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Sport-related concussion (SRC) is a form of mild traumatic brain injury (mTBI) induced by biomechanical forces that can lead to prolonged cognitive, emotional and physical effects.[[1,2]] SRC is a significant problem in New Zealand.[[2]] In 2019, there were 6,217 claims to the Accident Compensation Corporation (ACC, New Zealand’s no-fault accident compensation programme) for SRC, at a cost of NZ$22.5 million.[[3]] Rugby union, football and cycling were the sports with the greatest number of SRC claims.[[2,3]] SRC claims have increased steadily across the last decade, up 90% from 2010 to 2019.[[3]]

The assessment and management of SRC is an evolving field. Recommendations have changed following each of the five Concussion in Sport Group (CISG) International Consensus Conferences.[[4]] The latest of these guidelines were released in 2017 and cover care of SRC from side-line assessment through to clinical evaluation and steps for recovery.[[1]] In conjunction with the guidelines, the Sport Concussion Assessment Tool (SCAT) 5th Edition was also published.[[5]] This tool was designed to be used by medical professionals and includes screening assessments for the cognitive and physiological effects of concussion and a symptom report scale. The SCAT is included in the 2016 ACC guidelines on the management of SRC.[[6]] The ACC guidelines’ key message to players, coaches and umpires/referees is: “Recognise, Remove and Refer.” The ACC guidelines also recommend that players report to a medical doctor for definitive diagnosis and care.[[6]] Concussion is a medical diagnosis requiring clinical judgement and consideration of multiple non-specific history and examination features.[[1,4,6]] Doctors working in primary care must therefore have an understanding of SRC assessment, management and guidelines for return-to-sport, in order to appropriately treat these patients.

A survey of 93 general practitioners (GPs) and emergency doctors (EDs) conducted in Canada identified that GPs and trauma clinicians had limited awareness of consensus statements on SRC and rarely referred to guidelines.[[7]] In that study, there was very poor usage of the SCAT, with 86% of EDs and 54% of GPs reporting having never used the tool. It is unclear whether this reflected a lack of awareness or lack of utility of the tool outside of the sports-medicine context for which it was originally designed.

Although international studies have explored GPs’ and other primary care and specialist doctors’ knowledge and understanding of SRC,[[7–10]] no such studies have been undertaken in a New Zealand medical population. Therefore, the purpose of this study was to assess the current state of knowledge and use of SRC guidelines and management among primary care doctors in New Zealand.

Methods

We used an anonymous, online, 21-item multi-choice questionnaire based on a validated questionnaire used in previous studies.[[7]] Prior to its distribution, the survey was piloted and reviewed by nine sport and exercise physicians to ensure completeness and readability. The questionnaire included questions about the participant’s place of work, the number of SRC they see in clinical practice, where they obtained information on SRC, the tools they used to diagnose SRC and their knowledge, attitudes and behaviour towards SRC. The response to each question was predominantly captured on a 5-part Likert scale, and where appropriate there was the option for free-text comments. Anonymous demographic information included details about vocational training, postgraduate sports medicine qualifications completed, years since graduation and geographical location.

All doctors working as GPs or urgent care physicians (UCPs) were eligible to participate. An invitation to participate in the online survey (SurveyMonkey Inc., San Mateo California, USA, http://www.surveymonkey.com) was included in the newsletters of the Royal New Zealand College of Urgent Care (RNZCUC) and the primary care continuing medical education (CME) organisation the Goodfellow Unit  . Also, in order to gain the largest possible sample, the survey and an open invitation to disseminate were promoted via Facebook on the RNZCUC page and New Zealand medical practitioners’ group pages, . In addition, members of the research team attended the Goodfellow Symposium and webinars in 2018 and invited GPs and UCPs to participate. Questionnaire responses were collected from October to December 2017 and from March to May 2018.

Ethical approval was provided by Auckland University of Technology Ethics Committee (AUTEC Reference #16/187). The ACC Research Ethics Committee also approved the study. A survey was considered valid and included for analysis when respondents completed at least 80% of questions. Responses were summarised using frequencies and percentages; descriptive statistics were used to analyse the data. Comments in the free-text fields were categorised using conventional content analysis to assist in the interpretation of the quantitative results.[[11]]

Results

All data were extracted into SPSS (IBM SPSS, Chicago, version 25). A total of 183 potential participants read the Goodfellow Unit invitation, and 402 doctors on the RNZCUC mailing list were emailed and invited to attend; the total number of invites was 585. There were 145 responses, yielding an initial response rate of 25%. A further 61 completed the survey during the Goodfellow Symposium, and further promotion resulted in 230 total valid responses. We could not calculate the total number of invites, because of the use of social media, the encouragement to freely disperse the link to the study through professional contact lists and the invitation to participate during the Goodfellow Symposium, and so it was not possible to measure our final response rate.

The characteristics of the sample are outlined in Figure 1 and Table 1. The majority of participants were GPs (59%) or GP registrars (14%). Eighteen percent were UCPs or trainees, who were based across all regions of New Zealand (Table 1). The majority (77%) reported working in an urban practice. There were 52 doctors (23%) who reported working for a rural practice. Participants had been practicing clinically for an average of 21 years since graduation, with a range of 1–46 years. A small number (n=26, 11%) had undertaken postgraduate study in sports medicine. Forty-four percent had assessed ten or more SRCs in the past two years, and 3% had not seen any patients with SRC the past two years.

Figure 1: Distribution of responses by geographic area.

Table 1: Types of physicians surveyed (n=230).

Participants reported using a wide range of information sources on concussion as shown in Table 2. The information sources that were reported to be the most useful were those created by Best Practice Advisory Centre New Zealand (Bpac[[nz]] Ltd) and GP conference/CME presentations, with 73% and 69% of participants finding them useful respectively.

Table 2: Usefulness of information sources from the past two years. View Table 2.

All (100%) of the participants indicated that taking a history and conducting a physical exam was important when assessing for SRC. Only 41% had heard of the CISG Consensus Statement on Concussion in Sport. Although 83% had heard about the SCAT, only 43% of them found the tool was easy to use in a clinical setting. Of those familiar with the SCAT tool, 58% would prefer to have it integrated into their patient management software to facilitate its use. Less than half (43%) of all participants usually or always used the SCAT to assist with their assessment. Although we did not specifically ask about barriers to using the SCAT or other diagnostic tools, across the 25 free-text responses in this section of the survey, seven participants commented that time pressures and limitations in funding were barriers to concussion assessment and management, as the SCAT took longer to complete than the appointment time typically allocated. Few participants (3% for each) routinely used computer-based evaluations or diagnostic imaging when assessing for SRC.

Table 3 outlines responses related to the knowledge, attitudes and behaviours of the surveyed medical practitioners. All participants agreed that a player who has been concussed should not return to sport the day the concussion occurred. The majority of participants (82%) agreed that a concussed patient should not return to contact sport for three weeks and should follow a return-to-play protocol prior to returning to sport (94%). Most participants (89%) considered that a SRC could lead to long-term brain damage. Over 80% of those surveyed believed a player should seek assessment from a doctor on the day the injury occurred.

Table 3: Knowledge, attitudes and behaviours around sport-related concussion. View Table 3.

The most agreed upon strategies for management were cognitive and physical relative rest (activity at a level below that which provokes the patient’s symptoms). Seventy-eight percent of participants always or usually recommended relative cognitive rest, and 82% of doctors recommended relative physical rest. Seventy eight percent always or usually recommended use of non-narcotic analgesia, and 35% always or usually recommended nonsteroidal anti-inflammatory drugs. Use of opioid analgesia was appropriately low, with 88% never or rarely using them for SRC. There was a low utilisation of referral pathways to allied health practitioners, with a third of participants (34%) never or rarely referring SRC patients to physiotherapy and only a third (34%) usually or always referring a patient for specialist support from a concussion service. Free-text responses indicated a range of barriers to concussion specialist services, including declined referrals, access issues for rural practises and a lack of knowledge of the ACC concussion service. The majority of participants (66%) recommend that patients get reviewed within 7–10 days of the initial visit. Just under half (49%) stated that they would provide this follow-up, with 46% reporting they refer them back to the patient’s usual GP.

