Concussion Management for Primary Care Professionals

Concussion is defined as “the acute neurophysiological event related to blunt impact or other mechanical energy applied to the head, neck, or body that results in a transient impairment of neurological function.” This term is often defined interchangeably with mild traumatic brain injury (mTBI) in the medical literature.

Although people often associate concussions with sports accidents, this only accounts for 20 – 30% of events overall. Younger people are at highest risk.

People with suspected concussion will often seek immediate review at an emergency department. However, others will initially present to their local general practice, sometimes several days or weeks after the injury, particularly if they have mild or delayed symptoms.

Concussions can be difficult to recognize, as the symptoms and signs are often subtle, non-specific, and the combination of symptoms and signs can vary substantially. In general, concussion symptoms/signs can be divided into three main categories: physical, cognitive, and behavioral/emotional ( Table 1 ). However, no feature alone or in combination is specific and many overlap with those seen in other conditions or settings, for example, hypoglycemia, alcohol or drug intoxication.

Table 1. Symptoms and signs associated with concussion.

> Digging deeper to support suspicions

If a concussion is suspected, a plausible mechanism of injury needs to be established.

Patients should be asked to describe any recent accident or injury in as much detail as possible, including when/where it occurred, and what happened immediately afterwards up to the time of consultation.

Since confusion and short-term memory impairment are common features of concussion, this information can be derived from a witness’s account of the event, through a caregiver, or from a video.

No single test is validated to evaluate patients with suspected concussion in the absence of a baseline score; Instead, a variety of tests are usually part of the screening evaluation to identify any additional clinical deficits. Examples include vestibular ocular motor screening (VOMS; includes tests of balance, vision, and movement) and the standardized assessment of concussion (SACO; includes questions related to memory and cognitive function).

>  Red flags for emergency assessment

A specific clinical examination should be performed on all patients with suspected concussion in primary care, including evaluation of:

-  Neurological anomalies: primarily looking for marked motor or sensory deficits associated with the C1 - C8 cranial nerves.

-  Sensitivity of the cervical spine to palpation and evaluation of range of motion.

-  Skull fracture: A patient with an obvious scalp injury will usually have already sought medical attention, however, consider palpation to detect skull fractures, particularly depressed fractures.

>  Presentation may be delayed in some patients

A common misconception regarding concussion is that it always has an acute or early onset, with symptoms emerging minutes to hours after the causative event. However, concussion can sometimes present as an evolving injury with clinical features that change over time, for example, symptoms may be more subtle or absent at first, but develop or worsen after 48 – 72 hours. .

The current international consensus is that concussion occurs as a result of functional disorders rather than macrostructural damage, e.g. bruising, hemorrhage, swelling. As a result, imaging is not required to diagnose a concussion and should only be ordered if a more severe TBI is suspected.

Associated biomechanical forces (e.g., rapid acceleration/deceleration, rotational forces) alter cell membrane and axonal integrity, triggering an acute cascade of significant neurometabolic changes.

The minimum threshold of force required to cause a concussion is unknown and is difficult to quantify as the injury depends on confounding variables; for example, whether the person was able to stand before impact or whether they have had previous concussions.

Time can be a major limiting factor within a primary care consultation. BIST is a concussion screening tool developed by a group of clinical experts for use in people eight years of age and older when they present for medical response. It should be completed in six minutes and covers: patient details, the context of the injury, key questions about prognosis, a symptom severity checklist, and an assessment of the overall impact of the injury on the patient’s quality of life. patient.

Why use BIST over other tools like SCAT-5 and RPQ? Prior to the development of BIST, the most commonly used clinical assessment tools in primary care included the SCAT-5 and RPQ. Both encompass symptom scoring, neurocognitive and physical assessments, and alert questions. However, neither tool provides guidance on decision-making about the healthcare pathway.

>  Diagnose a concussion based on clinical judgment

Assessments such as BIST should be applied as supporting tools; They are not a substitute for clinical judgment and should ideally be used in conjunction with other relevant questions and neurocognitive or physical assessments (as needed). After ruling out more severe brain or structural injuries, a diagnosis of concussion can be made clinically, supported by evidence of a plausible mechanism of injury and symptoms/signs related to altered brain function.

