VOL 50: APRIL • AVRIL 2004d Canadian Family Physician • Le Médecin de famille canadien 537
Correspondance Letters
With this in mind, we recognize the irony of inte- grating a highly evidence-based guideline refer- ence with the MRC scoring criteria that lack this support. Please feel free to download our male and female periodic examination forms from http://67.69.12.117:8080/oscarResource/forms/
CPXforMale and http://67.69.12.117:8080/oscar- Resource/forms/CPXforFemale.
—Inge Schabort, MB CHB, CCFP
—Linda Hilts, RN, MED
—Jennifer Lachance, MD
—Nikolina Mizdrak, MD
—Mandy Schwartz, MD Hamilton, Ont by e-mail References
1. Kwiatkowski C. Food for thought [letter]. Can Fam Physician 2004;50:29.
2. Oboler SK, LaForce FM. The periodic physical examination in asymptomatic adults. Ann Intern Med 1989;110:214-26.
3. Cheney C, Ramsdell J. Effect of medical records checklists on implementation of periodic health measures. Am J Med 1987;83:129-36.
Summarizing ordinal
data. What is appropriate?
I
n the article by Midmer et al,1 Table 3, “Women’s ratings of the ALPHA form by type of form”used a scale that ranged from 1—very much to 5—not at all. It appears as though the variables are ordered, ie, that there is some order among the categories ranging from 1 (very much) to 5 (not at all). Ordinal data are characterized by the presence of order among the categories and by the fact that the difference between two catego- ries is not the same throughout the scale. For this reason, the most appropriate descriptive statisti- cal ways of summarizing ordinal data are through proportions and percentages and estimates of the median value.
—Tolulola Taiwo, MB BS, MPH, MSC(MED) Springdale, Nfld by e-mail Reference
1. Midmer D, Bryanton J, Brown R. Assessing antenatal psychosocial health. Randomized controlled trial of two versions of the ALPHA form. Can Fam Physician 2004;50:80-7.
New guidelines on
concussion management overlooked
C
oncussion is a serious problem that is often underappreciated and poorly managed by phy- sicians. I was, therefore, pleased to see an article1 on management of concussion in the February issue of Canadian Family Physician. The article does not reflect what is currently considered to be optimal concussion management, however, and fails to refer- ence the most important and comprehensive state- ment on this subject: “The summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001.”2 This statement was prepared by an international group of concus- sion experts (The Concussion in Sport Group) fol- lowing a conference sponsored by the International Ice Hockey Federation, FIFA (International Soccer), and the International Olympic Committee Medical Commission. For those of us who look after athletes with concussions, it is the definitive current refer- ence and was considered so important that it was simultaneously published in the Clinical Journal of Sport Medicine, British Journal of Sports Medicine, and Physician and Sportsmedicine. It is unfortunate that this publication was missed by the author and peer reviewers.Concussion grading systems are all anecdotal, with no hard scientific evidence. Return-to-play times accompanying these guidelines are simi- larly the personal estimates of the author. They are, therefore, not recommended by the Concussion in Sport Group and are not used by those of us deal- ing with concussion.
A summary of the key current concepts in con- cussion management follows.
1. Concussion can have multiple symptoms and signs that evolve over time, including physical (eg, headache, nausea, imbalance), cognitive (eg, memory, concentration alteration), and emo- tional (eg, mood changes) manifestations. You do not have to lose conciousness to have a concus- sion! This is perhaps the biggest misconception and mistake made in diagnosis of concussion.
538 Canadian Family Physician • Le Médecin de famille canadien dVOL 50: APRIL • AVRIL 2004
Letters Correspondance
2. It is absolutely unsafe to return to play while symptomatic in any way following a concussion.
Dr Hickey mentions Second Impact Syndrome,1 but this is extremely rare. Symptomatic people are far more likely to be concussed again, how- ever, to be concussed more easily, and to have postconcussion symptoms that are more severe and long-lasting. This is a very common reason for patients I see to have a prolonged postcon- cussion course.
3. Return to play should follow a stepwise progres- sion. Athletes should rest until asymptomatic, then start with very light aerobic activity, and progress gradually toward participation if asymp- tomatic. This progression will vary depending on the duration of postconcussion symptoms and the type of sport (eg, contact vs noncontact).
4. I add this point: prevention. Family physicians are in an ideal position to advocate for safe par- ticipation in sport (eg, use of helmets when snowboarding and in-line skating).
Physicians who follow these guidelines would be doing their patients a great service and would greatly decrease their risk. Physicians will likely be called upon more often to “clear” athletes for return to play after concussion; for example, the Greater Toronto Hockey League now requires a doctor’s certificate in this regard. It is, therefore, critical that physicians are up-to-date with the most recent information in this field.
—James Kissick, MD, CCFP, DIP SPORT MED Palladium Sport Medicine Centre Ottawa, Ont by e-mail References
1. Hickey J. Concussion [Just The Berries]. Can Fam Physician 2004;50:231-3.
2. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston KM, Kelly J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
* * * *
I
was glad to see an article1 on concussion man- agement in the February 2004 issue of Canadian Family Physician. I regret to inform you, however, that the article contains serious errors of omission. I am surprised that, in such a rapidly evolving field as con- cussion, the author and peer reviewers entirely missed the new guidelines2 that have altered managementof concussion worldwide. In addition, none of the author’s references were from the Concussion in Sport theme issue published in the Clinical Journal of Sport Medicine, volume 11, number 3, in July 2001.
Many of the issues raised in these new guidelines are not included in Dr Hickey’s article.
To say that “Nevertheless, these are the tools we have to use at present” is just an error, when alluding to guidelines using level IV evidence that have now been abandoned by Canadian concussion experts. We must inform Canadian family physi- cians that use of concussion grading systems is no longer advocated for return-to-play decisions. In addition, physicians are now being asked to give written permission for hockey players in some communities to return to play after a concussion.
This puts physicians who make the wrong decision at risk of legal action, especially if they use obsolete guidelines. Members of the Concussion Committee of the Canadian Academy of Sport Medicine and the Concussion Education Committee of the ThinkFirst-SportSmart group have been searching for the best method to relay these new concus- sion management guidelines to Canadian physi- cians. We request that you assist us in conveying the most current concussion management guide- lines through a full article in your journal at your earliest opportunity.
—James D. Carson, MD, CCFP, DIP SPORT MED Chair, Sport Safety Committee Canadian Academy of Sport Medicine Unionville, Ont by e-mail References
1. Hickey J. Concussion [Just The Berries]. Can Fam Physician 2004;50:231-3.
2. Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston KM, Kelly J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11.
