In a CMAJ practice article, Tator states that “the diagnosis of concussion is not easy.”1 However, the current diagnostic criteria for concussion2 are remarkably rudimentary and state that a single symptom (from a 22-item Likert scale) experienced after head shake, should prompt a clinician to diagnose concussion and institute treatment. Tator does not discuss the difficulty caused by the lack of specificity of the diagnostic criteria for concussion, as they are currently defined.2 Individuals with whiplash, depression, benign vertigo and other disorders all meet the diagnostic criteria for concussion. The problem is that once feelings of everyday life are attributed to a brain injury, concussion is not easily “undiagnosed.”
Tator describes removal from play, work and school as the most important aspects of initial management, but does not provide a citation. Current literature suggests that rest is not effective for the management of concussion.3 Tator also states that all symptoms have to have completely disappeared before an individual is allowed to return to play, work or school. Symptoms of concussion are present in healthy people — the average symptom score for healthy, uninjured people on the concussion Likert scale is not zero.4 The treatment goal of being asymptomatic is not evidenced-based, and has the potential for locking people in an isolated existence, while they wait for symptoms that may have nothing to do with brain injury to disappear. Tator has not discussed the substantial influence that psychological factors have in the genesis and perpetuation of postconcussion syndrome.
Of great concern are the consequences of concussion listed in Tator’s article.1 Second-impact syndrome is a dubious condition which may or may not even exist.5 The paper cited in Tator’s article states “the scientific evidence to support this concept is nonexistent, and belief in the syndrome is based upon the interpretation of anecdotal cases more often than not, lacking sufficient clinical detail to make definitive statements. The fear of this condition has driven many of the current return-to-play guidelines following concussion.”6
Articles such as Tator’s raise fear regarding a condition with an excellent prognosis. A balanced statement that indicates that up to 90% of concussed individuals get better without any intervention within 7 to 10days,7 would help readers understand that concussion is a benign condition, more analogous to the common cold than some sinister dementing condition.
References
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