Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison
- Constance M Lebrun1,
- Martin Mrazik2,
- Abhaya S Prasad3,
- B Joel Tjarks4,
- Jason C Dorman5,
- Michael F Bergeron5,
- Thayne A Munce5,
- Verle D Valentine5
- 1Department of Family Medicine, Faculty of Medicine & Dentistry, Glen Sather Sports Medicine Clinic, Edmonton Clinic, Level 2, 11400 University Avenue, University of Alberta, Edmonton, Alberta, Canada
- 2Department of Educational Psychology, Faculty of Education, University of Alberta, Edmonton, Alberta, Canada
- 3School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- 4Sanford School of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- 5Orthopedics and Sports Medicine, Sanford USD Medical Center, Sioux Falls, South Dakota, USA
- Correspondence to Dr Constance M Lebrun, Department of Family Medicine, Faculty of Medicine & Dentistry, Glen Sather Sports Medicine Clinic, Edmonton Clinic, Level 2, 11400 University Avenue, University of Alberta, Edmonton, Alberta, Canada T6G 1Z1;
- Received 25 July 2012
- Revised 19 October 2012
- Accepted 29 October 2012
- Published Online First 23 November 2012
Context Evolving concussion diagnosis/management tools and guidelines make Knowledge Transfer and Exchange (KTE) to practitioners challenging.
Objective Identify sports concussion knowledge base and practise patterns in two family physician populations; explore current/preferred methods of KTE.
Design A cross-sectional study.
Setting Family physicians in Alberta, Canada (CAN) and North/South Dakota, USA.
Participants CAN physicians were recruited by mail: 2.5% response rate (80/3154); US physicians through a database: 20% response rate (109/545).
Intervention/instrument Online survey.
Main and secondary outcome measures Diagnosis/management strategies for concussions, and current/preferred KTE.
Results Main reported aetiologies: sports/recreation (52.5% CAN); organised sports (76.5% US). Most physicians used clinical examination (93.8% CAN, 88.1% US); far fewer used the Sport Concussion Assessment Tool (SCAT1/SCAT2) and balance testing. More US physicians initially used concussion-grading scales (26.7% vs 8.8% CAN, p=0.002); computerised neurocognitive testing (19.8% vs 1.3% CAN; p<0.001) and Standardised Assessment of Concussion (SAC) (21.8% vs 7.5% CAN; p=0.008). Most prescribed physical rest (83.8% CAN, 75.5% US), while fewer recommended cognitive rest (47.5% CAN, 28.4% US; p=0.008). Return-to-play decisions were based primarily on clinical examination (89.1% US, 73.8% CAN; p=0.007); US physicians relied more on neurocognitive testing (29.7% vs 5.0% CAN; p<0.001) and recognised guidelines (63.4% vs 23.8% CAN; p<0.001). One-third of Canadian physicians received KTE from colleagues, websites and medical school training. Leading KTE preferences included Continuing Medical Education (CME) courses and online CME.
Conclusions Existing published recommendations regarding diagnosis/management of concussion are not always translated into practise, particularly the recommendation for cognitive rest; predicating enhanced, innovative CME initiatives.
Sport-related concussions have received escalating attention over the last decade, as they have both immediate and potentially cumulative health-related effects.1 ,2 Prevalent in recreational and competitive sports, concussion is a major public health concern worldwide. The Centre for Disease Control and Prevention (CDC) considers concussions to be at an ‘epidemic level’ in the USA, with an estimated 1.6−3.8 million mild traumatic brain injuries (mTBI) occurring annually.3 A recent review of hospital Emergency records from Edmonton and the surrounding area in Alberta, Canada documented 63 219 visits for sports or recreation injuries in persons aged 0–35 years, over a 10-year span. Head injuries (including concussions) accounted for 4935 or 7.8% of these visits, with over 70% of these occurring in individuals under 18 years of age.4 Other studies report similarly alarming numbers.5–7 According to McCrory,8 ‘short-term’ concussion disabilities (affecting mood, memory and concentration) may last months, with detrimental effects on quality of life at home, school, work and sports. Randolph9 identified potential risks from incurring multiple concussions or repetitive head trauma, especially when one or more subsequent concussions occur proximate to the previous one(s): death or permanent neurological injury, delayed or atypical recovery and persistent late-life effects.
