Concussion rehabilitation update and a free self-management concussion tool

Previous article: https://thischangedmypractice.com/concussion-rehabilitation/

Authors

Sue Barlow BPE BSc OT (biography)
Adult Concussion Service Coordinator, GF Strong Rehabilitation Centre
Clinical Assistant Professor, Department of Occupational Science & Occupational Therapy, University of British Columbia

Carolyn Rondeau BA MOT (biography)
Traumatic Brain Injury Service Coordinator, GF Strong Rehabilitation Centre

Disclosures: Susan Barlow and Carolyn Rondeau work at the GF Strong Rehabilitation Centre. Ms. Barlow owns a private OT practice. 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.

Acknowledgments: Dr. Derry Dance, Dr. Sarah Courtice, Trish Mahoney, and Julia Schmidt.

What we did before

Concussions or mild traumatic brain injury are the most common type of traumatic brain injury (1). It is estimated that every year in British Columbia (BC), there are approximately 14,500 visits to the emergency department and that this number is most likely an underestimate of the “true burden of concussion”. This “invisible injury” is believed to be under-reported, as many individuals are seen in doctor’s offices and walk-in clinics, placing them outside of the hospital data collection process (1).

There is an 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 healthcare system and in all regions of the province.

What changed our practice

In 2017, Ontario Neurotrauma Foundation (ONF) developed clinical concussion care standards for coordinated and interdisciplinary treatment. GF Strong previously had two adult concussion services: The Early Response Concussion Service (serving clients within six months of their injury) and the Self-Management Program (serving clients six months to 2 years post-injury). While both were highlighted as “excellent” in the 2015 Acquired Brain Injury (ABI) provincial services report funded by the BC Brain Injury Association (BCBIA), these services were not adequately integrated with physiatry, psychology, and physiotherapy services, and both services had waitlists (3). To minimize waitlists and align with current recommendations of interdisciplinary treatment (ONF, 2017), in 2019, the two concussion services amalgamated into the GF Strong Adult Concussion Service (GFACS).

The GF Strong Rehab Centre Adult Concussion Services (GFACS) have been redesigned to better meet clients’ needs within Vancouver Coastal Health (VCH). This redesign included the development of a publicly available virtual health tool to benefit clients and clinicians province-wide. The impetus for making program changes was to better serve clients who have had a recent concussion and to be more consistent with Ontario Neurotrauma Foundation’s (ONF) guidelines. While redesigning the GF Strong Adult Concussion Service, funding was also provided to develop the virtual health tool, MyGuide.Concussion website (http://concussion.vch.ca/).

This virtual health tool is integrated into the service and is available for free for any adult experiencing concussion symptoms (including individuals who do not meet the admission criteria for GFACS). Little did we know that within the next year, due to unforeseen circumstances of the pandemic, almost 100% of the GF Strong Adult Concussion Service would be provided virtually.

When redesigning the concussion service and developing the MyGuide.Concussion website there was much consideration about how to address the needs of a diverse clinical population. For example, the majority of clients recover well with early education and reassurance, while there is emerging evidence that some individuals (15 % or greater) continue to have prolonged symptoms (2, p. 29). There is also a subpopulation of very complex clients with co-morbidities of mental health conditions, prior disability, and pain conditions. We needed to address all these needs and we found that many of the answers to these questions were grounded in the ONF guidelines.

What we do now

We now provide an integrated interdisciplinary service consistent with the ONF guidelines’ emphasizing early education and reassurance. GFACS has two streams of service: 1) the group education session; and 2) interdisciplinary rehab program. Both streams of service use a self-management approach. Clients are required to attend the group education session in order to be eligible for the individualized rehab service. There are currently no wait times for either stream of service. More information about the service, how to refer, and admission criteria can be found at http://www.vch.ca/Locations-Services/result?res_id=811.

Group Education Stream: 

The objectives of the education session are to empower clients with the knowledge, skills, and confidence to implement self-management strategies to enhance the recovery process. Evidence demonstrates that early education and reassurance is an effective component in the treatment of concussion (2, p. 8).

