Concussion management by paediatricians: A national survey of Canadian paediatricians

A pilot study evaluating the effects of concussion on the ability to form cognitive maps for spatial orientation in adolescent hockey players

OBJECTIVE

In this pilot study, we investigated the impact of a sport-related concussion (SRC) on the ability to form cognitive maps, mental representations of the environment that are critical for spatial orientation and navigation.

PARTICIPANTS

We recruited 18 adolescent hockey players suffering from a SRC, and 19 age, sex and handedness-matched hockey players with no history of concussion.

MAIN MEASURE

We asked participants to perform the Spatial Configuration Task (SCT), a computerized tool used to quantitatively measure the ability of the individuals to form cognitive maps.

RESULTS

We found that athletes with a concussion performed significantly worse than controls on the SCT (F(1,34) = 5.82, p =.021, [Formula: see text] = -0.72), confirming a negative effect of a SRC on the ability to form cognitive maps. We found no significant difference between groups in average response time, and no significant correlation between participants' performance at the SCT and reported symptoms of concussion as rated on the Sport Concussion Assessment Tool (SCAT5).

CONCLUSIONS

Consistent with the integrity of extended neural networks required for effective spatial orientation and navigation, the findings of our pilot study provide preliminary evidence suggesting that a SRC may affect the ability to familiarize with a spatial surrounding and orient within it.

Awareness and Perceived Value of Eye Tracking Technology for Concussion Assessment among Sports Medicine Clinicians: A Multinational Study

Objective: The awareness of concussion as a serious and frequently occurring sports injury and its management has evolved significantly. One viable objective diagnostic tool is eye tracking technology. The authors hypothesized that while clinicians may be aware that assessing eye movements in concussed athletes can be beneficial, it is possible that, due to the novelty of the eye tracking technology and limited exposure, only a few actually use it in their practice. The study aimed to assess the awareness of eye movement deficits associated with concussion amongst sports medicine clinicians and to determine the utilization and perceptions of the eye tracking technology for concussion diagnosis.Methods: An online 18-question survey was distributed internationally from January until December 2017 and completed by 171 sports medicine clinicians (sport physicians, therapists, general practitioners, neuropsychologists) from 32 countries.Results: Respondents indicated that subjectivity of assessments remained a major limitation of established diagnostic tools. Eye tracking technology, despite its potential to attenuate this limitation, was only used by 12% of respondents. To diagnose concussion, 77% did not use any eye movement assessment tools other than own clinical assessment. With the exception of abnormal pupil light reflex, which was checked by 68%, eye movement deficits were inspected by less than half of the respondents (46.3 ± 12%).Conclusion: Even among sports medicine clinicians who regularly attend to patients with concussions, there is insufficient awareness that concussion can lead to abnormal eye tracking behavior. Lack of exposure to the sensitive eye tracking equipment may be a limiting factor for using eye movement metrics for concussion diagnostics. Facilitating the awareness of objective methods, like eye tracking technology, may help assure the appropriate continuum of identification and treatment for concussed athletes. Increasing educational opportunities and practical experience of clinicians regarding concussive symptoms and potential innovative technology is strongly advocated.

Considerations for Diagnosis and Management of Concussion

Concussion is an ongoing concern for health care providers. The incidence rates continue to be high and the rate of recovery is variable due to potential risk factors. With no valid biomarkers, diagnosis and assessment of concussion remain a clinical challenge. The heterogeneity in presentation following injury provides an additional level of complexity, requiring the screening and evaluation of diverse body systems, including oculomotor, vestibular, autonomic, psychiatric, cervical, and cognitive symptoms. While a few tools, such as the Vestibular/Ocular Motor Screening and Balance Error Scoring System, have been developed specifically for concussion, the vast majority of tests are adapted from other conditions. Further complicating the process is the overlapping and interactive nature of the multiple domains of postconcussion presentation. This commentary illustrates how clinicians can conceptualize the multiple profiles that present following concussion and describes tools that are available to assist with screening and evaluation of each area. The multifaceted nature of concussion warrants broad clinical screening skills and an interdisciplinary approach to management. J Orthop Sports Phys Ther 2019;49(11):787-798. doi:10.2519/jospt.2019.8855.

The Potential of Telemedicine to Improve Pediatric Concussion Care in Rural and Remote Communities in Canada

Concussion is a form of mild traumatic brain injury that affects thousands of Canadian children and adolescents annually. Despite national efforts to harmonize the recognition and management of pediatric concussion in Canada, timely access to primary and specialized care following this injury remains a challenge for many patients especially those who live in rural and remote communities. To address similar challenges facing patients with stroke and other neurological disorders, physicians have begun to leverage advances in telemedicine to improve the delivery of specialized neurological care to those living in medically underserved regions. Preliminary studies suggest that telemedicine may be a safe and cost-effective approach to assist in the medical care of select patients with acute concussion and persistent post-concussion symptoms. Here we provide an overview of telemedicine, teleneurology, the principles of concussion assessment and management, as well as the current state of concussion care in Canada. Utilizing preliminary evidence from studies of telemedicine in concussion and experience from comprehensive systems of care for stroke, we outline steps that must be taken to evaluate the potential of telemedicine-based concussion networks to improve the care of pediatric concussion patients living in underserved rural and remote communities in Canada.

