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| Journal of the New Zealand Medical Association,
16-February-2007, Vol 120 No 1249
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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.
MethodA 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.
ResultsA 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.
DiscussionOur 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
References:
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