Published September 2013 - Ontario Neurotrauma...

The project team would like to acknowledge the Ontario Neurotrauma Foundation (ONF), who initiated and funded the development of the original guideline, as well as the current update. ONF is an applied health research organization with a focus on improving the quality of lives for people with an acquired brain injury or spinal cord injury, and on preventing neurotrauma injuries from occurring in the first place. ONF uses strategic research funding activity embedded within a knowledge mobilization and implementation framework to build capacity within systems of care. ONF works with numerous stakeholders and partners to achieve its objective of fostering, gathering and using research knowledge to improve care and quality of life for people who have sustained neurotrauma injuries, and to influence policy towards improved systems. The foundation receives its

funding from the Ontario Government through the Ministry of Health and Long-Term Care.

Please note, the project team independently managed the development and production of the guideline and, thus, editorial independence is retained.

© Ontario Neurotrauma Foundation 2013

Ontario Neurotrauma Foundation90 Eglinton East

Toronto, ON, Canada M4P 2Y3Tel.: 1 (416) 422-2228Fax: 1 (416) 422-1240Email: [email protected]

www.onf.org

Published September 2013

MODULE 1: DIAGNOSIS/ASSESSMENT OFCONCUSSION/mTBI

The recommendations and resources found within the Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms are intended to inform and instruct care

providers and other stakeholders who deliver services to adults who have sustained or are suspected of having sustained a concussion/mTBI. These guidelines are not

intended for use with patients or clients under the age of 18 years. These guidelines are not intended for use by people who have sustained or are suspected of having

sustained a concussion/mTBI for any self-diagnosis or treatment. Patients may wish to bring their healthcare and other providers’ attention to these guidelines.

The recommendations provided in these guidelines are informed by best available evidence at the time of publication, and relevant evidence published after these

guidelines could influence the recommendations made within. Clinicians should also consider their own clinical judgement, patient preferences and contextual factors such

as resource availability in clinical decision-making processes.

The developers, contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of this

material, including loss or damage arising from any claims made by a third party.

Guidelines for Concussion/mTBI and Persistent Symptoms: Second EditionI

Table of Contents

Table of ContentsGUIDELINE RECOMMENDATIONS1. Diagnosis/Assessment of Concussion/mTBI ....................................................................................................................1 ALGORITHM1.1: Initial Diagnosis/Assessment of Adult mTBI ....................................................................................................................5

APPENDICES1.1: Acute Concussion Evaluation (ACE): Physician/Clinician Office Version ........................................................................61.2: Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS) ..............................................................................81.3: Brain Injury Advice Card (Long Version)........................................................................................................................ 111.4: Brain Injury Advice Cards (Short Versions) ...................................................................................................................151.5: Rivermead Post Concussion Symptoms Questionnaire ................................................................................................19A: Project Members ..............................................................................................................................................................20B: Other Useful Links/References for Resources to Consider .............................................................................................22

TABLES1.1: Risk Factors Influencing Recovery Post mTBI ................................................................................................................21.2: Key Features of mTBI Assessment in an Emergency Department or Doctor’s Office ....................................................2B: Diagnostic Criteria for Concussion/Mild Traumatic Brain Injury .........................................................................................4

FIGURE1.1: Canadian CT Head Rule .................................................................................................................................................1

Unique Features & Symbols in the Current Guideline

HyperlinksTo improve ease of use, the current guideline has embedded hyperlinks to improve navigation between sections, appendices,and so on. For example, by clicking any heading in the table of contents above, you will be taken directly to that particularsection in the current PDF document. Also, anytime there is mention of a particular table, figure, appendix or section, youcan simply click on it to go directly to that item.

Symbols

The following symbol has been placed to the left of each guideline recommendation that should be prioritized for implementation. This was determined by expert consensus members during the endorsement/prioritization process, where experts were allowed to provide 20 prioritization votes (seeMethodology in the Complete Version). Guideline recommendations with a summed prioritization score greater than 20 are key clinical practice guidelines recommendations for implementation.

The following symbol has been placed to the left of one key guideline recommendation in each of the sections that did not include a recommendation with a prioritization score greater than 20 (determined by expert consensus members during the endorsement/prioritization process).

At the bottom of each page in the current document, there is a hyperlinked footer that can be used to return to the tableof contents as desired. Also, clicking “Return to Last Page” will take you back to the previously viewed page. (Note: Whenscrolling through the pages, the “Return to Last Page” button will only return to the last page that was scrolled through).

Guidelines for Concussion/mTBI and Persistent Symptoms: Second Edition 1

Table of Contents

Diagnosis of mTBI (Table B) is the first critical step in successful management leading to improved outcomes and prevention of further injury. Patients may present to the Emergency Department or health care provider’s office following trauma and may be unaware that they have sustained mTBI. A high level of suspicion is required particularly when there is evidence of direct trauma to the head or mechanism of injury that is frequently associated with mTBI, such as motor vehicle collision. Patients may present in a post-traumatic amnestic (PTA) state, where they may have a Glasgow Coma Scale (GCS) score of 15/15; however, they may be variably oriented and not able to form continuous memories.

Formal evaluation with a standardized tool is often key to documenting confusion or disorientation, particularly when a patient is denying or minimizing symptoms. The initial purpose of establishing the diagnosis of mTBI is to monitor for and rule out acute, life-threatening complications, such as intracranial hemorrhage, although the reality is that the vast majority of patients will not experience these complications. The need for neuroimaging should also be determined upon review of the Canadian CT Head Rule (Figure 1.1).1 CT scans represent the most appropriate method of investigation for the exclusion of neurosurgically significant lesions, as normal skull x-rays are insufficiently sensitive and may mislead clinicians.2

When establishing the diagnosis of mTBI, primary care providers should also prepare the patient and family for possible delayed complications by providing both verbal and written information. Namely, given that the majority of patients will be symptomatic acutely post mTBI, education about anticipated symptoms and duration is a key component to assisting patients in recovery. For instance, patients are likely to initially experience reduced cognitive functioning post injury, which typically resolves in a few days but in some instances may persist for weeks to months.3 Provision of information regarding mTBI symptoms and expectations for recovery, as well as instructions for follow up, have been shown to be one of the more effective strategies in preventing the development of persistent symptoms post mTBI. Regular follow up by the family physician can monitor progress and ensure that patient symptoms are dealt with promptly and arrangements for specialty referral can be made if indicated. In both the initial assessment and the follow up period, the health care provider should also attempt to explore and document risk factors (Table 1.1) that may potentially delay recovery following mTBI, and consider closer monitoring of recovery or an acceleration of intervention strategies if needed. See Algorithm 1.1, which outlines the key steps for diagnosis/assessment and initial management of mTBI.

