Concussion Information on the Move: The Role of Mobile Technology in Concussion Management
Introduction
Mobile applications ("Apps") harness the power of the Internet with the simplicity of multi-touch technology on a small screen, and have seen significant growth in the last five years. Health Apps offer tremendous potential as they can be specifically geared towards particular conditions, in addition to focusing on providing support for specific users (such as practitioner, patient and carer communities). Research into the use, design and potential of health Apps for specific conditions is sparse at present, including concussion-related Apps. The aim of this paper is to examine the potential of mobile technology to be used in concussion management, both for the dissemination of best-practice concussion information and in online concussion communities. It provides an overview of currently available concussion-related Apps and evaluates the potential benefits and risks of using mobile technology in this manner.
Background
The emergence of the Internet has led to a fundamental shift in the way people communicate, with online information now capable of being disseminated irrespective of location or time. In recent years health and medical services have gradually shifted away from the traditional doctor-client relationship. Individuals now use the Internet to seek health information and medical support before, after or in lieu of personal consultation. The example of the United Kingdom shows that the continuity of the traditional doctor-patient relationship, whereby patients saw the same physician over a period of years, has gradually eroded. An increasing reliance is now placed on healthcare "buffer systems" such as frontline administration at doctors' surgeries and NHS (National Health Service) Direct, a telephone and Internet based service which facilitates access to healthcare information. These buffers are being used as a first point of contact for patients's health queries and for making decisions on whether a physical appointment at that time is necessary. As a consequence some patients are being forced, whilst others are deciding proactively, to take the initiative in seeking healthcare information online.
Online Support Groups
As the development of telemedicine - where health assessment and intervention services are provided through communication technologies (Forducey et al. 2003) - has increased, so has peer-to-peer interaction via online support groups. These groups have been suggested as being beneficial for patients with a wide range of conditions including Arthritis (Hadert & Rodham 2008), Breast Cancer (Bender et al (2011), Psoriasis (Idriss et al 2009), and Fibromyalgia (van Uden Kraan et al. 2009). Online support groups have also been shown to help address the emotional and social needs of patients with traumatic brain injury (Hibbard et al. 2002). Although such groups have many benefits to those using them, it should be recognised that supportive communal technology may not always be advantageous for health users. A notable example is the online pro-anorexia movement (Fox et al. 2005) which uses the Internet to disseminate an anti-recovery perspective. The movement encourages a non-healthy diet to sustain an anorexic way-of-life, and recommends the use of weight-loss pharmaceuticals to pursue and maintain low body weight. Munchausen by Internet (MBI) was originally identified by Feldman (2000) and describes an individual seeking attention by playing out a series of dramatic near-fatal illnesses and recoveries that increasingly strain credulity. Although this disorder does not yet appear as a heading in a diagnostic manual, it is a situation that is appearing with increasing frequency as the reach of the Internet increases. MBI can have devastating effects on online discussion groups, destroying trust in the group when the hoax is exposed (Pulman & Taylor 2012).
The Rise of Mobile Internet and Mobile Apps and their potential use in Healthcare
Mobile phones are now a ubiquitous part of global life with two-thirds of the world's population - over 4 billion people - now having access to a mobile phone (Pulman et al. 2012). Mobile services have a coverage rate of nearly 100% in Europe, with 400 million Europeans (80% of the population) having access (GSMA Europe 2008) and mobile services are used across all age groups and socio-economic population segments. In recent years mobile devices have become more flexible and capable of handling an increased range of functionality, and the ability to record audio and video has enabled them to become portable multimedia repositories. Locative GPS technology, web browsing, and email have brought enhanced functionality to mobile devices rivalling that of laptop and desktop computers.
Apps harness the power of the Internet with the simplicity of multi-touch technology on a small screen and can run on computers, Smartphones or tablets (e.g. the iPad). In 2007, Steve Jobs launched Apple's App Store with 500 applications (Ricker 2008). By 2011, over 200 million worldwide users had downloaded 15 billion Apps from the App Store and it now offered more than 425,000 Apps including a variety of health based Apps (Enhanced Online News 2011). Owned and operated by Google, the growth of Android has been just as fast with more than 100 million Android devices activated worldwide and over 200,000 Apps (including health related Apps) available via Android Market, Google's online App Store (Barra 2011).
In the UK Survey on Internet use (Office for National Statistics 2010), the mobile phone was found to be the most popular device used to access the Internet wirelessly, away from the home or workplace. Mobile phones also play an increasingly important role in social networking, as 23% of UK mobile web users now visit a social network through their handset (4% more than the US) (Nielsen Online 2009). Pearcy (2011) notes in the infographic "A Day in the Digital Life" that 35% of Smartphone users turn on Apps before getting up from bed, and 83% of young people slept within reach of their device. Recent surveys predict that mobile Internet usage will soon exceed desktop usage; the latest predictions suggesting this will occur sometime between 2014 and 2020 (Anderson & Rainie 2008; Richmond 2011).
