June, 2013

A Concussion Clinic: The Antigonish Model


Tara Sutherland CAT(C), Dr David Cudmore MD Dip Sports Med.

A 15 year old hockey player, a 40 year old construction worker and a 35 year old woman all received a hit to the head and report to the Emergency Room. After a standardized assessment is performed they all leave with diagnosis of a concussion. Who now provides the care for these people over the next several weeks and or months as they recover? This is the dilemma that many patients and medical personnel have been faced with after a diagnosis of a concussion.

Concussions are a hot topic. Sport organizations, schools and employers are now realizing that this injury has a significant short and or long term impact on people. There is a demand for medical assessment and active management of these patients.

The Antigonish Concussion Clinic (ACC), serving northeastern Nova Scotia, has taken a leadership role in aiding all community members who have sustained a concussion, be it in a sporting activity at work or at home. Sport Medicine Physician Dr. David Cudmore and, Certified Athletic Therapists Tara Sutherland, Angela Wylie, Katrina Lambert and Emergency Room Physician Dr Maureen Allen have developed a working model for the assessment and treatment of concussions in Antigonish and surrounding areas.

The ACC has been accepting patients for more than four years. After many years of treating the varsity athletes from St FX University, it was recognized that the community would benefit from a similar approach to concussion management.  Many patients are referred from the Emergency Department at St Martha’s Hospital and some from community physicians, and primary care nurse practitioners. When an individual reports to ST Martha’s with a suspected concussion they are given a modified Concussion Assessment Form( Appendix 1) to fill out and then are seen by a physician. If it is determined they have indeed suffered a concussion the hospital then gives the individual post –concussion instructions and is referred to the ACC. 

Referred patients are first seen by an Athletic Therapist, who completes a comprehensive history of injury and then performs a complete concussion assessment on the patient using a modified Sport Concussion Assessment Tool (SCAT2) (McCrory et al., 2009)(appendix 2) . This includes a thorough assessment of mental status, cognitive functioning and balance. The athletic therapist will often spend time with the patient on concussion education and explaining how recovery occurs and what is needed for the brain to recover. After this initial assessment the patient then meets with both the athletic therapist and physician and a individualized plan is designed for the patient. This will include advice regarding physical and cognitive rest. Modifications to work and or school schedules are often required.

Cognitive rest is as important as physical rest for recovery. Specific guidelines are set and patients are instructed to limit the use of computers, video games and text messaging. They may not be able to watch television or even read.

The patient is usually sent home with specific instructions and a follow up appointment is booked for one or two week’s time. The physician will often write medical notes for modified work and or school. Medication may be prescribed. A consult letter is sent back to the referring physician or nurse practitioner with a copy to the patient’s primary health care provider.  Worker compensation boards (WCB) forms are completed when necessary.

Ideally the patient is seen at the clinic regularly until they have fully recovered. Follow up is also done by the athletic therapists via phone calls and email between clinic visits when necessary. Progress notes are sent out after each visit to the primary health care provider (and WCB when necessary).

When the individual becomes asymptomatic at rest and is ready to return to a sport or activity the athletic therapists will do a standardized bike test at the Athletic Therapy Clinic at STFXU. If the patient completes this bike test satisfactorily then they are returned to activity according to the return to play guidelines set forth by McCrory et al., 2009. Follow up visits are done with the physician and the athletic therapist until an athlete returns to full activity, especially if they participate in contact sports. Similarly, non athletes are followed until they resume normal activities such as work and school.

We often call ourselves “concussion coaches” since we have to deal with many different issues ranging from family and home to work or school concerns. There is no one cure for concussions. The recovery guidelines are general at best. We try to deal with each patient on an individual basis and guide them through their recovery.

As a general rule our physician does not send our patients for diagnostic imaging, such as MRI or CT scans since imaging is usually normal  as reported by McCrory et al., 2009.  We do not refer many patients to medical specialists such as neurologists or neurosurgeons. The specialists are over two hours away by car and the travelling can cause worsening of symptoms. Most patients do not require their services. However we will send the patient if they are not improving and or have complicating issues such as persistent cognitive defects.

Pharmacological therapy for prolonged sleep disturbances has played a role in many of our patient’s recoveries.  In the ACC we have used amitriptyline in low doses. It helps restore a normal sleeping pattern and is useful for chronic pain. Sometime we use simple sleeping pills such as Imovane. There have been select patients that have needed antidepressant therapy for depression, one of the long term consequences of concussions.  In addition we will occasionally send patients to see a psychologist for treatment of depression or anxiety.

