Treating Concussions Better: An Interview with Brain Injury Expert Joseph F. Waeckerle, MD

MD Magazine recently spoke with Joseph F. Waeckerle, MD, FACEP, Clinical Professor of Emergency Medicine at the University of Missouri, Kansas City, and Editor Emeritus, Annals of Emergency Medicine, who has served for more than two decades on the NFL committees on brain injury.

Click here to read part 2 of this interview.

As the National Football League (NFL) season nears its climax—Super Bowl 50 in San Francisco—the country’s most popular sports league (by a lot) faces a challenge unlike any it has faced in its previous half century. Players of the violent game are getting hurt. And it’s not just broken bones or torn anterior cruciate ligaments—it’s also significant brain injury.

The NFL has been roundly criticized for being slow to create a safer environment for players. The recent movie Concussion, starring Will Smith, paints the league’s prevention and treatment efforts in a poor light. But the NFL has been closely involved in efforts to improve diagnosis and care of head injuries for more than two decades and is currently taking action on several fronts, including on-field rules designed to limit helmet-to-helmet contact, and off-the-field education efforts for players, their family members, and even physicians who may be in position to treat concussions.

Those efforts have culminated in a 90-minute continuing medical education (CME) course, accredited by both the American Medical Association and the American College of Emergency Physicians (ACEP), that covers a number of topics related to concussion, including: epidemiology, prevention and mitigation, recognition, management, and recovery and return to play. The course is potentially helpful for emergency physicians, primary care doctors, family physicians, neurologists, pain management specialists, and even mental health professionals. And it is designed for those treating brain injuries that result from all circumstances—not just sports-related injuries.

We recently spoke with Joseph F. Waeckerle, MD, FACEP, Clinical Professor of Emergency Medicine at the University of Missouri, Kansas City, and Editor Emeritus, Annals of Emergency Medicine, who has served for more than two decades on the NFL committees on brain injury.

Most ED physicians aren’t going to be treating NFL players, but there is great need across the care spectrum to treat both sports-related and non-sports-related head injuries. Tell me what went into this educational effort.

For the purposes of this discussion, we’ll consider mild traumatic brain injury and concussion one and the same, though some people argue differently. There are Genesis of the project, emergency docs, patients seek care for head injuries, truatic brain injuries, 2.5 million visits per year to an ED for patients seeking care for head injuries, and 2.2 million of them are for brain injuries and concussions. With these kinds of injuries, it’s crucial to get the diagnosis right and get it right immediately. The best way to help student-athletes—and many others—in this country is to present a best practices-type course on how to assess, manage, and care for potentially concussed individuals, to both minimize complications and maximize care.

EDs see head injury every day. The moderate and severe cases are easier, in the sense that we have trauma teams and systems, and we know what to do and how to do it. But for mild cases, there hasn’t yet been a consensus on how to take care of it. In past, we tried to apply prescribed standard definitions of what the injury is and how to treat it. That’s not the best way to do it. Every mild traumatic brain injury is different, because every patient is unique. Our goal in developing this course was to give our audience a complete perspective on diagnosis and care that runs the full gamut from diagnosis to return to follow-up treatment.

There is no criterion we can use to diagnose a concussion; it’s a constellation of signs and symptoms. The future may bring a blood test or an x-ray that can simplify diagnosis, but for now we’re dealing with symptoms that require multiple elements of concussion assessment. We wanted to provide practitioners with a discussion on how to do a cognitive exam and, after the concussion is diagnosed, important instructions on how to get proper care and get follow-up, including detailed discharge instructions. We also wanted some education on why what [practitioners] do in the beginning impacts long-term care.

The primary audience for the course is ED practitioners, but talk about how physicians across the care spectrum can benefit as well.

The course could be of value to the pain management community, nurses and physician assistants, primary care physicians—particularly in pediatrics—and family medicine physicians, as well as mental health professionals, all of whom may see these patients after initial care in the ED. The whole treatment strategy for concussions has changed over the last few years. We used to think concussions weren’t treatable—it was just a question of time. Now we know you can make injured brain cells heal more quickly if you follow a treatment strategy that includes rest, monitoring, physical therapy in some cases, and treatment of signs and symptoms that inhibit a return to wellbeing, such as headaches, sleep issues, and depression. If you address those things in a proactive way, patients seem to do better. We’ve stressed some of these new findings.

What are some of the challenges of having such a large, inter-disciplinary team working together to establish a course on concussion treatment?

It was and is a challenge, but over the past few years, there have been many areas of diagnosis and treatment of concussion in which the medical community has reached a consensus. We consulted with concussion experts who are active nationally and internationally to build a consensus on how to improve patient care. We developed the course regardless of the injury mechanism. This is the state of the art right now, and this is what you should do. We all sat down, looked at the very latest evidence, and came to some conclusions on what to include.

In part 2 of our interview, Dr. Waeckerle will discuss the NFL’s controversial role in dealing with concussions, including the real story you didn’t see in Concussion.