Just over half of participants (53%) felt confident in managing a patient with SRC. There was notable variance in participants’ confidence in advising on return-to-sport, with only 46% agreeing that they feel confident in advising patients on how to do this. We used Spearman’s correlation coefficients to explore whether there were any significant associations between physician type, years since graduation, practice type and number of concussions seen with level of confidence in managing SRCs; there was no significant association between physician type, years since graduation or type of practice (urban vs rural) and confidence in managing SRC at the p<0.05 level. However, participants who saw patients presenting with concussion more frequently had significantly higher confidence in managing these injuries (r=0.26, p<0.001).

Discussion

This study aimed to determine the current state of knowledge of existing SRC guidelines and the management of SRC among primary care doctors in New Zealand. We found that just over half of clinicians surveyed felt confident managing SRCs. However, a higher proportion did not feel confident advising on safely returning to sport. Our current ACC guidelines[[6]] recommend that sportspeople affected by SRC should seek an assessment from a doctor. These findings highlight the need to address knowledge gaps and provide support to doctors in managing SRC and return-to-sport.

There was a lack of consistency regarding the ease of use of concussion assessment tools. Less than half of participants reported using the SCAT, which is endorsed by ACC guidelines[[6]] and is currently the most widely used instrument for concussion assessment within the sports context. However, the SCAT does have limitations that might impact its use in primary care. For example, our study showed that time constraints were reported to be a barrier to using the SCAT. This is perhaps unsurprising given that, even for well-practised clinicians, this tool takes a minimum of 10 minutes to complete.[[4,5]] The symptom checklist has been reported to demonstrate clinical utility in tracking recovery,[[1,12]] although the utility of the remainder of the SCAT appears to decrease significantly 3–5 days after injury.[[4]] Evidence also suggests that the symptom scale has been found to potentially reflect non-brain injury processes such as migraine.[[13]] Poor uptake of the SCAT in primary care, as found in  this research and similar studies in Canada,[[7,8]] suggests the need for the development of a validated concussion assessment tool that can assist in diagnosis, identify patients who would benefit from early referral to multidisciplinary care and be used to track recovery. Any new tool should be time-efficient and able to be completed within a typical primary care consultation. It is also worth noting that doctors will be assessing patients with potential concussion from both sports- and non-sports-related trauma, and any new or modified tool would ideally be applicable to all concussion regardless of environment.

The most recent CISG Consensus Statement on Concussion in Sport recommends an initial period of physical and cognitive rest immediately after sustaining an SRC and a graduated return-to-sport only once concussion symptoms have resolved.[[1]] A brief period (24–48 hours) of cognitive and physical rest is appropriate for most patients.[[1,14–16]] Following this period, patients should be encouraged to gradually increase non-sporting activity while staying below their cognitive and physical symptom exacerbation thresholds and avoiding activities that have an increased risk of re-injury.[[1,16]] More research is needed to evaluate the optimal amount and type of rest after SRC.[[1,16,17]] However, no evidence indicates that strict rest for more than three days is beneficial to recovery from concussion.[[16–18]] In the current study, most participants reported using appropriate management strategies for patients with concussion, such as non-narcotic analgesia. That a high number of respondents recommended relative cognitive and physical rest indicates an understanding of the shift towards relative rest rather than absolute rest.[[1,14]] Furthermore, this appears to suggest that these clinicians may have a better understanding of how to manage SRC than prior cohorts of doctors in international studies, where less than half of family physicians were found to be advising appropriate cognitive rest.[[7]] This finding may also reflect the fact that the evidence advocating relative, rather than absolute, rest is reasonably new and therefore has become more established in clinical practice since the previous studies.

Studies have shown that the use of formal return-to-activity and return-to-school protocols can effectively change healthcare providers’ clinical practice and increase knowledge and confidence in treating concussion.[[19]] Progression strategies for return-to-sport and return-to-school are available online and incorporated into the SCAT 5th Edition document.[[1,5,15]] However, if less than half of those surveyed were using the tool regularly, and if a greater number were not aware of the CISG Consensus Statement on Concussion in Sport, those surveyed who were not familiar with the SCAT5 or CISG may not be aware of the corresponding rehabilitation, return-to-school and return-to-sport recommendations.

In recent years, as those in sport have become more aware of SRC, many New Zealand National Sports Organisations (NSOs) have introduced concussion policies. Aspects of these policies, such as mandatory stand-down periods after injury, differ across codes, which may have caused confusion for both clinicians and members of the public. This is a particular problem for young people who may play several different sports over the course of a week. The lack of consistency may influence clinicians’ confidence managing safe return-to-sport following SRC. It is suggested that NSOs consider developing a consistent return-to-sport message that can be delivered to all players. There does seem to be greater confidence in the recommendation that no player should return to sport on the day of the injury, where the advice is more definite and consistent.

Other knowledge gaps identified include the belief a patient must have a blow to the head to sustain a concussion (21% of respondents). Although concussion is caused by biomechanical forces, it may be caused by a direct blow to the head, the face or the neck, or elsewhere on the body if there is an impulsive force to the head.[[1]] This is an important area for further education to ensure all concussions are recognised and to capture an accurate diagnosis in those patients that may not have sustained a direct blow to the head.

The CISG define persistent symptoms as those beyond 14 days in adults and four weeks in children. Most patients are expected to recover within this timeframe.[[1]] However, this has been challenged by recent research.[[12]] Other studies have illustrated that 30–55% of those who sustain an SRC experience persistent post-concussive symptoms beyond two weeks.[[12,14,17]] Persistent symptoms can result in significant morbidity and impact for the affected individual and their whānau. It is increasingly recognised that there are a range of reasons for patients to experience persistent symptoms and that treatment should be individualised to the patient and their needs.[[1,20]] Prolonged symptoms may be due to persisting physiological concussion, cervical, vestibular and ocular post-concussion defects, psychological variables or a combination of these factors.[[1,17]] Recent research surveying physiotherapists in New Zealand indicated good levels of knowledge of SRC and that physiotherapists currently provide a wide range of primary care services for people with concussion that align with international recommendations.[[21,22]] Physiotherapists have a strong desire to be more involved in side-line recognition and player removal, concussion assessment testing and return-to-sport integration.[[21]] In addition to providing physiotherapy care for concurrent cervical injury and vestibular dysfunction, there may be other benefits of greater physiotherapist involvement in the care of these patients.[[22]] Physiotherapists are more likely to be present during training and games, and  they often have a close relationship with players and coaching staff;[[21]] therefore physiotherapists provide a useful role in recognition of possible concussion and are a source for supplementary history of the concussive event.[[22]] Following a doctor’s assessment and medical diagnosis, physiotherapists can then assist in supervising the agreed graduated return-to-sport protocol, monitoring a patient for persistent symptoms and providing a liaison between doctors and coaches. A collaborative approach, involving a range of different clinicians, is therefore most appropriate for SRC patients.[[1,16,20]]

Although relative rest and symptomatic treatments form the mainstay of initial management for SRC, recent research supports the use of sub-symptom threshold, sub-maximal exercise, for patients with persistent concussive symptoms.[[14,16,17,23]] Controlled exercise performed at an intensity, and for a duration, that does not exacerbate symptoms is safe and beneficial for adult and adolescent patients with persistent symptoms following concussion.[[16,17,23]] Makdissi et al’s review of the literature on the management of those with persistent concussion symptoms concluded that “cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion.”[[20]] In New Zealand, patients experiencing persistent symptoms can be referred to an ACC-approved multidisciplinary concussion service for ongoing management, including prescription of sub-threshold exercise for suitable patients. Given a New Zealand study of those presenting for treatment for SRC reported that only 45% of patients were clinically recovered by 14 days, it appears that a large number of patients may benefit from this type of service.[[12]] The current study revealed that only one third of doctors usually or always referred their patients to multidisciplinary concussion services, and identified some perceived barriers to access, including a lack of doctor knowledge of the ACC service, barriers in the referral process and geographical barriers to access to concussion services outside large urban centres. Barriers such as these may reduce referral rates. Further research may help to identify areas for system improvement. We agree with Maxtone et al that early access to active rehabilitation services in acute concussion may be an effective use of health resources in New Zealand.[[22]]

Finally, the current study also highlights the need to ensure information and guidelines on SRC reach those working in primary care. Our study indicates that primary care doctors do not utilise medical journals or ACC guidelines when looking for treatment recommendations. Provvidenza’s research on transferring knowledge from concussion consensus statements to improve patient care indicates that, although printed education materials are valuable for reinforcing knowledge transfer, they are an ineffective standalone method for improving physician performance.[[24,25]] GP CME conferences and Bpac[[nz]] publications were identified by our participants as the most helpful resources. Interactive education sessions or webinars, supplemented by print or online written material, may therefore provide an effective education strategy.[[24]] The integration of treatment pathways and guidelines into patient management software and health pathways may also support primary care clinicians in best practice management of concussion.

