- Email: [email protected]
Sports Concussions: Physiatrists Earning Their Seat at the Table
Invited Perspective
Sports Concussions: Physiatrists Earning Their Seat at the Table Stanley A. Herring, MD In this issue of PM&R, I am privileged to introduce to the readers the first publication of the Consensus Statement on Concussion in Sport from the 3rd International Conference on Concussion in Sport. This document is the culmination of the conference held in Zurich, Switzerland, in November 2008 and is being simultaneously published in several other national and international sports medicine journals. It is very appropriate that this new official journal of the American Academy of Physical Medicine and Rehabilitation participate in this important event in the field of sports medicine. This work is a revision and update of the 2 previous Consensus Statements from the 1st (Vienna) and 2nd (Prague) International Conferences on Concussion in Sport, and it was written by a world-class and worldwide group of experts. It was an honor to be one of the panelists invited to share my experiences as a physiatrist with an array of multidisciplinary clinicians and scientists, including certified athletic trainers, exercise scientists, internists, neurologists, neuropsychologists, neurosurgeons, pediatricians, and primary care sports medicine physicians, all with great interest in concussion in sport. The foundation for the statement was laid in a course that preceded the work of our writing group in which topics ranging from sideline assessment and return-to-play decisions, age and gender concerns, and long-term outcome issues and future directions were discussed and debated. Clinical care controversies and research advances facilitated a lively discussion as this multidimensional group of health care providers worked in concert to produce a guide that aims to limit suffering and maximize function in athletes with this neurological injury (concussion). This concept is one that should clearly resonate with all physiatrists. Although my participation at this meeting was prompted by my long-time role as a team physician, I was principally supported by my roots as a physiatrist. I unequivocally believe that physiatry should be represented in this forum. For the past 2 decades, this specialty has been undergoing a metamorphosis, and one of these evolutionary changes is a greatly expanded interest in musculoskeletal and sports medicine. Although members of various medical specialties participate in providing care to active people and athletes, the area of sports-related concussion represents an ideal opportunity for physiatrists to serve patients and demonstrate our unique knowledge base, clinical skills, and perspective. Too often I see my physical medicine and rehabilitation colleagues so anxious to enter the locker room that they abandon their unique physiatric approach to the management of musculoskeletal and neurological injury that sets them apart from other practitioners; the very approach that adds value to the care of the athlete and has earned the physiatrist a seat at the sports medicine table. In the Zurich monograph, the diagnosis and management of cognitive, somatic, and emotional sequelae in concussed athletes are addressed in detail. Although there was a spirited discussion among the international panel as to taxonomy, specifically whether or not the diagnosis of concussion should be separated from that of mild traumatic brain injury, the inherent challenges of addressing both the physical and psychological effects of a concussion in a patient-centered approach should be very recognizable to all physiatrists. In treating concussed athletes, it is frankly my physiatric training in traumatic brain injury that provides the knowledge base (neuroanatomy and physiology, neuropsychological testing, and clinical presentation) to effect appropriate care through the unique integration of structural and functional assessment. Whether the patient’s activities of daily living are PM&R
404
1934-1482/09/$36.00 Printed in U.S.A.