We will evaluate patients carefully for neck pain. There is often a coexisting injury which may require specific treatment. We will often refer to physiotherapy or massage therapy.

Many of our patients are injured while at work. We have therefore had to develop a good working relationship with the WCB. We have had to spend time educating WCB case workers regarding concussions and return to work guidelines. We have also worked with local teachers, professors and university deans to educate them on the effects of concussions and the difficulties that students may encounter. This helps to ensure that students return to school in a timely and healthy manner.

It is reported by the United States Centre for Disease and Prevention (CDCP) that there is 1 Traumatic Brain Injury (TBI) every 22 seconds in the USA. Seventy five percent of the TBI’s are concussions. (Majeske et al., 2008) In Canada in 2006 it was estimated that there were 110 concussions / 100,000 people/ year.  Sport organizations are now demanding medical assessment and follow up clearance before return to sport. The public is becoming better informed about the dangers of concussions and seeking more medical attention.

We believe that the program developed at the ACC has helped many individuals who have suffered from a concussion. Our goal is to enable them to return to a normal healthy active life. We consider our approach to be holistic and novel. We see adults and children, athletes and non-athletes. This injury has a tremendous impact on people’s lives and people deserve timely and high quality care. The following are two testimonials from injured athletes about how concussions have affected them.

“The lingering aspect of this concussion is definitely the most difficult part. I sustained three concussions in a one year period, most recently 2½ months ago, and I am still not feeling 100%. I didn’t get hit by a rampaging hockey player at the speed of a train. You wouldn’t think that volleyball was a high-risk sport. All of my concussions were accidental, but they still add up nonetheless. The worst part is, I don’t know when it’s going to get better, and frankly, I’m scared of what another concussion might mean.” (Varsity University athlete)

“As an athlete having a concussion is hard to explain to your coaches and teammates. There's no visible evidence that you're hurt - like there is with an ankle or knee. I felt that my coaching staff didn't take my head injury seriously and pushed me to return to play earlier that I should. Without the care of our athletic therapists and doctors I probably would have returned to play too early and done further damage.” (Varsity University athlete)

This multidiscipline collaboration practice with athletic therapists and physicians has been a successful model of care. It is sustainable in a medical fee for service environment, requiring no new funding. The care of concussed patients requires skill and time. Busy family physicians are hard pressed to add this work load to their already full schedules. Athletic therapists have the expertise in the area and can provided most of the care that the patient requires, with a small amount of medical supervision by the physician with expertise in caring for concussed individuals.

Using this model we are able to efficiently and expertly look after a large number of patients every week. Patients are treated in an up-to-date and consistent manner.  ER physicians are able to ensure correspondence and the feedback from them has been positive as well. Patient satisfaction has been extremely high.

 

References

Majerske, W., Mihalik, J., Ren, D., Collins, M., Reddy, C., Lovell, M., & Wagner,

A. (2008). Concussion in sports: Postconcussive activity levels, symptoms,

and neurocognitive performance. Journal of Athletic Training, 42(3), 265-

274.

McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J. L., Aubry, M., Molloy, M.,

& Cantu, R. (2009). Consensus statement on concussion in sport-the 3rd

international conference on concussion in sport help in zurich, november

2008 . South African journal of sports science, 21(2), 36-46.

 

Statistics

Over the last three years we have seen 217 patients.  Ages 8- 16:  27 males and 14 females. Ages 17- 80 97 males and 79 females (figure 1). We are currently seeing 10 – 12 patients per half day, 2 half days per week, on average. This would include about 6 new patients per week and 8- 9 number of follow-up patients per week.

 


ANTIGONISH CONCUSSION CLINIC











 

AGE

Total

Sports

Non sport




MALES

< 16 years

27

24

13


MALES

124

 

17-80 yrs

97

44

40




FEMALES

< 16 years

14

10

8


FEMALES

93

 

17-80 yrs

79

27

51




Totals

 

217

105

112



217









Jan 2009 to Dec 2011

Total patients 217


Pictures


School fair giving out info on concussions here in Antigonish NS


Tara Sutherland and Laura Leslie at Women’s National Hockey Reunion April 2013 in Ottawa.  The teams of 1992, 1995, and 1997 were brought back. Laura was both a player with the team and an athletic therapist with the team later on.


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