This study is the first to look at care of SRC in the New Zealand primary care context. It does have a number of limitations. Multiple methods of distribution were chosen to increase the number of participants and reduce barriers to participating in the study; however, as a result it is difficult to calculate our response rate. Primary care is also a heterogenous workforce and inevitably there are areas of this workforce who are not represented in these results. Additionally, as the study only explored sport-related concussion, these findings may not be representative to non-sport-related injury. Finally, there is the potential for recall bias in any survey, and there is a risk of selection bias, as it is likely that those clinicians with an interest in sport and SRC were more likely to participate.

Summary

Abstract

Aim

To assess the current state of knowledge around sport-related concussion (SRC) guidelines and management among primary care doctors in New Zealand.

Method

An online, self-administered, 21-item multi-choice questionnaire targeted at general practitioners and urgent care doctors in New Zealand was used. Main outcome measures were knowledge and management of patients with SRC through to return-to-sport.

Results

There were 230 total valid responses. Over half had no knowledge of the Consensus Statement on Concussion in Sport, and only 43% used the Sport Concussion Assessment Tool (SCAT) routinely. Fifty-eight percent would prefer to have a screening tool integrated into their patient management software. Most reported using appropriate management strategies for patients with concussion and recognised the potential benefit of relative cognitive and physical rest. There was low utilisation of referral pathways to allied health practitioners and specialist concussion services. Half (53%) felt confident in managing a patient with SRC and 46% felt comfortable managing return-to-sport.

Conclusion

Primary care doctors have good knowledge of SRC but are not as confident managing return-to-sport. Further education opportunities were identified. Development of concussion tools adapted for use in primary care, integrated with patient management software and that support pathways to optimise patient recovery are recommended.

Author Information

Caroline Stuart: Sport and Exercise Medicine Registrar, Axis Sports Medicine Specialists and High Performance Sport New Zealand, Auckland. Duncan Reid: Professor of Physiotherapy, School of Clinical Sciences, AUT University, Auckland. Alice Theadom: Director of the TBI Network, AUT University, Auckland. Mark Fulcher: Sport and Exercise Medicine Fellow and Director, Axis Sports Medicine Specialists, Auckland. Natalie Hardaker: BSc (Hons) Injury Prevention Specialist, Accident Compensation Corporation, Wellington.

Acknowledgements

ACC provided funding for this research. Thanks to Rachel Smith and Ethan Smith for assisting with the data collection and analysis. Thanks to James D Carson, Assistant Professor, Department of Family and Community Medicine at the University of Toronto in Ontario, for kindly sharing his validated questionnaire.

Correspondence

Prof. Duncan Reid, School of Clinical Sciences, AUT University, Auckland; Auckland University of Technology (AUT), Private Bag 92006, Auckland 1142, New Zealand; +64 9 921 9999

Correspondence Email

duncan.reid@aut.ac.nz

Competing Interests

Nil.

1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838-47.

2. Theadom A, Starkey NJ, Dowell T, et al. Sports-related brain injury in the general population: an epidemiological study. J Sci Med Sport. 2014;17:591-6.

3. Sport related concussions and TBI: OIA response 52244. ACC; [cited 2020 Jun 27]. Available from: https://catalogue.data.govt.nz/dataset/3317c3ef-8999-4edb-a9f7-be037df8520a/resource/953db280-f73e-4e90-b2a6-e483ee2c8471/download/52244.xlsm

4. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51:848-50.

5. Sport concussion assessment tool - 5th edition. Br J Sports Med. 2017;51:851-8.

6. ACC SportSmart. Sport Concussion in New Zealand National Guidelines [cited 2020 Oct 17]. Available from: https://www.accsportsmart.co.nz/assets/assets-final/resources-final/3152df545a/acc7555-accsportsmart-concussion-national-guidelines.pdf

7. Stoller J, Carson JD, Garel A, et al. Do family physicians, emergency department physicians, and pediatricians give consistent sport-related concussion management advice? Can Fam Physician. 2014;60:548-52.

8. Carson JD, Rendely A, Garel A, et al. Are Canadian clinicians providing consistent sport-related concussion management advice? Can Fam Physician. 2016;62:494-500.

9. Pleacher MD, Dexter WW. Concussion management by primary care providers. Br J Sports Med. 2006;40:e2.

10. Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison. Br J Sports Med. 2013;47:54-9.

11. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277-88.

12. Kara S, Crosswell H, Forch K, et al. Less Than Half of Patients Recover Within 2 Weeks of Injury After a Sports-Related Mild Traumatic Brain Injury: A 2-Year Prospective Study. Clin J Sport Med. 2020;30:96-101.

13. Sargeant M, Sykes E, Saviour M, et al. The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients. J Concussion. 2018;2:1-10.

14. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion: Curr Sports Med Rep. 2018;17:262-70.

15. McCrory P, Meeuwisse WH, Dvořák J, et al. Infographic: Consensus statement on concussion in sport. Br J Sports Med. 2017;51:1557-8.

16. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930-4.

17. Leddy J, Baker JG, Haider MN, et al. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train. 2017;52:299-308.

18. Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28:250-9.

19. DeMatteo C, Stazyk K, Singh SK, et al. Ontario Neurotrauma Foundation. Development of a conservative protocol to return children and youth to activity following concussive injury. Clin Pediatr (Phila). 2015;54:152-63.

20. Makdissi M, Cantu RC, Johnston KM, et al. The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? Br J Sports Med. 2013;47:308-13.

21. Reid DA, Hume P, Whatman C, et al. Knowledge, attitudes, and behaviours of New Zealand physiotherapists to sports-related concussion. NZJP. 2020;48:19-28.

22. Maxtone S, Bishop M, Chapple, et al. Physiotherapist involvement in concussion services in New Zealand: A national survey. NZJP. 2020;48:70-9.

23. Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319-25.

24. Provvidenza C, Engebretsen L, Tator C, et al. From consensus to action: knowledge transfer, education and influencing policy on sports concussion. Br J Sports Med. 2013;47:332-8.

25. Provvidenza CF, Johnston KM. Knowledge transfer principles as applied to sport concussion education. Br J Sports Med. 2009;43 Suppl 1:i68-75.

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Sport-related concussion (SRC) is a form of mild traumatic brain injury (mTBI) induced by biomechanical forces that can lead to prolonged cognitive, emotional and physical effects.[[1,2]] SRC is a significant problem in New Zealand.[[2]] In 2019, there were 6,217 claims to the Accident Compensation Corporation (ACC, New Zealand’s no-fault accident compensation programme) for SRC, at a cost of NZ$22.5 million.[[3]] Rugby union, football and cycling were the sports with the greatest number of SRC claims.[[2,3]] SRC claims have increased steadily across the last decade, up 90% from 2010 to 2019.[[3]]

The assessment and management of SRC is an evolving field. Recommendations have changed following each of the five Concussion in Sport Group (CISG) International Consensus Conferences.[[4]] The latest of these guidelines were released in 2017 and cover care of SRC from side-line assessment through to clinical evaluation and steps for recovery.[[1]] In conjunction with the guidelines, the Sport Concussion Assessment Tool (SCAT) 5th Edition was also published.[[5]] This tool was designed to be used by medical professionals and includes screening assessments for the cognitive and physiological effects of concussion and a symptom report scale. The SCAT is included in the 2016 ACC guidelines on the management of SRC.[[6]] The ACC guidelines’ key message to players, coaches and umpires/referees is: “Recognise, Remove and Refer.” The ACC guidelines also recommend that players report to a medical doctor for definitive diagnosis and care.[[6]] Concussion is a medical diagnosis requiring clinical judgement and consideration of multiple non-specific history and examination features.[[1,4,6]] Doctors working in primary care must therefore have an understanding of SRC assessment, management and guidelines for return-to-sport, in order to appropriately treat these patients.

