Case Study - Complex Concussion Patients in the MVA System
It is estimated that the incidence of mild traumatic brain injury (mTBI) and concussion in Ontario is between 493/100,000 and 653/100,000 (1). Concussions are caused by head or body trauma from a variety of mechanisms with motor vehicle accidents (MVA) and falls accounting for nearly 50% of cases in Canada (2).
According to the Guidelines for Concussion / Mild Traumatic Brain Injury & Persistent Symptom (1), concussion symptoms following mTBI are expected to resolve within 3 months in 85-90% of cases (1). However, one study completed in Saskatchewan, showed that six weeks after an MVA, 75% of patients diagnosed with a mTBI still had ongoing symptoms, and at the one-year mark, symptom prevalence was still over 50% (3).
Why do our mTBI patients who have been involved in MVA’s have a high occurrence of persistent symptoms? Could concussions sustained in MVAs have compounding factors that impact recovery? This article discusses concussions sustained in MVAs, potential compounding factors, the hierarchy of treatment planning with these patients, and reviews the additional challenges of working with MVA insurance companies.
What is a Concussion and Post-Concussion Syndrome?
Concussion/mTBI is defined as a complex pathophysiological process affecting the biomechanical forces (1). Table A shows the current accepted diagnostic criteria outlined by the Ontario Neurotrauma Foundation (1). Post-concussion syndrome is suspected when symptoms persist beyond the expected recovery time of three months. Researchers and clinicians alike have had trouble understanding the cause of persistent symptoms, however it now appears that a variety of interacting neuropathological and psychological contributors both underline and maintain post-concussion syndrome (1). Out of the various symptoms experienced by patients with mTBI, headache pain is the most common (1). As with any persistent pain, when concussion symptoms persist individuals often experience reduced functional ability, heightened emotional distress and delayed return to work or school (1).
Table A: Diagnostic Criteria for Concussion/Mild Traumatic Brain Injury (1, page 2)
Concussion/mTBI is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussion/mTBI include:
1. Concussion/mTBI may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head.
2. Concussion/mTBI typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
3. Concussion/mTBI may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
4. Concussion/mTBI results in a graded set of clinical symptoms that may or may not involve loss of consciousness Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.
Phil is a 54-year-old male who was involved in a MVA eight months prior to their initial visit. He attended physiotherapy at another clinic but stopped because he had plateaued. He reports primarily orthopaedic treatment at this clinic.
His complaints include cervical spine pain, left shoulder pain, headaches, dizziness, nausea, and light sensitivity. He is an accountant and has not yet returned to work or to managing his son’s hockey team. When questioned further he could only spend limited time in a grocery store or other busy environments before his headaches would worsen. He would also get dizzy while watching his son play hockey. Using a computer or cellphone tend to bring on symptoms. He has trouble falling asleep and staying asleep. He feels foggy often and is concerned about returning to work as he doesn’t feel as sharp as he once was, nor does he have the same focus and attention. He will often forget appointments and uses an agenda more regularly to compensate.
At home, he prefers to be alone and tends to avoid social gatherings, which is starting to have an effect on his relationship with his wife. He has a history of anxiety but used running as a tool to manage this in the past. Unfortunately, he has not been able to run since his accident because it would trigger a headache.
Post Traumatic Vision Syndrome is referred to eye coordination/teaming issues and accommodative dysfunction which is prevalent in concussion patients. It presents as anomalies of visual acuity, accommodation, version movements, vergence movements, photosensitivity, visual field integrity and ocular health (1). Typical testing includes visual acuity, extra-ocular motility, and vergence.
When being tested, both smooth pursuits and saccadic eye movements provoked a headache. He had a vergence insufficiency, with a near point convergence of 23cm from his nose.
Common vestibular dysfunction seen in mTBI patients includes altered vestibular-ocular reflex (VOR), impaired static and dynamic balance, and potentially the presence of benign paroxysmal positional vertigo (BPPV).
