Concussion Care Practices and Utilization of Evidence-Based Guidelines in the Evaluation and Management of Concussion: A Survey of New England Emergency Departments

Evaluating Post-concussion Clinical Management of University-Aged Performing Artists: A Systematic Review

INTRODUCTION

Contemporary concussion literature has yet to establish appropriate clinical management guidelines to address the unique needs of performing arts populations, especially at the collegiate level. Therefore, the purpose of this investigation was to collate current evidence regarding post-concussion return to performance management among university-aged performing artists to generate broad clinical implications.

METHODS

The research team was comprised of two faculty members in the performing arts, one concussion researcher, and athletic trainer, two university librarians, and one physical therapy graduate student with expertise in post-concussion management among performing arts patients. Two librarians searched the literature using PubMed, Cochrane, SPORTdiscus, and Education Research Complete. Studies were eligible for preliminary inclusion if they were written in English, conducted in the United States, as well as published in a peer-reviewed journal. There were no restrictions on publication date due to the limited literature on this topic. The most recent search was conducted in July 2023.

RESULTS

Of the 18 studies identified during the search process, only 2 met the inclusion criteria. Broadly, this investigation identified common mechanisms of injury among stage crew/technicians and dancers who are of university-age. Furthermore, both studies identified several patients who opted to return to performing arts on their own volition. However, there were no studies that solely focused on the collegiate performing arts population and their return to performance procedures.

CONCLUSIONS

Overall, these findings highlight a momentous gap in concussion literature regarding how to guide clinicians and academic teams when returning collegiate performing artists back to their performance environment(s). Thus, additional research is strongly warranted to understand the lived experiences of performing artists with concussion, as well as how to address specific coursework-related demands to support their recovery.

Just a head knock? Emergency physicians need to get serious about concussion

Attention and awareness regarding concussion injury in Australia have significantly increased in the last decade. Although most of this increase is because of discussion regarding concussions from sporting endeavours, the majority of concussions are from non-sport environments including motor vehicle crashes, workplace incidents, falls, accidents, assault and intimate partner violence. In all cases, hospital EDs are the first point of contact, yet as argued in our Opinion here, there are concerns regarding the consistency of care protocols, because of a number of reasons, as well as management and follow-up clinical practices. Our Opinion is to provide a constructive discussion as well as calling for ACEM to support research to provide evidence-based data. Finally, we provide some recommendations that could be implemented immediately to improve clinical practice for presentations of concussion injuries in EDs.

Specialist healthcare services for concussion/mild traumatic brain injury in England: a consensus statement using modified Delphi methodology

OBJECTIVE

To establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome.

DESIGN

This consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%.

SETTING

Specialist outpatient services.

PARTICIPANTS

Members of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England.

PRIMARY OUTCOME MEASURE

A consensus statement on the structure and process of specialist outpatient care for patients with concussion in England.

RESULTS

55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics.

CONCLUSIONS

This work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.

Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion

OBJECTIVE

This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure.

SETTING

Remote semistructured interviews and online surveys.

PARTICIPANTS

The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff.

DESIGN

An exploratory-sequential mixed-methods approach.

MAIN MEASURES

Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus.

RESULTS

The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements).

CONCLUSIONS

These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.

The Clinical Utility of the Child SCAT5 for Acute Concussion Assessment

Background

The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5 and 12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion.

Methods

Our participants included 34 concussed (21 boys, 13 girls; age = 12.8 ± 0.86 years) and 44 non-concussed (31 boys, 13 girls; age = 12.4 ± 0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r=\frac{Z}{\sqrt{n}}$$\end{document}r=Zn) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated.

Results

Concussed children endorsed more symptoms (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.45), higher symptom severity (p < 0.001, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.44), and had higher double leg (p = 0.046, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.23), single leg (p = 0.035, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.24), and total scores (p = 0.022, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r=0.26) for the mBESS than the non-concussed children. No significant differences were observed for the SAC-C scores (p’s ≥ 0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC = 0.76–0.77), negative predictive values (NPV = 0.84–0.88), and negative likelihood ratios (-LR = 0.22–0.31) of the Child SCAT5 scores.

Conclusions

Clinicians should prioritize interpretation of the symptom evaluation form of the Child SCAT5 as it was the most effective component for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.

Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey

Background

Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals.

Methods

This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0–17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020–March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable.

Results

71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006.

Conclusions

TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01022-4.

Variability in the indication of brain CT scan after mild traumatic brain injury. A transnational survey

PURPOSE

Clinical guidelines have been developed to standardize the management of mild traumatic brain injury (mTBI) in the emergency room, in particular the indication of brain CT scan and the use of blood biomarkers. The objective of this study was to determine the degree of adherence to guidelines in the management of these patients across four countries of Southern Europe.

METHODS

An electronic survey including structural and general management of mTBI patients and six clinical vignettes was conducted. In-charge physicians from France, Spain, Greece and Portugal were contacted by telephone and email. Differences among countries were searched using an unconditional approach test on contingency tables.

RESULTS

One hundred and eighty eight physicians from 131 Hospitals (78 Spain, 36 France, 12 Greece and 5 Portugal) completed the questionnaire. There were differences regarding the in-charge specialist across these countries. There was variability in the use of guidelines and their adherence. Spain was the country with the least guideline adherence. There was a global agreement in ordering a brain CT for patients receiving anticoagulation or platelet inhibitors, and for patients with seizures, altered consciousness, neurological deficit, clinical signs of skull fracture or signs of facial fracture. Aging was not an indication for CT in French centres. Loss of consciousness and posttraumatic amnesia were considered as indications for CT more frequently in Spain than in France. These findings were in line with the data from the 6 clinical vignettes. The estimated use of CT reached around 50% of mTBI cases. The use of S100B is restricted to five French centres.

CONCLUSIONS

There were large variations in the guideline adherence, especially in the situations considered to order brain CT after mTBI.

Examining racial and ethnic disparities in adult emergency department patient visits for concussion in the United States

Background

Racial and ethnic differences in emergency department (ED) visits have been reported among adolescent patients but are unsubstantiated among adults. Therefore, our purpose in this study was to examine the relationship between race/ethnicity and adult ED visits for concussions, their injury mechanisms, and computed tomography (CT) scan use among a nationally representative sample.

Methods

We used the National Hospital Ambulatory Medical Care Survey database from 2010-2015 to examine 63,725 adult (20-45 years old) patient visits, representing an estimated 310.6 million visits presented to EDs. Of these visits, 884 (4.5 million national estimate) were diagnosed with a concussion. Visit records detailed patient information (age, sex, race/ethnicity, geographic region, primary payment type), ED visit diagnoses, injury mechanism (sport, motor vehicle, fall, struck by or against, "other"), and head CT scan use. The primary independent variable was race/ethnicity (non-Hispanic Asian, non-Hispanic Black or African American, Hispanic/Latinx, non-Hispanic multiracial or another, and non-Hispanic White). We used multivariable logistic and multinomial regression models with complex survey sampling design weighting to examine the relationship between concussion ED visits, injury mechanisms, and CT scan use separately by race/ethnicity while accounting for covariates.

Results

There were no associations between race/ethnicity and concussion diagnosis among adult ED visits after accounting for covariates. Relative to sports-related injuries, non-Hispanic Black or African American patient visits were associated with a motor vehicle (OR = 2.69, 95% CI: 1.06-6.86) and "other" injury mechanism (OR = 4.58, 95% CI: 1.34-15.69) compared to non-Hispanic White patients. Relative to sports-related injuries, non-Hispanic Asian, multiracial, or patients of another race had decreased odds of falls (OR = 0.20, 95% CI: 0.04-0.91) and "other" injuries (OR = 0.09, 95% CI: 0.01-0.55) compared to non-Hispanic White patients. The odds of a CT scan being performed were significantly lower among Hispanic/Latinx patient visits relative to non-Hispanic White patients (OR = 0.52, 95% CI: 0.30-0.91), while no other race/ethnicity comparisons differed.

Conclusion

Our findings indicate that the overarching concussion ED visit likelihood may not differ by race/ethnicity in adults, but the underlying mechanism causing the concussion and receiving a CT scan demonstrates considerable differences. Prospective future research is warranted to comprehensively understand and intervene in the complex, multi-level race/ethnicity relationships related to concussion health care to ensure equitable patient treatment.

