Canadian pediatric emergency physician knowledge of concussion diagnosis and initial management.

UNLABELLED: Introduction The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion. METHODS: The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians. RESULTS: Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion. CONCLUSION: Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

Knowledge of paediatric concussion among front-line primary care providers.

OBJECTIVE: To assess the knowledge of paediatric concussion diagnosis and management among front-line primary care providers. METHODS: Experts from the Concussions Ontario Diagnosis and Early Education Working Group developed a 34-item survey incorporating case vignettes with the collaboration of experts in medical education. Electronic surveys were distributed via FluidSurveys using a modified version of Dillman's tailored design method. The survey was distributed to five Ontario professional associations. The target participants were front-line health care providers (family physicians, emergency medicine physicians, general paediatricians, nurse practitioners and physician assistants) in Ontario; only providers who diagnose and/or manage paediatric concussions were eligible to participate. RESULTS: The survey was fully completed by 577 health care providers who treat paediatric concussion. Of the respondents, 78% (95% CI 74% to 81%) reported diagnosing ≥5 concussions annually. Physicians and nonphysicians equally recognized concussion (90% [95% CI 86% to 92%]; 85% [95% CI 77% to 90%], respectively). Only 37% (95% CI 32% to 41%) of physicians correctly applied graduated return to play guidelines. Return to learn recommendations were also insufficient: 53% (95% CI 49% to 58%) neglected to recommend school absence and 40% (95% CI (35% to 44%) did not recommend schoolwork accommodations. Only 26% (95% CI 22% to 30%) of physicians reported regular use of concussion scoring scales. CONCLUSIONS: Considerable gaps in knowledge exist in front-line primary care providers with inadequate application of graduated return to play and return to learn following concussion, as demonstrated by the present broad population-based survey. Consistent application of best evidence-based management using comprehensive guidelines may help to reduce the impact of concussion and persistent postconcussive problems in children and adolescents.

OBJECTIF: Évaluer les connaissances des dispensateurs de soins de première ligne au sujet du diagnostic et de la prise en charge des commotions cérébrales en pédiatrie. MÉTHODOLOGIE: Avec l'aide d'experts en formation médicale, des experts du groupe de travail sur le diagnostic et l'éducation précoce de Concussions Ontario ont préparé un sondage de 34 questions incluant des capsules cliniques. Les sondages électroniques, inspirés d'une version modifiée du modèle conceptuel adapté de Dillman, ont été distribués à cinq associations professionnelles de l'Ontario par l'entremise de FluidSurveys. Les dispensateurs de soins de première ligne (médecins de famille, urgentologues, pédiatres généralistes, infirmières praticiennes et auxiliaires médicaux) de l'Ontario étaient ciblés. Seuls les dispensateurs qui diagnostiquent ou prennent en charge les commotions cérébrales en pédiatrie pouvaient y participer. RÉSULTATS: Ont entièrement répondu au sondage 577 dispensateurs de soins qui soignent les commotions cérébrales en pédiatrie. De ce nombre, 78 % (95 % IC 74 % à 81 %) ont déclaré en diagnostiquer au moins cinq par année. Les médecins et les non-médecins dépistaient tout autant les commotions (90 % [95 % IC 86 % à 92 %]; 85 % [95 % IC 77 % à 90 %], respectivement). Seulement 37 % (95 % IC 32 % à 41 %) des médecins appliquaient correctement les directives sur le retour au jeu graduel. Les recommandations sur la reprise de l'apprentissage étaient également insuffisantes : 53 % (95 % IC 49 % à 58 %) négligeaient de recommander de s'absenter de l'école et 40 % (95 % IC (35 % à 44 %) ne recommandaient pas d'aménagements des travaux scolaires. Seulement 26 % des médecins (95 % IC 22 % à 30 %) déclaraient utiliser régulièrement les échelles de notation des commotions cérébrales. CONCLUSIONS: Les dispensateurs de soins de première ligne présentaient d'importantes lacunes sur le plan des connaissances. En effet, comme le démontre le présent vaste sondage en population, ils n'appliquaient pas correctement les règles de retour au jeu et de reprise de l'apprentissage graduels après une commotion. L'utilisation généralisée de modes de prise en charge exemplaires tirés de directives détaillées pour-rait contribuer à réduire les conséquences des commotions et des problèmes persistants qui en découlent chez les enfants et les adolescents.