Clients are provided evidence-based concussion education; reassurance of symptom resolution and return to function; guided to learn practical tools to gradually resume pre-injury activities and proactively self-manage symptoms. Clients are also taught how to create an Action Plan to provide structure for implementing a self-management strategy (e.g. taking frequent brain breaks) or taking steps in returning to a meaningful activity (e.g. going hiking). For more details on Action Plans see http://concussion.vch.ca/what-is-an-action-plan.

A key message throughout the Group Education Session is that gradually getting active is the treatment, not something to start after being symptom-free (2). As some clients have photophobia and poor screen tolerance, clients are guided to take a “brain break” during the session, and to “take good care of themselves” (e.g. taking extra breaks if required, turning off the video/listening only, and are encouraged to not take in all details as more detailed resources are provided in the session).

After the education session, the client’s family physician or referring physician is sent a follow-up letter. This letter describes the GFACS program, provides web links to the ONF, and treatment algorithms from the ONF Guidelines regarding assessment and treatment of headaches, sleep-wake disturbances, and mental health conditions. A key ONF guideline recommendation speaks to a symptom treatment hierarchy, specifically prioritizing the treatment of post-traumatic headaches, poor sleep, and changes in mood (depression and anxiety). Early treatment of these top-tier symptoms can have a positive influence on secondary symptoms (fatigue, dizziness, cognitive changes, photophobia, hyperacusis, and tinnitus) and reduce the risk of prolonged symptoms (2, p. 29).

This letter also includes a referral to the GFACS rehab program stream, as clients are discharged back to the care of their family physician or medical clinic. For many clients, the education stream is the only intervention required from GFACS.

It is recommended that clients work on implementing self-management strategies for approximately 4 weeks following the education session, and also book an appointment with their attending physician within those 4 weeks to evaluate if a referral to the rehab program is warranted.

Rehab Program Stream:

Once clients are accepted to the Rehab Program stream of service, they are sent an online questionnaire package. The package includes requests for additional information on symptoms (questionnaires include: Rivermead Post Concussion Symptoms Questionnaire, Headache Impact Test 6, PHQ-9, GAD-7, and the Insomnia Severity Index) and how these symptoms affect the person’s life.

The client initially meets with a physiatrist and occupational therapist (OT) for the intake session. In this session, a rehab plan is developed. Clients are offered time-limited treatment sessions with an OT, and possibly a psychologist, physiotherapist, and vocational rehab counsellor. One to two follow-up sessions with a physiatrist are also offered. Clients are generally seen for clinical care over a 4-month period.

GFACS differs from other publicly funded outpatient programs as it places a strong emphasis on self-management principles, versus a traditional outpatient assessment and treatment model. For example, the GFACS model focuses on “HOW” clients can get active during their concussion recovery and empowers them with the knowledge, skills, and confidence to continue their recovery even after discharge from the service.

Transition to Virtual Care:

Prior to the pandemic, GFACS had begun working towards delivering services virtually. It was recognized that VCH is a vast health authority, and a virtual education session was in the works to serve clients in BC’s Central Coast and Sunshine Coast regions. However, driven by the immediate need to continue to provide services during the pandemic, there was a push to provide the program via telehealth more rapidly. Since the pandemic began last March, the program pivoted to deliver all aspects virtually, including group education sessions, one-to-one occupational therapy, psychology, and physiatry visits.

There have been strong benefits of providing a virtual program. The change has allowed clients to stay in their lives and continue their rehabilitation without coming into the centre or taking time out from their activities. Providing a virtual service supports the self-management philosophy of keeping clients in their lives versus spending excessive time travelling to and attending therapy appointments. There are also fewer physical and psychological barriers to attending group sessions as clients can attend sessions from home or another convenient space.

In addition, an anecdotal observation over the years is that for some clients coming into a rehabilitation centre (where one will find clients with more catastrophic injuries, such as spinal cord injuries, and moderate to severe traumatic brain injuries) can have unintended adverse effects. For example, some clients may associate their participation at GF Strong with permanent disability versus a transient condition with a good prognosis.

