Concussion

The Future of Concussion

and Medical Education

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Original artwork by Jessica Schwartz Rendered by Chris Freeman

Jessica B. Schwartz PT, DPT, CSCS

There is a paucity of quality concussion education in entry level, residency, and post-professional medical education.

Why?

Because there is no evidence based medicine for concussion.

A bold statement as I introduce what I believe to be the worlds first yearlong, multidisciplinary, and post-professional concussion education program for clinicians.

Let me start with a story:

It was the week I got promoted to junior partner of my company.

The week I took a deep breath for the first time in my life and said “OK Schwartz…You’ve arrived.”

I was surrounded by people whom I genuinely cared about, professionally and personally, and I felt like my nose to the grindstone personality the last 13 years of formal didactic education, business mentorship, and the chase to this finish line had come to fruition.

That was the week I was hit by a car.

That was the week my life changed forever.

On October 3, 2013, I went from being Dr. Schwartz to patient 237427 in a NYC Emergency Department getting rolled through a CT Scan.

It’s a difficult journey being on “the other side of healthcare.”

I was that patient rolling to CT with my MD Calculator in hand who was able to recite the Canadian CT Head Rules like a proud elementary school student who had just learned her speaking part for the school play.

Physical therapy was my craft. I was mastering the craft of treating the patient as person, developing my patient rapport tools, building a wonderful international referral network, and understanding the nuances of running multiple successful businesses.

I loved every minute of it. The more I learned the more I wanted to learn.

A one week medical leave of absence turned into 10+ hours of rehabilitation a week for a year.

How could an injury so seemingly benign change my life forever?

What We Know:

In 1997, the CDC reported 300,000 concussions in the United States. In 2016, the CDC estimates are 1.6-3.8 million sports related concussions based off of the most recent 2006-2010 data.

I strongly believe that these numbers continue to be greatly underestimated based off of the heterogenous nature of this injury, underreporting[1-4], ~25% of people not seeking emergency department or other medical care[5], and lack of an agreed upon definition and consensus on what the injury is in the literature[6-8].

We know that approximately 20-30% of patients develop persistent symptoms crossing over into the post concussion syndrome threshold each year with ranges from 5-58% in the literature[9-11].

If we look at ~30% of all concussions crossing over into the persistent symptom category, that is 1.14 million people in the United States based off of the current data alone.

Remember, I continue to believe that this data continues to be grossly underestimated.

The Gaps:

We know that TBI is grossly underfunded yet it is a major cause of death and disability in the United States, contributing to about 30% of all injury deaths[12].

NIH TBI v Cancer Funding

According to the National Institutes of Health (NIH), Cancer research received $5.6 Billion in 2015. Comparatively and up from $88 million in 2015, TBI is estimated to receive just $91 million in 2016[13]. Approximately 5.6 million people are living with the long terms effects of TBI and 138 deaths occur per day[12] amounting to ~50,000 deaths per year in the US. In 2015, there were 1,658,370 new cancer cases diagnosed and 589,430 cancer deaths in the US[14].

Why compare cancer and TBI? Because cancer has made huge gains by breaking down cancer. We don’t treat cancer. We treat large cell non-Hodgkin lymphoma. We need to do the same in the concussion community.

Scientifically, we must start with agreeing upon a universal definition of concussion, mTBI, and TBI. From there we need to be able to break down the injury appropriately based off of neurophysiological changes and injury to specific areas of the brain. While these are lofty goals, I also don’t see this being tangible in the near future nor is it clinically and functionally relevant to the patient seeking care in front of us today.

The above statistics indicate that we are doing much better at saving patients lives from severe cases of TBI vs cancer; however, the true burden exists with TBI survivors suffering from the lasting effects of what a TBI does to a person as a whole being.

We know that 100% of all neuroprotection phase III studies are negative, less than 5% of New Medical Entities (NME) in clinical assessment make it to FDA approval, and 100% of all Phase III trials in TBI are negative.

This means that there have been zero phase three clinical trials in TBI that have moved on to completion, there are zero drugs for TBI, and that TBI and concussion are strictly a clinical diagnosis.

We have to do better. And we can.

Medical Education and Healthcare:

Daniel Goleman discusses the key concept of “iatrogenic suffering” in medicine. This is an added anguish by medical personnel delivering insensitive messages that can often engender more emotional suffering than the actual illness itself[15].

Historically in medicine if we do not understand an injury or disease pathway, we prescribe rest or send the patient to a psychologist e.g. syphillis, low back pain, B12 deficiency, cardiac issues in women, etc.

We’ve missed the mark in the concussion community as medical providers. Over the last few decades, we’ve allowed the medico-legal literature to get ahead of us in the medical community.

It wasn’t until 1989, a neuropsychologist by the name of Jeffrey Barth, was part of the first group to suggest that cognitive testing in preseason athletes may have some value due to concussive injuries presenting lasting effects.

We’ve enabled a culture of “I got my bell rung” to prevail and have not addressed concussion from a systems level until recently.

I’ve heard time and time again that “We can’t teach it because there’s no empirical evidence”.

Nonsense.

As I was being well-cared for by my team of physicians and clinicians, I continued to do my best to take a step back and look at the inner workings of the healthcare team, system and educational offerings that are made available to all clinicians from physician to PT et al.

When I learned that 2015 was the first year that neurology residencies were receiving formal didactic education in concussion within the ‘Behavioral Neurology’ section springing from the work and advocacy of the Sports Neurology Section of the American Academy of Neurology, I knew there had to be something done.

A change.

A change in the global architecture of medicine with respect to the concussion patient of today.

A concussive injury is an all hands on deck injury. It can often require a team of clinicians to identify, treat, and manage this patient population.

Leading Causes of TBI

Concussion patients port of access to the clinician of today is infinite. It can range from the athletic trainer, the emergency department physician, the primary care physician, the pediatrician, the nurse practitioner, the physician assistant, the school nurse, psychologist, physical therapist, occupational therapist, speech therapist, and anyone who has direct access to the patient of today.

I emphatically deliver this message when I speak publicly: it is not a matter of if you treat concussion patients. It is a matter of when you will encounter, treat, and/or refer a concussion patient.

A concussion is not a broken bone. That’s easy. We know normal tissue healing parameters in healthy populations.

A concussion is a neurophysiologic injury that can affect all domains of a person’s life from somatic, cognitive, emotional, vestibular, sleep, and behavior often with non-specific answers to the all important patient question of “when will I get better?”

It is gut-wrenching as a clinician to have the self awareness to look into a patient’s eyes and say “I don’t know.” It is even more painful as a patient to be completely unaware of if you will ever get better when you are being cared for by one of the best clinicians in the world.

We can do better. And we will. Here’s how.

Healthcare Teams:

Long gone are the days of the one physician model, yet we seem to be in a conundrum when it comes to communication and teamwork in medicine.

The Doctor Sir Luke_Fildes_(1891)

The Doctor Sir Luke Fildes (1891) https://commons.wikimedia.org/wiki/File:The_Doctor_Luke_Fildes_crop.jpg

In the fall of 2014, I had the privilege to virtually attend the International College of Residency Education’s (ICRE) opening plenary delivered by rhetorician scientist Dr. Lorelei Lingard on Collective Competence: Adapting our concept of competence to healthcare teams[16].

During this time, I was finalizing my concussion rehabilitation and Dr. Lingard’s words helped facilitate my eureka moment of how I can aide in providing a solution to this medical world of specialists all attempting to treat the same poorly defined and heterogenous injury.

Summatively, she states that individual competence does not equal good healthcare.

She elaborates reviewing a case scenario describing the maze of disconnected care episodes that the patient of today is experiencing.

Dr. Lingard states that we need to “evaluate in situ, broaden focus beyond individual actions to include inter-actions among individuals, capture the ‘cracks’ between the care episodes, and consider interactions among elements of the system, not just among people…Competence is a way of ‘seeing’ that both directs and deflects our attention. The cracks between care episodes, experts cultivating collective competence ‘know how the system usually fails in this situation, and plans accordingly.’ Our attention is directed towards individual competence and deflected from collective competence. We need both[16].”

My role is to facilitate collective competence in the concussion community.

Let’s think about the concussion patient of today.

A concussed individual can experience any one of the following myriad of symptoms all at once or over a period of time [See Chart].

Concussion Signs and Symptoms

Each of these symptoms can be managed by individual specialists that may or may not cohesively integrate their treatment models with a co-treating clinician.

Concussion identification, treatment, management, and having the self awareness to know when and whom to refer appropriately can be a complex team model and clinical algorithm.

Each concussion case is unique and treatment models are 100% situationally dependent.

Kenneth Burke, an American literary theorist, once said that “every way of seeing is a way of not seeing.”

We can’t simply “treat the headache” or “treat the balance issue.” Treating the concussion patient of today involves a complex series of evaluations across all domains in order to systematically identify injury deficits in order to appropriately make the decision of what to treat, when to treat it, and when to refer appropriately.

If you treat together, you must learn together.

Here’s how.

Rapport and Clinician Synchronicity:

“To feel with, stirs us to act for[15].”

Get in-synch with your concussion patients.

These patients often feel very disconnected to the medical community. Patient stories of seeking care from 5+ medical providers until they “find their person” in healthcare is not uncommon.

Rapport is key to successful patient, provider and caregiver interactions. When people are in rapport, their physiology actually attunes. Robert Rosenthal published a landmark article revealing the central tenets of “relationship magic,” the recipe for rapport. This only exists when three elements are present: mutual attention, shared positive feeling, and a well-coordinated nonverbal duet. As these three emerge cohesively, we spark rapport[15].