Specific to the paediatric population, Emergency Departments in the USA have seen a tripling of visits for concussions by the 14-year-old to 19-year-old age group between 1997 and 2007.3 Overall, approximately 3–8% of sport-related injuries in young athletes arriving in Emergency Departments in large Canadian cities are concussions. This trend is alarming, and mandates a more deliberate and conservative management.5
Diagnosis and management of concussions
There have been considerable recent advances in the diagnosis, classification and management of sport-related concussions10; but with insufficient knowledge transfer to end-users, there is often confusion among providers. Greater clinical and scientific appreciation of concussion effects and recovery time, newly adopted legislation (such as the Zackery Lystedt or similar state laws)11 and revised management guidelines12 all have significantly increased attention from the media and healthcare organisations. However, with multiple sources of available information and significant revisions to practise standards, it remains challenging for healthcare professionals to remain well informed of relevant new evidence-based information.
In 1966, the Congress of Neurological Surgeons defined a concussion as ‘a clinical syndrome characterised by immediate and transient post-traumatic impairment in neural function, such as alteration of consciousness, disturbance of vision, equilibrium, etc. due to brain stem involvement due to mechanical forces’.13 Over time, lack of uniformity in the definition and understanding of concussions led to an array of complexities in identification, diagnosis and management. At one point, there were at least 17 different concussion-grading systems and guidelines—none scientifically validated.
Advancement in the field required a consensus definition of a concussion and strict parameters for diagnosis and return-to-sport participation after injury. In 2002, a multidisciplinary team of professionals formed the Concussion in Sport Group and created a definition for concussion that included clinical, pathological and biokinetic aspects.14 This group met in Prague in 2004, and developed a revised set of definitions, guidelines and recommendations.15 In 2008, a third International Consensus meeting in Zurich, Switzerland yielded a further revision of the consensus statement;16 containing the most up-to-date recommendations for diagnosis and management of concussions. A fourth Consensus Conference (November 2012) will likely result in further updates.
Subsequently, numerous national groups, including both American and Canadian organisations,17–24 have developed their own specific guidelines. Common to all is a multifaceted, multidisciplinary approach to the concussed athlete: immediate sideline assessment, removal from play, evaluation by a suitably trained physician and some form of serial neurocognitive testing and assessment of balance/postural control. Initial management includes both physical and cognitive rest, until symptom resolution. Student-athletes may require additional special accommodations.25 Return-to-play follows a graduated pattern, with increasing levels of symptom-free activities.
The most recent clinical tool from this group includes the Sport Concussion Assessment Tool 2 (SCAT2),26 which incorporates self-report symptom scores,27 ,28 the simple Standardised Assessment of Concussion (SAC)29 and measurement of balance.30 Computerised neurocognitive testing decreases practise effects by using multiple versions; and precisely measures reaction time, as well as percentage of correct and incorrect answers.31–33 Most commonly utilised in North America is the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT); other similarly designed tests, such as CogSport, Automated Neuropsychological Assessment Metrics (ANAM) and HeadMinder are also used. ImPACT scores are even being utilised to prognosticate a prolonged recovery from a concussion.34 ,35 Some normative values exist for ImPACT and for SCAT2 at the collegiate36 and high-school levels.37 ,38 Importantly, baseline testing for both SCAT2 and ImPACT is recommended to increase utility in management of concussion and return-to-play decisions. Accurate analysis of computerised test results for validity (by a suitably trained professional) is also essential. Although neuropsychological testing for a concussion is recognised and informative, some clinicians caution against over-enthusiastic reliance on these tests.39 ,40
Knowledge transfer and exchange
Notably, there has been a lag in effective communication and knowledge transfer in this area to healthcare professionals, coaches and athletes.41 As such, the committee in Zurich identified Knowledge Transfer and Exchange (KTE) as critical for dissemination of new information and to inform evidence-based practise.42 The needs and optimal learning styles for physicians, physiotherapists and athletic trainers, coaches and student athletes are not uniform; therefore, different and individualised strategies for concussion education must be employed. A recent update to the Team Physician Consensus Statement (a document co-written by six different member societies) provides both essential and desirable knowledge parameters regarding diagnosis and management of concussions.12 However, educational efforts must be targeted towards the ‘gatekeeper’ of the system, the family physician.
