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Objective: To determine whether the proportion of sport-related concussion (SRC) cases among student athletes that resulted in a relapse of their symptoms due to premature return to play (RTP) or premature return to learn (RTL) has changed compared with a prior (2006 to 2011) study., Design: Retrospective cohort study of electronic medical record charts from a 5-year period (2011 to 2016) compared with previous data., Setting: A sport and exercise medicine physician's office-based practice in Ontario., Participants: Two-hundred forty-one students who had 258 distinct cases of SRC diagnosed., Main Outcome Measures: Premature RTP and RTL were defined as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient's RTP or RTL., Results: Between 2011 and 2016, premature RTP and RTL resulted in a relapse of symptoms in 26.7% and 42.6% of cases, respectively. When compared with data from the 2006 to 2011 chart review, the incidence of premature RTP decreased by 38.6%. However, the rate of the relapse of symptoms associated with premature RTL decreased by only 4.7%. There was a relapse of symptoms in 43.4% of the cases involving female students and 29.7% of the cases involving male students, indicating that female patients are more likely to experience a relapse of symptoms. Cases involving female athletes also resulted in much later RTP clearance compared with those involving male athletes, with a median duration that was almost double that of male athletes' cases (49 days vs 25 days)., Conclusion: An important decrease in the relapse of symptoms in the context of premature RTP occurred over the 2006 to 2016 period. However, this decrease was minimal for RTL. This may reflect the fact that efforts to implement structured RTP strategies arose earlier than those to implement RTL strategies. Efforts are needed to find the best method of implementing a coordinated plan for the postconcussion athlete who is returning to school., (Copyright© 2022 the College of Family Physicians of Canada.)

Objective: To analyze the implementation of a concussion management protocol in which a team physiotherapist is involved in the identification of concussions and return-to-play (RTP) decisions., Design: A prospective injury surveillance cohort study in a school-based Canadian football program (4 teams; grades 8 to 12) over 4 years. For years 1 to 2, the team physician made all RTP decisions; over years 3 to 4, the team physiotherapist was allowed to make some RTP decisions using pre-established criteria defined in the protocol., Setting: A high school in Québec, Que., Participants: Male student athletes between 11 and 17 years old., Main Outcome Measures: Same-season recurrence (SSR) of concussion symptoms following RTP., Results: A total of 119 concussions were identified (55 during the first 2 years and 64 during the last 2 years) during 27,741 athlete-exposures in 672 athlete-years for an incidence rate of 4.3 per 1000 athlete-exposures. During years 1 to 3, no SSR was observed following RTP clearance. During year 4 there was 1 case of SSR that occurred 11 days after clearance. The overall SSR rate of concussion symptoms following RTP clearance was 0.8%., Conclusion: A very low rate of SSR was achieved whether the team physician made all RTP decisions or the team physiotherapist was allowed to make some of the RTP decisions through the terms of the protocol., (Copyright© 2022 the College of Family Physicians of Canada.)

Objective: To compare the knowledge and use of recommendations for the management of sport-related concussion (SRC) among sport and exercise medicine physicians (SEMPs) and emergency department physicians (EDPs) to assess the success of SRC knowledge transfer across Canada., Design: A self-administered, multiple-choice survey accessed via e-mail by SEMPs and EDPs. The survey had been assessed for content validity., Setting: Canada., Participants: The survey was completed between May and July 2012 by SEMPs who had passed the diploma examination of the Canadian Academy of Sport and Exercise Medicine and by EDPs who did not hold this diploma., Main Outcome Measures: Knowledge and identification of sources of concussion management information, use of concussion diagnosis strategies, and whether physicians use common and consistent terminology when explaining cognitive rest strategies to patients after an SRC., Results: There was a response rate of 28% (305 of 1085). The SEMP and EDP response rates were 41% (147 of 360) and 22% (158 of 725), respectively. Of the responses, 41% of EDPs and 3% of SEMPs were unaware of any consensus statements on concussion in sport; 74% of SEMPs used the Sport Concussion Assessment Tool, version 2 (SCAT2), "usually or always," whereas 88% of EDPs never used the SCAT2. When queried about how cognitive rest could best be achieved after an SRC, no consistent answer was documented., Conclusion: Differences and a lack of consistency in the implementation of recommendations for SRC patients were identified for SEMPs and EDPs. It appears that the SCAT2 is used more in the SEMP setting than in the emergency context. Further knowledge transfer efforts and research should address the barriers to achieving more consistent advice given by physicians who attend SRC patients., (Copyright© the College of Family Physicians of Canada.)

