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Reflections From The 2nd Annual Women In Physical Therapy Summit

Women In PT Logo

New York, New York On September 23, 2017, the 2nd Annual Women in Physical Therapy (PT) Summit took place at the University Club in New York City.

Organized by Erica Meloe, Sandy Hilton, and Karen Litzy, the Women In PT Summit is a catalyst for professional and personal growth empowering women to “show up and show out” as our American Physical Therapy Association (APTA) President, Dr. Sharon Dunn, stated so emphatically in her opening plenary.

The day was filled with relationship building, laughter, strategic storytelling of profit, loss, and the importance of self-care for longevity in the field of Physical Therapy, business management, and medical education.

As one would expect of a Women In PT Summit held in a historical all men’s club, a reoccurring theme across the summit for those in attendance was “it’s better to ask for forgiveness, than to ask for permission.” It was truly inspirational to hear Dr. Dunn eloquently remind us of our roots. She took us through the journey of the Reconstruction Aides of 1921 “who paved the way for us to occupy the land” to a thriving present day 100,000 member APTA leading the way with the #ChoosePT campaign. The #ChoosePT campaign is a pain management movement to safely address the opioid crisis in the United States.

In front of more than 14,000 attendees at the 2017 Combined Sections Meeting in San Antonio, Texas, the APTA announced its first Outcomes Registry. The Outcomes Registry has the capability to be one of the biggest influencers in over a century to afford us the opportunity to quantify how we advocate for our patients, reimbursement during a health care reform era, and transform health policy. Dr. Dunn reiterated that “along with big data, comes credibility.” Physical Therapy is the 6th largest healthcare profession in the United States and we are just entreêing into “big data” in order to transform society for a better patient encounter for tomorrow. It’s an exciting time to be a Physical Therapist, we’re able to show up, problem solve, and collaborate with our brothers and sisters in medicine at the healthcare table. 

President Sharon Dunn PT, PhD, OCS Opening Plenary Women In PT Summit "We have the ability to disrupt, like our foremothers did for polio, with disrupting the opioid crisis"

President Sharon Dunn PT, PhD, OCS Opening Plenary Women In PT Summit “We have the ability to disrupt, like our foremothers did for polio, with disrupting the opioid crisis” #ChoosePT

I’ve spent the latter portion of my career attending and lecturing at concussion conferences all over the United States. It was incredibly refreshing to hear Dr. Dunn empower the Women In PT attendees with “when you have something to say or something to say for others who can’t speak up, you better speak up.” This is true for our colleagues and our patients. I am deeply connected to this mantra as I have devoted myself to advocating and speaking up for concussion and brain injury survivors since my own motor vehicle collision in 2013.Brain Injury Association Keynote Address Dr. Jessica B. Schwartz PT, DPT, CSCS

 

Amplification and Boldness:

Dr. Ellie Somers, from Seattle, Washington, led with one of the most memorable quotes and themes of the entire day discussing her career trajectory: “amplification & loudness matter. Change & growth don’t happen by accident. Boldness breeds boldness” when discussing her uphill battle with sexism in the workplace. In fact, her attendance at last year’s Women In PT Summit encouraged her to amplify her own career by becoming a small business owner and starting her own clinic. Her powerful life lesson of not staying quiet when shocked and startled in the workplace is a lesson to us all to impart on ourselves, our mothers, sisters, wives, and children. Workplace sexual assault is reported at 38% by the National Sexual Violence Resource Center (NSVRC) and one in four, or every 98 seconds, a woman is sexually assaulted in the United States. 

Dr. Ellie Somers PT, DPT

The RETHINK Movement by Lolly Daskal:

Lolly Daskal, deemed “the most inspirational woman in the world” by the Huffington Post, co-keynoted the Women In PT Summit with a motivating executive leadership model of RETHINK she derived from her Lead From Within leadership program. Mrs. Daskal stepped up on stage and immediately got to work. There was no trepidation, stuttering, or computer glitches. She owned that stage and was there to deliver her message of empowerment. It was clear why she was named to Top-50 Leadership and Management Experts by Inc 100 Great Leader.

