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OHIP-Funded Program

We specialize in post-concussion syndrome

Our Concussion Program was started to help post-concussion patients get the necessary assessments and treatment advice they need.  Our Concussion Program focuses on lasting resolution to persistent concussion symptoms by retraining patients’ physiology and psychology so that they can be the versions of themselves they would like to be.  Our program consists of an interdisciplinary team to assist your primary health care provider and your rehab team with your recovery.  We are continually updating our network of expert concussion providers so that we can connect you with valuable resources in your area.  Our concussion doctors are available to coordinate your care so that you can recover as efficiently as possible.

 

    • Specialized medical assessments
    • OHIP-funded and privately-funded
    • Many services offered virtually
    • Available to all residents of Ontario
    • We see patients 18 and up
    • Expert advice rendered to your primary health care provider over OTN’s eConsult

Our Approach

To understand the approach of our concussion program, it’s important to first understand Persistent concussion symptoms.  For more information, you are welcome to attend our OHIP-Funded Virtual Orientation Groups Sessions.

What is Post-Concussion Syndrome?

It may surprise some to learn that post-concussion syndrome is not a real medical diagnosis anymore.  It’s still use frequently however, even by insurance companies and legal companies so sometimes you’ll still here doctors refer to it as post-concussion syndrome.  The new term is persistent concussion symptoms.

 

The reason why the name was changed was that post-concussion syndrome didn’t help in stereotyping patients.  That is, one person with post-concussion syndrome often looks clinically much different than the next, even if they have overlapping features to their concussion symptoms.  Typically, in medicine, specific interventions are matched up with certain diagnoses.  However, if a diagnosis doesn’t help match up patients with the right treatment, then the diagnosis is no longer helpful.

 

The term persistent concussion symptoms honours the fact that patients experience many new symptoms after an injury. However, it doesn’t give them a diagnosis yet.  Rather, it says: you had a concussion, and now you have all these post-concussion symptoms, which diagnoses best represent those symptoms?

 

This is important because practically you can’t treat post-concussion syndrome without knowing those diagnoses just like you can’t play baseball without catching a ball, throwing a ball or hitting a ball.

What diagnosis make up Persistent Concussion Symptoms

Many diagnoses may comprise your persistent concussion symptoms.  This is the main job of our concussion doctors:  to identify these diagnosis so that we can match you up with the correct treatments.  At the Toronto Concussion Clinic we do this by evaluating all of the most common diagnoses during their own individual assessments.  Some of the most common diagnoses post-concussion include:

 

 

Some post-concussion patients have diagnoses other than these most common ones and those are uncovered during flexible follow-up virtual post-concussion medical visits.  With every identified diagnosis, post-concussion treatment recommendations are added to the concussion care plan, even if we are not planning on starting those treatments right away.  Advice will be given about when to start which therapies.

How are persistent concussion symptoms generally treated?

Generally, it’s not efficient to treat all the diagnoses that comprise persistent concussion symptoms at the same time.  That is way too tiring and often counterproductive…and often unnecessary.  As the treatments mostly involve training your body to do something, you need to pace yourself properly just like an athlete wouldn’t do the whole years training in just one month.

 

Our concussion specialists will help streamline your treatment plan.  There are many factors they consider when organizing your treatment plan:

  • Your current level of disability from a specific diagnosis
  • The root (physiological) cause of a specific diagnosis
  • The most efficient way to rehabilitate it.  Usually we want to work with the body the way it naturally developed those skills the first time around during normal human development.  For example (see video explaining this further), before retraining your vestibular system, we often do neuromuscular control training as that’s a natural hack to our balance system. You’ll recognized that kids often learn to walk before they start walking on curbs and doing downward dog.
  • Practical and social considerations you share with us and compromises that we must consider.

 

Many times, when taking a logical step-wise approach to concussion treatment, we can eliminate the need for other treatments entirely!  See a case example of a patient who took a logical step-wise approach to rehabilitation and her visual system completely recovered on its own without any visual system treatment.

