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Should Concussion Be Called Mild Traumatic Brain Injury Instead?

Label sends wrong message about seriousness, leads to under-reporting, says Canadian study; other experts disagree

Although the terms mTBI (mild traumatic brain injury) and concussion are often used interchangeably in the context of sports [5] and particularly in the United States, others use the term to refer to different injury constructs. [1]  

The authors of a 2010 Canadian study [2] argue that labeling a child's head injury as a "concussion" convey the wrong message to parents, athletes and athletic trainers about its seriousness, and that to encourage full reporting of head injuries in sports and to allow adequate management and recovery time MTBI be used in its place.

The evidence seems to support their argument that how a brain injury is labeled can make a difference when it comes to treatment.

Researchers at McMaster Children's Hospital in Hamilton, Ontario, Canada, studied 268 children admitted with head injuries who had computed-tomography (CT) scan results.

Among their key findings:

  • During the process of recruiting study participants, both parents and clinicians were frequently heard expressing the opinion that the use of the term "concussion" erroneously implied the exclusion of brain injury, with both parents and medical staff frequently heard expressing the opinion that "he doesn't have a head injury, he has a concussion."
  • A normal CT scan result was the greatest predictor of a brain injury being labeled as a concussion, with the group of children most likely to be receive the diagnosis being those with a normal CT scan and some loss of consciousness;
  • Loss of consciousness was the next most important predictor of whether a child would receive the concussion label if the CT results were normal, even though LOC is no longer reguired for the diagnosis of concussion and, recent studies show, is present in only 5 to 10% of diagnosed concussions;
  • The danger is that a "normal CT result likely implies to parents that their child has no brain injury." (emphasis supplied). [Note: a normal CT or MRI scan is, in fact, one of the common features of concussion; and neither neuroimaging technique is recommended, absent a suggestion of a more serious brain injury].
  • A concussion diagnosis was strongly predictive of an earlier discharge from the hospital; the odds of being discharged were 1.5 times higher for those children who were diagnosed as having suffered a concussion.
  • Children diagnosed with concussion also were allowed to return to school significantly sooner (i.e. fewer days until school return); after discharge, the odds of a return to school sooner after discharge were 2.4 times higher for children with concussion.

The study authors questioned the use of the concussion label as being reflective of mild injury and found that its use supports the existence of continued confusion about what a concussion really is and how the term should best be used in the care of children.

Does concussion label lead to underreporting?

The negative consequences of the use of the concussion label, they noted, may be especially pronounced in the context of sports-related concussion, perhaps explaining, in part, the underreporting of head injuries by young athletes and their trainers as being due in part to the still-common belief that a concussion does not need to be treated seriously.  Several recent studies suggest, however, that underreporting of concussons by athletes persists even among those who have been educated about the dangers of continuing to play with concussion symptoms.[6-8]

The findings, both in the return-to-school data and the phenomenon experienced during recruitment (in which both parents and clinicians may use the term to imply the exclusion of brain injury) suggests that, if a child is given a diagnosis of concussion, then the family is less likely to consider it as a brain injury.

The authors suggest that "[i]f we want to encourage full reporting with subsequent adequate management and convalescence, perhaps we should use the term "MTBI."

AAP sticks with concussion label

"While acknowledging that the study "highlighted a general misinterpretation that an injury described as a concussion is less severe than one described as mTBI," and that it may result in a premature return to school and activity," the American Academy of Pediatrics' 2010 clinical report on sports-related concussion in children and teens [3] continues to refer to the injury as concussion.

Lisa L. Bakhos, M.D., a Pediatric Emergency Medicine Attending at Jersey Shore University Medical Center in Neptune, New Jersey and the lead author of a recent study on concussions in pediatric and adolescent athletes, told MomsTeam that the reason was that "neurologists and sports medicine specialists give concussion a very specific definition," such that "[s]ufferers have to meet certain criteria to be considered "concussed," with the term mTBI reserved for mild head injuries that do not meet the definition of concussion.

Likewise, William P. Meehan, III, MD, a MomsTeam concussion expert and Director of the Sports Concussion Clinic at Boston Children's Hospital, argues in his 2011 book, Kids, Sports and Concussion, that the term mTBI "should not be used interchangeably" with the term concussion.[4] 

The reasons, says Dr. Meehan, are that mTBI:

  • does not describe how significant the patient's symptoms can be or how long it can take for the patient to recover;
  • does not specify the way in which the injury occurred; and
  • is a classification based solely on the patient's score on the Glasgow Coma Scale, used by emergency  medicine providers to measure the patient's level of consciousness after suffering a head injury on a 15-point scale (patients with suspected concussive injury are catagorized as having mTBI if they score 14 or 15, with 15 being the score an uninjured person would typically score)
Recent consensus statements take Dr. Meehan's position. "While all concussions MTBIs, not all MTBIs are concussions," says the American Medical Society for Sports Medicine's position statement on concussion in sport.  "Concussions are a subset of MTBIs, on the less-severe end of the brain injury spectrum and are generally self-limited in duration and resolution." [5]

1. McCory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br J Sports Med 2013;47:240-258. 

2. Dematteo CA, Hanna SE, Mahoney WJ. et al. My child doesn't have a brain injury, he only has a concussion. Pediatrics 2010;125(2):327-334.

3. Halstead, M, Walter, K, Clinical Report - Sport-Related Concussion in Children and Adolescents, Pediatrics 2010;126 (3): 597-607.

4. Meehan WP. Kids, Sports, and Concussion (Praeger 2011).

5. Harmon K, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. NB: The AMSSM statement is endorsed by the National Athletic Trainers' Association (NATA) and the American College of Sports Medicine.

6. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW. Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study. J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

7. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives. Brain Injury 2013;27(7-8):878-886.

8. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.


 

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