This is how lifelong patient-provider and provider-provider relationships are formed.

Nature is based upon energy and timing. Basic science has identified symbiosis throughout the natural world ranging from the firing of an action potential to the marvelous making of what happens between winter and spring.

Concussion is an injury of asynchronous firings at a cellular level which accumulate amounting to a functional dysfunction with ones self and environment.

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

We need to learn how to adapt to the needs of our patients who carry a host of pre and post morbid medical conditions and circumstances presenting with the complexities that the heterogenous nature of a concussive injury presents.

The Program:

The Evidence In Motion Concussion Certificate Program is committed to educating the post-professional multidisciplinary clinician of today in concussion identification, treatment, and management by fostering a rehabilitative team approach.

This 12-month program provides the latest clinical conversations, evidence-based guidelines, and consensus statements while integrating real world experiences from patients, providers, and caregivers who have navigated the complex healthcare network of today.

Content delivery is both interactive and dynamic, exposing the student to some of the most influential clinicians in the concussion community coupled with the unique learning experience of provider to provider, patient to provider, and caregiver to provider storytelling.

By fostering a rehabilitative team approach, the EIM Concussion Certification hopes to facilitate collective competence across the healthcare continuum in order to better triage, treat, and appropriately refer the concussion patient of any age from acute to chronic stages.

This year long multidisciplinary concussion certificate sets the learner up for success utilizing an asynchronous and synchronous online learning environment for the busy post professional of today.

The in-person weekend intensive reviews the psychomotor properties of the concussion evaluation, treatment, management, and referral options based off of the providers scope of practice during the 12 month didactic education experience.

As a pre-requisite to the program, each post-professional student will undergo a therapeutic neuroscience education course. As we embark on a multidisciplinary educational journey together, I sincerely believe that we all speak the same language of medicine; however, we bring many different dialects to the clinical table.

Current best-evidence shows that therapeutic neuroscience education improves pain ratings, function, pain catastrophization, physical movement and cost of healthcare utilization.

I will utilize the TNE course to cohesively meld the post-professional multidisciplinary EIM Concussion students in language, compassion, and competency of the therapeutic neuroscience evaluation in order to jumpstart their experience of learning together in a new environment. 

A few months before physician Kenneth Schwartz died, he stated that “Quiet acts of humanity have felt more healing than the high dose of radiation and chemotherapy that hold the hope of a cure. While I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me[15].”

I hope to create kind, compassionate, and clinically efficient clinicians who foster rapport with patients, interdisciplinary colleagues, and across disciplines.

Care for the concussion patient. Care for him/her together. And care for him/her well.

The Faculty:

I’ve been fortunate enough to have returned back to patient care and have surrounded myself with some of the brightest and most dedicated faculty in the world in their respected specialties.

Over the last year, the energy that I’ve felt from this group of men and women has been palpable. I am honored everyday to have worked with and continue to collaborate with each and everyone of these passionate clinicians.

What do they all have in common? I systematically screened all interviewees for passion, high IQ, high EQ, and low ego who have the self awareness to take a step back from themselves and look at the big picture of clinical care.

We have a tall order in front of us and I know we’re here to do our best to help clinicians of today put our best foot forward to educate each other and our communities of coaches, parents, spouses, teachers, caregivers, and loved ones on the multifaceted injury that concussion can present itself as to the provider and patient of today.

Why Story?:

Paul Zak, a neuroeconomist, eloquently stated “Stories are powerful because they transport us into other people’s worlds but, in doing that, they change the way our brains work and potentially change our brain chemistry — and that’s what it means to be a social creature[17].”

Storytelling allows us to step back, view, and listen from an aerial and reflective standpoint while creating the neural groundwork of patient exposure by connecting to the story, the provider, the caregiver, and the patient.

Schwartz Rounds were invented by an ill physician who also experienced the dichotomy of both doctor and patient. His purpose was to facilitate understanding of how the patient perceives their own illness and treatment by deploying empathy and building rapport[15].

If we have no empirical data, then we need to learn from each other. I believe by deeply listening to each other, patients, and caregivers fosters an excellent way to change the way in which we begin to shift the global architecture of medicine with respect to the concussion patient of today.

How can we help and treat a mutual patient if we don’t sincerely understand what each of us can collectively do for one another in the best interest of the patient.

Story allows us to experience the injury through the eyes of experienced providers, patients, and caregivers who have navigated the complex healthcare system of today.

We need to learn from each other.

When we learn together we can treat together.

Welcome to the beginning of the Evidence in Motion Concussion Certificate Program.

“I did then what I knew how to do. Now that I know better, I do better.” ~Maya Angelou

#Concussion.

Bibliography

1. Register-Mihalik, J.K., et al., Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj, 2013. 27(7-8): p. 878-86.

2. Llewellyn, T., et al., Concussion Reporting Rates at the Conclusion of an Intercollegiate Athletic Career. Clin J Sport Med, 2014. 24: p. 76-79.

3. Kroshus, E., et al., Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med, 2015. 25(3): p. 243-7.

4. Kroshus, E., et al., Norms, athletic identity, and concussion symptom under-reporting among male collegiate ice hockey players: a prospective cohort study. Ann Behav Med, 2015. 49(1): p. 95-103.

5. Sosin, D.M., J.E. Sniezek, and D.J. Thurman, Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj, 1996. 10(1): p. 47-54.

6. Menon, D.K., et al., Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil, 2010. 91(11): p. 1637-40.

7. Quarrie, K.L. and I.R. Murphy, Towards an operational definition of sports concussion: identifying a limitation in the 2012 Zurich consensus statement and suggesting solutions. Br J Sports Med, 2014. 48(22): p. 1589-91.

8. Rose, S.C., A.N. Fischer, and G.L. Heyer, How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj, 2015: p. 1-6.

9. JJ, B., et al., Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population. Brain Inj, 1999. 13(3): p. 173-189.

10. Iverson, G., Outcome from mild traumatic brain injury. Curr Opin Psychiatry, 2005. 18(3): p. 301-317.

11. Babcock, L., et al., Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr, 2013. 167(2): p. 156-61.

12. CDC. Traumatic Brain Injury in the United States: Fact Sheet. 2016  January 11, 2016].

13. NIH. Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC). 2015  [cited 2016; Available from: https://report.nih.gov/categorical_spending.aspx.

14. ACA. Cancer Facts & Figures 2015. 2016  [cited 2016 January 11, 2016].

15. Goleman, D., Social Intelligence: The New Science of Human Relationships. Kindle ed. 2006: Random House.

16. Lingard, L., Collective Competence: Adapting Our Concept of Competence to Healthcare Teams. 2014.

17. Zak, P. The Neurochemistry of Empathy, Storytelling, and the Dramatic Arc, Animated. 2012  [cited 2016; Available from: https://www.brainpickings.org/2012/10/03/paul-zak-kirby-ferguson-storytelling/.

Infant Swimming Resource (ISR)

Infant and Toddler Rescue Floating and Swimming:

What the Medical Community Needs to Know about Safety and Prevention

Today Show HD Video and Article:  www.today.com/video/today/55513113

Dr. Kristine McCarren PT, DPT

Editors note: I initially learned about ISR when I saw a piece on NBC’s Today Show. I’m thrilled to have Dr. McCarren educate the medical community about the benefits of infant and child rescue swimming via her guest blog post on PT2Go. Here, she will touch upon pediatric emergency department drowning epidemiology, the American Academy of Pediatrics stance on swim lessons, and differentiate between the Infant Swimming Resource and traditional swim lesson model.

“All children should learn to swim before they learn to walk…”

I hope the above quote challenges your thought process. It certainly did mine. Allow me to introduce Dr. Kristine McCarren, PT DPT. ~JS


 

The American Academy of Pediatrics (AAP) recently changed its position statement on drowning prevention based on the study concluding “participation in formal swimming lessons was associated with an 88% reduction in the risk of drowning in 1 to 4 year old children…”.[1]

Other than congenital anomalies, drowning is the number one cause of accidental death in children 1-4 years old. [2] 

As clinicians who work directly with pediatric patients or treat an adult patient population, we all have contact with parents of young children professionally and familially.

As spring months turn into hot summer days and nights, what is the solution to assist our communities in keeping our children safe from the number one cause of pediatric accidental death?

The answer: Infant Swimming Resource (ISR).

What is Infant Swimming Resource (ISR)?:

Infant Swimming Resource (ISR) is a program that teaches infants as young as 6 months how to save themselves in the event they make it into the water alone.

ISR is recognized internationally as the safest provider of survival swimming lessons for children 6 months to 6 years.

With nearly 50 years of research and development, Dr Harvey Barnett adapted his theoretical knowledge as a behavioral scientist in order to pioneer ISR’s Self-Rescue® method after witnessing the drowning of his neighbors infant son.

How Does ISR Work?:

Infants 6-12 months learn survival floating. Lessons focus on teaching the child to roll onto their back to float, rest, and breathe maintaining this life-saving position until help arrives.

Children 1-6 years old learn to swim until they need air, roll back to float, and then resume swimming until they reach the side of the pool.

As of April 2015, there have been more than 800 documented cases where former ISR students have used their Self-Rescue® skills to independently save their own lives.

Since 1966, ISR has taught more than 260,000 children internationally.

Is an ISR Instructor More Specialized Than a “Typical Lifeguard”?:

ISR Instructors are infant aquatic specialists who have been trained to teach water survival skills to infants and children 6 months to 6 years.

Instructors undergo an intensive 8-week program.

