CONCUSSION IS A GROWING public health problem affecting over 3.8 million Americans annually1 and resulting in over 2.2 million emergency department visits each year.2 Although concussed patients may recover in days to weeks, about 10% to 30% have symptoms lasting longer than 3 months,3–5 which is often referred to as postconcussion syndrome (PCS). According to the Association for Blue Cross & Blue Shield,6 diagnoses for PCS increased by 81% between 2010 and 2015. During this same period, a series of guidelines and recommendations were published supporting the emerging concept that many of the symptoms of concussion are treatable7–12 (see Table 1). These guidelines reflect the recent paradigm shift away from conceptualizing concussion as a single clinical problem toward thinking of it as a combination of problems reflecting disruption in a number of functional brain domains.13 As can be seen from the Table, assessing and treating disruption in these brain domains falls under the purview of a range of medical specialists.
Primary care specialties such as pediatrics, family practice, and internal medicine have traditionally been on the front line of concussion care. However, several studies have documented lack of familiarity with current concussion practice standards among primary care practitioners.14–16 While these knowledge gaps have not been linked to poor patient outcomes, many more concussion patients appear to be accessing nongeneralists for care. In eastern Massachusetts, referrals to concussion specialists increased by 919% between 2007 and 2013.17 Moreover, limited evidence suggests that care provided by a concussion specialist is beneficial. In one study, evaluation of sports concussion by a concussion specialist was shown to be associated with shorter return to play.18 The authors speculated that specialists may be more likely to use updated concussion guidelines to provide care. Additional studies reveal that standardized application of guidelines by concussion specialists reduces practice variation and improves many aspects of care.19–21
If specialists are the preferred concussion provider, which specialty or specialties should be involved? A 2017 Internet search of concussion clinics in the United States revealed 184 online concussion healthcare providers from a variety of specialties, including sports medicine (49.5%), physiotherapy (43.3%), neuropsychology (40.8%), neurology (33.7%), orthopedics (26.6%), physiatry (29.3%), neurosurgery (21.7%), occupational therapy (13.6%), pediatrics (11.4%), and family medicine (10.3%).22 To a large extent, the range of specialists currently delivering care reflects those that have training in assessing and treating the symptoms that arise after concussion (Table). But how is the care they deliver organized and coordinated? According to this same Internet search study, 76% of online healthcare providers were working in a multidisciplinary setting, which was defined as “a facility that offered concussion-related services and access to more than one type of healthcare professional (i.e., a sports medicine clinic with access to a sports medicine physician and an athletic therapist [sic]) excluding support staff such as physician assistants and nurses.”22
Bringing multiple specialties to bear on a single patient requires a team approach. Medical teams are commonly described as “interprofessional,” “multiprofessional,” “interdisciplinary,” and “multidisciplinary,” with the latter being the most frequently used.23 Although there are several definitions for the term multidisciplinary, patients and healthcare providers functioning on medical teams appear most likely to agree on the following: “Practitioners from various health disciplines [who] collaborate in providing ongoing health care.”23
Given this rather broad definition, how might a multidisciplinary approach be applied to concussion care? In perhaps the most idealist model, all specialist providers would be located in a single clinic and evaluate each patient. But this model is neither efficient nor cost-effective. Alternatively, a single concussion specialist with broad training could screen each patient for the common concussion problems and then refer “off-site” to the appropriate specialist team member for a detected problem. This model is efficient and practical for the initial concussion specialist but not for the patient, who may be required to travel to multiple locations for follow-up appointments with various specialists on the team. Several authors have described multidisciplinary clinics using this model.19,24,25 Yet, a third option is to have select specialists “embedded” in the clinic who can be called on to evaluate a patient when a problem is detected. This option is attractive but requires knowledge of the key specialists that are most likely to be needed for the particular patient population of the clinic. This option may also be difficult to operationalize, as embedded providers may not always be required for each patient and have no way to generate income if they are not seeing patients.
Research investigating the effectiveness of multidisciplinary clinics on concussion outcomes is in its infancy. Janak et al26 reported a reduction in postconcussive symptoms among 257 active duty military service members with concussion undergoing multidisciplinary treatment; however, there was no comparison to a control group. Vikane et al27 studied 151 concussed adults with symptoms greater than 2 months and found those randomized to multidisciplinary concussion care had fewer postconcussive symptoms 12 months after injury but a similar number of days to return-to-work as those treated by a general practitioner. Interesting as these studies are, they leave many questions unanswered. What is the best structure for a multidisciplinary clinic? Do nonathlete patients require a different clinic structure than athletes? Are patient outcome affected by provider type, such as physician versus nonphysician, or neurologist versus sports medicine? Are there certain team members that should be embedded on-site and others who are more appropriately accessed off-site? Should all team members agree on collecting a standard set of history and physical examination elements? If so, what should these elements be?
This topical issue on multidisciplinary concussion care features studies focused on the use of specialist teams to provide outpatient treatment for this injury. The first series of articles highlights the provision of concussion care from the perspective of the specialist team. Bailey and colleagues28 report the added value of sub symptom threshold exercise therapy on overall recovery to multidisciplinary care provided by sports medicine and primary care concussion specialists. This study also describes the important role of the neuropsychologist in the multidisciplinary care team. Scratch and colleagues29 describe their experience with an interdisciplinary concussion clinic model. Interdisciplinary care is often considered a variation of multidisciplinary care in which team members collaborate to work directly with the patient, their caregivers, and family members to assess their needs and develop a treatment plan.30 In this study, interdisciplinary team members included physicians (neurologist and developmental pediatricians), nurse, occupational therapist, physiotherapist, social worker, neuropsychologists, and a team intake coordinator. In a multidisciplinary sports concussion clinic, Kontos and colleagues31 identified 5 pre- and postinjury factors associated with more prolonged recovery among concussed athletes: younger than 18 years, female sex, history of migraine, posttraumatic migraine symptoms, and high postconcussive symptom burden. Interestingly, the authors detected a significant relationship between the number of factors and the delay in recovery. Finally, Lee and colleagues32 describe the unique features of multidisciplinary concussion care provided to military service members by the Department of Defense and Veterans Administration. These include a residential treatment program (University Model), a 5-week outpatient treatment program (Return to Forces initiative), and a 3- to 12-week inpatient treatment program (Post Deployment Rehabilitation and Evaluation Program). These programs are highly interdisciplinary and treat patients in groups, rather than individually, to leverage the group dynamic of support and encouragement fostered by military training.
The final 3 articles in the issue are from the perspective of a single discipline—physician, neuropsychologist, and occupational therapist. Haider and colleagues present their approach to the physical exam of the concussed patient, including the use of sub threshold exercise testing.33 The studies by Baker and Harris highlight the positive impact of the neuropsychologist and occupational therapist, respectively, on multidisciplinary concussion care.34,35 In sum, this topical issue brings to light the different ways in which medical teams can coordinate and organize to provide care for an injury that is increasingly understood as complex and multifaceted. Recognizing that access to resources such university-based specialists varies widely across the United States, these articles provide practical options for tailoring a multidisciplinary concussion clinic based on local resources. Finally, these studies provide a solid foundation on which future research into the effectiveness of multidisciplinary concussion care can be based.
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