The Journal of Family Practice

NORD President and CEO Peter L. Saltonstall expressed disappointment “on behalf of the one in 10 Americans with rare diseases, most of whom are still waiting for a cure” at the US Senate’s decision to postpone a vote on the Senate Innovations for Healthier Americans Initiative until at least September.

“This vital package includes billions of dollars to spur medical innovation that would help the rare disease community,” Mr. Saltonstall said in a statement released by NORD, including needed funding for medical research at NIH and to accelerate product review at FDA, as well as for special initiatives such as the Cancer Moonshot headed by Vice President Joe Biden.

“Most pressing,” Mr. Saltonstall added, “is the reauthorization of the Rare Pediatric Disease Priority Review Voucher program, currently set to expire at the end of September.” NORD has been a strong and consistent advocate for that program, which encourages the development of therapies for rare pediatric diseases.

NORD President and CEO Peter L. Saltonstall expressed disappointment “on behalf of the one in 10 Americans with rare diseases, most of whom are still waiting for a cure” at the US Senate’s decision to postpone a vote on the Senate Innovations for Healthier Americans Initiative until at least September.

“This vital package includes billions of dollars to spur medical innovation that would help the rare disease community,” Mr. Saltonstall said in a statement released by NORD, including needed funding for medical research at NIH and to accelerate product review at FDA, as well as for special initiatives such as the Cancer Moonshot headed by Vice President Joe Biden.

“Most pressing,” Mr. Saltonstall added, “is the reauthorization of the Rare Pediatric Disease Priority Review Voucher program, currently set to expire at the end of September.” NORD has been a strong and consistent advocate for that program, which encourages the development of therapies for rare pediatric diseases.

NORD President and CEO Peter L. Saltonstall expressed disappointment “on behalf of the one in 10 Americans with rare diseases, most of whom are still waiting for a cure” at the US Senate’s decision to postpone a vote on the Senate Innovations for Healthier Americans Initiative until at least September.

“This vital package includes billions of dollars to spur medical innovation that would help the rare disease community,” Mr. Saltonstall said in a statement released by NORD, including needed funding for medical research at NIH and to accelerate product review at FDA, as well as for special initiatives such as the Cancer Moonshot headed by Vice President Joe Biden.

“Most pressing,” Mr. Saltonstall added, “is the reauthorization of the Rare Pediatric Disease Priority Review Voucher program, currently set to expire at the end of September.” NORD has been a strong and consistent advocate for that program, which encourages the development of therapies for rare pediatric diseases.

FDA Commissioner Robert Califf, MD, will deliver the keynote address on the opening morning of the annual NORD Rare Diseases and Orphan Products Summit, which is scheduled for October 17–18 in Arlington, Virginia. Dr. Califf will be among more than 20 FDA speakers and several from NIH at the event, which draws together patient advocates as well as government, industry, and academic professionals working with rare diseases.

David Flannery, MD, Medical Director of the American College of Medical Genetics, will talk about “Telemedicine and Rare Diseases,” and will present a live telemedicine demo. In a session on genetic innovation, moderator Nora Yang, PhD, MBA, from the NIH, and panelists from GeneDx, Intellia Therapeutics, Spark Therapeutics, and the FDA will discuss gene-editing, gene-sequencing and gene therapy.

Other topics to be addressed include the crucial role of data in advancing diagnosis and clinical drug development, focus on pediatric diseases, and the challenge of access and reimbursement.

The Summit will include a poster session. Poster abstracts may be submitted by students as well as professionals. August 19th is the deadline for abstracts. Read more about poster submissions.

FDA Commissioner Robert Califf, MD, will deliver the keynote address on the opening morning of the annual NORD Rare Diseases and Orphan Products Summit, which is scheduled for October 17–18 in Arlington, Virginia. Dr. Califf will be among more than 20 FDA speakers and several from NIH at the event, which draws together patient advocates as well as government, industry, and academic professionals working with rare diseases.

David Flannery, MD, Medical Director of the American College of Medical Genetics, will talk about “Telemedicine and Rare Diseases,” and will present a live telemedicine demo. In a session on genetic innovation, moderator Nora Yang, PhD, MBA, from the NIH, and panelists from GeneDx, Intellia Therapeutics, Spark Therapeutics, and the FDA will discuss gene-editing, gene-sequencing and gene therapy.

Other topics to be addressed include the crucial role of data in advancing diagnosis and clinical drug development, focus on pediatric diseases, and the challenge of access and reimbursement.

The Summit will include a poster session. Poster abstracts may be submitted by students as well as professionals. August 19th is the deadline for abstracts. Read more about poster submissions.

FDA Commissioner Robert Califf, MD, will deliver the keynote address on the opening morning of the annual NORD Rare Diseases and Orphan Products Summit, which is scheduled for October 17–18 in Arlington, Virginia. Dr. Califf will be among more than 20 FDA speakers and several from NIH at the event, which draws together patient advocates as well as government, industry, and academic professionals working with rare diseases.

David Flannery, MD, Medical Director of the American College of Medical Genetics, will talk about “Telemedicine and Rare Diseases,” and will present a live telemedicine demo. In a session on genetic innovation, moderator Nora Yang, PhD, MBA, from the NIH, and panelists from GeneDx, Intellia Therapeutics, Spark Therapeutics, and the FDA will discuss gene-editing, gene-sequencing and gene therapy.

Other topics to be addressed include the crucial role of data in advancing diagnosis and clinical drug development, focus on pediatric diseases, and the challenge of access and reimbursement.

The Summit will include a poster session. Poster abstracts may be submitted by students as well as professionals. August 19th is the deadline for abstracts. Read more about poster submissions.

The FP recognized this as diffuse palmoplantar keratoderma of the palms and soles. This is an inherited genodermatosis that may be autosomal dominant or sporadic. Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had diffuse hyperkeratosis, which can be distributed over most of the plantar surface.

This condition can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief. The family hoped that there would be some genetic treatment for this in the future.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP recognized this as diffuse palmoplantar keratoderma of the palms and soles. This is an inherited genodermatosis that may be autosomal dominant or sporadic. Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had diffuse hyperkeratosis, which can be distributed over most of the plantar surface.

This condition can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief. The family hoped that there would be some genetic treatment for this in the future.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP recognized this as diffuse palmoplantar keratoderma of the palms and soles. This is an inherited genodermatosis that may be autosomal dominant or sporadic. Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had diffuse hyperkeratosis, which can be distributed over most of the plantar surface.

This condition can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief. The family hoped that there would be some genetic treatment for this in the future.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP recognized this as focal palmoplantar keratoderma of the palms and soles, which is an inherited genodermatosis that is autosomal dominant. The lesions are located mainly on high pressure areas and spare the arches of the feet.

Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had focal hyperkeratosis, which is located mainly on pressure points and sites of recurrent friction.

Palmoplantar keratoderma can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP recognized this as focal palmoplantar keratoderma of the palms and soles, which is an inherited genodermatosis that is autosomal dominant. The lesions are located mainly on high pressure areas and spare the arches of the feet.

Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had focal hyperkeratosis, which is located mainly on pressure points and sites of recurrent friction.

Palmoplantar keratoderma can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP recognized this as focal palmoplantar keratoderma of the palms and soles, which is an inherited genodermatosis that is autosomal dominant. The lesions are located mainly on high pressure areas and spare the arches of the feet.

Palmoplantar keratoderma includes a rare heterogeneous group of disorders that are characterized by thickening of the palms and the soles that can also be an associated feature of some very rare syndromes. The patient in this case had focal hyperkeratosis, which is located mainly on pressure points and sites of recurrent friction.

Palmoplantar keratoderma can be differentiated from plantar warts as it is present on more diffuse locations on the palmoplantar surfaces (including palms and soles) and it lacks the black dots of thrombosed capillaries that are seen in plantar warts.

There is no cure for this genetic condition and the goals of treatment are functional and cosmetic improvement. The FP prescribed 12% ammonium lactate as an emollient and keratolytic. The patient applied this twice daily with some symptomatic relief.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with palmar warts, which are similar in morphology to plantar warts. Plantar (or palmar) warts are lesions caused by human papillomavirus (HPV) that occur on the soles of the feet and palms of the hands. Plantar warts occur mostly in adolescents and young adults and affect up to 10% of people in these age groups.

Plantar warts usually occur at points of maximum pressure, such as on the heels or over the heads of the metatarsal bones, but may appear anywhere on the plantar surface, including the tips of the toes. A cluster of multiple warts that appear to fuse together is referred to as a mosaic wart. HIV is a risk factor for any type of HPV infection.

Distinguish warts from calluses by noting the skin lines; warts lack skin lines crossing their surface, whereas normal skin lines cross through a callus without any disturbance. Additionally, plantar/palmar warts may have a highly organized mosaic pattern on the surface when examined with a hand lens and have prominent black dots (thrombosed capillaries).

The most common treatments for warts include topical salicylic acid and cryotherapy. Topical salicylic acid preparations are nonscarring, minimally painful, and relatively effective, but require persistent application of medication once a day for weeks to months. Cryotherapy with liquid nitrogen therapy is commonly used, but plantar warts are more resistant than other HPV lesions. The liquid nitrogen is applied to form a freeze ball that covers the lesion and 2 mm of surrounding normal tissue for usually 10 to 20 seconds per treatment. This can be performed as a single long freeze or divided into 2 freezing episodes with thawing in between. This allows for more freeze time in a way that is less painful to the patient.

In this case, the patient chose cryotherapy and arranged for a follow-up appointment in 3 to 4 weeks for a second round.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with palmar warts, which are similar in morphology to plantar warts. Plantar (or palmar) warts are lesions caused by human papillomavirus (HPV) that occur on the soles of the feet and palms of the hands. Plantar warts occur mostly in adolescents and young adults and affect up to 10% of people in these age groups.

Plantar warts usually occur at points of maximum pressure, such as on the heels or over the heads of the metatarsal bones, but may appear anywhere on the plantar surface, including the tips of the toes. A cluster of multiple warts that appear to fuse together is referred to as a mosaic wart. HIV is a risk factor for any type of HPV infection.

Distinguish warts from calluses by noting the skin lines; warts lack skin lines crossing their surface, whereas normal skin lines cross through a callus without any disturbance. Additionally, plantar/palmar warts may have a highly organized mosaic pattern on the surface when examined with a hand lens and have prominent black dots (thrombosed capillaries).

The most common treatments for warts include topical salicylic acid and cryotherapy. Topical salicylic acid preparations are nonscarring, minimally painful, and relatively effective, but require persistent application of medication once a day for weeks to months. Cryotherapy with liquid nitrogen therapy is commonly used, but plantar warts are more resistant than other HPV lesions. The liquid nitrogen is applied to form a freeze ball that covers the lesion and 2 mm of surrounding normal tissue for usually 10 to 20 seconds per treatment. This can be performed as a single long freeze or divided into 2 freezing episodes with thawing in between. This allows for more freeze time in a way that is less painful to the patient.