Phil presented with a positive head thrust test to the left. He had a 5-line difference on dynamic visual acuity testing, showing an abnormal VOR. This test also made him very nauseous and dizzy. He scored 90/120 on the mCTSIB and tended to fall to the right. He scored 21/30 on the FGA, and specifically had trouble with walking with head turns horizontal and vertical and walking with his eyes closed. BPPV testing was negative.
The metabolic and physiologic changes of concussion may result in altered autonomic function and control of cerebral blood flow (4). The Buffalo Concussion Treadmill Test (BCTT; see video of protocol https://www.youtube.com/watch?v=I9Z6rtwHVUs) has been shown to diagnose physiologic dysfunction in concussion patients safely and reliably, differentiate it from other diagnoses (e.g., cervical injury), and quantify the clinical severity and exercise capacity of concussed patients. The BCTT can be used to then establish a safe aerobic exercise treatment program which will assist with recovery and returning to activity (4).
Phil completed the BCTT and was able to walk for nine minutes. The test was terminated because of symptom onset, increased heart rate and blood pressure, while Phil reported a minimal increase in rate of perceived exertion.
Motor vehicle accident patients typically have musculoskeletal injuries, and these injuries can have an impact on concussion testing, especially in relation to static and dynamic balance testing, physiological testing, and vestibular testing. In addition, cervical spine dysfunction presents with many similar symptoms to concussions, and thus must be considered during your testing.
Phil presented with upper cervical joint restriction and increased tone in the suboccipital and left scalene muscles. Cervical testing triggered a mild headache. His left shoulder active range of motion was restricted due to pain compared to his right. He has a positive Empty Can Test and Hawkins Kennedy Test on the left.
We must always remember to screen for psychosocial factors that contribute to persistence of conditions. For post-concussion syndrome some complicating factors are: changes in the patient’s support system; mental health history; co-occurring conditions (chronic pain, mood disorders, stress disorders, personality changes); substance and medication use disorders; and unemployment or changes in job status (1).
Phil has not yet returned to work and has become isolated since his accident. As social gatherings bring on symptoms, he has avoided attending them. He reports changes in his relationship with his wife, which has led to some feelings of depression. He is not able to be as involved in his son’s hockey as he once was, and he feels this is affecting their bond. He has a history of anxiety which was managed through exercise, but he has not been able to exercise since his accident. He notes that his anxiety has been worse lately. Financial concerns are also present as he was the primary provider for his household, with his wife working part time.
Approach to Treatment
So where do you begin with Phil? The Ontario Neurotrauma Foundation created a set of Guidelines to provide clinicians with the most updated evidence regarding concussion and post-concussion treatment. In these guidelines they provide advice on treatment hierarchy, which is summarized in Table B. The concept is that we want to “first target specific difficulties that have both readily available interventions and the potential to yield significant symptomatic and functional improvement. That is, treat those symptoms that can be more easily managed and/or could delay recovery first, before focusing on more complex and/or difficult to treat symptoms” (1, page 4). Some symptoms are multifactorial and are influenced by physiological factors, psychological factors, pre-existing risk factors, coping style, and current stressors in their life. By treating the primary symptoms first, we often will have a positive influence on the secondary symptoms as well (1).
Table B: Symptom Treatment Hierarchy (1, page 4)
Primary Symptoms (to be addressed early)
Secondary Symptoms (recommended addressed secondarily)
Education is done early on and carried out throughout most treatment sessions. Some key components
to education are outlined in Table C.
Table C: Early Intervention Strategies (adapted from 1, page 16)
1) Initially, it is important to provide information regarding the patient’s symptoms, and having
them understand the source of their symptoms, as best as possible. Persistent symptoms are not
isolated to concussions, and are seen in various chronic pain conditions. As with chronic pain,
providing education can reduce anxiety and normalizes symptoms.
2) You also want to educate on the expected outcomes, especially with acute patients, and
emphasize the prevalence of a full recovery in most cases. Reassurance, along with education has
been shown more effective in the prevention of persistent symptoms then just education alone (1).