A survey of 93 general practitioners (GPs) and emergency doctors (EDs) conducted in Canada identified that GPs and trauma clinicians had limited awareness of consensus statements on SRC and rarely referred to guidelines.[[7]] In that study, there was very poor usage of the SCAT, with 86% of EDs and 54% of GPs reporting having never used the tool. It is unclear whether this reflected a lack of awareness or lack of utility of the tool outside of the sports-medicine context for which it was originally designed.

Although international studies have explored GPs’ and other primary care and specialist doctors’ knowledge and understanding of SRC,[[7–10]] no such studies have been undertaken in a New Zealand medical population. Therefore, the purpose of this study was to assess the current state of knowledge and use of SRC guidelines and management among primary care doctors in New Zealand.

Methods

We used an anonymous, online, 21-item multi-choice questionnaire based on a validated questionnaire used in previous studies.[[7]] Prior to its distribution, the survey was piloted and reviewed by nine sport and exercise physicians to ensure completeness and readability. The questionnaire included questions about the participant’s place of work, the number of SRC they see in clinical practice, where they obtained information on SRC, the tools they used to diagnose SRC and their knowledge, attitudes and behaviour towards SRC. The response to each question was predominantly captured on a 5-part Likert scale, and where appropriate there was the option for free-text comments. Anonymous demographic information included details about vocational training, postgraduate sports medicine qualifications completed, years since graduation and geographical location.

All doctors working as GPs or urgent care physicians (UCPs) were eligible to participate. An invitation to participate in the online survey (SurveyMonkey Inc., San Mateo California, USA, http://www.surveymonkey.com) was included in the newsletters of the Royal New Zealand College of Urgent Care (RNZCUC) and the primary care continuing medical education (CME) organisation the Goodfellow Unit  . Also, in order to gain the largest possible sample, the survey and an open invitation to disseminate were promoted via Facebook on the RNZCUC page and New Zealand medical practitioners’ group pages, . In addition, members of the research team attended the Goodfellow Symposium and webinars in 2018 and invited GPs and UCPs to participate. Questionnaire responses were collected from October to December 2017 and from March to May 2018.

Ethical approval was provided by Auckland University of Technology Ethics Committee (AUTEC Reference #16/187). The ACC Research Ethics Committee also approved the study. A survey was considered valid and included for analysis when respondents completed at least 80% of questions. Responses were summarised using frequencies and percentages; descriptive statistics were used to analyse the data. Comments in the free-text fields were categorised using conventional content analysis to assist in the interpretation of the quantitative results.[[11]]

Results

All data were extracted into SPSS (IBM SPSS, Chicago, version 25). A total of 183 potential participants read the Goodfellow Unit invitation, and 402 doctors on the RNZCUC mailing list were emailed and invited to attend; the total number of invites was 585. There were 145 responses, yielding an initial response rate of 25%. A further 61 completed the survey during the Goodfellow Symposium, and further promotion resulted in 230 total valid responses. We could not calculate the total number of invites, because of the use of social media, the encouragement to freely disperse the link to the study through professional contact lists and the invitation to participate during the Goodfellow Symposium, and so it was not possible to measure our final response rate.

The characteristics of the sample are outlined in Figure 1 and Table 1. The majority of participants were GPs (59%) or GP registrars (14%). Eighteen percent were UCPs or trainees, who were based across all regions of New Zealand (Table 1). The majority (77%) reported working in an urban practice. There were 52 doctors (23%) who reported working for a rural practice. Participants had been practicing clinically for an average of 21 years since graduation, with a range of 1–46 years. A small number (n=26, 11%) had undertaken postgraduate study in sports medicine. Forty-four percent had assessed ten or more SRCs in the past two years, and 3% had not seen any patients with SRC the past two years.

Figure 1: Distribution of responses by geographic area.

Table 1: Types of physicians surveyed (n=230).

Participants reported using a wide range of information sources on concussion as shown in Table 2. The information sources that were reported to be the most useful were those created by Best Practice Advisory Centre New Zealand (Bpac[[nz]] Ltd) and GP conference/CME presentations, with 73% and 69% of participants finding them useful respectively.

Table 2: Usefulness of information sources from the past two years. View Table 2.

All (100%) of the participants indicated that taking a history and conducting a physical exam was important when assessing for SRC. Only 41% had heard of the CISG Consensus Statement on Concussion in Sport. Although 83% had heard about the SCAT, only 43% of them found the tool was easy to use in a clinical setting. Of those familiar with the SCAT tool, 58% would prefer to have it integrated into their patient management software to facilitate its use. Less than half (43%) of all participants usually or always used the SCAT to assist with their assessment. Although we did not specifically ask about barriers to using the SCAT or other diagnostic tools, across the 25 free-text responses in this section of the survey, seven participants commented that time pressures and limitations in funding were barriers to concussion assessment and management, as the SCAT took longer to complete than the appointment time typically allocated. Few participants (3% for each) routinely used computer-based evaluations or diagnostic imaging when assessing for SRC.

Table 3 outlines responses related to the knowledge, attitudes and behaviours of the surveyed medical practitioners. All participants agreed that a player who has been concussed should not return to sport the day the concussion occurred. The majority of participants (82%) agreed that a concussed patient should not return to contact sport for three weeks and should follow a return-to-play protocol prior to returning to sport (94%). Most participants (89%) considered that a SRC could lead to long-term brain damage. Over 80% of those surveyed believed a player should seek assessment from a doctor on the day the injury occurred.

Table 3: Knowledge, attitudes and behaviours around sport-related concussion. View Table 3.

The most agreed upon strategies for management were cognitive and physical relative rest (activity at a level below that which provokes the patient’s symptoms). Seventy-eight percent of participants always or usually recommended relative cognitive rest, and 82% of doctors recommended relative physical rest. Seventy eight percent always or usually recommended use of non-narcotic analgesia, and 35% always or usually recommended nonsteroidal anti-inflammatory drugs. Use of opioid analgesia was appropriately low, with 88% never or rarely using them for SRC. There was a low utilisation of referral pathways to allied health practitioners, with a third of participants (34%) never or rarely referring SRC patients to physiotherapy and only a third (34%) usually or always referring a patient for specialist support from a concussion service. Free-text responses indicated a range of barriers to concussion specialist services, including declined referrals, access issues for rural practises and a lack of knowledge of the ACC concussion service. The majority of participants (66%) recommend that patients get reviewed within 7–10 days of the initial visit. Just under half (49%) stated that they would provide this follow-up, with 46% reporting they refer them back to the patient’s usual GP.

Just over half of participants (53%) felt confident in managing a patient with SRC. There was notable variance in participants’ confidence in advising on return-to-sport, with only 46% agreeing that they feel confident in advising patients on how to do this. We used Spearman’s correlation coefficients to explore whether there were any significant associations between physician type, years since graduation, practice type and number of concussions seen with level of confidence in managing SRCs; there was no significant association between physician type, years since graduation or type of practice (urban vs rural) and confidence in managing SRC at the p<0.05 level. However, participants who saw patients presenting with concussion more frequently had significantly higher confidence in managing these injuries (r=0.26, p<0.001).

Discussion

This study aimed to determine the current state of knowledge of existing SRC guidelines and the management of SRC among primary care doctors in New Zealand. We found that just over half of clinicians surveyed felt confident managing SRCs. However, a higher proportion did not feel confident advising on safely returning to sport. Our current ACC guidelines[[6]] recommend that sportspeople affected by SRC should seek an assessment from a doctor. These findings highlight the need to address knowledge gaps and provide support to doctors in managing SRC and return-to-sport.

There was a lack of consistency regarding the ease of use of concussion assessment tools. Less than half of participants reported using the SCAT, which is endorsed by ACC guidelines[[6]] and is currently the most widely used instrument for concussion assessment within the sports context. However, the SCAT does have limitations that might impact its use in primary care. For example, our study showed that time constraints were reported to be a barrier to using the SCAT. This is perhaps unsurprising given that, even for well-practised clinicians, this tool takes a minimum of 10 minutes to complete.[[4,5]] The symptom checklist has been reported to demonstrate clinical utility in tracking recovery,[[1,12]] although the utility of the remainder of the SCAT appears to decrease significantly 3–5 days after injury.[[4]] Evidence also suggests that the symptom scale has been found to potentially reflect non-brain injury processes such as migraine.[[13]] Poor uptake of the SCAT in primary care, as found in  this research and similar studies in Canada,[[7,8]] suggests the need for the development of a validated concussion assessment tool that can assist in diagnosis, identify patients who would benefit from early referral to multidisciplinary care and be used to track recovery. Any new tool should be time-efficient and able to be completed within a typical primary care consultation. It is also worth noting that doctors will be assessing patients with potential concussion from both sports- and non-sports-related trauma, and any new or modified tool would ideally be applicable to all concussion regardless of environment.