There is a minimum of 60 hours in-water training and 40 hours academic preparation and testing.  

Similar to many medical models, continuing education is required coupled with yearly re-certification to ensure maintenance of teaching skills.

Many ISR instructors come from medical backgrounds (physical therapy, occupational therapy, nursing, et al) and use evidence based knowledge regarding sensorimotor learning to teach these Self-Rescue® skills.

The ISR instructor monitors the child’s temperature through vasoconstriction checks throughout the lesson, and if the child is too cold, the lesson is over.

ISR instructors check for temperature fatigue and abdominal distention throughout lessons.  

Temperature fatigue precedes muscle fatigue, which leads to inefficient learning. Abdominal distention makes it hard to breathe, and if left untreated, can be dangerous.

ISR instructors rely on sensorimotor principles and positive reinforcement to teach each infant and child during their personalized lesson.

Based off of these sole principles alone, this is why the allied healthcare professional is the perfect fit to undergo this highly specialized training.

Tactile guidance and prompt reinforcement is the primary means of instruction.

ISR teaches infants as young as 6 months old; therefore, verbal instruction cannot be relied on to teach survival swimming skills which primarily involve instinct, cognitive and motor planning tasks.

The ‘Anatomy’ of an ISR Lesson:

ISR lessons are always one-on-one with the same instructor.

A child learning ISR receives 100% of the instructor’s attention 100% of the time.

Each child attends lessons for 5 days per week for 10 minutes each session.

The 10 minute lesson structure has been scientifically proven to optimize learning and increase retention for this pediatric age population.

A child learns survival skills by actively engaging in his/her environment. Instructors use the ambient air as a teaching tool coupled with the instructor’s touch. This facilitates creating an independent infant and/or child if they are ever faced with a dangerous water scenario.

How are Lessons Different than a Traditional Lifeguard Lesson?:

ISR pools are maintained at 78 to 88 degrees Fahrenheit.

Prolonged exposure to environments that are lower than a child’s body temperature are inefficient for motor learning.  ISR lessons are limited to a maximum of 10 minutes to prevent temperature fatigue and optimize efficiency. Children are monitored for temperature fatigue frequently throughout each lesson via vasoconstriction checks.  

Up to 86% of children who drown are fully clothed at the time of drowning [3]. ISR makes sure to build in real world scenarios with respect to having the infant and toddler fully clothed in the water upon graduation. 

ISR 16 Month Old Infant Survival Floating in Full Winter Gear

ISR Infant Survival Floating in Full Winter Gear

Training begins in summer clothes, sandals and sneakers. After this initial level of mastery, winter clothes including a coat, boots, hat, and gloves are added into the lesson. Swimming and floating in clothes is a completely different experience than in a bathing suit. The extra weight of the clothes and fully saturated diaper make moving in the water more difficult.

ISR lessons ensure that a child is competent and confident swimming and floating fully clothed.  

ISR Infant Sweater and Hat

ISR 6 Month Old Infant Survival Floating in Full Winter Outfit with Dr. McCarren

 

Infant Swim Resource

Traditional Swim Lesson

Registration

Family medical history, developmental milestones , current health conditions, developmental issues and medications. Specific conditions are reviewed by MDs and nurses, and instructors are notified of any specific safety measures to be applied during lessons

Child’s name and age is recorded and a parent signs a waiver to acknowledge risk of lessons.  

Specific health information is usually not recorded or taken into account

Documentation

Daily bowel, urine, diet and sleep patterns are documented in order to assess changes that may compromise the safety of lessons.  

If warranted, lessons will be shortened or cancelled

Do not assess the infant/child’s daily habits, and health concerns that may affect or compromise lesson safety

Lesson Duration& Frequency

10 Minutes

5 Days/Week

6 Weeks

30-45 Minutes

1 Day/Week

Instructor Training

CPR/First Aid Certified

Trained in:

Behavioral Psychology,

Sensorimotor Learning,

Shaping Behaviors,

Physiological conditions as they relate to exercise in the water, Emotional learning,

80+ hours of practical experience & studying/analyzing video.

Yearly recertification & continuing education required

Often medical professionals such as PT’s, OT’s, RN’s

CPR Certification not required

No formal training required

 

Critical Numbers:

For every pediatric fatal drowning, there are an additional 5 pediatric patients who visit the emergency department (ED) for nonfatal submersion injuries.

Within 2 minutes of submersion, a child loses consciousness. When a child is submerged underwater for 4-6 minutes, they can be left with irreversible brain damage.  

More than 50% of drowning victims treated in ED’s require long term hospitalization or transfer for further care. This potential irreversible brain damage may result in long term deficits, such as memory problems, learning disabilities, and permanent loss of basic functioning.[2]

Healthcare Community Challenge:

As an ISR instructor, it’s imperative to educate the community that water isn’t recreational until a child can survival float and swim. Accidents happen when children explore their environment by crawling, cruising or walking. Ensuring that infants and toddlers can survival float and swim before they walk is critical to prevent drowning.

If you are interested in holding a pediatric Grand Round for more in depth information, Harvey Barnett PhD provides in depth information to the healthcare community on the behavioral approach to pediatric drowning prevention.

I challenge you to educate five other healthcare professionals, friends, or family after reading this article. Not only will you be educating the medical community, you could directly be a part of saving a child’s life.

Kristine McCarren, PT DPT

Email: k.mccarren@infantswim.com

Facebook: ISR Seal Team Survival Swimming, Inc.

New York Contact: www.ISRNewYork.com

International Inquiries: www.infantswim.com

Twitter: @InfantSwimKris

Bibliography:

1. Brenner, R.A . et al., Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med, 2009. 163(3): p. 203-10. 

2. CDC: Centers for Disease Control and Prevention. [Accessed April 18, 2014]; Available from: www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html

3. ISR: Infant Swimming Resource. [Accessed April 19, 2015]; Available from: www.infantswim.com/blog/2012/01/86-of-children-who-drown-are-fully-clothed.html

 


Kristine McCarren ISRKristine McCarren is a Doctor of Physical Therapy (DPT) and Certified Infant Swimming Resource (ISR) Instructor residing in Mt. Sinai, NY.

Dr. McCarren received her B.S. in Exercise Science from Ithaca College and went onto receive her Doctoral degree in Physical Therapy at the University of Stony Brook. She underwent her Infant Swim Resource certification in Casselberry, Florida where she became a Certified ISR Instructor.

Dr. McCarren is experienced in the pediatric setting and dually practices physical therapy in the outpatient orthopedic and homecare settings. She is most passionate about preventing childhood drowning through parent education and instruction of ISR techniques. Her dream is to ultimately open an aquatic facility to teach infants and children ISR Self-Rescue® skills and practice aquatic physical therapy with the pediatric population. 

 

post

Nutrition 101 Series

Nutrition 101 Series for Healthcare Providers:

Keeping Healthy Eating Simple for You and Your Patients Part I

PT2Go Nutrition 101 Series

Written By Ms. Jenna Larsen, M.S.

Edited By Dr. Jessica B. Schwartz PT, DPT, CSCS

“Eat food, not too much, mostly plants.” – Michael Pollan

In the United States, a society that can be overly satiated with consumer information, we’ve made healthy eating complicated.

As a nutrition education professional working in the public health sector in New York City, I’ve learned that the most effective methods for delivering nutrition education to the community is to shift language away from weight loss and highlight the benefits of healthy eating.

Goals need to be clearly delineated with the limited amount of time providers have with patients. When speaking with patients, gently introducing nutritional concepts in a digestible format can make healthy eating fun and accessible.

I challenge you to move away from directly discussing weight loss and facilitate open ended conversation.

This shouldn’t take more than 3 minutes of an office visit. Keeping time constraints in mind, you should be able to quickly assess if your patient is eating primarily a whole food, fast food, or processed food diet.

This is a great segway to engage mutual conversation and ask your patient what their barriers are to healthy eating? (time, cost, lack of cooking skills, education) and gently facilitate the thought process of how eating healthy can benefit their life.

I’ve found that high yield language delivery can be as simple as educating communities with the following points*.

1. Choose more whole foods. A whole food has NOTHING added and NOTHING taken away from how it was found in nature.

2. To determine if a food is more whole, focus on the ingredients list instead of specific nutrients on a label. Choose foods that have the fewest ingredients. This removes confusion associated with marketing and labeling language found in supermarkets. Better yet- choose foods without a label (i.e. fruits and vegetables).

3. View food choices on a spectrum – the most whole foods on one end and the most processed on the other- rather than focusing on whether a food is ‘good’ or ‘bad’. Starting with short-term achievable goals, will be easier and more realistic for patients to turn healthy eating into a habit.

4. Taste buds will change and you’ll learn to like fruits and vegetables. Help patients understand that they will truly enjoy the experience of eating healthy, although perhaps not right away. They will feel more energized as they incorporate more whole foods into their diet.

Have patients set one goal for themselves to address at the follow up**. This will range depending on the patient, but it should be something they view as feasible. Encourage them to keep a journal.

Journal ideas include:

1. Try three new fruits or vegetables you don’t normally eat.

2. Drink fewer sugary drinks and more water. Carrying a water bottle will help.

3. Replace at least one snack with a fruit or vegetable each day.

4. Cook at home at least twice per week. Encourage friends and family- including children- to cook with you.

5. Make a salad for lunch at least one day per week.

It is important provide easily accessible and reliable resources to help patients address barriers.

If you work with low-income families, encourage them to check eligibility for SNAP (Supplemental Nutrition Assistance Program), or food stamps, and provide them an avenue for signing up.

