Rapid diagnosis and prompt treatment are the keys to success with concussion care. Luckily, new concussion centers are forming to handle the challenge and are often staffed by specially trained physicians and physician assistants as well as nurse practitioners that utilize new concussion technologies and protocols. Once a concussion is suspected, it’s imperative to instruct brain rest and then refer the patient for evaluation in order to quantify the degree of the concussion and provide proper school, sports and work accommodations.
Emergency Room Assessment
The ER staff is tasked with ruling out life-threatening situations and, in the case of head injuries, should rule out an intracranial bleed and a skull fracture via a CAT scan of the head and face if there is a concern of bleed or fracture. If the ER tells a patient that the CT scan is normal, most patients feel that they do not have a concussion. In the case of a concussion, the ER will ask the patient to follow up with their Primary Care Physician (PCP).
Delayed Referral is Counter-Productive
When symptoms such as headaches and dizziness continue for more than a week, most PCPs will then order a MRI or CT scan and refer the patient to a local neurologist. Delaying six to eight weeks (often the wait period for new patients at many local neurology practices) is too long a delay to begin proper concussion treatment per UPMC Protocols. Since the new concussion protocols are no longer passive, just resting at home and waiting for a neurology referral causes a loss of valuable recovery time with a locally trained physical therapy group.
Medical Professionals Should Become Involved
Primary care physicians (including pediatricians, family physicians and internists) can actively diagnose and treat concussion patients in their own group with further specialty training in programs like UPMC and certification with ImPACT physicians. Physical therapists with further training in the 5 Stage UPMC Concussion Program and vestibular therapy can help provide immediate access to this new technology for concussion patients. Also with proper training in vestibular screening for concussions, the physical therapist can often diagnose previously missed concussions in patients who they are currently caring for with other injuries including cervical strain with headaches. Similarly, athletic trainers with further ImPACT training can identify and screen athletes at the site of injury during practice or a competition. Positive results would precipitate prompt removal from play and referral to a concussion specialist.
Back to School/Work Clearance
Due to medical and legal risks, some states (like Delaware) have mandatory requirements stipulating that only physicians with concussion training can clear patients for return to school, work or sports. However, if the physician or medical professional clearing the patient is not capable of doing a thorough vestibular exam to show full recovery, and is not trained to read and interpret a neurocognitive test like ImPACT, the patient is at risk of returning to normal activity before the concussion is properly healed. In the case of sports and athletics, early return to play can lead to long-term effects including:
- Memory problems
- Increased risk of migraine headaches
- Attention deficit disorder
- Anxiety and depression
- Second Impact Syndrome, a rare but potentially deadly diagnosis (see sidebar)
Slipping Through the System?
Some patients and families do not agree with the assessment of a concussion and a doctor refusing to allow return to play. In some of these cases, the family or patient go “doctor shopping” to find any doctor that will clear their athlete for play. If they find a doctor unfamiliar with the new concussion technologies and vestibular screening, they might be able clear the athlete with the old school approach, meaning no symptoms reported, a normal gross neuro-exam (without vestibular exam). These medical providers will sign written clearance to allow the athlete to return to sports.
What that doctor may not realize is that with the availability of these new technologies, the standard of concussion diagnosis and care has been raised. If the athlete is not properly evaluated and returned before the concussion has healed, they are at a four-five times greater risk for another concussion with inherent imbalance and thus can end up with a second concussion with a long-term or potentially deadly outcome.
In order for an athlete to return to play, and to avoid long-term issues, UPMC Concussion Protocols dictate that the patient needs to:
- Receive a completely clear vestibular exam
- Show improvement in ImPACT Scores
- Successfully complete the 5 Stage UPMC concussion recovery program with a local physical therapist.
Even multiple concussions that are fully recovered in less than three months could end a season or cause up to three-six months of delayed play. Decisions for sport cessation should be made through evaluation of all technologies and therapies. Hopefully, upcoming technologies like very costly metabolic MRIs or possible future tests to diagnose the onset of CTE may help make these decisions more concrete.