By Steven Moskowitz, MD, Senior Medical Director, Paradigm Outcomes
Recent discussions in the news about concussions in athletes focus on a topic that has challenged healthcare providers for decades, if not centuries. Although press reports raise awareness of important issues, the headlines can over-hype the topic and cause fear or misunderstanding.
The medical community now commonly agrees that a concussion is a mild brain injury. As a mild brain injury, a concussion can cause a number of temporary neurological and non-neurological symptoms. However, not every bump on the head is a concussion. And most concussions do not cause devastating or lasting effects.
This newer scientific understanding of concussion and post-concussion syndrome is vital to better prevention, treatment and long-term outcomes. Concussions, like chronic pain, are typical biopsychosocial conditions and need to be treated that way. Much of the current research and news centers on sports concussions. In workers’ compensation, we are challenged to translate this information into practical and effective claims management strategies.
I would suggest a three-pronged approach that is systematic, biopsychosocial and evidence-based.
During the recent Paradigm Outcomes webinar Post-Concussion Syndrome; Examining a Controversial Diagnosis with Elizabeth Sandel, M.D., Paradigm Medical Director, we discussed common questions about these injuries that are pertinent to claims management.
Begin at the Beginning: The value of a systematic approach
Did a concussion even occur?
The criteria for concussion are generally agreed to include temporary loss or change in consciousness and post traumatic amnesia and/or a change in the Glasgow Coma Scale as assessed by a knowledgeable observer. These same measures help assess severity. These deficits may be quite transient, so immediate assessment is needed.
In workers’ compensation, often there is no early assessment or documentation of these findings. Better onsite concussion screening would be helpful to injured workers and employers, as it will lead to early identification and treatment.
Over the ensuing days, concussion symptoms may evolve with any combination of memory complaints, dizziness or balance issues, visual complaints, headache, emotional volatility and more. Most concussions resolve quickly, typically over days or [several? A few? A number of?] weeks.
Evaluation requires an expert neuromuscular assessment. Many primary providers either jump to a concussion diagnosis or can miss it entirely. The ideal provider – one experienced with brain injury — understands the diagnosis and the controversies and follows evidence-based diagnostic criteria.
If it is a concussion, how severe is it, and what are the deficits?
An important factor to keep in mind is that a concussion, or mild brain injury, should not be a progressive condition. The injury or neurological symptoms would not typically worsen with time after the first week or so. Injured workers may notice and report more symptoms, but the actual injury trajectory should be one of stability and recovery.
Most important is to see a provider who understands concussion, post-concussion syndrome and the numerous physical complaints. Not every complaint is due to brain injury per se or even part of the hit to the head.
A systematic approach to diagnosis would:
- Reassess the patient who feels his condition is worsening to rule out existence of an unexpected acute injury or alternative diagnosis.
- Get a comprehensive past history, since prior bodily symptoms can confuse diagnosis.
- Assess each symptom individually, deconstructing what may be a confusing pattern of complaints.
- Determine which symptoms are primary and which are secondary.
- Establish a treatment strategy for each ailment.
- Synthesize this information to create a unified diagnosis and treatment plan. Leaving an injured worker with the impression that they have 5 or 10 different diagnoses, rather than a single complex condition, may exacerbate the situation by leaving him or her feeling overwhelmed.
When symptoms persist, we call that post-concussion syndrome (PCS). Symptoms can include changes in mood, frustration, sleep disturbances, difficulty concentrating, excessive worry and persistent functional limitations. The number of complaints can give the impression of being hypochondriacal, unless understood as the interplay of the biopsychosocial factors. Though the brain injury is usually static, many patients’ complaints can seem to get worse and this is where the biopsychosocial model comes in.
Understand the Whole Person: The value of a biopsychosocial approach
The biopsychosocial model refers to the process of evaluating and treating medical conditions with a thorough understanding of how recovery from physical illness affects and is affected by a large number of real-life individual psychosocial factors.
The term biopsychosocial can be scary from a claims perspective because it is a huge umbrella for so many factors including personality, mood, coping styles, past experience, cultural factors, secondary gain, vocational and financial concerns. One way to sum it up is that these factors make us who we are.
These issues must be addressed, particularly with injured workers who are not getting better, because they greatly influence injured workers’ perceived illness and recovery. Though many of these factors are not medical per se, they impact the course of care and outcomes. Urging a structured, holistic approach to care allows us to customize a recovery plan, avoiding a repetitive biomedical cycle of diagnostic tests, prescriptions, procedures and therapies.
How does the biopsychosocial model apply to mild brain injury?
In concussion and PCS, some of the most disturbing medical symptoms can quickly lead to fear and frustration. Many of the symptoms are invisible. Symptoms such as dizziness, headache, nausea, memory difficulties are uncomfortable, at the least, and lifestyle limiting. If not managed early and well, any person can feel they are very ill.
Recognize that people’s natural tendency is to try to attribute every symptom to the concussion, which can lead to a downhill snowball of complaints and disability. Who among us does not blame a memory lapse on poor sleep, the glass of wine last night or some undiagnosed dementia we certainly must have?
