Pediatric providers' attitudes and practices regarding concussion diagnosis and management

Concussion Public Policy in Elementary and High Schools in Ontario, Canada: A Cross-Sectional Survey to Examine Implementation Compliance, Barriers, and Facilitators

BACKGROUND

Concussion public policies have been developed to address the burden of concussions. The aim of the present study was to examine implementation compliance, barriers, and facilitators of Canada's first concussion public policy, Ontario's Policy/Program Memorandum 158: School Board Policies on Concussion (PPM158).

METHODS

An electronic survey was sent to 515 randomly selected elementary and high school principals across specific geographic, language, and publicly funded school types in Ontario. Data were analyzed using both qualitative and quantitative methods.

RESULTS

One hundred and thirty-five principals responded to the survey (26%). Concussion education was provided to teachers in 81% of schools, to students in 83%, and coaches in 79%. Additionally, 89% reported having a return-to-learn protocol in place and 90% reported having a return-to-play protocol. Implementation barriers included difficulties in providing concussion education to parents (42%), obtaining notes from physicians, and maintaining the volume of documentation. Eighty-seven percent of respondents believed that PPM158 improves student well-being.

CONCLUSIONS

Identified implementation barriers and facilitators can inform concussion policy practices to improve student well-being. We recommend: (1) an appointed concussion policy lead at each school, (2) electronic documentation, (3) determining the optimal education format to improve parent/guardian education, (4) fostering relationships between schools and health care professionals, and (5) student concussion education in every grade in Ontario schools.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

A Scale Measuring Academic-Related Anxiety Following Concussion

Does academic-related anxiety contribute to an adolescent’s recovery process and return to activity after experiencing a concussion? The authors created a novel measure of academic-related anxiety (Mularoni Measure of Academic Anxiety following Concussion [MMAAC]) and administered it to adolescents following concussion in outpatient pediatric sports medicine clinics. Two previously validated measures of anxiety were also administered, and results were compared with the MMAAC scores as well as the lengths of time for return to school and sports. Results show that higher MMAAC scores positively correlate with the length of time an adolescent needs to return to school. Study results indicate that the MMAAC reliably measures academic-related anxiety in adolescents suffering from concussions and can be helpful in predicting a basic timetable for return to school. The authors believe that this brief survey can be used by physicians in clinic to evaluate anxiety and assist with return to school expectations to provide comprehensive recovery support.

A cross-sectional study reporting concussion exposure, assessment and management in Western Australian general practice

Background

General Practitioners (GPs) may be called upon to assess patients who have sustained a concussion despite limited information being available at this assessment. Information relating to how concussion is actually being assessed and managed in General Practice is scarce. This study aimed to identify characteristics of current Western Australian (WA) GP exposure to patients with concussion, factors associated with GPs’ knowledge of concussion, confidence of GPs in diagnosing and managing patients with concussion, typical referral practices and familiarity of GPs with guidelines.

Methods

In this cross-sectional study, GPs in WA were recruited via the RACGP WA newsletter and shareGP and the consented GPs completed an electronic survey. Associations were performed using Chi-squared tests or Fisher’s Exact test.

Results

Sixty-six GPs in WA responded to the survey (response rate = 1.7%). Demographics, usual practice, knowledge, confidence, identification of prolonged recovery as well as guideline and resource awareness of GPs who practised in regional and metropolitan areas were comparable (p > 0.05). Characteristics of GPs were similar between those who identified all symptoms of concussion and distractors correctly and those who did not (p > 0.05). However, 84% of the respondents who had never heard of concussion guidelines were less likely to answer all symptoms and distractors correctly (p = 0.039). Whilst 78% of the GPs who were confident in their diagnoses had heard of guidelines (p = 0.029), confidence in managing concussion was not significantly associated with GPs exposure to guidelines. It should be noted that none of the respondents correctly identified signs of concussion and excluded the distractors.

Conclusions

Knowledge surrounding concussion guidelines, diagnosis and management varied across GPs in WA. Promotion of available concussion guidelines may assist GPs who lack confidence in making a diagnosis. The lack of association between GPs exposure to guidelines and confidence managing concussion highlights that concussion management may be an area where GPs could benefit from additional education and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01384-1.

What are the knowledge, attitudes and beliefs regarding concussion of primary care physicians and family resident physicians in rural communities?

