post

Healthcare and Social Awareness: Safety Pin Solidarity

 

 

Healthcare and Social Awareness: Safety Pin Solidarity@DPT2Go PT2Go.co SafetyPin

Jessica B. Schwartz PT, DPT, CSCS

New York, NY November 8, 2016, Election Night, changed the world as we know it. This forum isn’t to comment on if that change was for the better or worse. This is a safe space to comment on how this change effects us ALL in healthcare.

For those of us who work in healthcare, law enforcement, or education, our jobs are to care for the ones we took an oath for to “do no harm” and keep people safe in an unbiased form. I’ll choose to wear a safety pin for solidarity for the people of my generation who are living in fear for the first time in our lives- LGBTQ, minorities, women and anyone else who feels threatened or unsafe.

I hope this image resonates with you and your patients to live a kinder and more thoughtful day. In the meantime, tolerate nothing but kindness and love for one another. 

#BeKindToOneAnother

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/.

Concussed: Collective Competence & the Patient Experience

Concussed: Collective Competence in Healthcare

and the Patient Experience

Silos Concussion Bridge final rev2 (1)

Jessica B. Schwartz PT, DPT, CSCS

On May 16, 2015, I had the privilege to speak in front of 200 of my colleagues at Evidence in Motion’s 3 day hands-on and didactic learning festival, Manipalooza, at the University of Colorado’s Anshutz Medical Campus in Denver, Colorado.

If I had to sum the entire weekend up in one word it would be:

Inspired.

Topics of discussion and practical application included concussion, neuroscience, biases in healthcare, manipulation, pelvic health, workplace safety, advanced soft-tissue mobilization, and an epidemiological review of low back pain: where it’s been, where we are going, and how the physical therapist is leading the way.

I was inspired by the impressive cohort of speakers (Timothy Flynn, John Childs, Larry Benz, Adrian Louw, Jennifer Stone, John Groves, Julie Whitman, Teresa Shuemann, Tim Fearon, and humbly- myself) and that of the volunteer Fellows, past and present, to assist with knowledge dissemination and translation throughout the entire weekend.

I have learned that when you are surrounded by some of the top minds in the world who collectively come together with two interests in mind: 1. How to immediately make the clinician better for next day patient care and 2: the importance of being connected to oneself, as provider, including self-awareness of biases and our past patient/life experiences which in turn correlate to increased self-management increasing efficacy in and out of the clinic…it’s well, inspiring.

This low-ego, incredibly fun, and contagiously charismatic group of doctors, clinicians, and scientists was truly an impressive group to be a part of in all domains to engage with, learn from, and disseminate knowledge to a hungry audience of motivated professionals.

May 16, 2015 was particularly profound for me because I essentially got to go public with my story for the first time…and who better to present to than “my own people”, Physical Therapists.

The Schwartz adaptation of the David Sackett’s, MD Evidence Based Medicine (EBM) triangle including patient experience. I encourage all clinicians to listen to and learn from our patients stories. We can learn so much by deeply listening to our patients as people first.

I was in a motor vehicle accident October 3, 2013 and my life changed forever. I underwent a year of rehabilitation living with post-concussive syndrome. I had the good fortune to be cared for by the incredible team of physicians, non-physician doctors, and clinicians at the New York University Concussion Center for 10+ hours a week for about a year of rehabilitation and guidance so I could successfully Return to Life with my new abilities.

I said it time and time again during my physical, orthopedic, neurologic, and cognitive rehabilitation throughout the year… “if I don’t share this story with the medical community it’s essentially malpractice in my eyes”. I continue to hold strong to these goals and values of transparency, story-telling, and sharing of my own personal journey with the goal of increasing concussion patient-provider connectedness in the medical community.

I have one goal: facilitate collective competence amongst the healthcare community in order to better identify, treat, and manage the concussion patient along the entire continuum of recovery from acute to chronic.

I was able to update the audience on some of the latest happenings in concussion research and development, review some stigmas associated with post-concussive syndrome, present my case revealing the patient was myself about half way through the presentation, share some poignant moments of what it was like to live through post-concussive syndrome, and announce the Evidence in Motion Concussion Certificate Program for the post-professional medical provider.

I am absolutely thrilled to be leading this program with the key concept of instilling collective competence across the healthcare continuum so we as clinicians can 1. better understand the scope of everyones interdisciplinary practice, 2. increase abilities to identify commonly missed post-concussive symptoms (cognition, vision, vestibulo-ocular, persistent pain, etc), 3. empower the provider to feel confident in his/her abilities when evaluating, treating, and appropriately referring the concussion patient to a colleague as needed, and 4. empower the provider to educate the community from sports leagues, coaches, parents, school districts, fellow medical professionals, care-takers, employers, and patients.

