Concussion: New Standards and Ever-evolving​ Guidelines for Treatment, Care and Research

As the evidence base around the incidence, circumstances and symptoms of concussion grows, new opportunities arise for the management and coordination of care, and associated services. Although the treatment of concussion or Mild Traumatic Brain Injury requires careful attention to contextual factors and the full attention of medical practitioners to catch case-specific symptoms, which can never be completely administered with a strict set of guidelines, leveraging this evidence base could empower practitioners, and families of those suffering from concussion to understand what to expect from care and associated services, and to guide the next-steps of treatment.

In Canada, some of the development of standards for treatment and care has come from the Ontario Neurotrauma Foundation (ONF). In June of 2018, the foundation released the updated Third Edition of the Guidelines for Concussion/ Mild Traumatic Brain Injury and Persistent Symptoms. The foundation has been able to gather enough data to conduct rigorous analysis of the incidence of these types of injuries. This has allowed for the development of an appropriate set of guidelines. These guidelines essentially form a framework within which individual cases can be allocated treatment interventions, or types of care, based on individual circumstances and case specific facts.

Although the current reported levels on the incidence of concussion may not be a clear indication of a rising trend of incidence, as much as it reveals increased levels of incidence reporting, as awareness of the symptoms of sufferers grows, it is still remarkable that, according to the Institute for Clinical Evaluative Sciences (ICES), there were 1480,710 diagnosed cases of concussion in Ontario alone in 2013. It is clear that the effective management of this quantity of cases requires guidance, and a structured set of mechanisms to advise on care and support services.

According to the ONF, there are three major issues which the guidelines aim to address. The first of these is that there is no clear care pathway, and services are often provided in an unstructured way. Treatment needs to be strategic as much as it is responsive, especially for something which is fast approaching epidemic proportions and is thus a public health issue. The second issue is around long waitlists, in an area where timing to diagnose and treat brain injury can be critical for desperate patients suffering from persistent symptoms, and can have significant weight in resolving associated legal issues. Finally, there remain gaps in the knowledge base of health care providers leading to inconsistencies in diagnoses and treatment. The iterative process of data analytics and implementation creates a feedback loop where the evidence base improves practice, as well as improving the quality of data on the incidence of brain injury and this work can leverage improvements in a crucial area of medical service provision.

There is however another critical gap which this research stands to close. In the case of concussion resulting from accidents, long and difficult court cases trying to establish liability and damages can occur. For patients suffering from persistent symptoms, this process can be traumatic and arduous. A sound base of evidence could remove the room for doubt in legal cases, as to the extent of damages and the potential effects on a patient’s life. This could be strengthened as the base of evidence grows, and if the data sets aim to include sufficient data for longitudinal studies which can begin to advise on predicting patient outcomes based on medical evidence.

The importance of understanding, accurately diagnosing, reporting and then treating concussion could prevent lasting cognitive damage for sufferers. The effects of even mild brain injury can have life long effects, and informing families of what to expect, and how to access care can influence the basic quality of life of patients. According to the ONF, “for patients who experience persistent symptoms and those at risk of a delayed recovery, it is necessary that they have access to appropriate and timely, coordinated, interdisciplinary and evidence-based care”.

With this rapid increase in incidence reporting, there has arisen an almost sensationalised response to a potentially serious medical condition. Treatment is offered by a range of providers, often not operating from an evidence base, and the general media hype around the subject only results in confusing the expectations of patients and their families. Thus, a clear and factual source of information is required to ensure that the condition is well understood.

The fact remains that outcomes can be uncertain, especially when it comes to brain injury, and the more clear and accurate information available on the subject the more long-term damage can be remediated.

Helmets – Legal Obligation or Legend?  

Over the years many of our clients have suffered head injuries while cycling, riding motorcycles or longboards, skiing or skating.

