1 Background

1.1 Definition

As per the the American Congress of Rehabilitation Medicine, concussion, also known as a mild traumatic brain injury (mTBI). It occurs in a person who has traumatically-induced physiological disruption of brain function and is manifested by at least one of the following: a period of loss of consciousness, any loss of memory, any alteration of mental state (confusion, dazed, disorientation) and focal neurological deficits may or may not be transient. However, the loss of consciousness is less than 30 min,after which the Glasgow Coma Scale (GCS) is 13–15 and posttraumatic amnesia (PTA) does not last longer than 24 h. This definition includes head being struck, head striking an object and the brain undergoing an acceleration or deceleration movement (whiplash) without direct external trauma to the head. mTBI excludes stroke anoxia, tumour, and encephalitis. Brain imaging may be normal. Due to the lack of emergency and/or health system barriers patients may not have the acute stage of mTBI documented [1]. The presentation of a concussion is complicated by a wide range of neurological, motor, and behavioural symptoms that may vary over time [2,3,4,5]. While symptoms often resolve quickly, some patients may experience the effects of a concussion for months [6], leading to impairments in learning, attention, memory, and emotional regulation. These effects can significantly impact a patient's quality of life and potentially result in cognitive disabilities. Furthermore, defining concussion symptoms in children remains a subject of ongoing debate [7].

2 Rationale

2.1 Incidence and prevalence

The incidence of concussions in Canada remains unknown. While there are multiple causes precipitating concussions including MVC and falls. Head injuries resulting from sports participation alone amounts to 1.8–3.8 million cases annually, making it a public health concern in North America and therefore much of focus for research [8, 9]. Nonetheless, 24% of concussions in Canada are reported to be due to falls. Traumatic brain injuries, including concussions, contribute to approximately 2.5 million emergency department visits, excluding cases where medical care was not sought [10]. In Ontario, the demand for follow-up care for concussions has tripled over a ten-year period from 2003 to 2013 [11]. It is worth noting that the actual incidence of concussions is expected to be even higher due to underreporting [12]. Langer et al. aptly point out that there is improving physician recognition of concussions from multiple causes. Given that patients are more likely to seek ongoing care from their family physicians rather than frequent visits to the emergency department, it is imperative for physicians to possess knowledge about concussion diagnosis and management.

2.2 Current challenges in concussion diagnosis and management

Despite the increase of concussion awareness over the last decade, the application of concussion guidelines remains inconsistent, posing challenges for physicians in assessing and managing concussions [13]. Inconsistencies in comprehensive concussion guidelines contribute to underdiagnosis and gaps in management, which have a negative impact on patients' quality of life after a concussion [14]. Moreover, the prevalence of persistent post-concussion syndrome (PPCS) remains unclear. 10–30% people sustaining concussion experience PPCS. Patients with repetitive brain injuries may be at a higher risk of mental health issues and long-term consequences, including early dementia. Therefore, the implementation of standardized concussion guidelines, with consistent application, plays a crucial role in early identification and optimal outcomes for patients.

2.3 Challenges in concussion medical education

To address these challenges and improve concussion care, focusing on educating physicians about this complex condition is important. However, teaching the topic of concussion poses unique challenges. Concussion manifests with a wide range of signs and symptoms, such as seizures, amnesia, and personality changes, resulting in a spectrum of presentations. Unfortunately, current imaging techniques are unable to detect diffuse axonal injury, a common occurrence in concussions [15]. Furthermore, studies have highlighted that medical student and residents in North America are not receiving adequate education on concussions, largely due to limited opportunities to learn about this condition [16, 17].

2.4 Gaps in concussion research

While systematic reviews on concussion education have primarily focused on its impact on care in the emergency department [6], two previous scoping reviews have examined concussion education from different perspectives. The first review, conducted by Caron et al. [18], specifically examined educational programs designed for athletes and coaches. The second review, carried out by Gardner and Heron [19], primarily focused on the delivery of concussion curriculum at the undergraduate level of medical education. As a result, to the best of our knowledge, this paper represents the first scoping review that comprehensively explores concussion education across the full spectrum of medical education.

3 Objectives

This scoping review aims to identify and evaluate the current literature up to 2021 on concussion curriculum in medicine to start exploring effective teaching and learning strategies to close the concussion knowledge gap seen in North American medical training.

4 Methods

In order to attain a broad overview of the available literature and synthesize the evidence, the Preferred Reporting Items for Systematic Reviews was selected for our scoping review [20]. This model adds transparency and reproducibility to the scoping review.