Lolly Daskal telling the story of Dr. Bennet Omalu's name origin as it pertains to his historical concussion journey: "He who knows speaks."

Lolly Daskal telling the story of Dr. Bennet Omalu’s name origin as it pertains to his historical concussion journey: “He who knows speaks.”

Mrs. Daskal took the audience on an archetypal journey to greatness. A key theme of her keynote presentation was that of sustainable success. Historically, businesses like Blockbuster, Xerox, Blackberry, and Polaroid have all failed after incredible fiscal success due to their inability to adapt to the exponential technical boom of the early 2000’s. Mrs. Daskal took us through a journey that we all have competing characters and how to leverage those gaps in order to embrace our own individual greatness.

Lolly Daskal's: RETHINK. Rebel, Explorer, Truth Teller, Hero, Inventor, Navigator, Knight archetypal path to greatness

Lolly Daskal’s: RETHINK. Rebel, Explorer, Truth Teller, Hero, Inventor, Navigator, Knight archetypal path to greatness

We are the sum of all of these archetypes. It is how we self-manage all of them in the different environments we have to navigate which will lead to our own greatness.

Endurance: A 53 Year Career

Dr. Roslyn Sofer PT, DPT, OCS was interviewed by Dr. Dunn to close the summit. Dr. Sofer is an active physical therapist, professor, and business owner of 53 years. “The key to a long meaningful career is to do a lot of different things.” She summarized that the gratitude she feels from her patients has kept her actively working in the profession for over half a century. Dr. Dunn connected to the audience about focusing on serving our community as opposed to focusing on the title of an elected official. Dr. Sofer is truly an embodiment of a female leader in Physical Therapy who has actively served our profession with a #MoveForward mindset as she has adapted to the demands of our educational requirements and population growth. She is a pinnacle example of sustainable success in the field of Physical Therapy. 

Dr. Rosyln Sofer being interviewed about her 53 year career by American Physical Therapy Association (APTA) President, Dr. Sharon Dunn

Dr. Rosyln Sofer PT, DPT, OCS being interviewed about her 53-year career by American Physical Therapy Association (APTA) President, Dr. Sharon Dunn PT, PhD, OCS

Networking, Rapport Building, and Laughter:

The organizers of the summit did an excellent job providing social events, happy hour(s), and breaks to allow enough time for collaboration and networking to ensure. 

Here are a few highlights:

#WomenInPT #PTPubNight kicked off at The Greenroom in NYC Friday evening

#WomenInPT #PTPubNight kicked off at The Greenroom in NYC Friday evening

Karen Litzy, Jessica Schwartz, and Emilio Rouco at The Greenroom #WomenInPT #PTPubNight Happy Hour

Doctors Karen Litzy, Jessica Schwartz, and Mr. Emilio Rouco at The Greenroom #WomenInPT #PTPubNight Happy Hour

Secili DeStefano, Peggy Lynam, Carrie Pagliano, Meg Cochran, Erin Jackson, Megan Mitchell et al at the #WomenInPT Summit

Doctors Secili DeStefano, Peggy Lynam, Carrie Pagliano, Meg Cochran, Megan Mitchell, Mrs. Erin Jackson et al at the #WomenInPT Summit

An incredible panel of women: Dr's Ellie Somers, Dee Kornetti, and Lisa Dorsey.

An incredible panel of women: Doctor’s Ellie Somers, Dee Kornetti, and Lisa Dorsey.

A rare moment when APTA Media Corps Members stand still long enough for a photo to celebrate the #WomenInPT Summit. APTA Media Corps Members Nicole Stout, Jessica Schwartz and Karen Litzy joined by APTA Director of Public and Media Relations, Emilio Rouco.

A rare moment when APTA Media Corps Members stand still long enough for a photo to celebrate the #WomenInPT Summit. APTA Media Corps Members Doctors Nicole Stout, Jessica Schwartz and Karen Litzy joined by APTA Director of Public and Media Relations, Emilio Rouco.

Chris Sebelski, Lisa Dorsey, and Jessica Schwartz touring the University Club library. A prime example: "Well behaved women rarely make history."