Just Say Yes to Fruits and Vegetables (JSY) ***, a USDA-funded program, features valuable money-saving tips that can provide excellent talking points in a discussion where cost barriers are almost certain to surface. Over 200 fruits and vegetable recipes are the highlight of the website and are featured in both English and Spanish. All recipes are simple with few ingredients, low-cost, and easy to prepare. They also offer valuable storage and preparation tips. Print some to offer as a resource. Make a few recipes yourself to provide a personal recommendation.

If you are be excited about healthy eating, your patients will be too!

Until next time,

Jenna

*Please note that these messages may require tweaking for certain patient populations, such as those with involved medical problems.
** Follow-up at subsequent appointments throughout your provider-patient relationship is key. This will let your patients know you are connected to them
***Just Say Yes to Fruits and Vegetables (JSY) is one of New York State’s premiere nutrition education services available to low income families. JSY is a nutrition education initiative designed to prevent overweight/obesity and reduce long term chronic disease risks through the promotion of increased fruit and vegetable consumption.

 

 

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Physician LBP Paradigm Shift and the DPT

Low Back Pain: Physician Paradigm Shifts and the Doctor of Physical Therapy 

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Dr. Jessica B. Schwartz PT, DPT, CSCS

What do the common cold and low back pain (LBP) have in common? They are the top 2 symptomatic reasons for primary care visits in the United States (US) [1, 2]. 

In 1998, total US health care costs for LBP were approximately $90 billion [3, 4]. Musculoskeletal (MSK) conditions account for roughly 25% of patient complaints in the primary care setting [5, 6].

In the emergency department (ED), MSK dysfunction accounts for 20% of all chief complaints with 2.7 million visits specifically devoted to LBP [7]. In fact, MSK conditions rank second only to respiratory illness with respect to prevalence of most common presentations in the ED[8].

The intent of this article is to identify global systematic weaknesses in medical education while discussing implementation of best practices as it pertains to low back pain intervention.

My hopes are that by exposing the physician to potential clinical decision and behavioral paradigm shifts that can be immediately implemented, we can reduce cost, increase efficiency, and make our patients feel better quicker.

One thing is for sure: I bet you didn’t learn this in Medical School…

II. Physician Confidence and Competence of MSK Conditions:

It has been recently cited that newly graduated medical students and residents lack the clinical knowledge and confidence necessary to care for patients with MSK injuries. Deficiencies have been shown at all levels of training from medical student to attending [8-11].

Approximately 50% of family practice physicians feel inadequately trained in MSK medicine [8, 12]. There have been similar numbers reported amongst the emergency physician with marked deficiencies in musculoskeletal education ranging from trainees to attending staff[8].

As exposure to MSK conditions increase and physician confidence remains low, we need to address this dilemma head on.

Identification and efforts to improve quality of MSK exposure and future physician education is presently being reviewed and developed[11].

What happens to present day practice in the mean time?

Allow me to take you down a paradigm shift in thinking for the present day physician as it pertains to patient access and prescriptive intervention.

III. Knowledge Translation Gaps:

Clinical Prediction Guidelines (CPGs) have proven to be an excellent tool to meld clinically relevant interdisciplinary conversation via individually competent clinicians.

CPG’s have been copiously produced in an effort to guide a broad range of clinicians along a mutually agreed upon diagnostic pathway. In conjunction with the Choosing Wisely campaign, CPGs combined with 2 of the 3 central tenets of Evidence Based Medicine, doctors should be prescribing fiscally responsible and safe interventions for our patients.

Unfortunately, this isn’t always the case.

There continues to be overuse of imaging in the emergency and primary care setting despite evidence based recommendations from the American College of Physicians, American Pain Society[4, 13], and the Choosing Wisely Campaign[14].

These organizations call for lumbar spine imaging only for patients who have severe or progressive neurologic deficits or signs and symptoms that suggest a serious or specific underlying condition[13].

Another example of physician knowledge translation failure occurs with the Ottawa Foot and Ankle Rules (OFARs). In a 2014 study of emergency physician application of the OFARs, there was no statistical evidence that application of the OFARs decreases the number of imaging orders.  In fact 58 of the 60 patients that qualified under the OFARs were imaged [15]. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Unlike the foot and ankle complex, pathoanatomic diagnoses in the lumbar spine is often more detrimental to clinically relevant patient care than not.

Excessive spinal imaging can lead to downstream pathways that can lead to instilling fear of the unknown or “too-much known” into the patient, unnecessary invasive interventions, time lost from work, familial, and social life, and the fiscal burden that all of the above places on government, third-party and private payers.

Evidence of false rates of herniated discs are shown on computerized tomography (CT) scans[16], MRI[17], and myelography[18] in 20% to 76% of persons sans radicular pain[19].

Savage et al[20] reported that 32% of their asymptomatic subjects had “abnormal” lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression) and only 47% of their subjects who were experiencing low back pain had an abnormality identified[19, 20].

Pathoanatomic abnormalities are so common in the asymptomatic individual it should be viewed as a normal sign of aging with present day knowledge of MSK advanced imaging.

As it pertains to the geriatric population, a cross- sectional study revealed[17] 36% of asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc [4, 17].

With 22% of the population about to cross over into the geriatric cohort, are we going to continue to expose our patients to undue radiation, opioids and costly-clinically irrelevant tests?

IV: Knowledge Translation Gaps due to…?

Minimal exposure to musculoskeletal education in medical school has previously been highlighted as a significant issue in both North America and the United Kingdom[8, 21-27].

Over the years, my physician friends and colleagues, international and domestic, have congruently agreed upon one common theme amongst their MD/DO medical education: a paucity of MSK learning opportunities during their formative years in medical school and residency training[11].

I’m fortunate to surround myself with people who are as equally as enthusiastic and curious with respect to medical learning.

My small conversational sample size over the years finally took me to the literature.

V. The Literature:

As the geriatric population continues to grow exponentially, there is an $848 billion annual fiscal estimate for treatment, diagnosis, and lost wage amounting to ~7.7% of the gross domestic product for MSK chief complaints [11, 28].

In 2030, the pediatric and geriatric population will account for 21% and 22% of our population due to the baby boomer surge[29].

Think about this for a moment. There will be more people 65 years and older than 17 years old and under.

As the geriatric population continues to stay active and educated, MSK conditions of all age cohorts are going to skyrocket. More severe forms of LBP increase with age with overall prevalence increasing until ages 60-65[19, 30, 31].

In a 2010 national study on LBP and diagnostic testing in the ED, imaging was performed in nearly 50% of all LBP patients and opioids were administered to nearly 2/3’s of the sample[7].

Emergency Medicine physician Judith Tintenalli, stated that we need increased “efforts to change consumer behaviors” with respect to patient access and referral to the ED. It has been cited that up to 43% of direct access ED visits are deemed unnecessary. When referred by a PCP, up to 44% of those referrals were also deemed inappropriate. [32] 

A modification of the Tintenalli statement would be we need increased efforts to change consumer and clinician behaviors. Clearly patients and providers are both lacking awareness of who should be utilizing ED skilled clinical services for MSK conditions.

With rates of chronicity related to an episode of LBP increasing [2], there needs to be a significant shift in intervention and clinical decision making for patients of all ages.

Change in behavior, intervention, and clinical decision making?

What else is there besides the physician ordered image, oral medication, invasive procedure and surgery?

Snarky @DPT2Go Wonka

VI. The role of the Non-Physician Doctor in Modern Day MSK Management:

Experienced doctors of physical therapy have higher levels of knowledge in managing musculoskeletal conditions than all physician specialists except for orthopedists [6]. This includes medical students, physician interns, residents, and attending physicians.

Open Access: www.biomedcentral.com/1471-2474/6/32

Childs J, et al A description of physical therapists’ knowledge in managing musculoskeletal conditions. Open Access: www.biomedcentral.com/1471-2474/6/32

I know that piece of information was not imparted on you in medical school.

Allow me to provide some high-yield clinical pearls that will hopefully expand your breadth and depth of knowledge as it pertains to low back pain and your patients.

Who is the present day Doctor of Physical Therapy (DPT)?

Simply stated, DPTs are body mechanics. Our sole purpose is to make people move and interact with their environment in the most energy efficient, symptom free, safe, and functional way.

DPTs are skilled doctoral degree level clinicians with core knowledge of all systems to allow us to appropriately screen and differentially diagnose all patients that we come in contact with for evaluation and treatment. Similar to the traditional medical model, we have intensive board specialities in cardiology, orthopedics, sport, geriatrics, pediatrics, neurology and hand. Residency and fellowship are also becoming more prevalent with ~2,500 DPT’s trained in residency or fellowship from 1999-2013[33].

Accessed: www.abptrfe.org/Home.aspx

Accessed: www.abptrfe.org/Home.aspx

As of January 2015, all 50 states will have direct access to DPT’s. This means that a prescription is no longer required to access our care for the MSK patient.

Image: http://webreprints.djreprints.com/1715540469703.html

Image: http://webreprints.djreprints.com/1715540469703.html

Direct access privileges have been present in the US Army for over 40 years. In fact, Army DPT’s are able to order imaging and administer medication as necessary.

A retrospective analysis of 472, 013 patient visits at 25 military healthcare sites, 45.1% of the visits were determined to be patients with direct access and without physician referral. No adverse events were determined from either physical therapy diagnosis or management [34].

What does direct access mean for the civilian population?

Simply stated: autonomy.

