Jan/Feb 2018

Over the last five years, the Pan Am Concussion Program has emerged as one of Canada's leading providers of care for patients with traumatic brain injury (TBI).

But it is also establishing a reputation for something else: research.

Since its inception in 2013, the program's multidisciplinary team, led by neurosurgeon Dr. Michael Ellis, has generated more than 30 research papers.

Some of these papers deal with specific issues relating to diagnosis and treatment of concussions. But others take a broader approach, touching on matters of public policy.

For example, a paper published in 2016 entitled "Multidisciplinary Management of Pediatric Sports-Related Concussion" suggests that management of pediatric concussion requires access to a team of health-care professionals with licensed training in traumatic brain injury sub-disciplines.

As the paper explains, concussions affect different pediatric patients in different ways and may co-exist with other neurological issues that could complicate diagnosis and treatment. As a result, these patients should ideally be evaluated and treated by a multidisciplinary team of health-care providers similar to the one found at the Pan Am Clinic Concussion Program. That team consists of a neurosurgeon, neurologists, a neuropsychologist, specially-trained physiotherapists, exercise scientists, psychiatrists and pediatric physicians.

Yet their research also suggests that such teams are hard to find outside of Manitoba.

"Our own research on Canadian concussion clinics suggests that there is an urgent, unmet need for multidisciplinary programs formed by health-care providers with nationally and provincially licensed training in TBI," the paper says.

The team carried out an online search to identify 10 to 15 "top" concussion-care providers in the country. It found that only 40 per cent listed an on-site medical doctor as a member of their treatment team.

"Strikingly, the proportion of concussion health-care providers who advertised access to a neurosurgeon (five per cent) and neurologist (seven per cent) were low compared with those with access to a massage therapist (33 per cent), athletic therapist (26 per cent), chiropractor (22 per cent) or osteopath (nine per cent)," the paper says.

"Taken together, these findings suggest that a significant proportion of specialized concussion care in Canada is undertaken by health-care professionals with little or no training in TBI and that many providers do not have access to health-care personnel with this specialized training."

The paper suggests other provinces would be well-advised to follow Manitoba's lead and create provincially-funded, multidisciplinary pediatric concussion clinics, similar to the Pan Am Concussion Program.

"Based on our early experience, optimizing the care of Canada's pediatric concussion patients can be accomplished through the establishment of government-funded regional concussion programs that have access to appropriate diagnostic resources and are powered by experts with national and provincially recognized training in TBI," says the paper.

A second paper co-written by Ellis and colleagues from the University of Buffalo entitled "Multidisciplinary Management of Athletes with Post-Concussive Syndrome: An Evolving Pathophysiological Approach" makes a similar point.

"Athletes who present with persistent concussion symptoms and PCS (post-concussion syndrome) represent a challenging patient population whose care must be individualized and is best carried out by a multidisciplinary team of experts with clinical training and experience in TBI."

Overall, the Pan Am Clinic Concussion Program and the Canada North Concussion Network are interested in concussion research that not only broadens the medical community's understanding of concussion but can also be translated into improving patient care.

Here is brief summary of some of the team's more interesting findings:

• Some pediatric concussion patients develop problems with their vestibular system and suffer cervical spine injuries. Those who develop these problems take longer to recover.
• Although some pediatric concussion patients have difficulties with school immediately after their injury, institutional and population-based research has shown that concussion patients typically do not experience a decline in teacher-assigned school grades.
• Graded aerobic treadmill testing is safe in children with concussion and more severe forms of traumatic brain injury, and is helpful in identifying the rehabilitation needs of these patients.
• Some pediatric concussion patients develop mood disorders that require a multidisciplinary approach to help manage.
• Pediatric concussion may be associated with changes in the way the brain regulates blood flow, and this may contribute to symptoms and exercise intolerance in some patients.

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