Pilot single-centre cross-sectional study to determine emergency physicians' knowledge and management of sports concussion: an experience from Singapore

INTRODUCTION

Sports concussion remains challenging to manage despite changes to policy and practice since the 2012 International Consensus Conference on Concussion in Sport. Emergency physicians (EPs) are usually the first line of medical care for athletes in amateur and youth collision sports. This single-centre cross-sectional study aimed to establish EPs' understanding and management of concussion in Singapore.

METHODS

An anonymised, 17-item online questionnaire was sent to EPs requesting for information on their clinical experience, training, exposure to concussion cases in the emergency department (ED) and assessed knowledge of the condition.

RESULTS

Out of 65 EPs, 52 (80%) responded, 25 (48.1%) of whom were medical officers. Over 90% had not received formal training in concussion management, and 73.1% regularly assessed concussion. 40 (76.9%) EPs recognised that loss of consciousness was not essential for diagnosis and only 24 (46.2%) knew the most common symptom. 26 (50.0%) incorrectly reported that they would perform brain imaging. Among those who indicated onward referral, 29 (55.8%) would refer concussed patients to neurosurgery. There were no significant differences between clinical grade or training in concussion and positive responses for definition, imaging modality or most common symptom of concussion.

CONCLUSION

Concussion is a common presentation to EDs in Singapore. However, understanding of the condition, its clinical diagnosis, investigation and onward management is limited. Although EPs reported training in concussion, it is likely to be insufficient. Commencing relevant education programmes for undergraduate and postgraduate medical students may enable progressive acquisition of knowledge and thereby improve patient management in the future.

Impact of Early Follow-Up Intervention on Parent-Reported Postconcussion Pediatric Symptoms: A Feasibility Study

OBJECTIVES

To investigate the effectiveness and feasibility of early intervention telephone counseling with parents in limiting postconcussion symptoms and impacts on children and youth.

SETTING

Recruitment occurred postdischarge from one pediatric emergency department.

PARTICIPANTS

Sixty-six parents of children aged 5 to 16 years with a diagnosis of a concussion injury.

DESIGN

A pilot, randomized controlled study compared the efficacy of telephone counseling (reviewing symptom management and return to activity with parents at 1 week and 1 month postinjury) with usual care (no formalized follow-up).

MAIN MEASURES

The Post-Concussion Symptom Inventory and the Family Burden of Injury Interview administered with parents by a blinded therapist at 3 months postinjury.

RESULTS

No significant difference between the groups at 3 months postinjury in postconcussion symptoms (P = .67) and family stress (P = .647).

CONCLUSION

The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children.

Rest and Return to Activity After Sport-Related Concussion: A Systematic Review of the Literature

OBJECTIVE

To systematically review the literature regarding rest and return to activity after sport-related concussion.

DATA SOURCES

The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity.

STUDY SELECTION

Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression.

DATA EXTRACTION

The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article.

DATA SYNTHESIS

Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-to-activity progression. A qualitative synthesis of the results was provided, along with summary tables.

CONCLUSIONS

Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-to-activity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers.

Survey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study

OBJECTIVE

The purpose of this study was to assess the self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners by means of a pilot study of the need, construct validity, and feasibility for further investigation of mild traumatic brain injury (MTBI) knowledge base.

METHODS

Two hundred forty-eight practicing chiropractic and 120 medical physicians in the south and northeastern sections of the United States were contacted by e-mail, telephone, and postal mail to answer an 18-item survey on knowledge, diagnosis, and common practice with respect to traumatic brain injury patients. Descriptive analysis was used to assess common trends.

RESULTS

Twenty-three chiropractic and 11 medical primary care practitioners returned completed surveys, making this a low-power pilot study. The majority claimed confidence in diagnosis of MTBI, but a lack of knowledge of many of the assessment tools and the international guidelines. Chiropractic and medical clinicians revealed similar competencies and differing deficiencies. Both groups admitted infrequent diagnosis of MTBI in practice. There was recognition of major TBI signs, but lack of recognition or inquiry for subtle MTBI signs.

CONCLUSIONS

There is a need and feasibility for further study of the knowledge transfer to the chiropractic physician with a larger population. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBI. The survey instrument appears to provide valid data on knowledge of MTBIs, with some modifications.

The Effect of the "Zero Tolerance for Head Contact" Rule Change on the Risk of Concussions in Youth Ice Hockey Players

BACKGROUND

Ice hockey is a popular winter sport in Canada. Concussions account for the greatest proportion of all injuries in youth ice hockey. In 2011, a policy change enforcing "zero tolerance for head contact" was implemented in all leagues in Canada.