Knowledge gained from the Brief Traumatic Brain Injury Screen--implications for treating Canadian military personnel.

OBJECTIVE: To compare physical and mental health outcomes of Canadian military personnel with probable mild traumatic brain injury (mTBI) to outcomes of those without and to report implications for collaboration and treatment. METHODS: One hundred forty-seven soldiers attending the Operational Stress Injury Clinic at Parkwood Hospital, London, Ontario, were screened for mTBI and completed several other measures of mental and physical health. Scores from these measures were compared across two groups (positive vs. negative screens for mTBI) using an independent samples t-test. RESULTS: Thirty-four of 147 participants screened positively for mTBI. Soldiers with probable mTBI were more likely to have poorer physical health but were less likely to engage in problem drinking than those who screened negatively for mTBI. CONCLUSIONS: In this initial study, we found that the wide range of physical and mental health difficulties experienced by Canadian military personnel with probable mTBI necessitates an interdisciplinary collaborative care model.

A systematic review of the rehabilitation of moderate to severe acquired brain injuries.

OBJECTIVE: To conduct a systematic review of the rehabilitation literature of moderate to severe acquired brain injuries (ABI) from traumatic and non-traumatic causes. METHODS: A review of the literature was conducted for studies looking at interventions in ABI rehabilitation. The methodological quality of each study was determined using the Downs and Black scale for randomized controlled trials (RCTs) and non-RCTs as well as the Physiotherapy Evidence Database (PEDro) scale for RCTs only. RESULTS: Almost 14 000 references were screened from which 1312 abstracts were selected. A total of 303 articles were chosen for careful review of which 275 were found to be interventional studies but only 76 of these interventional studies were RCTs. From this, 5 levels of evidence were determined with 177 conclusions drawn; however of the 177 conclusions only 7 were supported by two or more RCTs and 41 were supported by one RCT. CONCLUSION: Only 28% of the interventional studies were RCTs. Over half of the 275 interventional studies were single group interventions, pointing to the need for studies of improved methodological quality into ABI rehabilitation.

Cognitive interventions post acquired brain injury.

OBJECTIVE: Cognitive rehabilitation represents a substantial portion of rehabilitative efforts put forth in increasing independence following an acquired brain injury. MAIN OUTCOMES AND RESULTS: This review examined four major areas of cognitive therapy including: attention/concentration, learning and memory, executive functioning, and general cognitive rehabilitation approaches. In total, 64 studies were evaluated throughout the four major areas, which provided the evidence-base for 18 conclusions. The majority of the conclusions were based on moderate and limited evidence, however three strong and one conflicting conclusions were made. CONCLUSIONS: Future research should explore functional outcome measures and long-term effects of treatment interventions through follow-up.

Community reintegration following acquired brain injury.

OBJECTIVE: To evaluate the interventions and strategies used to enable transition from acute care or post-acute rehabilitation to the community following brain injury. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on ABI rehabilitation. Five major aspects of community reintegration, including: independence and social integration, caregiver burden, satisfaction with quality of life, productivity and return to driving were considered. RESULTS: With the exception of one, the majority of interventions are supported by only limited evidence, denoting an absence of randomized controlled trials (RCTs) in the literature. Of 38 studies evaluated for this review, only one RCT was found. That RCT provided moderate evidence that behavioural management, coupled with caregiver education, did not help to improve caregiver burden. CONCLUSIONS: Further research, using an interventional approach, is required to advance the evidence base of reintegration into the community following brain injury.