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The narrative around concussion awareness and prevention is beginning to change as society becomes more aware of the short- and long-term consequences of mild and moderate head trauma. However, the medical community has been slow to adopt a universal set of guidelines for proper evaluations and concussion management. This has led to conflicting medical advice being applied to concussion treatment, including inconsistent time frames for follow-up appointments, improper specialist referrals, premature medical care discharges and conflicting return to activity instructions.[1]

Developing Living Guidelines

In an effort to standardize treatment of concussions and mild traumatic brain injuries (mTBI), the Ontario Neurotrauma Foundation has created internationally recognized living guidelines for rehabilitating adults and children. Developed collaboratively by researchers, clinicians and policymakers from Ontario and Quebec, these guidelines include 71 recommendations related to brain injury rehabilitation and 195 recommendations on managing and treating the residual effects of concussions and mTBI.

The first of its kind, these living guidelines will allow for real-time updates based on the most current research, providing healthcare professionals with the tools needed to properly treat concussions and mTBI.

Proper Diagnosis

The guidelines state that proper diagnosis of mild traumatic brain injuries and concussions is the first critical step in successful management and will result in improved outcomes and injury prevention. Diagnosis is determined by ruling out more severe forms of TBI, cervical spine injuries and medical and neurological conditions that can present concussion-like symptoms through CT scans.[2] This is followed by accurate recording of symptoms for comparative analysis, written and verbal communication with the patient regarding the recovery process and persistent monitoring and exploration of potential risk factors.[3]

Addressing Individual Needs

Following diagnosis, the guidelines emphasize the need for an individualized management plan which includes monitoring for acute complications, re-assessments, education on anticipated symptoms and recovery, as well as follow-up recommendations.[4] While medical care professionals have traditionally advised patients to rest until symptoms subside, preliminary evidence is emerging that supports active rehabilitation including psychological and cognitive interventions to improve attention and memory.[5]

Psychological Impact  

There is a growing controversy within the medical community between the diagnosis of post-concussion symptoms and other diagnoses that can also result from traumatic experiences including depression, anxiety and post-traumatic stress disorder. At the psychological level, patients who have experienced a concussion or mTBI may encounter acute stress or become isolated from others, unable to engage in social interactions. These mental health symptoms and outcomes must be understood within the broader context of the individual’s medical history to properly assess and manage the duration of recovery.[6] 

Regardless of whether there is a causal link between a concussion or mTBI and mental health problems in patients, there is no evidence to indicate that treatment should be any different. Psychological and pharmacological interventions may be necessary given the patient’s unique circumstances. Others may simply require positive reinforcement, education, increased social support, as well as balanced meals and exercise.[7]

Conclusion

Where it is advantageous to include outside experts is in the assessment and management of balance and dizziness, according to the guidelines. Post-concussion or mTBI patients experience episodes of vertigo, nausea, migraines and vision disorders that require evaluation by healthcare professionals with specialized training in the vestibular system.[8] Treatment should be administered by a qualified physician or healthcare professional certified in addressing balance, dizziness and other vestibular dysfunctions.

The Ontario Neurotrauma Foundation’s living guidelines also provide specific recommendations for assessing and managing sport-related concussions and mTBI, post-traumatic headaches, sleep-wake disturbances, cognitive difficulties, fatigue and offer suggestions around returning to work, school or other activities.

As research surrounding brain health awareness, concussion protocol and treatment of mTBI continues to evolve, these living guidelines will provide comprehensive, up-to-date assessment and management protocol. This will ensure that healthcare professionals, patients and their families are equipped with a holistic understanding of their diagnoses and more importantly, their road to recovery.

[1]Stern, Robert, et al. “Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments.” Journal of Neurotrauma Volume 34, Feb. 15, 2017.

[2] Parachute. Canadian Guideline on Concussion in Sport. In. Toronto: Parachute; 2017

[3] Marshall S, Bayley M, McCullagh S, Berrigan L, Fischer L, Ouchterlony D, Rockwell C, Velikonja D, et al. Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms: 3nd Edition (for Adults 18+ years of age). Ontario Neurotrauma Foundation, 2018. 

[4] McAllister TW, Arciniegas D. Evaluation and treatment of postconcussive symptoms. NeuroRehabilitation. 2002;17(4):265-283.

[5] Cooper DB, Bunner AE, Kennedy JE, et al. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging Behav. 2015;9(3):403-420.

[6]  Marshall S, Bayley M, McCullagh S, Berrigan L, Fischer L, Ouchterlony D, Rockwell C, Velikonja D, et al. Guideline for Concussion/Mild Traumatic Brain Injury and Prolonged Symptoms: 3nd Edition (for Adults 18+ years of age). Ontario Neurotrauma Foundation, 2018. 

[7] Broshek DK, De Marco AP, Freeman JR. A review of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228-237.

[8] Hansson EE, Månsson NO, Håkansson A. Effects of specific rehabilitation for dizziness among patients in primary health care. A randomized controlled trial. Clin Rehabil. 2004;18(5):558-565.