First-Line Health Care Providers' Reported Knowledge of and Referrals to Speech-Language Pathologists for Clients With Mild Traumatic Brain Injury

Purpose People with mild traumatic brain injury (mTBI) may experience deficits in cognition or communication that go unnoticed by first-line health care providers (FHPs). Speech-language pathologists (SLPs) assess and treat these domains yet are often underrepresented on mTBI multidisciplinary teams. This study's aim was to evaluate FHPs' reported knowledge of and referral practices to SLPs for individuals across the life span with mTBI. Method Physicians, physician assistants, nurse practitioners, nurses, and athletic trainers (n = 126) completed an online survey, including two Likert scale questions and one free response question relating to SLPs' role in mTBI. Results More than half of FHPs rate their knowledge of the SLP's role in mTBI management as low (somewhat knowledgeable, 29%; not very knowledgeable, 23%). Similarly, nearly two thirds of FHPs indicated rarely (19%) or never (44%), referring to SLPs for management of patients with mTBI. The majority of FHPs' open responses on the role of the SLP in mTBI management were incomplete, with many including domains that were not relevant to an SLP's role in the management of mTBI (e.g., dysphagia). Within the article, we provide results overall and according to individual profession. Conclusions Results suggest a majority of FHPs lack knowledge in the role of the SLP in the management of mTBI, which may underpin the low referral patterns reported by FHPs for SLP services. Future educational efforts for FHPs regarding the role of SLPs in mTBI care are necessary.

Management of sport-related concussion in emergency departments in England: a multi-center study

OBJECTIVE

To establish the current knowledge of sport-related concussion (SRC) management of clinicians in emergency departments in the North West of England.

METHODS

A cross-sectional, multi-center study design was used and included emergency department clinicians (EDCs) across 15 centers in the North West of England. A 22-question survey was issued with questions focused on the 5th International Conference on Concussion Consensus Statement. Absolute and percentages were presented, and comparisons in knowledge of guidelines and confidence between EDCs were made using the Kruskal-Wallis test.

RESULTS

Of an estimated 300 EDCs, 111 (37%) responded. Thirty (27%) were aware of the guidelines, whilst 63 (57%) had heard of a graduated return-to-sport protocol. Physical rest was advised by 106 (95%) respondents, with 68 (61%) advising cognitive rest and 47 (42%) providing written advice. There was no difference (p > .05) in awareness of SRC guidelines or confidence between clinician grade, with most receiving no SRC training.

CONCLUSIONS

There is a lack of knowledge amongst EDCs in the North West of England in managing and providing discharge advice to patients with SRC. This is likely due to the limited awareness of guidelines and training, and therefore further education delivery on SRC management guidelines is required.

Healthcare Providers' Self-Reported Pediatric Mild Traumatic Brain Injury Diagnosis, Prognosis, and Management Practices: Findings From the 2019 DocStyles Survey

OBJECTIVE

To assess adherence to 5 key recommendations in the Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury, this article presents results from the 2019 DocStyles survey.

STUDY DESIGN

Cross-sectional, web-based survey of 653 healthcare providers.

RESULTS

Most healthcare providers reported adhering to the recommendations regarding the use of computed tomography and providing education and reassurance to patients and their families. However, less than half reported routinely examining their patients with mild traumatic brain injury (mTBI) using age-appropriate, validated symptom scales, assessing for risk factors for prolonged recovery, and advising patients to return to noncontact, light aerobic activities within 2 to 3 days. Self-reported mTBI diagnosis, prognosis, and management practices varied by specialty. Only 3.8% of healthcare providers answered all 7 questions in a way that is most consistent with the 5 recommendations examined from the Centers for Disease Control and Prevention Pediatric mTBI Guideline.

CONCLUSION

This study highlights several important information gaps regarding pediatric mTBI diagnosis and management. Further efforts to improve adoption of guideline recommendations may be beneficial to ensure optimal outcomes for children following an mTBI.