Previous small surveys conducted with primary care providers,43 ,44 athletic trainers45 ,46 and Emergency room physicians,47 have examined practise patterns and concussion knowledge, and documented some definite gaps and information needs. Bazarian et al43 showed that many primary care doctors were unaware of the existing concussion management guidelines, and only 20% used them; however, this was at a time when multiple guidelines were being promoted. Among primary care providers in the state of Maine, 68.4% used published guidelines; of those who did not, a lack of awareness was a barrier to guideline use (71.6%).44 An additional 16% reported not using published guidelines because they found them confusing.
In surveys of certified athletic trainers,45 ,46 their own (NATA) position statement17 was the most widely used for managing concussions (61%) and making return-to-play decisions (47%). However, approximately two-thirds of participants (66.4%) in one study had not heard of the then current recommendations (the Vienna guidelines), and the majority (85.9%) did not use them.45 In a population of Emergency physicians in Michigan, surveys were returned by 36/49 (74%) of attending physicians and 37/38 (97%) of resident Emergency Medicine physicians. Of the total of 73 respondents, only 23% used a nationally recognised guideline, with no significant difference between attending and resident Emergency physicians.47
Most recently, a Canadian survey at the University of Toronto asked graduating medical students and neurology/neurosurgery residents nine specific questions regarding diagnosis and management of concussions.48 Residents (25/80 or 31% response rate) provided significantly more correct answers than medical students (52/222 or 23% response rate). Twenty-four per cent of the medical students (n=18) did not think that ‘every concussed individual should see a physician’ as part of concussion management. Eight per cent of students and residents (n=6) answered that they had never learnt about concussions in their medical education; furthermore, 24% (n=18) could not even remember if they had ever learnt about concussions during their undergraduate medical education.
Athletes, parents and coaches have also been shown to exhibit serious deficiencies in concussion knowledge,49–52 despite the development of educational injury prevention programmes, such as the ThinkFirst Canada, Smart Hockey and a brain and spinal cord injuries prevention video.53 The importance of the family physician as a knowledge provider for coaches in particular has been highlighted: 36% of respondents in one study reported receiving information from family physicians about concussions; this was generally viewed as the most helpful source of information.41 A strong majority of these coaches (99%) would recommend that any athlete who suffers a head injury should see a family physician. In another study of concussions understanding and management among New England high-school football coaches, 70–95% of coaches reported that they would consult a healthcare professional before allowing a player to return to action, consistent with contemporary return-to-play guidelines.54
Therefore, it is paramount to incorporate knowledge transfer strategies when informing family physicians of current concepts in diagnosis and management of concussions.42 The CDC has previously documented favourable changes in knowledge, attitudes and practises towards the prevention and management of concussions behaviour with their initiative and a tool kit for high-school coaches: ‘Heads Up: Concussion in high-school sports’.55 ,56 They assembled a similar comprehensive multimedia toolkit specifically for physicians, and subsequently looked at practises in an intervention (n=183) and a control group (n=231) of paediatricians, family physicians and internists, either prior to, or after receiving the Tool Kit via mail (with no accompanying instructions).57 There were no differences in general concussion knowledge between groups, but physicians in the intervention group were significantly less likely to recommend next day return-to-play after a concussion (adjusted OR=0.31, 95% CI 0.12 to 0.76). Thus, it can be seen that there has been relatively little systematic evaluation of the impact of these and other resources on knowledge transfer and exchange to family physicians.