The big 4: Fundamentals of a concussion treatment program

There are some fundamental concussion treatments that we start with in all our post-concussion patients (who can do them) just because they are generally good for the brain and doing them has been correlated with better outcomes post-concussion.  These treatments are intuitive, even in non-concussion people.  Generally these are things parents focus on when ensuring that their kids are raised healthy.  Aren’t kids developing their brains faster than other groups?  Post-concussion patients have this in common with kids: they want to train their brains to perform things efficiently.

 

These fundamental treatments are:

  • Psychological well-being
  • Healthy sleep
  • Cardiovascular exercise
  • Healthy diet

 

Each one of these are big topic and there are many unique ways in which patients health can be optimized in this area to help put their brains in a state that progresses towards recovery.  There are well-defined protocols in how we implement healthy sleep and cardiovascular exercise in our patients.  At the Toronto Concussion Clinic, we have an occupational therapist that help post-concussion patients access these therapies virtually.  These therapies are not covered by OHIP but are often covered by your extended health benefits or by your car accident insurance benefits (for those patients who sustained their injuries during a car accident).  Promoting psychological well-being and helpful diets require collaboration with therapists/dietitians/naturopaths.  At the Toronto Concussion Clinic we have a psychotherapist who has a lot of experience in dealing with psychological issues (and opportunities) unique to post-concussion patients.  Her services can be accessed virtually.

 

Often, doing these four things well will lead to all other impairments correcting on their own.  For those patients who still have post-concussion impairments after doing these well (i.e.,  reaching certain defined targets) then having these healthy regimens in place will help improve their response to subsequent post-concussion treatments.

Specialized training to train your physiology back to a healthy version

There are specialized treatments for each identify diagnosis that makes up persistent concussion symptoms.  Our concussion doctors will help identify the treatments required.  Often the process starts with education.

 

For example, post-traumatic headache is a unique headache type that happens post-concussion.  It sometimes looks like a migraine, but it’s not technically a migraine.  In keeping with that, migraine preventative medications (medications migraine-sufferers take every day whether they feel a headache or not to keep migraines at bay) have not been shown to be helpful for post-traumatic headache.  So, how do we treat post-traumatic headache?

 

First we need to understand the neurophysiology behind the headache experience.  Once we understand that, we start to see how we can train our brains to fire differently to shape the headache experience (towards not having a headache).  What’s more, these same therapies work in non-concussion people just as well.  Often the main reason why non-concussion patients don’t focus on these therapies is because medications are easier to prescribe and easier to take.

 

Like this, every diagnosis has specific treatments that are evidence-based or based on training your physiology so you get rid of impairments and disability.  At the Toronto Concussion Clinic, we have some assessments (e.g., functional vestibular assessments) and treatments (e.g., biofeedback) we do in-house but we often will recommend you involve other specific clinics in your care to help you recover.  Our Concussion MDs will help ensure that the treatments are coordinated well so that you recovery efficiently.

How to get started?

To get started with our OHIP-Funded Concussion Program, fill out our Request a Concussion Consultation Form.

Virtual Care

    • Available to patients in Ontario looking for virtual post-concussion consultation and care
    • Expert advice to help your own rehab team (i.e., Neck, vestibular, vision therapy, etc.)

Diagram explanation

  1. EDUCATION. Educational resources (articles, educational group sessions and YouTube Concussion Rehab videos) can be found at torontoconcussion.ca. Our group counselling sessions also provide education and support from fellow patients and the MD.

 

  1. MINDFULNESS. Mindfulness is now widely used in health and performance fields. The use of mindfulness permeates all aspects of our program. The mantras “name it to tame it” and “feel it to heal it” are instrumental to consciously training. This can be done privately with our psychotherapist.

