Concussion Care Disparities
Bias in Medicine
Despite researchers aiming towards nonpartisan objectivity, medical science continues to be influenced by current and past societal power structures. It is crucial to recognize that US history is plagued with racial injustice that nurtured systemic racism, which still exists today. Learn more about systemic racism here. As a result of living in a society with systemic racism, we all unknowingly hold views based on stereotypes, known as implicit bias.
Recent studies on implicit bias and equitable healthcare reported in Health Affairs show that “racial and ethnic minorities and women are subject to less accurate diagnoses, curtailed treatment options, less pain management, and worse clinical outcomes.” When tackling treatment for concussion—a relatively new area of research and care, where resources are difficult to find for all individuals, it is imperative to aid individuals who are particularly vulnerable to the effects of current care disparities in health care.
Contents
Racial Disparities
Although there are a few objective tests for concussions that are recently FDA-approved, such as a test that tracks eye movement, only a few clinics have implemented such methods. Therefore, the majority of concussion diagnosis relies heavily on proper patient-doctor communication. In minority populations, concussions are even more challenging to diagnose because doctors may hold implicit biases and patients may face racial discrimination. As a result, discrimination and implicit bias lead to a miscommunication between the patient and medical professional, often leading to incorrect diagnoses.
Diagnosis and Mechanisms of Injury
A recent study found that non-Hispanic Non-White adolescents who visit the emergency room (ER) have lower concussion diagnosis rates and are more likely to sustain a concussion through an assault than their non-Hispanic white counterparts.
Black children are 34% less likely to receive a concussion diagnosis when compared to white children.
On average, Black children visit the ER less than white children with a concussion.
Amongst those who received a diagnosis, Black children are 3.8 times more likely to obtain a concussion from assault than from sports.
These statistics highlight significant discrepancies in concussion care received by Black patients compared to white patients. These discrepancies may exist because minority populations are less likely to have access to medical facilities and Medicare/insurance as a result of systemic racism. Accessibility to healthcare is a significant issue as concussions need to be diagnosed by medical professionals for patients to receive proper treatment. Furthermore, as mentioned before, discrimination and implicit bias also create barriers for minorities seeking concussion care.
There are many signs, and symptoms of concussions (a more comprehensive list can be found here), and not every patient exhibits the same symptoms. Concussion diagnosis is a clinical diagnosis, meaning it is diagnosed based on the signs and symptoms that the healthcare provider observes and the patient reports.
Assault as a Mechanism of Injury
Another study found that Black children are more likely to obtain concussions from assault than white children. However, this may be because medical practitioners are more likely to suspect assault for minority patients because of racial stereotyping. The study also found that sports-related concussions (SRC) and assault-related concussions (ARC) differ in initial signs and symptoms, such as ARC patients being more likely to report a “decline in grades.” There were also differences in the treatment received by ARC and SRC patients, with “ARC patients [receiving] less concussion-specific diagnostic evaluation.” These results are indicative of a need for more research on the subject.
When it comes to improving concussion diagnosis for Black and other people of color (BIPOC), it is difficult to break down the barriers created by years of systemic racism. Still, a good starting point would be to increase research into the relationship between race and concussion symptoms. For example, a study in Applied Neuropsychology: Adult found significant differences in the post-concussion symptoms presented in individuals with different racial identities. More research into the topic will allow medical providers to be more aware of the differences and thus increase accuracy in terms of diagnosis.
Perhaps by more awareness, reducing implicit bias is essential to increase the rate of concussion diagnosis for racial minorities. Although most individuals are unaware of their own biases, educating medical providers about common biases and unlearning them is a good start.
Race and Concussion Education
Black athletes had significantly lower scores on a concussion symptom knowledge assessment than white athletes in a study conducted by researchers Wallace et al. published in The Journal of Head Trauma Rehabilitation. Moreover, the researchers noted that Black athletes were less likely to identify “a variety of sleep, affective, somatic, and cognitive symptoms” for concussion.
Primary education of concussion symptoms may make it easier for minorities to navigate concussion care. As mentioned before, minorities are less likely to receive concussion diagnoses and may face racial discrimination. Proper knowledge of the signs and symptoms of concussion can help minorities better advocate for themselves when facing systemic racism. However, it is crucial to recognize that discrimination is a systemic issue, and minorities should receive proper concussion care regardless of prior concussion education.
