What is a Concussion?
A concussion is a form of mild traumatic brain injury. However, not all mild traumatic brain injuries are concussions. A concussion is defined by the Zurich Consensus Guideline 2012: a complex pathophysiologic process affecting the brain, induced by biomechanical forces. It has a number of common features:
- It may be caused by a direct blow to the head, or by an indirect force transmitted to the head (e.g. whiplash).
- It results in impaired neurological function, that usually resolves sequentially & spontaneously.
- Impairments are usually short-lived. However, in some cases, symptoms may be prolonged.
- Often no abnormality is seen on standard structural imaging, see below.
- It may or may not involve an initial loss of consciousness.
How is a Concussion diagnosed?
A medical practitioner should suspect a Concussion if one or more of the following changes are noted:
- Somatic symptoms (e.g. headaches)
- Cognitive symptoms (e.g. fogginess)
- Physical signs (e.g. loss of consciousness)
- Behavioural signs (e.g. irritability or emotional lability)
- Cognitive signs (e.g. slowed reaction times)
- Sleep disturbances (e.g. insomnia)
When assessing an individual for a concussion or former concussions, rather than asking them if they have had a concussion or mild traumatic brain injury, it is much better to ask them about whether they are experiencing, or have ever experienced, any of the following symptoms:
- Vertigo & Dizziness
- Sensitivity to light or noise
- Word finding difficulties
- Trouble in busy environments
- Difficulty speaking with several people
- Difficulty initiating or perseverating on tasks
- Irritability, Anxiety and/or Depression
If in doubt, given the EHC insurance system, for medical practitioners involved in Concussion Treatment in Toronto it is better to document “QUERY CONCUSSION” as a preliminary diagnosis, rather than to document no diagnosis.
Imaging and Concussions
For the most part, standard imaging such as CTs and MRs will show no abnormality after a concussion. Newer techniques such as Functional MRs, Diffuse Tensor Imaging, Qualitative EEG and Magnetoencephalography are showing promise in research. However these techniques are not generally available presently for medical practitioners involved in Concussion Treatment in Toronto.
- Rest, rest & rest.
- Reassurance that they will improve.
- Address sleep disturbances, if necessary, with medication. Initially do not limit amounts of sleep.
- Address issues with depression anxiety and pain, if necessary, with medication.
Rest does not include: TV, computer, handheld devices, video games or book reading; talking with friends; and puttering around doing household chores. Initially limit screen time to no more then 5 minutes every 2 hours.
Depending on the individual, rest may include: lying down & sleep; listening to audiobooks, radio, podcasts, & quiet music; meditation; gentle yoga; time-limited crafts; switching back and forth for short periods from physical to mental tasks.
Subsequent Treatment Components
A graduated and slow return to both mental and physical activities. Do not leave your patients in REST stage for too long. This will often lead to depression and/or non-compliance. In addition, remember a client with a mild traumatic injury will often have poor judgement and decision making capacity. Knowing how to progress your patients out of REST takes extensive knowledge, experience and skills on the part of the medical practitioner. The following components will assist the medical practitioner in knowing the what, how and when of returning patients to activities:
- Pacing and Planning via journaling to reduce their symptoms. This will help the clinician & patient to know which types of activities are triggers and the amount of activity they can tolerate.
- To enhance brain recovery, sub-symptom threshold cardiovascular exercising. This will help to overcome autonomic dysfunction, increase neurotrophic factors, and improve cerebral blood flow.
- Sleep restoration via sleep hygiene education and techniques.
- Vision assessment & rehabilitation for both the Spatial and Focal systems. Based on research, between 50-90% of patients with mild traumatic brain injuries have visual dysfunction.
- Vestibular and balance assessment & rehabilitation. Together with the visual system, the vestibular system modifies and coordinates information from the other senses.
- Proprioception assessment & rehabilitation. This helps to compensate for spacial deficits in the other senses.
- Orthopaedic assessment and rehabilitation of the neck. Concussion and neck injuries, such as whiplash, are often present simultaneously and have overlapping issues, e.g. proprioceptive dysfunction.
- Noise and light desensitization. Habituation exercises can gradually extinguish the noxious effects of over-stimulation.
- Cognitive retraining exercises e.g. word, number, memory and spatial games.
- Graduated work and leisure activity mimicking.
This information is not provided to self-diagnose. It is therefore very IMPORTANT that you also consult your doctor.