It is often unclear which treatments are most appropriate for the constellation of concussion symptoms. Thus, evidence-based education as well as treatment and management options to facilitate recovery are required.
Increased awareness, recognition, and diagnosis of concussion in recent years have resulted in a perceived epidemic. While the vast majority of concussed patients spontaneously recover relatively rapidly, for those with persisting symptoms, confusion regarding appropriate management strategies remains. Patients and clinicians need to navigate an overabundance of information on concussion and related treatments, many of which are not evidence-based. Moreover, it is often unclear which treatments are most appropriate for the constellation of concussion symptoms. Thus, evidence-based education as well as treatment and management options to facilitate recovery are required.
Concussions have received considerable media coverage especially in relation to sports. The proliferation of information, both substantiated and unsubstantiated, has magnified anxiety and worry for patients and their families. Furthermore, not all information provided to the public and patients by the media and other sources reflects the most current diagnostic and management data (eg, prolonged periods of rest).
Using rigorous methodology, The Ontario Neurotrauma Foundation (ONF) reviewed, evaluated, and synthesized the evidence on concussions into clinical practice guidelines for both pediatric and adult concussion populations.1 Using a consensus-building process with a broad range of stakeholders (clinicians, patients, families, and policy experts), the ONF has developed standards for post-concussion care (http://concussionsontario.org/standards/purpose-and-target/).
While most patients do not experience a prolonged recovery from concussion, many people know or have heard about someone who has suffered significant longer-term effects related either to the direct or secondary effects of concussion(s). It is important that patients and families receive clear and accurate information from trusted medical providers and clinicians with experience and training in concussion care. Patients and their caregivers/families should be provided with information on diagnosis, post-injury care during early and later stages of recovery, and about helpful resources that support recovery and provide reassurance.
The acute stage
In the acute stage, every patient who is suspected of having a concussion needs to be assessed by qualified medical practitioners licensed to provide this clinical diagnosis. A concussion is a mild traumatic brain injury. This diagnosis can only be made by those qualified and licensed to do so; other health care providers may suspect a concussion but cannot diagnose one. Following medical rule-outs, neuropsychologists are also able to assess and diagnose concussions, particularly in patients with persistent symptoms.
It is important that an initial medical assessment occur to rule-out more serious forms of traumatic brain and spine injuries or other medical and neurological conditions that can present with concussion-like symptoms. A diagnosis of concussion may be made (or ruled out) after conducting a comprehensive evaluation of the patient with a suspected concussion. This medical assessment includes:
• A clinical history
• Identification of potential risk factors that may impact the duration of recovery
• A review of current symptoms
• A physical examination with evidenced-based use of adjunctive diagnostic tests as indicated (eg, CT scan, MRI)
Major change in practice
The majority of individuals who experience concussions will make a full recovery and be able to return to their respective daily activities within 3 to 4 weeks. Recent research has found that after a concussion patients should not remain in a darkened room without any stimulation until they feel better, as this does not facilitate recovery. This is a change from what has been accepted practice. After a concussion, it is important to have relative rest during the first 24 to 72 hours followed by a gradual re-introduction of physical and cognitive activity to a level that is tolerated by the patient. Depending on the severity and symptoms, patients will progress at different rates. This is true of regular daily activities, school/work, and exercise at subthreshold levels.
Being active and having some stimulation is part of the healing process. This should not include a return to contact sports or other activities in which there is a high risk of re-injury. Resuming such activities should be done in consultation with the diagnosing professional and the interdisciplinary care team. Evidence indicates that physical and cognitive activities should be started at levels below that which would trigger symptoms (subthreshold).
