Concussion S024

Current RMA Instruments

Changes from previous Instruments

ICD Coding

• ICD-10-AM Codes: S06.00, S06.02

Brief description

Concussion is a temporary disturbance of brain function caused by an acute trauma.  The trauma is usually directly to the head.  Concussion may also occur from indirect or transmitted forces to the brain (resulting in acceleration, deceleration or rotation of the brain within the skull) without a direct blow to the head.

Concussion may also be described as a mild traumatic brain injury.  More significant brain damage from a single trauma is covered by separate SOPs for ‘moderate to severe traumatic brain injury’.

Concussion symptoms typically resolve within 2 weeks.  Symptoms may persist in a minority of cases.  However, the SOPs for concussion may or may not apply in cases where symptoms are attributed to a mild traumatic brain injury and persist beyond three months.  In such instances, there are other SOPs which may be able to be considered.  See comments section, below.

Confirming the diagnosis

Establishing the diagnosis may be challenging.

The diagnosis is preferably made based on contemporary medical records showing that there has been:

• Trauma (a transfer of kinetic energy) to the head; and
• An associated temporary disturbance of brain function with:
  • No loss of consciousness or loss of consciousness less than 30 minutes, or
  • No amnesia or anterograde amnesia less than 24 hours, or
  • Glasgow coma score of 13, 14 or 15 out of 15.

A contemporary Military Acute Concussion Evaluation (MACE or MACE 2) report, if available, will provide the necessary diagnostic information.  Other military medical records and records or reports from an emergency department, a general practitioner or a sports physician may all be useful for confirming a diagnosis.

In the absence of contemporary records the reported history and any associated evidence needs to be evaluated and the reasonable satisfaction (balance of probabilities) test applied to decide whether an acute trauma-induced temporary disturbance of brain function has occurred.  See comments section below.

There are no specific investigations required for diagnosis.  Brain imaging may be performed in some cases, generally to exclude more severe injury.  A concussion does not result in any abnormality that can be seen on routine CT or MRI scans of the brain. 

Specialist medical opinion will not generally be required for this diagnosis.  However, full evaluation of a head injury claim where persisting symptoms are contended may require input from a neurologist or a psychiatrist.

Additional diagnoses covered by SOP

• Acute mild traumatic brain injury (but claims for ongoing/persisting effects beyond 3 months are not covered)
• Concussion due to an MVA, a fall, sport, explosion or any other cause.

Other SOPS that should be considered

• Acute stress disorder
• Explosive blast injury
• Moderate to severe traumatic brain injury
• Migraine (for contended post-concussion headaches)
• Tension-type headache (for contended post-concussion headaches)

Conditions not covered by SOP

• Headaches 
• Non-specific symptoms persisting after acute phase of mild head injury
• Mild traumatic brain injury that is attributed to recurrent brain trauma*
• Chronic traumatic encephalopathy*
• Brain injury that is attributed to recurrent blast exposure^#
• Post-concussion syndrome (declared by the RMA to not be a particular disease or injury)
• Posttraumatic stress disorder*
• Dementia pugilistica *

* another SOP applies

# non-SOP condition

Clinical onset

The clinical onset will in most cases be at the time of the acute head injury event (the transfer of kinetic energy to the head).  Delayed onset, with symptoms evolving over a period of hours after the injury, can occur. 

Clinical worsening

The concussion SOP, by definition, covers only short term effects.  Any contended ongoing manifestations need to be separately considered and determined.

Comments

Persistent symptoms

A claim for enduring effects following a mild head injury falls outside the concussion SOP.  Consideration needs to be given in such cases to whether there is any additional diagnosis to be made.  Reported symptoms in such cases are typically non-specific.  There may be overlap with symptoms of other conditions.  The claimed symptoms may in fact be attributable to e.g. a psychiatric condition, a condition that results in persistent pain, or the effects of treatment for such conditions.  

Persistent symptoms that have been described following a concussion/mild head trauma may include: cognitive impairment; headaches; balance problems/dizziness; impaired vision; anxiety/mood disturbance; neck pain; fatigue; and postural hypotension. 

Attribution of persistent symptoms (beyond 3 months) to a concussion event should only be considered if those symptoms were first present within hours of the injury and were then present thereafter.  For any symptoms which developed a longer period after the acute event an alternative explanation/diagnosis should be sought.

The RMA has issued a declaration concerning ‘postconcussion syndrome’, concluding that it is not a distinct disease entity (not a particular kind of injury of disease).  This means that a claim for ‘postconcussion syndrome’ cannot be accepted. 

Acute single trauma

The SOP concerns brain injury from a single acute trauma event.  Claims concerning multiple minor head traumas or their contended consequences are not covered by the concussion SOP.  There is a SOP for dementia pugilistica, which concerns brain damage from a large number of physical blows to the head, most typically in boxers. The RMA has advised that a diagnosis of ‘‘chronic traumatic encephalopathy’ is answered by the existing SOPs for dementia pugilistica. Separately, moderate to severe traumatic brain injury is covered under its own SOP.

A head trauma (or transmitted force to the brain) needs to directly induce a (temporary) brain injury for the concussion SOP to apply.  Lesser degrees of trauma, such as an overpressure wave from firing a heavy weapon, may not be sufficient to cause a concussion in normal circumstances, however, there may be circumstances where an acute traumatic brain injury as a result of blast exposure could come within the Explosive Blast Injury SOP.

Absence of contemporary evidence

In the absence of contemporary medical records careful evaluation of the nature and severity of the trauma and of the reported manifestations (in relation to brain function) will need to be undertaken.

• Was there a significant force (transfer of kinetic energy) involved?
• Was the head struck?  Did the head strike an object?  Was there an indirect force transmitted to the brain?
• Was there a reported loss of consciousness (not essential) or a period of amnesia following the event (also not essential)?
• Were there acute/immediate symptoms or reported manifestations consistent with a concussion e.g.: confusion; disorientation; impaired balance; incoordination; dizziness; seizure/convulsion; impaired vision; altered speech.
• Are there any non-medical eyewitness accounts available or obtainable?

The evidence needs to be sufficient to support a diagnosis at the balance of probabilities standard of proof.