Survey of chiropractic clinicians on self-reported knowledge and recognition of concussion injuries

Mild traumatic brain injury (MTBI) is defined as a “low velocity injury that causes brain ‘shaking’ resulting in clinical symptoms, that are not necessarily related to a pathological injury [1].” It is commonly used synonymously with the term concussion and can result in one or more of a variety of neurological symptoms, which are often inconspicuous. A 2006 Center of Disease Control (CDC) estimate of the prevalence of traumatic brain injuries (TBI) was reported at 1.7 million annually in the United States [2] This was updated by the CDC in 2015 to 2.5 million TBI presenting to emergency departments annually [3]. This increased reporting may reflect increased incidence, detection or awareness. The actual prevalence for diagnosis of MTBI are estimated to be even higher than the reported figures, due to unaccountable care from private physicians and allied health practitioners vs hospitals who report [4‐6]. Many patients also do not seek care or not aware of their injury, further decreasing the reportable incidence [4‐6]. In addition, there often is no reporting of the symptoms for fear of restrictions of activities or due to psychosocial pressure [6, 7]. It has been found that next to falls, the highest cause of traumatic brain injuries (TBI) is from motor vehicle accidents This has been reported to be 17.3% of the cases reporting to emergency rooms [8, 9]. Chiropractic care is commonly sought by motor vehicle accident (MVA) patients. In fact Dalby mentions that the chiropractic physicians are often the first provider to see head injured patients [10] and Hartvigsen also acknowledged the seeking of chiropractic care [11]. A minimal number of case studies have been published or presented at research conferences that demonstrate improvement in MTBI with chiropractic care [12, 13].

A search of PubMed (2000–2017) for “mild traumatic brain injury prevalence and chiropractic” generates 8 citations without any of them really addressing the prevalence in the chiropractic office or the knowledge or recognition of MTBI by chiropractic clinicians. [3‐5] A recent study by Moreau et al. did discuss chiropractic sport physician recognition of TBI by reporting that chiropractic sport physicians agree with use of Sport Concussion Assessment Tool-3rd edition (SCAT3) as a standardized sideline assessment tool to recognize TBI [5]. Cassidy estimated that between 70 and 90% of all treated TBI are mild traumatic brain injuries (MTBI) [14].

Given this high percentage of MTBI; the risks of insufficient knowledge or skills to recognize MTBI can be devastating. It can result in lack of appropriate care. This may also include premature release of the patient to full activities, prior to the resolution of the acute inflammation. Premature release complications may include second impact syndrome, prolong post-concussive syndrome and increased morbidity, disability and mortality [15]. The extent of this problem in chiropractic MTBI patients is unknown. There has not been sufficient study of the prevalence of MTBI presenting to chiropractic offices.

There has been little study of the recognition of MTBI by the chiropractic practitioner, or the inquiry by the clinician to assess those patients who do not report the symptoms. Although severe cases of TBI are more often recognized and treated by attendance to hospital or emergency room [14], MTBI is less recognizable and would present a long-term risk to the patient. Thus, training of the clinician in the subtle signs of MTBI is imperative, given the clinical risk associated with failure to recognize such injuries. What we currently know about training in the recognition of MTBI is from limited recent knowledge based studies. One recent study of fourth year chiropractic interns and residents indicated that chiropractic students are as knowledgeable as medical students, although both have gaps in knowledge [16]. It revealed a need for further training of all the clinicians. An earlier study by Taylor et al. investigated the use of a survey to assess the MTBI knowledge of chiropractic and medical practitioners. This was a small pilot study of the survey instrument which appeared to indicate no difference between the medical and chiropractic practitioners in recognition of MTBI, [17] with mutual gaps in MTBI knowledge present. Review of the survey instrument demonstrated possible confusion and/or misinterpretation of the survey items. Therefore, the current study is intended to utilize a modified version of the survey instrument to investigate the chiropractic MTBI knowledge, recognition and common procedures.

There were125 attendees at the seminar in which the survey was distributed. There were 54 respondents for a 43% response rate.

Analysis of MTBI knowledge of the chiropractic clinicians demonstrated that a perfect score of 6 was not achieved by any of the respondents. The entire cohort had scores between 0% and 67%, with only 16% getting 3 or 4 correct answers, out of six items.

The cohort groups of clinicians (Table 1), demonstrated no significant difference between the performances. The Knowledge Quiz results were subsequently pooled.

There was a statistical difference in average knowledge quiz scores between those who often diagnosed MTBIs and those who reported that they would always diagnose MTBI correctly (p = 0.02). Interestingly, while the clinicians were confident in their ability to diagnose MTBI, those who claimed to always diagnose MTBI only scored 37% ± 5% in the knowledge quiz, while those who claimed to often diagnose MTBI only scored 24% ± 3% (Fig. 1).

A comparison of confidence vs knowledge revealed that those who said they always could recognize MTBI, scored significantly higher than those who felt that they often could recognize MTBI symptoms. The overall knowledge score indicated that those who were confident (always or often) in their diagnostic abilities scored no better than those who were not confident in MTBI recognition, 30 ± 18% and 33 ± 20% respectively. There is no significant difference in ability to recognize and diagnose MTBI between the general practitioner (GP) and the specialist. In fact, there was a slight inverse relationship, when comparing the confidence of the general practitioners to the specialists (Fig. 2).

Item 2 responses indicate that the frequency of MTBI patients presenting to the general chiropractic practitioner and specialists was less than one per month. This response may be lower than the actual number of MTBI patient presentations due to the knowledge quiz score indication of a possible under-diagnosis. This is especially noted when we analyze the knowledge of evaluative tools.

