There have been many attempts to create a concussion “game changer”, something that will bring the assessment and/or recovery into better focus and provide more concrete answers for all of us. One thing many people keep forgetting is that the human brain is not only very complex but it is also very individual. Creating blanket statements, guidelines, and recommendations are very difficult; unless of course you use a multidisciplinary approach that touches on every part of the concussion sequale.
If you have read long enough and seen the comment section you will know that we have been clamoring for a more comprehensive, evidence-based, set of recommendations that broach all four parts of a concussion: physical, cognitive, sleep, and social/behavioral. Perhaps the Ontario Neurotrauma Foundation has done just that (.pdf at end of post and in “Current Concussion Management Page” or you can go to the ONF website);
ONF is pleased to publicly release the Guidelines for Mild Traumatic Brain Injury (MTBI) and Persistent Symptoms. The Guidelines were generated through a consensus process using existing evidence and clinical expertise. 10 to 15% of people who sustain MTBI do not recover well or as expected. The guidelines are therefore aimed at treating and reducing the impact of persistent symptoms following MTBI in adults. On behalf of the project team that oversaw this work, ONF welcomes feedback on the Guidelines to firstname.lastname@example.org
There have been other guidelines, one we hold as the standard (note not gold standard) is the Zürich Consensus statement of 2008, however this was far from evidence-based, but it has proven to be a very useful guide at this time. The ONF funded 25 plus experts across Canada who came up with 77 different recommendations for the 10-15% of patients that have persistent symptoms of mTBI (also in use for concussions);
The Ontario Neurotrauma Foundation (ONF) initiated this project with the overall objective to create a set of guidelines that can be used by healthcare professionals to implement evidence-based, best practice care of individuals who incur a mild traumatic brain injury (mTBI) and experience persistent symptoms. Persistent symptoms are not an uncommon complication of mTBI; 10 to 15% of individuals who incur mTBI will continue to experience significant symptoms beyond the normal recovery period of three months (Iverson, 2005), which can include post-traumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue, and mood or affective disorders. With the high incidence of mTBI this potentially translates to a significant number of individuals who may experience associated disability.
Currently, the best practice for treatment of those who do not experience spontaneous recovery is not clearly defined. Therefore, the following clinical questions needed to be addressed — Can an approach be devised to screen for and identify patients that are at high-risk of persistent symptoms and, once identified, can a management plan be developed to treat the symptoms commonly associated with the disorder? Hence the purpose of developing the clinical guidelines is to improve patient care by creating a framework that can be implemented by health professionals to effectively identify and treat individuals who manifest persistent symptoms following mTBI.
The guidelines encompass 13 “domains” if you will:
- Diagnosis/Assessment of mTBI (including when to CT the head)
- Management of mTBI (including the need for proper education of the injury)
- Sport-Related mTBI
- General Recommendations Regarding Diagnosis/Assessment of Persistent Symptoms Following mTBI
- General Recommendations Regarding Management of Persistent Symptoms Following mTBI
- Post-Traumatic Headache
- Persistent Sleep Disturbances
- Persistent Mental Health Disorders
- Persistent Cognitive Difficulties
- Persistent Balance Disorders
- Persistent Vision Disorders
- Persistent Fatigue
- Return to Work/School Considerations
Also included in the fine work are charts, schematics, educational cards, resources that anyone who reads it can utilize.
This effort by the group and ONF is finally something that we can grasp on to and go forward with, in my opinion. As with anything in the concussion realm it is subject to change, but at least there is evidence-based information and it has a ton of transparency. Often a problem in America; these researchers and the ONF seems to be void of conflict of interests.