Developing a Mobile App for Concussion to aid Patient Empowerment and Symptom Management

Despite the high prevalence of concussions each year in Canada, access to consistent and science-based information on how to self-manage these injuries remains a significant hurdle for many patients. Currently, available mobile applications (apps) focus mainly on supporting patients with sports-related concussions, although falls account for more traumatic brain injuries (TBI) than sports-related TBI's in Alberta. Patients from a broader demographic may be limited from accessing information on how to correctly manage and track their symptoms as they feel that currently available resources are not applicable to them. Through collaboration between health system leaders, expert consultations, patients, and university students, a mobile app was designed as a platform to help patients manage and track symptoms at home, as well as to clarify misleading information and misconceptions surrounding injury. The team engaged numerous physicians, patient advisors, and health system leaders to improve upon the features of currently-existing concussion apps such as symptom tracking, insight into concussion, and strategies for returning to work/school that are more inclusive to adult, non-sports related injuries. We believe that these features will advance recovery by alleviating the burden of uncertainty and confusion for patients and their family members.

Time to Authorized Clearance from Sport-Related Concussion: The Influence of Healthcare Provider and Medical Facility

CONTEXT

Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time.

OBJECTIVE

Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities.

DESIGN

Prospective Cohort Study.

SETTING

High school.

PATIENTS OR OTHER PARTICIPANTS

Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics.

MAIN OUTCOME MEASURE(S)

Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan-Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses.

RESULTS

An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001).

CONCLUSIONS

Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

Awareness and Perceived Value of Eye Tracking Technology for Concussion Assessment among Sports Medicine Clinicians: A Multinational Study

Objective: The awareness of concussion as a serious and frequently occurring sports injury and its management has evolved significantly. One viable objective diagnostic tool is eye tracking technology. The authors hypothesized that while clinicians may be aware that assessing eye movements in concussed athletes can be beneficial, it is possible that, due to the novelty of the eye tracking technology and limited exposure, only a few actually use it in their practice. The study aimed to assess the awareness of eye movement deficits associated with concussion amongst sports medicine clinicians and to determine the utilization and perceptions of the eye tracking technology for concussion diagnosis.Methods: An online 18-question survey was distributed internationally from January until December 2017 and completed by 171 sports medicine clinicians (sport physicians, therapists, general practitioners, neuropsychologists) from 32 countries.Results: Respondents indicated that subjectivity of assessments remained a major limitation of established diagnostic tools. Eye tracking technology, despite its potential to attenuate this limitation, was only used by 12% of respondents. To diagnose concussion, 77% did not use any eye movement assessment tools other than own clinical assessment. With the exception of abnormal pupil light reflex, which was checked by 68%, eye movement deficits were inspected by less than half of the respondents (46.3 ± 12%).Conclusion: Even among sports medicine clinicians who regularly attend to patients with concussions, there is insufficient awareness that concussion can lead to abnormal eye tracking behavior. Lack of exposure to the sensitive eye tracking equipment may be a limiting factor for using eye movement metrics for concussion diagnostics. Facilitating the awareness of objective methods, like eye tracking technology, may help assure the appropriate continuum of identification and treatment for concussed athletes. Increasing educational opportunities and practical experience of clinicians regarding concussive symptoms and potential innovative technology is strongly advocated.

Clinical Predictors of 3- and 6-Month Outcome for Mild Traumatic Brain Injury Patients with a Negative Head CT Scan in the Emergency Department: A TRACK-TBI Pilot Study

A considerable subset of mild traumatic brain injury (mTBI) patients fail to return to baseline functional status at or beyond 3 months postinjury. Identifying at-risk patients for poor outcome in the emergency department (ED) may improve surveillance strategies and referral to care. Subjects with mTBI (Glasgow Coma Scale 13–15) and negative ED initial head CT < 24 h of injury, completing 3- or 6-month functional outcome (Glasgow Outcome Scale-Extended; GOSE), were extracted from the prospective, multicenter Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Pilot study. Outcomes were dichotomized to full recovery (GOSE = 8) vs. functional deficits (GOSE < 8). Univariate predictors with p < 0.10 were considered for multivariable regression. Adjusted odds ratios (AOR) were reported for outcome predictors. Significance was assessed at p < 0.05. Subjects who completed GOSE at 3- and 6-month were 211 (GOSE < 8: 60%) and 185 (GOSE < 8: 65%). Risk factors for 6-month GOSE < 8 included less education (AOR = 0.85 per-year increase, 95% CI: (0.74–0.98)), prior psychiatric history (AOR = 3.75 (1.73–8.12)), Asian/minority race (American Indian/Alaskan/Hawaiian/Pacific Islander) (AOR = 23.99 (2.93–196.84)), and Hispanic ethnicity (AOR = 3.48 (1.29–9.37)). Risk factors for 3-month GOSE < 8 were similar with the addition of injury by assault predicting poorer outcome (AOR = 3.53 (1.17–10.63)). In mTBI patients seen in urban trauma center EDs with negative CT, education, injury by assault, Asian/minority race, and prior psychiatric history emerged as risk factors for prolonged disability.