This means that patients can have instant access to a DPT as soon as they have MSK pain or dysfunction. We’ve accepted the role of greater diagnostic responsibility by achieving the clinical rigors of a doctoral education; this autonomy doesn’t mean we stop communicating with the medical community. DPT’s have worked hard to achieve autonomous practice. Working and communicating with the physician, physician assistant (PA-C), and Nurse Practitioner (NP) are still priority as our profession tends to lead the way in collective competence as we learn to adapt to today’s healthcare systems.

What’s new on the low back pain rehabilitation front?

Accessing LBP patients early is critical to improved outcomes and decreased economic, social, psychological and familial burdens. Early physical therapy (within 14 days of primary care) was associated with decreased use of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid medications, as compared to delayed physical therapy [2, 35].

LBP is not a homogenous entity.

Pathoanatomic diagnoses are no longer the gold standard for diagnosis and treatment of patients with acute, subacute or chronic LBP. Factually, this is why many LBP studies failed to achieve anything substantial, measurable and remarkable over the last two decades (see false positive and true negative rates above).

Presently, there has been some excellent work done by Fritz[36-38], Childs[6, 39], and Delitto[19] working on sub-grouping LBP patients. If you choose to do any interdisciplinary reading these are the articles you should be reading to expand your knowledge base.

The development of classification systems has been identified as a priority among researchers in the primary care management of patients with low back pain[19, 40].

An entirely separate article can be devoted to sub-groups and treatment based classification systems; however, for immediate knowledge translation integration, I’ve identified four of the subgroups for you below.

Treatment based classification systems use an in depth history, mechanism of injury, and physical examination. They include 1. mobilization, 2. specific exercise, 3. immobilization, and 4. traction subgroups [19].

We know that LBP is not a homogenous entity, therefore, we need to identify, triage, and treat these patients differently depending on where they are along the spectrum of their dysfunction and pain episode.

Every subspecialty in healthcare is going to come in contact with a LBP patient due to the incidence, prevalence, and potential debilitating nature of the injury.

Now is the time to think differently. Now is the time to stop putting the square peg in the round hole.

In a landmark study by Daker-White et al in 1999[41],  a randomized controlled trial was done comparing care of patients solely seen by the physician v. the PT.  Entitled, Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments, 244 patients were seen by a post-fellowship physician and 237 patients were seen by a physical therapist.

The results?

Patient centered outcomes in this RCT favored the PT.

Orthopedic physical therapy specialists are as effective as post-fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs. [41]

Lower costs, increased clinically relevant outcomes, and competent clinicians expediting patient care?

Image-1 (3)

Ladies and gentleman, welcome to the future of healthcare.

VII. Possible solutions:

There is a scarcity of dually trained specialty board certified, residency, and/or fellowship trained doctors of physical therapy in the US; however, we do exist and there are more and more physical therapists pursuing doctoral level degrees, speciality certification, and advanced training every year.

There needs to be a healthy interaction, rapport building and conversation amongst the physician and DPT in the #MedEd community. We need your presence for prescriptive intervention for the biochemistry needs and red flags that can occur with this patient population just as much as there is a need for a paradigm shift in prescriptive, existing clinical decision making, and intervention as it pertains to the LBP patient.

Doctors of Physical Therapy have slowly been introduced to the emergency medicine team and thus far with great success[42]. As this trend continues to grow, a more immediate solution needs to occur.

All 50 states in the US will have direct access to physical therapy services in January of 2015. Now is the time to refer that patient directly to the orthopedic physical therapy office (with or without prescription) so we can decrease unnecessary ED visits leading to opioid prescriptions, imaging, and other prescriptive screening tools leading to costly downstream clinically irrelevant interventions.

Use us. No, really. Use us.

Let us safely screen and differential this cohort of patients. Most of the time they need reassurance that they will be ok and we can provide them with the screening tools to differentially diagnose and refer out to the proper physician as needed.

Most important to the patient, we can make them feel better-if not physically, psychologically usually within the first visit in order to decrease fear-avoidance behaviors[37].

Providing patient education on positioning for comfort, relief and functional positioning for their activities of daily living while utilizing our manual therapy skills to massage, mobilize, manipulate, therapeutically exercise, or stretch this population of patient is key to successful clinically relevant outcomes.

Remember, the LBP patient is not a homogenous entity and neither is their interventional prescription. Let us identify their sub-group based off of treatment based classifications and safely intervene right away (ideally within the first two weeks).

I hope this review provided some new and thought provoking ideas that will hopefully plant the seed for you to share this blog with a fellow colleague, look further in to the literature, and expand the breadth and depth of your MSK knowledge base.

My name is Dr. Jessica Schwartz. I am a residency trained Doctor of Physical Therapy. How can I assist you and your patient’s needs today?

Quick Points:

1. Physician, PA-C, and NP colleagues #ThinkDifferent and take a pause in your clinical decision thought processes when encountering your next low back pain patient. Do you know a PT that you trust and can directly refer to? Now you have excellent conversational tools to engage in a conversation in an interdisciplinary way to best suit the patients needs.

2. PT’s in the United States will have direct access in all 50 states starting January 2015. This means a patient does not need a prescription to access our services. This can be for an acute, subacute, and chronic condition. Allow us to differentially screen and refer out as needed. See the American Physical Therapy Association (APTA) Overview

3. Use this article to expand the breadth and depth of your MSK knowledge base when speaking with fellow colleagues. Think beyond the opioid, radiographic image, and the “wait and see approach”. Take action within the first 14 days of an acute episode and be participative in your patients intervention

4. To my international colleagues, please use this article to engage in conversation. I’ve already learned so much from interdisciplinary conversation after publishing this article. Question medicine…always. Engagement is how we learn and continue to grow. Cheers to you!

Keep Calm @DPT2Go

Bibliography

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2. Childs, J.D., T.W. Flynn, and R.S. Wainner, Low back pain: do the right thing and do it now. J Orthop Sports Phys Ther, 2012. 42(4): p. 296-9.

3. Luo, X., et al., Estimates and Patterns of Direct Health Care Expenditures Among Individuals With Back Pain in the United States. Spine, 2004. 29(1): p. 79-86.

4. Chou, R., et al., Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med, 2011. 154: p. 181-189.

5. Pinney, S.J. and W.D. Regan, Educating Medical Students About Musculoskeletal Problems. JBJS, 2001. 83-A(9): p. 1317-1320.

6. Childs, J.D., et al., A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord, 2005. 6: p. 32.

7. Friedman, B.W., et al., Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976), 2010. 35(24): p. E1406-11.

8. Comer, G.C., E. Liang, and J.A. Bishop, Lack of Proficiency in Musculoskeletal Medicine Among Emergency Medicine Physicians. J Orthop Trauma, 2014. 28: p. e85-e87.

9. Freedman, K.B. and J. Bernstein, The Adequecy of Medical School Education in Musculoskeletal Medicine. JBJS, 1998. 80-A(10): p. 1421-1427.

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11. Truntzer, J., et al., Musculoskeletal education: an assessment of the clinical confidence of medical students. Perspect Med Educ, 2014. 3(3): p. 238-44.

12. Sneiderman, C., Orthopedic practice and training of family physicians: a survey of 302 North Carolina practitioners. J Fam Pract, 1977. 4: p. 267–350.

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16. Wiesel, S.W., et al., A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine, 1984. 9: p. 549-551.

17. Boden, S.D., et al., Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. JBJS, 1990. 72(3): p. 403-408.

18. Baliki, M.N., et al., Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci, 2006. 26(47): p. 12165-73.

19. Delitto, A., et al., Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2012. 42(4): p. A1-A57.

20. Savage, R.A., G.H. Whitehouse, and N. Roberts, The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J, 1997. 6(106-114).

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22. Lynch, J.R., et al., Important demographic var- iables impact the musculoskeletal knowledge and confidence of academic primary care physicians. J Bone Joint Surg Am, 2006. 88(7): p. 1589-1595.

23. Day, C.S., et al., Musculoskeletal medicine: an assess- ment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med, 2007. 82: p. 452-457.

24. Queally, J.M., et al., Deficiencies in the education of musculoskeletal medicine in Ireland. Ir J Med Sci, 2008. 177(2): p. 99-105.

25. Al-Nammari, S.S., B.K. James, and M. Ramachandran, The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom. JBJS, 2009. 91-B(11): p. 1413-1418.

26. Menon, J. and D.K. Patro, Undergraduate orthopedic education: Is it adequate? Indian J Orthop, 2009. 43(1): p. 82-86.

27. Bernstein, J., G.H. Garcia, and J.L. Guevara, Progress Report: the prevalence of required medical school instruction in musculoskeletal medicine at decade’s end. Clin Orthop Relat Res, 2011. 469: p. 895-897.

28. Facts in Brief.  [cited 2014 December 21, 2014]; Available from: http://www.boneandjointburden.org/highlights/FactsinBrief.pdf.

29. Hooyman, N.R. and H. Asuman Kiyak, Social Gerontology: A Multidisciplinary Perspective. Seventh ed. 2005, United States of America: Pearson.

30. Lawrence, R.C., et al., Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum, 1998. 41: p. 778-799.

31. Loney, P.L. and P.W. Stratford, The prevalence of low back pain in adults: a methodological review of the literature. Phys Ther, 1999. 79(4): p. 384-396.

32. Tintinalli, J.E., Emergency Medicine. JAMA, 1996. 275(23): p. 1804-5.

33. ABPTRFE: American Board of Physical Therapy Residency and Fellowship Education.  December 21, 2014]; Available from: http://www.abptrfe.org/home.aspx.

34. Deyle, G.D., Direct access physical therapy and diagnostic responsibility: the risk-to-benefit ratio. J Orthop Sports Phys Ther, 2006. 36(9): p. 632-4.

