Shelina Babul, PhD (biography, no disclosures) and Hadley Pearce, MSc, MSiMR (biography, no disclosures)
BC Injury Prevention Research Unit, BC Children’s Hospital, University of British Columbia
Traumatic brain injuries have received enormous attention in media and medicine. They are one of the leading causes of death and disability in North America1 with approximately 3.8 million cases from competitive sport alone.2 Without proper recognition and treatment early symptoms may progress to affect long term quality of life including depression, anxiety, chronic headaches, dizziness, lack of concentration, decreased memory and physical challenges, to name a few.3 Furthermore, recent research suggests an increased risk for developing neurodegenerative disorders such as Alzheimer’s disease, Amyotrophic lateral Sclerosis (ALS) and Parkinson’s disease from exposure to multiple concussions.4 Recognizing a concussion can be challenging, especially since they can occur without loss of consciousness and initial symptoms can be subtle and may not show up for the first few hours or days. Children are at a greater risk for concussion than adults, can take longer to recover, and are at higher risk for permanent brain damage. 5 Education and awareness is critical to how a concussion is handled in the minutes, hours and days after injury which can significantly influence the extent of damage and recovery time from this injury.
The Concussion Awareness Training Tool (CATT) was developed to provide British Columbians with online access to a free, evidence-based, up-to-date and frequently updated comprehensive concussion resource (www.cattonline.com). The target audiences for the CATT toolkits include: 1) medical professionals, 2) parents, players and coaches, and 3) school professionals. Each toolkit contains a variety of materials including a video tutorial as well as a wide range of selected publications, websites, articles, printable handouts and other relevant resources to help improve and inform the prevention, recognition, treatment and management of concussions.
What care gaps or frequently asked questions I have noticed
One gap that we have identified is the lack of standardization in the recognition, treatment and management of concussion among medical professionals. Despite the increased awareness of concussion incidence, there is insufficient education and continuing education on the best ways to recognize, treat and manage concussions. Medically, the current standard of care is inconsistent leading to a variety of different outcomes in what is already an uncertain treatment scheme.6,7 Research has now shown that some of the traditional recommendations are outdated and need to be revised to match current evidence. For example, waking someone with a concussion every few hours to ensure they are responsive is no longer recommended; as long as the person is resting comfortably, their sleep should not be disturbed. Recommended rest includes limiting cognitive activity as well as physical activity, and although recommended for the first few days, we now know that slow active rehabilitation, including slowly increasing cognitive and active stimulations can be beneficial for recovery.8
As the Sports Injury Specialist at the BC Injury Research and Prevention Unit, Dr. Babul has received numerous phone calls from anxious parents and teachers. With stories of both children and adults having received a hard hit during sports and other activities, they are seeking advise for what to do. Panicked questions such as: Do you think they have a concussion?, What do I do?, Where do I go?, How would I know?, What should I do so it doesn’t get worse?, and They sent us home from the Emergency Department but I don’t know what to do! are some of the most frequent questions that are asked. CATT is designed to help fill this gap for medical professionals as well as for parents, players, coaches and school professionals.
Data that answer these questions or gaps
Concussions are the most common form of brain injury in British Columbia, yet they are often under reported due to lack of awareness and education among the general public.9 Research suggests that children and youth up to age 19 years represent 22% of head injury hospitalizations and nearly 40% of emergency department visits.10 Children and youth are at the greatest risk for sustaining a concussion and take longer than adults to recover. Despite the high frequency of this type of injury, 85% of concussions usually resolve with out complications if treated properly. It is for these reasons that it is important to educate parents, particularly parents who have kids in active sport, the signs and symptoms for recognizing concussions.
Evaluation of the medical professional module involved a comparison of pre and post intervention surveys to assess the potential of CATT to improve physicians’ and nurses’ knowledge, attitude and practice around concussion. Both the physicians’ and nurses’ who took the online training showed a significant positive change in practices, but no change in knowledge, which already scored high in the pre-intervention survey. This suggests that despite having a good knowledge base, practitioners still could use help keeping up to date with the current concussion practices and guidelines.
