Concussion Care Pathway

Date of last update: September, 2024

9. Treatment Considerations for Concussion

Report of Findings (ROF) and Informed Consent

The Report of Findings (ROF) and Informed Consent process is crucial to patient care and to the therapeutic relationship. It involves explaining the diagnosis, prognosis, and treatment plan to the patient. This ensures the patient understands their condition and the proposed management strategies and agrees to the treatment plan voluntarily. Consider the following opportunities to develop a shared understanding:

1. Review of Diagnosis and Prognosis:

Clearly explain the diagnosis, results of examinations and tests, and the expected course of the condition using understandable language and visual aids if necessary.

2. Treatment Plan Overview:

Discuss the recommended treatments and their rationale.
Explain how each intervention aligns with the patient's goals and preferences.

3. Informed Consent:

Capacity to consent: Clinicians should increase their awareness and utilize a conservative approach in cases of concussion where memory, cognition or affect may compromise a patient’s ability to appreciate the reasonably foreseeable consequences of a decision or lack of decision. Depending on jurisdiction, a clinician may be able to rely on a presumption of capacity unless there is reasonable grounds (e.g. SCOAT6, consultation and exam findings, third-party reports, etc.) to believe the person is incapable.
Explain the condition: Use clear and simple language to describe the patient's condition and how it affects their health.
Discuss treatment options: Provide detailed information about each treatment option, including the potential benefits, risks, and alternatives.
Address questions and concerns:
1. Encourage the patient to ask questions and discuss any concerns they may have.
2. Provide thorough and understandable answers to ensure the patient feels comfortable and informed.
Obtain explicit consent:
1. Review the diagnosis.
2. Propose a plan of care that relates to the patient’s condition and circumstances.
3. Contextualize the potential risks and benefits of the proposed treatments.
4. Encourage the patient to ask questions or express any concerns they may have. Consider utilizing strategies such as “teach-back” to confirm patient understanding.
5. Ensure that all questions and concerns are appropriately addressed before proceeding.
6. Obtain explicit consent from the patient to proceed with the proposed treatment plan.
Document the consent: Ensure the patient's consent is documented in their clinical record. Concisely record the information provided, questions asked by the patient, and the patient's understanding and agreement to the treatment plan.
Adhere to jurisdictional standards: Ensure the practitioner is meeting their jurisdiction’s standards of practice for informed consent.

Initial Management:

Education and Reassurance:

Rationale: Helps patients understand their condition and what to expect during recovery. Empowers them to actively participate in their rehabilitation.
Advantages: Increases patient confidence, engagement in care, and adherence to the treatment plan.
Disadvantages: Requires time and effective communication skills.
Key Points: Provide clear information on the typical recovery process, emphasizing the gradual resumption of activities. Address any misconceptions and encourage questions to ensure understanding.

Rest and Gradual Return:

Rationale: Initial rest minimizes symptom exacerbation, while gradual return to activities helps restore function.
Advantages: Supports natural recovery processes and reduces the risk of prolonged symptoms by balancing rest with a gradual increase in activity levels.
Disadvantages: Balancing rest with the need for activity progression can be challenging; excessive rest may delay recovery, while premature increases in activity can exacerbate symptoms.
Key Points:
- Short-Term Rest: Emphasize short-term rest (24-48 hours) followed by a gradual increase in activity levels as tolerated.
- Gradual Return: A patient is typically ready for the next increment of activity when they can complete the current level without symptom exacerbation (sub-symptom) for a specified period post-exertion.
- Stages of Return: Reference documents like SCOAT or EMPWR, which divide the return to activity into 5 stages, to guide progression. These stages typically move from light aerobic activity to full return to normal activities, including work, school, and sports.
- Symptom Evaluation: Clinicians should regularly assess whether symptoms are pre-existing, related to the concussion, or a combination of both. This can be determined by asking:
  - Is the frequency of symptoms increasing or decreasing?
  - Is the intensity improving or worsening?
  - Are the symptoms lasting longer or resolving more quickly?
  - Are symptoms returning to their pre-injury status?
- Pre-Existing Symptoms: When dealing with patients who have pre-existing symptoms (e.g., headaches), it's important to differentiate between concussion-related symptoms and those associated with pre-existing conditions, such as whiplash or migraine. The questions above can help clinicians evaluate the nature of these symptoms and guide appropriate management.

Return-to-Learn and Return-to-Sport:

Rationale: Structured protocols ensure safe reintegration into daily activities and sports without exacerbating symptoms.
Advantages: Facilitates a balanced approach to recovery, prioritizing cognitive recovery before physical activities.
Disadvantages: May require coordination with schools, coaches, and other stakeholders.
Key Points: Follow SCOAT6 and child SCOAT6 protocols. Prioritize return to learning before returning to sports. Adjust the pace based on the patient’s tolerance and symptom response.