4.1 Protocol and registration

PRISMA protocol was followed (Fig. 1). The scoping review is registered on OSF: https://osf.io/p56c8

Fig. 1
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PRISMA flow chart

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4.2 Eligibility criteria and information sources

A systematic search was conducted in MEDLINE, Medline Epub Ahead of Print, Medline-in-Process & In-Data Review, and EMBASE Classic + EMBASE in the OvidSP search platform, covering the period from 1946 to 2021. Both database subject headings and text word terms such as "brain concussion" AND ("medical education" OR "specific specialty education") (Tables 1 and 2) were used as search criteria. Additionally, the PICO framework guided the searches in MEDLINE and EMBASE: Population was defined as any learner in medicine, including medical students, residents, and physicians; Interventions encompassed studies evaluating concussion awareness, skills, and knowledge; and Outcomes focused on diagnosis and management competency. The initial search retrieved 312 citations, of which four were identified as duplicates (Table 3). Subsequently, 308 unique references were screened against the inclusion and exclusion criteria (Fig. 1). The inclusion criteria were as follows: English language, original articles, full-text available, educational program, and medical field. Conversely, the exclusion criteria were as follows: abstracts or presentations, non-empirical studies, focus on other head injuries, and absence of an educational program or intervention. All relevant references were organized and stored in Zotero.

Table 1 Ovid MEDLINE(R) < 1946 to October Week 2 2021 > 
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Table 2 2021_Husain_concussion_teaching_EMBASE_FINAL3
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Table 3 Summary of searches from Embase and Medline
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4.2.1 Selection

14 studies were identified and all included in this review. These studies were analyzed for themes by their Kirkpatrick evaluation level. It is the most widely known and used model to evaluate effectiveness of education training. Themes emerged through inductive analysis and subsequently reported.

4.2.2 Data charting

Data was reviewed independently. Continuous consultation with AK to ensure relevant studies were included.

4.2.3 Data items and critical appraisal of individual evidence

Data was abstracted, and evaluated each study Kirkpatrick evaluation level (Table 4).

Table 4 Summary of examined papers identified by MEDLINE and EMBASE
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4.2.4 Synthesis of results

Patterns emerged through inductive analysis. These findings were grouped as themes that concussion programs need to address when designing concussion medical education.

5 Results

A total of fourteen papers were reviewed (Table 4), with thirteen primarily conducted in North America and one in England [21]. Notably, 50% (n = 7) of the studies were conducted in Canada [13, 22,23,24,25,26,27]. The studies also varied in duration, ranging from four weeks to one year [27]. They covered a wide range of educational training, including medical students (29%, n = 4) [18, 23, 24, 27], residents (14%, n = 2) [22, 28], and practicing physicians (36%, n = 5) [13, 25, 29,30,31]. One study included other healthcare professionals, such as nurse practitioners and physician assistants [27]. Furthermore, 14% of the studies included both undergraduate and postgraduate level trainees (n = 2) [21, 26].

In terms of the targeted medical fields, 50% (n = 7) of the studies focused on specific fields: family medicine (n = 4) [15, 22, 28, 31] and paediatrics (n = 3) [29, 30, 32]. Interestingly, emergency medicine was not studied as an individual specialty but in conjunction with other specialties [21, 25].

The primary method used to evaluate knowledge in these studies was surveys or questionnaires (86%, n = 12). Four studies implemented interventions and assessed their impact [21, 28, 31, 32]. In contrast, two papers focused on exploring the impact of existing trainee educational programs [24, 30] without implementing interventions. These interventions and educational programs employed various delivery methods, including didactic teaching, clinical exposure, and electronic medical record applications with reminders to prompt healthcare practitioners.

We also evaluated these studies using Kirkpatrick’s four levels of education [33]. Kirkpatrick level one, which assessed learners’ the reaction or perception of education, was included in three studies [28, 30, 31]. Ten studies included Kirkpatrick level two, which assessed learners’ knowledge, attitude, and/or skills [13, 16, 21, 22, 24,25,26, 29,30,31]. Only the study by Taylor et al. explored Kirkpatrick level three by evaluating behaviour change resulting from learning in a clinical environment [32]. None of the studies found in this scoping review addressed the impact on patient outcomes.

Out of the 10 studies at Kirkpatrick level two, three studies explored participants' interest in future continuing medical education (CME) related to concussions [13, 29, 30]. Stoller et al. emphasized the importance of disseminating concussion guidelines for clinicians managing patients with concussions [25]. However, despite recent CME efforts, Lebrun et al. highlighted the need for improved utilization of standardized scales in concussion management [13]. Overall, the findings indicate the importance of further research and educational initiatives to address the gaps in knowledge and improve the management of concussions in medical practice.

5.1 Summary of evidence

There are significant knowledge gaps about concussions, increased clinical exposure is required for competency which bolster physical examination skills and streamlined concussion guidelines are required for family medicine specialists that filter undifferentiated symptoms. We identified four main themes and factors regarding knowledge transfer.