For people seeking health information and support, the portable and accessible mobile phone is therefore increasingly likely to become preferable to the use of a static computer. For example, Schwimmer (2007) suggested that Apple's iPhone could be seen as a valuable aid for medical education and proposed utilising its integrated YouTube player with client specific medical education videos - which could be identified, bookmarked and played back at an appropriate time. Health Apps offer tremendous potential as they can be targeted towards particular conditions and focus on providing support for specific user groups (e.g. practitioner, patient and carer communities). However Health Apps require careful design to ensure that they suit the mobile platform they are created for, and that they are clinically accurate and fully consider the individual needs of its target audience.
Concussion
Concussion is the term used to describe an injury to the brain caused by a bump, blow or jolt to the head (Centre for Disease Control and Prevention 2011). It is common amongst contact sports such as football, rugby and ice hockey, and figures suggest that 3.8 million adults and children per year sustain a concussion in the USA alone (Gioia et al. 2009). Despite its frequency, concussion is largely under-reported; in New Zealand 62% of rugby players were shown to have not reported a concussion to a medical practitioner (Sye et al. 2006). Best-practice management strategies for concussion are outlined in the Consensus Statement on Concussion in Sport (McCrory et al. 2009), which emphasises the need for medical evaluation following a concussive injury. The importance of cognitive rest following concussion is particularly significant, as activities involving concentration and attention may exacerbate symptoms (McCrory et al. 2009).
Current Concussion-Related Technologies
Since the emergence of the Internet there has been a steady increase in the number of concussion-related websites. Many major national health organisations provide information relating to concussion on their websites, including the Center for Disease Control and Prevention in the USA (Centres for Disease Control and Prevention 2010), the National Health Service in the UK (NHS Choices 2010) and the Accident Compensation Corporation in New Zealand (Accident Compensation Corporation 2011). Established private organisations including the MayoClinic (MayoClinic 2011) and WebMD (WebMD 2011) who also provide concussion information, with a smaller number of international sporting federations offering concussion education on their websites (International Rugby Board 2011).
As Social Networking Sites become integrated into people's lives, they are increasingly being used for health-related purposes (Pulman 2009) and recent work has highlighted the role of Twitter and Facebook in the field of concussion. One thousand concussion-related Tweets over a 7-day period were analysed by Sullivan and colleagues (2012). The majority of these Tweets were sharing news relevant to concussion (33%) and sharing personal information on a situation (27%), while a smaller proportion of Tweets were providing inferred management (13%). These findings were similar to those in a study by Ahmed and colleagues (2010) who examined postings in concussion-related groups on Facebook. The role and purpose of seventeen Facebook groups which met specific inclusion criteria were evaluated. The majority of postings in the Facebook groups were relating personal experiences regarding concussion (65%), while other posts sought to seek (8%) or offer advice (2%).
Unlike Twitter, Facebook provides individuals with the ability to join concussion-specific groups where they can interact with each other and form virtual concussion communities. One of the key findings from the work of Ahmed and colleagues (2010) was that the majority of people were using these communities in a supportive manner, by sharing experiences relating to their concussion using the interactive medium of Facebook. This interactive support, or "iSupport", is a modern-day version of a peer support group, and is one of the major benefits of online concussion groups. In addition to sharing concussion-related experiences, individuals in these communities were also found to be seeking advice regarding concussion management, which would help them manage concussion symptoms.
The majority of individuals who sustain a concussion recover rapidly, with symptoms generally resolving in a few weeks (Iverson et al 2006). This would imply that for most people with a concussion the communities formed through Facebook concussion groups are transient, and that they are not long-term communities. Concussion communities may still be beneficial to individuals for their period of injury however; non-participation in sport due to concussion may lead to feelings of isolation, and these feelings are likely to be reduced by being part of such communities and interacting with others with the same condition (Bender et al 2011). In addition, obtaining information from peers regarding self-management may assist the resolution and management of their concussion symptoms. Members of the community who have made a full recovery following concussion might also elect to remain in the community even after their symptoms have resolved, in order to assist new members of the community.
Potential of Mobile Technology in the field of Concussion
The possibilities for the use of mobile technology to assist in concussion management are numerous. At a fundamental level, mobile technology permits easier access to concussion-related websites. Although studies have shown online concussion information to vary in standard (Ahmed et al. 2011), many websites contain best-practice information that can be a valuable post-concussion resource. The ability to obtain accurate concussion-related information from a smartphone or tablet may result in an individual being empowered with concussion management information that they may not otherwise have accessed, and lead to better management of their condition as a result.
