Concussion Management and the Prevention of Long-Term Deficits: Missing Pieces of the Public Health Interventions- Maureen Dunn

Concussion, or mild traumatic brain injury (mTBI), occurs when a direct hit or indirect jarring of the head causes enough force on the brain to alter brain physiology and lead to a complex array of symptoms (1). Concussions account for 8.9% of athletic injuries at the high school level and 5.8% of collegiate athletic injuries (2). While most concussions resolve within 7-10 days without long-term consequences, there are several long-term effects of concussion due to returning-to-play prior to recovery or repeat injury. These include post-concussion syndrome, when concussion symptoms persist long term, second impact syndrome, which leads to severe brain injury and even death, or chronic traumatic encephalopathy, leading to depression and dementia (1). In order to prevent these severe consequences, evidence-based guidelines stressing both physical and cognitive healing prior to return-to-play have been outlined in the Zurich Consensus Statement on Concussion in Sport (1).

Current Interventions

Interventions attempting to influence attitudes and behaviors surrounding concussive injury have come from professional sports organizations, the Centers for Disease Control and Prevention (CDC), state and local governments, and school policies. The target of these interventions has primarily been high school athletics. However, even with interventions at a variety of different levels, the culture surrounding concussions has been difficult for public health interventions to penetrate.

Heads Up

The CDC developed several “Heads Up” concussion “toolkits” which became available in 2005. There are several toolkits designed to specifically target physicians, coaches at the high school level, and youth coaches and can be order free of charge or downloaded directly. The toolkit targeting coaches could be further improved, but it has overall been successful in providing coaches with a useful and complete resource when handling concussions on their team and helped to educate coaches about the dangers of concussion in sport (3). The “Heads Up: Brain Injury in Your Practice” toolkit targeting physicians includes a 23-page booklet discussing the diagnosis and management of brain injury, an Acute Concussion Evaluation (ACE) card, a care plan, information for patients, and a CD with additional information (4). These toolkits are the cornerstone of the CDC’s concussion prevention and management program.

State Legislation

Since the first concussion prevention and management legislation was passed in 2009, concussion laws have been passed my many states while others have pending legislation. These laws are fairly similar, prohibiting same day return-to-play, mandating physician clearance for athletes, and requiring coaches to learn about concussion in sport (5).

NFL Public Service Announcement

During 2009, the NFL began running a public service announcement (PSA) during football games in coordination with the CDC. This PSA proceeded to run throughout the 2009-2010 season including the Super Bowl (6).

In looking at a few of these interventions, this paper attempts to identify reasons for the failure of this large scale and multilevel attempt to shift public attitude and behavior and identify mechanisms for change.

Critique 1. Failure of physician practice interventions undermines state laws

The current concussion management public health campaigns fail to adequately address physician knowledge. If physicians, particularly, the primary care providers, who parents and athletes are likely to contact in the event of a concussive injury, are not aware of the Zurich Consensus Statement guidelines for concussion management, then parents and athletes will receive inconsistent information about concussions and management. In addition, since state and school policies have mandated that athletes are cleared by a physician prior to return to play, if physicians fail to use the individualized, evidence-based standards athletes may be returned-to-play before they are adequately healed or held out from games longer than necessary. These laws require clearance by a medical professional; however, they fail to stipulate that providers should follow the published consensus concussion management guidelines. If local physicians are not aware of current management guidelines, requiring physician authorization is a much less effective measure and simply seems to take liability off of the school and state education departments and places the burden on physicians. While passing the burden of liability may help to shield schools, it does not ultimately lead to better care for student athletes.

The acquisition and application of new knowledge by individual physicians can be described using the Transtheoretical Model since change in medical practice involves behavior change on the part of the physician. This model includes five phases and individuals can enter the process at any of the phases: precontemplation, contemplation, preparation, action, and maintenance (7). In the precontemplation phase, physician may be unaware that their current practice does not meet current guidelines, or they may be choosing to actively avoid the current standards. For instance, one study found that the majority of physicians who were not following current concussion management guidelines were unaware of the guidelines, but other physicians disagreed with the content of the guidelines describing them as “too cookbook” and others too “too cumbersome” (8,9). Resistance to the adoption of concussion guidelines in the precontemplation phase could be due to the fact that there are over 20 published grading scales acting as a stand-in for evidence-based medicine (1). However, the current management standards no longer rely on these imprecise grading scales, so transitioning physicians from precontemplation to contemplation may become less of a challenge. The current public health interventions do not target physicians in this stage although the new guidelines make this an ideal time to begin targeting skeptical physicians.

