Original ResearchSurvey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study
Introduction
Concussion prevalence has been reported as being at the epidemic level by the U.S. Centers for Disease Control and Prevention.1 The leading causes of traumatic brain injuries (TBIs) are falls and motor vehicle accidents (MVAs).2, 3 The prevalence of concussion or mild traumatic brain injuries (MTBIs) has been reported to be 70% to 90% of all treated brain injuries,4 with it being present in 38% of MVA hospital admissions and 46% of trauma center admissions.5 In the age group of 15 to 44 years, MVAs are the leading cause of TBI hospital admissions.1 The frequency of MTBIs in sports is also significant. The sport prevalence has been reported as ranging from 2.5% to 18.9% of all participants, dependent on the sport and the level of activity.6, 7, 8, 9 The prevalence of MTBI in both MVA and sport injury patients may actually be higher than what has been reported.10, 11 Moreau et al11 propose that a low recognition rate by primary care chiropractic or family practitioners (PCPs) may be one of many reasons that result in underreporting. The frequency of these primary modes of injury with which people present to the PCP necessitates that the PCP have the requisite knowledge to question, evaluate, and treat MTBIs.
The type of TBI often determines the actions of the patient. A TBI is defined by the American Academy of Neurology as a trauma-induced alteration in mental status that may or may not involve a loss of consciousness.12 The type is graded (Table 1) as mild, moderate, or severe, contingent on the Glasgow Coma Scale, period of posttraumatic amnesia, and absence of or duration of loss of consciousness.13, 14, 15 Patients with severe brain injuries are commonly transferred to emergency rooms, where they can be evaluated by trauma specialists. Moderate brain injuries involve loss of consciousness longer than 5 minutes13, 16 (or 30 minutes by some classifications17), posttraumatic amnesia lasting from 1 to 24 hours, symptoms greater than 15 minutes in duration, and an initial decrease in verbal, motor, and/or eye response.13, 15, 18 These may be more likely to be recognized by the layperson who commonly seeks emergency or specialist care. However, even 63% of American Academy of Neurology member specialists have not received formal or informal training in sports neurology, including objective diagnostic criteria for concussion, and therefore may be missing some patients with delayed-onset symptoms.19 Mild brain injuries may not always be immediately recognizable by the layperson. They may not involve any loss of consciousness; any initial change in motor, verbal, or eye response; posttraumatic amnesia of less than an hour; and only transient or no confusion.20 Yet, these mild injuries can have other subtle signs such as selective loss of (anterograde and retrograde) memory, difficulty with continuous train of thought, cloudy thought process, decreased concentration, cognitive difficulties, transient losses of balance, disruption of sleep, fatigue, tinnitus, sensitivity to sound or light, headaches, diminished reaction time, changes in personality, and change in emotions.15, 20, 21
Some MTBIs may commonly self-resolve in 7 to 10 days. However, risks exist if there is a lack of appropriate action for some of these cases. The patient may progress to postconcussive syndrome or may unknowingly be prone to second-impact syndrome. This can have more severe consequences, including permanent neurologic injury or death.22, 23 If care is sought, the MTBI type of patient may consult his or her PCP for the initial consult for concurrent neuromusculoskeletal injuries or the mild subtle indescribable signs noticed by significant others. In fact, one study reported that 20% to 56% of MVA patients consult a chiropractor (96% consult a medical doctor) in the respective 6-week to 12-month postaccident period.24 Early recognition of MTBI is therefore imperative.
Increased predoctoral and postdoctoral MTBI training could improve the provider’s abilities in early recognition, diagnosis, and care of the MTBI patient. Previous studies reported inconsistent provider actions and insufficient training of pediatricians and emergency room physicians to adequately recognize, diagnose, and treat TBI.25 There is a reported lack of awareness of concussion guidelines among pediatricians.26 Other studies have reported the deficient TBI knowledge of coaches,27, 28 medical students,29 emergency physicians, and family medical physicians.30 Knowledge of chiropractors has not been well researched, and there is a lack of any cohort medical doctor (MD)/doctor of chiropractic (DC) studies. Specific predoctoral training in diagnosis and management of TBI is not outlined by the Council on Chiropractic Accreditation Standards31 and may vary between different training programs. This article describes a pilot study investigating the use of a survey instrument in evaluating the degree of the primary-contact clinician’s knowledge base and ability to recognize the subtle presentation of MTBI. Resulting information may indicate the need for further study that could help guide future educational programs.
The purpose of this study was to assess a survey instrument used to assess self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners. The intent was to assess1 the informative need for and feasibility of further investigation into the TBI knowledge base, and2 the construct validity of the questionnaire as a potential measurement tool for the concept of sufficient PCP knowledge base.
Section snippets
Methods
To survey the professions involved, a standardized set of questions needed to be developed that would allow independent investigation of the clinician’s TBI knowledge and common procedures performed with a TBI patient. The survey was designed with the objective of obtaining information on the knowledge and procedures of PCPs, when presented with a potential MTBI patient. The response rates would determine the feasibility of the targeted population. The specific question responses would help
Results
The survey response rate was 9.3% for DCs and 9.2% for MDs from the initial database. Among those who were mailed the survey, the response rates were 50% for DCs and 52% for MDs. Geographic distribution of the initial solicited population of DCs included the states of Massachusetts (50%), Texas (25%), and an even distribution of Florida, Louisiana, New Mexico, California, New York, Arizona, Ohio, Maryland, North Carolina, Oklahoma, Minnesota, Alabama, Montana, Nevada, South Dakota, North
Discussion
The reporting of concussions is dependent on the ability of the practitioner to diagnose them. The symptoms of MTBIs with which people present to the practitioner's office can vary and often are not overt. The patient may not be aware of the signs and symptoms or might be hiding them because of either embarrassment or a fear of restrictions in athletics, work, or play. Even those MTBI patients brought to the emergency room may be discharged without a TBI diagnosis because of the temporal delay
Conclusions
This study indicated that assessment of the self-reported knowledge of concussion recognition and treatment of first-contact family medical and chiropractic practitioners is feasible. Further study of knowledge transfer to the chiropractic physician in a larger population is needed and feasible. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBIs. The survey instrument appears to provide valid
Acknowledgments
The authors thank Dr. John Ward for his guidance during this study.
Funding Sources and Potential Conflicts of Interest
No funding sources or conflicts of interest were reported for this study
Contributorship Information
Concept development (provided idea for the research): D.N.T.
Design (planned the methods to generate the results): D.N.T., S.J.D.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): D.N.T.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): D.N.T.
Literature search (performed the literature search): D.N.T.
Writing (responsible for writing a substantive part of the manuscript): D.N.T.
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