In this case, the patient chose cryotherapy and arranged for a follow-up appointment in 3 to 4 weeks for a second round.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with palmar warts, which are similar in morphology to plantar warts. Plantar (or palmar) warts are lesions caused by human papillomavirus (HPV) that occur on the soles of the feet and palms of the hands. Plantar warts occur mostly in adolescents and young adults and affect up to 10% of people in these age groups.

Plantar warts usually occur at points of maximum pressure, such as on the heels or over the heads of the metatarsal bones, but may appear anywhere on the plantar surface, including the tips of the toes. A cluster of multiple warts that appear to fuse together is referred to as a mosaic wart. HIV is a risk factor for any type of HPV infection.

Distinguish warts from calluses by noting the skin lines; warts lack skin lines crossing their surface, whereas normal skin lines cross through a callus without any disturbance. Additionally, plantar/palmar warts may have a highly organized mosaic pattern on the surface when examined with a hand lens and have prominent black dots (thrombosed capillaries).

The most common treatments for warts include topical salicylic acid and cryotherapy. Topical salicylic acid preparations are nonscarring, minimally painful, and relatively effective, but require persistent application of medication once a day for weeks to months. Cryotherapy with liquid nitrogen therapy is commonly used, but plantar warts are more resistant than other HPV lesions. The liquid nitrogen is applied to form a freeze ball that covers the lesion and 2 mm of surrounding normal tissue for usually 10 to 20 seconds per treatment. This can be performed as a single long freeze or divided into 2 freezing episodes with thawing in between. This allows for more freeze time in a way that is less painful to the patient.

In this case, the patient chose cryotherapy and arranged for a follow-up appointment in 3 to 4 weeks for a second round.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Plantar warts. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:766-770.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

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Each year in the United States, more than 44 million young people participate in sports activities.¹ Yet the number of concussions incurred annually by children and adolescents engaged in sports and recreational play has been underestimated for years, and largely unknown.^1,2

Some estimates were based solely on the number of young athletes treated in emergency departments or sports concussion clinics. Others focused only on team players of middle school or high school age, excluding younger children who were hit in the head on playgrounds or during other recreational activities. What’s more, large numbers of concussions—as many as 4 in 10 incurred by high school athletes—were never reported to a coach or medical professional.³

In a new study published in the journal Pediatrics in June, researchers used national databases and current literature to provide what they believe to be “the most accurate and precise estimate of youth concussion” thus far: Between 1.1 and 1.9 million sports- and recreation-related concussions occur among US youth ages 18 or younger annually.¹

Standardized protocols for managing sport-related concussions have been adopted in most clinical settings. But use among primary care physicians is inconsistent.

Among young people playing team sports, concussions are between 2 and 7 times more likely to occur during competitive games than in practice sessions.^4-7 Boys on football and ice hockey teams have the highest rates of concussion in young athletes.For overall number of concussions, however, girls on soccer teams are second only to football players.⁴ Female soccer players are more likely than male soccer players to sustain concussions during equal number of hours of play.^4,7

An increase in incidence. The incidence of concussion among young athletes appears to have increased in the past decade, a likely result of greater involvement in team sports, an increasing focus on safeguarding young people from the potential dangers associated with a blow to the brain, and better diagnostic techniques.^4,8-10 And a recent study based on data from electronic medical records at a large regional pediatric health care network found that more than three-quarters of young people with sports-related concussions were first seen in a primary care setting.²

With this in mind, we present a comprehensive update of the evidence regarding the diagnosis and management of sport-related concussion. The recommendations we include are consistent with professional association guidelines.^8-10 Although we focus on concussion in children and adolescents involved in athletic activities, the principles generally apply to patients of all ages and to concussions that may not be sports related.

Removal from play: A vital first step

Whenever you conduct a physical exam for a young athlete, remind him or her—and the patient’s parents—that after a blow to the head, immediate removal from play is critical. Concussion is caused by a direct or indirect force to the brain that results in a transient disturbance in brain function,^8-10 manifested by alterations in neurocognitive and motor function. While the signs and symptoms (TABLE 1)^8-10 resolve within 10 days of injury in about 90% of cases, those who incur additional head impact within 24 hours have a higher symptom burden and prolonged recovery period.¹¹ Even without repetitive impact, younger athletes may take longer to recover.^8-10

The initial assessment

A child or adolescent who sustains a suspected concussion should be seen by a physician within 24 to 48 hours. Whether the initial assessment occurs in your office or on the sidelines of a game, it is important to confirm the time the incident occurred and the mechanism of injury.

Concussion is diagnosed by a combination of history, physical exam, and objective testing when symptoms or exam findings associated with mild brain trauma—headache, dizziness, light and/or noise sensitivity, among others—closely follow a head injury.^8-10 Certain maneuvers—assessing eye movements by asking the athlete to look in various directions, for instance, then to follow a pen or finger as you move it closer to his or her face—may provoke dizziness, headache, or other symptoms of concussion that were not apparent initially.

The differential diagnosis includes cervical musculoskeletal injury, craniofacial injury, epidural and subdural hematoma, heat-related illness, uncomplicated headache and migraine, upper respiratory infection, and vertigo.^8-10

Tools aid in diagnosis

Many clinical assessment tools exist to aid in the diagnosis of concussion (TABLE 2).^8-10,12-14 Any one of these tools, many of which use combinations of symptom checklists, balance exams, and cognitive assessments, may be included in your evaluation. No single tool has been found to be superior to any other.^8-10 A combination of tools may improve diagnostic accuracy, but assessment tools should not be the sole basis used to diagnose or rule out concussion.

Reserve neuroimaging, such as CT and MRI, for patients with more serious clinical findings or symptoms that persist longer than expected.

Any child or adolescent who had a blow to the head and at least one sign or symptom of concussion should be evaluated as soon as possible and assessed again later that day or the next day if any reason for concern remains.

Neuropsychological (NP) testing may involve computerized tests developed specifically for athletes. Patients may be required to react to objects that appear on a screen, for example, in a way that tests memory, performance, and reaction time. Because cognitive recovery often lags behind symptom resolution, NP testing may identify subtle brain deficits even in athletes who are asymptomatic at rest or with exercise. In general, NP testing has a sensitivity of 71% to 88% for athletes with concussion,¹⁰ but it is most beneficial when baseline test results are available. Interpretation of NP testing should be done only by qualified clinicians.

While NP testing may provide additional prognostic information, it should not alter the management of athletes who are symptomatic either at rest or with exercise.¹⁵ Nor is NP testing vital, as concussion can be accurately diagnosed and adequately managed without it.

Neuroimaging, including computed tomography (CT) and magnetic resonance imaging (MRI), is often used unnecessarily in the initial assessment of a patient who sustained a possible concussion.^8-10 In fact, neuroimaging should be reserved for cases in which it is necessary to rule out more serious pathology: intracranial or subdural hematoma or a craniofacial injury, for example, in patients with clinical findings that are red flags. These red flags include focal neurologic deficits, continuing nausea/vomiting, or persistent disorientation (TABLE 3),^8-10 or symptoms that worsen or persist beyond a few weeks. In such cases, further evaluation—with MRI of the brain, formal NP testing, and/or referral to a neurologist, physiatrist, or other physician who specializes in concussion care—is indicated.

Concussion management: Rest is key

While there is a dearth of high-quality studies on the management of sport-related concussion across all age groups, standardized protocols for both children and adults have been adopted in most clinical settings.^8-10,16,17 The protocols provide a framework for an individualized treatment plan. Yet their use among primary care physicians is inconsistent.^18-20

Traditionally, concussion management begins with relative physical and cognitive rest to allow the brain time to recover.^8-10 Recent randomized controlled trials have challenged this premise by suggesting that mild to moderate physical activity for post-concussion patients who are mildly symptomatic does not adversely affect recovery.^21,22 These studies have significant limitations, however, and further research is needed to provide specific guidance on this aspect of concussion management before it is adopted.

Physical restrictions include organized sports, recreational activity, recess, and physical education classes. Walking is permitted unless it exacerbates symptoms. These restrictions should continue until the patient is symptom-free.

Recent trials suggest that mild to moderate physical activity for mildly symptomatic post-concussion patients does not adversely affect recovery.

Cognitive restrictions include modifications at school and at home. Once an athlete is able to concentrate and tolerate visual and auditory stimuli, he or she may return to school. But classroom modifications should be considered, possibly including shortened school days, extra time for testing and homework, help with note taking, and restrictions from classes likely to provoke symptoms, such as computer science or music. Limiting use of mobile devices, television viewing, noisy environments, and other possible provocations may help speed symptom resolution. These restrictions, too, should remain in place until the patient is symptom-free.

Driving is often not addressed by physicians managing the care of athletes with concussion, but evidence suggests it should be. A study of patients presenting to the emergency department found that within 24 hours of a concussion diagnosis, individuals had an impaired response to traffic hazards.^23,24 And Canadian clinical practice guidelines recommend that athletes with mild traumatic brain injury (TBI) avoid driving within the first 24 hours.²⁵

While American guidelines are silent on the question of driving for this patient population, we recommend that athletes with concussion be restricted from driving and engaging in other risky complex tasks, such as welding or shop class, for at least 24 hours. For many athletes diagnosed with concussion, driving restrictions of longer duration may be necessary based on their symptom profile and neurocognitive test results. Continued dizziness or visual deficits would pose a greater risk than fatigue or short-term memory loss, for example.

Overseeing the return to play

Return-to-activity progression follows a stepwise protocol, with 6 steps that the injured athlete must complete before resuming full activity (FIGURE 1A).^8-10 This stepwise progression begins only when athletes are symptom free, even during provocative maneuvers; have had a normal neurologic exam, are back to school full time with no restriction; are off any medications prescribed for concussion symptoms (TABLE 4),^8-10 and when neurocognitive testing, if performed, is back to baseline. If an athlete develops symptoms at any stage of the progression, rest is required until he or she remains asymptomatic for at least 24 hours. The progression is then restarted at the last stage at which the patient was symptom free.

Some individualization, of course, is recommended here, too. Younger athletes and those with a prior history of concussion may require 10 days or more to complete all the steps, allowing an extra day at various steps. Neurologic maturation affects recovery time, and for younger individuals, a more conservative return-to-play protocol based on initial concussion symptom duration has been proposed (FIGURE 1B).¹⁶

Return to activity is often supervised by a certified athletic trainer at the athlete’s school. In the event that no athletic trainer is available, patients may be referred to physical therapists with experience in monitoring injured athletes.²⁶ Anyone involved in the patient’s care, including the athlete himself, may use a symptom checklist to monitor recovery.