Canadian CT Head RuleCanadian CT Head RuleC T h e a d is o n ly r e q u ir e d fo r m in o r h e a d in ju r y p a t ie n t s

w it h a n y o n e o f t h e s e f in d in g s :

H ig h R is k ( fo r N e u r o lo g ic a l In t e r v e n t io n )

1. GCS score < 15 at 2 hrs after injury2. Suspected open or depressed skull fracture3. Any sign of basal skull fracture*4. Vomiting ≥ 2 episodes5. Age ≥ 65 years

M e d iu m R is k ( fo r B r a in In ju r y o n C T )

6. Amnesia before impact ≥ 30 min7. Dangerous mechanism ** (pedestrian,

occupant ejected, fall from elevation)

Stiell IG, et al. The Canadian CTHead Rule for Patients with Minor Head Injury. Lancet 2001;357:1391-96.

Rule Not Applicable If:- Non-trauma cases- GCS < 13- Age < 16 years- Coumadin or bleeding disorder- Obvious open skull fracture

*Signs of Basal Skull Fracture

- hemotympanum, ‘racoon’ eyes, CSF otorrhea/rhinorrhea, Battle’s sign

** Dangerous Mechanism

- pedestrian struck by vehicle- occupant ejected from motor vehicle- fall from elevation ≥ 3 feet or 5 stairs

Figure 1.1 Canadian CT Head Rule (Reproduced with permission)

1Diagnosis/Assessment of Concussion/mTBI

Guidelines for Concussion/mTBI and Persistent Symptoms: Second Edition2

Table of Contents

Section 1. Diagnosis/Assessment of Concussion/mTBI

Medical Factors(red flags): Pre-existingmedicalconditions or post-injury symptomsthat are associatedwith poor outcomespost mTBI

• Post-traumatic amnesia (PTA)• History of previous traumatic brain injury• History of previous physical limitations• History of previous neurological or psychiatric problems• High number of symptoms reported early after injury• Skull fracture• Early onset of pain and in particular headache within 24 hours after injury• Reduced balance or dizziness during acute stage• Confounding effects of other health-related issues, e.g., pain medications, disabling

effects of associated injuries, emotional distress• Presence of nausea after injury• Presence of memory problems after injury

Contextual Factors(yellow flags):Personal,psychosocial, orenvironmentalfactors that maynegatively influencerecovery post mTBI

• Injury sustained in a motor vehicle accident• Potential influence of secondary gain issues related to litigation and compensation• Not returning to work or significant delays in returning to work following the injury• Being a student• Presence of life stressors at the time of the injury• Higher levels of symptom reporting is associated with mood symptoms and heightened

self-awareness of deficits• Older age• Lack of social supports• Less education/lower social economic status

Table 1.1. Risk Factors Influencing Recovery Post mTBI

Table 1.2. Key Features of mTBI Assessment in an Emergency Department or Doctor’s Office

(a) A medical history encompassing a review of:• Current symptoms and health concerns• Setting and mechanism of injury• Severity/duration of altered consciousness and immediate symptoms• Presence of co-occurring injuries• Pre-existing medical and mental health conditions, and• Potentially contributing psychosocial factors(b) An examination including an assessment of:• Mental status and cognition• Cranial nerves• Extremity tone, strength, and reflexes, and• Gait and balance(c) An assessment of the patient’s clinical status, including whether there has been improvement or deterioration since the time of injury. This may require additional information from others, including eyewitnesses to the injury.(d) Determination of the need for urgent neuroimaging to exclude a more severe brain injury (see Figure 1.1), such as a structural abnormality or hemorrhage.

RECOMMENDATIONS FOR DIAGNOSIS/ASSESSMENT OF mTBIGRADE

1.1 Concussion/mTBI in the setting of closed head injury should be diagnosed as soon as possible because early recognition is associated with better health outcomes for patients. a A

1.2

On presentation, the primary care provider should conduct a comprehensive review of every patient who has sustained mTBI (see Appendix 1.1). The assessment should include taking a history, examination, cognitive screen, post-concussive symptom assessment, and review of mental health (see Table 1.2). a

A

Adapted from the Motor Accidents Authority of NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA NSW, 2008)

Adapted from the NSW Health Guidelines: Initial Management of Closed Head Injury in Adults, 2nd Edition (NSW Health, 2011).

_________________________________________________________________________________________________________________________________________________________________

a. Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).


Table of Contents


RECOMMENDATIONS FOR DIAGNOSIS/ASSESSMENT OF mTBI (CONTINUED)GRADE

1.3

The need for early neuroimaging should be determined according to the Canadian CT Head Rule (see Figure 1.1). For patients who fulfill these criteria, CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant lesions, such as hemorrhage. Plain skull x-rays are not recommended. b

A

1.4Standardized measurement of post-traumatic amnesia (PTA) should be routinely performed to assist with the monitoring, diagnosis, early management, and prognosis of patients who have experienced mTBI (see Appendix 1.2). a

A

1.5

Patients with mTBI can be safely discharged for home observation after an initial period of in-hospital observation if they meet the following clinical criteria:• Normal mental status (alertness/behaviour/cognition) with clinically improving post-

concussive symptoms after observation until at least four hours post injury.• No clinical risk factors indicating the need for CT scanning or normal CT scan result if

performed due to presence of risk factors.• No clinical indicators for prolonged hospital observation such as:

• Clinical deterioration• Persistent abnormal GCS or focal neurological deficit• Persistent abnormal mental status• Persistent clinical symptoms (vomiting/severe headache)• Presence of known coagulopathy (clinical judgment required)• Persistent drug or alcohol intoxication (clinical judgment required)• Presence of multi-system injuries (clinical judgment required)• Presence of concurrent medical problems (clinical judgment required)• Age >65 (clinical judgment required) b

A

1.6

Patients with mTBI can be safely discharged for home observation after an initial period of observation if they meet the following discharge advice criteria:• Discharge summary prepared for primary care (or family) doctor.• Written and verbal brain injury advice (Appendix 1.3 and 1.4) given to patient (and nominated

responsible person) covering:• Symptoms and signs of acute deterioration and when to seek urgent follow-up• Lifestyle advice to assist recovery• Typical post-concussive symptoms and reassurance about anticipated recovery• Reasons for seeking routine follow up. b

C

1.7

If the patient re-attends an emergency department/urgent care service with symptoms related to the initial injury, the following should be conducted:• Full re-evaluation, including an assessment for ongoing post-traumatic amnesia (PTA)• CT scan, if indicated• Emphasis and encouragement to the patients to attend their family physician for follow-up

after discharge. a

C

1.8 Clinicians should assess, monitor, and document persisting somatic, cognitive, and emotional/ behavioural symptoms following mTBI using a standardized assessment scale (Appendix 1.5). a C

RESOURCESAPPENDICES1 Acute Concussion Evaluation - Physician/Clinician Office Version Appendix 1.12 Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS) Appendix 1.23 Brain Injury Advice Card (Long Version) Appendix 1.34 Brain Injury Advice Card (Short Version) Appendix 1.45 Rivermead Post Concussion Symptoms Questionnaire Appendix 1.5

_________________________________________________________________________________________________________________________________________________________________

a. Adapted from the Motor Accidents Authority NSW, Guidelines for Mild Traumatic Brain Injury following a Closed Head Injury (MAA, NSW, 2008).b. Adapted from the NSW Health Guidelines: Initial Management of Closed Head Injury in Adults, 2nd Edition (NSW Health, 2011).