S.A.H. UW Medicine Sports and Spine Phys, 325 Ninth Avenue, Box 359721, Seattle, WA 98104. Address correspondence to: S.A.H.; e-mail: [email protected] Disclosure: 2B, United Health Care Spine Scientific Advisory Board Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 404-405, May 2009 DOI: 10.1016/j.pmrj.2009.03.011
PM&R
feeding, bathing, and dressing or aerobic and strength training and graduated return to practice and play, the principles are the same. Transmuting traditional physiatric care regarding traumatic brain injury into a medical skill set necessary to assess and treat the concussed athlete is both an academic and experiential process. Such linear learning starts in the lecture hall but extends to the “field of play” and ultimately to the examination room. The physiatrist must become facile regarding sports-specific injury epidemiology, training and conditioning demands, return-to-play criteria, equipment issues, and a myriad of other details. I have spent more than 25 years on the sidelines and in training rooms as a team physician at all levels of athletic competition, from amateur to elite, and during this time period there has definitely been an expansion in the body of scientific information regarding sports-related concussion. I have learned that critical clinical evaluation and return-to-play decisions are based on multiple factors, including an athlete’s age, sport, concussion history, and school performance. Managing sports concussions almost always extends beyond the athlete to include various concerned parties (eg, parents, coaches, teachers, spouses, agents, and team officials), all with potentially competing agendas. Coordinating the care of multiple medical providers and experts often is necessary, particularly in the cases of persistent postconcussive symptoms. For example, one particularly vexing problem for many health care providers is differentiating persistent postconcussive symptoms from the psychological manifestations of a concussion (eg, anxiety and depression); yet, for physiatrists, such capability is part of the fabric of our training and parallels the traditional role of the physiatrist as a provider and care coordinator for those patients with complicated medical and psychosocial problems. Another application of physiatric principles to the field of sports medicine involves our role as advocates for disability prevention. A familiar role for members of our specialty is
Vol. 1, Iss. 5, 2009
405
working with various stakeholders on stroke prevention, fall prevention, seatbelt laws, and other public welfare issues to promote health while limiting disability. Striving to keep young athletes safe in sports is another important area in which our understanding of the physical and psychological consequences of serious injury compels us to take action. Such an initiative is presently occurring in Washington State, where the physical medicine and rehabilitation community—in concert with a strong coalition including the University of Washington Medical Center, Harborview Medical Center, the Brain Injury Association of Washington, the Washington Interscholastic Activities Association, the Washington State Athletic Trainers Association, the Washington State Youth Soccer Association, and many other organizations— has proposed a state law that would require middle school and high school student athletes who have experienced a concussion to receive clearance by a licensed health care provider, trained in the evaluation and management of sports concussions, before returning to practice or play. This forward-thinking legislation is currently working its way through the Washington State legislature, and I am hopeful that its passage will usher in an era in which the potentially devastating consequences of mismanaging concussions in young athletes will be minimized. Clearly, the assessment and care of the concussed athlete should be important to physiatrists. First, this represents an ideal opportunity for physiatrists to enter the world of sports medicine. Second, physiatrists already have the training that provides the foundation to serve in this capacity. Finally, by building upon this foundation, physiatrists can be justifiably recognized as experts in this field and become public advocates for an issue with great potential for disability. I hope that the reader finds the Zurich consensus statement educational, that it is helpful to those already involved in sports concussion care, and that it may stimulate others to explore this interesting, challenging, and rewarding area of medicine.
Sports Concussions: Physiatrists Earning Their Seat at the Table Stanley A. Herring, MD In this issue of PM&R, I am privileged to introduce to the readers the first publication of the Consensus Statement on Concussion in Sport from the 3rd International Conference on Concussion in Sport. This document is the culmination of the conference held in Zurich, Switzerland, in November 2008 and is being simultaneously published in several other national and international sports medicine journals. It is very appropriate that this new official journal of the American Academy of Physical Medicine and Rehabilitation participate in this important event in the field of sports medicine. This work is a revision and update of the 2 previous Consensus Statements from the 1st (Vienna) and 2nd (Prague) International Conferences on Concussion in Sport, and it was written by a world-class and worldwide group of experts. It was an honor to be one of the panelists invited to share my experiences as a physiatrist with an array of multidisciplinary clinicians and scientists, including certified athletic trainers, exercise scientists, internists, neurologists, neuropsychologists, neurosurgeons, pediatricians, and primary care sports medicine physicians, all with great interest in concussion in sport. The foundation for the statement was laid in a course that preceded the work of our writing group in which topics ranging from sideline assessment and return-to-play decisions, age and gender concerns, and long-term outcome issues and future directions were discussed and debated. Clinical care controversies and research advances facilitated a lively discussion as this multidimensional group of health care providers worked in concert to produce a guide that aims to limit suffering and maximize function in athletes with this neurological injury (concussion). This concept is one that should clearly resonate with all physiatrists. Although my participation at this meeting was prompted by my long-time role as a team physician, I was principally supported by my roots as a physiatrist. I unequivocally believe that physiatry should be represented in this forum. For the past 2 decades, this specialty has been undergoing a metamorphosis, and one of these evolutionary changes is a greatly expanded interest in musculoskeletal and sports medicine. Although members of various medical specialties participate in providing care to active people and athletes, the area of sports-related concussion represents an ideal opportunity for physiatrists to serve patients and demonstrate our unique knowledge base, clinical skills, and perspective. Too often I see my physical medicine and rehabilitation colleagues so anxious to enter the locker room that they abandon their unique physiatric approach to the management of musculoskeletal and neurological injury that sets them apart from other practitioners; the very approach that adds value to the care of the athlete and has earned the physiatrist a seat at the sports medicine table. In the Zurich monograph, the diagnosis and management of cognitive, somatic, and emotional sequelae in concussed athletes are addressed in detail. Although there was a spirited discussion among the international panel as to taxonomy, specifically whether or not the diagnosis of concussion should be separated from that of mild traumatic brain injury, the inherent challenges of addressing both the physical and psychological effects of a concussion in a patient-centered approach should be very recognizable to all physiatrists. In treating concussed athletes, it is frankly my physiatric training in traumatic brain injury that provides the knowledge base (neuroanatomy and physiology, neuropsychological testing, and clinical presentation) to effect appropriate care through the unique integration of structural and functional assessment. Whether the patient’s activities of daily living are PM&R
404
1934-1482/09/$36.00 Printed in U.S.A.
