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Fairview Sports Concussion Management Program

A Comprehensive Approach

Managed through Fairview Sports and Orthopedic Care

AGENDA

Algorithm Management Treating the Individual

1.  Entry point for athlete 2.  What ImPACT Testing is and is NOT 3.  Immediate care 4.  When to refer (best practices) 5.  Who can help? 6.  Tools and materials 2

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Entry point for athletes with sports concussions •  Athletic Trainers in local high schools •  Emergency departments •  Family Practice clinics •  Fairview Sports and Orthopedic Care physicians •  Direct access to physical therapy

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Immediate Care •  Rule out emergent situation •  Manage anything emergent •  Counsel on care and follow up -  Give patient education document -  Give sleep hygiene document (stress importance of sleep) -  Ask referring questions

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Concussion Treatment

Emotional • Nervousness • Irritability • Sadness • More emotional

Somatic • Headaches • Visual problems • Dizziness • Noise/Light Sensitivity • Nausea • Balance

Cognitive • Attention problems • Memory dysfunction • “Fogginess” • Fatigue • Cognitive slowing

Sleep • Sleeping more • Sleeping less • Difficulty falling asleep

The Law •  Minnesota passed a concussion law in the summer of 2011 which legislates training and educational materials for coaches and parents and return to play guidelines. •  “Athlete may not return until evaluated by a provider experienced in management of concussions (appropriate healthcare provider) and provider gives written permission to return”

Legal definition of Appropriate Healthcare Provider •  "Provider" means a health care provider who is: (1) registered, licensed, certified, or otherwise statutorily authorized by the state to provide medical treatment; (2) trained and experienced in evaluating and managing pediatric concussions; and (3) practicing within the person's medical training and scope of practice.

Minnesota State High School League (MSHSL) Perspective •  MSHSL Sports Medicine Advisory Committee •  National Federation of High School Associations •  Center for Disease Control •  International consensus statements •  Following “appropriate” clearance athlete will have a graded return to play

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MSHSL •  No return same day •  Cannot be returned by parent, even if they are an appropriate healthcare provider •  Stepwise progression should be medically supervised •  When in doubt, sit them out

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Stepwise progression for return 1. No activity, complete rest until all symptoms have resolved. Once asymptomatic, proceed to level 2. 2. Light aerobic exercise such as walking or stationary cycling, no resistance training. 3. Sport specific exercise—for example, skating in hockey, running in soccer; progressive addition of resistance training at steps 3 or 4. 4. Non-contact training drills. 5. Full contact training after medical clearance. 6. Game play. •  Each step must be a minimum of 24 hours

HORIZONTAL PICTURE

Athlete Concussion Management Model Algorithm 1-Preseason Baseline Testing and 2-Concussion is Suspected Education

3-Post Injury Testing and Treatment Plan

Educate athletes, parents, coaches, teachers on concussions -Utilize FV Concussion Program marketing handout TBD

As indicated, referral for evaluations by PT, OT, SLP and/or Audiology with ongoing treatment as necessary

Sideline assessment (MD and/or ATC)

Baseline ImPACT testing (every 2 years) If concussion is suspected, immediate removal from play/activity

Overseen by PT/ATC or ATC CRITERIA: A. Symptom free at rest and with cognitive exertion If symptoms are exacerbated by school – B. Post-ImPACT test within normal range athletic trainer contacts school nurse and of baseline 504 administrator for accomodations C. Written clearance for progression to activity by supervising doctor (non-ER doctor)

Return to play decisions should always be made by a concussion specialist. If the patient has been seen by a physician for their concussion, the physician makes the return to play decision.

Evaluation by Neuropsychology if indicated

IF NOT: Return to STEP 3

No recurring symptoms at rest or following physical or cognitive exertion

IF YES: Stepwise return to play progression beginning with light noncontact activity progressing to full noncontact exertion

After return to play, athlete's final ImPACT score is set as their new baseline.

"Watchful Waiting" period (3-5 days); Athlete to take post-injury ImPACT when provide consistent education and handouts symptom-free -Healing from a Sports Concussion (SW#521649) -Sleep Hygiene (SW#.....) -School accommodations - recommend 2 – 3 days off school Symptoms resolve-proceed to step 3 Refer to FSOC or MD for complete assessment

4-Is Athlete Ready for Non-Contact 5-Determining Safe Return to Activity Play

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NEUROPSYCH TESTING •  Fairview offers ImPACT through FSOC •  Many high schools and youth teams take baseline tests •  Tested 6,000 in 2012 •  If no baseline was done, there are normative values for ages 10 – 59 •  ImPACT tests are a tool to help determine if symptoms are lingering and which areas of the brain are affected •  Should not be used to get athlete in sooner “pass the test” •  Should be used to see if athlete should stay out longer

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Instructions for Patients It is OK to:

You do NOT need to:

DO NOT:

Use only acetaminophen (as recommended on the bottle) for headaches

Check eyes with flashlight

Take other over-the-counter medications such as ibuprofen, Advil, Motrin, Benadryl, Aleve, sleep aids, or Tylenol PM

Use an icepack on head and neck

Wake from sleep during the night

Drink Alcohol

Eat as tolerated

Test reflexes

Go to sleep or rest

Stay in bed

Use tobacco or other drugs including natural remedies or supplements Participate in any other exertional activities

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Patient Education “Healing after a Sports Concussion” - available in Smartworks # 521649 and in the avs in Epic §  Topics in document include – §  Rest §  School §  Treating the pain §  Monitoring symptoms

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Patient Education •  Working on Sleep Hygiene document that will also have a smartworks number and in avs •  Addresses -  Guidelines for good sleep habits -  Napping -  Routines -  Importance of quality sleep

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School Management •  Anecdotally, patients do better if they do not attend school for a few days after even a mild concussion. •  Missing school for 2-3 days following a concussion will have several advantages: -  Healing -  Missed work can be made up, failed work cannot

•  If a child needs accommodations at school a 504 plan should be put in place.