The most recent CISG Consensus Statement on Concussion in Sport recommends an initial period of physical and cognitive rest immediately after sustaining an SRC and a graduated return-to-sport only once concussion symptoms have resolved.[[1]] A brief period (24–48 hours) of cognitive and physical rest is appropriate for most patients.[[1,14–16]] Following this period, patients should be encouraged to gradually increase non-sporting activity while staying below their cognitive and physical symptom exacerbation thresholds and avoiding activities that have an increased risk of re-injury.[[1,16]] More research is needed to evaluate the optimal amount and type of rest after SRC.[[1,16,17]] However, no evidence indicates that strict rest for more than three days is beneficial to recovery from concussion.[[16–18]] In the current study, most participants reported using appropriate management strategies for patients with concussion, such as non-narcotic analgesia. That a high number of respondents recommended relative cognitive and physical rest indicates an understanding of the shift towards relative rest rather than absolute rest.[[1,14]] Furthermore, this appears to suggest that these clinicians may have a better understanding of how to manage SRC than prior cohorts of doctors in international studies, where less than half of family physicians were found to be advising appropriate cognitive rest.[[7]] This finding may also reflect the fact that the evidence advocating relative, rather than absolute, rest is reasonably new and therefore has become more established in clinical practice since the previous studies.

Studies have shown that the use of formal return-to-activity and return-to-school protocols can effectively change healthcare providers’ clinical practice and increase knowledge and confidence in treating concussion.[[19]] Progression strategies for return-to-sport and return-to-school are available online and incorporated into the SCAT 5th Edition document.[[1,5,15]] However, if less than half of those surveyed were using the tool regularly, and if a greater number were not aware of the CISG Consensus Statement on Concussion in Sport, those surveyed who were not familiar with the SCAT5 or CISG may not be aware of the corresponding rehabilitation, return-to-school and return-to-sport recommendations.

In recent years, as those in sport have become more aware of SRC, many New Zealand National Sports Organisations (NSOs) have introduced concussion policies. Aspects of these policies, such as mandatory stand-down periods after injury, differ across codes, which may have caused confusion for both clinicians and members of the public. This is a particular problem for young people who may play several different sports over the course of a week. The lack of consistency may influence clinicians’ confidence managing safe return-to-sport following SRC. It is suggested that NSOs consider developing a consistent return-to-sport message that can be delivered to all players. There does seem to be greater confidence in the recommendation that no player should return to sport on the day of the injury, where the advice is more definite and consistent.

Other knowledge gaps identified include the belief a patient must have a blow to the head to sustain a concussion (21% of respondents). Although concussion is caused by biomechanical forces, it may be caused by a direct blow to the head, the face or the neck, or elsewhere on the body if there is an impulsive force to the head.[[1]] This is an important area for further education to ensure all concussions are recognised and to capture an accurate diagnosis in those patients that may not have sustained a direct blow to the head.

The CISG define persistent symptoms as those beyond 14 days in adults and four weeks in children. Most patients are expected to recover within this timeframe.[[1]] However, this has been challenged by recent research.[[12]] Other studies have illustrated that 30–55% of those who sustain an SRC experience persistent post-concussive symptoms beyond two weeks.[[12,14,17]] Persistent symptoms can result in significant morbidity and impact for the affected individual and their whānau. It is increasingly recognised that there are a range of reasons for patients to experience persistent symptoms and that treatment should be individualised to the patient and their needs.[[1,20]] Prolonged symptoms may be due to persisting physiological concussion, cervical, vestibular and ocular post-concussion defects, psychological variables or a combination of these factors.[[1,17]] Recent research surveying physiotherapists in New Zealand indicated good levels of knowledge of SRC and that physiotherapists currently provide a wide range of primary care services for people with concussion that align with international recommendations.[[21,22]] Physiotherapists have a strong desire to be more involved in side-line recognition and player removal, concussion assessment testing and return-to-sport integration.[[21]] In addition to providing physiotherapy care for concurrent cervical injury and vestibular dysfunction, there may be other benefits of greater physiotherapist involvement in the care of these patients.[[22]] Physiotherapists are more likely to be present during training and games, and  they often have a close relationship with players and coaching staff;[[21]] therefore physiotherapists provide a useful role in recognition of possible concussion and are a source for supplementary history of the concussive event.[[22]] Following a doctor’s assessment and medical diagnosis, physiotherapists can then assist in supervising the agreed graduated return-to-sport protocol, monitoring a patient for persistent symptoms and providing a liaison between doctors and coaches. A collaborative approach, involving a range of different clinicians, is therefore most appropriate for SRC patients.[[1,16,20]]

Although relative rest and symptomatic treatments form the mainstay of initial management for SRC, recent research supports the use of sub-symptom threshold, sub-maximal exercise, for patients with persistent concussive symptoms.[[14,16,17,23]] Controlled exercise performed at an intensity, and for a duration, that does not exacerbate symptoms is safe and beneficial for adult and adolescent patients with persistent symptoms following concussion.[[16,17,23]] Makdissi et al’s review of the literature on the management of those with persistent concussion symptoms concluded that “cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion.”[[20]] In New Zealand, patients experiencing persistent symptoms can be referred to an ACC-approved multidisciplinary concussion service for ongoing management, including prescription of sub-threshold exercise for suitable patients. Given a New Zealand study of those presenting for treatment for SRC reported that only 45% of patients were clinically recovered by 14 days, it appears that a large number of patients may benefit from this type of service.[[12]] The current study revealed that only one third of doctors usually or always referred their patients to multidisciplinary concussion services, and identified some perceived barriers to access, including a lack of doctor knowledge of the ACC service, barriers in the referral process and geographical barriers to access to concussion services outside large urban centres. Barriers such as these may reduce referral rates. Further research may help to identify areas for system improvement. We agree with Maxtone et al that early access to active rehabilitation services in acute concussion may be an effective use of health resources in New Zealand.[[22]]

Finally, the current study also highlights the need to ensure information and guidelines on SRC reach those working in primary care. Our study indicates that primary care doctors do not utilise medical journals or ACC guidelines when looking for treatment recommendations. Provvidenza’s research on transferring knowledge from concussion consensus statements to improve patient care indicates that, although printed education materials are valuable for reinforcing knowledge transfer, they are an ineffective standalone method for improving physician performance.[[24,25]] GP CME conferences and Bpac[[nz]] publications were identified by our participants as the most helpful resources. Interactive education sessions or webinars, supplemented by print or online written material, may therefore provide an effective education strategy.[[24]] The integration of treatment pathways and guidelines into patient management software and health pathways may also support primary care clinicians in best practice management of concussion.

This study is the first to look at care of SRC in the New Zealand primary care context. It does have a number of limitations. Multiple methods of distribution were chosen to increase the number of participants and reduce barriers to participating in the study; however, as a result it is difficult to calculate our response rate. Primary care is also a heterogenous workforce and inevitably there are areas of this workforce who are not represented in these results. Additionally, as the study only explored sport-related concussion, these findings may not be representative to non-sport-related injury. Finally, there is the potential for recall bias in any survey, and there is a risk of selection bias, as it is likely that those clinicians with an interest in sport and SRC were more likely to participate.

Summary

Abstract

Aim

To assess the current state of knowledge around sport-related concussion (SRC) guidelines and management among primary care doctors in New Zealand.

Method

An online, self-administered, 21-item multi-choice questionnaire targeted at general practitioners and urgent care doctors in New Zealand was used. Main outcome measures were knowledge and management of patients with SRC through to return-to-sport.

Results

There were 230 total valid responses. Over half had no knowledge of the Consensus Statement on Concussion in Sport, and only 43% used the Sport Concussion Assessment Tool (SCAT) routinely. Fifty-eight percent would prefer to have a screening tool integrated into their patient management software. Most reported using appropriate management strategies for patients with concussion and recognised the potential benefit of relative cognitive and physical rest. There was low utilisation of referral pathways to allied health practitioners and specialist concussion services. Half (53%) felt confident in managing a patient with SRC and 46% felt comfortable managing return-to-sport.