Background

Primary care physicians and family medicine resident physicians report continued gaps in knowledge when diagnosing and managing pediatric patients with concussion.

Methods

A cross-sectional electronic survey of 130 primary care physicians and family medicine resident physicians in the Northeastern Ontario Local Health Integration Network (LHIN). Descriptive statistics, chi-squared Fisher exact tests, were used to compare physicians versus resident physicians with two-tailed p < 0.05 (with 95% confidence intervals).

Results

With a 48% response rate, when treating concussions 44% of providers either did not use any specific clinical practice guideline, standardized assessment tool, could not recall the source of a specific tool/guideline or omitted answering the question. However, 61% of all respondents would refer some or all concussion patients to a specialist for treatment. At least 41% of providers indicated they lacked access to a ‘Provider Decision Support Tool’ specific to concussion, and 88% of the 25 providers were without access to discharge instructions.

Conclusion

Similar to other jurisdictions, Northeastern Ontario primary care physicians and family medicine resident physicians report gaps in knowledge for both diagnosis and management of pediatric concussion. Consequently, they did not use current guidelines or best practices to guide management.

Evaluating the effectiveness of traumatic brain injury state laws among high school athletes

BACKGROUND

Traumatic brain injury legislation varies across states. A comprehensive nationwide evaluation of state traumatic brain injury laws is vital given growing populations of high school athletes. This study evaluates the effectiveness of traumatic brain injury laws by examining longitudinal trends in incident and recurrent concussion rates and determines if state level variations in legislation's language affected the observed trends.

METHODS

In this retrospective ecological study of a large national sample of US high schools from 2005/06 through 2017/18, piecewise regression models along with a profile likelihood approach were utilized to examine longitudinal trends in incident and recurrent concussion rates.

RESULTS

Overall incident concussion rates increased by an additional 1.85%/standardized month (STDM) (95% confidence interval (CI): 1.14, 2.56%) prior to law passage and decreased by an additional 1.08%/ STDM (95%CI: - 1.43, - 0.72%) after law passage. Similar trends were observed for overall recurrent concussion rates. Among states that specified the category of healthcare provider for return to play clearance, post-law recurrent concussion rates decreased on average by an additional 1.59%/STDM (95%CI: - 3.42, 0.22%) compared to states that did not specify the category of healthcare provider.

CONCLUSIONS

The passage of state level traumatic brain injury laws was associated with an increase in overall incident and recurrent concussion rates prior to law passage and a decrease in rates after law passage. Although not statistically significant, states with traumatic brain injury laws specifying the category of healthcare provider for return to play clearance had a greater rate of decline in post-law recurrent concussion rates compared to states not specifying the category of healthcare provider. The findings suggest that state traumatic brain injury laws may benefit from specifying the category of healthcare provider allowed to provide return to play clearance, if they do not already include such language.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population

OBJECTIVES

To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education.

DESIGN

Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit.

SETTING

Three military treatment facilities.

PARTICIPANTS

Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury.

RESULTS

Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time.

CONCLUSIONS

Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Attention-Deficit/Hyperactivity Disorder Mimics the Post-concussion Syndrome in Adolescents

The objective of this study was to evaluate concussion-like symptom reporting among uninjured adolescents with Attention-deficit/hyperactivity disorder (ADHD), stratified by several cooccurring conditions, and to examine the base rate and predictors of uninjured adolescents with ADHD meeting diagnostic criteria for the International Classification of Diseases, 10th Revision (ICD-10) post-concussional syndrome (PCS). Participants in this cross-sectional, observational study, were drawn from a cohort of 48,834 adolescent student athletes from Maine (ages 13-18) with no concussion in the past 6 months who completed a preseason, baseline testing program between 2009 and 2015. The final sample included 3,031 students with ADHD, 2,146 (70.8%) boys and 885 (29.2%) girls. They were 15.2 years old on average (SD = 1.3). Concussion-like symptom reporting was more common in girls than boys. Most students with ADHD reported one or more symptoms (69.3% of boys and 81.1% of girls). The presence of an additional, co-occurring condition or comorbidity was associated with increased symptom reporting. In the absence of a recent concussion, 28.8% percent of boys and 47.1% of girls with ADHD endorsed symptoms resembling an ICD-10 diagnosis of post-concussional syndrome (PCS). Adolescents with pre-existing conditions were even more likely to endorse symptoms that resembled PCS (28-47% of boys and 45-69% of girls). Prior treatment for a psychiatric condition was the strongest independent predictor for meeting PCS criteria in boys, followed by treatment for migraines and co-occurring learning disorder. For girls, the only independent predictor was prior treatment of a psychiatric condition. In uninjured adolescent student athletes, ADHD appears to mimic the post-concussion syndrome. Adolescents with ADHD commonly endorse concussion-like symptoms in the absence of a recent concussion. Demographic characteristics (sex) and the presence of co-occurring conditions are related to symptom reporting in adolescents with ADHD. Understanding factors associated with baseline symptom reporting, such as pre-existing ADHD, is important when evaluating youth who have persistent symptoms following concussion as well as making both return to school and return to athletics decisions.

