Physician knowledge gaps on concussion care

Concussion has a high burden of injury and risk of secondary sequelae across all Canadian demographics in various settings.[1,2] Despite concussion’s high prevalence, care is variable due to gaps in knowledge and evidence-based standardized management.[2,3] Recent advances (e.g., 6th International Conference on Concussion in Sport consensus statement on concussion in sport, American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury) have aimed to improve concussion outcomes and reduce prolonged recovery.[1] Recommendations are continually produced surrounding concussion knowledge, diagnosis, and management; however, there is a disconnect with dissemination to our frontline providers.

A 2018 Canadian public opinion survey of 391 physicians and medical professionals evaluated awareness of concussion diagnostic and management tools.[2] Approximately 60% recognized the Canadian Guideline on Concussion in Sport and the Sport Concussion Assessment Tool (SCAT; a standardized objective concussion diagnostic tool), while 15% were unaware of any commonly used tools.[2] Additionally, there is limited formal medical training in concussion.[4] A 2023 study on medical students and residents at Memorial University of Newfoundland found that 42.2% had concussion education and 25% could identify red-flag symptoms.[4] Although these statistics are limited, there have been improvements in concussion knowledge.[3] Between 2013 and 2022, the use of the SCAT by family physicians increased from 34.2% to 65.0%, and return-to-play guidelines increased from 29.8% to 56.1%.[3] Treatment recommendations shifted toward brief rest (24 to 48 hours) and subthreshold or modified exercises instead of complete rest.[1,3]

Numerous strategies can help narrow the gap between research and frontline practices. Starting with training, standardized updated concussion education is recommended across all Canadian medical schools to create a baseline of information. Some universities, such as the University of British Columbia, have included concussion education in their curriculum; however, uniform training across the country is limited.[4,5] Additionally, given the newest protocols incorporating nurse practitioners and other medical professionals to treat concussions, reviewing this education may be worthwhile.[1]

Many of our frontline providers are not up to date with the newest recommendations for concussion.[2] This gap can be addressed through CME, governing bodies (e.g., Doctors of BC, Divisions of Family Practice) endorsing the use of educational resources and guidelines (e.g., BC Guidelines and Protocols Advisory Committee, Pathways BC), updating commonly used websites (e.g., UpToDate, DynaMed), and social marketing or educational campaigns. CME is an effective avenue for knowledge translation across various subspecialties, and 53.7% of BC physicians dedicate 2–3 hours/week to professional development.[5] The Concussion Awareness Training Tool—a free, online, up-to-date, evidence-based educational tool endorsed provincially through the BC Ministry of Health and nationally through the Concussion Harmonization Project—is an effective CME resource that improves knowledge and concussion diagnostics and management.[5] Although successful, numerous CME barriers to knowledge translation have been reported, including time, accessibility, and awareness of resources and education that need to be addressed and mitigated.[5]

A substantial gap often persists between evidence-based practices and the delivery of frontline care in Canada, impacting concussion diagnosis and management. Addressing this disparity demands comprehensive strategies encompassing standardized education, ongoing training, and updated guideline and resource dissemination.
—Rylen A. Williamson, BSc
Southern Medical Program (class of 2026), Faculty of Medicine, University of British Columbia
—Shazya Karmali, PhD
Research Manager, BC Injury Research and Prevention Unit, BC Children’s Hospital
—Shelina Babul, PhD
Director, BC Injury Research and Prevention Unit, BC Children’s Hospital
Clinical Professor, Department of Pediatrics, Faculty of Medicine, University of British Columbia
Director, Canadian Hospitals Injury Reporting and Prevention Program, BC Children’s Hospital
Investigator, Djavad Mowafaghian Centre for Brain Health, University of British Columbia

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References

1.    Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: The 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med 2023;57:695-711.

2.    Public Health Agency of Canada. Baseline survey on understanding and awareness of sport-related concussions. 2018. Accessed 1 March 2024. https://epe.lac-bac.gc.ca/100/200/301/pwgsc-tpsgc/por-ef/public_health_agency_canada/2018/021-17-e/report.html.

3.    Boyd A. Concussion-related knowledge and patterns of practice in Ontario general and family practice and sport and exercise medicine physicians [master’s thesis]. Edmonton: University of Alberta, 2022.

4.    Bray S, Hart S, Kelly R, et al. An in-depth analysis of Canadian medical students and physicians concussion knowledge: A cross-sectional study. Int J Sport, Exercise Health Res 2023;7:34-38.

5.    Devji J, Karmali S, Turcotte K, Babul S. Barriers and facilitators to the uptake of the Concussion Awareness Training Tool as continuing medical education in primary care. Concussion 2023;8:CNC106.