Allowing asymptomatic athletes to engage in non-contact sports activity less than 7 to 10 days after concussion can help them avoid injury when they are cleared for full play.

Although there is no evidence that the ongoing use of a symptom checklist affects the course of recovery, its use is often helpful in identifying specific symptoms that can be managed by means other than physical and cognitive rest—a sleep hygiene program for an individual with lingering difficulty sleeping, for example, or the continued application of ice, heat, and massage for persistent neck pain.

Checklist monitoring may be especially helpful for athletes whose symptoms extend beyond 10 days or who have multiple symptoms. Final clearance once all the steps have been completed requires follow-up with a health care provider.

Is a symptom-free waiting period necessary?

There is no evidence suggesting a need for a symptom-free waiting period before starting the return-to-play protocol.^10,27 Because a repeat concussion is most likely within 7 to 10 days of the initial injury,^8,9 however, most athletes should not return to contact play during that time frame, regardless of symptom resolution.

It is helpful to have asymptomatic athletes participate in non-contact activity before the 7 to 10 days are up, however. Doing so can help prevent deconditioning and injury upon return to contact sport, as there is evidence of increased risk of lower-extremity injury in the 90 days after concussion.²⁸

What to tell athletes—and parents—about repetitive head trauma

There is growing concern about the long-term risks of concussion and repetitive head impact that may manifest as chronic traumatic encephalopathy (CTE) and chronic neurocognitive impairment (CNI) later in life. Indeed, some data strongly suggest—but do not definitively prove—a relationship between repetitive head injury and chronic neurodegenerative disease.^8-10 You can tell worried patients or parents, however, that the majority of research on CTE and CNI has been based on professional football players.

Studies of long-term effects of soccer heading have shown conflicting results, with some finding cognitive impairment, altered postural control, and anatomic changes of the brain, while others found no effect on encephalopathy, concussion symptoms, or neurocognitive performance.^29-36Here, too, most studies showing negative effects of soccer heading involved professional athletes.

Repetitive sub-concussive impact in high school football athletes has been found to induce biochemical changes to the brain,³⁷ but the long-term effects are unknown. And, while concussion in high school athletes has been associated with short-term cognitive impairment, altered neurochemistry, and evidence of increased symptoms on baseline neurocognitive testing,^8-10,38 no studies have linked concussion during middle school or high school with CNI. What’s more, a long-term (50-year) follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease compared with age-matched controls.³⁹

A 50-year follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease when compared with age-matched controls.

A new study of high school and college football players (mean age: 17.4 years) presented at the American Academy of Neurology 2016 Sports Concussion Conference in Chicago in July, however, found significant alterations in white matter 6 months post injury.⁴⁰ The researchers compared 17 athletes with sport-related concussion with matched controls, using diffusion tensor imaging and diffusion kurtosis tensor imaging as biomarkers of brain recovery. The concussed athletes underwent MRI and symptom assessment at 24 hours, 8 days, and 6 months. The controls followed identical protocols.

At the 6-month assessment, there were no differences between the concussed group and the controls in terms of self-reported concussion symptoms, cognition, or balance. However, the concussed athletes had widespread decreased mean diffusivity compared with the controls. Despite the lack of clinical symptoms, the concussed athletes showed significant alterations in white matter “that were related to initial symptom severity ratings,” the authors concluded. These findings have implications both for determination of recovery from concussion and concussion management, they added.⁴⁰

Although there is no way to eliminate all concussions, limited evidence suggests that improving athletic technique, limiting contact at practices, better enforcement of game rules, and rule changes regarding physical contact may decrease concussion risk.^41-43 Many youth sports organizations have developed policies placing restrictions on head impact during practices and games. Studies are ongoing, too, to see if better headgear—or requiring helmets for soccer players—makes a difference.

CORRESPONDENCE
Ryan A. Sprouse, MD, CAQSM, 203 East Fourth Avenue, Ranson, WV 25438; [email protected].

Each year in the United States, more than 44 million young people participate in sports activities.¹ Yet the number of concussions incurred annually by children and adolescents engaged in sports and recreational play has been underestimated for years, and largely unknown.^1,2

Some estimates were based solely on the number of young athletes treated in emergency departments or sports concussion clinics. Others focused only on team players of middle school or high school age, excluding younger children who were hit in the head on playgrounds or during other recreational activities. What’s more, large numbers of concussions—as many as 4 in 10 incurred by high school athletes—were never reported to a coach or medical professional.³

In a new study published in the journal Pediatrics in June, researchers used national databases and current literature to provide what they believe to be “the most accurate and precise estimate of youth concussion” thus far: Between 1.1 and 1.9 million sports- and recreation-related concussions occur among US youth ages 18 or younger annually.¹

Standardized protocols for managing sport-related concussions have been adopted in most clinical settings. But use among primary care physicians is inconsistent.

Among young people playing team sports, concussions are between 2 and 7 times more likely to occur during competitive games than in practice sessions.^4-7 Boys on football and ice hockey teams have the highest rates of concussion in young athletes.For overall number of concussions, however, girls on soccer teams are second only to football players.⁴ Female soccer players are more likely than male soccer players to sustain concussions during equal number of hours of play.^4,7

An increase in incidence. The incidence of concussion among young athletes appears to have increased in the past decade, a likely result of greater involvement in team sports, an increasing focus on safeguarding young people from the potential dangers associated with a blow to the brain, and better diagnostic techniques.^4,8-10 And a recent study based on data from electronic medical records at a large regional pediatric health care network found that more than three-quarters of young people with sports-related concussions were first seen in a primary care setting.²

With this in mind, we present a comprehensive update of the evidence regarding the diagnosis and management of sport-related concussion. The recommendations we include are consistent with professional association guidelines.^8-10 Although we focus on concussion in children and adolescents involved in athletic activities, the principles generally apply to patients of all ages and to concussions that may not be sports related.

Removal from play: A vital first step

Whenever you conduct a physical exam for a young athlete, remind him or her—and the patient’s parents—that after a blow to the head, immediate removal from play is critical. Concussion is caused by a direct or indirect force to the brain that results in a transient disturbance in brain function,^8-10 manifested by alterations in neurocognitive and motor function. While the signs and symptoms (TABLE 1)^8-10 resolve within 10 days of injury in about 90% of cases, those who incur additional head impact within 24 hours have a higher symptom burden and prolonged recovery period.¹¹ Even without repetitive impact, younger athletes may take longer to recover.^8-10

The initial assessment

A child or adolescent who sustains a suspected concussion should be seen by a physician within 24 to 48 hours. Whether the initial assessment occurs in your office or on the sidelines of a game, it is important to confirm the time the incident occurred and the mechanism of injury.

Concussion is diagnosed by a combination of history, physical exam, and objective testing when symptoms or exam findings associated with mild brain trauma—headache, dizziness, light and/or noise sensitivity, among others—closely follow a head injury.^8-10 Certain maneuvers—assessing eye movements by asking the athlete to look in various directions, for instance, then to follow a pen or finger as you move it closer to his or her face—may provoke dizziness, headache, or other symptoms of concussion that were not apparent initially.

The differential diagnosis includes cervical musculoskeletal injury, craniofacial injury, epidural and subdural hematoma, heat-related illness, uncomplicated headache and migraine, upper respiratory infection, and vertigo.^8-10

Tools aid in diagnosis

Many clinical assessment tools exist to aid in the diagnosis of concussion (TABLE 2).^8-10,12-14 Any one of these tools, many of which use combinations of symptom checklists, balance exams, and cognitive assessments, may be included in your evaluation. No single tool has been found to be superior to any other.^8-10 A combination of tools may improve diagnostic accuracy, but assessment tools should not be the sole basis used to diagnose or rule out concussion.

Reserve neuroimaging, such as CT and MRI, for patients with more serious clinical findings or symptoms that persist longer than expected.

Any child or adolescent who had a blow to the head and at least one sign or symptom of concussion should be evaluated as soon as possible and assessed again later that day or the next day if any reason for concern remains.

Neuropsychological (NP) testing may involve computerized tests developed specifically for athletes. Patients may be required to react to objects that appear on a screen, for example, in a way that tests memory, performance, and reaction time. Because cognitive recovery often lags behind symptom resolution, NP testing may identify subtle brain deficits even in athletes who are asymptomatic at rest or with exercise. In general, NP testing has a sensitivity of 71% to 88% for athletes with concussion,¹⁰ but it is most beneficial when baseline test results are available. Interpretation of NP testing should be done only by qualified clinicians.

While NP testing may provide additional prognostic information, it should not alter the management of athletes who are symptomatic either at rest or with exercise.¹⁵ Nor is NP testing vital, as concussion can be accurately diagnosed and adequately managed without it.

Neuroimaging, including computed tomography (CT) and magnetic resonance imaging (MRI), is often used unnecessarily in the initial assessment of a patient who sustained a possible concussion.^8-10 In fact, neuroimaging should be reserved for cases in which it is necessary to rule out more serious pathology: intracranial or subdural hematoma or a craniofacial injury, for example, in patients with clinical findings that are red flags. These red flags include focal neurologic deficits, continuing nausea/vomiting, or persistent disorientation (TABLE 3),^8-10 or symptoms that worsen or persist beyond a few weeks. In such cases, further evaluation—with MRI of the brain, formal NP testing, and/or referral to a neurologist, physiatrist, or other physician who specializes in concussion care—is indicated.

Concussion management: Rest is key

While there is a dearth of high-quality studies on the management of sport-related concussion across all age groups, standardized protocols for both children and adults have been adopted in most clinical settings.^8-10,16,17 The protocols provide a framework for an individualized treatment plan. Yet their use among primary care physicians is inconsistent.^18-20

Traditionally, concussion management begins with relative physical and cognitive rest to allow the brain time to recover.^8-10 Recent randomized controlled trials have challenged this premise by suggesting that mild to moderate physical activity for post-concussion patients who are mildly symptomatic does not adversely affect recovery.^21,22 These studies have significant limitations, however, and further research is needed to provide specific guidance on this aspect of concussion management before it is adopted.

Physical restrictions include organized sports, recreational activity, recess, and physical education classes. Walking is permitted unless it exacerbates symptoms. These restrictions should continue until the patient is symptom-free.

Recent trials suggest that mild to moderate physical activity for mildly symptomatic post-concussion patients does not adversely affect recovery.

