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. [1]
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.
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 [1] (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
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 [2] (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.
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 [3] after an initial acute visit, or routine re-evaluation for a diagnosed concussion):
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.
"It is critical that pediatric primary care and EM providers consistently diagnose concussion, initiate treatment in the form of cognitive and physical rest [7], and provide the necessary return to school [8] and return to play protocols [5]," 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 [7] 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:
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 [11] 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 [12] 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 [3] 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 [12].
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
Links:
[1] https://www.momsteam.com/node/203
[2] https://www.momsteam.com/node/4959
[3] https://www.momsteam.com/node/149
[4] https://www.momsteam.com/node/801
[5] https://www.momsteam.com/node/128
[6] https://www.momsteam.com/node/1335
[7] https://www.momsteam.com/node/4176
[8] https://www.momsteam.com/node/3394
[9] https://www.momsteam.com/node/3976
[10] https://www.momsteam.com/node/5131
[11] https://www.momsteam.com/node/3015
[12] https://www.momsteam.com/node/6780
[13] https://www.momsteam.com/health-safety/athletic-trainers-primary-care-doctors-treat-most-concussions-in-high-school-sports-study-finds
[14] https://www.momsteam.com/health-safety/childrens-er-visits-concussions-double-while-admissions-fall-sharply
[15] https://www.momsteam.com/under-5/rise-in-emergency-department-visits-concussions-result-increased-awareness-says-Centers-Disease-Control
[16] https://www.momsteam.com/health-safety/concussion-knowledge-primary-care-doctors-falls-short-study-says
[17] https://www.momsteam.com/health-safety/signs-requiring-immediate-hospitalization-after-concussion
[18] https://www.momsteam.com/health-safety/signs-deteriorating-mental-status-serious-brain-injury-immediate-hospitalization
[19] https://www.momsteam.com/health-safety/every-state-has-youth-sports-concussion-safety-law
[20] https://www.momsteam.com/academic-accommodations/ensure-successful-return-to-classroom-after-concussion--says-pediatrics-group