35. Fritz, J.M., et al., Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976), 2012. 37(25): p. 2114-21.

36. Fritz, J.M. and R.S. Wainner, Examining Diagnostic Tests: An Evidence-Based Perspective. Phys Ther, 2001. 81(9): p. 1546-1564.

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38. Fritz, J.M., J.A. Cleland, and J.D. Childs, Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther, 2007. 37(6): p. 290-302.

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40. Borkan, J.M., et al., A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities. Spine, 1998. 23(18): p. 1992-1996.

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Youth Sports Safety Summit

My Experience at the Inaugural MomsTeam Institute Youth Sports Safety Summit at Harvard Medical School September 15, 2014

By Jessica B. Schwartz PT, DPT, CSCS

Youth Sports Safety Summit

Brooke de Lench & Jessica B. Schwartz at The Youth Sports Safety Summit at Harvard Medical School

New York, NY September 19, 2014- As an orthopedic residency trained doctor of physical therapy who is passionate about my career in medicine, injury prevention and knowledge translation in academic medicine, it was a humbling experience to be surrounded by such an enthusiastic, knowledgeable and emotionally intelligent group of people advocating for one common goal: Youth Sports Safety.

Brooke de Lench, the Executive Director of the MomsTeam Institute, and her team launched the inaugural Youth Sports Safety Summit in the Joseph B. Martin Conference Center at Harvard University’s Medical School. The conference perfectly coincided with Ms. De Lench’s directorial debut of The Smartest Team: Making High School Football Safer airing on PBS, Amazon Prime and Vimeo this Fall. The Smart Team program is modeled on the community-centric approach to improving youth sports safety expanding on the Six Pillar approach to all sports injury and concussion risk management.

During the pilot-phase (Fall 2014) MomsTEAM Institute has selected leading researcher coordinators who are working with the following universities to bring the SmartTeams program into their communities: AT Still  (AZ), University of Tennessee, University of Texas, Michigan State, University of South Carolina and the University of Tulsa.

In collaboration with and input from all relevant youth sports stakeholders, the Institute has been designing and developing a set of comprehensive health and safety best practices, and will be awarding “Smart Team” status to Youth Sports Organizations (YSOs) which have demonstrated a commitment to minimizing the risk of physical and psychological injury and sexual abuse to young athletes by implementing the best available knowledge and data to provide current best practices.

SmartTeams pilot program is for the Pre-HS athletes (ages 7-14). The Pilot programs will be for select football teams and the national rollout will be with all sports teams (soccer, ice hockey, baseball, lacrosse, etc) in 2015.

During my decade of formal education and subsequent years practicing, I’ve learned that the world of medicine can have similar governmental “bipartisan issues” of not reaching across the aisle to help out a fellow clinician. 

The “great ones” across all aspects of medicine seem to have common attributes- professionally and personally. A clinicians ability to listen and be appropriately empathetic while having passion for their field of medicine is rare. Couple this with the desire to learn from others from multiple disciplines and this empirically leads to success for patient outcomes, professional growth, and knowledge translation. 

I was both humbled and impressed by Ms. De Lench’s passion and abilities to put together such a comprehensive summit from all walks of life ranging from Harvard physicians, collegiate athletic trainers, an internationally recognized physical therapist, lawyers, neuropsychologists, nutritional experts, motivational speakers, and professional athletes all coming together with the common goal of addressing the youth athlete from an all encompassing holistic approach of mind, body, psychological, emotional and sexual well-being. 

I am so very fortunate that I am able to surround myself with inspirational individuals across all aspects of medicine who are innovators in their fields via connections I have made across social media, residency, academia, and alongside my colleagues and associates I am lucky to work with everyday. 

It is apparent that Ms. De Lench has similar attributes and has also surrounded herself with a strong group of individuals from all over the country. The central tenet from the inaugural MomsTeam Youth Sports Safety Summit was that it takes a village…or in this case a team of individuals from all walks of life to come together to advocate to the masses from a grassroots level.

If we practice solely in these silos that we set up for ourselves professionally across medicine, law, athletic training, coaching, government policy, and education then we will never be able to reach whole communities in such a positive way in which change needs to occur culturally, fiscally, and individually for the safety of our athletes. 

I commend the incredibly comprehensive and still growing team of MomsTeam Institute for advocating and making change for the safety of athletes all across the United States. 

Cheers to the continued growth, advocacy and gusto of all the participants who made the inaugural Youth Sports Safety Summit such a positive and educational experience. 


Connect with the Youth Sports Safety Summit Speakers and Participants via Twitter:

@MomsTeam     @Dr_Capt_Ron     @SportingJim    @NeeruJayanthi     @DPT2Go

@BrookedeLench     @JoeEhrmann76     @HollySilversPT     @RosalindWiseman


Summative Themes and Highlights in 100 Words or less:

Lyle J. Micheli, MD: Youth Sports Safety: Two Steps Forward, One Step Back

• Discussed the history and evolution of Sports Medicine
• Discussed first epidemiological studies of sports injuries historically touching upon the Princeton v. Rutgers game of 1869 and Harvard v Yale in 1874
• Gracefully walked us along the historic perspectives of sport and injury prevention through the Greek, Renaissance and Modern times
• We have athletically gifted athletes who are not fit and at a high risk for injury

Director of the Division of Sports Medicine at Boston Children’s Hospital; Clinical Professor of Orthopaedic Surgery at Harvard Medical School; O’Donnell Family Professor of Orthopaedic Sports Medicine at Boston Children’s Hospital; Secretary General for the International Federation of Sports Medicine (FIMS)

Jim MacDonald. MD, M.P.H., FAAFP, FACSM: Injury Prevention Strategies For The Pediatric Athlete

• We need to think like Sweden (the safest place to drive on earth). Zero needs to be our north star (regarding injury prevention across a lifetime)
• 98% of kids will not be elite pro athletes. We can’t have our young kids doing sport specialization in their prepubescent years
• ‘If you build it they will NOT come’ is the central tenet in public health: education is not enough
• We need more comprehensive public health initiatives. If we bring together 3 public health strategies (see below), we will see injury prevention in our lifetime

    • a.  Look at the problem and change the individual
    • b. Use education and equipment to protect the individual
    • c. Change the environment both physically and culturally

Clinical Assistant Professor of Pediatrics and Family Medicine, The Ohio State University, Nationwide Children’s Hospital, Division of Sports Medicine, Web Editor, Clinical Journal of Sports Medicine

Brian Hainline, MD, CMO of the NCAA: Finding Solutions for the Youth Sports Injury Epidemic

• Sport specialization in early puberty develops the player, not the athlete. 
• Our kids are arriving broken even before the arrive through our doors at the NCAA level
• Mental health issues are the #1 concern amongst our NCAA athletes

Rosemarie Moser, Ph.D., ABN, ABPP-RP: Cognitive Rest: Is It Really Best?

• Explains the important role of Neuropsychology in the Post-Concussive Athlete
• Addresses the “workaholic” culture and challenges the audience and parents “Do we really know how to rest?” and “are we modeling this for our youth?”
• Rest=best for concussion and delineates four key components of how to progress the student-adolescent athlete in a structured and overseen environment

Director, Sports Concussion Center of New Jersey, author of “Ahead of the Game: The Parents’ Guide To Youth Sports Concussion.” 

Tracey Covassin, PhD, ATC: Gender Influences on Sport-Related Concussion Risks and Outcomes

• Females in sex comparable sports have higher rates of concussion than their male counterparts (basketball, ice hockey, lacrosse, and softball)
• Concussed females are cognitively impaired 1.7x more than male athletes
• You’ve evaluated an athlete on the field, now what? We must do due diligence and re-evaluate 24 and 48 hours post-injury

Associate Professor, Undergraduate Athletic Training Program Director, Michigan State University

Douglas J. Casa, PhD, ATC, FACSM, FNATA: Preventing Sudden Death in Youth Sports: The Challenges To Enacting Pro-Active Policies

• We need one singular goal: the development and implementation of policy in youth sports. Apropos policy changes can save lives
• 90% of all deaths in sport are from four causes (cardiac events, TBI, and heat illness)
• SMAC’s (sports medicine advisory committees) need to be comprised of sports medicine professionals like ATCs and MDs- not just policy makers who sit in a boardroom

Professor, Department of Kinesiology, Director, Athletic Training Education, Chief Operating Officer, Korey Stringer Institute, Research Associate, Human Performance Laboratory at the University of Connecticut

Allison Maurer, MS, RD, CSSD, CSCS: “What Do You Mean, You Didn’t Eat?”: The ABC’s of A High Performance Diet

• Nutrition is the missing link for our student athletes
• Our children are grossly overfed and severely undernourished
• Food=FUEL. 
• We need to discuss fueling our athletes at 3 different levels: the athlete, the coach, and the parents

Sports Dietitian, University of Tennessee

Toben Nelson, ScD: Orange Slices and Hot Dogs: How the food environment in youth sports undermines its health benefits and what to do about it

• There is no difference in weight in our children who play a sport and who don’t. Our children are in an energy surplus
• Adults need to shape healthy food environments for our kids
• Provide youth sport volunteers with education to inspire real change

Associate Professor, School of Public Health, Division of Epidemiology & Community Health, University of Minnesota

Holly Silvers, MPT, PhD(Candidate): Injury Prevention in Youth Sports: Can We Increase Coaching Compliance and Design Cost-Effective Prevention Programs?