Regardless of an individual's usual source of access to the Internet, the ability to view concussion websites from any location significantly facilitates the knowledge transfer process following concussion. Two factors cited as positive methods for enhancing knowledge transfer in concussion are communal peer support and the utilisation of online technologies (Provvidenza & Johnston 2009). Online peer support ("iSupport") has been reported by individuals using Facebook for concussion groups (Ahmed et al. 2010) and mobile technology has the capacity to significantly enhance the process of iSupport. By accessing Facebook through a smartphone or tablet device, it would permit an individual with concussion to participate in the peer support process from wherever they are, unencumbered by time or location.
There have been many concussion-specific Apps released recently, and at time of writing there are eleven Apps related to concussion available for smartphones and tablets in the UK. Many of these Apps include the Sports Concussion Assessment Tool 2 (SCAT2, 2009). The SCAT2 is a standardised method of concussion assessment developed as part of the Consensus Statement on Concussion in Sport (McCrory et al 2009), and contains a series of tests to help evaluate injured athletes for concussion. Concussion Apps have been designed to educate individuals about concussion and to help diagnose a concussion and have a focus towards different user groups:
Apps targeted towards medical professionals"SCAT2- Sport Concussion Assessment Tool" (iTunes 2012a) and "SCAT2" (iTunes 2011a) are both App versions of SCAT2 (SCAT2, 2009). They permit medical professionals using the App to conduct the SCAT2 and enter the test results into the App. These findings can then be emailed to other medical professionals to assist with follow up care. "SCAT2" allows users to save up to fifty tests on the App, while "SCAT2- Sport Concussion Assessment Tool" links to a central SCAT2 database. "Concussion Assessment & Response: Sport Version" (iTunes 2012b) contains similar functionality to these Apps, and also contains a return-to-play guide to assist recovering athletes to return to sport safely.
Apps targeted towards parents and coaches"ImCAT" (iTunes 2011b) is an educational App which provides a checklist of common signs and symptoms of concussion, and contains a quiz designed to teach non-medical individuals about concussion. "Pocket SCAT2" (iTunes 2011c) is intended to be used by coaches and parents to aid the diagnosis of a concussion and is a shortened version of the SCAT2. Whilst neither "ImCAT" nor "Pocket SCAT2" allow test results to be saved or emailed, they both prompt users to take any athlete with a suspected concussion for medical assessment. "Concussion Assessment & Response: Coach & Parent Version" (iTunes 2012c) does not directly reference the SCAT2 test, but contains a checklist of signs and symptoms which can be completed by a parent or coach to determine if a child needs medical assessment. This App allows parents to record a child's symptoms in the hours, days and weeks post-injury and this information can be emailed to a medical professional to provide an update on the child's recovery. An additional feature of "Concussion Assessment & Response: Coach & Parent Version" is the ability to customise the App with sport-related themes, to make it more aesthetically pleasing.
Apps targeted towards medical professionals AND parents and coachesThe "Concussion" (iTunes 2011d), "Concussion Test" (iTunes 2011e), and "Cognit" (iTunes 2009) Apps all contain components of the SCAT2. "Concussion" is an educational tool, and has an optional module which can be purchased for the App to help the diagnosis of a concussion. Both "Concussion" and "Concussion Test" allow the user to find nearby hospitals to seek further medical care if needed. "King-Devick Concussion Screening Test" (iTunes 2012d) is an App designed for medical and non-medical persons to screen athletes for concussion, and uses the King-Devick test (Galetta et al. 2011) instead of the SCAT2. The King-Devick test requires injured individuals to accurately read a series of single-digit numbers, which are compared to baseline test results to detect a concussion. The companion App is "KD Test Score" (iTunes 2011f), which helps the test administrator keep time and score whilst an athlete is taking the King-Devick test.
At present, there is little research dedicated to the design process and development of health-related Apps and Apps focusing on concussion by individuals or groups, although this is likely to change as they become more widely distributed and used. Curadeau et al (2011) documented the steps taken in the development of an iPhone App for concussion testing. The authors based their App on the Consensus Statement on Concussion in Sport (McCrory et al. 2009), and also aimed to make the App easy to use, adaptable, secure, and able to transmit data recorded. In contrast to administering traditional "pencil and paper" sideline concussion testing, Curadeau et al (2011) suggest that concussion Apps permit easier data collection, analysis, distribution, and storage, as well as having the additional benefit of portability. Although no research has yet proven the validity, reliability or usability of concussion-related Apps, they all have the potential to facilitate the process of concussion management through the use of mobile technology. With this in mind, the authors are keen to suggest that further research is undertaken to investigate how these Apps are being used, what medical standards are being followed in their creation, whether patients are being involved at any point in the creative process, whether the Apps are being used appropriately, and whether users are benefiting from the use of Apps.
