Exploring Return2Play’s Complex Case Clinic

Where to turn when concussion recovery isn’t straightforward.

Anyone who works in sport will know that diagnosing a concussion is at times far from straightforward. The symptoms are vague and non-specific, and identifying the concussion amongst the numerous tackles, collisions, trips, and falls can sometimes be akin to spotting the proverbial needle in a haystack. But as long as they’re appropriately removed from play and the diagnosis is confirmed, the process of managing the player’s graduated return to sport and exercise is usually fairly straightforward.

Until, of course, it isn’t.

It is commonly quoted that between 80-85% of people suffering from a concussion will feel back to normal within the first 14 days of their injury, but that leaves a not inconsiderable number with ongoing symptoms. Sometimes these symptoms are far from insignificant; difficulty returning to school can quickly spiral into anxiety relating to academic performance, and impact upon mental health and wellbeing.

And what about those for whom a concussion isn’t a new injury? Are they safe to be returning to contact sport at all?

Return2Play boasts a medical team with unrivalled experience in dealing with concussions. Our clinicians completed over 10,000 head injury and concussion appointments last year alone, and along with the diagnosis and management of Graduated Return to Sport (GRTS) following a concussion, an important aspect of the role involves the identification of people who require more specialist input from our most senior and experienced doctors.


What is the Complex Case Clinic?

The Complex Case Clinic is, as the name suggests, a clinic staffed by the most senior and experienced doctors at Return2Play who manage more complicated cases of concussion. Referrals are usually made following assessment by a Return2Play clinician, and the most common reasons include:

·       Prolonged symptoms at 2 weeks post injury

·       Severe and debilitating symptoms preventing return to school/university/work within 1 week

·       History of multiple or repeated concussions


What causes more severe or prolonged symptoms?

There are several different reasons as to why symptoms following a concussion may persist. On occasion it is simply that the brain hasn’t fully recovered from the injury – this is more likely to be the case if a concussion has been missed or ignored – but this is far from the sole cause. Given the area of injury, along with the subsequent effect on routine, structure, and daily activities that a concussion can have, there are often multi-factorial causes for ongoing symptoms. The infographic at the top of this article summarises some of these.


What treatment options are available?

Traditionally the advice for people suffering from persistent concussion symptoms has been to continue to rest until the symptoms resolve. And whilst rest plays an important part in the very early stages following a concussion, more recent research suggests that it is far from the most effective strategy in achieving symptom resolution.

The Complex Case Clinic will often take a much more proactive route and treat ongoing symptoms. Our doctors take a holistic approach in identifying the specific cause – or causes – of ongoing symptoms, and tailor their management plan accordingly. Often this involves rehab exercises focusing on the neck or the vestibulo-ocular system, along with targeted and specific return to graded exercise.


Case study

By way of example, take the case of AB, a 16-year-old boy passionate about hockey. He clashed heads with an opponent during the final game before school finished with the Christmas holidays. He didn’t lose consciousness, but was dazed, dizzy and felt ‘out of it’ immediately and for the remainder of the day. He was thoroughly assessed by the school nursing team and felt likely to have suffered a concussion, and this was confirmed following an appointment the following day with a Return2Play clinician.

Despite following the advice he was given religiously, AB’s symptoms persisted, leaving him fatigued, irritable, and unable to focus on any of the work he was hoping to complete over the Christmas break. He wasn’t himself at all – so much so that his mother took him to Accident & Emergency for further assessment. He was deemed not to require a scan and told to rest; his symptoms would likely resolve over time.

At his two-week review with Return2Play there had still been very little improvement, so he was referred to the Complex Case Clinic and seen the following day. Thorough assessment revealed a significant issue with his visual and balance system, as well as a stiff and painful neck. Both were likely contributing to his ongoing symptoms. It was felt highly likely that AB’s anxiety related to ongoing symptoms – and the potential impact this might have upon his preparations for GCSEs – was also playing a part in the severity of his presentation.

He was provided with exercises for both his vestibular system and his neck, and on review the following week had already started to show signs of improvement. He was followed up by the same doctor throughout his recovery, and experienced full resolution of symptoms by the start of the new school term.


How many patients does the clinic see?

12% of the patients diagnosed with a concussion in the last year were referred to the Complex Case Clinic.  About half of these were due to persistent symptoms at 2 weeks post-injury, which equates to approximately 6% of total recorded concussions.

This is quite a low number compared to published data, which we believe can be attributed to good medical advice (all patients referred are seen by our medical team and those with severe, debilitating symptoms are seen within 48hrs of injury) and early implementation of vestibular and cervical rehabilitation in cases that would benefit.


What about repeated concussions?

Repeated or multiple concussions have understandably caused significant concern in the last few years, with evidence showing a link between repeated head impacts and permanent cognitive impairment. There is no ‘one size fits all’ when it comes to advice regarding ongoing participation in contact sport, but our clinicians will generally offer a referral to the Complex Case Clinic in situations where they believe someone might benefit from a more detailed discussion around the risks associated with repeated head injuries.


Further information

In the realms of sporting and non-sporting settings, diagnosing concussion presents a challenge due to the vague and non-specific symptoms. Whilst in most cases symptoms resolve within 14 days, a significant minority endure, impacting daily life and mental health. Return2Play’s Complex Case Clinic steps in for such scenarios, offering tailored treatment for those with prolonged symptoms or a history of multiple and repeated concussions. The clinic’s proactive approach includes holistic management plans, rehab exercises, and specialised care from our most experienced doctors.


For more information regarding the Complex Case Clinic, or if you are interested in the services Return2Play can provide, please email support@return2play.org.uk.