It is important to assess the patient’s risk factors for a prolonged recovery, after a concussion. The presence of one or more risk factors should be identified in care plans and referrals. These risk factors include:
• High score on either the Post-Concussion Symptom Scale (PCSS; > 40), or the Rivermead Post-Concussion Questionnaire2-4
• Previous concussion history5-8
• Persistent post-traumatic headache and migraine7,9
• Symptoms/signs of vestibulo-ocular abnormalities (problems maintaining visual stability during head movements) and of cognitive difficulties (problems with perception, memory, judgment, and reasoning)5,6,14-17
• Pre-injury history of sleep disturbance and/or post-injury changes in sleep patterns, difficulty sleeping10,18,19
• Increased symptoms with return to school, work, or exercise16
• Returning to a contact/risk of contact sport activity12,20
Female concussion patients seem to be at higher risk for prolonged recovery and this should be considered along with the other risk factors when determining if multidisciplinary care is required.3,9,10
One to two weeks after a concussion, a follow-up assessment with a primary care provider or a physician who have experience in concussion management needs to be done, which includes:
• Corroboration of the diagnosis of concussion and/or re-evaluation based on observed symptoms
• Identification of ongoing symptoms that may require intervention if they persist beyond 3 to 4 weeks, or the identification of risk factors for a prolonged recovery (ie, high post-concussion symptom score, previous concussion history, migraine or mood symptoms)
• Considerations for diagnostic imaging and referrals for additional medical and clinical consultations
• Additional educational resources such as written information or video tutorials regarding symptom management strategies and reassurance
Some patients will need interdisciplinary care to help manage their post-concussion care. Post-concussion care requires the integration of interdisciplinary care to provide services for the constellation of symptoms that may present (physical, cognitive and/or emotional). Patients who experience persistent symptoms as well as those at risk of a delayed recovery, may benefit from a referral to a concussion clinic that has access to medical and clinical professionals with licensed training in brain injury (eg, sports medicine, neuropsychology, physiotherapy, occupational therapy, athletic therapy, speech and language therapy, neurology, neurosurgery, and rehabilitation medicine). Patients need access to timely coordinated interdisciplinary care that includes the primary care provider.
A concussion clinic consists of an interdisciplinary team with three or more different regulated health care provider disciplines. No one provider or discipline can manage and treat all persistent symptoms of concussion. The core functions required to manage post-concussion symptoms include:
• Diagnosis and access to medical services
• Physical treatment options
• Cognitive evaluation and treatment
• Evaluation and treatment of emotional conditions
• Functional integration
• Coordination of care
It can be difficult for a busy clinician to keep on top of clinical research and to evaluate the credibility of the new research. Because knowledge is continually changing it is important to stay up-to-date, which can be done by using clinical practice guidelines. Two examples of current guidelines can be found at concussionsontario.org: the Guideline for Pediatric Concussion, and the Second Edition of the Guidelines for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms; the third edition will be released in the fall of 2017).
Acknowledgement-Dr Marshall is grateful to Judith Gargaro, BSc, MEd, Ontario Neurotrauma Foundation; Diana Velikonja, PhD, CPsych, Hamilton Health Sciences and McMaster University; Deanna Quon, MD, FRPC, Ottawa Hospital Rehabilitation Centre; Ruth Wilcock, Ontario Brain Injury Association; Corinne Kagan, BPS Cert, Ontario Neurotrauma Foundation, and the members of the Concussion Standards Working Groups.
1. VA/DoD Clinical Practice Guidelines: Management of Concussion-Mild Traumatic Brain Injury (mTBI); 2016. https://www.healthquality.va.gov/guidelines/rehab/mtbi/. Accessed October 3, 2017.
2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus Statement on Concussion in Sport: the 5th International Conference on Concussion in Sport. Berlin, Germany: October 2016. Br J Sports Med. 2017. http://bjsm.bmj.com/content/early/2017/04/28/bjsports-2017-097699. Accessed September 28, 2017.
3. Parachute. Canadian Guideline on Concussion in Sport; 2017. http://www.parachutecanada.org/injury-topics/item/canadian-guideline-on-concussion-in-sport . Accessed September 28, 2017.
4. The Top 5 Key Messages From the Canadian Concussion Collaboration; June 32017. http://physicians.cattonline.com/resources/files/key-messages-eng.pdf. Accessed September 28, 2017.
Dr Marshall is Professor and Division Head, Physical Medicine and Rehabilitation, The Ottawa Hospital and University of Ottawa, Canada.