individual differences
schmidt says other conditions such as severe traumatic brain injury (tbi), stroke or parkinson’s disease aren’t as transient as concussion, which means they won’t go away and are easier to identify, which in turn eases the process of getting an individual into disability services.concussions typically require 10- to 14-day restrictions, schmidt adds, but the unknown is exactly how long concussion-related impairment lasts beyond symptoms, and what about potential differences based on age, gender or other demographic factors?“we used college-age athletes and non-athletes — mostly non-athletes — but what does this look like in your 16-year-old adolescent driver? what does this look like in your 50-year-old driver,” schmidt says. “concussion recoveries can differ quite a bit in those groups, as well.“so, i don’t have an answer for you, but i’m curious about the same thing.”significant in daily life
dow says medical personnel examining a patient with a possible concussion or head injury often start out by asking that individual if they can move their fingers or hands or having them count backwards, but they don’t think to tell that person to avoid driving for a few days.medical personnel “tend to forget” that driving is an everyday activity, particularly for canadians who don’t live in major city centres, he adds.to counter that situation, saaq has a workshop for physicians and other health personnel to underline the importance of driving and how it should be considered when they’re talking about the impact of whatever has happened on a patient’s life.to be fair, hoshizaki says, evaluating incapacity after a concussion is difficult even for specialists, so imagine the dilemma of a layperson trying to figure out if he or she is ready to return behind the wheel.physicians can provide guidance, hoshizaki adds, but there’s no real way of telling people they can’t drive.“when we talk about guidelines to return to play or (other) guidelines, they’re guidelines,” he says. “they’re not rules.”dow says the process of removing a driver’s licence takes about six weeks, so, effectively, saaq tells quebec physicians to report conditions only if the consequence of previous injury or disease — formally called “sequelae” — last six months or more. as one example, he refers to a former municipal transit driver who, following a severe concussion, functioned at the cognitive level of an eight-year-old.“temporary” conditions such as concussions do not have to be reported to provincial authorities unless they affect driving and a patient says he’ll drive anyway.“the point is, if you were advised by your physician not to drive and you do drive and you kill somebody, you can be liable for accidental homicide, which is something you have to bear in mind,” dow says. “you’re also going to have that on your conscience for the rest of your life.”looking for biomarkers
it would be easier to advise someone not to return behind the wheel after a concussion based on specific medical indicators or “biomarkers,” but nobody has figured that out, despite what hoshizaki describes as “a fair bit of money” invested in research in canada.there are known biomarkers for brain injury, marshall adds, but, because brain injury is a spectrum, even those biomarkers are not useful enough in diagnosing concussion.similarly, magnetic resonance imaging (mri) or diffusion tensor imaging (dti) scans can reveal signs of concussion, but marshall says that again they are neither sensitive nor specific enough to be gold-standard tests for diagnosing concussions. in other words, they could miss diagnosing concussions at the individual level, which is a clinical diagnosis anyway.the ideal, schmidt says, would be to use current clinical tools to predict or find patient patterns differentiating between someone who shouldn’t drive and someone who could.“even though they both have a concussion, maybe you’re having issues with reaction time, and we know that is a better predictor, better indicator of your driving safety,” she says. “however, you’re having more issues with your memory, which might not be as related to your safety in driving. it might hurt your ability to navigate in driving, but you’re ok, your safety on the road is fine …“my second preference, then, if that’s not possible because it’s possible that the clinical tools we use now don’t predict those things very well or are not sensitive enough to those things that they wouldn’t work in that way, would be then to introduce a new tool or assessment battery that was short and succinct, but got at someone’s readiness to return to driving so that, clinically, we could return them to driving as soon, as quickly, but as safely as possible.”out of the dark
guidelines to concussion management have changed, with “return to activity as tolerated” as a general counsel.marshall says “return to sport,” is easy since concussed athletes simply must go through established protocols and show themselves to be symptom-free because they’re otherwise at increased risk of injury.“return to school” is hard, he says, because it’s a distracting environment requiring cognitive and social energy, soa concussed student might have to start off by avoidinggym or taking only one class.for driving, perhaps a 10-minute commute would be ok, but not a long vacation trip, says marshall, who likens it to recovery from a sprained ankle: if you can walk without pain, proceed, but, if walking causes pain, back off temporarily before trying again.“obviously, if the person is acutely confused and doesn’t know the date or doesn’t know where they are, they shouldn’t be driving. most of us would say that,” he says.“we used to say, ‘go into a dark room and wait for your symptoms to get better.’ they tell them not to do that now. now they say, ‘after the first 24 to 48 hours, return to activity as tolerated.’ and, if you return to activity as tolerated, that would mean you get to make decisions on what you can handle and can’t handle.”gholder@postmedia.com
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to drive or not to drive? something to consider after a concussion, brain injury