Address Yellow Flags (Psychosocial Factors):

Rationale: Factors (fear of movement, anxiety, depression, and social or occupational stressors) can significantly influence recovery and long-term outcomes.
Advantages: Promotes a more comprehensive approach to treatment, promotes active participation, improves recovery outcomes.
Disadvantages: Requires time and resources; some people may resist addressing psychosocial factors; may require a multidisciplinary approach.
Key Points:
- Screen for psychosocial factors using validated tools, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Opioid Risk Tool (ORT), or the Pain Catastrophizing Scale (PCS).
- Educate patients on how these factors influence their pain and recovery, and incorporate cognitive behavioral techniques (CBT) to help them manage fear, anxiety, and negative thoughts.
- Refer to mental health professionals when necessary, especially for significant distress or mental health disorders. Collaborate with other healthcare providers for an integrated, multidisciplinary approach.
- Encourage support from family, friends, and support groups, and maintain open, empathetic communication to regularly discuss concerns and progress.

Promote Self-Care:

Rationale: Supports long-term health.
Advantages: Empowers patients.
Disadvantages: May require continuous motivation and support.
Key Points:
- Set SMART goals, prioritize a healthy diet, regular physical activity, good sleep habits, stress management, and avoid smoking/substance abuse.
- Implement ergonomics and behavior changes to reduce strain.
- Utilize techniques like Brief Action Planning to support self-management and promote regular movement and engagement in normal activities, including work.

Symptom Management:

Tailored to patient needs and preferences through shared decision-making (SDM). Interventions have varying evidence levels.

Headache and Neck Pain:

Exercise Therapy:

Rationale: Enhances strength, flexibility, and fitness.
Advantages: Improves function and reduces pain.
Disadvantages: Requires regular commitment and proper technique.
Key Points:
- Types of exercises: Sub-symptom aerobic exercise in the initial period. Incorporate cervicovestibular, oculomotor, strengthening, ROM, and aerobic exercises as needed. Tailor to individual needs and preferences.
- Psychological considerations: Educate the patient regarding appropriate progressions with the aim of developing self-efficacy. Challenging patients during exercise therapy (beyond psychotherapy) can have psychological implications. Watch for signs of increased anxiety, depression, or distress related to the exercise regimen. Be mindful if the person’s mental health condition worsens despite adherence to the exercise program or if the person expresses a strong aversion or fear of the exercises.
- Referral threshold: Consider referral to the appropriate provider (physician, psychologist, psychiatrist, mental health professional) when the psychological burden of exercise therapy exceeds the patient’s coping capacity or falls outside of the scope (e.g., person exhibits significant psychological barriers or disorders such as severe anxiety or depression).

Manual Therapy:

Rationale: Provides symptom relief and improves mobility.
Advantages: Immediate pain relief.
Disadvantages: Effects may be temporary; requires skilled practitioners.
Key Points: Techniques include mobilization, manipulation, soft tissue techniques, and massage. Tailor the approach to patient tolerance and response. Contraindications to spinal manipulation therapy of the cervical spine include:

Absolute Contraindications

Relative Contraindications

Region-specific Contraindications

- Acute fracture

- Acute infection (osteomyelitis, septic discitis, tuberculosis of the spine)

- Aggressive benign tumors (aneurismal bone cyst, giant cell tumor, osteoblastoma, osteoid osteoma)

- Anomalies such as dens hypoplasia,

unstable os odontoideum

- Arnold Chiari malformation

- Basilar invagination of the upper cervical spine

- Congenital generalized hypermobility

- Diastematomyelia

- Dislocation of a vertebra

- Frank disc herniation with progressive neurological deficit

- Hematomas (spinal cord or intracanalicular)

- Hydrocephalus of unknown etiology

- Internal fixation/stabilization devices

- Malignancy of the spine

- Meningeal tumor

- Neoplastic disease of muscle or soft tissue

- Positive Kernig’s or L’hermitte’s signs

- Signs or patterns of instability

- Spinal cord tumor

- Syringomyelia

- Articular hypermobility and uncertain joint stability

- Acute injuries of joints and soft tissues

- Benign bone tumors with risk of pathological

- Bone weakened by metabolic disorders

- Circulatory and hematological disorders

- Demineralization of bone (osteoporosis, long-term steroid therapy)

fractures

- Infection of bone and joint

- Malignancies, including malignant bone tumors

- Neurological disorders

- Postsurgical joints or segments with no evidence of instability

- Severe or painful disc pathology (discitis, disc herniations)

