Guidelines for the management of concussion

Sue Hughes | Disclosures

The American Academy of Neurology (AAN), the American Neurological Association, and the Child Neurology Society have joined together to produce a document on the legal and ethical implications on the evaluation and management of sports-related concussion.

The document is published online July 9 in Neurology to coincide with The Sports Concussion Conference taking place July 11-13, 2014, in Chicago, Illinois.

Lead author Matthew Kirschen, MD, The Children’s Hospital of Philadelphia, Pennsylvania, told Medscape Medical News that this is the first time an organization has put forward ethical guidelines for the management of concussion.

“The paper outlines the ethical duty and responsibilities of the physicians caring for athletes with concussion so that they prioritize the current and future physical and mental health of the patient,” Dr. Kirschen explained.

“Doctors have an ethical duty to provide information on concussion risk factors and symptoms and possible neurological impairments in both the short and long term,” he added.

In an accompanying editorial, Ellen Deibert, MD, Wellspan Adult Neurology, York, Pennsylvania, points out that with 1.6 to 3.8 million concussions occurring every year in the United States, this is a rapidly growing public health concern. She welcomes the new document, saying it is “a refreshing reminder of the issues surrounding the treatment of sports-related concussion and the need for continued education and research on this topic.”

The paper also tries to tackle some of the hurdles a physician may face when dealing with a concussed athlete, including the shared decision-making process with the athletes themselves, team coaches, parents, and schools. “The doctor has to protect the athlete from harm but at the same time respect the views of family and those managing the team,” Dr. Kirschen comments. “This can be a difficult line to tread sometimes.”

This document is designed to be used together with the clinical concussion guidelines issued by the AAN last year. “We do not delve into the science of concussion and specific clinical advice in this paper,” Dr. Kirschen says. “That was all dealt with in the guidelines paper. This document deals with legal and ethical issues that may be relevant when treating a concussed athlete and is seen as a companion paper to the clinical guidelines.”

Confidentiality Waivers

One of the recommendations, for example, deals with the situation when athletes are overmotivated to get back to play. “This can be a common occurrence as most athletes do not want to lose their place on the team and there is often big pressure from the coach/school or parents to get them included again,” Dr. Kirschen explains. “They often do not appreciate that they may have a cognitive deficit and this may worsen if they return too soon. Physicians need to balance these factors with the need to protect the athlete from worsening brain injury.”

Dr. Matthew Kirschen

He acknowledges that physicians are aware that they should protect the patient from further harm, but points out things can get complicated in a sports-related field. “Lines can get blurred. It is helpful to have reminders,” he said. “The goal of this document is to remind physicians that they have an ethical obligation to protect the athlete. If they do not feel it is in the best interest of the athlete to return to play they need to be able to express this to the patient, the coach, and the family.”

He noted that sometimes athletes visit numerous physicians until they get the result they want. “We call this ‘doctor shopping,’ and because of confidentiality rules, sometime legitimate concerns are suppressed.”

To deal with this situation, the new document suggests that physicians ask athletes and their families to sign a waiver before the consultation stating that the information can be shared with the athletic coach or school. “Being up front in the loop like this will minimize problems down the line,” Dr. Kirschen says.

He reports that some institutions have such waivers in place already, but normally only when dealing with an affiliated doctor. “It is not yet normal for them to apply to outside practitioners, but we think they should be standard practice.”

He adds: “This document gives physicians things to think about and questions to ask within their practice. Each physician practices in a different environment, so they need to look at what legislation is in place in their state, along with privacy laws and availability of waivers and decide if they need additional waivers or legal documentation in place in their practice.”

The document also calls for all physicians who are likely to encounter concussion patients to undertake new specialist training in the subject.

Athletes with concussion could be seen by a variety of physicians and other healthcare personnel, including those in sports medicine, physical therapy, neurology, family medicine, pediatrics, and emergency medicine. Few of these specialties have had concussion fellowships, although these are starting to be put in place now, Dr. Kirschen noted.

“The AAN has created a lot of CME [continuing medical education] courses to teach doctors about treating concussion. This will bring up to speed physicians who will have first point of contact with these patients.”

Role of the Neurologist?

In her editorial, Dr. Deibert notes that neurology residents are trained to deal with most of the symptoms encountered in a concussion patient.

“When it comes to residency and fellowship training, the argument could be made that neurology residents would be the best prepared to treat concussion patients compared to our medicine colleagues,” she says.

But she points out that because of a limited number of neurology training programs and a “paucity of neurologists comfortable with treating concussion patients,” most concussions are currently managed by other subspecialties, such as primary care, pediatrics, and psychiatry, with athletic trainers and nurse practitioners also playing a large role.

The document also recommends the development of a concussion registry in order to track and better understand the natural course of the injury. Dr. Deibert points out that this would need to be developed together with the many subspecialists already involved in concussion management, and this process would help define the role of the neurologist.

Neurology. 2014;83:352-358. Published online July 9, 2014. Abstract Editorial