Conclusion

Primary care doctors have good knowledge of SRC but are not as confident managing return-to-sport. Further education opportunities were identified. Development of concussion tools adapted for use in primary care, integrated with patient management software and that support pathways to optimise patient recovery are recommended.

Author Information

Caroline Stuart: Sport and Exercise Medicine Registrar, Axis Sports Medicine Specialists and High Performance Sport New Zealand, Auckland. Duncan Reid: Professor of Physiotherapy, School of Clinical Sciences, AUT University, Auckland. Alice Theadom: Director of the TBI Network, AUT University, Auckland. Mark Fulcher: Sport and Exercise Medicine Fellow and Director, Axis Sports Medicine Specialists, Auckland. Natalie Hardaker: BSc (Hons) Injury Prevention Specialist, Accident Compensation Corporation, Wellington.

Acknowledgements

ACC provided funding for this research. Thanks to Rachel Smith and Ethan Smith for assisting with the data collection and analysis. Thanks to James D Carson, Assistant Professor, Department of Family and Community Medicine at the University of Toronto in Ontario, for kindly sharing his validated questionnaire.

Correspondence

Prof. Duncan Reid, School of Clinical Sciences, AUT University, Auckland; Auckland University of Technology (AUT), Private Bag 92006, Auckland 1142, New Zealand; +64 9 921 9999

Correspondence Email

duncan.reid@aut.ac.nz

Competing Interests

Nil.

1. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838-47.

2. Theadom A, Starkey NJ, Dowell T, et al. Sports-related brain injury in the general population: an epidemiological study. J Sci Med Sport. 2014;17:591-6.

3. Sport related concussions and TBI: OIA response 52244. ACC; [cited 2020 Jun 27]. Available from: https://catalogue.data.govt.nz/dataset/3317c3ef-8999-4edb-a9f7-be037df8520a/resource/953db280-f73e-4e90-b2a6-e483ee2c8471/download/52244.xlsm

4. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51:848-50.

5. Sport concussion assessment tool - 5th edition. Br J Sports Med. 2017;51:851-8.

6. ACC SportSmart. Sport Concussion in New Zealand National Guidelines [cited 2020 Oct 17]. Available from: https://www.accsportsmart.co.nz/assets/assets-final/resources-final/3152df545a/acc7555-accsportsmart-concussion-national-guidelines.pdf

7. Stoller J, Carson JD, Garel A, et al. Do family physicians, emergency department physicians, and pediatricians give consistent sport-related concussion management advice? Can Fam Physician. 2014;60:548-52.

8. Carson JD, Rendely A, Garel A, et al. Are Canadian clinicians providing consistent sport-related concussion management advice? Can Fam Physician. 2016;62:494-500.

9. Pleacher MD, Dexter WW. Concussion management by primary care providers. Br J Sports Med. 2006;40:e2.

10. Lebrun CM, Mrazik M, Prasad AS, et al. Sport concussion knowledge base, clinical practises and needs for continuing medical education: a survey of family physicians and cross-border comparison. Br J Sports Med. 2013;47:54-9.

11. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277-88.

12. Kara S, Crosswell H, Forch K, et al. Less Than Half of Patients Recover Within 2 Weeks of Injury After a Sports-Related Mild Traumatic Brain Injury: A 2-Year Prospective Study. Clin J Sport Med. 2020;30:96-101.

13. Sargeant M, Sykes E, Saviour M, et al. The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients. J Concussion. 2018;2:1-10.

14. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion: Curr Sports Med Rep. 2018;17:262-70.

15. McCrory P, Meeuwisse WH, Dvořák J, et al. Infographic: Consensus statement on concussion in sport. Br J Sports Med. 2017;51:1557-8.

16. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930-4.

17. Leddy J, Baker JG, Haider MN, et al. A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train. 2017;52:299-308.

18. Silverberg ND, Iverson GL. Is rest after concussion "the best medicine?": recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28:250-9.

19. DeMatteo C, Stazyk K, Singh SK, et al. Ontario Neurotrauma Foundation. Development of a conservative protocol to return children and youth to activity following concussive injury. Clin Pediatr (Phila). 2015;54:152-63.

20. Makdissi M, Cantu RC, Johnston KM, et al. The difficult concussion patient: what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms? Br J Sports Med. 2013;47:308-13.

21. Reid DA, Hume P, Whatman C, et al. Knowledge, attitudes, and behaviours of New Zealand physiotherapists to sports-related concussion. NZJP. 2020;48:19-28.

22. Maxtone S, Bishop M, Chapple, et al. Physiotherapist involvement in concussion services in New Zealand: A national survey. NZJP. 2020;48:70-9.

23. Leddy JJ, Haider MN, Ellis MJ, et al. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019;173(4):319-25.

24. Provvidenza C, Engebretsen L, Tator C, et al. From consensus to action: knowledge transfer, education and influencing policy on sports concussion. Br J Sports Med. 2013;47:332-8.

25. Provvidenza CF, Johnston KM. Knowledge transfer principles as applied to sport concussion education. Br J Sports Med. 2009;43 Suppl 1:i68-75.

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Sport-related concussion (SRC) is a form of mild traumatic brain injury (mTBI) induced by biomechanical forces that can lead to prolonged cognitive, emotional and physical effects.[[1,2]] SRC is a significant problem in New Zealand.[[2]] In 2019, there were 6,217 claims to the Accident Compensation Corporation (ACC, New Zealand’s no-fault accident compensation programme) for SRC, at a cost of NZ$22.5 million.[[3]] Rugby union, football and cycling were the sports with the greatest number of SRC claims.[[2,3]] SRC claims have increased steadily across the last decade, up 90% from 2010 to 2019.[[3]]

The assessment and management of SRC is an evolving field. Recommendations have changed following each of the five Concussion in Sport Group (CISG) International Consensus Conferences.[[4]] The latest of these guidelines were released in 2017 and cover care of SRC from side-line assessment through to clinical evaluation and steps for recovery.[[1]] In conjunction with the guidelines, the Sport Concussion Assessment Tool (SCAT) 5th Edition was also published.[[5]] This tool was designed to be used by medical professionals and includes screening assessments for the cognitive and physiological effects of concussion and a symptom report scale. The SCAT is included in the 2016 ACC guidelines on the management of SRC.[[6]] The ACC guidelines’ key message to players, coaches and umpires/referees is: “Recognise, Remove and Refer.” The ACC guidelines also recommend that players report to a medical doctor for definitive diagnosis and care.[[6]] Concussion is a medical diagnosis requiring clinical judgement and consideration of multiple non-specific history and examination features.[[1,4,6]] Doctors working in primary care must therefore have an understanding of SRC assessment, management and guidelines for return-to-sport, in order to appropriately treat these patients.

A survey of 93 general practitioners (GPs) and emergency doctors (EDs) conducted in Canada identified that GPs and trauma clinicians had limited awareness of consensus statements on SRC and rarely referred to guidelines.[[7]] In that study, there was very poor usage of the SCAT, with 86% of EDs and 54% of GPs reporting having never used the tool. It is unclear whether this reflected a lack of awareness or lack of utility of the tool outside of the sports-medicine context for which it was originally designed.

Although international studies have explored GPs’ and other primary care and specialist doctors’ knowledge and understanding of SRC,[[7–10]] no such studies have been undertaken in a New Zealand medical population. Therefore, the purpose of this study was to assess the current state of knowledge and use of SRC guidelines and management among primary care doctors in New Zealand.

Methods

We used an anonymous, online, 21-item multi-choice questionnaire based on a validated questionnaire used in previous studies.[[7]] Prior to its distribution, the survey was piloted and reviewed by nine sport and exercise physicians to ensure completeness and readability. The questionnaire included questions about the participant’s place of work, the number of SRC they see in clinical practice, where they obtained information on SRC, the tools they used to diagnose SRC and their knowledge, attitudes and behaviour towards SRC. The response to each question was predominantly captured on a 5-part Likert scale, and where appropriate there was the option for free-text comments. Anonymous demographic information included details about vocational training, postgraduate sports medicine qualifications completed, years since graduation and geographical location.

