomes from inpatientrehabilitation after traumatic brain injury: How do Hispanicsfare? Archives of Physical Medicine and Rehabilitation2007;88:11–18.

8. Mailhan L, Azouvi P, Dazord A. Life satisfaction anddisability after severe traumatic brain injury. Brain Injury2005;19:227–238.

9. Bombardier CH, Fann JR, Temkin NR, Esselman PC,Barber J, Dikmen SS. Rates of major depressive disorderand clinical outcomes following traumatic brain injury. TheJournal of the American Medical Association 2010;303:1938–1945.

10. Engberg AW, Teasdale TW. Psychosocial outcome followingtraumatic brain injury in adults. a long-term population-based follow-up. Brain Injury 2004;18:533–545.

11. Underhill AT, Lobello SG, Stroud TP, Terry KS,Devivo MJ, Fine PR. Depression and life satisfaction inpatients with traumatic brain injury: A longitudinal study.Brain Injury 2003;17:973–982.

12. Novack TA, Labbe D, Grote M, Carlson N, Sherer M,Arango-Lasprilla JC, Bushnik T, Cifu D, Powell JM,Ripley D, et al. Return to driving within 5 years ofmoderate-severe traumatic brain injury. Brain Injury2010;24:464–471.

13. Johansson U, Bernspang B. Life satisfaction related to workre-entry after brain injury: A longitudinal study. Brain Injury2003;17:991–1002.

14. Lin MR, Chiu WT, Chen YJ, Yu WY, Huang SJ, Tsai MD.Longitudinal changes in the health-related qualityof life during the first year after traumatic brain injury.Archives of Physical Medicine and Rehabilitation 2010;91:474–480.

15. Jacobsson LJ, Westerberg M, Lexell J. Health-related quality-of-life and life satisfaction 6–15 years after traumatic braininjuries in northern Sweden. Brain Injury 2010;24:1075–1086.

16. Guilfoyle MR, Seeley HM, Corteen E, Harkin C,Richards H, Menon DK, Hutchinson PJ. Assessing qualityof life after traumatic brain injury: Examination of the shortform 36 health survey. Journal of Neurotrauma 2010;27:2173–2181.

17. Hawthorne G, Gruen RL, Kaye AH. Traumatic brain injuryand long-term quality of life: Findings from an Australianstudy. Journal of Neurotrauma 2009;26:1623–1633.

18. Emanuelson I, Andersson Holmkvist E, Bjorklund R,Stalhammar D. Quality of life and post-concussion symptomsin adults after mild traumatic brain injury: A population-based study in western Sweden. Acta NeurologicaScandinavica 2003;108:332–338.

19. Centers for Disease Control and Prevention. Measuringhealthy days: Population assessment of health-related qualityof life. Atlanta, GA: Centers for Disease Control andPrevention; 2000.

20. Findler M, Cantor J, Haddad L, Gordon W, Ashman T. Thereliability and validity of the SF-36 health survey question-naire for use with individuals with traumatic brain injury.Brain Injury 2001;15:715–723.

21. Andelic N, Hammergren N, Bautz-Holter E, Sveen U,Brunborg C, Roe C. Functional outcome and health-relatedquality of life 10 years after moderate-to-severe traumaticbrain injury. Acta Neurologica Scandinavica 2009;120:16–23.

22. Esselman PC, Uomoto JM. Classification of the spectrum ofmild traumatic brain injury. Brain Injury 1995;9:417–424.

23. Jagger J, Fife D, Vernberg K, Jane JA. Effect of alcoholintoxication on the diagnosis and apparent severity of braininjury. Neurosurgery 1984;15:303–306.

24. Lippert-Gruner M, Maegele M, Haverkamp H, Klug N,Wedekind C. Health-related quality of life during the firstyear after severe brain trauma with and without polytrauma.Brain Injury 2007;21:451–455.

25. Ulvik A, Kvale R, Wentzel-Larsen T, Flaatten H. Quality oflife 2–7 years after major trauma. Acta AnaesthesiologicaScandinavica 2008;52:195–201.

26. Li L, Wang HM, Shen Y. Chinese SF-36 Health Survey:Translation, cultural adaptation, validation, and normal-isation. Journal of Epidemiology and Community Health2003;57:259–263.

27. Colantonio A, Dawson DR, McLellan BA. Head injury inyoung adults: Long-term outcome. Archives of PhysicalMedicine and Rehabilitation 1998;79:550–558.

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