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.

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 ..

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


ThinkFirst Canada combatting head injury in sport

The issue of head injuries in sport has exploded onto the Canadian scene in 2011. The media frenzy caused by the National Hockey League’s biggest star, Sidney Crosby, falling victim to serious concussions grew with the deaths of former NHL and NFL players who suffered from chronic traumatic encephalopathy, a degenerative brain disease linked to repeated blows to the head. Whether sports fans or not, Canadians have clearly heard the message that it’s time to address the serious issue of head injury in sports.

One Canadian organization is doing its part to raise awareness of such sport-related injuries and to educate people on injury prevention. ThinkFirst, founded by renowned neurosurgeon Dr. Charles Tator, is a national non-profit organization dedicated to the prevention of brain and spinal cord injuries. ThinkFirst has tremendous online resources on safety prevention and, with the help of some well-known hockey players, has recently launched a ‘Smart Hockey’ campaign to educate the public on the symptoms and severity of concussions, particularly in reference to injury prevention in ice hockey.

In addition to their online presence at, ThinkFirst has 19 Chapters across Canada, including one in Vancouver. These chapters spread ThinkFirst’s injury prevention messages through school and community presentations with the help of a dedicated group of injury survivors who share their own powerful stories.

High profile cases draw attention to the prevalence and severity of concussion in professional and amateur athletes.

Sidney Crosby off the ice Sidney Crosby can’t help but make the headlines.  Since January 5th of this year, the Pittsburgh Penguin’s captain and Canada’s golden boy has been recovering from concussion, after enduring two massive blows to the head only days apart.  Hockey fans, the media, and medical professionals alike are on edge, waiting for the star to recover and wondering what kind of impact this injury will have on the young player’s season and his future career.

More and more medical evidence is showing that concussions (actually a ‘mild traumatic brain injury’), especially multiple concussions, can cause long term problems.  In our practice the most common difficulties are difficulty concentrating, problems with sleep, headaches and cognitive fatigue.

The recent suicide of former Chicago Bears safety, Dave Duerson, has also drawn attention to the long-term damage and persistent health problems that can be caused by chronic traumatic encephalopathy (CTE). Duerson shot himself in the heart with the hope that his brain would be used to research the long-term effects of concussion on the brain.

Despite the tragedy of Duerson’s suicide and the problems caused to Crosby’s health and career, these cases are drawing much needed attention to an area of brain injury that generally goes unreported or even undiagnosed. The media attention has highlighted to the public, the fact that those involved in amateur and professional sports of all kinds, need to increase their awareness and knowledge of concussions.

Concussion is just another word for brain injury – but people still don’t want to talk about brain injuries.  This is, in part, due to a lack of education, but is also due to the inherent difficulty in treating concussions. In a motor vehicle context, a person may have a “mild” or even “moderate” brain injury, but are discharged from hospital because there is no specific treatment.  Concussions and brain injuries have various symptoms, and can even occur without the person being knocked out.

The real problem, to be discussed in a later blog, is the variable recovery from concussions. I think that most people would realize that you could have Sidney Crosby over for dinner and have a normal conversation with him, while recognizing that we he can’t go to work.  Unfortunately, those we talk to don’t always have that response.  They are often treated sceptically, with comments like “it was just a ding to the head”, or “she can get to appointments, why can’t she go back to work”.  According to scientific literature approximately 15% of people who have received a brain injury have ongoing symptoms, beyond two years after the incident.  We call them the “walking wounded”.  For Sydney Crosby, and the rest of Canada, let’s hope he isn’t part of that unlucky group.

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Dr. Duhaime on concussions

I had the privilege of attending grand rounds at VGH where the guest lecturer was neurosurgeon Dr. Christine Ann Duhaime discussing new research on ‘concussion’.  I first became aware of her work while working on a Shaken Baby Case, because she was the neurosurgeon whose work resulted in the description of the most common symptoms of shaken baby syndrome known as ‘Duhaime’s triad’.  Dr. Duhaime was presenting on her work in the area of concussion and concussion in sport.  I found the talk  fascinating.  Dr. Duhaime described the studies she is involved in at some American universities.  They are installing sensors in the helmet’s of football players that measure the forces on the player’s heads as they play throughout the year.  Essentially, the data gathered shows rotational, angular and direct impact forces in “G-Forces” which is then compared to the reports of concussion.  The science is fantastic, but I expect that the researchers in the audience were disappointed with small sample sizes and the need for longitudinal studies and consistent measures.  She candidly stated that the science does not show any specific cut off for angular, direct or other force that can be related to result.  In other words, “host specific” or individual differences between individuals are important, but difficult to study.  Some people sustain huge forces with no impacts, but others develop concussions and symptoms with less force.

Dr. Duhaime described the fMRI studies that were conducted on some of the players following there concussions. Apparently they were given basic neuro-psychological testing while the fMRI studies were performed.  Comparing these test results to those who were not concussed revealed much greater areas of brain utilization amongst the concussed individuals, although the two groups scored the same on the testing.  This result is not surprising to those who have worked in this field, as our client’s constantly describe how they put in much more “cognitive” efforts to accomplish necessary tasks, resulting in cognitive fatigue and other sequalae.  While we have come far in our ability to image and see brain anatomy and physiology, we still don’t know who will sustain injury and who will have a difficult course of recovery.

Dr. Duhaime was also candid in describing her own history and that of neurosurgery.  She spoke about how medicine has changed from her perspective – where in the 1980’s a neurosurgeon might have told a patient that ““it’s just a concussion”, today, she would tell patient’s that it is a “brain injury”.  She believes that instead of denying injury to the brain, the focus should be on the recovery and on the potential for the individual to recover function.

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