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Ask the Neuroethicist
Is the Volume of Discordant Concussion Policies Available Online a Recipe for Disaster?

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DR. NIKKIE RANDHAWA

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DR. SHARMIN HOSSAIN

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DR. JUDY ILLES

QUESTION:Seventeen-year-old Sylvia Smith, a high-school competitive-level soccer player, sustained a traumatic blow to the head during a championship game that was attended by university scouts offering coveted scholarships. Sylvia's coach took her off the field in compliance with her school's concussion policy that any athlete suspected of a concussive injury must be removed from play and cleared by a medical professional prior to further participation. The coach conducted a sideline assessment to screen for overt concussion symptoms and informed her that she would need to provide written clearance from a doctor. Although feeling “not quite right” and having trouble hearing her coach over the ringing that had started in her ears, Sylvia and her parents vehemently protested the decision. The coach adhered to the school policy, however, and advised Sylvia's parents to take her to a licensed health care provider as soon as possible.

Back in the locker room, Sylvia decided to try to prove that she did not have a concussion, and could return to play in the second half of the game. When she used Google to search for information and guidelines on concussion, more than 400 different policies populated for four major sports, including soccer, from the US, Canada, UK, and Australia alone. She became increasingly frustrated and agitated as she read through policies that varied with regard to sport, age, country, organization and even how concussion is defined.

Weeks after her injury, Sylvia visited a neurologist for ongoing headaches, nausea, and difficulty concentrating. She brought 20 different documents to the office visit, including the AAN policy. The sheer volume of uncoordinated documents, with “everyone doing a different thing,” must mean that no one, not even doctors, understand concussion, she told the neurologist. Further, she charged that it is unfair for her future to be jeopardized by inconsistent and varied policy documents. Does uncoordinated concussion policy-making pose a threat to stakeholder trust in these policies? How should the neurologist advise the patient?

THE NEUROETHICIST RESPONDS: Yes, varied and inconsistent policies can sow skepticism and, perhaps, mistrust in decisions about concussion. But the neurologist could certainly advise the teen that her coach made the right decision to adhere to the mandatory school concussion policy, which aims to protect the health of student athletes.

Currently, each US state law requires schools involved in youth sports to create a concussion policy. These laws broadly entail: 1) education regarding concussion prior to sports participation, 2) immediate removal from play in the case of a suspected concussion, and 3) clearance by a medical professional for return to sports participation.

The problem is that these laws, as well as the policies created by individual organizations, vary with regard to who may remove an athlete from play, which concussion guidelines are used, and who specifically may provide clearance for return-to-play (RTP) protocols.

Furthermore, concussion laws often do not provide guidelines for who should be on the policy-making team, omitting whether it is necessary for a medical professional trained in concussion evaluation and management to be involved, how potential conflicts of interest of the policy-making team should be identified and resolved, and how to formulate strategies to keep these policies up-to-date with the most recent concussion guidelines.

Even the most well-intentioned enforcement of concussion policies, however co-coordinated or not, may jeopardize the athlete's health by generating confusion, mistrust, and subsequent potential injury due to disillusionment that leads to limited adherence.

Much of the initial impetus for concussion policy creation was borne out of public concern and awareness, as well as media attention. No doubt, the visibility of policies is a public health campaign unto itself. However, the benefits of visibility will be trumped by concussion policies that are ill-informed, uncoordinated, or potentially overzealous.

While concussion policies can be enforced and adopted at a local, state or nationwide level, they may posit a further danger by being applied too generally, especially if the protocol for how to treat the athlete does not factor in differences in concussion pathophysiology, clinical presentation and treatment based on age or gender. At worst, management advice given by a neurologist may be at odds with an athlete's school policy regarding RTP. Whose advice should prevail? In whose hands lies the responsibility to adjudicate the conflict to ensure athlete safety?

The policies of the AAN reflect advances in the science of concussion, but they do not exist in isolation. Their utility and effectiveness are challenged by other policies produced both by professional international bodies of potentially equal voice and authority, and by non-experts with goals for whom athlete's brain health may not be a first priority. Clear guidelines are needed to determine who may create policies, what guidelines they should be based on, how often they should be updated, and what features of policies should be specific with regards to sport, gender, age, among other factors.

While attempts of this nature have been made through multidisciplinary forums such as the AAN, the Consensus Statement on Concussion in Sport guidelines discussed yearly in Zurich, and the Centers for Disease Control and Prevention “Heads Up” campaign, the volume of heterogeneous concussion documents continues to rise.

For athletes like Sylvia to benefit from information that she can readily access online, or even devices and apps that she can subsequently purchase to self-monitor using her smart phone, unregulated, unfettered concussion policy creation must be curbed.

Neurologists, and the collective of the profession, have the ethical duty to lead in this goal, re-align the science with the best interests of athletes, and position both firmly at the focus of the concussion discussion.

Dr. Randhawa is a fourth-year neurology resident at the University of British Columbia. Dr. Hossain is a postdoctoral research fellow at the National Core for Neuroethics at the University of British Columbia. Dr. Illes is a professor of neurology. Canada Research chair in neuroethics, and director of the National Core for Neuroethics at the University of British Columbia.

LINK UP FOR MORE INFORMATION:

•. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 http://www.nrl.com/portals/nrl/RadEditor/Documents/ConcussioninSport.pdf. Br J Sports Med 2013;47(5):250–258.
    Hodge SD Jr, Kadoo S. Heads-up on traumatic brain injuries in sports http://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1317&context=jhclp, A J Health Care Pol 2014;17:155.
      Kirschen MP, Tsou A, Nelson SB, Russell JA, Larriviere D. Legal and ethical implications in the evaluation and management of sports-related concussion http://www.neurology.org/content/early/2014/07/09/WNL.0000000000000613.full.pdf+html. Neurology 2014;83(4):352–358.
        Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports report of the Guideline Development Subcommittee of the American Academy of Neurology http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd.full.pdf. Neurology 2013;80(24):2250–2257.