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 info@onf.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.
The Concussion Blog 
Just my two cents based on my son’s experience-I see the benefit of providing standardized written information sheets to patients/parents (brain injury advice card) with links for more comprehensive information. For schools that don’t have concussion management policies in place, an information sheet providing an expanded explanation of academic accommodations or the link for CDC materials might also be helpful (the implementation phase is where things often fall apart). I also like the idea of keeping a headache/symptom/medication calendar. I kept daily notes, but during office visits it was difficult to look back and clearly and briefly explain how he was doing. When I actually took the time to record his headaches on a calendar, it painted a pretty clear picture and the pediatrician could see that school work (especially afternoon computer lab) was triggering headaches on a regular basis.
I have relatives in Canada, and it does seem as though there are some differences with their university system. Perhaps that has an impact when it comes to conflicts of interest.
This is great – I’ll have to look at the PDF more closely this weekend to see what’s in there. Ideally, if it’s good, it can become a source for physicians and other professionals who need information explained in ways they understand. I hope to add my voice for the rest of us — those of us who need the info explained and expanded upon in an everyday sense. A lot of good science gets lost because people just don’t understand what it means or what the potential impact is.
An excerpt from my 2004 Dissertation re NFL Players’ Knowledge of Concussions seems approriate. It pertains to:
1- the need for a multidisciplinary team — no one discipline should ‘control’ the assessment or return to play /school. The brain is much to complex for one discipline to (attempt to) comprehend the brain functioning and dysfunctioning of a concussed indvidual.
2- The brain affects 3 major functions: physical, cognitive and emotional (suggest the use of the term ‘emotional’ rather than social/behavioral – as ‘emotional’ is a more precise base term…)…and these 3 functions are intertwined…and separated for discussion purposes only.
3- There is a ‘science’ and an ‘art’ involved in the asessement and management of each concussed athlete…as all concussions are not the same and must therefore be individually assessed and managed .
4- Caution must be exercised re accepting rush to judgment assessments and management / return to play/school approaches… Supporting research must be replicated and free from conflicts of interest (COIs). A former anti-drug abuse public announcement emphasized: “a mind [brain] is a terrible thing to waste…”. This protective perspective readily applies to the concussed athlete’s brain.
5- THERE IS MUCH UNCERTAINTY and a corresponding lack of desired preciseness re concussion assessment and management. Athletes, parents, treatent providers from all health disciplines and others concerned with the health and safety of the student/athlete or adult athlete need to be aware of, and cognitively digest, this fundamental fact.
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The 2004 NFL Players’ Concussion- related Dissertation excerpt follows:
The complex, varying, and individualized central nervous system response to a brain insult and resultant concussion injury not only justifies but requires a comprehensive assessment from a readily available and qualified multidisciplinary team of health care providers (McKeag, 2003). The utilization of a multidisciplinary team is particularly essential since consequences of TBI include both neurological and non-neurological consequences. In order to fully protect the athlete’s health and corresponding safety, return-to-play risks also need to be comprehensively assessed and thoroughly explained via a concerted effort of a multidisciplinary health care team. Suggested members of this health care team include the following: physician, neurologist, neurosurgeon, psychologist, neuropsychologist, optometrist, opthamologist, athletic trainer, speech pathologist, occupational therapist, and physical therapist. Equally important is the carefully culled input from close family members and significant others to assist in the concussion assessment and return-to-play decision-making process.
The uniqueness and subtleties of each concussion warrants an exploratory process that analyzes presenting concussion symptoms with an investigative clinical judgment. Therefore, this methodical and investigative process requires the inclusion of approaches that utilize the science and art of medicine (A. Joachimpillai, personal communication, September 15, 2003; Meeuiwisse, 2002). The utilization of a logical and investigative clinical judgment process is a core component of the concussion evaluation and the return-to-play assessment process since it has been clearly pointed out that many of the current neurocognitive and neuroimaging instrumentations and evaluation techniques are generally not sensitive enough in assessing and detecting mild brain injury (Bleiburg et al., 1998; Damasio,1994; Lovell, 1998). This lack of sensitive test instrumentation also acknowledges the limitations of a scientific methodology that only utilizes concrete, and thus observable, data as the sole valid and reliable data for drawing conclusions.
Yes, it would be great to get a multidisciplinary team, and I have tried repeatedly to get my own healthcare providers to even pick up the phone and talk to each other about my case. At the start, when I was on the verge of bankruptcy and divorce and in danger of losing my home, none of them were pro-active or took it upon themselves to reach out. They all said they were open to it, then they apparently just dropped the idea when I left their offices.
A team is essential, but forming one starts at the level of the experts themselves, and I don’t see that happening. Maybe if everyone could start agreeing on common definitions and approaches and quit defending their respective territories? Not sure how that will change.
This information (from all around) is incredibly important and helpful. I’ve passed it along to others, and they are as relieved and heartened as I. Thanks, Dustin, for letting us know about it.
Thank you so much for posting this, I came via brokenbrilliant’s reblogging this article and the parts I read are very insightful and encouraging. I am hoping to print it out this weekend to have a good look over it myself, and if fitting, will gladly give to my doctors. I’m now following your blog too, thanks to brokenbrilliant. Wishing you all the best today & always.
Blessings, Love & Peace,
RH