Once a diagnosis has been made, clinicians should provide patients or parents/caregivers with education using language and examples that are understandable to their level of health literacy and culturally appropriate, including: an explanation of what a concussion, how this condition should be managed, expectations for recovery time and realistic functional goals, and reassurance and information about the next follow-up step.

Data from randomized controlled trials (RCTs) have shown that patients who engage in prolonged, strict rest for five days after a concussion recover more slowly than those who engage in some form of physical activity after 24 to 48 hours.

Progressive participation in exercise after an initial rest period is proposed to aid recovery through several mechanisms, such as improving cerebral blood flow and promoting the production of brain-derived neurotrophic factor.

>  Management of specific symptoms

Headache or other pain : Concussion symptoms should be expected to resolve without pharmacological intervention. If analgesia is required, prescribe acetaminophen for short-term relief, but warn patients that excessive use of analgesics may prolong or worsen headaches associated with concussion.

Sleep disorders : They are recommended first of all, for example, establishing a regular bedtime, avoiding long naps during the day and not consuming foods or drinks with stimulating effects before going to bed.

Data collected shows that approximately half of people recover within two weeks of injury and almost all recover within two months. Good adherence to management advice and effective concussion education improves recovery time.

In a general practice setting, clinical recovery from a concussion can be defined as the patient having: minimal symptoms that do not worsen with activity, resolution of any abnormal findings on clinical examination, exercise tolerance, and return to activities. “normal”.

Risk factors associated with prolonged recovery : initial symptom burden, previous concussions, pre-existing mental health conditions, female gender, similar symptoms or history of migraine, younger and older age groups, people with alcohol abuse problems and substances, and predominance of vestibular symptoms.

After diagnosing the concussion and establishing a recovery plan, it is recommended that patients be followed up in primary care within 7 to 10 days to reevaluate their clinical status and adjust their rehabilitation protocol.

One of the top priorities when considering return to work, education, sport or independence in general is to avoid any further events of brain injury; Any safe return to “normal” must involve appropriate restrictions and limitations, which are progressively removed according to documented symptomatic improvement.

>  Back to work

An early return to some form of vocational commitment following the mandatory 24- to 48-hour rest period should be a priority for most employed persons who sustain a concussion, assuming the work environment or tasks do not put them at risk. or others at risk of injury.

>  Back to the studio

While early mental overexertion can worsen symptoms in people with a concussion and potentially prolong recovery, returning to school should not be delayed too much. Most students should be able to return to studying within two to four days.

>  Return to sport

They must complete a 24- to 48-hour period of physical and mental rest before beginning a gradual return-to-play protocol. Most recommend avoiding contact sports for at least two to three weeks, with some recommending a longer duration, for example in rugby. 

>  Persistent concussion symptoms may occur in a small number of people.

A full recovery can be expected in the majority of patients who suffer a concussion, however, a small number report persistent symptoms that affect their daily functioning and quality of life.

Historically, the persistence of symptoms for more than three months was called “post-concussion syndrome.” However, the use of this term is controversial because symptoms do not always cluster in a predictable pattern, are not specific, and the term implies persistent neuronal damage (not supported by the literature).

>  Recurrent concussions and the risk of future cognitive or neuropsychological deficits

While concussions have traditionally been thought to cause only limited, transient behavioral changes, there is growing evidence of an association between sustaining multiple concussions and having cognitive or neuropsychological deficits later in life. When neurodegenerative changes occur in a specific progressive pattern, it is called chronic traumatic encephalopathy (CTE).

Research is being conducted on the relationship between multiple concussions and cognitive or neuropsychological deficits later in life.

In retired professional American football players, those who had sustained more than three concussions were found to have a five-fold higher prevalence of diagnosed mild cognitive impairment and a three-fold higher prevalence of reported significant memory problems compared to those with no history of concussion. .

A prospective analysis of US military veterans showed that those who had suffered one or more concussions (with or without loss of consciousness) had more than double the risk of being diagnosed with dementia. The risk was highest in those who had suffered multiple concussions.

Despite these references, there is currently insufficient evidence to define a causal relationship between multiple concussions and CTE . This entity can only be diagnosed according to specific pathological criteria detected in autopsied brains; There are no validated clinical criteria to diagnose it in a living person.