What I recommend (practice tip)
CATT is a free online resource dedicated to providing resources and training to help increase the recognition, treatment and management of concussions. Encouraging medical professionals to participate in the online tutorial to ensure they are up-to-date and informed with the most recent evidence and practices for concussion will ensure all practitioners are providing patients with the best care possible. The resources for medical professionals contained in this toolkit include:
- 40 minute online training course (qualify for Mainpro+ credits)
- Online concussion assessment tools (Adult SCAT3 and Child SCAT3) and other guidelines that physicians can access easily and quickly in a clinical setting
- Printable resources for the patient and family
- Links to clinical resources, including evidence based journal articles
- Case studies and videos that include expert talks and in-office assessments
- Frequently asked questions
Furthermore, practitioners can then guide their patients to access CATT as well. The parents, players and coaches, and the school professional modules have resources including a training video, frequently asked questions, questions to ask your doctor, smartphone compatible concussion response tool, other pertinent websites, articles about concussion, videos from expert in concussion, personal stories from athletes who have suffered a concussion, and scientific articles.
Based upon the Zurich Consensus Statement on Concussion in Sport and other emerging evidence-based resources, CATT has the potential to dramatically improve the recognition and standardized treatment and management of concussions through education and awareness for medical professionals as well as parents, players, coaches and school professionals.
Tool:
The Concussion Awareness Training Tool (CATT) www.cattonline.com
Acknowledgements:
- CATT for Medical Professionals was funded by the BC Children’s Hospital Foundation and Child Health BC, and developed in collaboration with Doctors of BC .
- CATT for Parents, Players and Coaches was funded by and developed in partnership with the BC Ministry of Health and Child Health BC.
- CATT for School Professionals was funded by the BC Ministry of Health and Child Health BC and developed in collaboration with the BC Ministry of Education and the GF Strong Rehabilitation Centre.
References:
- Wu A, Ying Z, Gomez-Pinilla F. The salutary effects of DHA dietary supplementation on cognition, neuroplasticity, and membrane homeostasis after brain trauma. J Neurotrauma. 2011;28(10):2113-2122. (Request with CPSBC or view UBC) DOI:10.1089/neu.2011.1872
- Harmon KG, Drezner JA, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15-26. (Request with CPSBC or view UBC) DOI:10.1136/bjsports-2012-091941
- Mittenberg W, Canyock EM, Condit D, Patton C. Treatment of Post-Concussive Syndrome Following mild Head Injury. J Clin Exp Neuropsychol. 2001;23(6):829-836. (View withCPSBC or UBC) DOI: 10.1076/jcen.23.6.829.1022
- Lehman EJ, Hein MJ, Baron SL, Gersic CM. Neurodegenerative causes of death among retired national football league players. Neurology. 2012;79(19):1970-1974. (View withCPSBC or UBC) DOI: 10.1212/WNL.0b013e31826daf50
- Guskiewicz KM, Valovich McLeod TC. Pediatric Sports-related Concussion. PM R. 2011;3(4):353-364. (View with CPSBC or UBC) DOI:10.1016/j.pmrj.2010.12.006
- McCrory P. Real Politik Editorial. Br J Sports Med. 2002;36(1). (Request with CPSBC or view UBC) DOI: 10.1136/bjsm.36.1.1
- Cantor JB, Gumber S. Use of Complementary and Alternative Medicine in Treating Individuals with Traumatic Brain Injury. Curr Phys Med Rehabil Reports. 2013;1(3):159-168. (Request with CPSBC or view UBC) DOI:10.1007/s40141-013-0019-9
- Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. (View with CPSBC or UBC) DOI:10.1097/HTR.0b013e31825ad658
- B.C. Injury Research and Prevention Unit. Concussion statistics across BC health authorities among children & youth. March 2016. Accessed March 26, 2024. (View)
- Rajabali F, Ibrahimova A, Turcotte S, Babul S. Concussion among children and youth in British Columbia. Child Health BC. April 2013. Accessed March 26, 2024. (View)
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The authors note that concussions occur by the millions and are a leading cause of death and disability. They suggest that early treatment is essential (“Without proper recognition and treatment early symptoms may progress”) and reference a 15 y.o. paper (Ref 3) that finds that “early single session treatment can prevent the syndrome as effectively as traditional outpatient therapy.”