This research therefore examined current knowledge regarding concussions and clinical management strategies in two distinct populations of family physicians in Alberta, Canada and in North and South Dakota in the USA. These sites were chosen to compare two groups that treat the same condition, but whose training may be different. They have two different primary care organisations, variations in medical school, residency and fellowship training and differing cultural backgrounds; all of which present potential for variable education on the diagnosis and management of sports concussions. The present and preferred sources of information were elicited from these practitioners, with a view towards identifying and facilitating optimal KTE delivery methods. Future projects should involve further development of such initiatives, dissemination to the appropriate populations and follow-up surveys to assess and evaluate both retention and the impact of such KTE training on physicians’ practises.
A brief survey questionnaire (21 questions) on sport-related concussions was developed and put online using the SurveyGizmo. The majority of the questions were closed, with multiple responses permitted in some cases, and open text only allowed to clarify the original response(s). In Alberta, Canada (CAN), the research protocol required that recruitment letters be distributed through the Alberta Family Practice Research Network (AFPRN), inviting interested family physicians to either fax or email back consent; following which, they were sent the survey link. No further follow-up letters or phone calls were allowed. Eighty of 3154 family physicians (2.5%) responded.
A similar internet-based survey was directly distributed to 545 family physicians in North Dakota and South Dakota, USA identified through the American Academy of Family Physicians (AAFP) database. One hundred nine of these physicians completed the survey (20% response rate). Descriptive and frequency statistics were conducted using the SPSS statistical software (V.19.0). Responses from the two populations of family physicians were compared with STATA (V.10.0) using test of proportions, with a statistical significance set at p<0.05. There were minor variations between the two surveys (due to geographical and cultural differences); certain responses and questions were omitted from analyses if they only existed in one survey.
While results in both groups were similar in many aspects (table 1), there were notable differences in some responses between the two different geographical regions.
The majority of these physicians (96.3% CAN, 94.5% US) reported diagnosing and treating concussions in their work settings. Significantly more US than CAN family physicians worked in rural settings. This is likely the reason for the 13.9% US who reported working in Emergency rooms; in rural areas, family physicians more frequently do Emergency room shifts, than in urban settings. If this number is added to those working in walk-in or acute care settings (12.9%), the total percentage (26.8%) is not substantially different from the 28.8% of CAN physicians who reported that work setting. The main aetiologies of concussions seen (physician recall of patient interviews) were reported to be sports/recreation (52.5% CAN) and/or organised sports (76.5% US). The questionnaires given to each group did differ slightly in responses to this question.
Initial concussion management methods by both groups were similar (table 2), with several significant exceptions: more US than Canadian physicians still tended to use (outdated) concussion-grading scales; but interestingly, a larger percentage also incorporated computerised neurocognitive testing. Significantly, only 9.4% of US physicians reported using the recent Zurich Guidelines for diagnosis and management of concussions. Approximately one-quarter of each group also included some form of balance testing.
For treatment, most Canadian (83.8%) and US (75.5%) physicians always recommended physical rest; while far fewer advised cognitive rest (47.5% CAN, 28.4% US; p=0.008). Physicians relied primarily on clinical examination and player self-report of symptoms for return-to-play decisions (table 3); notably, there were disproportionally more US physicians who also utilised computerised neurocognitive testing, and published guidelines. Further subset analysis did not yield any obvious reasons for these differences; but this interpretation was limited due to a small overall sample size, and in particular, the low CAN response rate.
The majority of respondents (84.0–93.8%) indicated their desire for additional education on concussions. More Canadian physicians sought information about concussions through consultation with colleagues (31.3% CAN, 8.8% US; p<0.001), from websites (27.5% CAN, 15.7% US; p=0.052) or had received medical school training (35% CAN, 12.7% US; p<0.001). With many physicians already taking continuing medical education (CME) credits to increase knowledge; CME courses (65% CAN, 37.3% US, p<0.001) and online CME in particular (47.5% CAN, 29.4% US; p=0.012) were rated as the recognised and desired preferred resource and delivery mechanism for continuing education.