5.1.1 Theme 1: knowledge gap on concussion diagnosis and management

A critical theme that emerged from the literature is the existence of a significant knowledge gap regarding concussion diagnosis and management. Concussion is a clinical diagnosis and should be included in the differential diagnosis for appropriate management. However, undergraduate medical education often lacks sufficient didactics and clinical exposure to patients with concussion [16]. The inadequate concussion education exposure is reflected in the lack of understanding of diagnostic criteria and recognition of chronic traumatic encephalopathy versus second-impact syndrome as possible sequela of recurrent concussions [21, 26]. The deficiencies in concussion education among Canadian medical schools contribute to these inadequacies, with a 70% of schools lacking concussion education [23, 27]. The lack of concussion learning objectives at the licensure level is also evident, as postgraduate training shows limited knowledge or competency in this topic. For example, 32% of residents do not believe that a patient with concussion should be seen by a physician [22].

5.1.2 Theme 2: improving competency through clinical exposure

Another theme is the positive impact of clinical exposure on competency for concussion diagnosis and management. Ogren and Knobloch [28] hypothesized that increasing the exposure of medical learners to concussion cases will likely lead to improved patient outcomes. This hypothesis was supported in the study by Haider et al. where emergency medicine residents achieved the highest scores when tested on concussion knowledge and management compared to residents from paediatrics, family medicine, and sports medicine. The higher scores were attributed to the exposure to concussion cases in the emergency department [21]. This finding suggests that the exposure to real-life cases enhances competency in concussion care compared to residents from other specialties. By providing medical learners with increased clinical exposure to concussion cases, their ability to diagnose and manage concussions effectively can be significantly improved.

5.1.3 Theme 3: importance of physical examination skills for concussion diagnosis

An essential aspect of concussion diagnosis lies in the proficiency of physical examination skills. Lebrun et al. conducted a study that revealed a significant reliance on physical exams by family physicians, with 90% of them utilizing these exams for clinical decision-making and management. This finding underscores the critical role that physical examinations play in the diagnosis of concussions [13].

Furthermore, Reisner et al. conducted a study that demonstrated the impact of coaching clinicians on pertinent physical exam maneuvers. By providing guidance on relevant techniques such as vestibular oculomotor exams, the study found that clinicians' diagnostic skills improved, leading to greater accuracy in diagnosing concussions [30]. These findings emphasize the importance of honing physical examination skills to enhance concussion diagnosis and improve patient care.

5.1.4 Theme 4: need for standardized guidelines and awareness in concussion management

The fourth theme emphasizes the need for standardized guidelines for practitioners, particularly due to the lack of awareness in concussion management. Applying guidelines appropriately reduces unnecessary imaging and referrals, such as computed tomography scans (CT), which are costly and associated with potential deleterious effects like PPCS and permanent disability [4, 34,35,36,37]. Educational interventions have been shown to decrease the utilization of CT scans and referrals for CT scans in the emergency room [30]. However, inconsistencies in applying return-to-play guidelines and considering school absences and accommodations for paediatric patients still exist among physicians. Reisner et al. [30] found that 37% of physicians accurately applied the return-to-play guidelines, while 53% did not consider school absences for paediatric patients, and 40% of physicians did not proactively provide counselling on schoolwork accommodations. These findings indicate the importance of guideline-based education in reducing healthcare costs and maintaining resource sustainability [25].

By highlighting these four themes—knowledge gap, improving competency through clinical exposure, the importance of physical examination skills, and the need for standardized guidelines and awareness—this review brings attention to the areas that require attention and improvement in concussion education and management. This review also revealed a lack of studies focused on creating concussion educational programs for the medical field, with Fraser et al. [24] being the only study that designed a curriculum to increase knowledge. Their study found that a spiral curriculum for concussion education was more effective than a block curriculum [24]. The spiral curriculum not only increased clinical exposure to patients with concussion but also integrated basic science with clinical experience, resulting in better student learning outcomes compared to a block curriculum [24]. These findings underscore the significance of curriculum design and the incorporation of clinical exposure in promoting effective concussion education.

Concussion education can be effectively addressed at various levels, as highlighted in a study by Boggild and Tator [26], which recommended increasing concussion awareness opportunities in both undergraduate and postgraduate education. However, implementing changes to the curriculum requires a clear vision and a dedicated effort to reshape the organizational structure [38]. The ideal starting point for introducing concussion education is through lectures targeting medical students, who are exposed to a wide range of disciplines [27]. In terms of the educational format, we recommend utilizing lectures, seminars, or workshops instead of relying solely on written material, as these interactive formats tend to enhance engagement levels and knowledge retention [26]. Once they have acquired foundational knowledge, it is crucial to provide them with multiple clinical exposures to enhance their understanding [39].

