A 15-year-old rugby player with a head injury

Like many of the CMAJ readers, I welcome articles that support and further develop the Choosing Wisely Canada initiative. The recent article on management of concussion is a good example.[1] At the same time, as has been recently pointed out in the United States[2], the topics chosen for Choosing Wisely and the evidence for the advice given will come under close scrutiny. In our enthusiasm for developing wise choices, we may tend to provide advice that is not evidence-based, though well meaning.

Having been a part of the Canadian Rheumatology Association's Choosing Wisely recommendations, it is clear that finding the evidence to support a particular issue is not always easy.[3]

Pham and Zemek[1] provide advice regarding patients with concussion. In that advice is the statement "Keep a diary to identify triggers for fatigue...." There are two problems with this advice. First, it is not clear how this helps recovery other than to focus a patient on the particular symptom of fatigue, a symptom so common in the general population and with so few interventions, that tracking it may not be informative or helpful. Second, and more importantly, diary use may impair recovery. Even in healthy subjects without injury, it has been shown that keeping a symptom diary amplifies and increases recall of ordinary, every-day symptoms.[4] This cannot be expected improve one's sense of good health. It has been also been shown, albeit in adults, that keeping a diary reduces the recovery rate from both acute whiplash injury and acute low back pain injury.[5,6] These effects are not trivial, and until it can be shown that keeping any type of pain or symptom diary improves outcomes in head injury, we should be cautious in making this recommendation, or our advice may become part of the problem, and not the wisest choice.

References

1. Pham, H, Zemek, R. A 15-year-old rugby player with a head injury CMAJ January 12, 2015, cmaj.141089

2. Kerr EA, Chen J, Sussmna JB, Kalmerus ML, Nallamothu BK. Stress testing before low-risk surgery. So many recommendations, so little overuse. JAMA Intern Med. Published online February 09, 2015. doi:10.1001/jamainternmed.2014.7877

3. Chow SL, Thorne C, Bell MJ, Ferrari R, Bagheri Z, Boyd T, et al. Choosing Wisely Canada. Canadian Rheumatology Association: five things physicians and patients should question. J Rheumatol Published online January 27, 2015. doi: 10.3899/jrheum.141140

4. Ferrari R, Russell AS. Effect of a symptom diary on symptom frequency and intensity in healthy subjects. Journal of Rheumatology 2010; 37:2387- 2389.

5. Ferrari R, Louw D. Effect of a pain diary use on recovery from acute whiplash injury, a cohort study. Journal of the Zhejiang University- Science B 2013;14(11):1049-1053.

6. Ferrari R. Effect of a pain diary use on recovery from acute low back (lumbar) sprain. Rheumatology International 2015:35:55-59.

Conflict of Interest:

None declared