Doctors Chris Sebelski, Lisa Dorsey, and Jessica Schwartz touring the University Club library. A prime example: “Well behaved women rarely make history.”

Home Health Section President Dee Kornetti before her inspirational speech and Jessica Schwartz at the #WomenInPT

Home Health Section President Dr. Dee Kornetti before her inspirational speech with a ‘get’r done mentality’ and Jessica Schwartz at the #WomenInPT Summit

Power Panel Eva Norman, Amy Stein, Sandra Norby, and Michelle Collie bringing humor and incredible energy to the #WomenInPT Summit

Power Panel with Doctors Eva Norman, Amy Stein, Sandra Norby, and Michelle Collie bringing humor and incredible energy to the #WomenInPT Summit moderated by organizer, Erica Meloe.

Karen Litzy, Steph Wayrauch, Secli DeStefano, Julie Wiebe. and Carrie Pagliano post #WomenInPT Summit celebrations at ilili in New York City

Doctors Karen Litzy, Steph Wayrauch, Secli DeStefano, Julie Wiebe. and Carrie Pagliano post #WomenInPT Summit celebrations at ilili in New York City

Karen Litzy, Steph Wayrauch, Sandy Hilton, Sarah Haag, and Molly Galbraith closing down the the #WomenInPT Summit celebrations

Doctors Karen Litzy, Steph Wayrauch, Sandy Hilton, Sarah Haag, and Ms. Molly Galbraith of Girls Gone Strong closing down the #WomenInPT Summit celebrations

Closing Thoughts:

Physical Therapy is a young profession that was created by women. It was our foremothers who laid down the foundation for an incredible medical profession that encompasses what it means to serve and transform a society with our creative minds and hands with a do-no-harm centricity at our core.

I’ve read one book multiple times in my life and it’s Pat Summitt’s New York Times bestseller, Reach For The Summitt. As an avid basketball player through college, I equate Dr. Dunn as the Pat Summitt of medical association presidents and we are darn lucky to have her representing us as Physical Therapists on a domestic and international level.

Dr. Dunn is a pint-sized force to be reckoned with combining the triple threat of a high intelligence (IQ), high emotional intelligence (EQ), and a southern drawl that draws you in as she preaches the good work we offer in order to transform society one patient encounter at a time. Like Coach Summitt’s historical life’s work at the University of Tennesee, don’t let her southern drawl disarm you. If she doesn’t leave you inspired, elevated, and ready to take action, than you weren’t listening.

APTA President Dr. Sharon Dunn and Dr. Jessica Schwartz at the #WomenInPT Summit. This is the combination power pose. "Not all superheroes wear capes." #DoGoodWork

APTA President Dr. Sharon Dunn and Dr. Jessica Schwartz at the #WomenInPT Summit. This is the combination power pose. “Not all superheroes wear capes.” #DoGoodWork

Dr. Nicole Stout PT, DPT, FAPTA broadened our minds when she said: “we, as a Physical Therapy profession, need to think much broader on how we impact patients with models of care, administration, and models of workflow.” We’re problem solvers and absolutely excel when we think outside of the box.

Thought and career leaders like Dr. Lisa Dorsey PT, MBA, PhD elevating the crowd with a magnificent prop of a velcro pantsuit to reveal a beautiful dress and heels as she delivered her message of women in the workplace negotiating and navigating all realms of business and higher education as a Physical Therapist, Dr. Chris Sebelski PT, DPT, PhD, OCS discussing her research on self-efficacy and gender, and Mia Gonzales Dean PT, MBA, FACHE empowering the audience leading her way as a businesswoman and hospital administrator in the Philadelphia area, left the crowd with thought seeds planted providing limitless possibilities of cultivation for future Physical Therapists. 

As I continue to advocate for the underserved, underfunded, and mismanaged concussion patient community and educate an interdisciplinary group of healthcare providers on an international level, the central tenet of my life’s work was so apparent at the Women In PT Summit: we are better together by amplifying and elevating those around us.

Until next year, brava to Karen Litzy, Erica Meloe, and Sandy Hilton for throwing a world-class event!

