Many primary care physicians lack confidence in their ability to diagnose and manage concussions, says a University of Washington study (1), although doctors receiving a concussion education toolkit were significantly less likely to recommend next day return to play after concussion, considered premature under current guidelines.
Primary care physicians receiving the CDC's "Heads Up" toolkit had the same general concussion knowledge as those who did not, and generally responded to diagnosis and return to play (RTP) scenarios the same way.
Four in ten primary physicians - three quarters of whom saw at least one concussion or more a year in their practice and one in ten who treated 10 or more in the previous year - admitted to lacking confidence in diagnosing concussions and only between one and three and three in ten expressed confidence in concussion management, confidence levels which did not improve for those receiving the CDC concussion toolkit.
By contrast, a 2010 study (2) of those who requested the version of the CDC toolkit for coaches found that it helped them identify signs and symptoms of concussion, increased their awareness of the need to have concussed athletes evaluated by a health care professional, and provided helpful information about the possible length of recovery, with 82% regarding the information as extremely useful, 50% saying they viewed concussions more seriously after reading the materials, and 38% reporting that they changed the way they managed concussions based on the toolkit. The University of Washington researchers, however, interjected a note of caution about those results because of the fact that the coaches had requested the toolkit probably made them more likely to view the materials as helpful.
To determine the effectiveness of the CDC toolkit specifically designed for physicians - which includes a 23-page booklet on the diagnosis and management of concussion, a card for on-field concussion management, a standardized assessment of concussion form, patient information about concussions in English and Spanish, and a CD-ROM with additional resources - researchers at the University of Washington mailed toolkits to half of a group of randomly selected pediatricians, family physicians and internists, and then sent both groups two additional follow-up mailings 2 to 3 weeks apart.
Receiving the CDC toolkit, researchers found:
- did not increase a physician's level of confidence in their knowledge of concussion management (but only about 6 in 10 felt confident diagnosing concussion and only about 3 in 10 were confident in their ability to manage concussions, even though more than 7 in 10 had seen at least one concussion in the last year, and more than 1 in 10 had seen more 10+);
- did not lead to an increase in the use of standardized assessments of concussion (only 16% used them);
- did not lead to a signficant change in the number of physicians who felt that an athlete with concussion symptoms lasting 5 minutes had a concussion (more than 60% of physicians in both groups made that diagnosis), lasting more than 30 minutes (almost 90% for both groups), or that involved memory loss or loss of consciousness (nearly 100% for both groups);
- did not result in a significant difference in the percentage that felt it safe to return to play the same day if they had symptoms for 15 minutes or greater (77.2% versus 75.7 for doctors not receiving the toolkit) or 30 minutes (96.7% versus 93.9%) or where the concussion occurred 1 week before and the athlete was now symptom-free (more than 80% of physicians in both groups felt the athlete would be safe to RTP); but
- did lead to a greater percentage of physicians correctly disagreeing with the statement that "Wearing a helmet prevents concussions" (58.4% versus 48.0%); and
- did make it more than three times less likely that they would recommend next day RTP compared to the group not receiving the toolkit (3.4% versus 11.3%).
Concussion knowledge gaps
- 17.8% of doctors who did not receive the CDC toolkit and 13.1% of those who did felt same day RTP was safe if symptoms cleared in 15 minutes, despite laws in a growing majority of states barring same day return to play when a player displays concussion signs or experiences concussion symptoms of any duration and consensus guidelines3 recommending that athletes be restricted from activity while experiencing symptoms (physical and cognitive rest) and then gradually return to play over approximately six days;
- 15.3% of doctors in both groups disagreed with the statement that concussed athletes were at higher risk for a second concussion, despite numerous studies showing them to be at increased risk;
- A small but still significant number of doctors (7.4% of those in control group versus 8.7% of those who received the CDC toolkit) still incorrectly agreed with the statement that a loss of consciousness was required for diagnosis of concussion.
The fact that only six in ten physicians in both groups felt confident in diagnosing concussion, and that only between 3 in 10 and 1 in 3 felt confident in concussion management, is a cause for concern, especially given the findings in a 2011 Children's Hospital Boston study4 that physicians are involved in the assessment of almost 60% of concussions in U.S. high schools in schools with at least one athletic trainer on staff, and make half of the return to play decisions.
Concussion education of physicians: a continued challenge
The new findings by the University of Washington researchers is consistent with previous studies finding that many primary care physicians are unaware of current concussion management guidelines or found the guidelines too confusing or cumbersome to put into practice. This knowledge gap prompted the authors of the Children's Hospital Boston study, including lead author and MomsTeam concussion expert, Dr. William P. Meehan, III, as well as sports concussion neuropsychologist and MomsTeam expert, Rosemarie Scolaro Moser, to call for increased concussion education of such physicians.
While recognizing that "concussion guidelines have become more widely recognized recently, with the passage in more than 40 states of laws modeled on her own state's Zackery Lystedt Law ... requir[ing] that high school athletes in Washington State suspected of having a concussion must be seen by a clinician prior to returning to play," said Sara P. Chrisman, MD, of the Department of Pediatrics at the University of Washington, "such laws are not useful if clinicians do not recognize concussion or are unaware of RTP guidelines and allow athletes to return to play sooner than recommended."
"The challenge," Chrisman says, "is to create guidelines that are clear and concise, yet allow room for personal judgment," especially given that "in recent years, some have questioned whether practice guidelines are the best means for educating physicians regarding clinical management." She recommended that future studies "should focus on assessing whether concussion guidelines are effective for preventing further injury" from a premature return to play.
1. Chrisman SP, Schiff MA, Rivara FP. Physician Concussion Knowledge and the Effect of Mailing the CDC's "Heads Up" Toolkit. Clin. Ped. 2011;50(11):1031-1039.
2. Sarmiento K, Mitchko J, Klein C, Wong S. Evaluation of the Centers for Disease Control and Prevention's concussion initiative for high school coaches: "Heads up:concussion in high school sports". J. Sch Health. 2010;80:112-118.
3. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on Concussion in Sport held in Zurich, November 2008. Clin J Sport Med 2009; 19:185-200.
4. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).
Posted October 25, 2011