Table of Contents


RESOURCES (CONTINUED)TABLES1 Risk Factors Influencing Recovery Post mTBI Table 1.12 Key Features of mTBI Assessment in an Emergency Department or Doctor’s Office Table 1.23 Diagnostic Criteria for Concussion/Mild Traumatic Brain Injury Table BFIGURES1 Canadian CT Head Rule Figure 1.1ALGORITHM1 Initial Diagnosis/Assessment of Adult mTBI Algorithm 1.1

References

1 Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357:1391–1396.

2 Hofman PA, Nelemans P, Kemerink GJ, Wilmink JT. Value of radiological diagnosis of skull fracture in the management of mild head injury: meta-analysis. Journal of Neurology, Neurosurgery and Psychiatry. 2000;68(4):416-422.

3 Carroll LJ, Cassidy JD, Peloso PM, Borg J, von Holst H, Holm L, et al. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine. 2004;(43 Suppl):84-105.

Concussion/mTBI is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussion/mTBI include:

1. Concussion/mTBI may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head.

2. Concussion/mTBI typically results in the rapid onset of short-lived impairment of neurological function that resolvesspontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

3. Concussion/mTBI may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

4. Concussion/mTBI results in a graded set of clinical symptoms that may or may not involve loss of consciousness Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

Table B. Diagnostic Criteria for Concussion/Mild Traumatic Brain Injury*

* Adapted from McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sport Medicine. 2013;47(5):250-8.


Table of Contents

Algorithm 1.1Initial Diagnosis/Assessment of mTBI*

For a narrative description and recommendations related to this algorithm, please refer to Section 1._________________________________________________________________________________________________________________________________________________________________

* Taken with permission from the NSW Health Guidelines: Initial Management of Closed Head Injury in Adults, 2nd Edition (NSW Health, 2011).


Table of Contents

Appendix 1.1Acute Concussion Evaluation (ACE): Physician/Clinician Office VersionAcute concussion evAluAtion (Ace) Patient Name:

PhysiciAn/cliniciAn office version DOB: Age: Gerard Gioia, PhD1 & Micky Collins, PhD2

1Children’s National Medical Center Date: ID/MR# 2University of Pittsburgh Medical Center

A. Injury Characteristics Date/Time of Injury Reporter: __Patient __Parent __Spouse __Other________

1. Injury Description

1a. Is there evidence of a forcible blow to the head (direct or indirect)? __Yes __No __Unknown 1b. Is there evidence of intracranial injury or skull fracture? __Yes __No __Unknown 1c. Location of Impact: __Frontal __Lft Temporal __Rt Temporal __Lft Parietal __Rt Parietal __Occipital __Neck __Indirect Force

2. Cause: __MVC __Pedestrian-MVC __Fall __Assault __Sports (specify) Other

3. Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? __ Yes __No Duration

4. Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? __ Yes __No Duration

5. Loss of Consciousness: Did you/ person lose consciousness? __ Yes __No Duration

6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __Answers questions slowly __Repeats Questions __Forgetful (recent info)

7. Seizures: Were seizures observed? No__ Yes___ Detail _____

B. Symptom Check List* Since the injury, has the person experienced any of these symptoms any more than usual today or in the past day?

Indicate presence of each symptom (0=No, 1=Yes). *Lovell & Collins, 1998 JHTR

PHYSICAL (10) COGNITIvE (4) SLEEP (4)

Headache 0 1 Feeling mentally foggy 0 1 Drowsiness 0 1

Nausea 0 1 Feeling slowed down 0 1 Sleeping less than usual 0 1 N/A

Vomiting 0 1 Difficulty concentrating 0 1 Sleeping more than usual 0 1 N/A

Balance problems 0 1 Difficulty remembering 0 1 Trouble falling asleep 0 1 N/A

Dizziness 0 1 COGNITIvE Total (0-4) _____ SLEEP Total (0-4) _____

Visual problems 0 1 EMOTIONAL (4) Exertion: Do these symptoms worsen with:

Fatigue 0 1 Irritability 0 1 Physical Activity __Yes __No __N/A

Sensitivity to light 0 1 Sadness 0 1 Cognitive Activity __Yes __No __N/A

Sensitivity to noise 0 1 More emotional 0 1 Overall Rating: How different is the person acting

Numbness/Tingling 0 1 Nervousness 0 1 compared to his/her usual self? (circle)

PHYSICAL Total (0-10) _____ EMOTIONAL Total (0-4) _____ Normal 0 1 2 3 4 5 6 Very Different

(Add Physical, Cognitive, Emotion, Sleep totals) Total Symptom Score (0-22) _____

C. Risk Factors for Protracted Recovery (check all that apply)

Concussion History? Y ___ N___ √ Headache History? Y ___ N___ √ Developmental History √ Psychiatric History

Previous # 1 2 3 4 5 6+ Prior treatment for headache Learning disabilities Anxiety

Longest symptom duration History of migraine headache Attention-Deficit/ Depression Days__ Weeks__ Months__ Years__ __ Personal Hyperactivity Disorder Sleep disorder __ Family___________________If multiple concussions, less force ____________________ Other developmental Other psychiatric disorder caused reinjury? Yes__ No__ disorder_____________ _____________

List other comorbid medical disorders or medication usage (e.g., hypothyroid, seizures)

D. RED FLAGS for acute emergency management: Refer to the emergency department with sudden onset of any of the following: * Headaches that worsen * Looks very drowsy/ can’t be awakened * Can’t recognize people or places * Neck pain * Seizures * Repeated vomiting * Increasing confusion or irritability * Unusual behavioral change * Focal neurologic signs * Slurred speech * Weakness or numbness in arms/legs * Change in state of consciousness

E. Diagnosis (ICD): __Concussion w/o LOC 850.0 __Concussion w/ LOC 850.1 __Concussion (Unspecified) 850.9 __ Other (854) ______________ __No diagnosis

F. Follow-Up Action Plan Complete ACE Care Plan and provide copy to patient/family. ___ No Follow-Up Needed ___ Physician/Clinician Office Monitoring: Date of next follow-up ___ Referral:

___ Neuropsychological Testing ___ Physician: Neurosurgery____ Neurology____ Sports Medicine____ Physiatrist____ Psychiatrist____ Other ___ Emergency Department

ACE Completed by:______________________________ © Copyright G. Gioia & M. Collins, 2006

This form is part of the “Heads Up: Brain Injury in Your Practice” tool kit developed by the Centers for Disease Control and Prevention (CDC).


Table of Contents

Appendix 1.1: Acute Concussion Evaluation (ACE): Physician/Clinician Office Version

A concussion (or mild traumatic brain injury (MTBI)) is a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical

forces secondary to direct or indirect forces to the head. Disturbance of brain function is related to neurometabolic dysfunction, rather than structural injury,

and is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). Concussion may or may not involve a loss of consciousness

(LOC). Concussion results in a constellation of physical, cognitive, emotional, and sleep-related symptoms. Symptoms may last from several minutes to

days, weeks, months or even longer in some cases.

