September 2, 2021
The lead author of the quality measure set for concussion highlights the key clinical takeaways about the evaluation, clinical exam, and return-to-play protocols.
An evaluation of patient symptoms and a neurologic exam remain the bedrock of concussion care, according to a Concussion Quality Measurement Set developed by a working group of the American Academy of Neurology.
“Concussion remains a clinical diagnosis, inevitably involving some degree of subjectivity and uncertainty,” the document, published in the July 28 edition of Neurology, stated. The measure set also includes a third component of concussion care: documentation of a return-to-play strategy or protocol.
The measurement set is not meant to be all-encompassing but rather highlights some key aspects of concussion care by which physicians can judge whether they are providing quality care to their patients.
Measurement sets differ from guidelines, which are meant to inform specific aspects of diagnostic and treatment decisions.
Concussion accounts for approximately one million outpatient and emergency department visits annually for minor head injury in children and a similar number of visits involving adults with concussion, according to background information in the measurement set.
Neurology Today talked with the lead author, Sean Rose, MD, co-director of the complex concussion clinic and assistant professor of pediatric neurology at Nationwide Children’s Hospital in Columbus, OH. His comments along with excerpts from the document were edited for space and clarity.
Why was it time to develop a quality measurement set for concussion?
While there is evidence to guide the clinical diagnosis and management of concussion, there remains significant variability in care practices. We developed this measure set to support high-quality care for individuals with concussion and to improve patient outcomes. A previous set did not exist.
What evidence is the new measurement set based on?
The work group used evidence-based and consensus guidelines from several professional medical organizations, such as the Centers for Disease Control and Prevention, the AAN, and the American Academy of Pediatrics. We also included evidence from systematic reviews and individual research studies to identify elements of patient care that are considered key to quality medical care. While 19 measures were initially proposed, three measures were ultimately included after data review, group discussion, and public comment.
What are the key points in the new concussion document?
The first two measures highlight that concussion remains a clinical diagnosis based on history and neurologic exam. To meet these quality measures, history includes tracking symptoms during recovery, and exam includes a thorough neurologic physical exam.
Concussion symptoms evaluation: The measurement set does not tell clinicians which specific tools to use to do a symptoms evaluation, but does list some assessment tools to consider, such as the child or adult versions of the Sport Concussion Assessment Tool and the Post-Concussion Symptom Scale. Most of them free and available online.
“These tools are a springboard for the caregiver to discuss patient symptoms and track them over time,” the document says. “Symptom evaluation tools should not be used by themselves to manage concussion but should be used to make treatment decisions. Treatment for concussion varies widely and we cannot recommend a treatment follow-up component for this measure at this time.”
Appropriate neurologic exam: The measurement set is not intended to change the way someone is trained to complete a neurologic exam. But the neurologic exam should include at least seven key components: cervical assessment, cognitive function, vestibular function, extraocular movement, gait, balance, and coordination. The measure notes that “A general neuro exam to exclude spine and brain injury should be completed as part of the initial evaluation.”
Documentation of return-to-play strategy or protocol: The third measure affirms the consensus recommendation that a patient should complete and tolerate a progression of physical activities prior to being cleared for contact sports or other “at-risk” activities. The measure set includes a common six-step protocol as an example, beginning with physical activities that do not worsen symptoms, progressing to light aerobic activity, and ultimately arriving at normal game play. For example, a soccer player might start with light jogging, then more intense running and sprints, then basic soccer footwork and ball handling, then non-contact practice, then full scrimmage, then game competition.
How might this measurement set help clinicians improve the consistency and quality of concussion care they deliver?
It could be used by individual physicians to track whether they are performing key elements of care for every patient with concussion. It could also be used by organizations or funding agencies potentially to identify whether physicians are meeting basic quality measures.
It is important to recognize these three quality measures are considered foundational to the diagnosis and management of concussion. But they do not represent the only things that providers should do to provide high-quality care for patients with concussion. The three measures we picked were all practice-based rather than outcomes-based. Because concussion overall needs more research, it is not known conclusively what interventions result in better outcomes.
What measures were not included in the final document?
The workgroup held multiple meetings to identify proposed measures that have well-documented evidence. We explored other measures but determined that there is not currently enough evidence to support them or there is not a feasible way to track their completion. A single study with a handful of patients is not adequate.
“We developed this measure set to support high-quality care for individuals with concussion and to improve patient outcomes. A previous set did not exist.”—DR. SEAN C. ROSE
Some proposed measures had too many unknown variables. For instance, in regards to neuroimaging and whether repeat CT scans should be avoided, a lot of factors, such as whether a patient develops new symptoms, can influence that decision. Another proposed measure focused on referral to a concussion clinic. That measure would be hard for physicians to complete based on the limited availability of clinics. In some areas of the country there may not be a multi-disciplinary concussion clinic within hundreds of miles of a patient’s home.
Another proposed measure was to screen concussion patients for depression using a validated tool. There is potentially an increased risk for depression after concussion, but current guidelines do not recommend that patients with concussion should be screened for depression.
The use of computer-based tests (sometimes a baseline score versus a score at time of injury or post-injury) is often touted in concussion care, especially for athletes. Are such tools part of the quality measurement set?
Computer-based cognitive testing was not included in this measure set because it is not considered an essential part of concussion management. However, assessment of cognitive function is a required part of the neurologic exam for patients with concussion. This can be accomplished in various ways, including computerized cognitive testing.
Can you talk more about the note in the measurement set that most concussions are not sports-related?
Most concussion research and published guidelines are focused on sports-related concussion, but only one-third to one-half of concussions are sports-related. Many concussions are caused by falls, accidents during recreational activities, car accidents, workplace injuries, or assault. This measure set applies to patients with concussion for any reason.
What are some of the little-known facts or misperceptions about concussion?
The measurement set notes that “there appear to be sex differences in concussion incidence and recovery. In sports with similar rules for both sexes (for example, basketball, soccer) females have a higher risk of concussion than males.” Females tend to be more at risk for a prolonged recovery. Researchers are currently studying tests and other technologies to predict a patient’s recovery.
There are a lot of misunderstandings about concussion. The more I learn about concussion, the more nuance I see. It is difficult to slot individual patients into protocols or treatment pathways. Concussion care should be individualized to each patient, but these quality measures identify key elements that should be applied to all patients. While there is ongoing research looking for new tools to aid in the assessment, diagnosis of concussion remains clinical, so the experience of the medical provider is crucial.