In the contemplation phase, physicians begin to consider both the costs and benefits of changing their concussion diagnosis and management practices. For the consensus guidelines, attempting to integrate computerized neuropsychological testing into their practice may seem cumbersome since some of the sports batteries require a training course, or the practice may not have the space and resources for athletes to take a computerized test. However, as practice is trending towards evidence-based medicine, the ability to individualize management may appeal to physicians and encourage them to consider a change in their current practice. Again, the current intervention targeted towards physicians fails to address individuals at the contemplation stage.

The current intervention, the CDC Heads Up, targets physicians in the preparation phase. During this stage, physicians begin to actively seek out information and can utilize the toolkit materials to develop a concussion management policy for their medical practice. However, even at this stage the toolkit falls short.

Studies of the effectiveness of continuing education on physician behavior cite that physician have about 1 hour each week to review current literature, and print materials are not as effective as live or multimedia methods (7). This concept is supported by the fact that a study of the Heads Up: Traumatic Brain Injury In Your Practice that found even when physicians were mailed the toolkit, the only significant differences identified between physicians who received the toolkit and the controls were that physicians who received the toolkit were less likely to recommend next day RTP or to affirm the statement “wearing a helmet prevents concussions.” (9). Overall, mailing the Heads Up toolkit did not change general concussion knowledge or response to example scenarios. The authors suggest that minimal differences in knowledge and recommendation may be attributed to the fact that physicians who received the toolkit did look at the ACE card, which contained RTP guidelines but did not thoroughly review the other information. So, even the limited intervention targeting physicians in the preparation phase fails to adequately influence the knowledge base within the time constraints of physician schedules.

While intervention in the preparation phase may seem adequate to push physicians to implement a concussion management program, moving to the action phase requires further intervention. A study examining the effectiveness of Continuing Medical Educations (CME) courses found that only 58% of CMEs had an effect on the short-term practices of physicians (7). The Heads Up toolkit does not provide the stimulus to move individuals from preparation to action, and with weak motivations in the preparation phase, implementing change is even less likely.

In the maintenance phases, physicians need to continue utilizing the newly enacted protocols when treating patients with concussions. Of the individuals who actually implement changes within their practice after completing CMEs, only 50% maintained these changes for more than 30 days (7). No part of the intervention provides support for physicians within the maintenance phase, so physicians who struggle to continue evaluating and managing concussion based on individualized guidelines may forgo the new practices for their previous, well learned methods of concussion management.

Overall, the CDC Heads Up Brain Injury in Your Practice toolkit, designed for physicians fails to target physicians at the various stages of change. In addition, the toolkit intervention at the preparation phase is not based on best practice for CMEs and is not tailored to the demanding schedule of physicians. Failure to properly target physicians undermines the state laws designed to protect student athletes from premature return to play.

Critique 2: NFL public service announcement fails to serve as a call to action

Other than the fact that the 2009 NFL sponsored PSA aired during NFL games, including the Super Bowl, giving the commercial an excellent timeslot for maximum viewership, there are very few positive merits to this PSA.

This commercial fails to define a target audience. In a 30 second commercial spot, this PSA directly speaks to athletes, coaches, and parents, three distinct target groups of varying age, knowledge, and motivation. One reason Florida’s “truth” campaign, an anti-smoking campaign, was successful was that rather than creating a campaign “broad enough to encompass all ages” and addressing multiple social issues, all of the initiatives addressed one problem (10). While the NFL PSA had the benefit of airing during highly watched time slots just like the truth campaign, it did not have one specific target audience.