We strongly recommend that everyone who could possibly benefit from wearing an approved helmet while engaging in sporting activities should wear one. A blow from a fall or collision can occur without warning and we have seen too many lives devastated by brain injuries to not want everyone who suffers a head trauma to have every bit of protection possible. Just like seatbelts, helmets can protect a person involved in an accident. However, it is important to be aware not every head injury can be prevented by helmet use, and a failure to wear a helmet is not always negligence.

We have observed that some people have had their claims wrongly denied by ICBC and other insurers with the explanation that the injured person’s failure to wear a helmet caused his injuries. While in some cases, a claimant can be found to have contributed to their injuries as a result of a failure to wear a helmet, the reality is that in many cases a helmet would not have made any difference to a person’s injuries.

The Scientific Situation

Extensive research into the benefits of helmet use has been ongoing since the mid 1990’s.

In general, due to limitations in current helmet technologies and materials, a trade-off exists between protecting against concussion and profound non-recoverable head injury. Most helmet standards for bicycles, motorcycles, snow sports etc. are based on helmet criteria designed to protect heads against severe or catastrophic brain injury. As a result, helmeted participants who engage in activities which may involve head impacts remain at risk for mild to moderate traumatic brain injury until either helmet designs are changed to specifically protect against concussion or new helmet designs and materials are developed which can protect against a greater range of impacts.

The Legal Situation

The Supreme Court of Canada has repeatedly stated that “It is not now necessary, nor has it ever been, for the plaintiff to establish that the defendant’s negligence was the sole cause of the injury”…. “As long as a defendant is part of the cause of an injury, the defendant is liable, even though his act alone was not enough to create the injury.”

We strongly recommend seeking legal advice from an experienced brain injury lawyer if you or a loved one has suffered a brain injury, whether that injury occurred when wearing a helmet or not.  in our firm, we work with accident reconstruction engineers and helmet design experts to determine whether the use of a helmet in a particular case would have made any difference in our client’s particular situation.

 

Chronic pain and depression – what’s the link?

Chronic pain and depression – what’s the link?

A recent study on mice, conducted by scientists at the Icahn School of Medicine at Mount Sinai in New York, found that chronic neuropathic pain (pain from nerve injury) can induce genetic changes in areas of the brain that are correlated with depression and anxiety.  Nearly 40 genes were identified with significantly higher or lower activity in those with chronic pain than in those without. This is an interesting development, particularly as it may lead to better pharmacological development to address chronic pain, which is a complex condition characterized by a variety of symptoms that can affect a person’s entire being.

Those who have experienced or are currently experiencing chronic pain will not necessarily be surprised by this study.  If you suffer from hypersensitivity to touch, or a never-ending pain to an area of your body, or altered sensation to heat and cold, you may be well aware of how this type of chronic condition is debilitating not only physically but also to your motivation and mood.

In our practice, we hear from many clients who suffer psychological effects along with a physical condition such as chronic pain.  The science around pain medicine and therapies is still evolving, but this doesn’t mean there is no hope!  It is important to speak to your physician about chronic pain and whether resources such as a coordinated pain clinic, pain medications or injections, a conditioning and strength training exercise program, or nutritional adjustments can help.  However, it is equally to consider and discuss with your physician whether psychological counselling can be of benefit, to address loss and frustration, to help restore your mental and social well-being, and to provide strategies on how to adapt to your “new normal”.  Addressing your mental and emotional state is a significant part of a rehabilitation plan after trauma and injury, and we are here to help.

Reference:

Descalzi G, Mitsi V, Purushothaman I, Gaspari S, Avarampou K, Loh YH, Shen L, Zachariou V.  Neuropathic pain promotes adaptive changes in gene expression in brain networks involved in stress and depression.  Sci. Signal. 2017 Mar 21;10(471):eaaj1549.

Review and Clarification on the law on “confidentiality between patient and doctor” in a legal context

As part of a significant medical malpractice decision released in Ontario (Bauer v Kilmurry, 2016 ONSC 7749 (CanLII) ) the court discussed important issues regarding physician / patient confidentiality.