What this change means for the program, clients, how does it benefit clients outside of VCH: 

These changes have meant that GFACS is now a more comprehensive and integrated interdisciplinary service, and has effectively led to reduced wait times for clients to access services. Within weeks, clients are able to receive early education and potentially receive further support through the rehab program if warranted. Finally, the redesign of GFACS has also demonstrated the successful adoption of a virtual program model to serve clients recovering from a concussion. This information is potentially helpful for other concussion services looking to integrate their services virtually.

Through the creation of the MyGuide.Concussion website, access to evidence-based information has increased for those who do not meet the GFACS admission criteria. As treatment recommendations provided on MyGuide.Concussion are directly from various GFACS disciplines, clients who may reside outside of VCH or are not eligible for GFACS, are still able to learn self-management tools to facilitate their concussion recovery. In addition, MyGuide.Concussion was specifically designed for clients with concussion, individuals can navigate through the website at their own pace, take breaks, use dark mode, and information is displayed specifically to reduce scrolling. The website is also a tool that can be shared with family and friends. Further, the website is consistent with the key concept from the education group that getting active is the treatment and allows for clients to gradually build their screen tolerance through reviewing materials.

Resources and Practice Tips:

1. MyGuide.Concussion: MyGuide.Concussion is a virtual tool that provides best practice knowledge to help adults with concussion manage symptoms, develop skills and confidence to take action in their recovery, and feel empowered to get back to their life after a concussion. MyGuide generates an individualized reading guide for each user on the common symptoms and concussion recovery basics, guidance for gradually returning to activities, strategies for becoming a self-manager, and tips for navigating the health care system.For medical professionals, this resource could be easily shared with clients and could be used to supplement concussion education provided in appointments.Self-management tools available on MyGuide include: action planning, developing a wellness checklist, strategies for pacing, and stress management — located under the “Becoming a Self-Manager” section on MyGuide. https://concussion.vch.ca/
2. Ontario Neurotrauma Foundation (ONF) Guideline for Concussion/mTBI & Prolonged Symptoms 3^rd Edition. A tool to assist healthcare providers and clients. Guidelines are provided for diagnosis; early management; and detailed guidelines for prolonged symptoms, including post-traumatic headache, sleep disturbance, mental health conditions, cognitive difficulties, vestibular and visual dysfunction, fatigue, and gradually returning to activity. These guidelines also have clinician and patient version modules. https://onf.org/3rd-edition-guidelines-for-concussion-mild-traumatic-brain-injury-and-persistent-symptoms/
3. The Concussion Awareness Training Tool (CATT). Providing concussion online education and training for medical professionals, coaches, parents, school professionals, athletes, workers and workplace, and women’s support workers. https://cattonline.com/
4. Canadian Guideline on Concussion in Sport: Best practices for the evaluation and management of athletes who sustain a concussion during a sport activity: https://parachute.ca/en/professional-resource/concussion-collection/canadian-guideline-on-concussion-in-sport/
5. Free virtual resources:

• Kelty’s Key: free and confidential online cognitive behavioral therapy (CBT) service: https://www.keltyskey.com/
• Mindfulness Apps: MindShift CBT, HeadSpace, Calm, Insight Timer, Balance
• Anxiety Canada: https://www.anxietycanada.com/
• Positive Coping with Health Conditions Workbook: https://psychhealthandsafety.org/pcwhc

6. Referring to GF Strong Adult Concussion Service (GFACS): http://www.vch.ca/Locations-Services/result?res_id=811

References

1. Rajabali F, Turcotte K, Pike I, Babul S. The Burden of Concussion in British Columbia. Published January 27, 2017. (View)
2. Ontario Neurotrauma Foundation (ONF). Guidelines for Concussion /mTBI and Persistent Symptoms. 3rd Ed. Toronto, ON: Ontario Neurotrauma Foundation; c2018. (Request with CPSBC)
3. BC Brain Injury Association. Acquired Brain Injury Services Evaluation Initiative: Phase 1 Report. Published July 31, 2015. (View)
4. Silverberg ND, Iverson GL. (2013). Is rest after concussion “the best medicine?”. J Head Trauma Rehabil. 2013:28(4);250–259. DOI: 10.1097/htr.0b013e31825ad658. (View with CPSBC or view with UBC)

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