Without one specific target audience, it is difficult for advertisers to identify the wants and needs of the group. The commercial begins with the traditional public health marketing strategy, thinking about what people should want, to prevent head injury and tailoring the PSA to “sell” this idea (11). What the commercial fails to recognize is that not only is health not a strong core value, but also, their slogan works contrary to core values. The slogan of “take head injuries out of play” does not give support to what athletes and coaches want which is to compete; it actually creates negative associations insinuating that athletes will not be allowed to compete if they report concussion symptoms (6, 12). In failing to identify what the target athletes and coaches want, the NFL actually developed a commercial that creates negative associations with reporting concussion symptoms.

This commercial also fails to successfully utilize advertising theory, so it lacks a promise that appeals to core values and strong support for that promise. Advertising theory is based on three concepts: the appeal to core values, a promise, and support that is visual, story, or music (14). This advertisement promises that if you do not take head injuries seriously you will sustain a serious injury, a promise that does not appeal to the core values of an athletic community. The black screen and ominous music support the promise that danger is eminent, but visual images and or a story are not included. The PSA does not even include causal or non-causal evidence as support. While fear may be a strong core emotion, fear based advertisement is not generally a successful tactic, fear advertisements may backfire or individuals may tune out statements that seem too strong or not credible (14) And with such weak support in this commercial does not have the strength to provoke any change with the fear response. In addition, the black screen with white text eliminates opportunities for self-referencing. While the NFL could have used professional athletes, coaches, high school athletes, or parents either in images or telling stories, without any people in the PSA, it makes it difficult for individuals to visualize themselves changing behavior towards concussions.

This PSA is intended to serve as a call to action for coaches, athletes, and parents, encouraging them to learn more about concussions and other head injuries. It directs individuals to the CDC’s website to learn more about concussions. However, since the PSA did not target a group, affirm core values, or provide support for the need to report concussions, it fails to encourage these groups to seek out information, and with negative connotations, it may even discourage individuals from finding out more.

Critique 3. Failure to address social norms

While the CDC Heads Up Concussion in High School Sports toolkit, which is based on diffusion of innovation theory, hopes that as coaches identify the utility of information and pass it onto other coaches, parents, and athletes, the information will hit a “tipping point” where all members of the athletic community will recognize the importance of identifying and managing concussions (12). While the toolkit has proven to be effective in changing the knowledge and attitudes of coaches, this diffusion of innovations is opposed by prevailing social norms in athletics making it difficult to successfully lead to actual change in behavior (3).

One significant reason why the high numbers of concussions go undiagnosed is the failure of athletes to report concussions. With the significant underreporting, up to 80% of concussion may go undiagnosed and untreated (15). McCrea et al. found that 53% of high school football players failed to report concussions because they were not aware they suffered a concussion, did not recognize the seriousness of the injury, or did not want to be removed from play (16). Simply training coaches and other athletic staff to identify potential concussion is not enough because many of the symptoms are subjective rather than objective. For example, loss of consciousness is an objective sign of concussion, but only 8% of concussions result in loss of consciousness (1). However, “fogginess” was one of the symptoms most associated with a protracted recovery post-concussion (17). While coaches may easily be able to identify athlete with loss of consciousness or balance problems, they have to rely on athletes to report symptoms like headache or fogginess.

While athletes may be aware of concussion symptoms, the social norms within athletics directly compete with call to report symptoms. There are two factors that feed into an individual’s perception of social norms, the individual’s perception of what others think about the behavior and the individual’s motivation to conform to the perceived norms. In the case of a concussive injury, the behavior individuals consider is reporting symptoms. If an athlete reports symptoms, knowing that they will be taken out of play, they are violating the perceived norms within the sport. For athletes, the views of teammates hold substantial weight, whereas the recommendation of an athletic trainer or team physician do not hold as much weight. “Ignoring pain and injury becomes the sport norm when the culture praises stoicism in the face of injury” (13). This perceived social norm is further reinforced by well publicized cases of professional athletes playing through serious injuries. High school athletes can model professionals like Curt Schilling who’s bloody sock from the 2004 World Series can be found in the Baseball Hall of Fame or Tiger Woods who competed in and won the 2008 US Open with a torn ACL (18). It is these images that are cemented in the minds of young athletes leading to the perception that not only does playing through an injury give an athlete heroic standing, but also “the of the sports world are such that coaches, teammates, and fans negatively judge the athlete who refuses to play hurt” (13).