Cognitive restrictions include modifications at school and at home. Once an athlete is able to concentrate and tolerate visual and auditory stimuli, he or she may return to school. But classroom modifications should be considered, possibly including shortened school days, extra time for testing and homework, help with note taking, and restrictions from classes likely to provoke symptoms, such as computer science or music. Limiting use of mobile devices, television viewing, noisy environments, and other possible provocations may help speed symptom resolution. These restrictions, too, should remain in place until the patient is symptom-free.

Driving is often not addressed by physicians managing the care of athletes with concussion, but evidence suggests it should be. A study of patients presenting to the emergency department found that within 24 hours of a concussion diagnosis, individuals had an impaired response to traffic hazards.^23,24 And Canadian clinical practice guidelines recommend that athletes with mild traumatic brain injury (TBI) avoid driving within the first 24 hours.²⁵

While American guidelines are silent on the question of driving for this patient population, we recommend that athletes with concussion be restricted from driving and engaging in other risky complex tasks, such as welding or shop class, for at least 24 hours. For many athletes diagnosed with concussion, driving restrictions of longer duration may be necessary based on their symptom profile and neurocognitive test results. Continued dizziness or visual deficits would pose a greater risk than fatigue or short-term memory loss, for example.

Overseeing the return to play

Return-to-activity progression follows a stepwise protocol, with 6 steps that the injured athlete must complete before resuming full activity (FIGURE 1A).^8-10 This stepwise progression begins only when athletes are symptom free, even during provocative maneuvers; have had a normal neurologic exam, are back to school full time with no restriction; are off any medications prescribed for concussion symptoms (TABLE 4),^8-10 and when neurocognitive testing, if performed, is back to baseline. If an athlete develops symptoms at any stage of the progression, rest is required until he or she remains asymptomatic for at least 24 hours. The progression is then restarted at the last stage at which the patient was symptom free.

Some individualization, of course, is recommended here, too. Younger athletes and those with a prior history of concussion may require 10 days or more to complete all the steps, allowing an extra day at various steps. Neurologic maturation affects recovery time, and for younger individuals, a more conservative return-to-play protocol based on initial concussion symptom duration has been proposed (FIGURE 1B).¹⁶

Return to activity is often supervised by a certified athletic trainer at the athlete’s school. In the event that no athletic trainer is available, patients may be referred to physical therapists with experience in monitoring injured athletes.²⁶ Anyone involved in the patient’s care, including the athlete himself, may use a symptom checklist to monitor recovery.

Allowing asymptomatic athletes to engage in non-contact sports activity less than 7 to 10 days after concussion can help them avoid injury when they are cleared for full play.

Although there is no evidence that the ongoing use of a symptom checklist affects the course of recovery, its use is often helpful in identifying specific symptoms that can be managed by means other than physical and cognitive rest—a sleep hygiene program for an individual with lingering difficulty sleeping, for example, or the continued application of ice, heat, and massage for persistent neck pain.

Checklist monitoring may be especially helpful for athletes whose symptoms extend beyond 10 days or who have multiple symptoms. Final clearance once all the steps have been completed requires follow-up with a health care provider.

Is a symptom-free waiting period necessary?

There is no evidence suggesting a need for a symptom-free waiting period before starting the return-to-play protocol.^10,27 Because a repeat concussion is most likely within 7 to 10 days of the initial injury,^8,9 however, most athletes should not return to contact play during that time frame, regardless of symptom resolution.

It is helpful to have asymptomatic athletes participate in non-contact activity before the 7 to 10 days are up, however. Doing so can help prevent deconditioning and injury upon return to contact sport, as there is evidence of increased risk of lower-extremity injury in the 90 days after concussion.²⁸

What to tell athletes—and parents—about repetitive head trauma

There is growing concern about the long-term risks of concussion and repetitive head impact that may manifest as chronic traumatic encephalopathy (CTE) and chronic neurocognitive impairment (CNI) later in life. Indeed, some data strongly suggest—but do not definitively prove—a relationship between repetitive head injury and chronic neurodegenerative disease.^8-10 You can tell worried patients or parents, however, that the majority of research on CTE and CNI has been based on professional football players.

Studies of long-term effects of soccer heading have shown conflicting results, with some finding cognitive impairment, altered postural control, and anatomic changes of the brain, while others found no effect on encephalopathy, concussion symptoms, or neurocognitive performance.^29-36Here, too, most studies showing negative effects of soccer heading involved professional athletes.

Repetitive sub-concussive impact in high school football athletes has been found to induce biochemical changes to the brain,³⁷ but the long-term effects are unknown. And, while concussion in high school athletes has been associated with short-term cognitive impairment, altered neurochemistry, and evidence of increased symptoms on baseline neurocognitive testing,^8-10,38 no studies have linked concussion during middle school or high school with CNI. What’s more, a long-term (50-year) follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease compared with age-matched controls.³⁹

A 50-year follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease when compared with age-matched controls.

A new study of high school and college football players (mean age: 17.4 years) presented at the American Academy of Neurology 2016 Sports Concussion Conference in Chicago in July, however, found significant alterations in white matter 6 months post injury.⁴⁰ The researchers compared 17 athletes with sport-related concussion with matched controls, using diffusion tensor imaging and diffusion kurtosis tensor imaging as biomarkers of brain recovery. The concussed athletes underwent MRI and symptom assessment at 24 hours, 8 days, and 6 months. The controls followed identical protocols.

At the 6-month assessment, there were no differences between the concussed group and the controls in terms of self-reported concussion symptoms, cognition, or balance. However, the concussed athletes had widespread decreased mean diffusivity compared with the controls. Despite the lack of clinical symptoms, the concussed athletes showed significant alterations in white matter “that were related to initial symptom severity ratings,” the authors concluded. These findings have implications both for determination of recovery from concussion and concussion management, they added.⁴⁰

Although there is no way to eliminate all concussions, limited evidence suggests that improving athletic technique, limiting contact at practices, better enforcement of game rules, and rule changes regarding physical contact may decrease concussion risk.^41-43 Many youth sports organizations have developed policies placing restrictions on head impact during practices and games. Studies are ongoing, too, to see if better headgear—or requiring helmets for soccer players—makes a difference.

CORRESPONDENCE
Ryan A. Sprouse, MD, CAQSM, 203 East Fourth Avenue, Ranson, WV 25438; [email protected].

Each year in the United States, more than 44 million young people participate in sports activities.¹ Yet the number of concussions incurred annually by children and adolescents engaged in sports and recreational play has been underestimated for years, and largely unknown.^1,2

Some estimates were based solely on the number of young athletes treated in emergency departments or sports concussion clinics. Others focused only on team players of middle school or high school age, excluding younger children who were hit in the head on playgrounds or during other recreational activities. What’s more, large numbers of concussions—as many as 4 in 10 incurred by high school athletes—were never reported to a coach or medical professional.³

In a new study published in the journal Pediatrics in June, researchers used national databases and current literature to provide what they believe to be “the most accurate and precise estimate of youth concussion” thus far: Between 1.1 and 1.9 million sports- and recreation-related concussions occur among US youth ages 18 or younger annually.¹

Standardized protocols for managing sport-related concussions have been adopted in most clinical settings. But use among primary care physicians is inconsistent.

Among young people playing team sports, concussions are between 2 and 7 times more likely to occur during competitive games than in practice sessions.^4-7 Boys on football and ice hockey teams have the highest rates of concussion in young athletes.For overall number of concussions, however, girls on soccer teams are second only to football players.⁴ Female soccer players are more likely than male soccer players to sustain concussions during equal number of hours of play.^4,7

An increase in incidence. The incidence of concussion among young athletes appears to have increased in the past decade, a likely result of greater involvement in team sports, an increasing focus on safeguarding young people from the potential dangers associated with a blow to the brain, and better diagnostic techniques.^4,8-10 And a recent study based on data from electronic medical records at a large regional pediatric health care network found that more than three-quarters of young people with sports-related concussions were first seen in a primary care setting.²

With this in mind, we present a comprehensive update of the evidence regarding the diagnosis and management of sport-related concussion. The recommendations we include are consistent with professional association guidelines.^8-10 Although we focus on concussion in children and adolescents involved in athletic activities, the principles generally apply to patients of all ages and to concussions that may not be sports related.

Removal from play: A vital first step

Whenever you conduct a physical exam for a young athlete, remind him or her—and the patient’s parents—that after a blow to the head, immediate removal from play is critical. Concussion is caused by a direct or indirect force to the brain that results in a transient disturbance in brain function,^8-10 manifested by alterations in neurocognitive and motor function. While the signs and symptoms (TABLE 1)^8-10 resolve within 10 days of injury in about 90% of cases, those who incur additional head impact within 24 hours have a higher symptom burden and prolonged recovery period.¹¹ Even without repetitive impact, younger athletes may take longer to recover.^8-10

The initial assessment

A child or adolescent who sustains a suspected concussion should be seen by a physician within 24 to 48 hours. Whether the initial assessment occurs in your office or on the sidelines of a game, it is important to confirm the time the incident occurred and the mechanism of injury.

Concussion is diagnosed by a combination of history, physical exam, and objective testing when symptoms or exam findings associated with mild brain trauma—headache, dizziness, light and/or noise sensitivity, among others—closely follow a head injury.^8-10 Certain maneuvers—assessing eye movements by asking the athlete to look in various directions, for instance, then to follow a pen or finger as you move it closer to his or her face—may provoke dizziness, headache, or other symptoms of concussion that were not apparent initially.

The differential diagnosis includes cervical musculoskeletal injury, craniofacial injury, epidural and subdural hematoma, heat-related illness, uncomplicated headache and migraine, upper respiratory infection, and vertigo.^8-10

Tools aid in diagnosis

Many clinical assessment tools exist to aid in the diagnosis of concussion (TABLE 2).^8-10,12-14 Any one of these tools, many of which use combinations of symptom checklists, balance exams, and cognitive assessments, may be included in your evaluation. No single tool has been found to be superior to any other.^8-10 A combination of tools may improve diagnostic accuracy, but assessment tools should not be the sole basis used to diagnose or rule out concussion.

Reserve neuroimaging, such as CT and MRI, for patients with more serious clinical findings or symptoms that persist longer than expected.

Any child or adolescent who had a blow to the head and at least one sign or symptom of concussion should be evaluated as soon as possible and assessed again later that day or the next day if any reason for concern remains.

Neuropsychological (NP) testing may involve computerized tests developed specifically for athletes. Patients may be required to react to objects that appear on a screen, for example, in a way that tests memory, performance, and reaction time. Because cognitive recovery often lags behind symptom resolution, NP testing may identify subtle brain deficits even in athletes who are asymptomatic at rest or with exercise. In general, NP testing has a sensitivity of 71% to 88% for athletes with concussion,¹⁰ but it is most beneficial when baseline test results are available. Interpretation of NP testing should be done only by qualified clinicians.