 

  1. DETAILED HISTORY. A concussion history needs to be thorough. That is because the goal is to retrain a patient’s physiology and psychology to get them to their recovery goals. To achieve this, we have to understand patients’:
  • goals
  • pre- and post-injury health status, consultations and treatments
  • current level of functioning
  • lifestyle habits
  • psychological state
  • resources, including social network
  • social factors
  • stressors
  • This is a good time to gather any documentation you may have like previous cognitive testing, most recent optometric prescription, etc.
  • The initial intake assessment and intake physical exam are done in-person and subsequent assessments can be done virtually.

OHIP-funded medical assessments are usually carried out over several visits and may focus on headache, mood, sleep, energy/fatigue, dizziness, vision and psychotherapy. Physiological, cognitive and psychological assessments are privately-funded. MVA specialized assessments, case management and care coordination are privately funded.

 

  1. PHYSICAL EXAM. A thorough neurological exam is required. For those receiving virtual care, this can be done by your primary health care provider, a sports physician, a neurologist or a physiatrist, possibly in consultation with an ENT. This is OHIP-funded.

 

  1. PAIN MANAGEMENT. It helps if you can work with your primary health care provider to manage any pain you may have after your injury. This helps decrease sensitization to pain and it helps improve function.

 

  1. HEALTH OPTIMIZATION. This is a good time to see your primary health care provider to investigate for general medical conditions. Many patients post-concussion will have changes to pre-existing health conditions. Also, many patients had minor issues before the injury that they weren’t aware of (i.e., it wasn’t bothering them, or they got used to it, or they never noticed it) but post-concussion is a good time to identify any factors that can be improved to help you to your goals. Examples of things that are often picked up in the general public that may be an issue post-concussion are iron deficiency, vitamin B12 deficiency, sleep apnea, etc.

 

  1. SLEEP OPTIMIZATION. We offer privately-funded online CBT-insomnia group counselling sessions and brief follow-up appointments. Most patients find this sufficient to correct sleep issues. Few patients will require more assistance beyond this. As an example, this can be seen in sleep disturbances caused by obstructive sleep apnea, severe post-traumatic headache of a migraine phenotype, more severe psychological distress and chronic pain. Some may need to consult their primary health care provider and possibly other providers for assistance. Our team will recommend the same if it is needed.

 

  1. BEHAVIOURAL ACTIVATION & ENERGY MANAGEMENT. Guidelines can be found in the Ontario Neurotrauma Foundation Guidelines.  Patients will then rely on the support of their primary health care providers or with an OT (privately-funded). An article on our website “Behaviours associated with prolonged recovery” has helped a lot of patients develop more awareness of how important this is to recovery.

 

  1. OCCUPATIONAL AND SOCIAL READJUSTMENTS. It is extremely important that patients learn about endurance behaviours and fear avoidance behaviours and be supported back to their desired activities in a supportive manner. This may require supporting them with the completion of forms for accommodations and modifications, STD, LTD and MVA forms. This can be handled by your primary health care providers, psychologists, psychotherapists and occupational therapists. If you prefer to have the forms completed by a multi-disciplinary team, we can also assist. These services are privately-funded.

 

  1. NECK ASSESSMENT AND THERAPY. Often patients present with neck or other MSK complaints stemming from the injury that caused the concussion. An integral part of therapy that is often overlooked is neuromuscular retraining. This can be coordinated in a way to help prepare someone for vestibular therapy, visual therapy, and for working towards their goals. Patients should discuss with their rehab providers if they can receive neuromuscular retraining at their establishments. This type of therapy is generally more efficiently done in-person. These services are privately-funded.

