After my last blog, a colleague messaged me privately and said that one thing he might add is, what does properly managed really mean?
Great question! While there is no gold-standard credential that denotes appropriate training or care, I’ll provide some ideas below, as well as red flags to watch for….
Do look for…
- Providers with expertise with concussion management specific to the target age range – individuals who see all kinds of problems across all age ranges tend not to have the specialized training needed for concussion management in particular. See the membership list for the Sports Neuropsychology Society for neuropsychologists in particular with this kind of expertise http://www.sportsneuropsychologysociety.com/find-a-doctor/ .
- Providers who work collaboratively with other specialists, and who don’t try to do everything themselves – concussions are multi-faceted injuries, and so you need a group of providers with different areas of expertise to assess different aspects of the injury, according to their own areas of expertise. As a neuropsychologist, for example, my expertise is brain-behavior relationships, so my training and expertise is in managing behavior, symptoms of brain injury, functional impact on learning and the return-to-learn, and in administering and interpreting tests of neurocognitive functioning. I also function as a case-manager, coordinating referrals among related healthcare providers which may include:
- PCP – keeping your primary care physician informed, and consulting as indicated
- Sports medicine specialist to evaluate physical – not the cognitive! – aspect of the injury (typically orthopedist or primary care sports-medicine physician, or athletic trainer)
- Physical therapist – evaluating or treating cervicogenic, balance-related, and vestibular aspects of the injury
- Neurology – for headache management, and ruling out more serious brain injury
- Behavioral psychologist – to facilitate stress management and sleep
Sometimes these providers work for the same facility, but not always – the important thing is a collaborative, interdisciplinary approach that transcends institutional boundaries.
It can also be helpful to know “red flags” that may signal less than optimal care. The science and practice of concussion management is a rapidly evolving field, and it can be difficult for non-specialists to keep up with changes in practice standards.
Some of the common myths and mistruths that we hear that suggest that a provider may not have the most updated knowledge or requisite training and experience include the following:
- Primary reliance on computerized testing like ImPACT to assess recovery, and administration and interpretation by non-neuropsychologists. This is neuropsychological testing, and you want the experts in that interpreting results. Plus, it should only be one piece of the evaluation approach, and I really don’t need formal testing to confirm that someone is feeling badly and functioning poorly. I will use ImPACT, and a number of other evaluation tools, as needed to help inform clinical decision-making, but decisions to use these tools, and which tools to use, are made on an individual basis.
- Providers who discuss ImPACT in terms of passing or failing scores – there’s no such thing.
- Recommendations to remain at home until symptoms resolve or significantly improve – there is increasing evidence that prolonged bedrest and withdrawal from routine activities do not facilitate recovery and can even be associated with a worsening of symptoms.
- Grading of concussions – concussions are no longer graded, or rated.
- Providers who explain the injury by saying that the brain is bruised – an actual bruise is a more serious injury. Symptoms of concussion are associated with the metabolic (chemical) changes associated with a hard bump or jolt to the brain, and not a bruise.
- Hearing that “it just takes time,” for weeks on end – 80-85% of young adults should recover fully in 2-3 weeks, if their injuries are appropriately managed, with 90% recovering fully within a month. Even when specialized vestibular therapy is needed, most experts tell me that full symptom resolution is typically attained within 6 weeks or so with compliance with the prescribed home exercise program, and in the context of a comprehensive management plan that typically includes lifestyle adjustments as well.
- It is not necessary to carbo load, remove all electronics, remain home for set periods of time, or return to school in a scripted way – recommendations for concussion management should be highly individualized, based on the individual’s history, symptoms, risk factors and settings. Moreover, school-related recommendations need to involve adjustments to demands and workload that are specific to the individual’s symptoms, setting and history. While reduced screen-time is often recommended, it’s based on the person’s symptom threshold and how long screen use can be tolerated before symptoms worsen.
- There is no such thing as “3 strikes and you’re out” – there is absolutely no medical or scientific basis for this, and decisions about retirement from sport are, like general injury management, highly individualized and based on many factors.
- Neuropsychologists who insist on long batteries of neuropsychological tests without first ruling out other factors to treat – I rarely need to administer extended testing batteries, since I can usually identify areas needing intervention that might provide more plausible and treatable explanations of prolonged symptoms. Most often I see prolonged symptoms due to migraines (for which I refer to neurologists), vestibular deficits (for which I refer to vestibular therapists), or poor stress management, cognitive overload, inadequate sleep and/or hydration, which I address in a treatment plan or for which I provide referrals to behavioral psychologists if additional help is needed. Unless a child or adolescent athlete has a very complex medical or concussion history, hours of testing should not be needed, and especially not before other avenues of evaluation and treatment are explored.