• Commented on the tremendous socioeconomic benefits for communities who implement ACL prevention programs
• $100/athlete savings w/respect to ACL prevention & screening programs see www.ncbi.nlm.nih.gov/pubmed/?term=24806006 for article 
• Updated the audience on the differences of the FIFA 11+ v. the old FIFA 11 
• Discussed the importance of neural preparedness before going into practice/competition 

Director of Research, Santa Monica Sports Medicine Foundation, FIFA Medical Center of Excellence

Neeru Jayanthi, MD: Keeping Up With the Joneses: How Much Is Too Much in Youth Sports?

• We have to pay attention to the data at some point. Hours of training per week shouldn’t exceed a child’s age
• The more specialized you are in sport the more predisposed you are to injury
• It’s a perceived success with early sport specialization

Associate Professor, Department of Family Medicine, Orthopaedic Surgery and Rehabilitation, Medical Director, Primary Care Sports Medicine, Loyola University Chicago, Stritch School of Medicine 

Rosalind Wiseman, Author and Mother: Navigating Youth Sports’ Troubled Waters: Concrete Strategies For Parents and Coaches

• Discussed the power of coaches and entrusting them with the emotional welfare of her children
• A call of action to create and sustain this social contract with our coaches and kids
• Adults don’t have the market cornered on emotional maturity. We have to manage ourselves so we can role model for our kids.
• Stand up for whats right when we hear youth using derogatory language and phrases like “that’s so gay” or “don’t be retarded”. Make these moments shocking and memorable

Best-selling author of Queen Bees and Wannabes and Masterminds and Wingmen: Helping Our Boys Cope With School Yard Power, Locker Room Tests, Girlfriends, and the New Realities of Guy World

Joe Ehrmann, Retired NFL Player & Motivational Speaker: InSideOut Coaching: How Sports Can Transform Lives

• We need transformational coaches to teach our youth to win with humility and lose with honor
• Coaches are educators. If we have student-athletes than we need teacher-coaches. We can’t just put a whistle in a math teachers possession and expect greatness. 
• Discussing old school belittling coaching practices: Is it best practice or are we just repeating what was taught and how it was delivered 

Katherine Starr: Best practices in Preventing Sexual Abuse in Youth Sports

• Addressed the uncomfortable conversation of sexual abuse in youth sports from a reflective, personal and informative role of advocate

Two-time Olympic Swimmer, Founder and Executive Director, Safe4Athletes  

Donald Collins, JD: The View From the Commissioner’s Box: How Sports Officials Can Help Develop Athletes and Keep Them Safe

• Comprehensively and inspirationally reviewed officiating rules and roles in sport

Commissioner of Athletics, California Interscholastic Federation, San Francisco Section

Douglas E. Abrams, JD: The Power of the Permit in Youth Sports Safety

• Reviewed jurisdiction, paperwork, and permit laws pertinent to Youth Sports Safety

Professor of Law, University of Missouri School of Law           

Deron Colby, JD: To an Athlete Dying Young: Why the Time for SmartTeams™ Is Now 

• Poignantly connects with the audience discussing the array of medical errors and red flags missed over his 17 year old nephew, Matthew Colby’s, fatal concussion history

Janus Capital Law Group, PC and Co-Founder Matthew Colby Foundation


 

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FIFA

We Can Do Better: A Multidisciplinary Proactive Medical Education Push in the Management of Sports Concussion Inspired by the 2014 FIFA World Cup

Sports Concussion

By Dr. Jessica B. Schwartz PT, DPT, CSCS & Mrs. Katy Harris MS, ATC

According to a July 10, 2014 press release from the American Academy of Neurology (AAN), “Physicians have an ethical obligation to ensure that their primary responsibility is to safeguard the current and future mental health of their patients” [1]. I’d like to extend this scope of practice to all healthcare practitioners, in particular, the Athletic Trainers (AT) and Sports Physical Therapists (PT) who are engaging, treating, examining and differentially diagnosing these athletes right on the sideline. Initiating conversation regarding this multidisciplinary push is apropos as the AAN just led the inaugural Sports Concussion Conference in Chicago, July 11-13, 2014, and did an excellent job discussing the multidisciplinary and multifactorial components of Concussion in Sport [2-4].

Alvaro Pereira, of Uruguay’s National Soccer Team, was the first and the most notable concussed athlete in the 2014 Fédération Internationale de Football Association (FIFA) World Cup. Pereira’s concussion was the concussion heard and felt around the world. Television newscasters and millions of people sitting in their local sports bars and living rooms around the world witnessed Pereira laying lifeless on the field after receiving a blow to the head during match play. 

Unfortunately, Pereira’s concussion incident was not an isolated one during this 2014 FIFA World Cup. During the 27th minute of the Holland v. Argentina semi final, Javier Mascherano of Argentina collided heads with an opposing player losing balance and collapsing on the field. During the 16th minute of the Argentina v. Germany final, Christoph Kramer of Germany was blindsided by an Argentine player collapsing to the ground clearly dazed and in pain. Pereira and Mascherano’s concussions are of particular interest because these world class athletes were not only medically escorted off the field for examination, they returned to match play unlike Kramer who was benched for the remainder of the final. 

I’d like to use the Pereira concussion incident to facilitate conversation amongst the medical community. Pereira’s concussion is of particular controversy because of his loss of consciousness (LOC), his dazed appearance, and blatant disregard for the sideline physician’s poor attempt to keep him out of the game. 

Medical professionals that are a part of a comprehensive concussion management team (Physicians, Physical Therapists, Athletic Trainers, Neuropsychologists, Vision Therapists, etc) are educated that during an acute head injury where a concussion is suspected, an athlete’s cognitive ability may be transiently compromised [1]. This transient loss in cognitive ability is unsafe for the player in question as the injured athlete is often dazed, confused and displays poor kinesthetic awareness, thus making it unsafe for everyone around him or her.

World class athletes need to be represented by world class medical care. This leaves us with the glaring question that every medical professional should be asking themselves after the Pereira incident: how are we allowing players to make autonomous medical decisions during match play when they are clearly medically unstable?

If an elite professional soccer player who is visibly dazed and confused returns to play after being knocked unconscious on a world stage, what is happening at the youth, high school and collegiate levels?  

Medical Presence on the Athletic Field:

In a 2014 position statement by the National Athletic Trainers’ Association (NATA): Management of Sport Concussion, Athletic Trainers should be present at every sporting event, regardless of level of play, age or sport [5].

In the United States, there are only a few states that mandate Athletic Trainers in middle schools and high schools. The timeliness of the NATA position statement coincides perfectly with the epidemic injury prevalence of anterior cruciate ligament (ACL) tears and concussions in our youth and collegiate athletes.  Likelihood of an ACL injury in the female athlete is eight times [6] higher than that of their male counterparts [7] while there are 1.6-3.8 million sport-related concussions diagnosed per year [8]. 

Medical presence needs to become a priority for the safety of our children and athletes. 

In the United States, youth coaches are often parents, volunteers, history teachers, gym teachers, athletic directors and so-on.  The bottom line is that they have limited (generally a basic life support (BLS) CPR certification) to no medical background. How are we not advocating for the safety and rights of our children to have an Athletic Trainer present for all sporting events, including practices?  How do we have the best medical personnel for our professional athletes and a glaring absence of coverage for our youth athletes? 

Fiscal deficits are often the primary “rationale” for the lack of Athletic Trainer presence in school districts.  A global educational push for parents, coaches, and school districts should be addressed with our vast and ever growing knowledge of concussion and athletic injury. 

Protocol for an injured athlete for most school districts and tournaments in the state of New York is to dispatch for an ambulance via a 9-1-1 call. For non-emergent issues, this is not only a waste of precious time and resources for Emergency Medical Services (EMS) and the Emergency Department (ED), it is incredibly expensive bordering fiscally irresponsible for an athlete with a non-emergent injury to go to the ED. With an average ambulance ride 25 miles or under costing $858 [9] v. an approximate rate of $35/hr or $150/match for a Certified Athletic Trainer, hiring an Athletic Trainer appears to be the most ethically and fiscally responsible long-term action step.

Our job as medical professionals is to practice with nonmaleficence (do no harm). Ethically, it can be inferred that it is our job to step in and step up for our athletes during the most intense and heated game day situations. We are always mindful of case specific scenarios with regard to a multi-billion dollar event like FIFA’s World Cup or if their is a scholarship scenario for an athlete on the line pending injury report. With respect to sport concussions, we are aware of the potential short term and long term neurological sequelae of second impact syndrome [12], repetitive head injuries and/or subconcussive blows to the body that can result in serious neuropsychological, neurocognitive, and neurobehavioral deficits [10-11]. 

Second Impact Syndrome (SIS) occurs when an athlete suffers from another concussion while still recovering from the initial one. While SIS is rare, it can have detrimental or even fatal effects long term if a neuroaxonal injury is repeated during a time of acute injury or during the healing stage after the neurometabolic cascade [12]. Athletes, parents, coaches and school boards need to be thoroughly educated of the potential risks of the long-term neurological sequelae that can exist post-concussion. 

Subconcussive blows, impact to the body not directly contacting the head, cannot be overlooked. While they are nearly impossible to be accounted for, both animal and human research models have elicited signs and symptoms of concussion in conjunction with damage to the central nervous system causing pathophysiological changes despite an absence of acute changes in observational behavior[13-15]. 

Using Pereira as a talking point, although he played on during the remainder of match play and did not have another direct blow to the head, soccer is a very physical sport. Man to man contact and accidental collisions occur on the field all the time. In fact, this is part of sport. As clinicians, we are aware that post-mortem research after head injury with repeated subconcussive blows have a cumulative effect [16] and may accelerate cognitive decline leading to an altered neuronal biology later on in life [17]. 

