Journal of the New Zealand Medical Association, 16-February-2007, Vol 120 No 1249
Concussion clinic referral demographics and recommendations: a retrospective analysis
Hamish Alexander, Nicola Shelton, Jacob Fairhall, Harry McNaughton
‘Concussion’ is often used as a synonym for mild traumatic brain injury (MTBI), a common problem in primary and secondary healthcare.
The World Health Organization defines MTBI as an acute brain injury resulting from mechanical energy transmission to the head from external physical forces. It usually has one or more of the following: confusion or disorientation; loss of consciousness for 30 minutes or less; a Glasgow Coma Scale Score of 13–15, 30 minutes or later after injury;8 post-traumatic amnesia for less than 24 hours; or other transient neurological abnormalities such as focal neurological signs, seizure, or cerebral contusion not requiring surgery.
These manifestations must not be due to other conditions, penetrating brain injury or intoxication. Common causes include assault, sport, and accidents involving motor vehicles and bicycles.
Post-concussion symptoms such as headache, dizziness, poor sleep, depression, and emotional lability may occur in many trauma patients even without diagnosis of MTBI.2 Attentive deficits in visual and cognitive domains are common. Ability to withstand distraction and multi-task is also impaired.
Concussion is associated with a significant socioeconomic cost because it affects a predominantly productive, young age group.3 Although most patients recover within 6 to 12 weeks, longer recovery is associated with increased age, previous head injury, and pre-existing medical conditions.1
Management of persisting post-concussion symptoms involves careful diagnosis and consideration of the physical, neuropsychological, social, and emotional factors contributing to the patient’s impairment.4
Randomised controlled trials have shown that intervention from a specialised service reduces the social disability and minor post-concussive symptoms after head injury compared with standard services.7 Often this intervention is delivered in the setting of a specialised concussion clinic, such as that operating at Capital and Coast District Health Board (C&CDHB), offering a multidisciplinary approach.
The C&CDHB Adult Concussion Clinic operates from the Capital Coast Rehabilitation department. Paediatric referrals (0-15 years) are seen by a child development team.
Referrals for assessment and treatment of the ongoing effects of a mild TBI are received from general practitioners, Accident Compensation Corporation (ACC) case managers, and ward & emergency department staff. Referrals from the ward are usually made via medical, physiotherapy or occupational therapy (OT) staff. Funding is via ACC under the Mild Traumatic Brain Injury contract.
The service provides assessment by a rehabilitation physician, screening assessment by a neuropsychologist, and may also include functional assessment by an Occupational Therapist (OT). Following approval from the ACC Case manger, up to 12 OT sessions can be provided.
The aim of this analysis is to identify the demographic trends and mechanisms of injury of patients presenting to the concussion clinic, and to identify recommendations for ongoing management, in relation to diagnosis.
A retrospective analysis of concussion clinic data was performed for 1 January 2003 to 31 December 2004. Data was collected via electronic records. In the event that electronic records were unavailable, paper clinical records were accessed.
The following data were collected: age, sex, mechanism of injury, medical diagnosis, and recommendations following medical and neuropsychological assessment. Patient demographics were collated.
Medical diagnosis was grouped into one of several categories: external force to the head with no traumatic brain injury, mild traumatic brain injury, and greater than mild traumatic brain injury (i.e. moderate to severe TBI), based to the medical report. Categorical variables were analysed using the Chi-squared (χ2) statistical measure.
A total of 161 (101 male, 62 female) patients were included in the study; their mean age was 38 years (SD 14).
The mechanism of injury is shown in Table 1. In six cases, the mechanism of injury was unclear due to post-traumatic amnesia or alcohol, and was recorded as unknown. Falls were divided into ‘fall’, defined as fall from standing (e.g. trip over curb) and ‘fall from height’ greater than standing (eg. fall from ladder). Involvement of alcohol and sub-classifications of sport are also displayed.
Table 1. Mechanism of injury
The diagnosis documented by the physician was divided into three categories. Medical considerations included loss of consciousness, duration of post-traumatic amnesia, seizure activity, and post-concussion symptoms. Table 2 shows the diagnoses in absolute and proportional terms respectively.
Table 2. Medical diagnoses
The recommendations following each consultation are recorded in Table 3. Multiple recommendations were made for many patients. The return to work program was administered by the clinic’s occupational therapist (OT), and is accounted for under both OT and return to work headings.
The recommendations made following medical and neuropsychological consultations are shown against diagnosis in Table 4.
Overall there were significantly more treatment recommendations (OT and other vs nil) made for those patients who had diagnosis of TBI (of any severity) compared to no TBI (χ2=6.555, p=0.038).