The study by Wallace et al. mentions that “16% fewer Black athletes gained concussion knowledge from school-based professionals...than white athletes”. This disparity is worrying, considering that most of the athletes participating in the study were at risk of a sports-related concussion in high school. Another article reports that Black athletes who had high school athletic trainers were more likely to have comprehensive concussion knowledge than those who did not have athletic trainers. Furthermore, a previous issue of the Concussion Alliance Newsletter (in the Culture section) reports that lower funded schools, with a majority BIPOC student body, are less likely to have athletic trainers.
The proper solution to achieve equity in concussion education is to identify institutions that lack adequate concussion modules and help those students learn more about concussions at a young age. This change will help bridge the gap in concussion knowledge at a fundamental level.
Race Norming
Race Norming is the practice where baselines are set separately for different races. In the case of concussions, this may mean a different set of severity based on race. Historically and now, race norming has had the most significant effect on the wellbeing of Black people. It is a practice that has been debunked and outlawed for employment purposes in the Civil Rights Act. However, until recently, the NFL has used race norming to determine whether an athlete receives compensation for suffering from traumatic brain injuries (TBIs). In this case, the testing used to determine whether or not an athlete has suffered from a TBI had a lower cognitive ability baseline for Black athletes than white athletes.
An article from NPR reports there is suspicion that white players are two to three times more likely to be accepted for the payout than Black players. However, in a new court settlement, the NFL has agreed to quit all race norming practices. Although there has been considerable progress, it is disappointing to see how long this practice continued in the NFL and shows that race norming still exists today in almost every field.
More information on NFL’s race-norming can be found in the articles below:
Vox on Race Norming in Medicine; NYT Report Racial Disparities in Concussion Care for NFL Players; WSJ on Race-Norming in the NFL
Gender
According to a study by Children's Hospital of Philadelphia, female athletes seek specialty medical treatment later than male athletes for sports-related concussions (SRC). This could be one reason for the recent research showing that women suffer more concussions than men, have more severe symptoms, and are slower to recover. Thus, more research into concussions in women is essential for gender-specific prevention and treatment strategies. For another source about how concussions disproportionately affect women, please see this volume of Brain Injury.
Women in Sports
Research suggests that female athletes are more likely to experience a concussion in any given sport, have more severe symptoms, and take longer to recover. Nature.com provided a comprehensive overview of why women athletes experience concussions more frequently and of greater intensity in “Why sports concussions are worse for women.” Further, a study in The American Journal of Sports Medicine found that female athletes were less likely to be removed from gameplay than their male counterparts in the same sport.
Domestic Violence
Domestic violence against women provides another way concussions affect women especially intensely. This study explores how brain injury sustained from intimate partner violence (IPV) can lead to deficits in cognitive-motor function. Another study found that only 35% of the women who were hit in the head or strangled during IPV received medical treatment, even though many reported losing consciousness or feeling confused. The authors urge organizations serving IPV survivors to screen for brain injury and refer TBI patients to neurorehabilitation services. For more information about recognizing, understanding, or advocating for those affected by IPV-related traumatic brain injuries, please visit this source. Also, for information about TBI screening for shelter-seeking women with IPV head injuries, please see this study.
Women and Pregnancy
The Journal of Head Trauma Rehabilitation published a study that found that two years after their injury, the pregnancy rate of women who sustained a concussion was 76% lower than extremity-injured women. Further, the concussed women who experienced “menstrual and/or sexual dysfunction” six weeks post-concussion had an even lower pregnancy rate of 84% less than the extremity-injured group.
Hormones
A Journal of Head Trauma Rehabilitation study found that women who were injured during the last two weeks of the menstrual cycle, in the luteal stage, had worse concussion symptoms than women who were injured in the first two weeks, the follicular phase, and worse than those taking contraceptive pills. Progesterone, which produces a calming effect and can improve cognitions and symptoms of concussion, is highest at the luteal phase and lower at the follicular phase. For more information about how hormones create differences in how women experience concussions, please visit the sources below.
Hormone Therapy; Endocrine Responses to Sport-Related Brain Injury in Female Athletes; Peripheral blood neuroendocrine hormones are associated with clinical indices of sport-related concussion
Women Service Members and Veterans
A Stanford article analyzing a study by Odette Harris et al. explores how veteran women’s trauma recovery differs from men’s. Through the analysis of the Department of Veteran Affairs, Harris et al. noticed “gender difference in the aftermath of traumatic brain injuries.” They found that cortical thinning after concussion, which may be associated with unexpected behavioral trends, neurological diseases, and more intense post-concussion symptoms, was worse in women than men. Further, they found that women had “higher rates of depression, substance abuse, memory problems and homelessness” than veteran men with brain trauma. Finally, women are 30% more likely to suffer from PTSD and vertigo than males after a TBI.