The plaintiff, Ms. Bauer, had a medical condition requiring surgery and following that surgery, she suffered a cerebral artery stroke that left her paralysed. The case itself was about whether that surgery was performed negligently and whether negligence led to the stroke and paralyzation.

While the main part of the case discussed the usual components of medical malpractice action (standard of care of a physician and causation), it’s Canada-wide implication arises from a part of the decision that reviews and clarifies the law on “confidentiality between patient and doctor” in a legal context.

While medical professionals reading this might say, “What are you talking about? That’s sacrosanct.” We have seen much confusion over the years. In law, there is “no property in a witness” meaning that either side can seek to speak to anyone who is not a party in the specific case. For example, a lawyer for the defence can phone up a treating practitioner and fairly say “there is no legal reason that you can not speak to me or tell me anything about person X”. There is even a legal process for giving notice before trying to speak to a physician (called a Swirski interview).

This decision helps bring the law back in line with the ethical practices of most medical professionals. It references a 2003 Ontario decision where the plaintiff had committed suicide and the defence obtained a medical report from the plaintiff’s treating psychiatrist without consent and then wanted to use that opinion at the trial. In a complicated decision, the Judge did not allow the defense to do so.

This case reaffirms that physician-patient confidentiality is the clear rule. It repeats that the defence should not be permitted to speak to a plaintiff’s doctor without clear permission from the patient. “Ex parte” or without the consent of the plaintiff discussions should not be allowed. Copying an eloquent American decision it states:

many courts have permitted defense counsel to engage in ex parte conferences with a plaintiff’s treating physician. … We find the reasoning of these decisions, however, to be flawed for they attempt to deal with a question of great societal importance by merely looking to a set of codified rules and procedures for the answer. Indeed, those decisions which permit ex parte conferences fail to acknowledge that a physician is ethically required not to speak to a third party regarding a patient’s confidences absent patient consent. … Moreover, a decision permitting ex parte conferences demonstrates a gross lack of regard for the confidentiality and fiduciary relationship existing between a patient and his physician. … And finally, a decision to allow ex parte conferences neglects to take into account the modern public policy that favours the confidentiality of the physician-patient relationship and thereby prohibits, because of the threat posed to that relationship, ex parte conferences between defense counsel and a plaintiff’s treating physician.

In short, if you have a patient and someone else (anyone else) is asking about them – look first to your college and ethical obligations to that patient, then ask for legal advice that considers your moral and ethical obligations.

Here is the link to the decision. The section dealing with the above issue is found on page 20 (Part 1, section 7).

Depression following brain injury or concussion

It’s upsetting to read stories about the death of young people, directly or indirectly, related to brain injury or concussion.Ty Pozzobon’s death following his concussion is certainly a tragedy.

The CBC story discusses the statistical frequency of depression following brain injury. In our practice, we see depression following TBI every day. Frequently I meet survivors and their families shortly after an injury. At that time they are thankful that they or their loved one survived. They praise the medical system and the “miraculous” recovery so far. That’s when I caution about depression and do everything I can to set up a full rehabilitation program. The pattern we often see, as lawyers working with survivors, is that as symptoms persist and survivors don’t recover or get back to “normal” as they hoped, depression sets in. It happens in Merritt, Vancouver and everywhere that people who have persistent post concussion symptoms live.

The risk of suicide is real. Whenever possible, the best plan is to set up a system of service so that survivors can be assisted as they encounter recovery struggles that they did not expect. Perhaps this is worse in brain injury cases because survivors and those around them look “normal” and so desperately want to be “back to normal”. The trajectory of recovery from TBI is different than a broken leg, where there is an expected period of immobility followed by physiotherapy and re-strengthening. We should expect that those recovering from concussion will encounter psychological or psychiatric hurdles. In an ideal world supports to combat the high prevalence of depression following concussion or brain injury would be available for all.

Read CBC article

The ever-changing world of concussion rehabilitation

Concussion Rehabilitation Research

A recent article in JAMA (Journal of the American Medical Association) suggests that physical activity following concussion (in youth) is better than rest.