Table 3. Medical and neuropsychological recommendations
Table 4. Recommendations by medical diagnosis (n, % of total)
There was no significant difference in recommendations (nil, OT, other) by diagnosis (no TBI, mild TBI, moderate/severe TBI) for medical recommendations (χ2=2.773, p=0.60) but there was a significant difference (χ2=13.795, p= 0.008) for neuropsychological recommendations.
Similarly, the relationship was non-significant for medical recommendations (χ2=0.838, p=0.36) and significant for neuropsychology recommendations (χ2=4.458, p=0.035) when the groupings were simplified: TBI/no TBI vs no treatment/any treatment.
These groups were further stratified to TBI/no TBI vs no treatment/OT (thus excluding other treatments). Analysis of these groups showed again no significant difference between these groups in medical recommendations (χ2=1.266, p=0.261) and a significant difference for neuropychology recommendations (χ2=6.476, p=0.011). These analyses were considered because a proportion of the medical recommendations concerned symptomatic management of headache and dizziness which might apply whatever the diagnosis.
Our patients were predominantly male, with sport injuries and assaults (with alcohol involvement) being common modes of presentations. This is similar to figures in the neurotrauma and rehabilitation literature.2 A previous local study showed comparable mechanisms of injury and mean age.5 It was unfortunately not always clear if alcohol was directly involved in the injury from the patient notes.
It is interesting to compare sporting mechanisms of injury. Cycling was the dominant sport responsible for MTBI referral. Rugby and soccer presentations were less frequent. This contrasts with most of the world literature where contact sports are responsible for a greater number of presentations.
The relatively small number of rugby presentations is surprising, considering the prevalence of rugby as a sport in the Wellington region—there may be a bias in presentation with players not being appropriately referred because of a lack of perceived need or accessing alternative services, particularly sports medicine doctors.
Recommendation for further investigations was low (11% of patients). This likely reflects that the majority of patients were referred by services that had investigated appropriately at the time of injury and/or investigations are not usually indicated outside the acute phase for mild TBI.
It was anticipated by the researchers that diagnosis would impact on recommendations made. However, we identified no significant difference in recommendations arising from medical consultations between the three diagnostic groups, but a significant difference from the neuropsychological consultations.
One factor that may contribute to these results is that OT sessions were contractually funded (pending approval) for clinic attendees. OT was by far the most common recommendation, made for 43% of patients on medical assessment, and 65% on neuropsychological assessment. Because the OT sessions were funded, it is likely that there was a low threshold for recommending OT, even in the absence of diagnosed TBI.
Another factor contributing to these findings is that because the concussion clinic is a secondary referral service with a proportion of attendees being referred due to ongoing symptoms (rather than a representative sample from all head injuries), then regardless of diagnosis the patients’ ongoing symptoms may require treatment.
Patients are referred to the concussion clinic from the emergency department, ACC case managers, inpatient services, and GP clinics. In the latter group, referrals are made due to ongoing issues related to the injury, necessitating further treatment or advice regardless of the diagnosis. These patients are already in a subclass of those with persistent post-concussive symptoms. In these cases, Concussion Clinic recommendations are important in symptom management and return to societal, occupational, and family roles.
During consultations, advice was given regarding vestibular rehabilitation, modification of activity levels, and avoidance of ‘at risk’ activities and behaviours. Data pertaining to such advice was not collected however.
The concussion clinic’s funding is based on the premise that MTBI is a syndrome with societal and economic impact. The clinic is potentially a valuable tool.
These results suggest at least four separate functions for such a clinic:
The numbers seen in the clinic suggest that it currently does not serve much of a screening role for people with more than very mild TBI, for example seeing all patients for one-off review that have been admitted to hospital with TBI of any severity. Unfortunately this is probably the only role of such a clinic that is supported by strong evidence from randomised controlled trials.6,7
So that the precise functions of mild TBI clinics, appropriate volumes, and timing of assessments can be determined, more comprehensive research measuring appropriate end points for the subjects along with costs is necessary.
Conflict of interest statement: There are no conflicts of interest.
Author information: Hamish Alexander, House Surgeon; Nicola Shelton Physiotherapist; Jacob Fairhall, Neurosurgical Registrar; Harry McNaughton, Rehabilitation Physician; Capital and Coast DHB, Wellington
Correspondence: Dr H Alexander, Hutt Valley DHB, PO Box 31-907 , Lower Hutt. Fax: (04) 566 6999, email: Hamish.Alexander@huttvalleydhb.org.nz
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