All doctors working as GPs or urgent care physicians (UCPs) were eligible to participate. An invitation to participate in the online survey (SurveyMonkey Inc., San Mateo California, USA, http://www.surveymonkey.com) was included in the newsletters of the Royal New Zealand College of Urgent Care (RNZCUC) and the primary care continuing medical education (CME) organisation the Goodfellow Unit  . Also, in order to gain the largest possible sample, the survey and an open invitation to disseminate were promoted via Facebook on the RNZCUC page and New Zealand medical practitioners’ group pages, . In addition, members of the research team attended the Goodfellow Symposium and webinars in 2018 and invited GPs and UCPs to participate. Questionnaire responses were collected from October to December 2017 and from March to May 2018.

Ethical approval was provided by Auckland University of Technology Ethics Committee (AUTEC Reference #16/187). The ACC Research Ethics Committee also approved the study. A survey was considered valid and included for analysis when respondents completed at least 80% of questions. Responses were summarised using frequencies and percentages; descriptive statistics were used to analyse the data. Comments in the free-text fields were categorised using conventional content analysis to assist in the interpretation of the quantitative results.[[11]]

Results

All data were extracted into SPSS (IBM SPSS, Chicago, version 25). A total of 183 potential participants read the Goodfellow Unit invitation, and 402 doctors on the RNZCUC mailing list were emailed and invited to attend; the total number of invites was 585. There were 145 responses, yielding an initial response rate of 25%. A further 61 completed the survey during the Goodfellow Symposium, and further promotion resulted in 230 total valid responses. We could not calculate the total number of invites, because of the use of social media, the encouragement to freely disperse the link to the study through professional contact lists and the invitation to participate during the Goodfellow Symposium, and so it was not possible to measure our final response rate.

The characteristics of the sample are outlined in Figure 1 and Table 1. The majority of participants were GPs (59%) or GP registrars (14%). Eighteen percent were UCPs or trainees, who were based across all regions of New Zealand (Table 1). The majority (77%) reported working in an urban practice. There were 52 doctors (23%) who reported working for a rural practice. Participants had been practicing clinically for an average of 21 years since graduation, with a range of 1–46 years. A small number (n=26, 11%) had undertaken postgraduate study in sports medicine. Forty-four percent had assessed ten or more SRCs in the past two years, and 3% had not seen any patients with SRC the past two years.

Figure 1: Distribution of responses by geographic area.

Table 1: Types of physicians surveyed (n=230).

Participants reported using a wide range of information sources on concussion as shown in Table 2. The information sources that were reported to be the most useful were those created by Best Practice Advisory Centre New Zealand (Bpac[[nz]] Ltd) and GP conference/CME presentations, with 73% and 69% of participants finding them useful respectively.

Table 2: Usefulness of information sources from the past two years. View Table 2.

All (100%) of the participants indicated that taking a history and conducting a physical exam was important when assessing for SRC. Only 41% had heard of the CISG Consensus Statement on Concussion in Sport. Although 83% had heard about the SCAT, only 43% of them found the tool was easy to use in a clinical setting. Of those familiar with the SCAT tool, 58% would prefer to have it integrated into their patient management software to facilitate its use. Less than half (43%) of all participants usually or always used the SCAT to assist with their assessment. Although we did not specifically ask about barriers to using the SCAT or other diagnostic tools, across the 25 free-text responses in this section of the survey, seven participants commented that time pressures and limitations in funding were barriers to concussion assessment and management, as the SCAT took longer to complete than the appointment time typically allocated. Few participants (3% for each) routinely used computer-based evaluations or diagnostic imaging when assessing for SRC.

Table 3 outlines responses related to the knowledge, attitudes and behaviours of the surveyed medical practitioners. All participants agreed that a player who has been concussed should not return to sport the day the concussion occurred. The majority of participants (82%) agreed that a concussed patient should not return to contact sport for three weeks and should follow a return-to-play protocol prior to returning to sport (94%). Most participants (89%) considered that a SRC could lead to long-term brain damage. Over 80% of those surveyed believed a player should seek assessment from a doctor on the day the injury occurred.

Table 3: Knowledge, attitudes and behaviours around sport-related concussion. View Table 3.

The most agreed upon strategies for management were cognitive and physical relative rest (activity at a level below that which provokes the patient’s symptoms). Seventy-eight percent of participants always or usually recommended relative cognitive rest, and 82% of doctors recommended relative physical rest. Seventy eight percent always or usually recommended use of non-narcotic analgesia, and 35% always or usually recommended nonsteroidal anti-inflammatory drugs. Use of opioid analgesia was appropriately low, with 88% never or rarely using them for SRC. There was a low utilisation of referral pathways to allied health practitioners, with a third of participants (34%) never or rarely referring SRC patients to physiotherapy and only a third (34%) usually or always referring a patient for specialist support from a concussion service. Free-text responses indicated a range of barriers to concussion specialist services, including declined referrals, access issues for rural practises and a lack of knowledge of the ACC concussion service. The majority of participants (66%) recommend that patients get reviewed within 7–10 days of the initial visit. Just under half (49%) stated that they would provide this follow-up, with 46% reporting they refer them back to the patient’s usual GP.

Just over half of participants (53%) felt confident in managing a patient with SRC. There was notable variance in participants’ confidence in advising on return-to-sport, with only 46% agreeing that they feel confident in advising patients on how to do this. We used Spearman’s correlation coefficients to explore whether there were any significant associations between physician type, years since graduation, practice type and number of concussions seen with level of confidence in managing SRCs; there was no significant association between physician type, years since graduation or type of practice (urban vs rural) and confidence in managing SRC at the p<0.05 level. However, participants who saw patients presenting with concussion more frequently had significantly higher confidence in managing these injuries (r=0.26, p<0.001).

Discussion

This study aimed to determine the current state of knowledge of existing SRC guidelines and the management of SRC among primary care doctors in New Zealand. We found that just over half of clinicians surveyed felt confident managing SRCs. However, a higher proportion did not feel confident advising on safely returning to sport. Our current ACC guidelines[[6]] recommend that sportspeople affected by SRC should seek an assessment from a doctor. These findings highlight the need to address knowledge gaps and provide support to doctors in managing SRC and return-to-sport.

There was a lack of consistency regarding the ease of use of concussion assessment tools. Less than half of participants reported using the SCAT, which is endorsed by ACC guidelines[[6]] and is currently the most widely used instrument for concussion assessment within the sports context. However, the SCAT does have limitations that might impact its use in primary care. For example, our study showed that time constraints were reported to be a barrier to using the SCAT. This is perhaps unsurprising given that, even for well-practised clinicians, this tool takes a minimum of 10 minutes to complete.[[4,5]] The symptom checklist has been reported to demonstrate clinical utility in tracking recovery,[[1,12]] although the utility of the remainder of the SCAT appears to decrease significantly 3–5 days after injury.[[4]] Evidence also suggests that the symptom scale has been found to potentially reflect non-brain injury processes such as migraine.[[13]] Poor uptake of the SCAT in primary care, as found in  this research and similar studies in Canada,[[7,8]] suggests the need for the development of a validated concussion assessment tool that can assist in diagnosis, identify patients who would benefit from early referral to multidisciplinary care and be used to track recovery. Any new tool should be time-efficient and able to be completed within a typical primary care consultation. It is also worth noting that doctors will be assessing patients with potential concussion from both sports- and non-sports-related trauma, and any new or modified tool would ideally be applicable to all concussion regardless of environment.

The most recent CISG Consensus Statement on Concussion in Sport recommends an initial period of physical and cognitive rest immediately after sustaining an SRC and a graduated return-to-sport only once concussion symptoms have resolved.[[1]] A brief period (24–48 hours) of cognitive and physical rest is appropriate for most patients.[[1,14–16]] Following this period, patients should be encouraged to gradually increase non-sporting activity while staying below their cognitive and physical symptom exacerbation thresholds and avoiding activities that have an increased risk of re-injury.[[1,16]] More research is needed to evaluate the optimal amount and type of rest after SRC.[[1,16,17]] However, no evidence indicates that strict rest for more than three days is beneficial to recovery from concussion.[[16–18]] In the current study, most participants reported using appropriate management strategies for patients with concussion, such as non-narcotic analgesia. That a high number of respondents recommended relative cognitive and physical rest indicates an understanding of the shift towards relative rest rather than absolute rest.[[1,14]] Furthermore, this appears to suggest that these clinicians may have a better understanding of how to manage SRC than prior cohorts of doctors in international studies, where less than half of family physicians were found to be advising appropriate cognitive rest.[[7]] This finding may also reflect the fact that the evidence advocating relative, rather than absolute, rest is reasonably new and therefore has become more established in clinical practice since the previous studies.

