The Challenge of Concussion Care

Media attention on concussions has raised the profile of this frequent injury. But because the underlying biological pathophysiology is not clearly defined, progress has been slow in defining the critical features, course, and prognostic signs. Variability in diagnosis and treatment becomes a rate-limiting step as research studies include cases of unknown diagnostic validity. The relatively mild nature of the injury means that: 1. There is no visible mark to denote injury, and 2. most cases do not become incapacitated. Thus, the relatively mild nature belies the all-too-frequent lengthy consequences of sub-optimal performance in academic, social, vocational, and athletic arenas that result in many cases.

Obtaining a clear understanding of concussions’ etiology and nature has been bedeviled by the lack of a biologic gold standard that defines the injury. Clinical signs and symptoms are the standard and are less than reliable. Further, clinical diagnoses are often made out of caution and not certainty. While this may protect the individual, having less than certain diagnoses can influence research findings by injecting measurement error. It is therefore not too surprising that there is so little consensus in concussion research. Almost every issue has support on both sides. There is also a socio-economic consequence of over-diagnosis, particularly for athletes. Individuals with “too many” concussions have been denied college scholarships and potential draft positions. Yet, there is no consensus on what “too many” means. Characterizing diagnoses such as definite, likely, possible, no-diagnosis is one approach; however, some criteria need to be created for such a scheme to have validity and usefulness.

Until such work is undertaken, it remains important to provide the best possible care in spite of diagnostic accuracy. There are several key pieces to concussion management that are important for a swift and positive recovery

1. Appropriate removal from play if a concussion is suspected
2. Timely and accurate diagnosis based on signs and/or symptoms and mental status.
3. Communicating with appropriate parties (parent, PCP, school)
4. Standardized assessment protocol
5. An initial rest period followed by supervised and structured increases inactivity
6. Regular monitoring and adjustments based on response to “treatment” including a step-wise physical exertion challenge
7. Assessing recovery; includes a return to full academic functioning before returning to sport. 

Besides the difficulty in diagnostic accuracy, documentation of these stages of the course and management of concussion has proven to be difficult due to the decentralized nature of care. Athletes are hurt at one venue and may or may not be seen by medical staff at the venue or even the next day. They may return to school where athletic training (physiotherapy) services may or may not be provided. A primary care physician may be the first trained medical personnel to see them 5 or 6 days from injury. While self-management is not recommended, even when all of the steps are properly taken by professionals, communication is difficult amongst them. However, closing the communication loop is critical to ensure that steps are not missed and not duplicated.

One useful strategy with clinically defined disorders is to standardize protocols for assessment and treatment as much as possible. In this way, comparisons between centers and labs become more feasible, and clinical questions can become more focused. However, situations requiring urgent care and subsequent follow-up can be chaotic and pressured. Using technology to create decision support tools would be important for achieving these goals.