People with Impairments due to Concussion Symptoms
Concussion symptoms can be disruptive and disabling. Because cognitive dysfunction, headaches, and vision changes are common post-concussion symptoms, finding and accessing healthcare can prove an overwhelming task for post-concussion patients.
Challenges Accessing Healthcare and How Providers Can Help
While finding quality healthcare can be difficult for everyone, those with cognitive challenges can find it especially daunting. Further, concussions may result in physical and mental changes, leading to headaches and emotional triggers. Laura Jantos is a healthcare IT consultant and patient advocate who suffered from a snowboarding accident that left her with a traumatic brain injury and cognitive dysfunction. In an interview with Healthcare IT News, She emphasizes that “there needs to be options for phone-based encounters, video, and combination of analog and digital.” Overall, there needs to be a multitude of options for the patient to connect with the provider so that they can interact with them in a meaningful way.
Jantos suggests that telehealth may be another route for making healthcare more accessible for patients, as transportation, public spaces, and accessibility hurdles in clinics are often obstacles for people who are disabled. However, if not provided correctly, telehealth may even further health inequities for those within that population. Difficulties navigating screens and fatigue can be barriers to accessing telehealth for concussion patients. Also, without a physical exam, diagnosing a concussion or addressing chronic pain may prove challenging or impossible.
Concussion Alliance aims to help those with cognitive challenges after concussion through the use of the yellow speaker icon at the top of each page, which will read the entire page to the audience. Further, this page provides helpful information on how to manage light and sound sensitivities.
Telehealth may worsen digital divide for people with disabilities; Ensuring full participation of people with disabilities in an era of telehealth; Disability Rights Education & Defense Fund; World Institute on Disability
How Family Can Help
Many common myths about concussions circulate the media. For example, rather than leaving the patient in a dark room without stimulation, which can be detrimental to the healing process, concussion patients should have an active recovery. Knowing the myths about concussions and becoming educated about concussion research is one of the many things that family members can do for concussion patients to help them towards recovery.
Supporting Active Recovery
By helping your family member have an active recovery in which they try some physical and cognitive activities that do not carry risk for reinjury can help them recover quicker than excessive rest. See the pages below for more information on how to maintain a healthy active recovery.
Aerobic exercise as therapy; Graduated Exercise Therapy; Guidelines for Recovery
Youth Support
The importance of social support during youth concussion recovery cannot be understated. Please visit the resources below for options for youth social support.
Social support during youth concussion recover; Youth Concussion Awareness Network (You-CAN)
Helping at Home and In-Clinic
Tasks like accessing healthcare or duties around the house may become difficult, so asking the family member how you can be of help can be very relieving. Driving to and from treatment may be very helpful, especially if the loved one cannot drive due to symptoms or if taking public transportation becomes a sensory overload. Once at the clinic, family members can help by writing down what happened, especially if the patient has experienced memory issues or confusion. Further, because in-clinic visits are so short, family can help patients organize what the physician needs to know most. Finally, offering your presence during at-home therapy can be helpful to keep the family member on track with recovery and for company. For options and information about support through concussion recovery, please see the sources above.
Intersectionality and Resources
Although we only addressed racial, gender, and ability disparities in healthcare, we want to acknowledge that there are many other disparities within this system, including socioeconomic status and age. The following organizations are working towards equitable care for many populations above. The video above shows Monique Pappadis answering questions about how minority women are affected disproportionally by concussions. She has also published this article, which explains how Native American and Black women are at an increased risk for mTBIs due to domestic violence.
Soar (IPV and Gender Disparities)
National Collaborative for Health Equity (Racial Disparities)
Congressional Black Caucus Foundation (Racial Disparities)
American Public Health Association (Racial and Gender Disparities)
Undoing Racism by the People’s Institute for Survival and Beyond (Racial Disparities)
We also understand that the identities explored on this page and those mentioned above do not exist independently. For example, some people may identify with more than one identity listed above (e.g. women of color).
Concussion Alliance will develop a page dedicated to finding low-cost and accessible treatment for those without healthcare and will continue to work on the accessibility of the website itself.