The study itself examined symptoms for PPCS (persistent post concussion syndrome) a month after the concussion and found that the children who had some physical activity within seven days had fewer symptoms than those who had no physical activity. For those of us who have worked with brain injury and concussion for many years this would seem to challenge current recommendations that kids have no symptoms before they return to play.

While this is a useful research tool that researchers and people like myself will look at, a closer examination of the study shows that we still don’t know what brings a reduction to some, but not to others. In some ways it supports the common sense view that one should start slow on the road to recovery. What it should not be taken to mean is that a return to “full contact” without medical clearance is in any way a good idea.

What is encouraging is to know that concussions and traumatic brain injuries are increasingly studied and of interest to researchers, which leads to hope that over time better and better diagnosis and treatment will follow.

Read the article abstract

Watch the video 

Diagnosis “Concussion”: Legal battle or medical?

In most personal injury cases involving an “mTBI” or “concussion”, there is no physical evidence of the injury.  In other words, actual damage to tissue can not be seen and must be inferred from the mechanism of injury and observed symptoms.  Most of the medical diagnoses for mTBI or concussion, according the WHO or DSM 5 or ICD 10, are based on observation of symptoms.  No imaging on CT Scan or MRI scan is required. Legal cases about the issue are hard fought and the cases often succeed or fail depending on the ‘credibility’ of the plaintiff.  This can be tough when the injured plaintiff is struggling because of the concussion.

Wouldn’t it be amazing if that all changed? If a simple blood test could “prove” a concussion. Well, maybe it will and Canadian doctors are at the forefront of this change. Medical doctors in Ontario have been studying whether a simple blood test which examines chemical changes that can now be measured might be able to show that a concussion has occurred.   There research is new, but if you are interested here are a few places where you can read more about there studies ..

http://www.webmd.com/brain/news/20161111/blood-test-may-someday-diagnose-concussion#1

http://www.ctvnews.ca/health/canadian-made-blood-test-for-concussions-could-radically-simplify-diagnosis-1.3223579

http://mediarelations.uwo.ca/2016/11/07/western-lawson-scientists-develop-game-changing-blood-test-concussions/

It just might change the legal landscape in years to come.

 

The Importance of Helmets

Three years ago, Courtney King-Dye was a world class dressage rider and member of the 2008 olympic team. Courtney’s life was forever changed when a horse slipped and fell with her.

Today, she has a serious message about the importance of wearing a helmet while riding.

http://www.horsecollaborative.com/index.php?option=com_blog&view=comments&pid=1890&Itemid=56#.UzYAsvldXHU

 

Johns Hopkins study: Traumatic spinal cord injuries on the rise in US

The number of serious traumatic spinal cord injuries is on the rise in the United States, and the leading cause no longer appears to be motor vehicle crashes, but falls, new Johns Hopkins research suggests.

The same research shows, moreover, that rates of these injuries — whose symptoms range from temporary numbness to full-blown paralysis — are rising fastest among older people, suggesting that efforts to prevent falls in the elderly could significantly curb the number of spinal injuries.

“We have demonstrated how costly traumatic spinal cord injury is and how lethal and disabling it can be among older people,” says Shalini Selvarajah, M.D., M.P.H., a postdoctoral surgical research fellow at the Johns Hopkins University School of Medicine and leader of the study published online in the Journal of Neurotrauma. “It’s an area that is ripe for prevention.”

For their study, the Johns Hopkins researchers analyzed a nationally representative sample of 43,137 adults treated in hospital emergency rooms for spinal cord injury in the United States between 2007 and 2009. While the incidence among those aged 18 to 64 ranged from 52.3 per million in 2007 to 49.9 per million in 2009, the incidence per million in those 65 and older increased from 79.4 in 2007 to 87.7 in 2009. Falls were the leading cause of traumatic spinal cord injury over the three-year study period (41.5 percent), followed by motor vehicle crashes (35.5 percent). Fall-related spinal cord injuries increased during the study period overall. Among the elderly, they increased from 23.6 percent to 30 percent of injuries.

