Facing the new concussion rules and requirements for GPs head on

Australia and New Zealand have just launched their first national concussion guidelines [1] for GPs, marking a major shift in how head injuries are assessed and managed. This welcome update, whilst not compulsory, provides clear direction for GPs to assist with the uniform management of mild traumatic brain injury/concussion. The new guidelines have been developed by a wide range of medical specialists and consumer representatives across Australia and New Zealand, including first nations people, carers and people living with disability.

Why this matters?

Annually, there are approximately 180,000 cases of mild traumatic brain injury (mTBI) and concussion in Australia. They most commonly occur in children under 16 years of age and adults over the age of 75. People who have experienced mTBI are at an increased risk of repeated mTBI, often resulting in more severe or protected symptoms.

Historically, concussion treatment in Australia has lacked consistency. Patients have often received outdated or incorrect advice, such as being told to rest in a dark room and avoid all activity. These approaches are now recognised to delay recovery by about a week, and increase long-term risks of concussion-related complications, including longer term symptoms and Persisting Post-Concussion Symptoms lasting beyond a month of the trauma, themselves causing emotional or financial burden on individuals.

In September 2023, an Australian Senate committee released a landmark report on concussions and repeated head trauma in contact sports. The committee made 13 recommendations to improve outcomes for past, present and future players.

At that time, the diagnostic criteria for mTBI was revised and required a biomechanically plausible mechanism of injury to include one or more of:

• an acute physiological disruption of brain function (such as loss of consciousness, alteration in mental status, complete or partial amnesia or other neurological sign/s)
• two or more acute symptoms, (e.g. subjective altered mental status, physical, cognitive or emotional) and clinical symptoms (e.g. cognitive, balance, oculomotor, vestibular-oculomotor signs on examination) or laboratory findings (e.g. blood biomarker indicative of intracranial injury); and
• neuroimaging evidence of TBI which symptoms and signs are not accounted for by an alternative diagnosis or a more severe TBI.

The terms mTBI and concussion are interchangeable and are used to describe cases where there is no structural injury identified on conventional CT or MRI brain.

Since 2023, some progress has been made but has largely been focused on concussion education and there have not been any wide-ranging policy shifts or guidelines which assist best practice in injury management.

In the context of the AFL concussion class actions, and sporting codes reviewing their concussion and head trauma policies and management, these guidelines will inform best practice for everyone.

University of Queensland and Paediatric Neurologist, Prof Karen Barlow, Chair of the Concussion Guideline Development Group, says that about 50% of people with concussion and mild traumatic brain injuries have historically not received the care they needed.

Prof Barlow notes that about 40% of GPs do not feel confident managing concussions, especially when symptoms persist.[2]

What are the guidelines?

These are the first Australia and New Zealand-specific and detailed guidelines for all forms of concussion from injury to recovery.

The guidelines will be implemented across Australian and New Zealand healthcare systems with an initiative called Mind the Gap.

The guidelines provide an evidence-based and nationally unified model for the initial assessment, diagnosis and management of concussion and mTBI return-to-activity procedures, persisting symptoms, sleep disturbance, mental health and cognitive difficulties, and address the issue of repeat concussion and long term risks and effects. They provide helpful ‘practice points’ and links for further guidance.

The guidelines come with a concussion toolbox for GPs with assessment and education tools and care planners and links to other related recommendations from other agencies, such as the RACGP. They provide simple flow-charts for GPs and primary medical professionals to assess patients and determine appropriate risk factors, and the escalation of care.

In essence, they are a ‘one-stop shop’ for GPs caring for patients post mTBI.

While not mandatory, they are widely supported by the medical community and may become the standard of care moving forward.

Implications

This is a pivotal moment for mTBI/concussion management in Australia and New Zealand.

The guidelines are specific for clinical practitioners and should be a welcome resource for further education of GPs and other clinicians facing the challenges of mTBI/concussion injury management and advice to patients to facilitate recovery and reduce ongoing risks.

They are also a valuable resource for:

• insurers, by providing an opportunity to update risk frameworks, educate policyholders, and align coverage with best-practice care. Staying ahead of these changes will be key to risk management and supporting safer outcomes. and
• Schools, community sports groups, recreational organisations and café facilities for residents with increased falls risks, to help with them for best-practice mTBI/concussion management moving forward.

For schools, sporting and recreational organisations in particular, these guidelines may inform the circumstances in which they permit an individual to return to their activities following a mTBI/concussion to fulfil their own duty of care to that individual and are fulfilling their statutory occupational health and safety obligations.

Although we have seen cases where a defence that the risk was obvious being a successful defence [3] the class actions are exploring issues of foreseeability, reasonable precautions and social utility of concussion management, among other claims. A number of medical practitioners (GPs and sport physicians, for example) are parties to those actions.

This area is an evolving area of potential claims across a range of sectors. Adherence to the guidelines will limit the risks of future claims in some circumstances.