While NP testing may provide additional prognostic information, it should not alter the management of athletes who are symptomatic either at rest or with exercise.¹⁵ Nor is NP testing vital, as concussion can be accurately diagnosed and adequately managed without it.

Neuroimaging, including computed tomography (CT) and magnetic resonance imaging (MRI), is often used unnecessarily in the initial assessment of a patient who sustained a possible concussion.^8-10 In fact, neuroimaging should be reserved for cases in which it is necessary to rule out more serious pathology: intracranial or subdural hematoma or a craniofacial injury, for example, in patients with clinical findings that are red flags. These red flags include focal neurologic deficits, continuing nausea/vomiting, or persistent disorientation (TABLE 3),^8-10 or symptoms that worsen or persist beyond a few weeks. In such cases, further evaluation—with MRI of the brain, formal NP testing, and/or referral to a neurologist, physiatrist, or other physician who specializes in concussion care—is indicated.

Concussion management: Rest is key

While there is a dearth of high-quality studies on the management of sport-related concussion across all age groups, standardized protocols for both children and adults have been adopted in most clinical settings.^8-10,16,17 The protocols provide a framework for an individualized treatment plan. Yet their use among primary care physicians is inconsistent.^18-20

Traditionally, concussion management begins with relative physical and cognitive rest to allow the brain time to recover.^8-10 Recent randomized controlled trials have challenged this premise by suggesting that mild to moderate physical activity for post-concussion patients who are mildly symptomatic does not adversely affect recovery.^21,22 These studies have significant limitations, however, and further research is needed to provide specific guidance on this aspect of concussion management before it is adopted.

Physical restrictions include organized sports, recreational activity, recess, and physical education classes. Walking is permitted unless it exacerbates symptoms. These restrictions should continue until the patient is symptom-free.

Recent trials suggest that mild to moderate physical activity for mildly symptomatic post-concussion patients does not adversely affect recovery.

Cognitive restrictions include modifications at school and at home. Once an athlete is able to concentrate and tolerate visual and auditory stimuli, he or she may return to school. But classroom modifications should be considered, possibly including shortened school days, extra time for testing and homework, help with note taking, and restrictions from classes likely to provoke symptoms, such as computer science or music. Limiting use of mobile devices, television viewing, noisy environments, and other possible provocations may help speed symptom resolution. These restrictions, too, should remain in place until the patient is symptom-free.

Driving is often not addressed by physicians managing the care of athletes with concussion, but evidence suggests it should be. A study of patients presenting to the emergency department found that within 24 hours of a concussion diagnosis, individuals had an impaired response to traffic hazards.^23,24 And Canadian clinical practice guidelines recommend that athletes with mild traumatic brain injury (TBI) avoid driving within the first 24 hours.²⁵

While American guidelines are silent on the question of driving for this patient population, we recommend that athletes with concussion be restricted from driving and engaging in other risky complex tasks, such as welding or shop class, for at least 24 hours. For many athletes diagnosed with concussion, driving restrictions of longer duration may be necessary based on their symptom profile and neurocognitive test results. Continued dizziness or visual deficits would pose a greater risk than fatigue or short-term memory loss, for example.

Overseeing the return to play

Return-to-activity progression follows a stepwise protocol, with 6 steps that the injured athlete must complete before resuming full activity (FIGURE 1A).^8-10 This stepwise progression begins only when athletes are symptom free, even during provocative maneuvers; have had a normal neurologic exam, are back to school full time with no restriction; are off any medications prescribed for concussion symptoms (TABLE 4),^8-10 and when neurocognitive testing, if performed, is back to baseline. If an athlete develops symptoms at any stage of the progression, rest is required until he or she remains asymptomatic for at least 24 hours. The progression is then restarted at the last stage at which the patient was symptom free.

Some individualization, of course, is recommended here, too. Younger athletes and those with a prior history of concussion may require 10 days or more to complete all the steps, allowing an extra day at various steps. Neurologic maturation affects recovery time, and for younger individuals, a more conservative return-to-play protocol based on initial concussion symptom duration has been proposed (FIGURE 1B).¹⁶

Return to activity is often supervised by a certified athletic trainer at the athlete’s school. In the event that no athletic trainer is available, patients may be referred to physical therapists with experience in monitoring injured athletes.²⁶ Anyone involved in the patient’s care, including the athlete himself, may use a symptom checklist to monitor recovery.

Allowing asymptomatic athletes to engage in non-contact sports activity less than 7 to 10 days after concussion can help them avoid injury when they are cleared for full play.

Although there is no evidence that the ongoing use of a symptom checklist affects the course of recovery, its use is often helpful in identifying specific symptoms that can be managed by means other than physical and cognitive rest—a sleep hygiene program for an individual with lingering difficulty sleeping, for example, or the continued application of ice, heat, and massage for persistent neck pain.

Checklist monitoring may be especially helpful for athletes whose symptoms extend beyond 10 days or who have multiple symptoms. Final clearance once all the steps have been completed requires follow-up with a health care provider.

Is a symptom-free waiting period necessary?

There is no evidence suggesting a need for a symptom-free waiting period before starting the return-to-play protocol.^10,27 Because a repeat concussion is most likely within 7 to 10 days of the initial injury,^8,9 however, most athletes should not return to contact play during that time frame, regardless of symptom resolution.

It is helpful to have asymptomatic athletes participate in non-contact activity before the 7 to 10 days are up, however. Doing so can help prevent deconditioning and injury upon return to contact sport, as there is evidence of increased risk of lower-extremity injury in the 90 days after concussion.²⁸

What to tell athletes—and parents—about repetitive head trauma

There is growing concern about the long-term risks of concussion and repetitive head impact that may manifest as chronic traumatic encephalopathy (CTE) and chronic neurocognitive impairment (CNI) later in life. Indeed, some data strongly suggest—but do not definitively prove—a relationship between repetitive head injury and chronic neurodegenerative disease.^8-10 You can tell worried patients or parents, however, that the majority of research on CTE and CNI has been based on professional football players.

Studies of long-term effects of soccer heading have shown conflicting results, with some finding cognitive impairment, altered postural control, and anatomic changes of the brain, while others found no effect on encephalopathy, concussion symptoms, or neurocognitive performance.^29-36Here, too, most studies showing negative effects of soccer heading involved professional athletes.

Repetitive sub-concussive impact in high school football athletes has been found to induce biochemical changes to the brain,³⁷ but the long-term effects are unknown. And, while concussion in high school athletes has been associated with short-term cognitive impairment, altered neurochemistry, and evidence of increased symptoms on baseline neurocognitive testing,^8-10,38 no studies have linked concussion during middle school or high school with CNI. What’s more, a long-term (50-year) follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease compared with age-matched controls.³⁹

A 50-year follow-up study of individuals who played football in high school found no difference in rates of neurodegenerative disease when compared with age-matched controls.

A new study of high school and college football players (mean age: 17.4 years) presented at the American Academy of Neurology 2016 Sports Concussion Conference in Chicago in July, however, found significant alterations in white matter 6 months post injury.⁴⁰ The researchers compared 17 athletes with sport-related concussion with matched controls, using diffusion tensor imaging and diffusion kurtosis tensor imaging as biomarkers of brain recovery. The concussed athletes underwent MRI and symptom assessment at 24 hours, 8 days, and 6 months. The controls followed identical protocols.

At the 6-month assessment, there were no differences between the concussed group and the controls in terms of self-reported concussion symptoms, cognition, or balance. However, the concussed athletes had widespread decreased mean diffusivity compared with the controls. Despite the lack of clinical symptoms, the concussed athletes showed significant alterations in white matter “that were related to initial symptom severity ratings,” the authors concluded. These findings have implications both for determination of recovery from concussion and concussion management, they added.⁴⁰

Although there is no way to eliminate all concussions, limited evidence suggests that improving athletic technique, limiting contact at practices, better enforcement of game rules, and rule changes regarding physical contact may decrease concussion risk.^41-43 Many youth sports organizations have developed policies placing restrictions on head impact during practices and games. Studies are ongoing, too, to see if better headgear—or requiring helmets for soccer players—makes a difference.

CORRESPONDENCE
Ryan A. Sprouse, MD, CAQSM, 203 East Fourth Avenue, Ranson, WV 25438; [email protected].

Point-of-care ultrasound is increasingly being integrated into clinical practice, as an adjunct to the physical examination and patient history,¹ and into medical school curricula across North America.^2,3 Research confirms that this technology improves patient survival in emergency medicine settings;⁴ however, the benefits of point-of-care ultrasound administered by family physicians (FPs) in the office setting are less well documented.

Here we provide a comprehensive review of the indications for ultrasound in the office setting, which range from diagnosing musculoskeletal injuries and guiding injections to screening for abdominal aortic aneurysm (AAA). We also address the accuracy and cost-effectiveness of ultrasound use and the training needed to make family medicine ultrasound (FAMUS) successful.

Ultrasound: A useful screening tool for abdominal aortic aneurysm

The US Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) in men ages 65 to 75 years who have ever smoked (See: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/abdominal-aortic-aneurysm-screening.) Ultrasound is a reliable tool for identifying AAA⁵ (FIGURE 1); its sensitivity and specificity range from 94% to 98.9% and 98% to 100%, respectively.^6-9 It is also superior to physical examination for AAAs,¹⁰ which has a sensitivity of 29% for small AAAs (30-39 mm) and 76% for larger AAAs (>50 mm).¹¹

Most importantly, research has demonstrated that long-term mortality benefits are associated with ultrasound screening of asymptomatic patients for AAA. For example, one study found that screening asymptomatic men ages 65 to 74 (a population-based sample, with no particular risk factors) for AAA resulted in a reduction in all-cause mortality and that the benefit of AAA-related mortality continued to accumulate throughout follow-up.¹²

In fact, nationwide programs to screen for AAA using ultrasound have been established in England, Northern Ireland, Scotland, Sweden, the United States, and Wales to help prevent deaths associated with AAA rupture.¹³ Despite the documented benefits of ultrasound screening for AAA, a large retrospective cohort study conducted in an American integrated health care system found that only about 9% of patients eligible for screening according to USPSTF guidelines were screened for AAA with ultrasound in primary care practices in 2012.¹⁴

While most AAA screening occurs in the hospital, screening for the condition can be just as easily and effectively performed in an FP’s office or outpatient clinic. A Canadian prospective observational study demonstrated that aortic diameter measurements were comparable whether they were obtained by ultrasound performed by an office-based physician (who had completed an emergency ultrasonography course and performed at least 50 ultrasonographer-supervised ultrasound scans of the aorta), or by a hospital-based technologist whose scans were then reviewed by a radiologist.¹⁵ (See the TABLE for an overview of the research involving family medicine ultrasound.)