Objective: To determine what proportion of patients experience an exacerbation of their symptoms as a result of premature return to play (RTP) and return to learn (RTL) following sport-related concussions., Design: Retrospective study of electronic medical records from the office-based practice of one family and sport medicine physician who had systematically provided recommendations for cognitive and physical rest based on existing consensus recommendations. Two blinded authors independently reviewed each chart, which included Sport Concussion Assessment Tool (SCAT) and SCAT2 symptom self-report forms to determine whether an athlete had returned to play or learn prematurely. If there was a discrepancy between the 2 reviewers then a third author reviewed the charts., Setting: A sport medicine and family practice in Ontario. The physician assessed sport-related concussions after self-referral or referral from other primary care physicians, teams, and schools., Participants: A total of 170 charts of 159 patients were assessed for sport-related concussion during a 5-year period (April 2006 to March 2011). All participants were students who were participating in sports at the time of injury. There were 41 concussions in elementary students, 95 concussions in high school students, and 34 concussions in college or university students., Main Outcome Measures: Premature RTP and RTL were defined as chart records documenting the recurrence or worsening of symptoms that accompanied the patients' RTP or RTL. Measures were compared using the earliest available SCAT forms and self-reporting., Results: In 43.5% of concussion cases, the patient returned to sport too soon and in 44.7% of concussion cases, the patient returned to school too soon. Patients with a history of previous concussion required more days of rest before being permitted to participate in any physical activity than those patients without a previous history of concussion. Elementary school students required fewer days of rest before being permitted to return to any physical activity compared with high school students and college or university students., Conclusion: Currently, physicians recommend restrictions on mental and physical activity following sport-related concussion. This is done without clear guidelines as to what cognitive rest entails for students. Further research is required to determine how to implement a management plan for student athletes to facilitate complete recovery after concussion., (Copyright© the College of Family Physicians of Canada.)

Objective: To identify differences and gaps in recommendations to patients for the management of sport-related concussion among FPs, emergency department physicians (EDPs), and pediatricians., Design: A self-administered, multiple-choice survey was e-mailed to FPs, EDPs, and pediatricians. The survey had been assessed for content validity., Setting: Two community teaching hospitals in the greater Toronto area in Ontario., Participants: Two hundred seventy physicians, including FPs, EDPs, and pediatricians, were invited to participate., Main Outcome Measures: Identification of sources of concussion management information, usefulness of concussion diagnosis strategies, and whether physicians use common terminology when explaining cognitive rest strategies to patients after sport-related concussions., Results: The response rate was 43.7%. Surveys were completed by 70 FPs, 23 EDPs, and 11 pediatricians. In total, 49% of FP, 52% of EDP, and 27% of pediatrician respondents reported no knowledge of any consensus statements on concussion in sport, and 54% of FPs, 86% of EDPs, and 78% of pediatricians never used the Sport Concussion Assessment Tool, version 2. Only 49% of FPs, 57% of EDPs, and 36% of pediatricians always advised cognitive rest., Conclusion: This study identified large gaps in the knowledge of concussion guidelines and implementation of recommendations for treating patients with sport-related concussions. Although some physicians recommended physical and cognitive rest, a large proportion failed to consistently advise this strategy. Better knowledge transfer efforts should target all 3 groups of physicians., (Copyright© the College of Family Physicians of Canada.)

Objective: To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process., Design: Randomized trial., Setting: Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que., Participants: Fifteen second-year family medicine residents., Intervention: Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database., Main Outcome Measures: The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine's effect on the decision-making process in clinical practice., Results: Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either search engine. The mean (SD) time of the initial search for each question was 23.5 (7.6) minutes with InfoClinique and 22.3 (7.8) minutes with the Trip database (P = .30). Participants' perceptions of each engine's effect on the decision-making process were very positive and similar for both search engines., Conclusion: Family medicine residents' ability to provide correct answers to clinical questions increased dramatically and similarly with the use of both InfoClinique and the Trip database. These tools have strong potential to increase the quality of medical care.

Objective: To develop and test the reliability of a tool for rating websites that provide information on evidence-based medicine., Design: For each site, 60% of the score was given for content (eight criteria) and 40% was given for organization and presentation (nine criteria). Five of 10 randomly selected sites met the inclusion criteria and were used by three observers to test the accuracy of the tool. Each site was rated twice by each observer, with a 3-week interval between ratings., Setting: Laval University, Quebec city., Participants: Three observers., Main Outcome Measures: The intraclass correlation coefficient (ICC) was used to rate the reliability of the tool., Results: Average overall scores for the five sites were 40%, 79%, 83%, 88%, and 89%. All three observers rated the same two sites in fourth and fifth place and gave the top three ratings to the other three sites. The overall rating of the five sites by the three observers yielded an ICC of 0.93 to 0.97. An ICC of 0.87 was obtained for the two overall ratings conducted 3 weeks apart., Conclusion: This new tool offers excellent intraobserver and interobserver measurement reliability and is an excellent means of distinguishing between medical websites of varying quality. For best results, we recommend that the tool be used simultaneously by two observers and that differences be resolved by consensus.