Such knowledge of the evaluative tools utilized to diagnosis MTBI was assessed by item #7. (Fig. 3) It indicated that 69% of the respondents used clinical exams and history for diagnosis of MTBI. None used Balance Error Scoring System (BESS), less than 20% utilized Standardized (Sport) Concussion Assessment Tool (SCAT) or Neuropsychological testing. Almost 40% use a symptom check list. Specialists were more likely to use SCAT compared to general practitioners (24% compared to 8%). Interestingly general practitioners (GP) were reported to be more likely to use neuropsychological testing compared to specialists.

The doctors were asked about inquiry to the patient’s significant others (or inquiry to the patient about comments from significant others). Seventy percent (70%) of GP and 88 % (88%) of specialist respondents indicated that they inquired about the common symptoms and cognitive changes greater than 50%of the time.

In the analysis of action steps of the practitioners following a suspected MTBI, 49% of the general practitioners would order imaging. Seventy six percent (76%) would refer to a neurological specialist. Only 14% would treat the patient symptomatically, while only 3% would only prescribe rest. Eleven percent (11%) would provide or recommend alternative treatment. Other actions included diagnostic workup which included co-management with physician, ordering PET scan or referring to Emergency Department.

Item (10) sought to specifically inquire about the clinician’s knowledge of post-concussion syndrome. Of 54 clinicians, 35 answered item 10 incorrectly, while 19 answered the item correctly. When the scores of the general knowledge quiz for each of these groups were assessed, the clinicians who answered item 10 correctly scored significantly higher than those who answered item 10 incorrectly (39 ± 16% versus 22 ± 16%, p = 0.0002) (Fig. 4). Interestingly, both groups scored well below 60% for their general knowledge of post-concussion syndrome.

The purpose of this paper was to investigate the recognition, knowledge, and common procedures of chiropractic physicians when a potential mild traumatic brain injury patient presents to their office. This was done through implementation of a self-reported survey instrument utilized by a previous pilot study [17]. The study population consisted of only chiropractic physicians in general practice and specialty board certification and/or practice.

There was no difference in MTBI recognition between types of chiropractic practitioners. There is little revealed in the literature from any previous studies of MTBI recognition via general vs specialist types of practitioner. The lack of a significant difference in ability to recognize and diagnose MTBI in this study must be taken in the context of the universally very low scores. This would indicate that some symptoms are not being recognized. Both GPs and specialists are poor at recognizing the MTBI. Some symptoms are not being recognized by both GPs and specialists.

The lack of sufficient overall symptom recognition of MTBI demonstrated in this study was due to insufficient knowledge of the subtle signs and symptoms, an over reliance on the history and the exam and a lack of follow up with more specific testing such as the BESS, physical exam or screening with standardized neuropsychological tools. This conflicted with the self-reported degree of patient inquiry of the common signs and symptoms. The practitioner knowledge quiz seemed to contradict the confidence of the doctors in their clinical evaluation. This would result in insufficient prognosis, patient education and follow up. There appears to be a level of doctor over-confidence in their own abilities to recognize and manage MTBI, which may result in increased risk of long term sequela.

An earlier study [17] revealed a lack of recognition of major signs of MTBI and insufficient inquiry of minor signs of MTBI [17]. The findings in this current study concur with the earlier pilot study, [17] indicating a lack of sufficient knowledge and recognition of MTBI by DC’s. This also appears to demonstrate a similar deficiency in knowledge when compared to a small study on pediatricians [19]. The low degree of knowledge of assessment tools concur with studies performed on emergency room physicians, pediatricians, and primary care family physicians regarding knowledge transfer of assessment tools and consensus statements [20, 21]. Clinicians still rely upon their physical exam findings without utilizing assessment tools, or balance testing [21]. The extent of use of neuropsychological testing by the GP over the specialists appears to be attributed to an error in judgment or mistaken meaning of the test. This type of testing is intensive, time consuming, and the GP is commonly not trained in its administration.

Although 27% of the respondents indicated that the majority of their TBI training was obtained in the doctoral program (Q15), there was a demonstrated insufficient knowledge in diagnosis and recognition of MTBI and 70% of the respondents had to seek their knowledge through post-graduate training, self-study, experience or other means. This would indicate a need for further emphasis on traumatic brain injury education in the chiropractic doctoral programs. Although Kazemi’s findings that chiropractic fourth year interns answered TBI knowledge survey items correctly more often than fourth year medical students [16], gaps were still present. The knowledge gaps demonstrated by Kazemi were also present in this current study. This was especially noted regarding SCAT 3 knowledge. However, the current study group showed increased knowledge of second impact syndrome when compared to Kazemi’s group (76% vs 57%). The signs and symptoms of MTBI are often subtle when compared to moderate and severe traumatic brain injuries. They can have one or more signs involving attention, cognition, mild signs of anterograde or retrograde memory loss and/or emotional changes [22]. These signs are often not as recognizable on physical exam or by significant others. The survey item of common action steps performed indicated that most of chiropractic practitioners are more likely to refer MTBI patients for either diagnostics, transfer of care or co-management of the patient. Further education should include common causes of the condition, symptom recognition, history taking, instruction in the common evaluative tools that could be utilized in independent clinical practice, and the current international guidelines for care of the traumatic brain injured patient. It is interesting to note that 95% of the clinicians stated that they would be interested in continuing education in MTBI.

The self-reported MTBI knowledge, recognition and treatment by chiropractic practitioners is incongruent with the knowledge demonstrated via the knowledge survey items answered by the chiropractic physicians. There appears to be overconfidence in the recognition of MTBI by the practitioners without the demonstrated knowledge. When a mild TBI patient presents to a chiropractic office, the subtle signs may be frequently missed. This would result in a diagnosis not rendered and follow up treatment or advice not provided. Further doctoral education and continuing education in recognition of mild traumatic brain injuries is needed.