Early Predictors and Management of Concussion in The General Population: Findings from The Hull-Ellis Concussion and Research Rapid Access Clinic

Presenters:

  • Mark Bayley
  • Tharshini Chandra
  • Olinda Habib Perez
  • Lesley Ruttan
  • Catherine Wiseman-Hakes
  • Noah Silverberg
  • Richard Wennberg
  • Evan Foster

Objectives:

  • Provide participants with findings on typical trajectory of symptoms and recovery in the concussion population and build awareness of prognostic indicators, including sex-based differences in early recovery
  • Provide guidance on evidence based, targeted and innovative early care for individuals with concussion from the general population
  • Provide direction in returning to work/school and exercising in early stages of recovery from concussion

Description:

Introduction: There is limited evidence to guide the prevention of chronicity by early care for concussion. The clinic follows adults with acute concussions caused by various mechanisms through the subacute period, simultaneously integrating research and care. The symposium purpose is to present findings from this interdisciplinary team of researchers including early psychophysical, neurophysiological, imaging assessments and emerging interventions.

Methods: Patients diagnosed with concussion in four Emergency Departments in Toronto are admitted to the clinic within one week. Data collected include demographics, symptoms, sleep, cognitive functioning, observation-based (i.e. Balance Error Scoring System: BESS) and posturographic measures of balance, psychosocial/psychological profiling, magnetoencephalography (MEG) and physician assessments at 2, 3, 4, 5, 6, 7, 8, 12 and 16 weeks post injury.

Results: The clinic sees M=16.55, SD=5.38 new patients per month. Of the initial cohort (N= 202, Females =117; Males= 85), 21% of patients remain symptomatic from concussion at Wk. 8; (23% of Females; 7 % of Males). Personality factors appear to influence recovery.

Headache is the most commonly reported symptom. The majority (90%) of patients report headache onset within 24 hours. The most common phenotype is pressure headache. Headache frequency returns to baseline within the first 8 weeks post injury. Only 8.9% endorse more frequent headaches than pre-injury at week 16.

Increased sleep need, un-restful sleep, and difficulty maintaining day-time wakefulness are seen initially post injury. For most, sleep returns to baseline within 8-12 weeks post injury. Gender differences are noted, with females experiencing greater disturbances. Positive associations were found between measures of mood and sleep for females and measures of cognition and sleep for males.

Despite reported mild to moderate cognitive symptoms at Week 1, there is no evidence of clinically significant cognitive impairment on cognitive testing.

Mood measures scores show a steady decline in Somatization, Anxiety and Depression subscales of the Brief Symptom Inventory-18 (BSI-18) across the acute to post-acute concussive period. At week 4, 25% of our total sample demonstrated high albeit declining levels on all subscales. Collection of data on coping patterns (avoidance and endurance behavior) is ongoing.

There is no clear relationship between the subjective balance disturbance complaints and objective measures of balance impairment. Although balance recovery is cited to occur within 1-2 weeks in athlete populations, we found limited recovery (as per the BESS and posturographic measures) at 12 weeks post-injury in the adult general population.

MEG studies show M60 latencies were significantly increased in the patient group compared to controls at 1 week (p=0.00000), gradually recovering at each subsequent time point, although still prolonged compared to controls at 4 months (p<0.05).

Conclusion: This unique clinic continues to refine best practice for early evaluation, prognostication and management of concussion based on individual differences.

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