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

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Concussion & Nutrition Series Part III

Concussion and Nutrition Series Part III:

The Most Promising Nutrients for Affecting TBI Outcomes and Recommendations for Patients

475 vege brain

Ms. Jenna Larsen, M.S.

As Traumatic Brain Injuries (TBIs) continue to lead to a third of all injury-related deaths in the United States each year, researchers remain at a loss for a drug to treat them. The fact that brain injuries vary depending upon the location, type, intensity, and duration of force make them difficult to study and an even bigger challenge for the healthcare practitioner making recommendations for appropriate care.

The concept that the brain is an impressionable organ affected by its environment is finally gaining acceptance. Much remains to be discovered, but nutrition as a preventive intervention is a practical and safe proposal. The ability of nutrients to interact with a variety of physiological processes associated with TBI suggests that including nutritional approaches as a complementary therapy when managing a brain injury could be beneficial.

In 2011, the Institute of Medicine (IOM) published a report entitled Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. In the report, the committee cites the most promising connections between specific nutrients and TBI. Nutrients are suggested based on the evidence behind their ability to affect physiological processes involved in TBI. Those nutrients deemed most likely to be effective target four main mechanisms- decreasing brain swelling, decreasing inflammation and oxidation, decreasing cell death and increasing energy production.

Choline, creatine*, omega-3 fats, zinc, magnesium and Vitamin D were identified as the most promising nutritional interventions, although more research is warranted. Table 1 below explains their modes of action, foods highest in nutrient density, and an easy way to prepare a dish high in them. I encourage you to share this with your patients and colleagues.

Table 1: Whole Foods and Recipe Preparations Highest in Suggested Nutrients for Adjunctive TBI Therapy 

PT2Go Concussion & Nutrition Table

©PT2Go.co 2014

Should TBI patients be supplementing or are food sources better?

There is a double edged sword when conducting studies as supplementation is necessary for researchers to separate the nutrient of interest from the other nutrients in food. However, it can lead the public to assume that supplementation will be effective for their health.

When considering the connection between brain injuries and nutrition, it is helpful to separate acute versus long term symptomatic events. Supplementation may be beneficial to improve treatment outcomes immediately after the injury as a high turnover of nutrients required. However, for those most at risk for traumatic brain injuries (i.e. athletes, motor vehicle accident survivors, etc) and for those that experience long-term symptoms, whole foods such as fruits, vegetables, nuts, fish and legumes may be a better option for acquiring resilience.

We have to also be cognoscente and connected to our patients that have no intention or ability to eat well. A supplement may be indicated, but it should be emphasized that it won’t replace the enhanced benefits they’ll get from whole foods. Our bodies evolved to respond to whole foods and all of the benefits they have to offer- not just one specific nutrient. Prescribing them offers not only fiber, energy, satiety but also the brain-boosting effects of so many other vitamins, minerals and protective substances (see Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods) that are missing in a supplement.

*Creatine is created in our bodies and there are few foods that contain it.  Therefore, they are not listed on the chart. Supplementation may be beneficial immediately after injury and requires further scientific investigation.

Until next time,

Jenna

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Concussion & Nutrition Series Part II

Concussion and Nutrition Series Part II: Effects of a High Fat, Low Carbohydrate Diet on Brain Metabolism

By Jenna Larsen, M.S.

With respect to nutrition and concussion, there isn’t concrete evidence that there is one type of diet or panacea to aide with concussion symptoms due to the multi-system nature of this injury. 

The intention behind this article is not to propose that you, as a healthcare provider, prescribe a defined diet to concussion patients or even to recommend it as an alternative therapy. Simply, it is to encourage you to consider the evidence behind the idea that (1) what we eat affects the body; and (2) nutrition may be more powerful in healing than many of us have been taught to believe.

The ketogenic diet.

What is it? Who is it prescribed for? And why has this prescribed diet continually intrigued me as it correlates to concussion patients. The ketogenic diet was developed to mimic starvation and has been used and studied for almost an entire century [1]. It is a high-fat diet in which carbohydrates are all but eliminated (less than 50g per day). For reference, there are 27g of carbohydrates in a banana. It is presently most commonly used to control epileptic seizures especially in children [1-3]. More recently, researchers have some evidence that the diet may be effective for improving traumatic brain injury (TBI) outcomes as well [14].

