Concussion is being treated as a minor injury in too many cases, according to a researcher in the field.
Doctors are failing to flag concussion patients for critical follow-up and the absence of surveillance is being described by scientists as an overlooked public health crisis.
A nationwide US study has found that more than half of the patients with concussion-related issues seen at top-level trauma centers may fall off the radar shortly after diagnosis, placing in jeopardy treatments for long-term effects.
Among 831 patients treated in hospital emergency departments for concussion, or mild traumatic brain injury (TBI), only 44 percent saw a physician or other medical provider within three months afterwards, the scientists report.
The findings of the study, led by scientists at the University of California, San Francisco, (UCSF) and the University of Southern California, have been reported in the open-access journal, JAMA Network Open.
Concussion and other more serious forms of traumatic brain injury affect between 3.2 million and 5.3 million Americans, according to the Centers for Disease Control and Prevention.
An expanding volume of research has found that traumatic brain injuries are associated with an elevated risk for neurodegenerative and psychiatric disorders. Research includes two UCSF studies published recently that found a link between concussion and Parkinson’s disease, and concussion and dementia.
“The focus of concussion has been directed at a very narrow segment of the population – football players and professional athletes,” said the study’s co-author Geoffrey Manley, a professor of neurosurgery in the UCSF Department of Neurological Surgery and a member of the university’s Weill Institute for Neurosciences.
“Everyone who falls off their bike or slips off their skateboard or down the steps needs to be aware of the potential risks of concussion.
“This is a public health crisis that is being overlooked,” said Manley, who was the principal investigator in the study, which collected and analyzed clinical data on close to 3000 traumatic brain injury patients from 18 top-level trauma centers nationwide.
“If physicians did not follow up on patients in the emergency department with diabetes and heart disease, there would be accusations of malpractice. For too many patients, concussion is being treated as a minor injury.”
The researchers found that, of those patients who saw a provider within three months, 15 percent visited a clinic that specialized in concussion or traumatic brain injuries, while about half saw a general practitioner, who may or may not have had training in managing this condition.
More worrisome was the finding that even among those concussion patients with more serious signs and symptoms, many had no further care after hospital discharge.
Of the 236 patients whose CT scans indicated a lesion, 40 percent did not see a physician or health provider within three months after discharge. Of the 279 patients with three or more moderate-to-severe post-concussive symptoms, 41 percent did not see a physician again within the three-month time-frame.
Additionally, about half of the patients were discharged without a handout explaining symptoms and red flags requiring follow-up.
“The lack of follow-up is concerning because these patients can receive adverse and debilitating symptoms for a very long time,” said lead author Seth Seabury, who is director of the Keck-Schaeffer Initiative for Population Health Policy at the University of Southern California.
“Even patients who reported experiencing significant post-concussive symptoms often failed to see a provider. This reflects a lack of awareness among patients and providers that their symptoms may be connected to brain injury.”
Undiagnosed and untreated traumatic brain injuries are endemic in the homeless and incarcerated populations, said Manley, who is also chief of neurosurgery at the Zuckerberg San Francisco General Hospital and Trauma Center.
“We have all these people untreated and no real system of care,” he said. “Even in the best trauma centers in the country, patients with concussion are not getting the follow-up care they desperately need.”
Among the patients in the study who had been recruited from 11 trauma centers nationwide, 58 percent were white, 65 percent were male and their average age was 40. About one-third suffered moderate-to-severe post-concussive symptoms.
In total, 59 percent of the concussions resulted from a road traffic incident; versus 24 percent from falls, such as being unseated from a horse, and 6 percent from assaults.
The study was supported by grants from the National Institutes of Neurological Disease and Stroke.
Co-authors were Amy Markowitz, Dana Goldman, Jordan Brooks, David Okonkwo, and Michael McCrea. Additionally, 57 scientists from the TRACK-TBI project, an ongoing observational study of patients with traumatic brain injuries, contributed to the research. Data for this research was derived from patients involved in the TRACK-TBI project.
Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion – Results From the TRACK-TBI Study
Seth A. Seabury, Étienne Gaudette, Dana P. Goldman, et al.
JAMA Network Open. 2018;1(1):e180210. doi:10.1001/jamanetworkopen.2018.0210