Although pediatric primary care and emergency medicine providers regularly treat concussions, many admit to lacking the training or tools needed to diagnose and manage concussed patients, a 2012 study finds. 
Researchers at Children's Hospital of Philadelphia and the University of Pennsylvania surveyed primary care physicians (PCPs) and emergency medicine (EM) providers at a large pediatric care network to learn more about their practices and attitudes surrounding diagnosis and management of concussion.
All able to diagnose concussion
Survey participants were asked to diagnose concussion when presented with two hypothetical concussion scenarios: the first, a 11-year old boy presenting 5 days after a head injury suffered while riding a bicycle without a helmet who had not previously seen a doctor, had returned to school the next day, but was observed by his mother to be more irritable than normal and taking longer to complete homework (subtle concussion symptoms), the second, a 17-year-old boy presenting 1 day after direct helmet-to-helmet contact with another player while playing football who was stunned and confused for 10 minutes, sat out the rest of the game but did not seek acute medical care but now had headaches and amnesia (overt concussion symptoms). Researchers found that nearly all (97% of primary care physicians; 100% of emergency medical providers) were able to diagnose concussions in both scenarios
Subtle concussion signs sometimes missed
While nearly all the providers, when presented with the 2 concussion scenarios correctly identified subtle mood and cognitive changes after head trauma as concussion, some providers did not view the more subtle signs of concussion, such as abnormal eye tracking (17%), difficulty concentrating (11%), vestibular (ie, inner ear/balance) disturbances, decline in school performance (6%), and sensitivity to light or noise (6%), as related to concussion.
Most referred patients to specialists
While the vast majority (91%) of the physicians surveyed had seen at least one concussion patient in the previous 3 months, either at acute presentation (ie, first medical visit within 24 hours after injury) or non-acute presentation (ie, first medical visit more than 24 hours after injury, persistent symptoms after an initial acute visit, or routine re-evaluation for a diagnosed concussion):
- 92% had referred at least 1 concussion patient after the initial visit, with emergency medical providers (EM) more likely to refer than primary care physicians (PCPs);
- PCPs were more likely to refer because they were not as comfortable with management or did not have adequate time and resources, when compared with EM providers. They most frequently referred to a neurologist or neuropsychologist; and
- EM providers were more likely to refer because they did not perceive it to be their role or did not believe the emergency department setting was appropriate for ongoing management. They most frequently referred to a trauma surgeon or clinic.
Asked whether they would refer to a specialist either of the concussion patients in the two hypothetical scenarios, nine out of ten (89%) EM providers and nearly half (47%) of PCPs said they would refer the patient with the subtle concussion symptoms to a concussion specialist; while virtually all (96%) EM providers, and nearly three-quarters (72%) of PCPs, said they would refer the patient with the overt concussion symptoms to a concussion specialist.
Barriers to concussion management
- While nearly all providers believed that educating patients and families about concussion was their role, one in five (21%) of EM providers and four in ten (41%) of PCPs viewed inadequate training and inadequate time as significant barriers to providing such education;
- Thirteen percent of PCPs and 45% of EM providers did not believe completing formal neurocognitive testing for concussed patients, however, was their role, with substantial majorities of both viewing inadequate training (64% for EM providers/75% for PCPs) or inadequate time (77% for EM providers/69% for PCPs) as significant barriers to their performing such testing.
- One in 8 of EM providers (12%) and one in 4 of PCPs (25%) felt they had inadequate training to be in a position to recommend the appropriate time for a concussed patient to return to school, and nearly one in five (18%) of EM providers and one in three (30%) of PCPs identified inadequate training as a significant barrier for prescribing a gradual return to play protocol for concussed athletes.
- Ninety-six percent of providers without a provider decision support tool (such as a clinical pathway or protocol) specific concussion, and 100% of providers without discharge instructions specific to concussion to provide to patients and their families (such as provided in the SCAT2 believed those resources would be helpful.
Need for more training and support seen
"It is critical that pediatric primary care and EM providers consistently diagnose concussion, initiate treatment in the form of cognitive and physical rest, and provide the necessary return to school and return to play protocols," said lead author, Mark R. Zonfrillo, MD, MSCE, of the Center for Injury Research and Prevention, the Division of Emergency Medicine, and Sports Medicine and Performance Center at the Children's Hospital of Philadelphia.
In particular, Zonfrillo and his colleagues recommended shifting EM provider referral patterns to PCPs for more minor concussion, or even have them initiate formal cognitive rest and return to school plans, with the recommendation of follow-up only if symptoms do not improve, and lowering the barriers to continuing concussion management by PCPs by:
- including concussion in graduate medical education and continuing medical education;
- arming providers with standardized evaluation and decision-making tools, such as the CDC's online concussion tools in the "Heads Up" series designed for health care providers [Note, however, that one recent study (2) found that the CDC concussion materials did not significantly improve concussion knowledge among primary care physicians], and incorporating such tools into existing electronic health record infrastructure to enhance and automate evidence-based decision support by providers, which was found to be highly valued by survey participants; and
- utilizing contemporary technologies such as mobile phone applications and social networking to assist diagnosis and management of concussion.
Implementation of such steps, said Zonfrillo, was particularly critical in view of the adoption by most states in recent years of youth concussion safety laws that include some combination of education, removal from play, and clearance by a health care professional before a return to play; laws which the study's authors predicted would "dramatically increase the number of concussion patients who need clearance by a health care provider" and "require providers to have evidence-based decision models that allow for systematic and safe clearance before a concussion patient can resume sports." Indeed, the study said that "possibly even more imperative is the need for a return to school protocol based on regular assessment of symptoms by the patient, family, and provider."
Update: In October 2013, the American Academy of Pediatrics, citing the Zonfrillo study and heeding its call, issued a clincial report  to provide pediatricians with a better understanding of the possible factors that may contribute to a student's difficulties in the classroom after a concussion to serve as a framework for health care professionals, schools, teachers, and parents, to guide a student's successful and safe return to learning. For an article on the AAP's clinical report, click here.
1. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric Providers' Self-Reported Knowledge, Practices, and Attitudes About Concussion. Pediatrics 2012;130(6). DOI: 10.1542/peds.2012-1431)(published online ahead of print)(accessed November 19, 2012).
2. 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.
3. Halstead ME, et al. Clinical Report: Returning to Learning Following a Concussion. Pediatrics doi:10.1542/peds.2013-2867 (epub October 27, 2013).
Posted November 19, 2012; revised October 27, 2013