- Traumatic events requiring careful examination for excessive motion

- Tumor-like and dysplastic bone lesions

- Aneurysm involving a major blood vessel

- Atlantoaxial instability

- Bleeding disorders (anticoagulant therapy, blood dyscrasias)

- Vertebrobasilar insufficiency syndrome

Medications:

Rationale: Alleviates pain and discomfort.
Advantages: Quick relief.
Disadvantages: Potential side effects and risk of dependency.
Key Points: Includes over the counter (OTC) pain relievers, muscle relaxants, NSAIDs. Use judiciously and combine with other treatments. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

Electrotherapies (e.g., TENS, IFC, low-level laser):

Rationale: May provide temporary relief.
Advantages: Non-invasive.
Disadvantages: Limited evidence on benefits.
Key Points: Should be considered as supportive to essential interventions.

Sleep Problems or Fatigue:

Behavior Modification:

Rationale: Improves sleep quality and reduces fatigue.
Advantages: Non-pharmacological approach, supports long-term health.
Disadvantages: Requires patient adherence and lifestyle changes.
Key Points: Emphasize sleep hygiene and gradual activity pacing to manage fatigue.

Psychological Support:

Rationale: Addresses underlying mental health issues contributing to sleep disturbances.
Advantages: Comprehensive care for both physical and mental aspects of recovery.
Disadvantages: Requires patient engagement.
Key Points: Consider cognitive behavioral therapy (CBT) or psychoeducation for sleep issues.

Supplements:

Rationale: May help supports sleep regulation and recovery.
Advantages: May be easy to implement as part of a broader management plan.
Disadvantages: Evidence is mixed; some patients may experience side effects or have contraindications to certain supplements.
Key Points:
- Consider supplements such as melatonin, zinc, or magnesium as part of a broader sleep management plan.
- Other supplements like riboflavin (vitamin B2) or coenzyme Q10 may also be considered, especially for managing symptoms like headaches.
- Individualized Recommendations: Supplement use should be tailored to the individual. Patients should consult with an appropriate healthcare provider (e.g., pharmacist, physician, nurse practitioner) to ensure safety, especially considering potential contraindications or interactions with other medications

Mental Health, Emotional, or Behavioral Problems:

Psychological Support:

Rationale: Addresses the emotional and cognitive aspects of concussion recovery.
Advantages: May help reduce psychological barriers to recovery.
Disadvantages: Requires patient engagement.
Key Points: Consider CBT, psychoeducation, and consider referral to mental health professionals if needed.

Cognitive/Memory Problems:

Behavior Modification:

Rationale: Supports cognitive recovery and management of memory issues.
Advantages: Tailors interventions to the individual’s needs.
Disadvantages: May require adjustments over time.
Key Points: Use work/school accommodations, modify daily activities to match cognitive load, and reinforce sleep hygiene.

Psychological Support:

Rationale: Addresses the mental load associated with cognitive recovery.
Advantages: Provides coping strategies and reduces stress.
Disadvantages: Requires patient engagement.
Key Points: Apply CBT and other supportive therapies as needed.

Dizziness or Vestibular/Oculomotor Problems:

Vestibular and Oculomotor Rehabilitation:

Rationale: Improves symptoms related to balance, dizziness, and eye movement coordination.
Advantages: Targeted exercises can reduce symptoms and improve function.
Disadvantages: Requires consistent practice and may provoke symptoms initially.
Key Points: Include sub-symptom threshold aerobic exercise, cervicovestibular exercises, and vestibulo-oculomotor exercises.

Behavior Modification:

Rationale: Adjusting activities helps manage symptoms while promoting gradual recovery.
Advantages: Reduces symptom exacerbation while supporting return to normal activities.
Disadvantages: May require temporary changes in daily routines.
Key Points: Implement work/school accommodations and adjust daily activities to minimize symptom provocation.

Canalith Repositioning Maneuvers:

Rationale: Treats benign paroxysmal positional vertigo (BPPV).
Advantages: Can provide immediate relief for vertigo.
Disadvantages: Requires proper technique and may not be effective for all types of dizziness. May provoke symptoms.
Key Points: Use Epley Maneuver or Brandt-Daroff exercises as indicated, and consider referral to a vestibular therapist if symptoms persist.

Examples

Example 1: Concussion with Persistent Headache and Neck Pain

Patient Presentation: A patient presents with persistent headache and neck pain two weeks after a concussion. The pain is described as dull and throbbing, often worsening with physical activity or prolonged screen time. The patient reports difficulty sleeping and mild anxiety about their recovery.