Let’s take a look at how the ketogenic diet works. The brain craves carbohydrates. Whenever they are available, the brain will use them for energy- before breaking down fats and certainly before breaking down protein. When a patient is on a ketogenic diet, carbohydrates aren’t available. The brain settles and breaks down fats instead, converting triglycerides into fatty acids and ketone bodies– the ketone bodies are then used to make ATP and fuel the brain cells. In fact, they may even be a more efficient source of energy than glucose [1]. But how might this translate to protecting the brain?

Ketone bodies were found to prevent neuron cell death in a variety of studies through many different mechanisms [1]. Most of them used animal models so the effectiveness in humans requires more investigation. However, ketogenic diets are highly effective in treating epilepsy [4], so we do know that the brain is most certainly affected by the diet.

We also know that processes in TBI associated neuronal death include energy (ATP) depletion, reactive oxygen species (ROS) production, and inflammation. Since ketone bodies are an alternative source of energy, they are thought to lessen the harmful effects of energy depletion that occur with injury. Multiple studies have shed light on their ability to increase the cell’s resistance to oxidation, inflammation and programmed cell death [5-10]. One caveat is that the diet may be more effective in children – adherence is easier and younger brains are better at transporting and utilizing ketone bodies [11-13].

If the ketogenic diet has so much fat, you may be wondering about health-related consequences. Over the long term, it was actually found to decrease the level of triglycerides and LDL cholesterol while increasing HDL cholesterol. On the contrary, gastrointestinal disturbances are common and children on the diet may be at slightly higher risk for stunted growth, bone fractures and kidney stones. Supplements are prescribed by a medical professional to counter deficient micronutrients [13].

There are a lot of unknown variables with respect to this diet in humans living with TBI. Do short periods on the diet lead to long-term benefits or are the effects reversible? Should the diet be administered right after the injury? What time window is most effective? Are low glucose levels necessary or could you administer ketone bodies without the need to restrict carbohydrates?

A better understanding might provide insights into therapeutic approaches that eliminate the need for strict adherence to diet that is difficult to maintain. Ideally, the ketogenic diet could inform scientists developing a drug that is effective in treating TBI.

Presently, the best course of action a healthcare professional can take with regards to nutrition is to prescribe patients with TBI an increased intake of fruits and vegetables in conjunction with their present course of treatment. Fruits and vegetables are full of flavonoids and antioxidants which have been found to have positive impacts on concussion outcomes and are a more feasible alternative to carbohydrate restriction. See Concussion and Nutrition Series Part I: Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods for a comprehensive review.

Until next time,

Jenna

References:

1. Gasior M, Rogawski MA, and Hartman AL. Neuroprotective and disease-modifying effects of the ketogenic diet. Behav Pharmacol. 2006 Sep 17(5-6):431-439

2. Kossoff EH, Rho JM (2009) Ketogenic diets: evidence for short- and long-term efficacy. Neurotherapeutics 6(2):406–414

3. Neal EG1, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomised controlled trial.Lancet Neurol. 2008 Jun;7(6):500-6.

4. Veech RL. The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism. Prostaglandins Leukot Essent Fatty Acids. 2004;70:309–319.

5. Ziegler DR, Ribeiro LC, Hagenn M, Siqueira IR, Araujo E, Torres IL, et al. Ketogenic diet increases glutathione peroxidase activity in rat hippocampus. Neurochem Res. 2003;28:1793–1797.

6. Sullivan PG, Rippy NA, Dorenbos K, Concepcion RC, Agarwal AK, Rho JM. The ketogenic diet increases mitochondrial uncoupling protein levels and activity. Ann Neurol. 2004;55:576–580.

7. Stamp LK, James MJ, Cleland LG. Diet and rheumatoid arthritis: a review of the literature. Semin Arthritis Rheum. 2005;35:77–94.

8. Cullingford TE. The ketogenic diet; fatty acids, fatty acid-activated receptors and neurological disorders. Prostaglandins Leukot Essent Fatty Acids. 2004;70:253–264.