ACE Instructions

The ACE is intended to provide an evidence-based clinical protocol to conduct an initial evaluation and diagnosis of patients (both children and adults)

with known or suspected MTBI. The research evidence documenting the importance of these components in the evaluation of an MTBI is provided in the

reference list.

A. Injury Characteristics:

1. Obtain description of the injury – how injury occurred, type of force, location on the head or body (if force transmitted to head). Different

biomechanics of injury may result in differential symptom patterns (e.g., occipital blow may result in visual changes, balance difficulties).

2. Indicate the cause of injury. Greater forces associated with the trauma are likely to result in more severe presentation of symptoms.

3/4. Amnesia: Amnesia is defined as the failure to form new memories. Determine whether amnesia has occurred and attempt to determine length

of time of memory dysfunction – before (retrograde) and after (anterograde) injury. Even seconds to minutes of memory loss can be predictive

of outcome. Recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following

concussion than is LOC (less than 1 minute).1

5. Loss of consciousness (LOC) – If occurs, determine length of LOC.

6. Early signs. If present, ask the individuals who know the patient (parent, spouse, friend, etc) about specific signs of the concussion that may have

been observed. These signs are typically observed early after the injury.

7. Inquire whether seizures were observed or not.

B. Symptom Checklist: 2

1. Ask patient (and/or parent, if child) to report presence of the four categories of symptoms since injury. It is important to assess all listed symptoms as

different parts of the brain control different functions. One or all symptoms may be present depending upon mechanisms of injury.3 Record “1” for Yes

or “0” for No for their presence or absence, respectively.

2. For all symptoms, indicate presence of symptoms as experienced within the past 24 hours. Since symptoms can be present premorbidly/at baseline

(e.g., inattention, headaches, sleep, sadness), it is important to assess change from their usual presentation.

3. Scoring: Sum total number of symptoms present per area, and sum all four areas into Total Symptom Score (score range 0-22). (Note: most sleep

symptoms are only applicable after a night has passed since the injury. Drowsiness may be present on the day of injury.) If symptoms are new and

present, there is no lower limit symptom score. Any score > 0 indicates positive symptom history.

4. Exertion: Inquire whether any symptoms worsen with physical (e.g., running, climbing stairs, bike riding) and/or cognitive (e.g., academic studies,

multi-tasking at work, reading or other tasks requiring focused concentration) exertion. Clinicians should be aware that symptoms will typically worsen

or re-emerge with exertion, indicating incomplete recovery. Over-exertion may protract recovery.

5. Overall Rating: Determine how different the person is acting from their usual self. Circle “0” (Normal) to “6” (Very Different).

C. Risk Factors for Protracted Recovery: Assess the following risk factors as possible complicating factors in the recovery process.

1. Concussion history: Assess the number and date(s) of prior concussions, the duration of symptoms for each injury, and whether less biomechanical

force resulted in re-injury. Research indicates that cognitive and symptom effects of concussion may be cumulative, especially if there is minimal duration

of time between injuries and less biomechanical force results in subsequent concussion (which may indicate incomplete recovery from initial trauma).4-8

2. Headache history: Assess personal and/or family history of diagnosis/treatment for headaches. Research indicates headache (migraine in particular)

can result in protracted recovery from concussion.8-11

3. Developmental history: Assess history of learning disabilities, Attention-Deficit/Hyperactivity Disorder or other developmental disorders. Research

indicates that there is the possibility of a longer period of recovery with these conditions.12

4. Psychiatric history: Assess for history of depression/mood disorder, anxiety, and/or sleep disorder.13-16

D. Red Flags: The patient should be carefully observed over the first 24-48 hours for these serious signs. Red flags are to be assessed as possible signs of

deteriorating neurological functioning. Any positive report should prompt strong consideration of referral for emergency medical evaluation (e.g. CT Scan

to rule out intracranial bleed or other structural pathology).17

E. Diagnosis: The following ICD diagnostic codes may be applicable.

850.0 (Concussion, with no loss of consciousness) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus

evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture or

intracranial injury (A1b).

850.1 (Concussion, with brief loss of consciousness < 1 hour) – Positive injury description with evidence of forcible direct/ indirect blow to the head

(A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); positive evidence of LOC (A5),

skull fracture or intracranial injury (A1b).

850.9 (Concussion, unspecified) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus evidence of active

symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC (A5), no

skull fracture or intracranial injury.

Other Diagnoses – If the patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A 1b)

such as from neuroimaging, a moderate TBI and the diagnostic category of 854 (Intracranial injury) should be considered.

F. Follow-Up Action Plan: Develop a follow-up plan of action for symptomatic patients. The physician/clinician may decide to (1) monitor the patient in the

office or (2) refer them to a specialist. Serial evaluation of the concussion is critical as symptoms may resolve, worsen, or ebb and flow depending upon

many factors (e.g., cognitive/physical exertion, comorbidities). Referral to a specialist can be particularly valuable to help manage certain aspects of the

patient’s condition. (Physician/Clinician should also complete the ACE Care Plan included in this tool kit.)

1. Physician/Clinician serial monitoring – Particularly appropriate if number and severity of symptoms are steadily decreasing over time and/or fully

resolve within 3-5 days. If steady reduction is not evident, referral to a specialist is warranted.

2. Referral to a specialist – Appropriate if symptom reduction is not evident in 3-5 days, or sooner if symptom profile is concerning in type/severity.

Neuropsychological Testing can provide valuable information to help assess a patient’s brain function and impairment and assist with treatment

planning, such as return to play decisions.

Physician Evaluation is particularly relevant for medical evaluation and management of concussion. It is also critical for evaluating and managing

focal neurologic, sensory, vestibular, and motor concerns. It may be useful for medication management (e.g., headaches, sleep disturbance,

depression) if post-concussive problems persist.

_________________________________________________________________________________________________________________________* Taken with permission from the authors. Gioia GA, Collins M, Isquith PK. Improving identification and diagnosis of mild traumatic brain injury with evidence: psychometric support for the acute concussion evaluation. Journal of Head Trauma Rehabilitation. 2008;23(4):230-42.


Table of Contents

Appendix 1.2Abbreviated Westmean Post Traumatic Amnesia Scale (A-WPTAS)

PUPIL ASSESSMENT

T1 T2 T3 T4 T5 + = REACTS BRISKLY

R L R L R L R L R L SL = SLUGGISHSize C = CLOSED

Reaction - = NIL

Comments

Pupil Size (mm)

2 3 4 5 6 7 8

Date:

Time

T1 T2 T3 T4 T5 Use of A-WPTAS and GCS for patients with MTBI

The A-WPTAS combined with a standardised GCS assessment is an objective measure of post traumatic amnesia (PTA). Only for patients with current GCS of 13-15 (<24hrs post injury) with impact to the head resulting in confusion, disorientation, anterograde or retrograde amnesia, or brief LOC. Administer both tests at hourly intervals to gauge patient’s capacity for full orientation and ability to retain new information. Also, note the following: poor motivation, depression, pre-morbid intellectual handicap or possible medication, drug or alcohol effects. NB: This is a screening device, so exercise clinical judgement. In cases where doubt exists, more thorough assessment may benecessary.