 

  1. RESILIENCE TRAINING. This is a broad area of training that has promising results in concussion rehabilitation. It honours the biopsychosocial model (i.e., one’s biological, psychological and social constitution). It aims to develop an internal locus of control using behavioural, cognitive, affective and physiological training. This permeates our program, and specific Resilience skills are trained by our psychotherapist and occupational therapist (privately-funded)
  1. VESTIBULAR THERAPY. Vestibular therapy is a broad field. It is important patients seek out vestibular rehabilitation specialists with expertise in post-concussion syndrome. Often, vestibular therapy is geared towards vestibular conditions, rather than post-concussion syndrome (PCS). PCS has unique pathophysiology and requires a methodical, customized approach to help patients work on balance and dizziness, while helping them progress towards their functional goals. We can help connect you with skilled resources in your area to assess and treat dizziness and instability complaints. These services are privately-funded.

 

  1. BINOCULAR VISION ASSESSMENT & VISION THERAPY. Generally, it is a good idea to see your optometrist after a head injury, especially if patients have more severe balance issues that are felt to relate to their visual system. In non-concussion patients, many have minor visual acuity issues that doesn’t bother them. In fact, often optometrists will identify this but tell patients that they don’t really need glasses if it’s not bothering them, and for the most part, that advice works out fine. However, for post-concussion patients, minor prescription corrections can be helpful for rehabilitation. Some patients do well with prism lenses, others with plus lenses for accommodative support (i.e., the kind of glasses people start wearing when they hit their 40s to help see closer up). And then, some post-concussion patients don’t need glasses at all. Our team can make recommendations to your optometrist regarding some less-routine exams they can include in your assessment to help identify issues if they are there. Sometimes, you will need to see a more specialized optometrists who deals with eye issues that happen post-concussion. Our team can recommend the same if needed. Vision therapy is often helpful for post-concussion patients with visual complaints. Training this is best done later on after patients have a stable social situation, good stress management and relaxation strategies, and improved autonomic functions and neuromuscular control. Sometimes, vision therapy is not needed and there is spontaneous correction of any post-traumatic visual issues. Unravelling the best approach to making your vision therapy most effective is something our team routinely helps with. 

 

  1. COGNITIVE TRAINING. We recommend cognitive testing. Cognitive rehabilitation that we offer involves computerized cognitive training forums for virtual patients and “real-life” situational training for those seeing occupational therapists or psychologists. For those doing computerized cognitive training, their ability to tolerate screens must be considered. There are many factors that influence one’s cognitive abilities, e.g., headache, chronic pain, sleep difficulties, psychological stress, etc. Managing these at times are more helpful in improving cognitive complaints than cognitive training. Our team works on making recommendations and offering behavioural and lifestyle treatments that optimize these factors so that you can think more clearly. Cognitive assessments are privately-funded; cognitive training is offered by our occupational therapist (privately-funded).

 

  1. HEADACHE MANAGEMENT. Headache is the most common symptom post-concussion. For some, this is the most important first step in their care. Generally, prophylactic medication (i.e., medication you take every day for headaches, whether you have a headache or not that day) for post-traumatic headaches are less effective. Moreover, post-concussion patients are more prone to side effects. Hence, we provide patients with a thorough headache assessment (OHIP-funded) and several evidence-based behavioural and lifestyle measures to treat headaches (privately-funded through our OT). Some patients do well with pharmacotherapy and/or peripheral nerve blocks managed by their primary health care providers and/or neurologists.

 

  1. PSYCHOLOGICAL SUPPORT. Our program focuses on behavioural and lifestyle treatments. As such, we provide several “types” of  psychotherapy (privately-funded) to help patients “show up” the way they would like to in life. Our program does not prescribe medications to manage psychological conditions. If using psychologist/psychotherapist outside our organization, we can offer support and guidance.

 

  1. FATIGUE MANAGEMENT. Post-traumatic brain injury fatigue is one of the most pervasive and distressing symptoms after a concussion. It often slows down the rehabilitation process. Its non-specific nature can make it quite challenging to address. Our OT offers a comprehensive post-traumatic brain injury fatigue program (PTBIF) to train energy in our patients (privately-funded).

Still have questions?

Check out our FAQs or feel free to email us

FAQs
Email us at team@torontoconcussion.ca