A key theme of my professional being and future lecture series as it pertains to the concussion patient is built around the concept that there is no one provider who can comprehensively treat this population of patient. My core clinical values foster interdisciplinary knowledge translation. How can we refer to one another if we sincerely don’t have a grasp of what each of us across the healthcare continuum can do for one another as provider and for our mutual patient? I would like to facilitate this forward and collective thinking necessary to provide the concussion patient the best possible care. 

Faculty will include some of the top minds, researchers, and clinicians in the world collectively coming together to educate the post-professional academic learner. Faculty will include the neurologist (adult and pediatric), emergency medicine physician, vestibular physical therapist, traumatic head and neck disorder scientists, occupational therapist/vision therapy, neurogenic speech language pathologist, board certified sports clinical specialist physical therapist, certified athletic trainer, neuroscientist, and the neuropsychologist.

Specialty topic areas will include: Pediatrics, Geriatrics, Sports, Trauma, and the Service Member/Veteran.

Collectively, these incredibly bright and motivated minds will come together and I, as program director, will bridge the gaps empowering the clinician along the course of one year to become comfortable with their clinical abilities, their interdisciplinary colleagues, and most importantly- this cohort of concussion patient who is so often mismanaged in this maze of disconnected care episodes that healthcare system of today has unfortunately bred.

Future information will be launched soon on the Evidence in Motion’s website for a Summer 2015 launch date.

I look forward to being a part of an incredible movement to educate the healthcare practitioner in an online and in-person synchronous and asynchronous learning environment.

Cheers to a tremendous year to come for both the patient and provider with respect to the identification, treatment, and management of the concussion patient!

Thank you for time, attention, and coming along this exciting journey of advocacy as post-concussive survivor, story-teller, and educator.

*Please excuse the cough. The Colorado altitude got the best of me

Kind Regards,

Jessica B. Schwartz PT, DPT, CSCS

*Special thank you’s to Tim and John for the invite to Colorado!

Tim Flynn and Jess Schwartz

Timothy Flynn PT, PhD, FAAOMPT and Jessica B. Schwartz PT, DPT, CSCS at Manipalooza 2015 at the University of Colorado Anshutz Medical Campus May 16, 2015

John Childs, Jess Schwartz, and Tim Flynn #Manipalooza

John Childs PT, PhD, MBA , Timothy Flynn PT, PhD, FAAOMPT and Jessica B. Schwartz PT, DPT, CSCS at Manipalooza 2015 at the University of Colorado Anshutz Medical Campus May 16, 2015

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.

 

 

post

Choosing Wisely

Simplicity and Elegance of Positive Language Communication: Recommendations for How to Mentally Prime Our Patients for Success with the Choosing Wisely Campaign

Executive points out a spinning manager

Dr. Jessica B. Schwartz PT, DPT, CSCS

The impetus behind this article is to address the language behind the Choosing Wisely campaign. I hope by providing feedback and subtle paradigm shifts in language, I can aide in increasing communication success between both doctor and patient. 

Join me as I take you through the Choosing Wisely campaign background, my reflections on the American Physical Therapy Association’s (APTA) campaign, and action steps on how we can achieve optimal communication between clinicians and patients. 

Choosing Wisely

The Choosing Wisely campaign is a patient centered educational campaign based in the United States that seeks to improve doctor-patient communication and relationships about overutilization of medically prescribed resources[1].

I came across the APTA’s Choosing Wisely Campaign and the Consumer Reports article reviewing the campaign as I was sifting through my Twitter feed one morning. Not only was I excited to find out that we were the first non-physician organization to take part in this campaign[2], I felt proud that my organization was leading the way in advocating for patients to take control of their health and well-being.

The APTA campaign, entitled “Five Things Physical Therapists and Patients Should Question”, was my first exposure to the Choosing Wisely campaign. As I continued to read through other Choosing Wisely sections in Nursing, Orthopedic Surgery, Emergency Medicine and Neurology, I realized this whole campaign was speaking to patients using a structure based solely on negative language. Each sentence began with the words “don’t” or “avoid”.

Choosing Wisely Slide Images.001

Choosing Wisely Slide Images.003

Choosing Wisely Slide Images.002

Screenshots Accessed October 19, 2014 via www.choosingwisely.org/doctor-patient-lists/

As soon as I read these articles, I knew there was a better approach when it comes to speaking with our patients.