Concussion Care in the Emergency Department: A Prospective Observational Brief Report

STUDY OBJECTIVE

Emergency physicians are often the initial-and only-clinical providers for patients who have sustained a mild traumatic brain injury. This prospective observational study seeks to examine the practice patterns of clinicians in an academic Level I trauma center as they relate to the evaluation of patients who were presumed to be at high risk for mild traumatic brain injury. Specifically, we describe the frequency of a documented mild traumatic brain injury evaluation, diagnosis, and discharge education.

METHODS

This pilot study took place in a single academic Level I trauma and emergency care center during a 4-week period. Patients were identified by triage nurses, who determined whether they responded affirmatively to 2 questions that indicated a potential risk for mild traumatic brain injury. Data were abstracted from emergency department clinician documentation on identified patients to describe the frequency of a documented mild traumatic brain injury evaluation (history and physical examination), diagnosis, and discharge education among those who were identified to be at risk for a mild traumatic brain injury.

RESULTS

Ninety-eight subjects were included in the present study. Documentation of a mild traumatic brain injury evaluation was present for less than 50% of patients, a final diagnosis of mild traumatic brain injury was included for 36 (37%; 95% confidence interval 27.8% to 46.7%), and discharge education was provided to 15 (15%; 95% confidence interval 9.2% to 21.4%). Of the 36 patients who received a documented mild traumatic brain injury diagnosis, 15 (41.5%; 95% confidence interval 26.7% to 57.9%) received mild traumatic brain injury-specific discharge education.

CONCLUSION

This study suggests that the majority of patients at high risk for mild traumatic brain injury have no documentation of an evaluation for one. Also, patients with a mild traumatic brain injury diagnosis were unlikely to receive appropriate discharge education about it. Education and standardization are needed to ensure that patients at risk for mild traumatic brain injury receive appropriate evaluation and care.

The symptom experience of adolescents with concussion

PURPOSE

The incidence of concussions in adolescents has increased in recent years. Concussion causes an array of symptoms that can interfere with the daily life of an adolescent, yet the symptoms and recovery vary greatly. Concussion management is based on expert consensus guidelines but they are not specific for adolescents and it is unclear how adolescents actually manage their symptoms. This study aimed to describe the symptom experience of adolescents with a concussion and their self-management strategies.

DESIGN AND METHODS

The study used a qualitative design to explore the symptom experiences of adolescents. Ten adolescents aged 14-17 years were recruited from a concussion clinic. Using a semi-structured interview, adolescents were asked about their concussion symptoms, the interference with their daily life, and their symptom self-management strategies. Data were analyzed using descriptive statistics and content analysis.

RESULTS

Adolescents reported 17 different symptoms they experienced following their concussion. All of the adolescents reported a headache but descriptions varied. The symptoms interfered with many aspects of their daily life including school and activities. The majority of the school responses were related to difficulties attending school and learning (n = 21). The self-management strategies were organized into 11 categories. The most common strategies fell under three categories: rest (n = 20), controlling the environment (n = 20), and using motivational thoughts and activities (n = 9).

PRACTICE IMPLICATIONS

This study indicates that adolescents experience multiple symptoms after their concussion and use a variety of strategies to manage the symptoms. Each adolescent had a unique symptom experience, highlighting the need for developing personalized concussion management plans. Nurses can coordinate the development of management plans and provide education about managing concussion symptoms and promoting recovery.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Feasibility of a postacute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomised controlled study

Objective

The utility of structured exercise for rehabilitation purposes early in the postacute phase (ie, beyond the initial 24–48 hours of advised rest) following sport-related concussion (SRC) remains largely unexplored. This study examined the feasibility of implementing a standardised aerobic exercise (AE) intervention in the postacute stage of SRC recovery in a sample of adolescent students with SRC compared with usual care.