Initial Management:

Education and Reassurance:
- Frequency: Initial visit and reinforced in follow-up visits.
- Protocol: Provide a clear explanation of concussion, its typical recovery timeline, and the importance of gradually returning to daily activities. Address any misconceptions and reassure the patient that full recovery is expected. Use visual aids or digital resources to enhance understanding.
Gradual Return to Activities:
- Frequency: Daily.
- Protocol: Encourage the patient to continue increasing their activity levels gradually, staying within their symptom tolerance. Emphasize the importance of resuming normal activities like work, school, and light exercise, such as walking. Monitor for symptom exacerbation and advise adjusting activity levels accordingly.
Promote Self-Care:
- Frequency: Daily.
- Protocol: Advise on maintaining proper nutrition, adequate sleep, and stress management. Encourage gentle stretching and strengthening exercises that do not exacerbate symptoms. Provide guidance on avoiding smoking and substance abuse.
Address Yellow Flags (Psychosocial Factors):
- Frequency: At each visit
- Protocol: Identify and address factors like anxiety or fear of movement that may delay recovery. Use cognitive-behavioral strategies and provide reassurance to build confidence in the patient’s ability to recover.

Symptom Management:

Exercise Therapy:
- Frequency: 3 times per week for up to 12 weeks.
- Protocol: Implement cervicovestibular exercises, strengthening exercises, and range of motion (ROM) activities tailored to the patient’s abilities and pain levels. Supervised sessions may be necessary initially to ensure proper technique and adherence.
Manual Therapy:
- Frequency: Six sessions over 8 weeks.
- Protocol: Use spinal manipulation or mobilization techniques to relieve neck pain and improve mobility. Techniques should be adjusted based on the patient’s response.
Medications:
- Frequency: As needed.
- Protocol: For medical provider to oversee: Over-the-counter analgesics like NSAIDs or acetaminophen may be used judiciously for pain relief; discuss the risks of medication overuse headaches and advise the patient to use medications sparingly.
Sleep Problems or Fatigue:
- Frequency: Daily
- Protocol: Encourage behavior modification strategies like sleep hygiene and activity-to-tolerance. If needed, consider supplements such as melatonin to improve sleep quality. Provide psychological support like cognitive-behavioral therapy (CBT) for managing sleep-related anxiety.

Follow-Up:

Regular follow-up at each visit. Reassess pain levels, functional status, and goal achievement every 2-4 weeks. Adjust the treatment plan as necessary, and consider referral if symptoms persist beyond the expected recovery timeline.

Example 2: Concussion with Dizziness and Vestibular/Oculomotor Problems

Patient Presentation: A patient presents with persistent dizziness and balance issues following a concussion that occurred four weeks ago. The patient experiences vertigo when turning their head quickly and reports difficulty focusing on objects, especially when moving.

Initial Management:

Education and Reassurance:
- Frequency: Initial visit and reinforced in follow-up visits.
- Protocol: Explain the nature of vestibular and oculomotor dysfunction post-concussion, including expected recovery time. Use visual aids to demonstrate how rehabilitation exercises will help improve symptoms over time.
Rest and Gradual Return:
- Frequency: Daily.
- Protocol: Encourage sub-symptom threshold aerobic exercise, such as walking or stationary cycling, to aid recovery. Advise the patient to gradually return to activities, avoiding rapid head movements or activities that trigger dizziness.
Promote Self-Care:
- Frequency: Daily.
- Protocol: Recommend maintaining a healthy diet, ensuring adequate sleep, and managing stress. Encourage gentle exercises and mindfulness practices to reduce anxiety associated with dizziness.

Symptom Management:

Vestibular and Oculomotor Rehabilitation:
- Frequency: Daily
- Protocol: Include sub-symptom threshold aerobic exercise, cervicovestibular exercises, and vestibulo-oculomotor exercises. Techniques like gaze stabilization and saccades should be practiced to improve eye movement coordination and reduce dizziness.
Canalith Repositioning Maneuvers:
- Frequency: As needed
- Protocol: Adjust techniques based on patient response and pain levels.
Behavior Modification:
- Frequency: As needed
- Protocol: Adjust daily activities to minimize symptom provocation while promoting gradual recovery. Implement work or school accommodations, such as reducing screen time or allowing breaks.

Follow-Up:

Regular follow-up at each visit. Reassess dizziness, balance, and eye movement coordination every 2-4 weeks. Adjust the rehabilitation exercises as the patient progresses, and consider referral to a vestibular therapist if symptoms persist or worsen.