By Josh Shore
“I would say it is a Wild West and unfortunately the people who suffer in this culture are kids and families.”
That is how Dr. Nick Reed, concussion researcher and Associate Professor in the Department of Occupational Science and Occupational Therapy at the University of Toronto, described concussion care in Canada during an interview with the Canadian Broadcasting Company (1). But what is this “Wild West” of concussion care? Why does it exist? And how can you find appropriate care if you or someone you know gets a concussion?
Interviewed by rehabINK, Reed explained that the Wild West of concussion care refers to an unregulated field in which any healthcare practitioner can open a private clinic, advertise expertise in concussion, and start charging clients for treatment.
In Canada, healthcare practitioners are licensed by regulatory bodies specific to their professional practice. These organizations protect the public by setting entry-to-practice requirements, enforcing standards of practice, and investigating complaints from the public. For individuals with moderate and severe traumatic brain injury (TBI), medical care and rehabilitation are typically provided by physicians and allied health professionals (e.g., occupational and physical therapists) with licensed specialty training in TBI (2).
But when it comes to concussion, a form of mild TBI, there is limited national or international guidance to dictate the care that is offered, which providers should be involved, and what type of specialty training is required (1,3).
“Anything can happen out there,” said Reed. “There is no real standard of care or coordinated system for concussion.”
“Anything can happen out there,” said Reed. “There is no real standard of care or coordinated system for concussion.”
Although most concussions resolve within a few weeks under appropriate medical guidance, an uncoordinated healthcare system can have significant consequences for the 15-30% of people with concussion who experience persistent symptoms requiring specialty care (4).
“Without standards, regulations, or policing of concussion care, perhaps that can lead to inappropriate care that is not evidence-based,” said Reed. “Engaging in inappropriate care that may not really help families with their issues can be a burden with respect to time and money.”
While many deliver exceptional care, some clinics in Canada indeed provide concussion services that do not adhere to rehabilitation guidelines, and some offer services from professionals with insufficient training (1,3).
Concussion Awareness on the Rise
According to Reed, growing public awareness about concussion has driven the growth of the Wild West as more people now seek medical attention. In Ontario, the number of physician and emergency department visits for concussion has increased substantially over the past 15 years (5,6).
However, with significant wait times in hospital-based clinics, some individuals opt for care from one of the many private concussion clinics that have recently opened across North America (7,8).
While increased care-seeking is positive, ensuring appropriate care remains a challenge.
Training Evidence-Based Concussion Providers
In both hospital settings and private community-based clinics, it is essential that healthcare providers are trained to deliver concussion care according to the best research evidence.
“When training healthcare professionals to deliver evidence-based care, you need to make sure there is fidelity,” said Reed, referring to how providers stay true to the evidence when treating clients. “From the trainer, who might be extremely informed on concussion, down the people they train and how they deliver care in their own community”.
Unfortunately, adequate oversight is not always there to ensure that trained practitioners are delivering the most appropriate care in line with the best available evidence.
Training practices must also keep up with rapidly changing research evidence for how to best treat concussion. The rest-until-symptom-free approach that was the mainstay of treatment for years is no longer recommended (9). Experts now regard concussion as a “rehabilitative injury” that can be responsive to active therapies such as low-intensity exercise, balance training, and vision therapy (10).
While ongoing research allows clients to receive more informed treatment, the challenge lies in making sure practitioners stay current with developments and use the best research evidence to inform the care they give.
“We need to get a sense of why practitioners are not engaging with these guidelines. What are the barriers and facilitators?” – Nick Reed
Bringing Research Evidence to Clinical Practice
Even clinical practice guidelines―resources with specific treatment recommendations for clinicians to use―can lag behind the rapid changes in concussion care research.
“Years of great effort and collaboration go into developing these guidelines,” said Reed. “But when new evidence comes out, it often sits until the next iteration of those guidelines, which could be years later.”
