Concussion Urgent Care Centers for Young Athletes: NewPublicHealth Q&A Robert Graw, MD
A recent report from the Institute of Medicine found that young athletes in the United States face a "culture of resistance" to reporting when they might have a concussion and to complying with treatment decisions. That culture can result in students heading back to school too quickly—when they should be resting their brains to prevent short- and long-term complications.
"The findings of our report justify the concerns about sports concussions in young people," said Robert Graham, chair of the committee and director of the national program office for Aligning Forces for Quality, at George Washington University, Washington, D.C. (Aligning Forces is a program of the Robert Wood Johnson Foundation.) "However,” says Graham, “there are numerous areas in which we need more and better data. Until we have that information, we urge parents, schools, athletic departments, and the public to examine carefully what we do know, as with any decision regarding risk, so they can make more informed decisions about young athletes playing sports."
Recently, Righttime Medical Care, a chain of urgent care centers in Maryland, opened a number of HeadFirst sports injury and concussion centers in the state, staffed with health professionals who can assess injuries for concussions as well as evaluate students for return to play—in consolation with a team of experts who work with HeadFirst staff. HeadFirst will this year be presenting and publishing data on the more than 10,000 youth it has examined and treated for concussion in just the past two years.
NewPublicHealth recently spoke with Robert Graw, MD, head of Righttime and HeadFirst, about the need for better prevention, evaluation and treatment of concussions to prevent long-term health problems and disability.
NewPublicHealth: Why did Righttime add concussion care to the services provided?
Robert Graw: My son is an orthopedic surgeon and talked to me about the number of injuries he was seeing. We decided a few years ago that we’d learn as much as we could about preventing head injury and the consequences of head injury, and then promote that information through Righttime’s call center and through the visits that people made to our sites.
In the process of learning as much as we could we realized that the knowledge base of how people evaluate and manage concussions had changed drastically in the last five years as people have done more research. So, we then gathered together a group of consultant physicians and neuropsychologists to determine best practices. We met with them frequently, and then had them train our provider staff so that all of them became much more informed about what a concussion really is, the best way to evaluate them and the guidelines for management going forward.
About that time a law was passed in Maryland requiring anyone with a suspected head injury to be taken out of play. That was a great opportunity to educate the community physicians, so we reached out to the family practice and pediatric communities and shared with them what we had learned, including how to document the evaluation and management of the head injury to see whether there were symptoms or neurologic deficits.
We began using the Impact Test, which is a neuropsychological test developed by the University of Pittsburgh for its football players. A neuropsychologist in the past would take out a pencil and paper and have different assignments and puzzles and a stopwatch. It would take several hours—sometimes a day—to do a thorough neuropsychological evaluation on someone with a possible concussion. They developed this technique that was then put on a computer and it could be done reproducibly and reliably, becoming similar to an EKG or an EEG as way to assess and monitor.
If the test was done before you were injured it could help determine whether a concussion had occurred, as well as its severity. And you could see whether somebody was improving or was failing to improve back to the level that they had before the injury.
We would send all that information back to the child’s pediatrician, but pretty soon many patients would head back to us saying my doctor really doesn't feel comfortable managing my recovery. So we began opening the concussion centers, which are in the same locations as the Righttime Medical Centers, though with their own facilities including space for the impact testing.
NPH: What’s the trajectory of a concussion?
Graw: The majority of people will recover from a concussion within weeks to the best of our current understanding, as evidenced by exams and their symptoms. About 15 to 20 percent of those injured take a longer time to recover. Sometimes that’s because they have other, preexisting conditions ranging from a tendency to migraine headaches to having a history of concussion.
We manage all our patients under the guidelines set by our consultants, and we refer out patients who don’t seem to be recovering as quickly or will need more expert attention base of their particular injury or any preexisting conditions. Someone with balance issues they may need physical therapy, for example, while someone with vision problems may need to see an eye specialist trained in post-concussion care.
NPH: What are you doing with the community on concussion prevention and management?