The average age of adults with a traumatic spinal cord injury in a previous study that covered the years 2000 to 2005 was 41; the new study suggests it is now 51.

The investigators say that even when taking into account injury severity and other illnesses experienced by the patients, older adults with traumatic spinal cord injury are four times more likely to die in the emergency room from such an injury compared to younger adults. If they survive and are admitted, they are six times more likely to die during their inpatient stay.

While the researchers say they can’t pinpoint the exact reason that falls have surpassed car crashes as a cause of traumatic spinal injuries, they believe it may be a combination of the general aging of the population, the more active lifestyles of many Americans over 65, and airbags and seatbelt laws that allow drivers and passengers to survive crashes.

“We are seeing a changing face in the epidemiology of spinal cord injury,” says Edward R. Hammond, M.D., Ph.D., a research associate at the International Center for Spinal Cord Injury at Kennedy Krieger Institute and another of the study’s leaders.

Beyond the personal toll of disability and death, spinal cord injuries are a growing financial burden on the health care system, the researchers say. They estimate that from 2007 to 2009, emergency room charges alone for traumatic spinal cord injury patients totaled $1.6 billion. But that is “just the first drop in a long-filling bucket,” says Eric B. Schneider, Ph.D., an epidemiologist at the Johns Hopkins University School of Medicine’s Center for Surgical Trials and Outcomes Research. Those charges increased by 20 percent over the study period, far more than just the cost of inflation.

The spinal cord injuries captured by the data for this study were those serious enough to land the patient in the emergency room and included temporary bruising to severed or permanently damaged cords that cause paralysis, difficulty breathing, an inability to fill and empty the bladder and other motor disabilities.

According to the National Spinal Cord Injury Statistical Center, lifetime costs of care for someone with a serious spinal cord injury can range from $1 million to $5 million, depending on the age of the person at the time of injury and the severity of the injury. Improvements in rehab care are leading to longer life expectancy among patients with spinal cord injury — and bigger medical bills.

“With so much emphasis on trying to reduce health care costs right now, this is another reason why preventing the injury altogether is so vital,” Selvarajah says.

A recent campaign by the National Institutes of Health is funding the search for better ways to prevent falls that lead to traumatic brain injury in the elderly. Schneider says the effort could also lead to a coincidental reduction in traumatic spinal cord injury.

The spinal cord is a long bundle of nerve tissue that sits inside a bony structure called the vertebral column or backbone. It is the conduit that connects the brain to the rest of the body, enabling nearly all of the latter’s functions.

Source: Johns Hopkins Medicine

 

Another long boarding tragedy: lessons for riders and drivers!

According to the recent news, another BC teen has been killed by a vehicle while long boarding.

This teen was apparently riding adjacent to his school, shortly after school, and reportedly he was not wearing a helmet.

While even the best helmets can’t prevent all injuries and deaths in a conflict between a boarder and a vehicle (or a motorcycle or bicycle for that matter), without engineering and medical evidence, all we do is speculate that with a helmet, his chances of survival would have been better. While we don’t know if it made a difference in this case, safety suggestions for longboard and skateboard riders would include wearing helmets and reflective garments and riding only in well lit areas, off the portion of the roadway travelled by cars.

For drivers there are vital lessons too. Areas near schools are always well used by students, especially before and after school hours. Regardless of the speed limit, drivers need to exercise caution when driving near schools, pay attention to their speed, and keep a close lookout for children who may be on or near the roadway.

Remember posted speed limits are the maximum allowed for ideal travel conditions. If the conditions are not ideal, and include darkness, rain, fog, or children on the roadway, drivers have a heightened obligation to slow down and keep a careful lookout for children.

The recent death caused by the collision between the long boarder and vehicle will have a life long impact on the family of the deceased teen and the driver.

We have seen many cases involving collisions between riders and vehicles. Every case is different but they share two common factors: they involve great suffering for those involved and are usually preventable.