(p. 110) Assessing and Managing Concussion
Injury to the brain can have both obvious and subtle consequences for an individual’s daily functioning at school, at work, at home, or in his or her social life. A concussion is a type of mild traumatic brain injury that has gained significant attention over the past 10 years with a better understanding of its functional effects. The Centers for Disease Control and Prevention (CDC, 2007) defines concussion as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. The blow to the head or body results in significant movement of the brain with shear strain disrupting its function due to changes in neurometabolism and neurotransmission. This disturbance of brain function is typically associated with normal head computed tomography and magnetic resonance imaging findings, as concussion does not typically result in structural damage to the brain tissue or blood vessels. A constellation of physical, cognitive, emotional, and sleep symptoms ensues, infrequently involving loss of consciousness (less than 10%–20%). The duration of these symptoms can vary widely from minutes to months, and even longer in a small number of cases.
By virtue of their training in behavioral and cognitive assessment, psychologists (clinical, neuro-, school) are well suited to assist in assessment and management of this injury. As a foundation, the clinician must possess appropriate knowledge of concussions and associated symptom domains. An approach to the assessment and management of concussion, using the Acute Concussion Evaluation (ACE) and ACE Care Plan, is presented to assist the clinician.
Individuals may present for evaluation early (days to weeks) or later (months to years) following the injury. Typically, early postinjury evaluation focuses on acute symptom assessment while later evaluation would additionally assess the progression of symptoms over time and other intervening activities or treatments that may have influenced the persistence of symptoms. In most cases, recovery is relatively rapid, with symptoms resolving for most individuals within a few weeks to a few months. A small minority of individuals exhibit persisting symptoms and/or neurocognitive changes.
A thorough understanding of injury characteristics and the type and severity of postconcussion symptoms in the context of the individual’s preinjury history is fundamental to the concussion evaluation. The job of the clinician is to determine whether there is new onset of symptoms, exacerbation of preexisting symptoms, or both. Understanding the individual’s developmental, medical, family, educational, and psychological history is critical to delineating the postinjury versus preinjury symptoms as there can be a tendency to overascribe symptoms to (p. 111) the injury. The evaluation of a concussion can be further complicated as many symptoms of concussion are also common to those of other medical or psychiatric conditions (e.g., posttraumatic stress disorder, depression, attention-deficit/hyperactivity disorder, headache). Determining the temporal proximity to the injury is an important aspect of the evaluation.
The concussion evaluation focuses on (1) defining injury characteristics, (2) identifying symptom status and neuropsychological dysfunction, (3) establishing the reported symptoms as greater than preinjury status, and (4) determining effects on the individual’s life (e.g., school, work, home, social). To assist the clinician’s assessment, Drs. Gioia and Collins developed the Acute Concussion Evaluation (ACE; see Appendix) to provide a systematic, evidence-based protocol to assess children and adults with known or suspected concussions. The ACE can be found online in the CDC’s “Heads Up: Brain Injury in Your Practice” toolkit (www.cdc.gov/concussion). The ACE Symptom Checklist can be used for initial identification and to serially track symptom recovery over time. The ACE is appropriate for patients in which concussion is clearly indicated (e.g., loss of consciousness or change in mental status, confusion, or amnesia) and where concussion is suspected (e.g., forcible blow to the head or body with functional changes). A description of the ACE protocol follows.
Defining Injury Characteristics
Injury description. Assess how the injury occurred, type of force, and location on the head or body where the force (blow) was received. The force to the head may be indirect, such as with an individual being struck in the body resulting in the head accelerating forward and then backward quickly (e.g., whiplash).
Cause. The cause of the injury can help to estimate the force of the blow that was sustained. Generally, the greater the force, the more significant the symptoms. Symptoms associated with a relatively light force, however, may indicate increased vulnerability to concussion, or the presence of other physical or psychological factors contributing to symptom presentation.
Amnesia (retrograde, anterograde). Determine whether amnesia (memory loss) has occurred for events before the injury (retrograde) or after the injury (anterograde) and attempt to determine the length of time of memory dysfunction. Anterograde amnesia is also referred to as posttraumatic amnesia (PTA).
Loss of consciousness (LOC). Inquire whether LOC occurred or was observed and the estimated length of time the patient lost consciousness.
Early signs observed by others. Ask those who know the patient (parent, spouse, friend, etc.) about observed signs of the concussion early after the injury.
Seizures. Inquire whether seizures were observed (although this is uncommon).