Malcom, in studying a girls softball team, found that coaches and other teammates teach young athletes the importance of accepting pain of minor injuries by indicating that it is inappropriate to complain about minor pain or injury. Coaches encourage athletes develop this perception of social norms by teasing and joking about small injuries, using phrases like “shake it off”, and leading by example downplaying their own pain (18). After learning from childhood that a portion of sports ethic is playing through pain and injury, teaching athletes that concussion is an exception to this social norm is a daunting task. However, the current concussion prevention interventions fail to even attempt to begin shifting social norms about head injury in sports, it predominantly relies on information.

From Critique to Intervention

In such a widespread public health intervention with overlapping input at the federal, state, and organizational levels, it is important to identify the program flaws in order to better target future intervention, avoid redundancy, and avoid repeat errors. Identifying the shortcomings of the current concussion prevention and management interventions, sheds light on the fact that, social norms, conflicting medical knowledge, and a failed call to action all need to be addressed to strengthen the campaign.

Intervention 1. Address the gap in physician knowledge using CME best practices

While it is important that high school are taking cues from the NFL and requiring physician clearance before athletes can return to play, schools and communities need to take this intervention one step further. School management plans should require that the health care professionals making the return to play decision are properly educated in the most up to date concussion management guidelines. Right now, there are only 34 physicians, neuropsychologists, or practices in Massachusetts that have completed the ImPACT training course, which teaches physicians how to manage concussion based on current guidelines requiring both physical and cognitive healing prior to beginning the return to play protocol (19). If Massachusetts schools began to require that not any physician, but an ImPACT trained physician certify that the athlete is prepared to return to athletics, this would not only improve the health of student athletes, but it would also help to encourage physicians in the contemplation stage of the transtheoretical model to consider the lost of patients to other physicians with ImPACT training and the endorsement of consensus management guidelines by state a local groups in their consideration of whether or not to implement a program.

Secondly, the intervention targeting physicians in the preparation stage needs to be altered to address the needs of physicians and encourage moving forward to the action phase. Pleacher and Dexter recommend that meetings and conferences providing concussion management education can be used to overcome the low use of published concussion management guidelines by physicians (8). Conferences, with interactive session, case studies, and multimedia presentations would help further engage physicians in the information leading to better outcomes that the CDC booklet that had a very small effect of physician knowledge (7). In addition, physicians are required to complete CME hours in order to maintain medical licensure. Offering conferences with CME credits would provide further incentive for interested physicians to attend.

Finally, to assist in the action and maintenance phases, physicians who are experienced with the most recent concussion management protocols and the integration of computerized neuropsychological testing, ideally the same physicians who hosted the CME, should continue to provide support after the course is completed. For example, physicians experienced with the current, evidence-based guidelines should consult on the first few concussion cases a newly trained physician handles (19). In addition, a neuropsychologist, who would have more training in interpreting the computerized test results, would be available to discuss difficult to interpret cases. Through these support measures, physicians beginning to use new guideline would not have to fall back on their old methods when struggling to identify a proper management plan for a student-athlete, they could use the case as an opportunity to become better familiar working in this realm of evidence-based medicine.

Intervention 2. Use advertising as a call to action and to re-frame symptoms reporting

The target of the commercials should be high school athletes. While encouraging parents and coaches to become better educated about concussions and recognized the importance of better management could have some impact on behavior, it needs to start with the athlete. The athletes need to report symptoms before coaches and parents can really have an impact on the care of an individual athlete.

A partnership with the NFL provides the CDC with an extremely valuable resource. The previous commercial aired during NFL games, including the Super Bowl, so the timeslot was optimal to reach maximum viewership. Presenting a more effective commercial in this timeslot, with a NFL player as the spokesperson would help to make these commercials more effective. A study of generation Y found that individuals in this generation do respond to celebrity endorsement. “Celebrity sports athletes have a positive influence on adolescents’ favorable word-of-mouth and brand loyalty, [and…] it is extremely important that advertising managers understand the impact of these celebrity athletes and consider utilizing these influencers in their message” (20). Utilizing an well-known NFL player telling his story about a severe concussion, discussing his symptoms, and talking about how he got back in the game would encourage young athletes to follow the example of the professionals , and in modeling their behavior better report their own symptoms.

