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As part of our commitment to being leaders in our field we have recently formalized our program for the assessment and treatment of those with concussion and mild traumatic brain injury. We pride ourselves in being able to offer care for these complex patient populations.
According to the most recent Zurich Guidelines1, rest is the cornerstone of concussion management. It is estimated that with proper rest in the early stages of injury up to 90 % of those with concussion will have complete resolution of symptoms within the first ten days.1 What do we do with those patients who continue to be symptomatic even after prolonged rest? A supplemental publication released with the Zurich Guidelines discussed emerging evidence of the use of graded and sub-symptom exercise in patients with delayed recovery.2 The publication further recommends a multidisciplinary assessment for other factors that may be contributing to continued symptoms including: vestibular, cervical, visual or cognitive.
Our Concussion Program begins with a thorough subjective history that includes details regarding the mechanism of injury, current symptoms and their trajectory, results of investigations and treatments, past medical history, medications, activity level and tolerance to various stimuli. Objective testing includes a neurological exam, assessment of the cervical spine6 and comprehensive balance testing. As dizziness is one of the most common3 and persistent4 symptoms after concussion and is associated with delayed recovery4,5, a detailed vestibular exam is also done with the use of infrared goggles.
A treatment program is designed specifically for the particular needs of each patient and is based on the results of testing and is reflective of the available evidence. As patients are often doing too much or too little it is important that they keep track of daily activities and symptom levels to help them identify their optimum level of activity. Exercise programs often include balance and motion training7, sensorimotor6 and proprioceptive exercises for the neck and graded sub-symptom exercise8.
As the best practice for concussion management is multidisciplinary1,2, we believe in an open communication with the primary care physician and other health professionals involved in each case to help better serve the patients’ needs and goals. A return to work or return to sport is an important aspect in the final stages of recovery so we will routinely coordinate with coaches, employers or third party payers to help with a safe and timely transition.
McCrory P, et al Consensus statement on concussion in sport, Zurich November 2012 Br J Sports Med 2013;47:250-258
Schneider KJ, et al. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med 2013;47:304-30
Yang CC et al The association between the postconcussion symptoms and clinical outcomes for patients with mild traumatic brain injury. J Trauma 2007 Mar;62(3):657-63
Masson F et al Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Inj. 1996;10:487-497
Lau, BC et al Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J of Sport Med, Vol. 39, No 11 2311-2318
Kristjansson, E; Treleavan, J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Ortho & Sports Physical Therapy, Vol 39, 5 May 2009 364-377
Schneider, K et al Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med 2014; 0: 1-6 Leddy, JJ; Willer, B.
Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports Vol 12, No 6, Nov/Dec 2013 370-376