BLOG: An undiagnosed concussion is an untreated concussion
by Jeffrey J. Milroy, MPH, DrPH
Although there are four million sport-related concussions reported annually, these likely represent only half the concussions that actually occur.
Estimates suggest that in some student athlete populations, up to 80% of suspected sports-related concussions (SRCs) go unreported (Torres et al., Williamson et al., Baugh et al.). This is important, not only from the public health perspective of understanding the incidence of concussion, but also because it means that many individuals with SRCs are going untreated, putting young athletes at risk of a second injury and longer recovery time.
Unlike a broken bone or torn ligament, a concussion is often not apparent on imaging and must be diagnosed largely by the athlete’s symptoms. That makes it essential that athletes disclose (rather than hide) symptoms.
Willingness to disclose
At the Institute to Promote Athlete Health and Wellness, my colleagues and I have been studying a variety of factors that influence athletes’ willingness to disclose. We have previously reported that collegiate athletes who have a trusting, open relationship with a coach are more likely to say they would disclose symptoms to that coach. Currently, we are exploring the role that coaches and parents play in symptom disclosure at the recreational sports level.
Parents can be advocates for disclosure and appropriate concussion care for their kids, but on the other hand, they may also be a barrier to disclosure. Parents who are fearful of jeopardizing the athlete’s status on the team or eligibility for a college scholarship, for example, may pressure their son or daughter not to report. This is a very overt type of pressure they may place on their child athlete. Less obvious but potentially just as impactful, parents may directly or indirectly convey a “play through the pain” attitude, intending to encourage persistence and physical toughness.
Disclosure is just the first step. Ideally, if the potentially concussive event wasn’t observed, we want whoever the athlete talks to — whether that is a coach, parent or doctor — to respond by following appropriate concussion protocols, including removal from play if necessary.
To that end, my team and I are investigating the use of digital media interventions such as very short videos that could be shared via text, an app or social media to educate athletes, parents and coaches about concussion, the benefits of disclosure and the potential consequences of ignoring symptoms.
The OD’s role
Primary care providers, including optometrists, play an important role not only in treating concussions but also in educating families about visual symptoms related to concussion. These can include blurred vision, double vision, difficulty following a moving target or difficulty concentrating when reading. In fact, up to 90% of patients with concussions will have some type of visual dysfunction as a result of their injury (Ciuffreda et al.). Talking about this in advance of an SRC can be very beneficial.
For example, in examining a young patient, you might ask how school is going and whether they play any sports. A simple follow-up would be to say to the parents, “Have you had a chance to talk about concussions and what the symptoms might look like?” or “Do you know how to recognize the symptoms of a concussion?” In addition, you might also take a moment to let the parent know that their attitudes about concussion can have a negative effect on their child athlete’s willingness to seek help and that supporting their child athlete though injury, especially a head injury, is critical to the treatment process. This simple and brief conversation can help model for families the importance of talking about concussion symptoms so that they can protect their child’s vision, brain health and ability to continue in sports over the long term.
Baugh CM, et al. J Law Med Ethics. 2014;doi:10.1111/jlme.12148.
Ciuffreda KJ, et al. Optometry. 2007;doi:10.1016/j.optm.2006.11.011.
Williamson IJ, et al. Br J Sports Med. 2006;doi:10.1136/bjsm.2005.021832.
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Jeffrey J. Milroy , MPH, DrPh, is assistant professor in the Department of Public Health Education at the University of North Carolina Greensboro, where he also serves as associate director of the Institute to Promote Athlete Health and Wellness. His research has been funded by grants from the U.S. Department of Defense, National Collegiate Athletic Association, National Institute of Nursing Research and the Small Business Administration’s SBIR/STTR technology development programs. Milroy hopes to motivate athletes, coaches, parents and society in general to begin developing and fostering a culture of care seeking among young athletes.
Disclosure: Milroy reports no relevant financial disclosures.
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