Adolescents With ADHD Do Not Take Longer to Recover From Concussion

The objective of this study was to determine whether adolescents with attention-deficit/hyperactivity disorder (ADHD) have prolonged return to school and sports following concussion compared to those without ADHD and whether medication status or concussion history is associated with recovery time. We hypothesized that having ADHD would not be associated with longer recovery time. This prospective observational cohort study, conducted between 2014 and 2019, examined concussion recovery among school sponsored athletics throughout Maine, USA. The sample included 623 adolescents, aged 14-19 years (mean = 16.3, standard deviation = 1.3 years), 43.8% girls, and 90 (14.4%) reported having ADHD. Concussions were identified by certified athletic trainers. We computed days to return to school (full time without accommodations) and days to return to sports (completed return to play protocol) following concussion. Adolescents with ADHD [median days = 7, interquartile range (IQR) = 3-13, range = 0-45] did not take longer than those without ADHD (median days = 7, IQR = 3-13, range = 0-231) to return to school (U = 22,642.0, p = 0.81, r = 0.01; log rank: χ 1 2 = 0.059, p = 0.81). Adolescents with ADHD (median days = 14, IQR = 10-20, range = 2-80) did not take longer than those without ADHD (median days = 15, IQR = 10-21, range = 1-210) to return to sports (U = 20,295.0, p = 0.38, r = 0.04; log rank: χ 1 2 = 0.511, p = 0.48). Medication status and concussion history were not associated with longer recovery times. Adolescents with ADHD did not take longer to functionally recover following concussion. Recovery times did not differ based on whether adolescents with ADHD reported taking medication to treat their ADHD or whether they reported a prior history of concussion.

Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment

OBJECTIVE

To compare Child Sport Concussion Assessment Tool Fifth Edition (Child SCAT5) performance between uninjured children with attention-deficit/hyperactivity disorder (ADHD) and precisely matched controls without ADHD.

STUDY DESIGN

A nested case-control study was conducted within a cohort of middle school athletes (age 11-12 years) who completed preseason testing. Students with ADHD were individually matched to students without ADHD based on age, sex, language spoken at home, number of prior concussions, sport, and school they attended. The final sample included 54 students (27 with ADHD and 27 controls), 38 (70.4%) boys and 16 (29.6%) girls (average age: 11.7 years, SD = 0.5).

RESULTS

Children with ADHD reported more symptoms (M = 13.33, SD = 5.69, P < .001) and greater symptom severity (M = 22.59, SD = 1 1.60, P < .001) compared with controls (total symptoms: M = 6.44, SD = 4.96; symptom severity: M = 8.04, SD = 6.36). Children with ADHD performed similarly to controls on the Child SCAT5 cognitive tests. Children with ADHD committed 3 times as many total balance errors (median = 6) than children without ADHD (median = 2) and committed twice as many errors on single leg stance (ADHD median = 4; No ADHD median = 2) (P values < .001).

CONCLUSIONS

Children with ADHD endorsed more concussion-like symptoms and performed worse on balance testing during preseason Child SCAT5 assessment compared with matched controls without ADHD. These findings highlight the challenges of interpreting Child SCAT5 performance in children with ADHD following a concussion or suspected concussion and illustrate the value of administering the measure to children to document their pre-injury performance.

Patient Presentations in Outpatient Settings: Epidemiology of Adult Head Trauma Treated Outside of Hospital Emergency Departments

BACKGROUND

While deaths, hospitalizations, and emergency department visits for head trauma are well understood, little is known about presentations in outpatient settings. Our objective was to examine the epidemiology and extent of healthcare-seeking adult (18-64 years) head trauma patients presenting in outpatient settings compared with patients receiving nonhospitalized emergency department care.

