Preface to Multidisciplinary Concussion Clinics No abstract available

Multidisciplinary Concussion Management: A Model for Outpatient Concussion Management in the Acute and Post-Acute Settings Objective: To describe a model of multidisciplinary concussion management and explore management methods in the acute and post-acute settings. Setting: A multidisciplinary concussion management program within a large health system. Participants: Patients with sports and non–sports-related concussions aged 14 to 18 years with persisting concussion symptoms at 4 weeks postinjury or beyond. Design: Pilot randomized controlled trial comparing a subsymptom threshold exercise program with standard-of-care treatment in the post-acute setting. Main Measures: Beck Depression Inventory-II and the Post-Concussion Scale-Revised. Results: Across groups, 60% improvement in concussion symptoms was noted. After removing the influence of depression, the intervention showed a large effect on symptom reduction, with participants in the intervention group improving more than those in the control group. There was no difference in response to the intervention by the sports and nonsports groups. Conclusion: Results demonstrate that exercise intervention is effective in reducing symptoms in adolescents with persisting symptoms. The finding that participants in the control group who underwent education, light activity, and sophisticated monitoring still had meaningful recovery supports the utility of active engagement in a multidisciplinary management program. Finally, depression had a clinically meaningful effect on recovery, highlighting the need for targeted intervention of noninjury factors relevant to persisting symptoms.

Pediatric Concussion: Managing Persistent Symptoms With an Interdisciplinary Approach Objective: We outline the development of a clinic that works directly with youth clients, their caregivers, and family members to help address symptoms that are persisting long after the youth sustained a concussion. Client referral characteristics are described, as well as general clinic flow and procedures. Particular emphasis is placed on a novel interdisciplinary team assessment pathway designed with input from clients and families to help provide consistent treatment plans, education, direction, and conclusions for those clients with complex psychosocial, cognitive, and physical presentations. Setting and Participants: The Persistent Concussion Clinic at Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada. Conclusions: Youth with persistent concussion symptoms have limited access to interdisciplinary clinics and supports. This article outlines the practices of a large, hospital-based interdisciplinary clinic whose model can inform clinical care pathways and practices for this underserved population. Facilitators and barriers to access are discussed and future directions for the clinic and persistent concussion care in Ontario and internationally are reviewed.

Recovery Following Sport-Related Concussion: Integrating Pre- and Postinjury Factors Into Multidisciplinary Care Objective: Update concussion recovery curves by considering pre- and postinjury modifying factors. Determine whether there is a dose-response for modifying factors on recovery. Setting: Sports medicine concussion clinic. Participants: A total of 314 athletes aged 12-23 years within 7 days of a concussion enrolled between 2015 and 2018. Design: Prospective cohort study. Main Measures: Categorical recovery time defined as days from injury to full medical clearance for return to play per established criteria. Preinjury factors included age, gender, concussion history, and migraine history. Postinjury factors included loss of consciousness, posttraumatic amnesia, posttraumatic migraine symptoms, and high symptom burden. Results: Average recovery was 27.5 ± 25 days. Five factors were prognostic of recovery: (1) younger than 18 years, (2) female, (3) history of migraine, (4) posttraumatic migraine symptoms, and (5) high symptom burden (P < .05). Recovery percentage at 21 days after injury was 96.7% for participants with 0 factor, 65.3% for those with 1 to 2, and 31.8% for those with 3 to 5—with prognostic separation in low- to high-risk groups of 62%. Conclusions: Findings support a dose-response for combined pre- and postinjury factors on recovery. Both the type and quantity of modifying factors influence recovery and should be considered in prognosis and approaches to multidisciplinary care.

Using Decision Tree Methodology to Predict Employment after Moderate to Severe Traumatic Brain Injury: Erratum No abstract available

Unique Features of the US Department of Defense Multidisciplinary Concussion Clinics The US Department of Defense (DoD) and the Department of Veterans Affairs (VA) actively address care needs for a subset of service members (SMs) who experience prolonged symptoms and adverse sequelae interfering with their usual level of function after sustaining mild traumatic brain injury. The development of multidisciplinary concussion clinics and implementation of several reinforcing policies within the DoD and the VA address this unique patient population. A network known as the National Intrepid Center of Excellence and Intrepid Spirit Centers and the VA, primarily support these patients through intensive outpatient programs. The VA also has an inpatient program that utilizes specialized capabilities. The features unique to several of these centers are described in this article. While providing for similar patient care needs, each clinical setting implements unique evaluation and treatment modalities to target analogous goals of return to the highest functional level possible and develop life skills to enhance health, quality of life, and readiness to perform military duties. Currently, patient-reported outcomes are being collected.

Physician Medical Assessment in a Multidisciplinary Concussion Clinic Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.

Integrating Neuropsychology Services in a Multidisciplinary Concussion Clinic Objective: To describe the integration of neuropsychology services in a multidisciplinary concussion clinic and provide descriptive information on patients, services, and initial health status. Setting: A university-based outpatient sports medicine concussion clinic. Participants: A consecutive sample of 338 patients ages 8 to 84 years (median 23.5 years, 35% 13-18 years), 49.1% male, seen between 2014 and 2018. Patients' injuries included sports 42%, work 28.4%, and vehicular 12.1% and 48.5% were students. Design: Descriptive statistics with group comparisons. Main Measures: 12-Item Short Form Health Survey (SF-12) T scores (mean = 50, SD = 10) referenced to US population. Results: Half of the patients were seen within 24 days of their injury and showed reduced physical functioning (40.2) and average mental (emotional) functioning (48.8). Patients seen after 24 days showed even more reduced physical functioning (33.9) and reduced mental functioning (41.0), both P < .0001. Average treatment time was also longer, 88.1 (173.9) versus 186.8 (211.1) days, P < .0001. Two-thirds of patients were referred for cervical or vestibular physical therapy at their initial visit. Conclusion: Early referral for specialized care, including neuropsychology services, may be beneficial.

Addition of Occupational Therapy to an Interdisciplinary Concussion Clinic Improves Identification of Functional Impairments Background: Concussions, or mild traumatic brain injuries, are prevalent among youth and young adults. These injuries may disrupt a person's daily activities (occupations) including school, physical activity, work, and socialization. Rehabilitation professionals, such as occupational therapists (OTs), are experts in providing individualized intervention to address these temporary life changes during recovery. Objective: This article aims to identify the benefit of having an occupational therapy practitioner on an interdisciplinary treatment team when providing intervention to patients with concussion. Setting: Concussion clinic at an academic institution. Participants: Participants ages 12 to 24 years with a reported history of mild traumatic brain injury or concussion were evaluated by a physician, or by a physician and OT, in an initial evaluation appointment. Design: A single researcher (OT) with training in concussion qualitatively compared reported impacted occupational domains as defined in the Occupational Therapy Practice Framework, using both a retrospective and a prospective cohort. The prospective group differed from the retrospective group in that an OT was present, and participated in the initial evaluation. Results: The domains of performance patterns (P = .007) and performance skills (P ≤ .001) were identified significantly more often when an occupational therapy practitioner participated in the initial evaluation. Conclusions: Rehabilitation professionals, such as OTs, play an important role in identifying impacted domains after a concussion, which can help optimize patient care.

Ethical Considerations in Chronic Brain Injury A growing number of individuals are living with chronic traumatic brain injury. As these individuals and their families attempt to reintegrate into their communities, several ethical questions arise for clinicians and researchers. These include issues around alignment of perspectives and priorities, as well as responsibilities for ongoing treatment, education, community outreach, and research. An action plan for addressing these questions is outlined.