Admission and Discharge Criteria:

A patient is considered to be out of PTA when they score 18/18.

Both the GCS and A-WPTAS should be used in conjunction with clinical judgement.

Patients scoring 18/18 can be considered for discharge.

For patients who do not obtain 18/18 re-assess after a further hour.

Patients with persistent score <18/18 at 4 hours post time of injury should be considered for admission.

Clinical judgement and consideration of pre-existing conditions should be used where the memory component of A-WPTAS is abnormal but the GCS is normal (15/15).

Referral to GP on discharge if abnormal PTA was present, provide patient advice sheet.

Motor Obeys commands

6 6 6 6 6

Localises 5 5 5 5 5Withdraws 4 4 4 4 4Abnormal flexion 3 3 3 3 3Extension 2 2 2 2 2None 1 1 1 1 1

Eye Opening Spontaneously 4 4 4 4 4

To speech 3 3 3 3 3

To pain 2 2 2 2 2None 1 1 1 1 1

Verbal Oriented ** (tick if correct)

Name

Place

Why are you here

Month

Year

5 5 5 5 5

Confused 4 4 4 4 4Inappropriate words

3 3 3 3 3

Incomprehensible sounds

2 2 2 2 2

None 1 1 1 1 1

GCS Score out of 15 /15 /15 /15 /15 /15 Target set of picture cardsPicture 1

Picture 2

Picture 3

A-WPTAS Score out of 18 /18 /18 /18 /18

Abbreviated Westmead PTA Scale (A-WPTAS)incorporating Glasgow Coma Scale (GCS)

MRN sticker here

Show pictures

(see over)

Shores & Lammel (2007) - further copies of this score sheet can be downloaded from http://www.psy.mq.edu.au/GCS

ABBREVIATED WESTMEAD PTA SCALE (A-WPTAS)GCS & PTA testing of patients with MTBI following mild head injury

** must have all 5 orientation questions correct to score 5 on verbal score for GCS, otherwise the score is 4 (or less).


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Appendix 1.2: Abbreviated Westmean Post Traumatic Amnesia Scale (A-WPTAS)

Administration and Scoring

1. Orientation Questions

Question 1: WHAT IS YOUR NAME?

The patient must provide their full name.

Question 2: WHAT IS THE NAME OF THIS PLACE?

The patient has to be able to give the name of the hospital. For example: Westmead Hospital. (NB: The

patient does not get any points for just saying ‘hospital’.) If the patient can not name the hospital, give them a

choice of 3 options. To do this, pick 2 other similar sized hospitals in your local area or neighbouring region. In

Westmead Hospital’s case the 3 choices are ‘Nepean Hospital, Westmead Hospital or Liverpool Hospital’.

Question 3: WHY ARE YOU HERE?

The patient must know why they were brought into hospital. e.g. they were injured in a car accident, fell,

assaulted or injured playing sport. If the patient does not know, give them three options, including the correct

reason.

Question 4: WHAT MONTH ARE WE IN?

For emphasis the examiner can ask what month are we in now? The patient must name the month. For

example, if the patient answers ‘the 6th month’, the examiner must ask the further question ‘What is the 6th

month called?’.

Question 5: WHAT YEAR ARE WE IN?

It is considered correct for patients to answer in the short form ‘08’, instead of ‘2008’. Also, an acceptable

alternative prompt (for the rest of the 2000’s) is ‘The year is 2000 and what?’

2. Picture recognition Straight after administering the GCS (standardised questions), administer the A-WPTAS by presenting the

3 Westmead PTA cards. Picture Cards the first time - T1 : Show patients the target set of picture cards for

about 5 seconds and ensure that they can repeat the names of each card. Tell the patient to remember the

pictures for the next testing in about one hour. Picture Cards at each subsequent time T2-T5: Ask patient,

“What were the three pictures that I showed you earlier?” Scoring:

For patients who free recall all 3 pictures correctly, assign a score of 1 per picture and add up the patient’s

GCS (out of 15) and A-WPTAS memory component to give the A-WPTAS score (total = 18). Present the 3

target pictures again and re-test in 1 hour.

For patients who can not free recall, or only partially free recall, the 3 correct pictures, present the 9-object

recognition chart. If patient can recognise any correctly, score 1 per correct item and record their GCS

and A-WPTAS score (total = 18). Present the target set of pictures again and re-test in 1 hour.

For patients who neither remember any pictures by free call nor recognition, show the patient the target

set of 3 picture cards again for re-test in 1 hour.

GLASGOW COMA SCALE (GCS) AND ABBREVIATED WESTMEAD PTA SCALE (A-WPTAS)


Research and development of the A-WPTAS supported by the Motor Accidents Authority NSW


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Appendix 1.2: Abbreviated Westmean Post Traumatic Amnesia Scale (A-WPTAS)


Table of Contents

Appendix 1.3Brain Injury Advice Card - Long Version

Brain Injury Advice Card (Long Version)

Important Points about Mild Brain Injury• You had a mild brain injury or what is sometimes called a concussion. Most people recover quickly

following a mild brain injury. A few people may experience symptoms over a longer period.• There is a small risk of you developing serious complications so you should be watched closely by another

adult for 24 hours after the accident.• Please read the following. It outlines what signs to look for after a brain injury and what you need to do if

you have problems.

Warning SignsIf you show any of these symptoms or signs after your brain injury, or you get worse, go to the nearest hospital, doctor or call 911 immediately.• Fainting or blacking out, drowsiness, or can’t be woken up• A constant severe headache or a headache that gets worse• Vomiting or throwing up more than twice• Cannot remember new events, recognise people or places (increased confusion)• Acting strange, saying things that do not make sense (change in behaviour)• Having a seizure (any jerking of the body or limbs)• Inability to move parts of your body, weakness in arms or legs, or clumsiness• Blurred vision or slurred speech• Being unsteady on your feet or loss of balance• Continual fluid or bleeding from the ear or nose

The First 24-48 Hours After Injury• Warning Signs: You should be observed and return to hospital if you develop any of the above

warning signs.• Rest/Sleeping: Rest (both physical and mental) and avoid strenuous activity for at least 24 hours. It is

alright for you to sleep tonight but you should be checked every four hours by someone to make sure you are alright.

• Driving: Do not drive for at least 24 hours. You should not drive until you feel much better and can concentrate properly. Talk to your doctor.

• Drinking/Drugs: Do not drink alcohol or take sleeping pills or recreational drugs in the next 48 hours. All of these can make you feel worse. They also make it hard for other people to tell whether the injury is affecting you or not.

• Pain Relief: Use acetaminophen or acetaminophen/codeine for headaches (e.g., Tylenol). • Sports: Do not return to sports until you have received medical clearance from your health care provider.

See your local doctor if you are not starting to feel better within a few days of your injury.