PURPOSE

To determine if the risk of game-related concussions and more severe concussions (ie, resulting in >10 days of time loss) and the mechanisms of a concussion differed for Pee Wee class (ages 11-12 years) and Bantam class (ages 13-14 years) players after the 2011 "zero tolerance for head contact" policy change compared with players in similar divisions before the policy change.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The retrospective cohort included Pee Wee (most elite 70%, 2007-2008; n = 891) and Bantam (most elite 30%, 2008-2009; n = 378) players before the rule change and Pee Wee (2011-2012; n = 588) and Bantam (2011-2012; n = 242) players in the same levels of play after the policy change. Suspected concussions were identified by a team designate and referred to a sport medicine physician for diagnosis. Incidence rate ratios (IRRs) were estimated based on multiple Poisson regression analysis, controlling for clustering by team and other important covariates and offset by game-exposure hours. Incidence rates based on the mechanisms of a concussion were estimated based on univariate Poisson regression analysis.

RESULTS

The risk of game-related concussions increased after the head contact rule in Pee Wee (IRR, 1.85; 95% CI, 1.20-2.86) and Bantam (IRR, 2.48; 95% CI, 1.17-5.24) players. The risk of more severe concussions increased after the head contact rule in Pee Wee (IRR, 4.12; 95% CI, 2.00-8.50) and Bantam (IRR, 7.91; 95% CI, 3.13-19.94) players. The rates of concussions due to body checking and direct head contact increased after the rule change.

CONCLUSION

The "zero tolerance for head contact" policy change did not reduce the risk of game-related concussions in Pee Wee or Bantam class ice hockey players. Increased concussion awareness and education after the policy change may have contributed to the increased risk of concussions found after the policy change.

Sport Concussion Knowledge and Clinical Practices: A Survey of Doctors of Chiropractic With Sports Certification

OBJECTIVE

The purpose of this study is to describe the knowledge base and clinical practices regarding concussion by sports-certified doctors of chiropractic.

METHODS

A 21-item survey was distributed to the 312 attendees of the 2014 American Chiropractic Board of Sports Physicians Sports Sciences Symposium. Results were measured by frequency analysis and descriptive statistics for all surveys completed by sports-certified chiropractors.

RESULTS

Seventy-six surveys were returned by sports-certified doctors of chiropractic. All (N = 76) 100% of respondents believe that the evaluation of concussion should be performed by a health care provider with training in concussion. The respondents actively assess and manage concussion in adults (96%), adolescents (95%), and children (75%). A majority (79%) of respondents believe that the Sideline Concussion Assessment Tool-3 represents a current standard of care for the sideline evaluation of the athlete who possibly has sustained a sport concussion. Most respondents agreed or strongly agreed that manual therapies may be appropriate in certain circumstances in adults (80%) and minors (80%).

CONCLUSION

This cross section of certified sports chiropractors strongly believes that the evaluation of concussion should be performed by a health care provider with specific training in concussion. A high percentage of the sports-certified chiropractors who responded assess and manage sport concussion in their practice, and many of them endorse the use of the Sideline Concussion Assessment Tool-3 as a sideline assessment tool.

An innovative web based system for reporting rare diseases in paediatrics

Background

Surveillance of rare diseases in children is an important aspect of public health. Rare diseases affect thousands of children worldwide. The Canadian Paediatric Surveillance Program (CPSP) has been in existence since 1996, and provides an innovative means to undertake paediatric surveillance and increase awareness of childhood disorders that are high in disability, morbidity, mortality, and economic costs to society, despite their low frequency. Traditionally, CPSP used manual paper-based reporting on a monthly basis, which although had an impressive response rate, it had inherent longer processing times and costs associated with it.

Objectives

To provide an overview and evaluate an innovative web-based system that enables seamless reporting from participants across the country providing a quick, reliable and simple mechanism for the participants to submit data while yielding better data quality, timeliness and increased efficiencies.

Methods

In 2011, a proprietary electronic CPSP (eCPSP) system was developed to provide a simple, quick and reliable reporting environment for participants. It supports both the electronic and hardcopy reporting. The analysis presented in this paper was conducted based on usage data of this system.

Results

The response rates of the new eCPSP were found to be very favorable with adjusted rate of 80%, which equals the baseline. Approximately 50% of online participants report the first day they receive the notification e-mail. The response time was also reduced considerably. Furthermore, there has been significant reduction in data handling related activities (by almost 70%) from estimated 690 hours per year. Finally, the number of cases reported that do not fit the study case criteria has fallen, likely because participants can now immediately access the case definition and protocol via the online system. This has reduced both staff and investigator time for case processing.

Conclusion

The eCPSP has modernized the CPSP program from paper-based reporting to efficient online technology while maintaining the core principles of the program. This simple and intuitive approach has proven to be an efficient approach cutting response times significantly while maintaining the desired response rates.