The need for increasing concussion clinical opportunities, particularly at the undergraduate level, was also highlighted in the scoping review by Gardner and Heron [19]. Their recommendations align with our paper, particularly the need for a shift in delivery format for effective knowledge transfer. Although lectures continue to be the predominant format, there has been a significant increase in the dedicated time for concussion education. This increase in dedicated concussion education time reflects the growing awareness of concussions amongst medical schools. Standardized guidelines were not mentioned in Gardner and Heron's [19] recommendations, possibly due to their focus on undergraduate education, while our review encompasses all medical education levels. Therefore, our recommendations extend beyond the undergraduate level, aiming to improve concussion care and management across the medical field.

At the postgraduate level, it is recommended to provide residents with focused experience in concussion clinics, which can be achieved by emphasizing tailored active learning approaches and transitioning towards competency-based education [21, 40]. Educational supports for physician should facilitate “Knowledge to Action” and help to address difficult cases [31, 41]. Emphasizing active learning during rotations is crucial, as it has been demonstrated to be more effective than passive learning methods such as didactic teaching. At the physician level, the distribution of toolkits containing guidelines and concussion approaches from specialists would be advantageous in assisting physicians in navigating challenging cases, ultimately leading to improved patient outcomes [30]. These educational initiatives should be tailored for specialties that frequently encounter concussion cases, with a particular emphasis on the development of educational toolkits specific to pediatric concussion. These specialized toolkits have the potential to significantly enhance clinical decision-making and management for this patient population [30]. Another way to greatly support the clinical assessment of concussions is the implementation of templates within electronic medical records that provide real-time prompts and structured guidance. Furthermore, conducting practice audits accompanied by tailored feedback can help reduce cognitive dissonance and improve overall performance in managing concussions [31, 42].

In addition to comprehensive concussion education and initiatives, it is essential to evaluate and modify clinician behaviour to enhance the quality of care provided to individuals with concussions. However, it is important to recognize that changing clinician behavior is a time-consuming process. Nonetheless, the use of self-reflective surveys, which were commonly employed in the reviewed studies, can serve as valuable tools for fostering competence among healthcare professionals. Looking ahead, it is imperative for future medical educational programs to address the barriers that impede effective knowledge translation [42]. To facilitate this process, the integration of concussion research and guidelines for relevant stakeholders should be guided by the Workgroup for Intervention Development and Evaluation Research (WIDER) checklist [43]. Moreover, the implementation of evidence-based policies at a systemic level has the potential to enhance healthcare practices and reduce the economic burden associated with concussion-related sequelae. For instance, Burke et al. recommend that the Medical Council of Canada add concussion-specific objectives for identification and management [27].

6 Limitations

This scoping review has certain limitations that should be acknowledged. While the search in MEDLINE and EMBASE yielded fourteen relevant papers, there were limited studies that involved interventions, thus providing insufficient evidence to definitively identify effective concussion learning methods. Moreover, the studies included in this review exhibited significant heterogeneity, mainly due to selection and publication biases. To enhance the comprehensiveness of the review, grey literature, papers from different languages, and diverse countries could have been considered. Since the scoping review was conducted, there have been further published literature that can be reviewed whether including those studies markedly change the findings.

Further research is warranted to assess various aspects related to concussion education, including behavioural changes, skill enhancement, competency development, and knowledge translation. It is important to note that evaluating the impact of a new curriculum on patient health can be challenging, particularly in the absence of surrogate markers for concussions. Nonetheless, conducting more long-term studies is essential to effectively evaluate the outcomes and benefits of improved patient care resulting from enhanced concussion education [18, 39, 44].

7 Conclusion

Concussion is difficult condition to diagnose, manage and therefore, to effectively teach. Different specialties have different guidelines globally and the incidence is underreported. As such, there remains a significant challenge in effectively transferring this knowledge to physicians across different specialties especially family physicians, the cornerstone of healthcare systems [45,46,47,48,49,50]. The persistence of knowledge gaps regarding concussion symptoms hinders early detection and effective management by physicians. Bridging this gap in competency is essential to enhance patient care and prevent potential long-lasting neurological sequelae, ultimately improving patients' quality of life.

Promising education tools for addressing this issue include the implementation of spiral curriculum, blended learning approaches, and active learning experiences within the community. Incorporating clinical exposure in medical curricula is crucial to facilitate active learning among students. Future studies should focus on assessing the impact of different medical curriculum designs on both patient and population outcomes, aiming to identify the most effective strategies for improving concussion education and management. We collaborated with dissemination of a novel education design to increase awareness, confidence and knowledge in family medicine residents about concussions that then informed research further understanding FM resident perceptions [51, 52].

By addressing these gaps and advancing concussion education, physicians can play a vital role in preventing and managing concussions, leading to improved patient outcomes and overall population health.