CALL FOR CONSISTENCY ON CONCUSSIONS
Misdiagnosing brain injury is all too common in sports and life. A UBC study says it's time to standardize assessments
The goal J.D. Burke scored in his beer league game last December was pretty spectacular.
What happened next was the opposite.
After a backhand-to-forehand deke that sent the goalie sprawling in the wrong direction, the leftshot Burke deposited the puck in the net but then caught his skate on the left post. He lost his feet and slid, hard and backwards, into the end boards. He whipped the back of his head hard into the boards.
It was immediately clear he had hurt himself.
After catching his breath, and his senses, Burke was helped by his mates off the ice, where arena personnel gave him a head-injury assessment.
Though he was dazed, woozy and unsure of himself, the assessment tool used by arena staff didn't conclude that he had been concussed. Nonetheless, Burke pulled himself from the game.
“I passed all of their tests with flying colours. Hell, my first weekend wasn't even that bad symptoms-wise. I'd almost started to buy into the idea that I wasn't concussed myself,” he said.
But symptoms soon started to present themselves and, days later, he took himself to see a doctor, who diagnosed him with a concussion.
“As the presentation of symptoms intensified in the following week before I could see a doctor — light sensitivity, insomnia, we're talking one-to-two hours of sleep a night, if that, migraines, inability to focus, declining mood — it became clear to me and then my doctor that I had, indeed, suffered a concussion,” he said.
He hasn't played hockey since. University of B.C. researcher Noah Silverberg said Burke's experience was a familiar one.
“The story that you've described is a pretty typical one and we expect it would continue,” he said. “Anyone can make an apparent assessment. Diagnosis is something that should be left to medical doctors.”
Concussions can be tricky to diagnose, he said, because they often are not detectable with brain scans and the symptoms often vary widely or even overlap with other issues.
Silverberg is an associate professor in the department of psychology at the University of B.C. and, along with Dr. Grant Iverson of Spaulding Rehabilitation Hospital, has just published a study in Archives of Physical Medicine and Rehabilitation that found that although the basic tools to assess concussions were standardized 30 years ago, the methods used by medical practitioners still vary widely, leading often to misdiagnosis.
“We focused narrowly on who has this injury and ensuring equitable access to care,” he explained. “The issue is about consistency, a lot of diagnoses were getting missed and people were getting incorrectly diagnosed.
“A lot of people who had a concussion were not identified as such, maybe because their doctor was using an idiosyncratic method,” he added.
Harjas Grewal is a family doctor in Richmond who has a keen interest in sports medicine. He called the new standards proposed by Silverberg and Iverson's study great news.
“Clear guidelines for use of any diagnosis claim is so key on multiple fronts. This article focuses on how it's important for research, but it'll be important for everything from insurance claims to accessing specialized services to an accurate description for someone's symptoms,” he explained.
“I also think that standardization is the first step to accurately determining the best possible treatment plans and protocols as the research will better align moving forward. It will also work on an education standpoint to tell people that they cannot chalk up their symptoms to poor sleep or fatigue or another cause to avoid the diagnosis of a concussion.”
Clearer standards will also more clearly define who should go into concussion treatment protocol, he added.
“I just hope people don't say, `Well, this patient does not meet all the criteria and so he's all good,' and then potentially rush someone back. I do still hope from a clinical standpoint that we err on the side of caution still even with this change,” he said.
“There's been lots of emerging research and we have moved forward a lot with concussion diagnosis and treatment but there's still room for growth. It will take time for clinicians to adopt this, though, and there might be changes still as their research is scrutinized by other leading researchers across the world.”
One of Burke's teammates, Gord Yamanaka, also suffered a concussion last year when he was knocked over from behind by an opponent. He struck his head on the ice.
In his case, it was pretty clear from the outset that he was dealing with a concussion. His wife took him straight to emergency and, after a four-hour wait, Yamanaka met with a doctor who diagnosed him with a concussion.
“The doc looked me over and gave me a sheet of paper,” he recalled. “It was a Fraser Health sheet about head injuries with symptoms, timeliness, what to expect, etc.”
Yamanaka's followup care was with his family doctor. He's back working but still suffers from headaches and, like Burke, has yet to return to playing hockey.
Silverberg hopes their research will get everyone on the same page and establish a new global standard that can be applied across age groups, health systems and injury circumstances.
“Historically, we've had a bunch of different definitions. Some just used in sports, some in military, but we've learned that this is the same injury, no matter how it occurs,” he explained.
He's also hopeful that their research will bring consistency into the concussion research.
“If different studies are defining concussions differently, the research is hard,” he said. “So having a clear understanding of what a concussion is will make research more consistent.”
Burke, who at the same time was also battling with long-COVID symptoms, struggled with the after-effects of his concussion for quite some time. He missed a work trip around new year's because of his symptoms and then, in early January, his headaches got so bad that he went to emergency, fearing he was suffering from something far worse.
After an assessment, the ER doctor reconfirmed his concussion diagnosis and was able to refer him to a concussion clinic, where Burke does feel like he's finally making progress. The process is slow, but he's getting there.
Burke's doctor and the physician at the concussion clinic believe he's dealing with whiplash as well, and Burke said he's hoping a physiotherapist will be able to confirm the whiplash diagnosis.
This is his fifth concussion, Burke said. The previous ones hadn't led to much post-diagnosis care.
“First one, I was out cold and pretty much immobilized when I came to, so they had the impression it might even be a neck injury and I was taken to emergency in an ambulance where it was confirmed that night.
“The rest? Same deal as this one. Make my way to the doctor, describe what had happened, my symptoms, etc., and get told to rest up for a bit. Usually within a few days of it happening,” he said.
Burke said he's thankful that this time around he's been referred to the clinic, though it frustrates him that it took so long.
“It just seemed like the process to go from family doctor to hands-on care was the real obstacle. It took about two months before I actually spoke to someone at a clinic, then a fair bit longer before I even had an in-person appointment. Based on my experience, I just got the sense that you really have to earn your access to care and the way you do it is with prolonged suffering,” he said.
More than anything, Silverberg hopes his research will lead toward a smoother diagnosis path for all patients.
“If (J.D. or Gord) had gone to a different doctor there's a good chance he might have been assessed with a concussion,” he said. “It shouldn't matter what kind of doctor, you should get the same assessment.”