Let us stop to ask ourselves and educate our players and coaches, is it worth it?

Working with athletes who have undergone neurocognitive decline is heartbreaking. The powerful documentary Head Games: The Global Concussion Crisis is a powerful movie that illustrates the elite athletes plithe with neurocognitive decline and Alzheimer’s like degenerative disease. This movie can be easily accessed and used as an educational tool for the lay public and medical professional. The carryover is excellent and provides excellent question and answer opportunities for parents, coaches, and athletes to engage with their medical professional. 

Medical Education for the Clinician Working with the Concussed Athlete:

FIFA’s own concussion guidelines clearly indicates “loss of consciousness or responsiveness”, “lying motionless on ground” and “dazed, blank or vacant look” as visible clues to aide in sideline concussion identification (see image below). 

FIFA Concussion Guidelines

Image Credit: (http://www.fifa.com/mm/document/footballdevelopment/medical/01/42/10/50/130214_pocketscat3_print_neutral.pdf)

The World Cup employs some of the top medical professionals in the world. If Alvaro Pereira was allowed to return to match play after exhibiting LOC, balance problems, appearing emotional labile, dazed and confused on a world stage, then we have some serious work to do as a medical community. 

Alvaro Pereira apologized in a formal public statement to the Uruguayan physician the day after the match. Professionally, FIFA and the team physician should’ve reciprocated this apology to Pereira as it was  ethically irresponsible for him to return to same day play sans rest, a full neurological and sideline evaluation. Players blatant disregard for medical opinion and feedback needs to be overridden by professional, medical, and legal protocols. Moving beyond the FIFA Concussion Recognition Tool, protocols leave no room for negotiation. Simplicity in prose, for example, if a player loses consciousness they cannot return to same day match play. Period. End of discussion. 

At the youth and collegiate levels, there has been a recent push in concussion education for coaches. As of January 2014, all 50 states including the District of Columbia individually implemented youth sports concussion laws [1, 18]. On May 29, 2014, President Obama announced an initiative headed by the National Football League (NFL) and NATA to place Athletic Trainers in schools who do not currently have access to the appropriate medical professionals. Presently, only 55% of high schools have access to Athletic Trainers. It should be noted that access does not mean daily treatment and presence. Access can mean weekly visits to a school or a team. We need to do better.

As of July 1, 2014, The Indiana State Senate enforced a Bill to be the first state to require football coaches to participate in the “Heads Up” concussion training course every two years. “Heads up: Concussion in High School Sports” is a national concussion awareness initiative that started in 2005.  It is a multimedia tool kit of educational flyers, videos, and fact sheets meant for coaches, parents, athletes, athletic directors and athletic trainers [19].

The implementation of individual state laws for youth sports concussion and mandating coaches participation in concussion awareness is an excellent step in a proactive direction with the safety of our athletes in mind; however, there needs to an increased focus on the medical professional and his or her role in taking charge of the athlete medically on and off the field. 

It is unfair to place injury recognition responsibilities on the coach whose sole responsibility should be coaching. It is also unsafe for the player not to receive care by a certified medical professional who has the ability to differentially diagnose and identify the red and yellow flags necessary to keep the players short term and long term health and safety as number one priority. 

Making a Proactive and Educated Change in Sport Culture:

A July 9, 2014 article published in Neurology discusses the paucity of skilled Neurologists who are comfortable with treating concussion [20]. It has been refreshing to work professionally with a wide array of medical professionals who have set aside ego while keeping the interest of education and patient outcomes a top priority.

Implementing multidisciplinary concussion management teams are going to be the future of fully comprehensive sport programs for athletes of all ages and abilities. 

Educating ourselves as medical professionals is the first step in understanding multidisciplinary scopes of practice. Communication between a tightly knit team of Physicians, Physical Therapists, Occupational Therapists, Athletic Trainers, Neuropsychologists, Psychotherapists, and Speech Therapists will provide the best overall team outcomes for the concussed athlete who can experience an overwhelming array of physical, cognitive, social and emotional distress in a short amount of time.

Tug of war

A prime example of cross disciplinary education and interaction regarding concussion advocacy recently occurred with a colleague of mine who has the same passion for concussion advocacy and management. Katy Harris, M.S., A.T.C., is a seasoned Athletic Trainer who has a particular interest and expertise in sports concussion. She has exemplified the role of Athletic Trainer over the years with her ability to educate her athletes, coaches and parents on health and safety as it pertains to concussion. 

Early in her career, Katy was the sole responsible Athletic Trainer for 400+high school and middle school athletes. While New York State does not require an Athletic Trainer in its public high schools, we need to be able to set up these qualified professionals for success and not career burn out. A common theme of frustration amongst Katy’s Athletic Training colleagues is wanting to provide the highest standard of care for all athletes, but not having access to or funding for delivering proper care combined with yearly job uncertainty due to frequent state budget cuts. 

When discussing past memorable experiences regarding lack of concussion awareness amongst coaches and school districts, she immediately recalled a scenario when she happened to pass by a coach coming home from an away game. The coach informed her that one of his athletes was forcefully kicked in the head, had a headache, saw stars and was dizzy, but insisted he didn’t think it was a concussion and sent the child home. The coach dismissed the glaring prognostic indicators of a concussed athlete, not because he is negligent, but because he is not a trained medical professional. It should not be the job of a coach to make critical health decisions for his or her athletes. 

When Katy was the supervising Athletic Trainer for a high school football team, she was in charge of 50+ boys at a time. If an injury was suspected or occurred,  in order to reduce confusion on the field and to assert herself professionally,  she would physically confiscate the athletes helmets so they were not able to return to play.

Katy’s exemplary action steps and advocacy for concussion education and management on and off the field is a lesson that FIFA’s World Cup legislators can take note of for future tournaments. 

I look forward to being a part of the proactive concussion conversation in the years to come. In the mean time, lets continue to facilitate passionate multidisciplinary conversations at conferences, utilizing social media, continuing education across all professions, and accessing the medical professional at the entry level and residency components of their educational journey. 

In conclusion, we can and will do better proactively educating ourselves as doctors and clinicians for the health, safety and future well-being of our athletes. 

References:

  1. Kirschen, M. P., et al. (2014). “Legal and ethical implications in the evaluation and management of sports-related concussion.” Neurology.
  2. http://www.symplur.com/healthcare-hashtags/aanscc/ accessed July 14, 2014. 
  3. https://twitter.com/search?f=realtime&q=%23AANSCC&src=typd accessed July 14, 2014.
  4. https://www.aan.com/conferences/sports-concussion-conference/ accessed July 14, 2014. 
  5. Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., Kutcher, J., Palm, M., & Valovich McLeod, T. C. (2014) National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49 (2), 245-265.
  6. Hutchinson, M R. (1995) Knee injuries in female athletes. Sports Med, Apr;19(4):288-302.
  7. Knowles, S. B. (2010). “Is there an injury epidemic in girls’ sports?” Br J Sports Med 44(1): 38-44.
  8. Langlois JA, Rutland-Brown W, Wald MM. (2006) The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 375–378.
  9. Delgado, M. K., et al. (2013). “Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States.” Ann Emerg Med 62(4): 351-364 e319.
  10. Shuttleworth-Edwards AB, Radloff SE. (2008). Compromised visuomotor processing speed in players of Rugby Union from school through to the national adult level. Arch Clin Neuropsychol 23:511–520.
  11. Wall SE, Williams WH, Cartwright-Hatton S, et al. (2006). “Neuropsychological dysfunction following repeat concussions in jockeys.” J Neurol Neurosurg Psychiatry 77:518–520.
  12. Weinstein, E., et al. (2013). “Second impact syndrome in football: new imaging and insights into a rare and devastating condition.” J Neurosurg Pediatr 11(3): 331-334. 
  13. Dashnaw ML, Petraglia AL, Bailes JE. (2012). “An overview of the basic science of concussion and subconcussion: where we are and where we are going.” Neurosurgical FOCUS 33(6). 
  14. Bauer JA, Thomas TS, Cauraugh JH, Kaminski TW, Hass CJ. (2001). “Impact forces and neck muscle activity in heading by collegiate female soccer players.” J. Sports Sci 19(3):171-179. 
  15. Talavage, T. M., et al. (2014). “Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion.” J Neurotrauma 31(4): 327-338.
  16. Shultz SR, MacFabe DF, Foley KA, Taylor R, Cain DP. (2012). “Sub-concussive brain injury in the Long-Evans rat induces acute neuroinflammation in the absence of behavioral impairments.” Behav Brain Res 229(1):145-152.
  17. Broglio SP, Eckner JT, Paulson HL, Kutcher JS. (2012). “Cognitive Decline and Aging: The Role of Concussive and Subconcussive Impacts.” Exerc. Sport Sci. Rev 40(3):138-144.
  18. National Conference of State Legislatures. Traumatic brain injury legislation. Available at: http://www.ncsl.org/research/ health/traumatic-brain-injury-legislation.aspx. Accessed June 3, 2014.
  19. Sawyer, R. J., Hamdallah, M., White, D., Pruzan, M., Mitchko, J., & Huitric, M. (2010).  “High school coaches’ assessments, intentions to use, and use of a concussion tool kit: Centers for Disease Control and Prevention’s Heads Up: Concussion in High School Sports.”  Health Promotion Practice, 11 (1), 34-43. 
  20. Deibert, E. (2014). “Concussion and the neurologist: A work in progress.” Neurology.