This study sought to measure knowledge, clinical practise and CME needs of family physicians in two regions in North America. A larger proportion of the US physician respondents were in rural settings, but no significant correlations were found with any of the other outcome measures; and the numbers were too small to draw any firm conclusions. In comparison, a recent survey of concussions evaluation methods among Washington State high-school football coaches and athletic trainers (30% response rate) found that those in urban schools were more likely than those in rural schools to use SCAT2 and neurocognitive testing.58 It is clear that concussion management is a relevant topic, as over 95% of family physicians see, assess and treat concussions but there appears to be variance in the base knowledge level and management strategies. It was concerning that only 9.4% of the US physicians used the Zurich Guidelines, widely considered to be the most up-to-date. Furthermore, 11.3% of Canadian and 11.9% of US physicians reported using grading scales (outdated since 2002) to make return-to-play decisions. In addition, less than half of CAN and US physicians always advocated cognitive rest, when current recommendations include both physical and cognitive rest as cornerstones of effective concussion management.
These data, however, also contained positive signs. Over half of surveyed family physicians reported recent CME on sport-related concussions. An overwhelming majority desired further education, suggesting strong interest in having up-to-date information. Accordingly, there is significant potential to use high-quality educational tools to fine-tune knowledge and clinical practise. It was encouraging to see that 90% of these physicians relied upon physical examination skills for clinical decision making, and 96% recommended physical rest in their initial management of concussions.
We recognise several limitations to this survey-based study. The response rate of 20% in the states of North and South Dakota is low, but more typical of online surveys. The 2.5% response rate in Alberta likely does not represent reliable sampling of family physicians in this area. This problem has previously been addressed by regional researchers using the same research network, who had an overall response rate of only 7% in their survey of 2572 primary care physicians regarding management of asthma, a more commonly seen condition that might attract more interest than concussions.59 They suggested the use of the modified Dillman method60 (which was precluded here by the additional high cost of a second mailout), or else purposeful sampling and focused targeted surveys. In addition to larger surveys, which could also include other primary care providers, such as paediatricians, physiatrists and Emergency room physicians; it would be worthwhile to engage focus groups of key informants (eg, family physicians representing urban or rural groups; new graduates or older, more experienced physicians) to qualitatively assess perceived gaps, and to explore means of bridging them in terms of knowledge dissemination.
Because of the differing response rates between surveyed CAN and US physicians, comparisons of their responses provides initial insight only, and cannot be generalised to the larger population of family physicians in either area. Inherent methodological limitations for our study may have also included volunteer bias, recall bias and bias related to perceived desirability of responses. Most notably, it only measured physicians’ responses, not actual implementation. Furthermore, this research did not elucidate underlying factors that might influence practise patterns and behaviours.
Despite the wide availability of published guidelines emphasising up-to-date practises for clinical diagnosis and treatment of sport-related concussions, our survey provides some initial indications that family physicians may be managing sport-related concussions using practises inconsistent with current information and recommendations. Accordingly, more deliberate educational efforts and training opportunities for family physicians (KTE) are needed to optimise physician management of this common condition, enhancing patient care in this population.
Contributors CML designed the study, provided expert content review of the questionnaire and data interpretation, and wrote the draft manuscript. MM also participated in the project and questionnaire design, data interpretation and review of the manuscript. ASP formatted the online survey questionnaire, collected and analysed the Canadian data and contributed to final data interpretation and approval of the manuscript. BJT assisted with project design, acquisition of data in the US group, revision of the article and approval of the final version. JCD, MFB and TAM assisted with data interpretation, initial draught development, edits and critical revisions of the manuscript content, clarity and flow; as well as responses to reviewers and the final approval. VDV provided input on initial project design, expert content review of the questionnaire, facilitation of Ethics/IRB Review at his institution and project supervision. He assisted with data interpretation, revisions to the manuscript and the final approval.
Competing interests None.
Ethics approval University of Alberta Research Health Ethics Board; Sanford Research Institutional Review Board.
Provenance and peer review Not commissioned; externally peer reviewed.