Methods

Symptomatic adolescents with SRC were randomised to one of two groups: Aerobic Exercise (n=8) or Usual Care (n=7). The AE intervention, beginning on day 6 postinjury, comprised eight sessions with progressive increases in intensity and duration on a cycle ergometer. Usual care consisted of rest followed by physician-advised progressions in activity levels in an unsupervised setting. All participants were evaluated by physician at weeks 1, 2, 3 and 4 postconcussion. Outcome measures included: (1) Intervention feasibility: symptom status pre-post exercise sessions and completion of intervention and (2) Clinical recovery: symptom status at weeks 1, 2, 3 and 4 postinjury and medical clearance date.

Results

All participants completed the exercise sessions as part of the AE intervention and symptom exacerbation was not associated with any exercise session. The AE group experienced greater symptom resolution compared with the Usual Care Group across the recovery timeline.

Conclusion

A structured AE protocol appears to be safe and feasible to administer in the postacute stage of SRC recovery in adolescents and should be explored as part of a full Phase III Clinical Trial.

Healthcare providers' attitudes and behaviours related to paediatric mild traumatic brain injury: results from the 2014 DocStyles survey

OBJECTIVE

Explore healthcare providers' experiences managing mTBI and better understand their use of mTBI assessment tools and guidelines. Cross-sectional Methods: A random sample of 1,760 healthcare providers responded to the web-based DocStyles survey between June 18 and 30, 2014. The sample included family/general practitioners, internists, pediatricians, and nurse practitioners who reported seeing pediatric patients. We examined their experiences with mTBI to identify opportunities to increase preparedness and improve management of mTBI.

RESULTS

Fifty-nine percent of healthcare providers reported that they diagnosed or managed pediatric patients with mTBI within the last 12 months. Of those, 44.4% felt 'very prepared' to make decisions about when pediatric patients can safety return to activities, such as school and sports after a mTBI. When asked how often they use screening or assessment tools to assess pediatric patients with mTBI, almost half reported that they 'seldom' or 'never' use those resources (24.6% and 22.0%, respectively).

CONCLUSION

Most healthcare providers reported seeing pediatric patients with mTBI, yet most feel only somewhat prepared to manage this injury in their practise. Broader use of screening tools and guidelines, that include clinical decision support tools, may be useful for healthcare providers who care for pediatric patients with mTBI.

Medical retirement from sport after concussions: A practical guide for a difficult discussion

Purpose of review

In patients with a considerable history of sports-related concussion, the decision of when to discontinue participation in sports due to medical concerns including neurologic disorders has potentially life-altering consequences, especially for young athletes, and merits a comprehensive evaluation involving nuanced discussion. Few resources exist to aid the sports medicine provider.

Recent findings

In this narrative review, we describe 10 prototypical vignettes based upon the authors' collective experience in concussion management and propose an algorithm to help clinicians navigate retirement discussions. Issues for consideration include absolute and relative contraindications to return to sport, ranging from clinical or radiographic evidence of lasting neurologic injury to prolonged concussion recovery periods or reduced injury threshold to patient-centered factors including personal identity through sport, financial motivations, and navigating uncertainty in the context of long-term risks.

Summary

The authors propose a novel treatment algorithm based on real patient cases to guide medical retirement decisions after concussion in sport.

Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review

OBJECTIVES

Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice.

METHODS

A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies.

RESULTS

Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations.

CONCLUSIONS

The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.

The 5th Annual One Mind Summit: Lessons Learned About "Science Informing Brain Health Policies and Practice"

Advances in science frequently precede changes in clinical care by several years or even decades. To better understand the path to translation, we invited experts to share their perspectives at the 5th Annual One Mind Summit: "Science Informing Brain Health Policies and Practice," which was held on May 24-25, 2016, in Crystal City, VA. While the translation of brain research throughout the pipeline-from basic science research to patient care-was discussed, the focus was on the implementation of "best evidence" into patient care. The Summit identified key steps, including the need for professional endorsement and clinical guidelines or policies, acceptance by regulators and payers, dissemination and training for clinicians, patient advocacy, and learning healthcare models. The path to implementation was discussed broadly, as well as in the context of a specific project to implement concussion screening in emergency and urgent care centers throughout the United States.