The office-based scans had a high degree of correlation (0.81) with the hospital-based ones, a sensitivity and specificity of 100%, and lasted a mean of 3.5 minutes. The researchers concluded that ultrasound screening for AAA can be safely performed in the office setting by FPs who are trained to use point-of-care ultrasound technology, and that the screening can be completed within the time constraints of a typical family practice office visit.¹⁵

In a separate study, cardiologists compared hand-held ultrasound screening for AAA to standard 2-dimensional echocardiography. This study found that screening for AAA in an outpatient clinic with a hand-held ultrasound device is feasible and accurate with a sensitivity of 88% and a specificity of 98%.¹⁶

Ultrasound in the obstetrician’s office—and the FP’s office, too

The use of ultrasound in obstetrics (FIGURE 2) is particularly well documented, with evidence supporting the use of FAMUS for various obstetrical indications dating back 30 years.¹⁷ The American Academy of Family Physicians has a position paper endorsing diagnostic ultrasound for women’s health care and has offered obstetric ultrasound courses organized by, and for, FPs since 1989.¹⁸

In a prospective observational study conducted in the United Kingdom, an FP and a nurse midwife used ultrasound to assess 240 pregnant women presenting with vaginal bleeding in early pregnancy.¹⁹ Fetal heartbeat detection by an office ultrasound scan predicted fetal progression to 20 weeks with a sensitivity of 97% and a specificity of 98%. The clinicians also detected anomalies such as molar pregnancy, blighted ovum, and ectopic pregnancy.

FAMUS and its ability to accurately estimate delivery date was examined in another prospective study involving 186 patients at a community health center.²⁰ Accuracy for the estimated date of delivery was 96% using stratified confidence intervals for first-, second-, and third-trimester examinations. The office-based ultrasound scans also detected one case of placenta previa, one fetal death, and 2 unsuspected twin pregnancies. Another study showed no difference in estimations of gestational age provided by ultrasound performed by supervised FP residents with 3 years’ ultrasound training (including 3 lectures per year and an annual 4-hour workshop), and radiologists.²¹

Further evidence that FAMUS can confirm fetal death and multiple gestations was provided by a retrospective review of almost 498 obstetric ultrasound examinations.²² FPs accurately predicted the presence or absence of fetal death, multiple gestations, and the estimated date of confinement. Another study demonstrated that 86% of 248 FP obstetrical scans were judged acceptable by a radiologist, 10% were repeated due to technical errors and subsequently found to be acceptable, and 3% were unacceptable and referred for formal ultrasound.²³ These scans were performed by FPs who completed 5 days of theory and hands-on training and 3 half-days of apprenticeship in an ultrasound laboratory.

In a study conducted in Tanzania, bedside ultrasound scans performed by nurse midwives had 100% agreement with scans performed by a sonographer when evaluating for twins, the presence of fetal heartbeat, or fetal positioning. Overall, bedside ultrasound aided in the diagnosis (39%) and management plan (22%) of 542 patients.²⁴ It is important to note, as highlighted in a multisite study, that consultation with specialists when appropriate is paramount to the successful use of ultrasound by the FP for prenatal care.²⁵

Guiding joint injections, assessing LV function

Sports/exercise medicine. FPs with expertise in sports and exercise medicine commonly use office ultrasound to diagnose musculoskeletal (MSK) injuries, including rotator cuff tears, muscle ruptures, tendinitis, and bursitis.²⁶ It is superior to magnetic resonance imaging (MRI) in terms of cost-to-benefit ratio, precision, and sensitivity (due, in part, to the fact that clinicians can obtain patient feedback during the examination).²⁶ In addition, a review of office-based procedures for MSK indications demonstrated the usefulness of ultrasound for the guidance of joint aspirations and joint and tendon injections.²⁷ Ultrasound guidance is commonly used to ensure procedural accuracy during aspirations and injections of the shoulder (glenohumeral joint; subacromial bursa), elbow, wrist (carpal tunnel tendons), hip, knee, and ankle.^27-29

Cardiology (FIGURE 3). General practitioners in Norway found that 8 hours of training on a hand-held ultrasound device was sufficient to assess left ventricular function with a sensitivity and specificity of 78% and 83%, respectively.³⁰ Their measurements of septal mitral annular excursion (a surrogate measurement of left ventricular function) were similar to those of a cardiologist using the same device and added no more than 5 minutes to the examination.

Other uses. In a separate study, military FPs with 16 hours of training found that FAMUS was easy to learn and effective in the outpatient and inpatient setting for the detection of AAA, trauma, musculoskeletal injuries, and certain obstetric, echocardiographic, and biliary indications.³¹ They reported that the average time spent per ultrasound examination was one to 5 minutes for the majority of the indications.

The authors of a retrospective study involving a suburban family practice reported that FAMUS was successfully used to identify the causes of epigastric and right upper quadrant pain, and to check post-void residual urinary bladder volume.³²

The ultrasound-assisted physical examination can detect pathologies not apparent on history and physical examination alone (FIGURES 4 and 5). In one study, an FP used ultrasound in the office to identify pathologies in 31% of patients that were not detected on physical examination alone. The pathologies included AAAs, a thyroid cyst, mitral stenosis, gallstones, renal cysts, urinary retention, hydronephrosis, ectopic kidney, and an endometrial tumor.³³

In another study, an FP performed ultrasound examinations on 189 patients during their annual exams.³⁴ The technology identified pathologies that were not suspected after clinical assessment in 22% of these patients. With the emphasis in the current clinical landscape on choosing diagnostic tests wisely, it will be important to determine if findings like these positively impact patient care.35,36

Portable ultrasound machines are affordable

Despite the documented benefits of ultrasound screening for an abdominal aortic aneurysm, only about 9% of patients received this screening in a primary care practice in 2012.

The relative affordability of portable ultrasound contributes to the cost-effectiveness of FAMUS. For FPs seeking to initiate an office-based ultrasound program, expenses to consider include the price of the machine itself, which ranges from $7500 to $50,000, depending on the technology included. Other expenses include the cost of disposables (eg, ultrasound gel and disinfectant wipes or spray), which may total about $400 per year.

In-office exams facilitate savings elsewhere. Other factors that contribute to the cost-effectiveness of FAMUS include reduced radiologist expenses and hospital visits. The cost savings of in-office ultrasound was highlighted almost 30 years ago when the cost of a FAMUS obstetrical scan was reported to be half that of a radiologist scan.²³ This same study reported that increased costs for additional investigations caused by incidental findings using FAMUS could be offset by the decreased costs associated with an earlier diagnosis of serious conditions.²³

A 2002 study demonstrated that office-based FAMUS scans (N=131) reduced the number of hospital scans, emergency admissions, and outpatient and inpatient hospital visits.³⁷ Although the unit cost of a FAMUS scan was higher than an inpatient one, the total cost of the FAMUS scan was lower due to decreased hospital visits. In addition, research has shown that patients are more satisfied with office-based ultrasound examinations and prefer ultrasound performed by their FP to hospital-based ultrasound scans.^31,37

Training: Cost and availability

Training in office-based ultrasound is available at the undergraduate, postgraduate, and continuing medical education levels. Undergraduate bedside ultrasound education is evident in medical schools around the globe including in Australia, Austria, Canada, China, Germany, France, the United States, and the United Kingdom.³ In an American survey of family medicine residency programs published in 2015, only 2.2% reported an established ultrasound curriculum; however, 29% had started a program within the past year.³⁸ In Canada, one- and 2-day bedside ultrasound courses are offered to family medicine residents at a number of universities. And continuing medical education (CME) courses in bedside ultrasound are available to physicians on a regular basis internationally.³⁹ In North America, CME courses exist specifically for urban and rural family medicine clinicians,^40-43 and offer training for a wide range of applications.

The average time spent per ultrasound examination is one to 5 minutes for the majority of indications.

Courses are often available for $1000 to $2000. Many of these courses run over a one- to 3-day period. Some provide a general overview of ultrasound for the primary care physician while others specialize in topics such as musculoskeletal uses, obstetric uses, or emergency department echocardiography.^40-44

Challenges remain

More research is necessary to demonstrate that office-based ultrasound produces patient outcomes that are comparable to those resulting from hospital-based ultrasound. Also, bedside ultrasound is only as good as the operator who performs the examination,⁴⁵ which highlights the importance of developing bedside ultrasound training programs tailored for FPs. National policies are essential for standardizing indications, training, and credentialing so that this effective tool can be used in a safe and effective manner.

CORRESPONDENCE
Peter Steinmetz, MD, CCFP, St. Mary’s Hospital, 3830 Ave Lacombe, Montreal, Quebec, Canada H3T1M5; [email protected].

ACKNOWLEDGEMENTS
We thank Assistant Professor Marion Dove, MD, CCFP, Department of Family Medicine, McGill University, for her suggestions and critical review of an earlier version of the manuscript. The term FAMUS is pending registration and is advertised with the Canadian Intellectual Property Office (Steinmetz, Volume 63, Issue 3217).

Point-of-care ultrasound is increasingly being integrated into clinical practice, as an adjunct to the physical examination and patient history,¹ and into medical school curricula across North America.^2,3 Research confirms that this technology improves patient survival in emergency medicine settings;⁴ however, the benefits of point-of-care ultrasound administered by family physicians (FPs) in the office setting are less well documented.

Here we provide a comprehensive review of the indications for ultrasound in the office setting, which range from diagnosing musculoskeletal injuries and guiding injections to screening for abdominal aortic aneurysm (AAA). We also address the accuracy and cost-effectiveness of ultrasound use and the training needed to make family medicine ultrasound (FAMUS) successful.

Ultrasound: A useful screening tool for abdominal aortic aneurysm

The US Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) in men ages 65 to 75 years who have ever smoked (See: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/abdominal-aortic-aneurysm-screening.) Ultrasound is a reliable tool for identifying AAA⁵ (FIGURE 1); its sensitivity and specificity range from 94% to 98.9% and 98% to 100%, respectively.^6-9 It is also superior to physical examination for AAAs,¹⁰ which has a sensitivity of 29% for small AAAs (30-39 mm) and 76% for larger AAAs (>50 mm).¹¹

Most importantly, research has demonstrated that long-term mortality benefits are associated with ultrasound screening of asymptomatic patients for AAA. For example, one study found that screening asymptomatic men ages 65 to 74 (a population-based sample, with no particular risk factors) for AAA resulted in a reduction in all-cause mortality and that the benefit of AAA-related mortality continued to accumulate throughout follow-up.¹²

In fact, nationwide programs to screen for AAA using ultrasound have been established in England, Northern Ireland, Scotland, Sweden, the United States, and Wales to help prevent deaths associated with AAA rupture.¹³ Despite the documented benefits of ultrasound screening for AAA, a large retrospective cohort study conducted in an American integrated health care system found that only about 9% of patients eligible for screening according to USPSTF guidelines were screened for AAA with ultrasound in primary care practices in 2012.¹⁴

While most AAA screening occurs in the hospital, screening for the condition can be just as easily and effectively performed in an FP’s office or outpatient clinic. A Canadian prospective observational study demonstrated that aortic diameter measurements were comparable whether they were obtained by ultrasound performed by an office-based physician (who had completed an emergency ultrasonography course and performed at least 50 ultrasonographer-supervised ultrasound scans of the aorta), or by a hospital-based technologist whose scans were then reviewed by a radiologist.¹⁵ (See the TABLE for an overview of the research involving family medicine ultrasound.)