9. Hu ZG, Wang HD, Qiao L et al. The protective effect of the ketogenic diet on traumatic brain injury-induced cell death in juvenile rats.Brain Inj. 2009 May;23(5):459-65.

10. Rafiki A, Boulland JL, Halestrap AP, Ottersen OP, Bergersen L. Highly differential expression of the monocarboxylate transporters MCT2 and MCT4 in the developing rat brain. Neuroscience. 2003;122:677–688.

11. Vannucci SJ, Simpson IA. Developmental switch in brain nutrient transporter expression in the rat. Am J Physiol Endocrinol Metab. 2003;285:E1127–E1134.

12. Pierre K, Pellerin L. Monocarboxylate transporters in the central nervous system: distribution, regulation and function. J Neurochem. 2005;94:1–14.

13. Duchowny MS. Food for Thought: The Ketogenic Diet and Adverse Effects in Children. Epilepsy Curr. Jul 2005; 5(4): 152–154.

14. Institute of Medicine Report: Nutrition and Traumatic Brain Injury- Improving Acute and Subacute Health Outcomes in Military Personnel by the Committee on Nutrition, Trauma and the Brain Food and Nutrition Board. Accessed June 23, 2014. http://www.iom.edu/Reports/2011/Nutrition-and-Traumatic-Brain-Injury.aspx

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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.

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Concussion & Nutrition Series Part I

Concussion and Nutrition Series Part I: Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods 

475 vege brain

 

By Jenna Larsen, M.S.

When you visualize concussion treatment, what comes to mind? Physical rest? Cognitive rest? Pain relievers? Limitations in physical and social activity? Eating the right foods? Id venture to guess that the latter is not on your list. 

How can a traumatic brain injury (TBI) respond to food? Visualize treatments for cardiovascular disease and diabetes. Do nutritional interventions come to mind? Id speculate that they do. The events happening in the body after a TBI are not all that different than many other chronic diseases. The common links are oxidative damage and inflammation. There is a growing body of evidence supporting antioxidant and anti-inflammatory diets as a way to prevent complications associated with traumatic brain injuries. 

Lets take a moment to understand oxidative damage and inflammation in the context of a concussion. After a TBI, an inflammatory cascade is set off as a healing mechanism. Although beneficial in the short-term, the inflammation can persist while the healing effects do not. This creates oxidative stress as too many cell-damaging free radicals lead to tissue damage and eventual cell death. In the case of a concussion, cognitive problems are common long-term complications [1,2]. 

Diets rich in antioxidant-rich foods may be useful approaches to promote protective mechanisms associated with TBI [3]. There is promising research that foods high in the class of compounds called flavonoids act on the inflammatory cascade and are linked to improving cognitive performance and lowering the risk of Alzheimers-a brain disease with similar symptom presentation with deficits in memory and thinking skills.

What Are Flavonoids?

Flavonoids are the pigments that give fruits and vegetables their color. They are the main reason why fruits and vegetables are considered to be so healthy. There are over 4,000 compounds considered to be flavonoids. The more deeply colored the fruit or vegetable, the more flavonoids it provides. They are also abundant in garlic, teas, spices, nuts and beans. 

A few flavonoids that may sound familiar include quercetin (apples), resveratrol (red wine), epicatechin (cocoa), curcumin (curries), catechins and polyphenols (tea), anthocyanins (berries).

How Do Flavonoids Work in the Brain?

Flavonoids are antioxidants that are also anti-inflammatory. In a human randomized controlled trial, the flavonoid resveratrol, was shown to exert anti-inflammatory and anti-oxidative stress in humans [4]. Flavonoids, like all antioxidants, work by stopping free radicals from damaging cells, including neurons. Flavonoids are neuroprotective because of their ability to turn down inflammation and increase cognitive function via two processes. The first is by preventing the neuronal cell death that occurs during the inflammation-signaling cascade. The second is to induce the blood flow needed for new nerve cell growth to prevent or reverse loss of cognitive performance [5]. 