3) Self-management is key to concussion recovery, so review concepts of pacing, planning, and
energy conservation establishes skills to assist with reduction of symptoms, but also empowers the
patient early on.
4) Sleep hygiene is important for all patients, regardless of injury, and concussion patients are
no different. Reviewing key concepts to improve sleep, and addressing any biomechanical and
equipment needs should be done early.
5) Education on techniques to manage stress, along with potential stress triggers in their life
and environment should be implemented.
6) Lastly, you want to encourage return to normal work/school/activity and life roles as
tolerated. This is initiated early, and is something that should be discussed and progressed at
each session. Careful monitoring by yourself with this will help your
patient feel comfortable and confident when taking steps towards return to activity.
The management of post-traumatic headaches is difficult, and the research is varied, with no clinical guidelines available. Education, discussed above, especially regarding pacing, planning, and energy conservation, is advised. However, communication and involvement with the family physician, neurologist, or physiatrist is important to address pharmacological treatment.
Once the primary symptoms have been addressed, look towards the secondary symptoms. These involve vestibular physiotherapy, orthopaedic physiotherapy, vision therapy, and physiological/aerobic training. With multiple systems in play, these systems are going to influence each other, and thus treatment should not be just in isolation of one system at a time. This gets into the “art” of concussion rehabilitation, and each therapist will have a preference. Typically, I would begin with simple exercises from two or three of the categories and progress each exercise based on the patient's abilities and improvements. Typical early exercises could include eye stretches, static balance training, cervical range of motion, and a below symptom threshold walking program.
Mentioned above were the psychosocial changes that can occur with any patient. Based on your screen, referrals should be made to appropriate healthcare professionals. Common healthcare teams for concussion patients include, but not limited to, a neurologist, neuropsychologist, occupational therapist, neuro-optometrists, and vestibular physiotherapists. Establishing a multidisciplinary team approach with complex patients is key to overall success.
Furthering your knowledge on concussion and post-concussion management may be the next step to aid these patients. Starting with a foundation in vestibular rehabilitation is recommended, and then expand your knowledge with concussion rehabilitation courses. This area is becoming more recognized, and post-graduate courses are available and developing in Canada and the United States.
Challenges of working with MVA insurance companies.
There have been certain factors associated with poor recovery of mTBI, some of which include: number of symptoms reported at follow-up; post-traumatic stress; reduced social interaction (compared to pre-injury); and financial compensation-seeking, amongst others (1). These factors listed are often seen with our MVA patients, providing additional challenges to us as healthcare providers, and reinforces the value of a multidisciplinary healthcare team.
Beyond the complications the patient presents, there can be challenges with funding from MVA insurance companies. Despite all the knowledge and education that exists, some adjusters and physicians still do not understand the diagnosis or recommended treatment. This leads to denials of MVA treatment plans, patients being incorrectly categorized in the auto insurance system, and poor results from Insurance Medical Examinations (IME). Having a healthcare team which includes medical professionals recognized to diagnose a concussion is important early on. Using your treatment plan and/or report to provide the definition of a concussion, of persistent symptoms, and recent literature regarding the benefit of physiotherapy for concussion treatment can be of value. Lastly, working with a patient's legal representative to reviewinaccurate IMEs and assist with ensuring proper healthcare providers are selected to review your treatment plan is imperative.
Complex MVA patients with components of vestibular and concussion symptoms are not ones to shy away from. Persistent concussion symptoms can be approached similarly to how you would approach a chronic pain patient. You want to reduce anxiety around their condition and provide them with education they can use to begin to make steps in a positive direction. As psychosocial factors have such an influence on concussion recovery and are seen so often in our MVA patients, establishing a healthcare team can be one of the most important things you do for your patient. With the approach discussed, along with a good healthcare team, our patient Phil made an excellent recovery and was able to return to work on modified duties and began to attend his son’s hockey games successfully.