Reducing this evidence-to-practice lag time is why Reed works with the Ontario Neurotrauma Foundation (ONF) to maintain “living guidelines” for pediatric concussion management (11). Along with Dr. Roger Zemek from the Children’s Hospital of Eastern Ontario, Reed leads a team of North American concussion experts with a range of medical and rehabilitation expertise to develop these guidelines. First released in September 2019, the “living” aspect of these guidelines means that recommendations are continuously updated based on the newest research evidence.
“Whenever there is new research relevant to a given recommendation for clinical practice, we reengage our expert team to review that literature and change the guideline in real time,” said Reed.
With this method of continuous updating, clinicians should always have the latest evidence readily available to provide the most appropriate care to their clients.
While this process ensures the guidelines stay current, there remains no guarantee that clinicians will use them. Indeed, only about three-quarters of concussion clinics in Ontario report using formal guidelines most or all the time, according to a 2017 survey sponsored by the ONF (12). Reed contends that more effort should focus on guideline implementation and understanding clinician perspectives.
“We need to get a sense of why practitioners are not engaging with these guidelines,” he said. “What are the barriers and facilitators?”
With answers to these questions, Reed believes the ONF can better support clinicians in using these evidence-based resources to improve the care provided to clients and families.
“These are great products that will make a difference,” he said. “We just need to make sure that they are usable and relevant to the care sector.”
Navigating the Wild West as a Client
Without a coordinated system for concussion rehabilitation, choosing appropriate care can be daunting. Fortunately, the Canadian Concussion Collaborative, comprised of 17 health-related organizations, outlines characteristics of a good concussion clinic to help Canadians make informed decisions (13).
The Concussion Collaborative recommends choosing a clinic with direct access to a physician trained in concussion management (13). This can be an emergency, family, or sports medicine physician, paediatrician, neurologist, neurosurgeon, or physiatrist. Unfortunately, many clinics advertising concussion services in Canada do not indicate access to a physician (3).
Physician diagnosis is important to differentiate concussion from other conditions, such as more severe brain trauma, neck injury, or significant mental health concerns. Physicians can also direct targeted treatments based on comprehensive assessments, and along with nurse practitioners, are the only healthcare professionals qualified to provide medical clearance for return to sport, school, and work-related activities.
Since concussion symptoms are diverse and vary from individual to individual, it is essential to select a clinic with a multidisciplinary team of licensed healthcare professionals (13). According to Reed, this team approach can identify specific deficits in individual cases and determine which healthcare professional can best help manage those deficits. Yet, few clinics offer this complete multidisciplinary team of healthcare professionals with experience in concussion (3).
Standards of care are further supported by recommendations from the Concussion in Sport Group Consensus Statement (10) and ONF guidelines (11,14). Good clinics should only use tools, tests, and therapies supported by research evidence and expert recommendations.
With the goal of “having the right care, delivered at the right time, by the right provider,” the ONF also released Standards for Post-concussion Care to help clients understand the type of care they should expect from concussion clinics and service providers (4). The Standards are designed to improve the coordination of concussion services in Ontario by outlining a pathway of care and by describing the roles of various healthcare providers in managing concussion.
The Road Through the Wild West
Without regulated standards of practice, concussion care in Canada can be given by healthcare personnel with varied levels of training, some of whom provide services inconsistent with research evidence and expert recommendations (1,3).
To improve access to appropriate care, Reed says Canada needs a coordinated system in which anyone who experiences a concussion knows exactly where to go, who they will see, and what type of evidence-based care they are going to receive.
Ensuring evidence-based concussion care will also require further efforts focusing on knowledge translation―the process of disseminating research evidence into clinical practice―to facilitate the implementation of clinical practice guidelines.
Finally, coordinated care also means addressing wait times and accessibility issues, which Reed says will require collaborative efforts across sectors of healthcare and government.