Consuming flavonoid-rich foods has been associated with the delayed onset of Alzheimer’s disease, while some studies have linked them to improved mental function [6-9]. Although the research specifically linking brain traumas to flavonoids is at an early stage, we know that a diet rich in fruits and vegetables is invaluable for health and to prevent other inflammatory-related diseases (i.e. cardiovascular disease, diabetes, cancer). If not for the long-term, the short-term effects of eating the foods that are high in flavonoids will at the very least help the concussed patient have higher energy levels, to combat fatigue and to feel as well as possible. 

Diet v. Supplementation?

Since fruits and vegetables are healthy and also high in flavonoids, it should follow that flavonoids are also healthy and the more you ingest the better off youll be. Shouldnt flavonoid supplements be a fool proof way to make sure that you get enough of them? It is important to consider that we dont yet know how the body responds to the high blood levels reached all at one time when we take a supplement. Visualize how flavonoids enter the bloodstream through healthy foods eaten consistently throughout the day- the spike in the bloodstream is never reached to that same level as when a supplement is taken.

It is also important to understand that fruits and vegetables have thousands of phytochemicals, many of which we have not even been identified. So taking one type of flavonoid in high quantities is unlikely to have the same health benefits as eating the whole food [10]. There is no such thing as a silver bulletand we have to be very careful when choosing to supplement, especially when little is known about safety, contraindications, interactions, or effectiveness. Save your money and invest in colorful, delicious, flavonoid-rich foods instead.

When it comes to flavonoids, more colors mean more antioxidants. Here are some quick ways to add flavonoids to your day:

1. Top cereal with strawberries, blueberries, or bananas

2. Mix fruits with yogurt or cottage cheese.

3. Add chopped tomatoes to scrambled eggs

4. Use sweet potatoes in place of the white variety

5. Add chopped peppers to rice dishes or broccoli to pasta dishes

6. Mix pineapple into muffin or bread mixes

Until next time,

Jenna

References:

1. Johnson VE, Stewart JE, Begbie FD et al. Inflammation and white mater degeneration persist for years after a single traumatic brain injury. Brain. 2013 Jan;136(Pt 1):28-42. 

2. Arciniegas DB1, Held K, Wagner P. Cognitive Impairment Following Traumatic Brain Injury.Curr Treat Options Neurol. 2002 Jan;4(1):43-57.

3. Vauzour D, Vafeiadou K, Rodriguez-Mateos A et al. The neuroprotective potential of flavonoids: a multiplicity of effects. Genes Nutr. Dec 2008; 3(3-4): 115126.

4. Ghanim H1, Sia CL, Abuaysheh S et al. An antiinflammatory and reactive oxygen species suppressive effects of an extract of Polygonum cuspidatum containing resveratrol.J Clin Endocrinol Metab. 2010 Sep;95(9):E1-8.

5. Spencer JPE. Flavonoids and brain health: multiple effects underpinned by common mechanisms. Genes Nutr. 2009 4:243-250

6. Williams RJ1, Spencer JP. Flavonoids, cognition, and dementia: actions, mechanisms, and potential therapeutic utility for Alzheimer disease. Free Radic Biol Med. 2012 Jan 1;52(1):35-45. 

7. Cedars-Sinai Medical Center. “Plants’ Flavonoids Have Beneficial Effect On Alzheimer’s Disease, Study In Mice Suggests.” ScienceDaily. ScienceDaily, 8 May 2008. <www.sciencedaily.com/releases/2008/05/080507105646.htm>.

8. Williams RJ and Spencer JPE. Flavonoids, cognition, and dementia: Actions, mechanisms, and potential therapeutic utility for Alzheimer disease. Free Radic Biol Med. 2012 Jan 1;52(1)

9.  Rezai-Zadeh K, Shytle D, Bai Y et al. Flavonoid-mediated presenilin-1 phosphorylation reduces Alzheimer’s disease β-amyloid production. J Cell Mol Med. 2009 May;13(5):1001.

10. Egert S and Rimbach G. Which Sources of Flavonoids: Complex Diets or Dietary Supplements?Adv Nutr January 2011 Adv Nutr vol. 2: 8-14, 2011