Evaluating Acute Sport-related Concussion In The Primary Care Setting: Are We Dropping The Ball?

Abstract

Concussed athletes are increasingly introduced into the medical care continuum via the primary care setting. As such, primary care physicians (PCPs) are expected to make more decisions regarding return-to-play, symptom management, and specialist referral than ever before. Concussion-specific history and physical examination is vital for this decision-making process. PURPOSE: To review clinic documentation and determine how PCPs are evaluating concussed athletes in clinic relative to published consensus and guidelines. METHODS: We conducted a retrospective records review for all patients evaluated by PCPs with no formal sports medicine training at a single large academic medical center. We restricted our review to pediatric patients (7-18 yrs) diagnosed with sport-related concussion between 2014-2017. RESULTS: We included 490 patients (age=14.7 ± 2.2 years; 184 females). Patients presented most frequently to pediatricians (60%) at a median of 3 days from injury (range 0-64 days, IQR 1-6). Most patients participated in football (25.9%), soccer (19.8%), and basketball (15.1%). Prior concussion history was documented in 28.8% of visits. Providers documented headache presence or absence in 94% of patients, compared with nausea (52.2%), dizziness (51.8%), vision changes (45.7%), cognitive complaints (45.7%), emotional changes (17.1%), sleep difficulties (15.8%) and neck pain (13.5%). Basic neurologic examination was documented in 95.5% of visits compared to detailed neurologic assessment including strength, sensation, cranial nerves, and cerebellar function (26.9%), clinical cognitive assessment (13.5%), balance testing (41%), and neck exam (45.7%). Return-to-play was frequently discussed (94.5% of visits) and 13.1% of PCPs referred the patient to a dedicated sports medicine provider. CONCLUSIONS: Symptom-based return-to-play algorithms cannot be effective if the signs and symptoms driving their decision-making aren’t being properly evaluated and documented. The PCPs caring for the patients in our retrospective study often omit important components of the history and physical examination for concussed athletes. New tools are needed to empower PCPs to more completely evaluate and manage these patients, and PCPs should be encouraged to thoroughly document the care provided.