As I transitioned over to the Consumer Reports review of the APTA Choosing Wisely campaign, I was somewhat biased reading an article about my own profession written by a freelance writer who authored “Still Hot Your Uncensored Guide to Divorce, Dating, Sex, Spite and Happily Ever After”.

I would be remiss if I didn’t say I felt frustrated with the Consumer Reports article educating the masses using phrases like “wimpy exercise programs” to describe a doctoral level education plan of care with regards to exercise prescription for the elderly.

My discontentment with the Choosing Wisely campaign is not with the information being delivered, but how it is being delivered to the consumer.

I’d like to take a moment to address how I believe the Choosing Wisely campaign could be shifted to improve communication between the medical community and our patients.

Reflections:

It was during my undergraduate career when I took a sports psychology class in the hills of Ithaca, NY, I realized the importance of positive psychology and its role in achieving peak performance for all individuals.

Clinically, I have had the opportunity to work with patients who have felt absolutely helpless and hopeless about their present health situation to elite athletes who would like to conquer a new athletic endeavor.

As a novice or a master clinician I ask you, what do these completely different patients’ treatment paradigms have in common?

One central tenet: I treat them exactly the same. I cater to their individual needs, goals and desires while addressing their fears and uncertainties with confidence, realistic, and positive outcomes and goals.

Richard Boyatzis, a psychologist from Weatherhead School of Management at Case Western Reserve University, advocates that when we focus on strengths, there is a tendency to move toward a desired future which internally stimulates openness to new ideas, people, and plans. Talking about positive goals activates brain centers that opens you up to new possibilities. Reciprocally, focusing on the alternative, or negatives, evokes a defensive mechanism and leads us to close down[3].

A positive language and motivational model is often used when speaking with professional athletes and elite executives in corporate America. Rick Aberman, peak performance director for the Minnesota Twins, states that “when the coach reviews plays from a game and only focuses on what not to do next time, it’s a recipe for players to choke.”[4]

During my days coaching basketball, I remember watching every inspirational sports movie I could get my hands on from Hoosiers to The Mighty Ducks, speaking to other coaches about their best practices, referring back to coaching lectures, and reading coaching books by Pat Summit from the University of Tennessee for guidance.

I remember coaching a close game one winter in upstate New York. The score was tied and I called a time out. Tapping into all of my coaching research, I looked each and everyone of my players in the eye and initiated my plan of action to my point guard, “Alicia, you’re going to pass the ball to Katy and she’s going to roll off of the screen that Meg is going to set. She’s going to bank the shot in and all of you are going to full court press until the clock runs out to win the game so we can go home and celebrate”.

Why aren’t we speaking to our patients like this?

We can mentally prime our patients for success with the simplicity and elegance of positive language communication.

Master clinicians discuss this in academic medicine all the time: language and delivery matter.

Recommendations:

I challenge you to think about how you speak with your patients and colleagues on an interdisciplinary level. Every interaction doesn’t need to be a critical life changing beat the buzzer intense moment; however, words and language matter.

Moving forward as a cohort of passionate, capable and autonomous Doctors of Physical Therapy in the United States, it is imperative that we adopt this positive language delivery system ranging from our everyday practice in patient care to an elevator pitch when fellow doctors and clinicians ask us how Physical Therapy can benefit their patients.

This is my challenge to the healthcare community: Choose Your Language Wisely.

My name is Dr. Jessica Schwartz. I am a residency trained Doctor of Physical Therapy in Orthopedics and here is how I can help you Choose Wisely.

1. Do use passive physical agents as an adjunct to skilled manual therapy and supervised therapeutic exercise in order to aide in inflammatory pain management. If time is an issue or compliance is not an issue, do educate patients that they can ice, heat or use a TENs unit at home.  

-Our job is to make people feel better. The number one reason patients come to Physical Therapy is because they are in pain. The 21st century patient is busy and often stressed. In order for me to provide skilled one on one orthopedic manual Physical Therapy, I need my patient to be calm, mentally primed to disassociate themselves from life’s stressors i.e. to be as relaxed as possible so they are present and active in their treatment session, and for the area to be ready to receive treatment. Moist heat, cold and/or electric stimulation are all non invasive and safe alternatives to an anti-inflammatory or other oral medications. Patients are consumers and should be educated that it is not ok to receive passive physical agents as a sole form of treatment.