Concerns with the use of mobile technology for concussion
Improved access to concussion related information via mobile technology may accelerate the accurate diagnosis and subsequent management of a concussion, however it also creates the possibility of self-diagnosis and therefore misdiagnosis. Several studies have highlighted the potential for self-diagnosis online and the challenges associated with this (Giles & Newbold 2011; White & Horvitz 2009). A key issue regarding self-diagnosis is the lack of moderation from trained medical practitioners to contextualise a diagnosis and accurately explain the findings (Ryan and Wilson 2008). This lack of moderation from healthcare professionals may lead to people who have incorrectly self-diagnosed themselves becoming falsely reassured, and dangerously abstaining from seeking further medical investigations (Ryan and Wilson 2008).
A further concern with self-diagnosis is the exacerbation of Cyberchondria, defined as the unfounded escalation of concerns about common symptoms based on the review of online search results and literature (White and Horvtiz 2009a). Although Cyberchondria and its associated challenges are no different for individuals whether they use mobile or desktop technology to access the Internet, the immediacy of information retrieval via mobile technology means that the problem may be accelerated. In addition, a study by Pinnock and colleagues (2007) which assessed the role of mobile phones in assisting asthma self-management inferred that the technology might create a state of dependence on the technology by the user.
Although online communities may provide a source of support and information for individuals with concussion, there are potential dangers related to their use. The concussion-related Facebook groups identified by Ahmed and colleagues (2010) were unmoderated, meaning that there was no quality control or vetting of the information posted. This has inherent risks; well-meaning individuals may attempt to provide helpful advice to others based on their own experiences, however without a medical professional to check these postings there is the potential for harm. Incorrect information in the early stages following a concussion may lead to an individual returning to sporting activity before their symptoms have resolved, and placing themself at risk of a more serious injury. An additional concern is that individuals participating in these communities may view the support and advice in these groups as a substitute for face-to-face medical contact with a doctor. Best-practice concussion management guidelines emphasise the need for medical evaluation following a concussion (McCrory et al. 2009) and it is crucial that individuals seek medical review.
Cognitive rest is crucial following a concussion and therefore engaging with mobile technology for sustained periods could aggravate concussion-related symptoms. The use of text messaging was specifically mentioned in the Consensus Statement on Concussion in Sport as having the potential to exacerbate symptoms (McCrory et al. 2009), and thus mobile technology needs to be used with caution during the immediate stages post-injury. This does not completely negate the use of mobile technology during this period; the vast array of recreational media in modern society (television, internet, video games, and mobile phones) means that total cognitive rest is almost impossible to attain. McGrath (2010) outlines a model for management of the student athlete with concussion and suggests that "the goal is to support the recovering student...in a way that does not overstress the cognitive functions and result in worsening symptoms." It could therefore be argued that short periods of time spent accessing best-practice concussion information via mobile technology (in a manner which does not overstress cognitive function) might improve management of an individual's concussion.
The size of mobile devices has been proposed as a potential barrier to usability (Pulman 2010). The small screen size and lack of keyboard may therefore be seen as additional obstacles for individuals seeking mobile concussion information or support via a social network (Haddon 2008). Although these findings point to compromised usability, the touchscreen interface offered by many smartphones appears to be on the rise (Mobile Choices 2010). The appeal of touchscreen phones may be the aesthetic of the smooth interface, or the bigger screen (as a result of the lack of keyboard). The emerging popularity of tablet computers (e.g. the iPad) which incorporate a touchscreen interface also suggests that this could be a medium that users may employ to retrieve concussion information.
Conclusions
The increasing capability of mobile technology, allied with the global population's desire to access health information and communal support groups online, suggests that mobile technology has a growing significance in disseminating best-practice information for concussion. Care must be taken to ensure that any information provided through such devices is accurate, and that adapted forms of delivery (particularly Apps) take into consideration the specific needs of individuals. For example, concussion-related Apps need to highlight how much time individuals should be spending on the Apps following their concussion (maybe via an in-built timer), in addition to providing the appropriate clinically approved medical advice and support. By incorporating these issues into their design, mobile technology has the potential to be a valuable community-based tool for concussion management. As with other health-related Apps and information/support pathways being developed for patients, practitioners and carers, further research should be undertaken. This should focus on the end-to-end development process of creating clinically accurate and user-centric concussion Apps, with appropriate consideration given to how effectively these Apps are being used by individuals suffering from a concussion.