Concussion rehabilitation

Sue Barlow, OT (biography) and Jennifer Loffree, OT (biography)

Disclosures: Susan Barlow and Jennifer Loffree work at the GF Strong Rehabilitation Centre. Ms. Barlow owns a private OT practice. Ms. Loffree is a member of the BC Concussion Advisory Network and is a community partner on a research study with WorkSafe BC. No conflicts of interest.

Mitigating Potential Bias:

• • Recommendations are consistent with published guidelines (Ontario Neuro-trauma Foundation (ONF) Guidelines)
  • Recommendations are consistent with current practice patterns

Article

There is increased awareness in the community and medical field regarding the physical, psychological and functional effects of concussion. The growing demand for concussion rehabilitation services is realized at all levels of the health care system. Over the past year, the number of referrals to the GF Strong Rehabilitation Centre concussion services has dramatically increased. These services include the Early Response Concussion Service (ERCS) and the Self-Management Program (SMP).

ERCS and SMP were developed based on evidence that supports the benefits of early education and reassurance. The Ontario Neurotrauma Foundation (ONF) Guidelines for Concussion/mTBI state: Education should be provided in printed material combined with verbal review and consist of:

• Symptoms and expected outcomes
• Normalizing symptoms (education that current symptoms are expected and common after injury event)
• Reassurance about expected positive recovery
• Gradual return to activities and life roles
• Techniques to manage stress” (1, p7).

The statistics regarding recovery from concussion indicate that the majority of individuals will be symptom-free at 3 months; within 6 months 70-75% will be symptom free; and within a year 10% will have 1 persisting symptom and 5% will have 4 or more persisting symptoms (2).

Early Response Concussion Service: The Early Response Concussion Service (ERCS) is an Occupational Therapist led early intervention and follow-up service for patients living with the effects of a recent concussion. The mandate is to provide patients with education on symptom management and return to activities as soon as possible post-injury to reduce the risk of prolongation of recovery.

Self-Management Program: The Self-Management Program (SMP) is a telephone and community based rehabilitation program designed for patients with persistent concussion symptoms (> 6 months). Patients work with an Occupational Therapist and a Psychologist to learn adaptive strategies with the focus on improving function rather than symptom reduction. Trans-disciplinary interventions are based in ‘self-efficacy’ and ‘cognitive behavioral therapy’ frameworks. Outcome measures have been captured in a pilot study published in 2012 (3).

What are the care gaps?

The identified care gaps are two fold:

• Difficulties disseminating the most current, evidence based concussion education/guidelines to patients at all levels of the health care system.
  • Up to 78% of patients with concussion will present to their family physician for follow-up care after injury (4,5). Until recently, there were no comprehensive guidelines to assist practitioners to support patients’ recovery from concussion.
  • The literature indicates that the majority of family physicians (48-84%) advised their patients to rest (6,7). Without more specific guidelines on self-managing symptoms and gradually returning to activities, patients are unsure of how to operationalize this recommendation. Of note, prolonged rest can have a negative impact on recovery (8,9). In regards to “rest”, 2 days is the recommended amount. However, then it’s about a “gradual resumption” to activities (8).

• Patients not being able to receive timely access to publicly funded concussion rehabilitation services when required.
• Over the past 2 years, a significant increase in referrals to ECRS and SMP, without an equitable increase in resources has meant increased wait times. The delayed access to service has had potential adverse affects for patients. Research and clinical experience suggest that patient distress, perception of lack of control over symptoms and feeling unsupported and unclear of how to manage symptoms can contribute to an exacerbation of concussion symptoms and can increase the risk of persisting symptoms (3,10). In response to this care gap, the ERCS and SMP service delivery models were adjusted in order to improve patients’ timely access to evidence based guidelines and rehabilitation service. However, both publically funded programs are still pressed to meet this care gap.

Data that answers these questions or gaps

• The number of referrals to ERCS has doubled over the past 5 years resulting in a 4 month waitlist for direct intervention, thus no longer an early response service. Recent changes to the education delivery model from individual to group-based has eliminated the wait-list and freed up clinical time for the Occupational Therapist to provide individual intervention to more complex patients at high risk for prolongation of symptoms.
• The waitlist for SMP services was consistently 4 months since developed in 2003; however this wait-time increased to 11 months in 2014.   In response to this care gap, a Phase 1 portion of the SMP was implemented, offering clients telephone-based education and coaching to apply self management strategies while on the “wait-list”.  This change to the service delivery model reframes the “waitlist” to a “Phase 1” which allows for immediate active engagement by the patient, rather than passive waiting. This change also creates an opportunity for the patient, in collaboration with their family physician, to apply evidence based self-management strategies.
• In 2013, the number of ERCS patients who required a referral to the SMP was 3/700. This data supports the efficacy of an early education and reassurance service, as described in the literature (1,11).

What we recommend/our practice tip:

The Ontario Neurotrauma Foundation (ONF) Guidelines for Concussion/mTBI & Persistent Symptoms are a practical and user friendly tool to guide health care practitioners to diagnose and treat patients with concussion. The ONF completed systematic reviews of the evidence regarding diagnosis and management of concussion. These evidence based guidelines are broken down to address specific symptoms. Both the adult and pediatric versions are available for free download at www.onf.org.