Studies have shown that the use of formal return-to-activity and return-to-school protocols can effectively change healthcare providers’ clinical practice and increase knowledge and confidence in treating concussion.[[19]] Progression strategies for return-to-sport and return-to-school are available online and incorporated into the SCAT 5th Edition document.[[1,5,15]] However, if less than half of those surveyed were using the tool regularly, and if a greater number were not aware of the CISG Consensus Statement on Concussion in Sport, those surveyed who were not familiar with the SCAT5 or CISG may not be aware of the corresponding rehabilitation, return-to-school and return-to-sport recommendations.

In recent years, as those in sport have become more aware of SRC, many New Zealand National Sports Organisations (NSOs) have introduced concussion policies. Aspects of these policies, such as mandatory stand-down periods after injury, differ across codes, which may have caused confusion for both clinicians and members of the public. This is a particular problem for young people who may play several different sports over the course of a week. The lack of consistency may influence clinicians’ confidence managing safe return-to-sport following SRC. It is suggested that NSOs consider developing a consistent return-to-sport message that can be delivered to all players. There does seem to be greater confidence in the recommendation that no player should return to sport on the day of the injury, where the advice is more definite and consistent.

Other knowledge gaps identified include the belief a patient must have a blow to the head to sustain a concussion (21% of respondents). Although concussion is caused by biomechanical forces, it may be caused by a direct blow to the head, the face or the neck, or elsewhere on the body if there is an impulsive force to the head.[[1]] This is an important area for further education to ensure all concussions are recognised and to capture an accurate diagnosis in those patients that may not have sustained a direct blow to the head.

The CISG define persistent symptoms as those beyond 14 days in adults and four weeks in children. Most patients are expected to recover within this timeframe.[[1]] However, this has been challenged by recent research.[[12]] Other studies have illustrated that 30–55% of those who sustain an SRC experience persistent post-concussive symptoms beyond two weeks.[[12,14,17]] Persistent symptoms can result in significant morbidity and impact for the affected individual and their whānau. It is increasingly recognised that there are a range of reasons for patients to experience persistent symptoms and that treatment should be individualised to the patient and their needs.[[1,20]] Prolonged symptoms may be due to persisting physiological concussion, cervical, vestibular and ocular post-concussion defects, psychological variables or a combination of these factors.[[1,17]] Recent research surveying physiotherapists in New Zealand indicated good levels of knowledge of SRC and that physiotherapists currently provide a wide range of primary care services for people with concussion that align with international recommendations.[[21,22]] Physiotherapists have a strong desire to be more involved in side-line recognition and player removal, concussion assessment testing and return-to-sport integration.[[21]] In addition to providing physiotherapy care for concurrent cervical injury and vestibular dysfunction, there may be other benefits of greater physiotherapist involvement in the care of these patients.[[22]] Physiotherapists are more likely to be present during training and games, and  they often have a close relationship with players and coaching staff;[[21]] therefore physiotherapists provide a useful role in recognition of possible concussion and are a source for supplementary history of the concussive event.[[22]] Following a doctor’s assessment and medical diagnosis, physiotherapists can then assist in supervising the agreed graduated return-to-sport protocol, monitoring a patient for persistent symptoms and providing a liaison between doctors and coaches. A collaborative approach, involving a range of different clinicians, is therefore most appropriate for SRC patients.[[1,16,20]]

Although relative rest and symptomatic treatments form the mainstay of initial management for SRC, recent research supports the use of sub-symptom threshold, sub-maximal exercise, for patients with persistent concussive symptoms.[[14,16,17,23]] Controlled exercise performed at an intensity, and for a duration, that does not exacerbate symptoms is safe and beneficial for adult and adolescent patients with persistent symptoms following concussion.[[16,17,23]] Makdissi et al’s review of the literature on the management of those with persistent concussion symptoms concluded that “cases of concussion in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussion.”[[20]] In New Zealand, patients experiencing persistent symptoms can be referred to an ACC-approved multidisciplinary concussion service for ongoing management, including prescription of sub-threshold exercise for suitable patients. Given a New Zealand study of those presenting for treatment for SRC reported that only 45% of patients were clinically recovered by 14 days, it appears that a large number of patients may benefit from this type of service.[[12]] The current study revealed that only one third of doctors usually or always referred their patients to multidisciplinary concussion services, and identified some perceived barriers to access, including a lack of doctor knowledge of the ACC service, barriers in the referral process and geographical barriers to access to concussion services outside large urban centres. Barriers such as these may reduce referral rates. Further research may help to identify areas for system improvement. We agree with Maxtone et al that early access to active rehabilitation services in acute concussion may be an effective use of health resources in New Zealand.[[22]]

Finally, the current study also highlights the need to ensure information and guidelines on SRC reach those working in primary care. Our study indicates that primary care doctors do not utilise medical journals or ACC guidelines when looking for treatment recommendations. Provvidenza’s research on transferring knowledge from concussion consensus statements to improve patient care indicates that, although printed education materials are valuable for reinforcing knowledge transfer, they are an ineffective standalone method for improving physician performance.[[24,25]] GP CME conferences and Bpac[[nz]] publications were identified by our participants as the most helpful resources. Interactive education sessions or webinars, supplemented by print or online written material, may therefore provide an effective education strategy.[[24]] The integration of treatment pathways and guidelines into patient management software and health pathways may also support primary care clinicians in best practice management of concussion.

This study is the first to look at care of SRC in the New Zealand primary care context. It does have a number of limitations. Multiple methods of distribution were chosen to increase the number of participants and reduce barriers to participating in the study; however, as a result it is difficult to calculate our response rate. Primary care is also a heterogenous workforce and inevitably there are areas of this workforce who are not represented in these results. Additionally, as the study only explored sport-related concussion, these findings may not be representative to non-sport-related injury. Finally, there is the potential for recall bias in any survey, and there is a risk of selection bias, as it is likely that those clinicians with an interest in sport and SRC were more likely to participate.

Summary

Abstract

Aim

To assess the current state of knowledge around sport-related concussion (SRC) guidelines and management among primary care doctors in New Zealand.

Method

An online, self-administered, 21-item multi-choice questionnaire targeted at general practitioners and urgent care doctors in New Zealand was used. Main outcome measures were knowledge and management of patients with SRC through to return-to-sport.

Results

There were 230 total valid responses. Over half had no knowledge of the Consensus Statement on Concussion in Sport, and only 43% used the Sport Concussion Assessment Tool (SCAT) routinely. Fifty-eight percent would prefer to have a screening tool integrated into their patient management software. Most reported using appropriate management strategies for patients with concussion and recognised the potential benefit of relative cognitive and physical rest. There was low utilisation of referral pathways to allied health practitioners and specialist concussion services. Half (53%) felt confident in managing a patient with SRC and 46% felt comfortable managing return-to-sport.

Conclusion

Primary care doctors have good knowledge of SRC but are not as confident managing return-to-sport. Further education opportunities were identified. Development of concussion tools adapted for use in primary care, integrated with patient management software and that support pathways to optimise patient recovery are recommended.

Author Information

Caroline Stuart: Sport and Exercise Medicine Registrar, Axis Sports Medicine Specialists and High Performance Sport New Zealand, Auckland. Duncan Reid: Professor of Physiotherapy, School of Clinical Sciences, AUT University, Auckland. Alice Theadom: Director of the TBI Network, AUT University, Auckland. Mark Fulcher: Sport and Exercise Medicine Fellow and Director, Axis Sports Medicine Specialists, Auckland. Natalie Hardaker: BSc (Hons) Injury Prevention Specialist, Accident Compensation Corporation, Wellington.

Acknowledgements

ACC provided funding for this research. Thanks to Rachel Smith and Ethan Smith for assisting with the data collection and analysis. Thanks to James D Carson, Assistant Professor, Department of Family and Community Medicine at the University of Toronto in Ontario, for kindly sharing his validated questionnaire.

Correspondence

Prof. Duncan Reid, School of Clinical Sciences, AUT University, Auckland; Auckland University of Technology (AUT), Private Bag 92006, Auckland 1142, New Zealand; +64 9 921 9999

Correspondence Email

duncan.reid@aut.ac.nz

Competing Interests

Nil.

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