01/04/2021
Speakers
Elizabeth Sandel, MD, Medical Director, Paradigm Catastrophic Care Management
Deborah M. Benson, PhD, ABPP, Associate Vice President, Clinical Services, Paradigm Catastrophic Care Management
A concussion, or a mild traumatic brain injury (TBI), can be extremely challenging to diagnose and treat due to variability in symptoms, inadequate treatment, and confounding medical, psychosocial, and environmental factors. While most notably associated with sports-related injuries, concussions are also increasingly diagnosed in the workplace. They can also delay or limit recovery from other work-related injuries, impacting functional independence and return to work efforts.
Because of the risk for long-term symptoms and the growing body of evidence supporting the effectiveness of early and evidence-based intervention, it is very important for the health care community, including the workers’ compensation field, to be able to recognize concussions when they occur and to respond appropriately.
In a webinar held on Thursday, December 10th, two Paradigm clinical experts provided a detailed discussion on achieving positive outcomes with a proactive management approach that includes early diagnosis and education, appropriate provider identification, and evidence-based treatment approaches that can mitigate the long-term disability and financial impact of these injuries. This requires facilitating appropriate medical, psychological, and rehabilitative care and follow up, as well as driving functional outcomes through a systematic, biopsychosocial model.
Defining terms—including mild brain injury, concussion, and post-concussion syndrome
Opening the discussion was Dr. Elizabeth Sandel. In addition to her role at Paradigm, Dr. Sandel is one of the nation’s foremost experts on brain injuries and author of the new book, “Shaken Brain: The Science, Care, and Treatment of Concussion.” Dr. Sandel first laid out some of the basic definitions at the core of this topic, including the agreement among experts that concussion and mild traumatic brain injury (mTBI) are essentially interchangeable terms.
Basic diagnostic criteria for mTBI include the following:
Dr. Sandel also covered the most common symptoms of post-concussion syndrome (PCS), including headache, fatigue, difficulty concentrating, irritability, memory impairment, insomnia, reduced tolerance to stress or alcohol, and dizziness. She stressed that one of the issues with diagnosing PCS is that these symptoms are not exclusive to concussion and mTBI, which makes it relatively complex for physicians to positively identify.
Epidemiology and outcomes for concussion
In discussing the prevalence of work-related concussions, Dr. Sandel started with an overview comparing Paradigm and industry data on the mechanism of mTBI and distribution among occupations. For mechanism, falls were the most common cause among both sets of data. While occupation had some variance, both sets showed that around 25% of those affected were construction workers.
One of the most significant findings from an industry perspective according to Dr. Sandel was that 78% of concussion claims lost time from work, compared to 15% of non-concussion claims, underscoring the need for attention on this topic.
In terms of recovery and outcomes, some recent studies have refuted the notion of concussions being a short-term problem. For example, Dr. Sandel pointed to a US TRACK TBI Study of 375 subjects where 80% had at least one PCS symptom at six and also at 12 months. Other studies had lower rates, but still pointed to long-term PCS symptoms being ongoing in a substantial number of people.
Dr. Sandel also discussed some of the factors associated with poor outcomes, including biological sex or gender, a previous brain injury, and pre-existing conditions. She also discussed neuroimaging and the future potential for advanced imaging and laboratory biomarkers to more accurately diagnose mTBI.
Diagnostic approaches and challenges
While discussing the diagnostic approaches and challenges, Dr. Sandel began by highlighting the wide range of ways that patients with concussions are initially diagnosed and treated, including in emergency departments, by primary care physicians, and in concussion clinics. She stressed that patients whose symptoms do not resolve in a two-to-four week time period should be referred to a physical medicine and rehabilitation physician with a specialization in brain injury medicine (PB&R/BIM).
By receiving a thorough evaluation and an individualized treatment program, patients can have the best chance of a positive outcome that avoids a chronic condition, including cognitive, physical, and behavioral health-related symptoms and disability.
Importance of neuropsychological assessment
Dr. Sandel then turned the presentation over to Paradigm Associate Vice President of Clinical Services, Dr. Deborah M. Benson. Dr. Benson is a board-certified rehabilitation psychologist and co-editor of “Acquired Brain Injury: An Integrative Neuro-Rehabilitation Approach” and explained that a comprehensive neuropsychological evaluation is critical to ensuring best possible outcomes for patients with persistent PCS.
While there are a number of brief screening tools that are used to determine if patients are experiencing cognitive deficits after concussion/mTBI, these are often inadequate and miss important indicators due to their brevity and lack of expertise of administering providers. In contrast, a thorough neuropsychological assessment performed by an experienced clinician can identify subtle deficits, help understand other contributing factors, and help patients who are still dealing with PCS symptoms after 30 days.
Components of a comprehensive neuropsychological evaluation should include:
Above all, Dr. Benson emphasizes the need for analysis and interpretation of the findings by a qualified and experienced neuropsychologist. He or she will evaluate performance on standardized testing, identify potential contributory/confounding factors, and interpret results within the context of rendering an opinion regarding causality.
One of the biggest challenges is untangling symptoms directly caused by the injury versus those related to other psychological, medical, environmental or other factors. While ‘malingering’, or exaggerating symptoms for secondary gain, is a common label for patients with persistent PCS symptoms, Dr. Benson discussed alternative explanations for the presence of symptoms that are beyond what would likely be explained solely by direct effects of the injury. These include misattribution, comorbidities, and stress. She emphasized that it is important for neuropsychologists to intervene and educate patients and their families about these potential contributors. Balancing the need to validate a patient’s experience while not enabling illness behavior and dependency is key to positive patient outcomes, according to Dr. Benson.
Paradigm case study and care management strategies
Dr. Sandel then took the presentation over again to discuss care management for these cases, particularly stressing the effectiveness of a biopsychosocial approach. Once a diagnosis has been confirmed, finding the right provider is crucial. Particularly, providers with a dismissive approach to mTBI care should be avoided, as well as those who over-treat, thereby inadvertently enabling a chronic condition to continue.
Instead, providers should always take an evidence-based approach based on the latest peer-reviewed guidelines in the field. Dr. Sandel recommended the Ontario Neurotrauma Foundation Guidelines and Veteran’s Affairs Guidelines in the presentation.
Dr. Benson then highlighted a recent Paradigm case that represented the challenges of treating PCS and the potential for a positive outcome. After a 56-year-old man fell from a ladder, a CT scan showed a small hemorrhage, meaning he met the criteria for a complicated mTBI. After three days in the hospital, he was transferred to an acute rehabilitation unit for one week prior to discharge home.
The patient had a prior history of depression, anxiety, and migraines and there were a number of management challenges which needed to be overcome to achieve a positive outcome. These included late referral, persistent symptoms, lack of access to specialized and experienced providers, and a suboptimal treatment plan.
When Paradigm took over care of this patient, the first goal was identifying and vetting qualified providers who could take a collaborative and evidence-based approach to treatment. Eventually, the patient was able to complete restorative rehabilitation within nine months post-injury. He achieved complete functional independence, without the need for home or community based supports. His symptoms largely resolved or were able to be self-managed. The patient also reported resuming pre-injury family roles and positive relationships. Eventually, he was discharged from care of all medical specialists with the exception of a brain injury medicine specialist; psychological treatment was transitioned to his health insurance for chronic (pre-injury) issues; and he was released to return to work with restrictions.
Webinar resources
Download a replay of the webinar, the presentation slides, and webinar FAQs here.
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