This is why the biopsychosocial approach to concussion and PCS includes:
- Early expert evaluation of cognitive function; cognitive issues are the cornerstone on a concussion diagnosis
- Early education and reassurance about concussion, the common symptoms and expectation for recovery, including time course
- Early treatment and self-management strategies
- Cognitive and psychosocial support , such as cognitive behavioral therapy and/or evaluation and education by a neuropsychologist, speech therapist and/or cognitive OT
- Helping the person avoid the pitfalls of an overly biomedical approach such as routine and repetitive prescription of medication for each symptom
Apply the Science: The Value of an evidence-based approach
Medical evidence suggests that about half of all brain injuries in the U.S. occur in the workplace. About 10% of those with concussion have persistent symptoms, or PCS. Though the timeline varies, PCS is often used with symptoms that persist beyond four weeks.
Is research into sports-related concussion relevant to workers’ compensation?
Current research is leading to a better understanding of concussion and PCS. A lot of the new data comes from sports concussion, which does have significant differences from the typical workers’ compensation concussion. In addition to differences in age group, and mechanics of the injury, sports concussions are often a repetitive process.
So one must be cautious in translating the research. But one thing is certain: If a person did not have a concussion, they cannot have PCS. They may have other physical complaints from physical trauma, but it is not PCS.
Though the amount of force appears to matter and concussion is not expected with a trivial bump of the head, torsion or twisting type injuries combined with force appear to be more likely to cause concussion.
Brain CT scan or MRI is usually negative in concussion but may pick up some abnormalities. But given that all MRIs pick up incidental findings, one has to be careful to not overinterpret the MRI. Newer techniques may be better at indicating subtle findings, such as diffuse axonal injuries, that would make diagnosis of an actual brain injury more objective. Though there is ongoing research looking for a concussion biomarker, no blood test, physiological test or imaging test is yet considered a reliable diagnostic test for concussion.
What can I expect to learn from neuropsychological testing?
A key component of concussion and PCS is complaint of cognitive deficits: poor memory, poor concentration, or difficulty with usual tasks such as balancing the checkbook. These can be very disturbing, but they can be objectively measured via neuropsychological testing. In fact, many times, despite a person’s cognitive complaints, neuropsychological testing can rule out ongoing cognitive deficits and brain injury. This alone can be very reassuring to injured workers and their families.
This testing can also help identify what psychosocial factors can be masquerading as cognitive deficits. Best practice is to use only board certified neuropsychologists for assessment of mild brain injury. Specially trained psychologists, speech therapists and occupational therapists can perform screening evaluations, but only a full neuropsychological testing battery has the sensitivity and specificity needed for comprehensive testing and validation.
What therapies have proven effective in restoring function?
Studies suggest that education and reassurance are vital to helping a person recovery from this plethora of symptoms. Many therapies are available to treat the symptoms of concussion or PCS. The evidence of effectiveness is mixed, but an evidence-based approach would include:
- Neuropsychological testing, if cognitive complaints last more than 3 months; this should include post evaluation feedback and education and a treatment plan of specific identified weaknesses.
- Speech therapy, occupational therapy for functional cognitive training. A rigorous monitored history and physical HEP should be integrated between sessions.
- Physical Therapy for pain and balance complaints, but we should expect objective measurement and to see functional improvement and compliance with a home exercise program.
- Ophthalmology, neuroophthalmology and/or vision therapy may be indicated if there are vision complaints. Though it may seem that vision findings can be over-diagnosed, there are reasons to consider evaluations: baseline vision problems are common in the general population and there may be subtle changes with concussion, the visual and visual/vestibular connections are complex and vulnerable and may be instrumental in causing some of the PCS symptoms. Like all therapies, these interventions should be time limited and should rely heavily on a HEP.
- Regular MD (neurologist/physiatrist) follow-up and reassessment.
- Avoid clinics which appear to apply the concussion/ PCS diagnosis to everyone who enters the facility and which, despite extensive treatment, do not demonstrate measurable improvement for patients.
Concussions and PCS can be frustrating injuries for injured workers and claims professionals alike. The significance of some concussions or PCS should not be ignored, nor should injured workers function as though this mild brain injury is a more severe brain injury. The mild nature of this mild brain injury means there are few or subtle objective findings. Symptoms that are predominantly subjective lead to frustration by an invisible disability, as well as potential for apparent symptom and disability magnification — intentional or not.
However, it also should portend a good prognosis. By fostering an early systematic approach to each injured worker, informed by evidence-based knowledge regarding diagnosis and recovery, we can support a biopsychosocial treatment plan that includes the appropriate treating professionals who educate the injured worker and foster home exercise programs and functional improvement within realistic timeframes.
About Steven M. Moskowitz, MD
Steven M. Moskowitz, MD, is the Senior Medical Director and supervisor of Paradigm Outcome’s pain program. Dr. Moskowitz is a specialist in physical medicine and rehabilitation with clinical expertise in complex musculoskeletal and neurologic rehabilitation including spinal cord injury, multiple sclerosis and chronic pain. Dr. Moskowitz earned his medical degree from Tufts University School of Medicine, is certified in Managed Care Medicine, and he is a member of the American Academy of Pain Medicine, the American Academy of Physical Medicine and Rehabilitation, and the American Pain Society.
About Paradigm Outcomes
Paradigm Management ServicesParadigm Outcomes is the nation’s leading provider of catastrophic and complex case management, Paradigm achieves 5x better medical outcomes and lowers total costs by 40%. Paradigm accomplishes this by bringing together nationally recognized doctors, the best providers in the country, and 25 years of clinical data to guide decisions. Paradigm is the only company designed and built specifically to address the needs of those with acquired brain injuries, spinal cord injuries, amputations, burns and chronic pain, and is the only company to stand behind their promises with medical and financial guarantees. Visit www.paradigmcorp.com to learn more.