S.A.H. UW Medicine Sports and Spine Phys, 325 Ninth Avenue, Box 359721, Seattle, WA 98104. Address correspondence to: S.A.H.; e-mail: [email protected] Disclosure: 2B, United Health Care Spine Scientific Advisory Board Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 404-405, May 2009 DOI: 10.1016/j.pmrj.2009.03.011
PM&R
feeding, bathing, and dressing or aerobic and strength training and graduated return to practice and play, the principles are the same. Transmuting traditional physiatric care regarding traumatic brain injury into a medical skill set necessary to assess and treat the concussed athlete is both an academic and experiential process. Such linear learning starts in the lecture hall but extends to the “field of play” and ultimately to the examination room. The physiatrist must become facile regarding sports-specific injury epidemiology, training and conditioning demands, return-to-play criteria, equipment issues, and a myriad of other details. I have spent more than 25 years on the sidelines and in training rooms as a team physician at all levels of athletic competition, from amateur to elite, and during this time period there has definitely been an expansion in the body of scientific information regarding sports-related concussion. I have learned that critical clinical evaluation and return-to-play decisions are based on multiple factors, including an athlete’s age, sport, concussion history, and school performance. Managing sports concussions almost always extends beyond the athlete to include various concerned parties (eg, parents, coaches, teachers, spouses, agents, and team officials), all with potentially competing agendas. Coordinating the care of multiple medical providers and experts often is necessary, particularly in the cases of persistent postconcussive symptoms. For example, one particularly vexing problem for many health care providers is differentiating persistent postconcussive symptoms from the psychological manifestations of a concussion (eg, anxiety and depression); yet, for physiatrists, such capability is part of the fabric of our training and parallels the traditional role of the physiatrist as a provider and care coordinator for those patients with complicated medical and psychosocial problems. Another application of physiatric principles to the field of sports medicine involves our role as advocates for disability prevention. A familiar role for members of our specialty is
Vol. 1, Iss. 5, 2009
405
working with various stakeholders on stroke prevention, fall prevention, seatbelt laws, and other public welfare issues to promote health while limiting disability. Striving to keep young athletes safe in sports is another important area in which our understanding of the physical and psychological consequences of serious injury compels us to take action. Such an initiative is presently occurring in Washington State, where the physical medicine and rehabilitation community—in concert with a strong coalition including the University of Washington Medical Center, Harborview Medical Center, the Brain Injury Association of Washington, the Washington Interscholastic Activities Association, the Washington State Athletic Trainers Association, the Washington State Youth Soccer Association, and many other organizations— has proposed a state law that would require middle school and high school student athletes who have experienced a concussion to receive clearance by a licensed health care provider, trained in the evaluation and management of sports concussions, before returning to practice or play. This forward-thinking legislation is currently working its way through the Washington State legislature, and I am hopeful that its passage will usher in an era in which the potentially devastating consequences of mismanaging concussions in young athletes will be minimized. Clearly, the assessment and care of the concussed athlete should be important to physiatrists. First, this represents an ideal opportunity for physiatrists to enter the world of sports medicine. Second, physiatrists already have the training that provides the foundation to serve in this capacity. Finally, by building upon this foundation, physiatrists can be justifiably recognized as experts in this field and become public advocates for an issue with great potential for disability. I hope that the reader finds the Zurich consensus statement educational, that it is helpful to those already involved in sports concussion care, and that it may stimulate others to explore this interesting, challenging, and rewarding area of medicine.