METHODS

We used 2004-2013 MarketScan Medicaid/commercial claims to identify head trauma patients managed in outpatient settings (primary care provider, urgent care) and the emergency department. We examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, and extent of and reasons for postindex visit ambulatory care use within 30/90/180 days by index visit location, as well as annual and monthly variations in head trauma trends. We used outpatient incidence rates to estimate the US nationwide outpatient burden.

RESULTS

A total of 1.19 million index outpatient visits were included (emergency department: 348,659). Nationwide, they represented a weighted annual burden of 1.16 million index outpatient cases. These encompassed 46% of all known healthcare-seeking head trauma in 2013 (outpatient/emergency department/inpatient/fatalities) and increased in magnitude (+31%) from 2004 to 2013. One fourth (27%) of office/clinic visits led to diagnosis with concussion on index presentation (urgent care: 32%). Distributions of demographic factors varied with index visit location while injury-specific factors were largely comparable. Subsequent visits reflected high demand for follow-up treatment, increased concussive diagnoses, and sequelae-associated care.

CONCLUSIONS

Adult outpatient presentations of head trauma remain poorly understood. The results of this study demonstrate the extensive magnitude of their occurrence and close association with need for follow-up care.

Concussion knowledge among family physicians in Croatia

Aim

The objective of this study was to administer and analyze results of a survey targeting knowledge about concussion symptoms, diagnosis, treatment and expected recovery among family medicine specialists in the Split-Dalmatia County of Croatia.

Methods

An electronic survey questionnaire was developed utilizing concepts from previously published studies on concussion knowledge, attitudes and beliefs completed by physicians. The survey was intended to briefly and broadly assess concussion knowledge of Croatian healthcare providers. The first section of the survey included five questions clarifying professional practice, years of experience and experience with concussions; the second section included 15 questions about typical concussion symptoms; the third section included 12 questions focused upon three primary components of concussion knowledge: concussion diagnosis, treatment and recovery.

Results

Out of 242 surveys mailed, 81 questionnaires (33%) were completed while 161 respondents (67%) did not answer. Out of the 81 completed surveys, 76 (94%) were returned by family physicians specialist and five (6%) by resident physicians in training. 39 (48%) had treated less than ten patients with concussion during last year: 40 (49%) treated 11-20 patients with concussion; and two (3%) treated greater than 20 patients with concussion during last year. While most responses did accurately reflect knowledge of common symptoms (90-100% correct), there was significant lack of knowledge in three areas: only 19% of participants stated that diagnosis of concussion does not require loss of consciousness; three quarters of respondents believed that a diagnosis of concussion requires direct contact to the head and 83% of the respondents believed that persistent subjective complaints are always the result of a more severe initial injury.

Discussion

This is the first investigation conducted in Croatia to examine knowledge of concussion diagnosis, as well as the management practices held by medical professionals. Overall, the findings suggest that the knowledge and management practices among family doctors in the region are not consistent with current worldwide views and recommendations. There was not an accurate knowledge of concussion diagnosis, treatment, recovery and prognosis among family physicians. Continued education of medical staff to better identify concussion and increased reliance on objective methods for managing concussion will improve patient management and outcome.

Evaluation and Management of Concussion in Young Athletes

Learning about concussion diagnosis and management is important for all individuals who will be taking care of young athletes. There are about 1.7million reported concussions per year, and, of these, about 20% are sports related. There are risks in all sports, but the highest rates of concussions are from football, rugby, and hockey, with soccer being the highest cause for girls. An on-field assessment includes evaluating airway, breathing, and circulation, followed by cervical spine assessment. Then, concussion evaluation tools can be used to aid in making the diagnosis. While concussion symptoms for the majority of youth resolve within a few weeks, some individuals may have persistence of symptoms for 3 months or more, referred to as postconcussive syndrome. Providers should consider ongoing symptoms in assessing when an athlete may safely return to sports and to learning. A major concern that has become more apparent in recent years is the possibility that concussions may have a longitudinal effect on health, such as in the development of chronic traumatic encephalopathy. Research has shown that there is an increase in the number of patients presenting to their primary care physician with concussions. Knowing how best to prevent, diagnose, and manage concussions will help to minimize risks to young athletes.