Graw: We offer impact testing for free for kids whose high schools don’t provide it. And at the same time we can educate kids about concussion prevention and treatment. Educators at those sessions talk about what a concussion is; symptoms to recognize it in yourself and your friends; and how to talk to the coach. We also talk to the coaches about being good advocates for the kids and being accessible.
We feel that one of the things that has always been difficult in sports such as football is that we've all been raised to be pretty strong and tough and deny there’s a problem. But now we want the coaches to say look, I'm here for you, if you have anything you come see me, I'm going to take care of you, and I’m going to get you the care you need.
NPH: What data are you collecting and how will you use it?
Graw: We're gathering data on who comes in to urgent care with a head injury, why they come to our centers rather than somewhere else, when they come to see us and what we found in terms of management of their concussions—imaging, what sort, results, treatment, specialist care, therapies such as ocular therapy for vision problems. We’ll be presenting that data at the Brain Injury Society of Maryland this year and preparing that for submission to one of the sports medicine journals.
NPH: What do you want parents and kids to know about sports head injuries?
Graw: We would like to have a chance to talk with any athletic child and their parent to stress the fact that often head injuries are assumed to be pretty innocent but they can actually be quite severe. I don’t care if they come to HeadFirst or not, I want them to know that.
A concussion is really the brain moving independently of the skull—it’s like an egg yolk inside an eggshell. As the brain twists inside the damage occurs to the brain even though the skull itself doesn't get damaged. So, you have this little piece of tissue—the brain—twisting, but all of the anchors remain in place, so you're getting this irritation of the brain on the bony skull and then all those attachments to the exit parts where the nerves go out. So sometimes those twisting injuries are much more significant and troublesome than if you just got a hit from the front or the back.
NPH: What changes have you seen that can help reduce concussions?
Graw: I think people are pretty aggressive about this now. For example, many schools are trying to decrease the contact of the practices because we know a lot of the practices go under the radar—there’s not a trainer there, there’s a not medical personnel.
My dream would be that everybody should get a chance to educate people about concussion, just like we educate for CPR or the Heimlich maneuver for foreign bodies. You could get into the head of the young children before they know any better, and concussion management and recognition would be the same kind of thing. You don't want to hit your head, it’s dangerous to hit your head, don’t joke around doing it, and when you get hit be aware that there are symptoms that can occur.
We did a little project this year in Anne Arundel County in Maryland, which was very well received. We went to the Department of Education and promoted in the art departments a contest about what they felt like or what they thought their brain was like when they had sustained a head injury or a concussion. It was absolutely wonderful. Some of them were photography, some were painted, some of them were ceramic, and some people made video games. A lot of different mediums were used to let children express what they thought they’d seen. It gave the teachers a chance to have an audience on something so significant, that wouldn’t’ otherwise has been part of the curriculum.
I think education may really need to begin with mothers of young babies, before there’s an injury. I think if you go at it and try to educate them while they're all playing football, there’s a little bit of denial. There are a lot of people who want to become a college scholarship opportunity and they're not going to hold back even though they may know better.
NPH: How could this expand to other parts of the country?
Graw: So you could have somebody in a much more remote location who is trained and has learned all of this evaluation who could participate once a week when we bring all our providers and consultants together on case management. So, somebody could dial in or they could telemedicine in and speak about the patients that they're managing so that they could benefit from this consortium.
NPH: Spring Training is starting. What do you want coaches, parents and especially players to know about concussion prevention and treatment?
Graw: Well, I think most importantly I don't want them to be afraid. I think that they need to be knowledgeable and they want to make sure that they have an environment where the coach is aware, not just acknowledging that he read something quickly on concussion, but he really is aware. That he speaks to the athletes in a tone that says look, this is an important possibility and I want you to protect your head, I don't want you to abuse it and I'm going to be here and we know that we can get good treatment for you so don’t deny it if you are hurt.
And I think the parents need to have that certainty that the coach is knowledgeable and will protect their child. Whenever I speak to coaches, I always end by saying “I don’t think any mother will be upset if you do everything you can to protect her baby’s brain.”