- Page 1 - Brain Injury Advice Card (Long Version)


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Appendix 1.3: Brain Injury Advice Card - Long Version

The First 4 Weeks After InjuryYou may have some common effects from the brain injury which usually resolve in several weeks to three months. These are called post concussion symptoms (see below). Tiredness can exaggerate the symptoms. Return to your normal activities gradually (not all at once) during the first weeks or months. You can help yourself get better by:

• Rest/Sleeping: Your brain needs time to recover. It is important to get adequate amounts of sleep as you may feel more tired than normal and you need to get adequate amounts of both physical and mental rest.

• Driving: Do not drive or operate machinery until you feel much better and can concentrate properly. Talk to your doctor.

• Drinking/Drugs: Do not drink alcohol or use recreational drugs until you are fully recovered. They will make you feel much worse. Do not take medication unless advised by your doctor.

• Work/Study: You may need to take time off work or study until you can concentrate better. Most people need a day or two off work but are back full time in less than 2 weeks. How much time you need off work or study will depend on the type of job you do. See your doctor and let your employer or teachers know if you are having problems at work or with study. You may need to return to study or work gradually.

• Sport/Lifestyle: It is dangerous for the brain to be injured again if it has not recovered from the first injury. Talk to your doctor about the steps you need to take to gradually increase sports activity and return to play. If in doubt, sit out.

• Relationships: Sometimes your symptoms will affect your relationship with family and friends. You may suffer irritability and mood swings. See your doctor if you or your family are worried.

Recovery• You should start to feel better within a few days and be ‘back to normal’ within about 4 weeks. See your

local doctor if you are not starting to feel better.• Your doctor will monitor these symptoms and may refer you to a specialist if you do not improve over 4

weeks up to 3 months.

Post Concussion SymptomsThere are common symptoms after a mild brain injury. They usually go away within a few days or weeks. Sometimes you may not be aware of them until sometime after your injury like when you return to work.

» Mild headaches (that won’t go away)Headaches are a common problem after a mild brain injury. They can be made worse by fatigue andstress. Sleeping, resting or taking a break from activities requiring concentration or effort will usuallyrelieve headaches. Pain relievers may help to break a cycle of headaches - use acetaminophen oracetaminophen/codeine, limited to <15 days per month. If your headache gets worse, or cannot be relieved, see your doctor.

» Having more trouble than usual with attention & concentrationNo one can concentrate well when they are tired, so it is not surprising that many people have trouble concentrating for a while after they have had a mild brain injury. Maybe you cannot even concentrate well enough to read the newspaper. If you really need to, just read for a short time, and then come back to it when you have had a break. The same thing applies to other areas where concentration is needed. Leave things that need your complete concentration until you are feeling better. If you need to concentrate on something important, do it when you are feeling fresh.



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» Having more trouble than usual with remembering things (memory difficulties/forgetfulness)You cannot expect your brain to be as good at remembering things as it usually is. Don’t worry if you can’t think of a name or a phone number that you ought to know, or if you go to get something, and then can’t remember what it is. Your memory is only going to be a problem until you recover. In the meantime, get your family and friends to remind you of important dates and appointments, or write things down.

» Feeling dizzy or sick without vomiting (nausea)Occasionally, people find that they get a sick or uncomfortable feeling if they move or change their position quickly. Usually it is only a problem for a few days. If you find that things seem to spin round if you sit up suddenly after lying down, or if you turn your head sharply, it is best to avoid such sudden movements or changes in position until it clears. If the dizziness persists for more than a week or two, see your doctor.

» Balance problemsYou may find that you are a bit more clumsy than usual. Don’t worry if you do find that you are a bit unsteady on your feet, or bump into furniture, or maybe drop things. Just take everything you do a little more slowly. Your brain is the control centre for your whole body. It has to make sense out of all the messages coming in from your eyes and ears and other senses, and to send the right signals to the right muscles for you to be able to do anything. So give yourself more time to do things.

» More difficulty than usual with making decisions and solving problems, getting things done or beingorganizedYou may find you are less able to plan ahead or follow through the steps that are required in carrying out an activity. These kinds of difficulties may cause particular problems during the first few days after a mild brain injury but they are usually temporary in nature. When facing situations that present problems or opportunities to plan, it may help to think things through in a more structured and objective way. For example, you may want to ask yourself a series of questions like:1. What do I want to achieve?2. What are the available options?3. What is the best option?4. What steps will I need to take to achieve this?After these questions have been considered and answered, you can then carry out your plan. Writing down a goal, plan or problem also helps to give structure to your thinking and helps to make things clearer. Using a daily and weekly time table, planner, or keeping a diary can provide structure and ensure that plans are made routinely and on an ongoing basis.

» Feeling vague, slowed or ‘foggy’ thinkingSome people who have sustained a mild brain injury find their thinking is a bit slower. This means they might have some difficulty keeping up with conversations or following directions, and things take longer to get done. Encourage others to slow down by asking questions and having them repeat what they have said. Allow yourself extra time to complete tasks and avoid situations where you are under pressure to do things quickly.

» Balance problemsAt first, even a little effort may make you feel very tired. Your brain has less energy to spare than it normally does. If you feel sleepy, go to bed. You will probably find that you need several hours more sleep than you usually do. Let your brain tell you when it needs to sleep, even if it is the middle of the day.

» Tinnitus. Ringing in the ears.Tinnitus is due to damage to the inner ear after brain injury. It is usually described as a whistling, ringing or roaring sound and may be accompanied by some hearing loss. It usually settles on its own within a few weeks after injury. If the ringing in your ears gets worse or does not go away, see your doctor. Reduce your normal intake until you feel fully recovered.




Table of Contents

» Irritability/mood swings. Losing your temper and getting annoyed easilySome people who have had a mild brain injury find that they get annoyed easily by things that normally would not upset them. This does not last very long, but it can be difficult for you and for your family. It happens because the brain controls your emotional system as well as the rest of your body. After a mild brain injury your emotions may not be as well controlled as they usually are. There are several ways to deal with this. Some people find that going out of a room, or away from a situation as soon as it begins to get annoying is enough. Others use relaxation techniques (controlled breathing, progressive muscle relaxation) to help them get back on an even keel. You may find that you can stop the irritability from developing by doing an activity that uses up some physical energy like riding an exercise bicycle, if tiredness permits. Irritability will be worse when you are tired, so rest will also help.

» Anxiety or depressionFeeling anxious, worried, frightened, angry and low in mood are normal emotions after sustaining a mild brain injury. These feelings often pass in the weeks following the injury, as a person gradually resumes their usual activities. Recognise that emotional upset and worry is a normal part of recovery, even though you may have suffered an injury in the past and not felt like this before. Explain any difficulties that you are experiencing to your family and friends, so that they can understand the effect the injury has had on you and support you in managing your difficulties. Recognise if your worry about symptoms intensifies and a vicious circle develops. If that happens remind yourself of the point above. If symptoms nevertheless do not improve, or if you have suffered from anxiety or depression before the injury and the brain injury has intensified those feelings, visit your doctor.