Assessment of Postconcussion Symptoms
Symptom assessment. The ACE Symptom Checklist assesses symptoms reported by the patient (and/or parent or other informant, if necessary) in each of the four symptom areas: physical, cognitive, emotional, and sleep. As symptoms can be present prior to the injury (e.g., inattention, headaches), assess any changes from typical presentation. Any Total Symptom Score greater than “0” indicates the presence of postinjury symptoms.
Exertion. Symptoms often worsen or reemerge with exertional activity, which is important information for management recommendations. Assess any worsening of symptoms with physical activity (e.g., running, climbing stairs, bike riding) and/or cognitive activity (e.g., academic studies, multitasking at work, reading, or other tasks requiring focused concentration).
Overall “difference” rating. The ACE contains an overall 0–6 rating from the patient (and/or parent or informant) regarding his or her overall perceived change from their preinjury status. This rating is helpful in summarizing the overall impact of the symptoms.
(p. 112) Historical Factors that may Prolong Recovery
The follow risk factors have been associated with a longer period of recovery from a concussion. Their assessment can be helpful to frame the recovery process.
Concussion history. Assess history of prior concussions, including the duration of symptoms for each injury. The effects of multiple concussions may be cumulative, especially if there is insufficient recovery time between injuries. A sign of increasing vulnerability is that less biomechanical force results in subsequent concussion.
Headache history. Assess personal and family history of treatment for chronic headaches (migraines in particular).
Developmental/school history. Assess for a history of learning disabilities, attention-deficit/hyperactivity disorder, or other developmental disorders.
Psychiatric history. Assess for history of depression, anxiety, and sleep disorder.
With a full definition of the concussion and its symptom manifestations, individualized management planning can proceed. The general psychologist who is less experienced with ongoing management should consider referring to a concussion specialist for management. In addition, referral for focused neuropsychological assessment should be considered when symptoms persist or assisting return to risk activities. Brief test batteries (computerized or abbreviated paper and pencil) have been validated for assessment and tracking of recovery. Testing can also be helpful in developing treatment strategies and to assist the process of return to safe sports participation, school, or work. Referral for more comprehensive neuropsychological assessment should be considered if symptoms persist beyond expectations.
The foundation to concussion treatment is managed rest with individualized management of physical and cognitive exertional activity. A basic treatment assumption is that symptom exacerbation or reemergence in the wake of physical or cognitive activity is a signal that the brain’s dysfunctional neurometabolism is being pushed beyond its tolerable limits. Therefore, in guiding recovery, the therapeutic goal is to manage cognitive and physical activity at a level that is tolerable, that is, does not exacerbate or cause the reemergence of symptoms. The ACE Care Plan, also available on the CDC Web site, was developed to guide clinicians’ management.
The presence of any postconcussion symptoms or cognitive impairment dictates that patients must not return to high-risk activities (e.g., sports, physical education, high-speed activities). Only when symptoms resolve should a patient slowly and gradually return to his or her daily cognitive and physical activities. Children and adolescents will need the help of their parents, teachers, and other adults to assist with their recovery. Symptom management involves all aspects of the patient’s life, including home life, school, work, and social-recreational activities.
Daily Home/Community Activities
In developing an appropriate treatment plan with the patient, the clinician defines the typical schedule and types of activities at home and in the community. Patients should be advised to get adequate sleep at night and to take daytime naps or rest breaks when significant fatigue is experienced. Teach the patient that the return or exacerbation of symptoms is a guide to the level of activity that is safe and tolerable, limiting physical and cognitive exertion accordingly. Physical activity to be managed might include PE, sports practices, weight training, running, exercising, and heavy lifting. Cognitive activities to be managed might include heavy concentration, memory, reasoning, reading, or writing (e.g., homework, classwork, computer or other electronic screens, job-related mental activity). As symptoms decrease, patients may return to their regular activities gradually. Return to high-risk activities such as driving or operating heavy machinery must be carefully considered, especially if the patient has problems with attention, processing speed, or reaction time.
(p. 113) Return to School
The school team (e.g., teacher(s), the school nurse, psychologist/counselor, and administrator) should be informed of the student’s injury, symptoms, and cognitive deficits with active efforts to put the appropriate supports in place for the student. School personnel should be advised to monitor for increased problems paying attention/concentrating, problems remembering/learning new information, longer time required to complete tasks, increased symptoms (e.g., headache, fatigue) during schoolwork, and greater irritability/less tolerance for stressors. Symptomatic students will require active supports and accommodations in school. Students with prolonged symptoms (i.e., longer than several weeks) may require special accommodations and services, such as those provided under a Section 504 Plan. As symptoms decrease, and/or as cognitive test results show improvement, patients may return to their regular activities gradually. The School Version of the ACE Care Plan was developed to assist management of cognitive tasks to accommodate the student’s tolerance. Students who fatigue easily may benefit from regular rest breaks in the school nurse’s office. Students with neurocognitive deficits in attention or concentration may benefit from breaking down larger assignments into smaller tasks or lightening of the workload. Other supports include time off from school (e.g., first several days post injury), shortened day, shortened classes, and scheduled rest breaks during the day. Students may also need allowances for extended time to complete coursework/assignments and tests, as well as a reduced workload and no significant testing while symptomatic. Symptom status should be monitored periodically to modify the types and intensity of the academic supports across recovery.
