The 3 things you should know before choosing a doctor for your concussion.
The concussion puzzle: Finding the right doctor.
"In the United States, the Centers for Disease Control and Prevention estimate that up to 75% of the 1.5 million traumatic brain injuries each year are concussions and suggest that this number is rising."
(This statistic is old. Numbers may actually be higher.)
If you’ve been following the news, sports, social media, even Netflix… You’ll know that concussion/mTBI is gaining more awareness among the public and medical communities thanks to research around chronic traumatic encephalopathy (CTE). This increased awareness is a great thing, because concussion is not something to dismiss.
"Concussion is considered to be among the most complex injuries in sports medicine to diagnose, assess, and manage."
A concussion, often used interchangeably with the term “mild traumatic brain injury (mTBI),” is far from mild and is absolutely a brain injury. Appropriately managing concussion is a community ordeal starting with the athletes, up to the coaches/parents, and finally managed by a properly trained healthcare professional.
How does all of this look in the real world?
Medicine and concussion.
"We found substantial gaps in knowledge surrounding concussion diagnosis and management among family medicine residents."
The studies I’m referencing here essentially quizzed fourth-year medical students, family medicine residents, and neurology/neurosurgery residents on their knowledge of the diagnosis and management of concussion.
The survey had 9 questions:
Medical students correctly answered 4 questions.
Family medicine residents correctly answered 5 questions.
Neurology/Neurosurgery residents correctly answered 6 questions.
These results were independent of age, sex, history of personal concussion, history of sport, etc... These docs generally averaged about 50% when it came to diagnosing and managing concussions.
That's not what got the researchers' attention, though.
It was actually the following inconsistencies in knowledge surrounding concussion…
Approximately 50% (1 in 2) of medical students and neurology/neurosurgery residents did not recognize chronic traumatic encephalopathy (CTE) or second-impact syndrome as possible consequences of repetitive concussions.
Second-Impact Syndrome is rare, but life-threatening. CTE is still mostly a mystery in the literature, but should still be on the radar of physicians.
Approximately 25-32% (1 in 3 to 4) of the medical students did not think that every concussed individual should see a physician as a part of management.
Seeing a physician is necessary to rule out cervical spine damage or other more severe problems. A “concussion literate” physician can also guided return-to-play decisions.
Approximately 16-33% (1 in 3 to 7) of the students and 25% (1 in 4) of the neurology/neurosurgery residents think that a concussion requires direct physical contact to the head.
Concussion is an acceleration-deceleration injury to the brain. Any impact that can transmit forces to cause acceleration-deceleration at the head can cause concussion. Think of a car accident with no head impact - just a seatbelt restraining your torso while your head whips around freely. The torso took the brunt of the force, but your brain still wiggled like jelly.
Around 8-12% (1 in 8) of all these students and doctors report never learning about concussion in their residency training.
Most physicians receive anywhere from 1 to 3 hours of concussion training during their education. Frankly, this is not adequate. Many advanced concussion specialization trainings range between 40 and 150 hours of training. Which doctor do you want?
Coaches (Parents) and concussions.
"Coaches bear an important part of the responsibility to prevent, identify, and manage concussions in young athletes."
This is often because coaches are on the sidelines and the first to witness and direct the next steps following a potential or actual concussion. Athletes, especially younger ones, often need their coaches for guidance and comfort in reporting concussion symptoms.
A funny side-note, when studied, most medical professionals (including neurosurgery residents) objectively scored around 50% when it came to their knowledge of concussion. So, how would coaches subjectively feel about concussion?
In response to the question “I am confident in my ability to recognize concussion symptoms in youth athletes,” 85.4% of coaches replied “strongly agreed” or “agreed”... Eight in ten coaches (80.8%) agreed or strongly agreed that “I am confident in my ability to help an athlete with the return to play process”... About 93.9% of coaches strongly agreed or agreed that “there are things I can do to help prevent concussion among my athletes.”
I poke fun at these numbers, but the ability for the coach to recognize, encourage, and participate in appropriate concussion identification and management process, the better their athletes are likely to do in their recovery. Coaches are still very important in this puzzle.
It's encouraging to know that around 80% (8 in 10) of coaches talk with their athletes about concussion and encourage them to report symptoms, and that almost 95% (nearly 10 in 10) of coaches plan to teach their athlete concussion prevention strategies.
However, it's a bit discouraging to know that only 47% (1 in 2) of coaches thought that their athletes would tell them if they were experiencing concussion symptoms AND only about 20% (1 in 5) of coaches had access to an athletic trainer at all games and practices.
Youth Athletes and concussions.
It's estimated that around 60 million youth athletes are participating in sport each year. Did you ever wonder what youth and high school athletes would say if you asked them why they play a sport?
So, what do teenagers (12-17yo) know about concussion?
The important thing, really, is that they are aware of concussion as a problem, the symptoms, and are comfortable reporting these symptoms to their coaches, parents, or trainers.
Around 55% of youth athletes report having some sort of education around concussion, and approximately 92% of them say that they would report concussion symptoms to a coach if they were experiencing them. This education and reporting were typically better if the kids were older (16 and up) and from higher-income families.
But, wait? Just a second ago I said that almost half of all coaches said they think their athletes would not report concussion symptoms. What's with this 92% number from these goodie good kids?
Here's why kids said they would likely not report a concussion:
Let’s bring this all back: Finding the right doctor.
the blind leading the blind leading the young.
We have data showing that medical professionals, even those specializing in neurology, are not so great at diagnosing and managing concussions. We have data showing that coaches feel (overwhelmingly) confident in their abilities to identify and manage concussions. All while we have kids, that as long as they’re educated and not ashamed of it, will open up to these adults about their symptoms.
And here we are again realizing that we have data that shows these adults the kids are turning to may or may not be a great resource in appropriately identifying and managing their traumatic brain injury.
The bummer about this whole cycle is that the conventional management of concussion is largely “rest until your symptoms go away.” Which is a separate problem, as I’ll explain to you all in a later post, because symptom resolution most certainly does not equal concussion resolution. The brain sustains a period of damage recovery that goes beyond the symptoms we experience with concussion.
Does your family doctor know that? If they do, do they know what to do with that information?
Said another way…
You need to be sure that you are seeing a doctor that specializes in concussion management to be sure that you are getting the right diagnosis and the right care for optimal recovery.
The CDC Heads Up training is minimal, at best.
Your brain is not a joke. Mild is not an appropriate label for concussion. recovery to performance is possible with the right care.
References:
Boggild, M., & Tator, C. H. (2012). Concussion knowledge among medical students and neurology/neurosurgery residents. Canadian journal of neurological sciences, 39(3), 361-368.
Donnell, Z., Hoffman, R., Sarmiento, K., & Hays, C. (2018). Concussion attitudes, behaviors, and education among youth ages 12–17: Results from the 2014 YouthStyles survey. Journal of safety research, 64, 163-169.
Mann, A., Tator, C. H., & Carson, J. D. (2017). Concussion diagnosis and management: knowledge and attitudes of family medicine residents. Canadian Family Physician, 63(6), 460-466.
Sarmiento, K., Daugherty, J., & DePadilla, L. (2019). Youth and high school sports coaches' experience with and attitudes about concussion and access to athletic trainers by sport type and age of athlete coached. Journal of Safety Research, 69, 217-225.