» More sensitive to lights or soundsYou may find that your eyes are sensitive to bright light. Wearing dark glasses in strong light can help to manage this and the need for dark glasses will likely clear up within a few days. When you want to shut out something you don’t want to look at, all you have to do is close your eyes. It is much harder to shut your ears. When your brain is fully awake it uses part of its energy to dampen down noises that would interfere with what you are doing. After a mild brain injury your brain may not have enough energy to spare to do this, and you may find that most noises bother you. Explain to your family and friends, and ask them to keep the noise level down if they can.

» Change in sleep patterns. Trouble sleeping or sleeping too much.Don’t worry about the sleep disturbance. This is usually temporary and your normal routine will come back gradually. If you are having trouble falling asleep you may try things like reducing stimulation by not watching TV in bedroom or spending long times on the computer, avoiding a large meal before bed, avoiding caffeine, using relaxation techniques (controlled breathing, progressive muscle relaxation), or getting up for about 30 minutes if you are unable to sleep for long periods. It is best to avoid sleep medications but if your sleeping pattern has become very disrupted, discuss with your doctor if a short course of medication may be helpful in re-establishing your sleeping pattern.

» Reduced tolerance to alcohol.After a mild brain injury you may be more sensitive to the effects of alcohol. A small amount may worsen the effects of the brain injury. It can cause unsteadiness and dizziness which may lead to a fall and further injury. It is sensible to avoid alcohol for at least one week after injury and then monitor carefully how alcohol affects you. Reduce your normal intake until you feel fully recovered.

Information included on this advice card was adapted from the Motor Accidents Authority of NSW, Guidelines for MildTraumatic Brain Injury following Closed Head Injury (MAA NSW, 2008) and the Information about Mild Head Injury or Concussion booklet (Ponsford, Willmott, Nelms & Curran, 2004).




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Appendix 1.4Brain Injury Advice Cards - Short Versions: Example # 1

brain injuryWhat to expect after a

concussionor

�

CDC’s “Heads Up” Series

For more information about concussion, please visit:www.cdc.gov/Concussion.

PATIENT INSTRUCTIONS

You have been examined at[name of hospital emergency department]

for a head injury and possible concussion. Be sure to let a family member

or friend know about your injury. They may notice symptoms before you do

and can help you.

Take time off from work or school for days or until you and your doctor think you are able to return to your usual routine.

Your next appointment with [Doctor’s name]

is

[date and time] .


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What to Expect Once You’re Home from the HospitalMost people with a concussion recover quickly and fully. During recovery,

you may have a range of symptoms that appear right away, while others

may not be noticed for hours or even days after the injury. You may not

realize you have problems until you try to do your usual activities again.

Most symptoms go away over time without any treatment. Below is a list

of some of the symptoms you may have:

Thinking/Remembering

Difficulty thinking clearly � Feeling slowed down

Trouble concentrating � Difficulty remembering new information

Physical

Headache � Balance problems � Blurred vision � Dizziness

Nausea or vomiting � Lack of energy � Sensitivity to noise or light

Emotional/Mood

Irritability � Nervousness � Sadness � More emotional

Sleep

Sleeping more than usual � Sleeping less than usual � Trouble

falling asleep

�

�

�

�

�

�

�

�

How to Feel Better

Get plenty of rest and sleep.

Avoid activities that are

physically demanding or

require a lot of thinking.

Do not drink alcohol.

Return slowly and gradually

to your routine.

Ask a doctor when it is safe

to drive, ride a bike, or

operate heavy equipment.

WHEN TO RETURN TO THE HOSPITAL

Sometimes serious problems develop after a head injury. Return to the

emergency department right away if you have any of these symptoms:

Repeated vomiting

Worsening or severe headache

Unable to stay awake during times you would normally be awake

More confused and restless

Seizures

Difficulty walking or difficulty with balance

Difficulty with your vision

Any symptom that concerns you, your family members, or friends

�

�

�

�

�

Appendix 1.4: Brain Injury Advice Cards- Short Versions: Example #1


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Brain Injury Advice Cards - Short Versions: Example # 2

Brain Injury Advice Card (Short Version)

Important Points about Mild Brain Injury• You had a mild brain injury or what is sometimes called a concussion. Most people recover quickly

following a mild brain injury. A few people may experience symptoms over a longer period.• There is a small risk of you developing serious complications so you should be watched closely by another

adult for 24 hours after the accident.• Please read the following. It outlines what signs to look for after a brain injury and what you need to do if

you have problems.

Warning SignsIf you show any of these symptoms or signs after your brain injury, or you get worse, go to the nearest hospital, doctor or call 911 immediately.• Fainting or blacking out, drowsiness, or can’t be woken up• A constant severe headache or a headache that gets worse• Vomiting or throwing up more than twice• Cannot remember new events, recognise people or places (increased confusion)• Acting strange, saying things that do not make sense (change in behaviour)• Having a seizure (any jerking of the body or limbs)• Inability to move parts of your body, weakness in arms or legs, or clumsiness• Blurred vision or slurred speech• Being unsteady on your feet or loss of balance• Continual fluid or bleeding from the ear or nose

The First 24-48 Hours After Injury• Warning Signs: You should be observed and return to hospital if you develop any of the above

warning signs.• Rest/Sleeping: Rest (both physical and mental) and avoid strenuous activity for at least 24 hours. It is

alright for you to sleep tonight but you should be checked every four hours by someone to make sure you are alright.

• Driving: Do not drive for at least 24 hours. You should not drive until you feel much better and can concentrate properly. Talk to your doctor.

• Drinking/Drugs: Do not drink alcohol or take sleeping pills or recreational drugs in the next 48 hours. All of these can make you feel worse. They also make it hard for other people to tell whether the injury is affecting you or not.

• Pain Relief: Use acetaminophen or acetaminophen/codeine for headaches (e.g., Tylenol). • Sports: Do not return to sports until you have received medical clearance from your health care provider.

See your local doctor if you are not starting to feel better within a few days of your injury.

- Page 1 - Brain Injury Advice Card (Short Version)

Appendix 1.4 (Continued)


Table of Contents

The First 4 Weeks After InjuryYou may have some common effects from the brain injury which usually resolve in several weeks to three months. These are called post concussion symptoms (see below). Tiredness can exaggerate the symptoms. Return to your normal activities gradually (not all at once) during the first weeks or months. You can help yourself get better by:

• Rest/Sleeping: Your brain needs time to recover. It is important to get adequate amounts of sleep as you may feel more tired than normal and you need to get adequate amounts of both physical and mental rest.

• Driving: Do not drive or operate machinery until you feel much better and can concentrate properly. Talk to your doctor.

• Drinking/Drugs: Do not drink alcohol or use recreational drugs until you are fully recovered. They will make you feel much worse. Do not take medication unless advised by your doctor.

• Work/Study: You may need to take time off work or study until you can concentrate better. Most people need a day or two off work but are back full time in less than 2 weeks. How much time you need off work or study will depend on the type of job you do. See your doctor and let your employer or teachers know if you are having problems at work or with study. You may need to return to study or work gradually.

• Sport/Lifestyle: It is dangerous for the brain to be injured again if it has not recovered from the first injury. Talk to your doctor about the steps you need to take to gradually increase sports activity and return to play. If in doubt, sit out.