2. Do make your Physical Therapist fully aware of your activities of daily living, familial responsibilities, work requirements, athletic abilities and desires. All of the above are independent of your chronological age. Chronological and biological age of our patients vary greatly. It is our job to dose the exercise prescription intensity, duration, and frequency not to your chronological age, but to your biological age and abilities. We work with 80 year old triathletes and 20 year olds living in hospice facilities. Our job is to individually tailor realistic, functional, safe, and achievable short term and long term goals for our patients. 

 -Physical Therapists are educated so that we fully comprehend the physiological demands of the musculoskeletal, neurological, cardiovascular, pulmonary, and integumentary systems, how these systems interact with each other in order to differentially diagnose different pathologies appropriately for referral as needed, and how to get all of these systems working as efficiently as possible with a patient spectrum ranging from the frail elderly to the elite athlete. In other words, our job is to make the patient function to the best of their ability in a pain-free and energy efficient way. 

3. Do move with the skilled supervision of a Physical Therapist after an acute deep vein thrombosis (DVT) and initiation of anticoagulant therapy, unless significant medical concerns are present.  

-Patients lose 0.5–0.6% of total muscle mass per day on bed rest. Bed rest was the appropriate prescription for low back pain and DVT 20 years ago. Evidenced based practice has led us to present day conclusions that bed rest causes more harm than good (muscle atrophy, strength decrease, onset of insulin resistance, decline in basal metabolic rate, and other negative pathophysiological breakdowns). [5-6]

4. Do use continuous passive motion (CPM) machines in the complicated total knee replacement. Active prescribed therapeutic exercise for range of motion (ROM) and weight bearing (WB) status should be achieved multiple times per day after total joint replacement. If the patient is not compliant or not able to achieve post-operative requirements of prescribed movement, the CPM is a good adjunct with skilled physical therapy. 

5. Do use directed wound irrigation or a pulsed lavage with suction for wound management. Be wary of whirlpools due to bacterial cross contamination concerns. 

Choosing Wisely is an excellent campaign to involve multidisciplinary levels of communication to patients, consumers, and other healthcare professionals; however, I believe a subtle shift in the delivery can make all the difference in how patients perceive and receive the information geared towards them.

Physical Therapy as a profession is in a transitional time doing our very best to educate the masses about all the various therapies we can provide independently and complementarily to aide in optimal functioning across the lifespan. 

It is important to be comfortable with your doctor. If your Doctor of Physical Therapy is comfortable with his/her clinical abilities, he/she should welcome patient questions or concerns after a thorough review of their plan of care. Remind patients that it is okay to ask questions. If rapport is not established, more often than not patients are intimidated by asking questions due to fear, intimidation, risking feeling silly, etc.

I encourage questioning during the course of a plan of care because this way I know the patient is comprehending the value of their treatment session, are engaged, and are invested in advocating for themselves.

A master clinician is able to field all of the intangibles that the day to day environment brings in healthcare. Some clinics are busier than others. If a patient does not feel comfortable with their provider, remember to educate them that they have a choice to seek out a new provider to achieve their functional desires and goals. 

Finally, when a patient finds their ideal Physical Therapist remind them to stick with them! Having a healthcare professional who is easily accessible and who is knowledgeable in treating all of their musculoskeletal concerns throughout the lifespan is a wonderful relationship to cultivate in order to achieve optimal health and well-being.

We all have different strengths, specialties, and abilities, so make sure patients are educated to seek out a Physical Therapist that melds well with their personality, goals, and geographical location.

Good luck in finding the Physical Therapist right for you and here’s to Choosing Wisely! 

Bibliography

1.Cassel, C.K. and J.A. Guest, Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA, 2012. 307(17): p. 1801-2.

2.APTA releases its Choosing Wisely list of what to question. 2014  [cited 2014 October 28, 2014]; Tuesday September 16, 2014:[Available from: http://news.todayinpt.com/article/20140916/TODAYINPT04/140915009/0/TODAYINPT0%20105.

3.Goleman, D. (2013b). Focus (Kindle ed., pp. 320): Harper Collins.

4.Goleman, D. (2013b). Focus (Kindle ed., pp. 30): Harper Collins.

5. Brocca, L., et al., The time course of the adaptations of human muscle proteome to bed rest and the underlying mechanisms. J Physiol, 2012. 590(Pt 20): p. 5211-30.

6. Wall, B. T., Dirks, M. L., & van Loon, L. J. (2013). Skeletal muscle atrophy during short-term disuse: implications for age-related sarcopenia. Ageing Res Rev, 12(4), 898-906. doi: 10.1016/j.arr.2013.07.003

 

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


 

post

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.