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Who to refer to? •  The physicians at Fairview Sports and Orthopedic Care are trained and appropriate to manage sports concussions. •  Any physician who has had training in the management of concussions could follow these athletes and should refer as needed. •  Athletic trainers manage return to play per the MSHSL protocol •  Fairview’s rehab. staff manage lingering symptoms •  Neuropsychology steps in for complex assessments down the road if symptoms don’t resolve.

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Physical Therapists address these areas related to sports concussions: •  Headaches •  Musculoskeletal symptoms •  Physical exertion •  Exercise progression •  Patient/family education •  Balance •  Dizziness •  Positional vertigo •  Space and motion discomfort •  Eye/head coordination (convergence, oculomotor) •  Gait or dynamic postural control

•  Physical Therapy (PT): Questions to Ask Your Patients Are you having neck, upper back or shoulder pain at rest or with activity? Do you have headaches with rest or activity?

If “Yes”Consider a referral to Physical Therapy

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Vestibular Physical Therapists Specialize in Dizziness and Balance Disorders •  Are you dizzy? •  Do you feel dizzy/yucky with motion (walking & texting, riding in a car) •  Does sitting to standing bother you? •  Do your symptoms return when reading? •  Do you have trouble with your balance or feel unstable? •  Do you get a headache or get nauseated when you are on a computer, text or play video games? Following the Acute Recovery Phase, Questions to Ask Your Patients:

If “Yes”Consider a referral to Vestibular PT

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Occupational Therapists address these areas related to sports concussions: •  Hypersensitivity (Sensory Integrative Accommodations) •  Mood and behavior changes •  Fatigue management/energy conservation (physical and cognitive rest) •  Attention and concentration for ADL/ IADL’s •  Problem solving with IADL’s (work, school, medications, cooking, etc.) •  Executive cognitive function -  Money/math skills -  Study skills and accommodation -  Self awareness/judgment

•  Skill Building for: -  Return to driving -  Return to school/work -  Upper extremity reaction and coordination -  Visual motor speed, reaction time and perceptual processing •  Patient/family education

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Occupational Therapy (OT): Questions to Ask Your Patients •  Do you have any difficulty with multi-tasking? •  Do you have any difficulty being in community settings where there is a lot of stimulation or a busy environment (i.e. mall, grocery store, school events)? •  Do you get easily lost when driving? •  Is it hard to focus on your homework due to blurry vision/ vision changes?

If “Yes”Consider a referral to Occupational Therapy

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Speech Language Pathologists address these areas related to sports concussions: •  Short term memory; recall, working memory, new learning •  Sustained/divided/alternating attention for tasks •  Compensatory strategies and modifications in home/ classroom •  Problem solving/goal setting, reasoning skills, prioritizing •  Behavior management, Social Communication (pragmatics) •  Thought expression

•  Word finding •  Patient/family education •  Reading comprehension •  Written expression •  Auditory comprehension •  Speech and verbal expression

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Speech Language Pathology (SLP): Questions to Ask Your Patients • 

Are there daily activities that you’re having trouble completing that you didn’t before (i.e. getting ready in morning, chores)?

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Are you having difficulty remembering new info for long periods of time (forgetting after a couple of hours, or next day)? (i.e. assignments given, tasks parent’s told you to do?

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Are you having difficulty completing assignments that didn’t give you difficulty before? Math? Do you forget to turn assignments in?

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Are you able to pay attention during class? Do you continue to take notes, use a planner to help? Is it effective?

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Do you feel moody, or not interested in the same activities you were before? Do you get irritated or bored easier?

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Do you get lost in conversations, or get confused when doing tasks?

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Are you having trouble putting your thoughts into words?

If “Yes”Consider a referral to Speech Language Pathology

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Chiropractors address these symptoms related to sports concussions •  Headaches •  Neck Pain

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Chiropractor: Questions to ask your patients •  Are headaches related to your neck motion? •  Do you feel like you have restrictions in neck motion? •  Was your concussion caused by a hit or blow to the head?

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If “Yes”Consider a referral to Chiropractor

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Neuropsychology •  There are Neuropsychologists at the U of MN that we work closely with and manage issues that become chronic (60-90 post injury) -  Typically have underlying issues (depression, ADHD, family issues) -  These athletes are the “puzzles” -  Run a battery of tests to determine issues (2 days) •  Neuropsychologists are evaluators—they refer to other specialists for the “treatment”. This may include mental health professionals or rehabilitation specialists. •  They often are contributing to the patients IEP.

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Communication •  Extremely important that all caregivers communicate about care •  Common symptom scales in Epic •  Communicate through in-basket messaging, phone and e-mail •  Athletic trainers who work for Fairview are in outlook -  Contact Lori Glover for names and schools

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Scheduling Numbers •  SLP, OT, Vestibular and PT – 612-273-6228 •  Fairview Sports and Orthopedic Care and IAM PT and Chiropractic 612-672-7100 (24/7)

•  For Questions – •  Call the concussion hotline: 952-460-4440 (staffed by athletic trainers who work for FSOC) answered 9a–5p •  athletic medicine hotline: 952-920-8850 (staffed by athletic trainers who work for IAM) answered 24/7 29