Many family physicians use the Sport Concussion Assessment Tool – 3rd Edition (SCAT3), a standardized tool for assessing patients with concussions. This tool was originally intended for “evaluating injured athletes” on the sidelines, but it can be easily adapted for a medical office environment (12).  While the SCAT3 is an excellent tool to assist in evaluating a concussion, the ONF provides more information in regards immediate treatment/management. Specifically, the ONF Guidelines can assist Family Physicians with not only diagnosis, but also management of concussion. With the recommendations outlined in the ONF Guidelines, Family Physicians can provide their patients with evidence-based self-management strategies that they can start to implement immediately upon leaving the Physician’s office, as opposed to waiting until they are seen at a concussion rehabilitation service to hear this information.

Another key practice tip is for Family Physicians to provide education and reassurance to patients regarding the non-specificity of concussion symptoms and the interconnection between the medical condition (concussion), physiological symptoms (headaches, dizziness, sleep, pain, etc), psychological factors (anxiety, depression, PTSD, etc) and situational demands (demanding responsibilities and high expectations of self). This approach supports the use of self-management strategies to address patients’ presenting symptoms, and is the current practice of the concussion rehab specialists at GF Strong Rehab Centre.

In addition to providing patients with recommendations outlined in the ONF Guidelines, Family Physicians can offer their patients tools to support self-management of their recovery such as the following:

• HEADWays: concussion self-management App developed by GF Strong Physiatrists and ERCS Occupational Therapist https://itunes.apple.com/ca/app/headways/id738391144?mt=8
• Brainstreams: Concussion 101 www.brainstreams.ca
• Video: Concussion management and return to learn – Dr. Mike Evans https://www.youtube.com/watch?v=_55YmblG9YM
• Positive Coping with Health Conditions: A Self-Care Workbook http://www.comh.ca/pchc/
• Pain BC Webinars www.painbc.ca/chronic-pain/webinars
• Good Night Mind – C. E. Carney & R. Manber, CBT approach to insomnia
• Mindfulness Meditation resources:
  • Headspace – www.headspace.com
  • One Moment Meditation – www.onemomentmeditation.co
• Return to work handout: Concussion-Info-Return-to-work
• Concussions: A guide to understanding symptoms and recovery: booklet by GF Strong Rehab Centre: Concussions-Symptoms-Recovery-Apr-2014
• Work Safe BC: for work related concussions Work Safe BC offers rehabilitation services http://www.worksafebc.com/claims/rehab_and_rtw/default.asp
• ICBC also offers rehabilitation services when a patient’s concussion is sustained in a MVA http://www.icbc.com/claims/injury/Treatment-and-Injury/Pages/default.aspx

Community based Occupational Therapy and Psychology services can be funded through ICBC, and Work Safe BC. Family physicians can recommend and refer to these services once the claim is accepted.

References

1. Ontario Neurotrauma Foundation (ONF) Guidelines for Concussion/mTBI & Persistent Symptoms.  2^nd Toronto:  Ontario Neurotrauma Foundation; 2013.  (View)
2. Iverson G, Zasler N, Lange RT. Post-concussive disorder.  Post-Concussive Disorder.  Brain Injury Medicine:  Principles and Practice. New York:  Demos Publications; 2006. (Request 2013 edition with CPSBC or view 2006)
3. Kendrick D, Silverberg ND, Barlow S, Miller W, Moffat J. Acquired brain injury self management programme: A pilot study. Brain Injury. 2012; 26 (10): 1243-1249. (View with CPSBC or UBC)
4. Ryu WH, Feinstein A, Colantonio A, Streiner DL, Dawson DR. Early identification and incidence of mild TBI in Ontario. J. Neurol. Sci. 2009;36(4):429-435. (View with CPSBC or UBC)
5. Bazarian JJ, McClung J, Cheng YT, Flesher W, Schneider SM. Emergency department management of mild traumatic brain injury in the USA. Emerg. Med. J. 2005;22(7):473-7. doi:10.1136/emj.2004.019273. (View)
6. Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison. Br. J. Sports Med. 2013;47(1):54-59. Request with CPSBC or view UBC)
7. Stoller J, Carson JD, Ccfp D, et al. Do family physicians, emergency department physicians, and pediatricians give consistent sport-related concussion management advice? Can. Fam. Physician 2014;60(6):548-552. (View)
8. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. J. Head Trauma Rehabil. 2013;28:250-259. (View with CPSBC or UBC)
9. Craton N, Leslie O. Is rest the best intervention for concussion? Lessons learned from the whiplash model. Curr. Sports Med. Rep. 2014;13(4):201-4.(View with CPSBC or UBC)
10. Whittaker R, Kemp S, House A.  Illness perceptions and outcome in mild head injury:  a longitudinal study.  J Neurol Neurosurg Psychiatry 2007; 78(6):  644-646. (Request with CPSBC or view UBC)
11. Dhawan P, Rose A, Krassioukov A, Miller WC.  Early interventions for mild traumatic brain injury:  Reflections on experience.  BC Med Journal 2006; 48(9):  442-446. (View)
12. Sports Concussion Assessment Tool. 3^rd Edition (SCAT3).  The Concussion in Sport Group; 2013. (View)

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