• Relationships: Sometimes your symptoms will affect your relationship with family and friends. You may suffer irritability and mood swings. See your doctor if you or your family are worried.

Recovery• You should start to feel better within a few days and be ‘back to normal’ within about 4 weeks. See your

local doctor if you are not starting to feel better.• Your doctor will monitor these symptoms and may refer you to a specialist if you do not improve over 4

weeks up to 3 months.

Information included on this advice card was adapted from the Motor Accidents Authority of NSW, Guidelines for MildTraumatic Brain Injury following Closed Head Injury (MAA NSW, 2008) and the Information about Mild Head Injury or Concussion booklet (Ponsford, Willmott, Nelms & Curran, 2004).

- Page 2 - Brain Injury Advice Card (Short Version)

Appendix 1.4: Brain Injury Advice Cards - Short Versions: Example #2


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The Rivermead Post Concussion Symptoms Questionnaire*

Appendix 1.5

After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer.

0 = Not experienced at all1 = No more of a problem2 = A mild problem3 = A moderate problem4 = A severe problem

Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from:

Headaches................................................................................................................. 0 1 2 3 4Feelings of dizziness.................................................................................................. 0 1 2 3 4Nausea and/or vomiting.............................................................................................. 0 1 2 3 4Noise sensitivity, easily upset by loud noise............................................................... 0 1 2 3 4Sleep disturbance....................................................................................................... 0 1 2 3 4Fatigue, tiring more easily.......................................................................................... 0 1 2 3 4Being irritable, easily angered.................................................................................... 0 1 2 3 4Feeling depressed or tearful....................................................................................... 0 1 2 3 4Feeling frustrated or impatient.................................................................................... 0 1 2 3 4Forgetfulness, poor memory....................................................................................... 0 1 2 3 4Poor concentration..................................................................................................... 0 1 2 3 4Taking longer to think.................................................................................................. 0 1 2 3 4Blurred vision.............................................................................................................. 0 1 2 3 4Light sensitivity, easily upset by bright light................................................................ 0 1 2 3 4Double vision.............................................................................................................. 0 1 2 3 4Restlessness ............................................................................................................. 0 1 2 3 4

Are you experiencing any other difficulties?1.________________________________________________________ 0 1 2 3 42.________________________________________________________ 0 1 2 3 4

_________________________________________________________________________________________________________________________* King N, Crawford S, Wenden F, Moss N, Wade D. The Rivermead Post Concussion Symptoms Questionnaire: A measure of symptoms commonly experienced after head injury and its reliability. Journal of Neurology. 1995;242:587-592.

Taken with permission from the authors and the publisher.


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Project Members

PROJECT TEAM MEMBERS

Project Team Leader

Shawn Marshall, MD, MSc, FRCPCOttawa Hospital Research Institute

Project Investigators

Mark Bayley, MD, FRCPCToronto Rehabilitation Institute, University Health Network

Lindsay Berrigan, PhD Dalhousie University

Scott McCullagh, MD, FRCPCSunnybrook Health Science Center

Donna Ouchterlony MD, CCFPSt. Michael’s Hospital

Diana Velikonja, PhD, CPsychHamilton Health Sciences

Project Coordinator

Kelly Weegar, PhD (Candidate)Ottawa Hospital Research Institute

Student Research Assistants

Andrew Bayne, BSc (Candidate)McGill University

Natalie Fersht, BSocSc (Candidate)University of Ottawa

Hayley MacLeay, BA & Sc (Candidate)McGill University

Chantal Rockwell, BA (Hons)Ottawa Hospital Research Institute

Kelsey Scheier, BSc (Candidate)University of Waterloo

EXPERT CONSENSUS GROUP

Robert Brison MD, MPH, FRCPQueen’s University

Carol Cancelliere DC, MPHToronto Western Research Institute, University Health Network

Angela Colantonio PhD, OTUniversity of Toronto, Toronto Rehabilitation Institute

Victor Coronado, MD, MPHCenters for Disease Control and Prevention (USA)*

Nora Cullen, MD, MSc, FRCPCToronto Rehabilitation Institute, University Health Network

Lisa Fischer MD, CCFP, DipSportMed Western University

Anne Forrest, PhDmTBI Survivor

Bryan Garber, MDNational Defence, Government of Canada

Jonathan Gladstone, MD, FRCPCUniversity of Toronto

Wayne Gordon, PhD, ABPP/CnMount Sinai School of Medicine

Robin Green, PhD, CPsychToronto Rehabilitation Institute, University Health Network

Grant Iverson, PhD, RPsychUniversity of British Columbia

Corinne Kagan BA, BPS CertOntario Neurotrauma Foundation

Vicki Kristman, PhDLakehead University

Andrea Laborde, MDRoyal Hobart Hospital (Australia)

Appendix A

_________________________________________________________________________________________________________________________* The recommendations in this document are those of the Ontario Neurotrauma Foundation, identified by the guideline development team and expert consensus group members, and do not necessarily represent agreement of or endorsement by the Centers for Disease Control and Prevention.


Table of Contents

Appendix A: Project Members

Patricia McCord, DC

Willie Miller, MD, FRCPCUniversity of Ottawa

Gregory O’Shanick, MDCenter for Neurorehabilitation Services (USA)

Marie-Christine Ouellet, PhD Université Laval

Angela Peddle, OD, FCOVDUniversity of Waterloo

Laura Rees, PhD, CPsychThe Ottawa Hospital Rehabilitation Center

Wendy Shama MSW, RSWmTBI Survivor

Mary Stergiou-Kita, PhDUniversity of Toronto

Rob van Reekum, MD, FRCPCUniversity of Toronto

Catherine Wiseman-Hakes, PhD, Reg CASLPOHôpital du Sacré-Coeur de Montréal

STAKEHOLDERS/AUDITORS

Humberto LaranjoEmergency Nurses Association of Ontario

Ruth WilcockOntario Brain Injury Association

Roger ZemekChildren’s Hospital of Eastern Ontario Injury Claims Managers from the Property and Casualty Insurance Industry

EXTERNAL REVIEWERS

Markus Besemann, LCol, BSc, MD, FRCP, DipSportMedCanadian Forces Health Services - Rehabilitation Medicine

Pierre Côté, DC, PhDUniversity of Ontario Institute of Technology

David Cifu, MDVirginia Commonwealth University, US Department of Veterans Affairs

Mark Rapoport, MD, FRCPCSunnybrook Health Sciences Center, University of Toronto

Noah Silverberg, PhD, RPsych, ABPPUniversity of British Columbia

Bonnie Swaine, PT, PhD Université de Montréal

Charles Tator, PhD, MDUniversity of Toronto


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Appendix BOther Links/References for Resources to Consider

Section 1: Diagnosis/Assessment of Concussion/mTBI

Ohio State University TBI Identification Method - Short FormThis tool is used to assess a patient’s lifetime history of any previous TBI. It consists of a series of questions to be administered to the patient by a health care professional.

Corrigan JD, Bogner J. Initial reliability and validity of the Ohio State University TBI Identification Method. Journal of Head Trauma Rehabilitation. 2007;22(6):318-329.

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