The office-based scans had a high degree of correlation (0.81) with the hospital-based ones, a sensitivity and specificity of 100%, and lasted a mean of 3.5 minutes. The researchers concluded that ultrasound screening for AAA can be safely performed in the office setting by FPs who are trained to use point-of-care ultrasound technology, and that the screening can be completed within the time constraints of a typical family practice office visit.¹⁵

In a separate study, cardiologists compared hand-held ultrasound screening for AAA to standard 2-dimensional echocardiography. This study found that screening for AAA in an outpatient clinic with a hand-held ultrasound device is feasible and accurate with a sensitivity of 88% and a specificity of 98%.¹⁶

Ultrasound in the obstetrician’s office—and the FP’s office, too

The use of ultrasound in obstetrics (FIGURE 2) is particularly well documented, with evidence supporting the use of FAMUS for various obstetrical indications dating back 30 years.¹⁷ The American Academy of Family Physicians has a position paper endorsing diagnostic ultrasound for women’s health care and has offered obstetric ultrasound courses organized by, and for, FPs since 1989.¹⁸

In a prospective observational study conducted in the United Kingdom, an FP and a nurse midwife used ultrasound to assess 240 pregnant women presenting with vaginal bleeding in early pregnancy.¹⁹ Fetal heartbeat detection by an office ultrasound scan predicted fetal progression to 20 weeks with a sensitivity of 97% and a specificity of 98%. The clinicians also detected anomalies such as molar pregnancy, blighted ovum, and ectopic pregnancy.

FAMUS and its ability to accurately estimate delivery date was examined in another prospective study involving 186 patients at a community health center.²⁰ Accuracy for the estimated date of delivery was 96% using stratified confidence intervals for first-, second-, and third-trimester examinations. The office-based ultrasound scans also detected one case of placenta previa, one fetal death, and 2 unsuspected twin pregnancies. Another study showed no difference in estimations of gestational age provided by ultrasound performed by supervised FP residents with 3 years’ ultrasound training (including 3 lectures per year and an annual 4-hour workshop), and radiologists.²¹

Further evidence that FAMUS can confirm fetal death and multiple gestations was provided by a retrospective review of almost 498 obstetric ultrasound examinations.²² FPs accurately predicted the presence or absence of fetal death, multiple gestations, and the estimated date of confinement. Another study demonstrated that 86% of 248 FP obstetrical scans were judged acceptable by a radiologist, 10% were repeated due to technical errors and subsequently found to be acceptable, and 3% were unacceptable and referred for formal ultrasound.²³ These scans were performed by FPs who completed 5 days of theory and hands-on training and 3 half-days of apprenticeship in an ultrasound laboratory.

In a study conducted in Tanzania, bedside ultrasound scans performed by nurse midwives had 100% agreement with scans performed by a sonographer when evaluating for twins, the presence of fetal heartbeat, or fetal positioning. Overall, bedside ultrasound aided in the diagnosis (39%) and management plan (22%) of 542 patients.²⁴ It is important to note, as highlighted in a multisite study, that consultation with specialists when appropriate is paramount to the successful use of ultrasound by the FP for prenatal care.²⁵

Guiding joint injections, assessing LV function

Sports/exercise medicine. FPs with expertise in sports and exercise medicine commonly use office ultrasound to diagnose musculoskeletal (MSK) injuries, including rotator cuff tears, muscle ruptures, tendinitis, and bursitis.²⁶ It is superior to magnetic resonance imaging (MRI) in terms of cost-to-benefit ratio, precision, and sensitivity (due, in part, to the fact that clinicians can obtain patient feedback during the examination).²⁶ In addition, a review of office-based procedures for MSK indications demonstrated the usefulness of ultrasound for the guidance of joint aspirations and joint and tendon injections.²⁷ Ultrasound guidance is commonly used to ensure procedural accuracy during aspirations and injections of the shoulder (glenohumeral joint; subacromial bursa), elbow, wrist (carpal tunnel tendons), hip, knee, and ankle.^27-29

Cardiology (FIGURE 3). General practitioners in Norway found that 8 hours of training on a hand-held ultrasound device was sufficient to assess left ventricular function with a sensitivity and specificity of 78% and 83%, respectively.³⁰ Their measurements of septal mitral annular excursion (a surrogate measurement of left ventricular function) were similar to those of a cardiologist using the same device and added no more than 5 minutes to the examination.

Other uses. In a separate study, military FPs with 16 hours of training found that FAMUS was easy to learn and effective in the outpatient and inpatient setting for the detection of AAA, trauma, musculoskeletal injuries, and certain obstetric, echocardiographic, and biliary indications.³¹ They reported that the average time spent per ultrasound examination was one to 5 minutes for the majority of the indications.

The authors of a retrospective study involving a suburban family practice reported that FAMUS was successfully used to identify the causes of epigastric and right upper quadrant pain, and to check post-void residual urinary bladder volume.³²

The ultrasound-assisted physical examination can detect pathologies not apparent on history and physical examination alone (FIGURES 4 and 5). In one study, an FP used ultrasound in the office to identify pathologies in 31% of patients that were not detected on physical examination alone. The pathologies included AAAs, a thyroid cyst, mitral stenosis, gallstones, renal cysts, urinary retention, hydronephrosis, ectopic kidney, and an endometrial tumor.³³

In another study, an FP performed ultrasound examinations on 189 patients during their annual exams.³⁴ The technology identified pathologies that were not suspected after clinical assessment in 22% of these patients. With the emphasis in the current clinical landscape on choosing diagnostic tests wisely, it will be important to determine if findings like these positively impact patient care.35,36

Portable ultrasound machines are affordable

Despite the documented benefits of ultrasound screening for an abdominal aortic aneurysm, only about 9% of patients received this screening in a primary care practice in 2012.

The relative affordability of portable ultrasound contributes to the cost-effectiveness of FAMUS. For FPs seeking to initiate an office-based ultrasound program, expenses to consider include the price of the machine itself, which ranges from $7500 to $50,000, depending on the technology included. Other expenses include the cost of disposables (eg, ultrasound gel and disinfectant wipes or spray), which may total about $400 per year.

In-office exams facilitate savings elsewhere. Other factors that contribute to the cost-effectiveness of FAMUS include reduced radiologist expenses and hospital visits. The cost savings of in-office ultrasound was highlighted almost 30 years ago when the cost of a FAMUS obstetrical scan was reported to be half that of a radiologist scan.²³ This same study reported that increased costs for additional investigations caused by incidental findings using FAMUS could be offset by the decreased costs associated with an earlier diagnosis of serious conditions.²³

A 2002 study demonstrated that office-based FAMUS scans (N=131) reduced the number of hospital scans, emergency admissions, and outpatient and inpatient hospital visits.³⁷ Although the unit cost of a FAMUS scan was higher than an inpatient one, the total cost of the FAMUS scan was lower due to decreased hospital visits. In addition, research has shown that patients are more satisfied with office-based ultrasound examinations and prefer ultrasound performed by their FP to hospital-based ultrasound scans.^31,37

Training: Cost and availability

Training in office-based ultrasound is available at the undergraduate, postgraduate, and continuing medical education levels. Undergraduate bedside ultrasound education is evident in medical schools around the globe including in Australia, Austria, Canada, China, Germany, France, the United States, and the United Kingdom.³ In an American survey of family medicine residency programs published in 2015, only 2.2% reported an established ultrasound curriculum; however, 29% had started a program within the past year.³⁸ In Canada, one- and 2-day bedside ultrasound courses are offered to family medicine residents at a number of universities. And continuing medical education (CME) courses in bedside ultrasound are available to physicians on a regular basis internationally.³⁹ In North America, CME courses exist specifically for urban and rural family medicine clinicians,^40-43 and offer training for a wide range of applications.

The average time spent per ultrasound examination is one to 5 minutes for the majority of indications.

Courses are often available for $1000 to $2000. Many of these courses run over a one- to 3-day period. Some provide a general overview of ultrasound for the primary care physician while others specialize in topics such as musculoskeletal uses, obstetric uses, or emergency department echocardiography.^40-44

Challenges remain

More research is necessary to demonstrate that office-based ultrasound produces patient outcomes that are comparable to those resulting from hospital-based ultrasound. Also, bedside ultrasound is only as good as the operator who performs the examination,⁴⁵ which highlights the importance of developing bedside ultrasound training programs tailored for FPs. National policies are essential for standardizing indications, training, and credentialing so that this effective tool can be used in a safe and effective manner.

CORRESPONDENCE
Peter Steinmetz, MD, CCFP, St. Mary’s Hospital, 3830 Ave Lacombe, Montreal, Quebec, Canada H3T1M5; [email protected].

ACKNOWLEDGEMENTS
We thank Assistant Professor Marion Dove, MD, CCFP, Department of Family Medicine, McGill University, for her suggestions and critical review of an earlier version of the manuscript. The term FAMUS is pending registration and is advertised with the Canadian Intellectual Property Office (Steinmetz, Volume 63, Issue 3217).

Point-of-care ultrasound is increasingly being integrated into clinical practice, as an adjunct to the physical examination and patient history,¹ and into medical school curricula across North America.^2,3 Research confirms that this technology improves patient survival in emergency medicine settings;⁴ however, the benefits of point-of-care ultrasound administered by family physicians (FPs) in the office setting are less well documented.

Here we provide a comprehensive review of the indications for ultrasound in the office setting, which range from diagnosing musculoskeletal injuries and guiding injections to screening for abdominal aortic aneurysm (AAA). We also address the accuracy and cost-effectiveness of ultrasound use and the training needed to make family medicine ultrasound (FAMUS) successful.