Return to Work
Similar to school, return-to-work planning (see Work Version of ACE Care Plan) should be based upon careful evaluation of symptoms and cognitive status. Employers/work supervisors should be informed of the employees’ injury, symptoms, and cognitive deficits with an active effort to put the appropriate supports in place. To help expedite recovery, patients initially will need to reduce both physical and cognitive exertion. Repeated evaluation of symptom status is recommended to help guide the level of management. Until a full recovery is achieved, individuals may need the following supports: schedule considerations such as a shortened work day, allowance for breaks during work when symptoms increase, and reduced task assignments and responsibilities. Safety considerations while symptomatic also should be given, including no driving, heavy lifting/work with machinery, and no heights due to risk of dizziness and balance problems.
Return to Play (Sports and Recreation)
For persons of any age who participate in competitive or recreational activities, avoiding reinjury or prolonging recovery is a central management goal. Collision sports require special management to ensure full recovery prior to their return to play. As a fundamental tenet of sports concussion management, an individual should never return to competitive sport or recreational activities while experiencing any lingering or persisting concussion symptoms, including PE class, sports practices and games, and other high-risk/high-exertion activities such as running, bike riding, skateboarding, climbing trees, jumping from heights, playful wrestling, and so on. The individual must be completely symptom free at rest and with physical exertion (e.g., sprints, noncontact aerobic activity) and cognitive exertion (e.g., studying, schoolwork) prior to return to sports or recreational activities. As articulated by the international Concussion in Sport Group (McCrory et al., 2009), return to play should occur gradually and systematically with medical supervision, monitoring for symptoms, balance, and cognitive function during each stage of increased exertion.
Psychologists can actively participate in the evaluation and management of concussions (mild traumatic brain injury). They should (p. 114) develop a working understanding of the injury and its clinical manifestations. Individualized evaluation requires the clinician to define the characteristics of the injury, conduct a full assessement of postconcussion symptoms, and define any risk history that may modify recovery. Treatment involves active management of daily activities. The Acute Concussion Evaluation (ACE) and ACE Care Plan can assist the psychologist in this endeavor.
References and Readings
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. (2007). Heads up: Brain injury in your practice. Atlanta, GA: Author.Find this resource:
Gioia, G. A., & Collins, M. W. (2006). Acute concussion evaluation. Retrieved January 2013, from www.cdc.gov/concussion/headsup/pdf/ACE-a.pdf
Gioia, G. A., Collins, M. W., & Isquith, P. K. (2008). Improving identification and diagnosis of mild TBI with evidence: Psychometric support for the acute concussion evaluation (ACE). Journal of Head Trauma Rehabilitation, 23, 230–242.Find this resource:
Giza, C. C., & Hovda, D. A. (2001). The neurometabolic cascade of concussion. Journal of Athletic Training, 36, 228–235.Find this resource:
Halstead, M. E., Walters, K. D., & The Council on Sports Medicine and Fitness. (2010). Sport-related concussion in children and adolescents. Pediatrics, 126, 597–615.Find this resource:
McCrea, M. (2007). Mild traumatic brain injury and postconcussion syndrome. New York: Oxford University Press.Find this resource:
McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu, R. (2009). Consensus Statement on Concussion in Sport: The 3rd International Conference held in Zurich, November, 2008. British Journal of Sports Medicine, 43, i76–i84.Find this resource:
Sady, M. D., Vaughan, C. G., & Gioia, G. A. (2011). School and the concussed youth: Recommendations for concussion education and management. Physical Medicine and Rehabilitation Clinics of North America, 22, 701–719.Find this resource:
Chapter 12, “Evaluating Dementia”
Chapter 17, “Adult Neuropsychological Assessment”
Chapter 19, “Assessment and Intervention for Executive Dysfunction”
Chapter 58, “Practicing Psychotherapy with Adults Who Have Cognitive Impairments”
(p. 115) Appendix: Acute Concussion Evaluation (ACE)