Another commercial could target the core values utilizing advertising theory. In athletics those core values are teamwork and success (13). The promise of the commercial should be success through teamwork, this theme runs throughout athletics. In order to support this promise, the PSA would feature a group of high school athletes, in uniforms, muddy, sweaty, having just won the state tournament. As the athletes huddle raising their trophy and offering congratulations to one another, further musical support of the promise could be provided by “Eye of the Tiger” playing as the background. Then rather than utilizing a slogan that references being taken out of play, use a tag line that leads to thoughts of success and not letting the team down. This PSA would help to change the focus of concussion reporting from one of letting the team down and violating social norm to one of supporting the team by choosing not to hold them back. The success of this advertisement would tie responsibility to the team with reporting, not hiding symptoms.

Intervention 3. Change terminology to re-frame concussive injury

The terminology used when discussing concussive injuries varies greatly in its connotations. Reframing concussive injuries through changing terminology can help to work on the social norms of athletics which expect athletes to “rub some dirt on it” and get back in the game. In altering concussion terminology, there are two levels to consider, the colloquial level of language used on the field by coaches and athletic trainers, and the medical terminology used by care providers after an injury has been identified.

Referring to concussions as “dings”, “bell ringers” or “seeing start” minimizes the severity of concussive injury characterizing it as a transient injury with only momentary consequences. These phrases seem consistent with the sports ethics that some pain is a necessary and expected aspect of athletics (18). Utilizing these terms may limit athletes’ decisions to report concussions. Materials, specifically the CDC toolkit, targeting coaches should discourage the use of this terminology to refer to head injury at all levels of athletics.

At the level of nosology, many articles allow for the terms concussion and mTBI to be used interchangeably. However, regardless of whether these two terms are equivalent, studies looking at both parents and athletes have found that these two terms illicit different perceptions of injury (21,22). While concussion is the most familiar term to both athletes and parents, this term is associated with less negative expectations of injury outcome (21). While some studies suggest utilizing the term concussion rather than mTBI because of its connotation as less negative, but athletes underestimate the severity of their injuries when referring to it as a concussion. Athletes’ expectations of mTBI tended to me more consistent with the reality of the injury (21). However, mTBI was also associated with perceptions of long-term injuries from which the athlete might not recover, so the terminology may lead to greater concern for injury outcome that only affect a limited number of people (21).

In order to alter the varying perceptions athletes and parents have towards concussion and mTBI, neither of these terms should be used to deliver diagnosis alone. Rather than deliver the diagnosis of concussion then attempting to correct of the optimistic perspective or delivering a diagnosis of mTBI and attempting to ease concerns about long-term disability, practitioners should use these two terms in concert and then manage expectations. By delivering the two terms in concert, athletes and parents will have reasonable expectations without an overly negative outlook. By linking these two terms, clinicians may better be able to express the nature of injury even prior to further patient education.

As this terminology of brain injury disseminates from the physician’s office back to the field, coaches and teammates may begin to develop more realistic expectations of concussive injury changing it from an injury athletes should brush off and play though to a serious injury that could lead to long-term consequences. If concussion becomes one of the injuries that are acceptable violations of the sports ethic, such that people with concussions are considered injured not just hurt, this could lead to increased symptoms self-report and more careful management.

By developing an advertising campaign that will help encourage athletes to view concussions as a serious injury that can not only hurt them but also harm their team if ignored, athletes will be encouraged to report their symptoms. An increase in symptoms reporting will lead to further physician intervention. From encouraging physicians to take stock in the new evidence-based concussion management guidelines to increasing support as they implement these changes in their practice, a physician targeted intervention will help to deliver consistent information and consistent care to athletes. In addition, training these providers to use terminology that accurately reflects the severity of concussive injury can help to reframe concussions as serious injuries. Through these interventions, the public health community should be able to take significant strides towards preventing some of the severe consequences of concussions.

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