“We need to come together as a system from policy down to delivery of care to ensure that people in Canada, wherever they are, have access to high-quality, evidence-based multidisciplinary care that is necessary to manage concussions,” said Reed. “Right now, we are a ways away from that, and it’s going to take all of us together to get there.”
Featured illustration by Anique McIntosh for rehabINK.
To refer to this article, it can be cited as:
Shore J. Concussion in Canada: Exploring the “Wild West.” rehabINK. 2020:9. Available from: https://rehabinkmag.com
- Crowe K. Private concussion clinics called a “Wild West” of unregulated treatment [Internet]. Canada: Canadian Broadcasting Company; 2016 Nov 3. Available from: https://www.cbc.ca/news/health/concussion-hotline-baseline-testing-treatment-industry-for-profit-unregulated-1.3833158
- Bayley M, Swaine B, Lamontagne ME, Marshall S, Allaire AS, Kua A, et al. INESSS-ONF Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury [Internet]. Toronto, Canada: Ontario Neurotrauma Foundation; 2016. Available from: https://braininjuryguidelines.org/modtosevere/
- Ellis MJ, Ritchie L, Selci E, Chu S, McDonald P, Russell K. Googling concussion care: a critical appraisal of online concussion healthcare providers and practices in Canada. Clinical Journal of Sport Medicine. 2017;27(2):179-82.
- Standards for post-concussion care: From diagnosis to the interdisciplinary concussion clinic [Internet]. Toronto, Canada: Concussion Advisory Sub-Committee of the Ontario Neurotrauma Foundation; 2017. Available from: http://concussionsontario.org/wp-content/uploads/2017/06/ONF-Standards-for-Post-Concussion-Care-June-8-2017.pdf
- Zemek RL, Grool AM, Duque DR, DeMatteo C, Rothman L, Benchimol EI, et al. Annual and seasonal trends in ambulatory visits for pediatric concussion in Ontario between 2003 and 2013. Journal of Pediatrics. 2017;181:222-228.
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- Gillmor D. Concussion business is booming, but players are still taking a hit [Internet]. Toronto, Canada: Toronto Star Newspapers Limited; 2015 Jun 7 [cited 2020 May 20]. Available from: https://www.thestar.com/news/insight/2015/06/07/concussion-business-is-booming-but-players-are-still-taking-a-hit.html
- McFarling UL. Concussion, Inc.: The big business of treating brain injuries [Internet]. STAT; 2016 Dec 16 [cited 2020 May 20]. Available from: https://www.statnews.com/2015/12/16/concussion-brain-big-business/
- Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. Journal of Head Trauma Rehabilitation. 2013;28(4):250-9.
- McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine. 2017;51(11):838-47.
- Reed N, Zemek R, Dawson J, Ledoux AA, Provvidenza C, Paniccia M, et al. Living guideline for diagnosing and managing pediatric concussion [Internet]. Toronto, Canada: Ontario Neurotrauma Foundation; 2019. Available from: https://braininjuryguidelines.org/pediatricconcussion/
- York University Institute for Social Research. Survey of Ontario clinics providing concussion services [Internet]. Toronto, Canada: Ontario Neurotrauma Foundation; 2016. Available from: http://concussionsontario.org/wp-content/uploads/2016/07/Survey-of-Clinics-Providing-Concussion-Services-2016.pdf
- 4 characteristics of a good concussion clinic [Internet]. Canada: Canadian Concussion Collaborative; 2017 Jul. Available from: https://casem-acmse.org/wp-content/uploads/2018/06/CCES-PUB-CCC-4Qs-E-FINAL.pdf
- Marshall S, Bayley M, McCullagh S, Berrigan L, Fischer L, Ouchterlony D, et al. Guideline for concussion/mild traumatic brain injury and persistent symptoms: 3rdedition (for adults 18+ years of age) [Internet]. Toronto, Canada: Ontario Neurotrauma Foundation; 2018. Available from: https://braininjuryguidelines.org/concussion/index.php?id=158