They note that “Concussions are the most common form of brain injury in British Columbia,” that “they can occur without loss of consciousness and initial symptoms can be subtle and may not show up for the first few hours or days,” and that “85% of concussions usually resolve with out complications if treated properly.”
I would find this paper much more useful if it defined the condition it was discussing and then gave evidence-based evidence about treatments that are useful.
The video clip of Drs. Tator and Taunton seems unfortunate, to me. It lacks scientific rigor and is more akin to scare-mongering around this important and complex topic. I found it rather off-putting, since it suggested to me that the module for medical education provided may provide a similar un-nuanced, emotional and simplistic approach.
While there may be significant morbidity from concussions, I was unaware they are a leading cause of death. Most traumatic brain injury deaths occur at the more severe end of the spectrum than concussion. An intracranial bleed or a coma is not a concussion. Even the feared “second impact syndrome” death is such an exceedingly rare event that it’s existence is debated by some and has only case series level evidence at best.
The hyperbole linking death to concussion is misguided and creating unnecessary fear.
Even less forgivable is the cited reference #1 that links concussion to death must be a typo or a mistake. It seems unlikely the authors of “The salutary effects of DHA dietary supplementation on cognition, neuroplasticity, and membrane homeostasis after brain trauma. J Neurotrauma. 2011;28(10):2113-2122” are discussing concussion death rates.
Warren Thirsk, MD, FRCPC, Dip Sport Med (CASEM)
Thank you for your comments. Sorry for the confusion and we will revise the opening line to say “Traumatic brain injuries are….”. In the literature, the terminology around the word concussions, mild TBIs, TBIs, head injury, etc. are used interchangeably and concussions are considered a traumatic brain injury, albeit mild in most (approx. 85%) of cases. Second impact syndrome is rare but does occur as recently seen with the death of Rowan Stringer in Ontario which has led to the discussion around a national concussions strategy to avoid unnecessary deaths. It was not our intention to create fear by any means but to simply say that concussions are a brain injury and should be taken seriously. In terms of the reference, I have appended the first couple of sentences taken from the article. Again we will make the suggested change outlined above.
Traumatic brain injury (TBI) is one of the most common causes of death and disability in the United States, with
220,000 hospitalizations, 52,000 deaths from head trauma, and 80,000–90,000 patients suffering from permanent disability
each year. The total costs of TBI in the U.S. are about $44 billion each year (Sosin et al., 1995;Waxweiler et al., 1995).
Dr. Alexander Moll: Thank you for your comment. The videos of Drs. Taunton and Tator by no means were meant to be a scare tactic but to provide commentary by world renowned experts in the field. The tool is built and based on the Consensus Statement of Concussion in Sport held every four years (last one in Zurich ) as well as new and emerging evidence. It was built to provide medical professionals a site for up-to-date guidelines as well as resources with ease.
Tom Finucane: Thank you for your comment. The referenced paper (#3) outlines symptoms that can progress if initial physical and cognitive rest aren’t followed, which is still the case today. Concussions are a precarious injury with individuals responding very differently. One may recover in the normal course of 2 weeks while another may still be recovering months later. Given the lack of concrete diagnostic tools for diagnosis, concussion diagnosis is based on history, symptoms, cognitive and balance testing, with no treatment but immediate cognitive and physical rest to allow the brain to heal, followed by slow integration back to activity as tolerated.