Ultrasound: A useful screening tool for abdominal aortic aneurysm

The US Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) in men ages 65 to 75 years who have ever smoked (See: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/abdominal-aortic-aneurysm-screening.) Ultrasound is a reliable tool for identifying AAA⁵ (FIGURE 1); its sensitivity and specificity range from 94% to 98.9% and 98% to 100%, respectively.^6-9 It is also superior to physical examination for AAAs,¹⁰ which has a sensitivity of 29% for small AAAs (30-39 mm) and 76% for larger AAAs (>50 mm).¹¹

Most importantly, research has demonstrated that long-term mortality benefits are associated with ultrasound screening of asymptomatic patients for AAA. For example, one study found that screening asymptomatic men ages 65 to 74 (a population-based sample, with no particular risk factors) for AAA resulted in a reduction in all-cause mortality and that the benefit of AAA-related mortality continued to accumulate throughout follow-up.¹²

In fact, nationwide programs to screen for AAA using ultrasound have been established in England, Northern Ireland, Scotland, Sweden, the United States, and Wales to help prevent deaths associated with AAA rupture.¹³ Despite the documented benefits of ultrasound screening for AAA, a large retrospective cohort study conducted in an American integrated health care system found that only about 9% of patients eligible for screening according to USPSTF guidelines were screened for AAA with ultrasound in primary care practices in 2012.¹⁴

While most AAA screening occurs in the hospital, screening for the condition can be just as easily and effectively performed in an FP’s office or outpatient clinic. A Canadian prospective observational study demonstrated that aortic diameter measurements were comparable whether they were obtained by ultrasound performed by an office-based physician (who had completed an emergency ultrasonography course and performed at least 50 ultrasonographer-supervised ultrasound scans of the aorta), or by a hospital-based technologist whose scans were then reviewed by a radiologist.¹⁵ (See the TABLE for an overview of the research involving family medicine ultrasound.)

The office-based scans had a high degree of correlation (0.81) with the hospital-based ones, a sensitivity and specificity of 100%, and lasted a mean of 3.5 minutes. The researchers concluded that ultrasound screening for AAA can be safely performed in the office setting by FPs who are trained to use point-of-care ultrasound technology, and that the screening can be completed within the time constraints of a typical family practice office visit.¹⁵

In a separate study, cardiologists compared hand-held ultrasound screening for AAA to standard 2-dimensional echocardiography. This study found that screening for AAA in an outpatient clinic with a hand-held ultrasound device is feasible and accurate with a sensitivity of 88% and a specificity of 98%.¹⁶

Ultrasound in the obstetrician’s office—and the FP’s office, too

The use of ultrasound in obstetrics (FIGURE 2) is particularly well documented, with evidence supporting the use of FAMUS for various obstetrical indications dating back 30 years.¹⁷ The American Academy of Family Physicians has a position paper endorsing diagnostic ultrasound for women’s health care and has offered obstetric ultrasound courses organized by, and for, FPs since 1989.¹⁸

In a prospective observational study conducted in the United Kingdom, an FP and a nurse midwife used ultrasound to assess 240 pregnant women presenting with vaginal bleeding in early pregnancy.¹⁹ Fetal heartbeat detection by an office ultrasound scan predicted fetal progression to 20 weeks with a sensitivity of 97% and a specificity of 98%. The clinicians also detected anomalies such as molar pregnancy, blighted ovum, and ectopic pregnancy.

FAMUS and its ability to accurately estimate delivery date was examined in another prospective study involving 186 patients at a community health center.²⁰ Accuracy for the estimated date of delivery was 96% using stratified confidence intervals for first-, second-, and third-trimester examinations. The office-based ultrasound scans also detected one case of placenta previa, one fetal death, and 2 unsuspected twin pregnancies. Another study showed no difference in estimations of gestational age provided by ultrasound performed by supervised FP residents with 3 years’ ultrasound training (including 3 lectures per year and an annual 4-hour workshop), and radiologists.²¹

Further evidence that FAMUS can confirm fetal death and multiple gestations was provided by a retrospective review of almost 498 obstetric ultrasound examinations.²² FPs accurately predicted the presence or absence of fetal death, multiple gestations, and the estimated date of confinement. Another study demonstrated that 86% of 248 FP obstetrical scans were judged acceptable by a radiologist, 10% were repeated due to technical errors and subsequently found to be acceptable, and 3% were unacceptable and referred for formal ultrasound.²³ These scans were performed by FPs who completed 5 days of theory and hands-on training and 3 half-days of apprenticeship in an ultrasound laboratory.

In a study conducted in Tanzania, bedside ultrasound scans performed by nurse midwives had 100% agreement with scans performed by a sonographer when evaluating for twins, the presence of fetal heartbeat, or fetal positioning. Overall, bedside ultrasound aided in the diagnosis (39%) and management plan (22%) of 542 patients.²⁴ It is important to note, as highlighted in a multisite study, that consultation with specialists when appropriate is paramount to the successful use of ultrasound by the FP for prenatal care.²⁵

Guiding joint injections, assessing LV function

Sports/exercise medicine. FPs with expertise in sports and exercise medicine commonly use office ultrasound to diagnose musculoskeletal (MSK) injuries, including rotator cuff tears, muscle ruptures, tendinitis, and bursitis.²⁶ It is superior to magnetic resonance imaging (MRI) in terms of cost-to-benefit ratio, precision, and sensitivity (due, in part, to the fact that clinicians can obtain patient feedback during the examination).²⁶ In addition, a review of office-based procedures for MSK indications demonstrated the usefulness of ultrasound for the guidance of joint aspirations and joint and tendon injections.²⁷ Ultrasound guidance is commonly used to ensure procedural accuracy during aspirations and injections of the shoulder (glenohumeral joint; subacromial bursa), elbow, wrist (carpal tunnel tendons), hip, knee, and ankle.^27-29

Cardiology (FIGURE 3). General practitioners in Norway found that 8 hours of training on a hand-held ultrasound device was sufficient to assess left ventricular function with a sensitivity and specificity of 78% and 83%, respectively.³⁰ Their measurements of septal mitral annular excursion (a surrogate measurement of left ventricular function) were similar to those of a cardiologist using the same device and added no more than 5 minutes to the examination.

Other uses. In a separate study, military FPs with 16 hours of training found that FAMUS was easy to learn and effective in the outpatient and inpatient setting for the detection of AAA, trauma, musculoskeletal injuries, and certain obstetric, echocardiographic, and biliary indications.³¹ They reported that the average time spent per ultrasound examination was one to 5 minutes for the majority of the indications.

The authors of a retrospective study involving a suburban family practice reported that FAMUS was successfully used to identify the causes of epigastric and right upper quadrant pain, and to check post-void residual urinary bladder volume.³²

The ultrasound-assisted physical examination can detect pathologies not apparent on history and physical examination alone (FIGURES 4 and 5). In one study, an FP used ultrasound in the office to identify pathologies in 31% of patients that were not detected on physical examination alone. The pathologies included AAAs, a thyroid cyst, mitral stenosis, gallstones, renal cysts, urinary retention, hydronephrosis, ectopic kidney, and an endometrial tumor.³³

In another study, an FP performed ultrasound examinations on 189 patients during their annual exams.³⁴ The technology identified pathologies that were not suspected after clinical assessment in 22% of these patients. With the emphasis in the current clinical landscape on choosing diagnostic tests wisely, it will be important to determine if findings like these positively impact patient care.35,36

Portable ultrasound machines are affordable

Despite the documented benefits of ultrasound screening for an abdominal aortic aneurysm, only about 9% of patients received this screening in a primary care practice in 2012.

The relative affordability of portable ultrasound contributes to the cost-effectiveness of FAMUS. For FPs seeking to initiate an office-based ultrasound program, expenses to consider include the price of the machine itself, which ranges from $7500 to $50,000, depending on the technology included. Other expenses include the cost of disposables (eg, ultrasound gel and disinfectant wipes or spray), which may total about $400 per year.

In-office exams facilitate savings elsewhere. Other factors that contribute to the cost-effectiveness of FAMUS include reduced radiologist expenses and hospital visits. The cost savings of in-office ultrasound was highlighted almost 30 years ago when the cost of a FAMUS obstetrical scan was reported to be half that of a radiologist scan.²³ This same study reported that increased costs for additional investigations caused by incidental findings using FAMUS could be offset by the decreased costs associated with an earlier diagnosis of serious conditions.²³

A 2002 study demonstrated that office-based FAMUS scans (N=131) reduced the number of hospital scans, emergency admissions, and outpatient and inpatient hospital visits.³⁷ Although the unit cost of a FAMUS scan was higher than an inpatient one, the total cost of the FAMUS scan was lower due to decreased hospital visits. In addition, research has shown that patients are more satisfied with office-based ultrasound examinations and prefer ultrasound performed by their FP to hospital-based ultrasound scans.^31,37

Training: Cost and availability

Training in office-based ultrasound is available at the undergraduate, postgraduate, and continuing medical education levels. Undergraduate bedside ultrasound education is evident in medical schools around the globe including in Australia, Austria, Canada, China, Germany, France, the United States, and the United Kingdom.³ In an American survey of family medicine residency programs published in 2015, only 2.2% reported an established ultrasound curriculum; however, 29% had started a program within the past year.³⁸ In Canada, one- and 2-day bedside ultrasound courses are offered to family medicine residents at a number of universities. And continuing medical education (CME) courses in bedside ultrasound are available to physicians on a regular basis internationally.³⁹ In North America, CME courses exist specifically for urban and rural family medicine clinicians,^40-43 and offer training for a wide range of applications.

The average time spent per ultrasound examination is one to 5 minutes for the majority of indications.

Courses are often available for $1000 to $2000. Many of these courses run over a one- to 3-day period. Some provide a general overview of ultrasound for the primary care physician while others specialize in topics such as musculoskeletal uses, obstetric uses, or emergency department echocardiography.^40-44

Challenges remain

More research is necessary to demonstrate that office-based ultrasound produces patient outcomes that are comparable to those resulting from hospital-based ultrasound. Also, bedside ultrasound is only as good as the operator who performs the examination,⁴⁵ which highlights the importance of developing bedside ultrasound training programs tailored for FPs. National policies are essential for standardizing indications, training, and credentialing so that this effective tool can be used in a safe and effective manner.

CORRESPONDENCE
Peter Steinmetz, MD, CCFP, St. Mary’s Hospital, 3830 Ave Lacombe, Montreal, Quebec, Canada H3T1M5; [email protected].

ACKNOWLEDGEMENTS
We thank Assistant Professor Marion Dove, MD, CCFP, Department of Family Medicine, McGill University, for her suggestions and critical review of an earlier version of the manuscript. The term FAMUS is pending registration and is advertised with the Canadian Intellectual Property Office (Steinmetz, Volume 63, Issue 3217).