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CRM: Delayed Recovery Overview
Concussion Recognition & Management
Module 6 Delayed Recovery

Overview

young man turned away from teacher in class
Some mTBI patients experience delayed recovery. To treat these cases, it’s important to determine first whether or not the patient is attempting to do too much too soon, thereby generating symptoms. It’s advisable to remind the patient to cut back on activities now, rather than wait two weeks to see if the symptoms resolve. Treating issues up front can prevent complications from developing.

Some symptoms show up after the initial cluster of symptoms. For example, a patient may become more anxious and / or more depressed, and this becomes a problem for treatment. Or, under high-demand activities, symptoms may emerge that before were absent or seemingly resolved. For example, your patient injured in July may think she is fine, but when she returns to class at the end of the summer, she finds she can’t concentrate.

If a patient is complying with the treatment plan and yet his or her symptoms have not cleared up in a reasonable amount of time (ten days to two weeks), it is time to adjust the treatment. Education will not be enough, nor will piecemeal, single-discipline therapy. A multidisciplinary team should be assembled to address the patient’s delayed recovery.

The starting place for the team is based on these three issues:
  1. Where is the patient with his or her symptoms? What is the type, intensity, and frequency of each symptom?

  2. Is the patient complying with recommended treatments and activities?

  3. What are the pre-morbidities and co-morbidities?
young man in suit, sitting on porch, holding head in hands

Symptoms are almost always multifactorial. It isn’t necessary (or perhaps even possible) for a single team member to treat all of the symptoms, but each team member can look for and be aware of all the symptoms, to ensure nothing is missed. The patient’s array of persisting symptoms may eventually develop into a syndrome.

Post-Concussion Syndrome

After one to three months of continuous symptoms, the ongoing post-concussion symptoms are identified as Post-Concussion Syndrome (PCS). Post-Concussion Syndrome is defined as:
"An aggregate of symptoms presenting after head injury including physical, cognitive, emotional, and sleep symptoms that persist beyond the usual recovery period after a concussion or past the acute post-injury period."

Institute of Medicine (IOM)
Sports-Related Concussions in Youth: Improving the Science, Changing the Culture
There are differences in diagnostic criteria between the ICD-10 and DSM-V systems. DSM-V does not identify Post-Concussion Syndrome. They changed the nomenclature to Neurocognitive Disorders.

Diagnostic Criteria

ICD-10
for Post-Concussion Syndrome

DSM-V
for Major and Mild Neurocognitive Disorders


Must have a history of traumatic brain injury and present at least three of the eight symptoms:
  1. Headache.
  2. Dizziness.
  3. Fatigue.
  4. Irritability.
  5. Insomnia.
  6. Concentration.
  7. Memory difficulty.
  8. Intolerance of stress, emotion, or alcohol.
Medscape: Postconcussive Syndrome
  1. The criteria are met for major or mild neurocognitive disorder.

  2. There is evidence of a traumatic brain injury – that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following:
    1. Loss of consciousness.
    2. Post-traumatic amnesia.
    3. Disorientation and confusion.
    4. Neurological signs.

  3. The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury, or immediately after recovery of consciousness, and persists past the acute post-injury period.
The ICD-9 to ICD-10 Crosswalk made Easy: ICD-10 Code Lookup


3 medical personnel looking at computer

The mTBI Multidisciplinary Team

As described in the Fourth International Conference on Concussion in Sport Statement,
"Cases of concussion in sport where clinical recovery falls outside the expected window (i.e., 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion."

Ideally, the team should include professionals from a variety of disciplines, each of whom have special knowledge and training in mTBI, including (but not limited to):
  • Physician (such as primary care, neurologist, sports medicine, physiatrist).
  • Physical therapist, with special training in balance disorders.
  • Occupational therapist, with special training in the treatment of visual processing disorders.
  • Speech therapist, who will typically address cognitive rehabilitation.
  • Neuropsychologist, who will assess brain function, as well as the contribution of behavioral, emotional, and motivational factors.
  • Neurooptometrist and / or neuroophthalmologist, an advanced specialist who will assess vision processing disorders.
  • Educational specialist, who can serve as the liaison with the school.
  • Other professionals who may also possess specialized training of value to a particular case requiring complex management, such as
    • Athletic trainer.
    • Audiologist.
    • Psychiatrist.
    • School nurse.

Team Advantage in Delayed Recovery

Mention of any specific health care facility or organization in the videos reflects an individual’s specific experience and is not intended as an endorsement from this site.


Depending on the patient’s needs, the team will provide specific medical and behavioral treatments for symptoms such as:
  • Sleep disruption.
  • Pain.
  • Noise sensitivity.
  • Poor attention.
  • Memory difficulties.
  • Executive function issues.
  • Mood instability.
  • Personality change.
  • Anxiety.
  • Depression.

BIRSST Teams

In Nebraska, the Nebraska Department of Education’s Educational Service Units (ESUs) have BIRSST (Brain Injury Regional School Support Teams) who have training in managing TBI. The teams can provide Nebraska educators with materials, training, and consultative services to support students with brain injuries.
BIRSST Resources
on the NDE Concussion and Brain Injury Supports page
(including BIRSST Team Contacts)
map of Nebraska with BIRSST regions

Module 6 Delayed Recovery

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