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WellSpan sports medicine experts develop algorithm to help identify and treat concussions

Tuesday, July 22, 2014

WellSpan sports medicine experts have developed an algorithm that helps providers to know what steps to follow in diagnosing and treating concussions.

Goal is to provide appropriate level of care regardless of complexity of the case

A high school football player takes a severe blow to the head. He shows signs of a concussion. The next steps are critical.

WellSpan sports medicine experts are seeking to ensure that young athletes—and others with head trauma—receive the care they need.

The team of six experts has created an algorithm for diagnosing and treating concussions. Their step-by-step guide helps providers navigate this notoriously elusive injury.

“We’re trying to bring all providers onto the same playing field so our patients can benefit,” said Mark E. Lavallee, MD, CSCS, FACSM, director of the WellSpan York Hospital Sports Medicine Fellowship Program.

Lavallee said recent research has proven many past treatment methods ineffective.

“For example, we no longer grade concussions,” he said. “You either have one or you don’t.”

“There’s a whole cascade of symptoms, and people can experience a broad range of severity with those symptoms,” added Troy Rang, MPT, ATC, director of clinical operations at WellSpan Rehabilitation. “The algorithm is a standardized progression for reading the symptoms.”

Some warning signs are obvious: headache, nausea and confusion. Others are more subtle, like insomnia, trouble concentrating, or clumsiness.

“You can measure a person’s loss of ability to balance, so that’s one of the tools we use,” Lavallee explained.

Another tool is ImPACT (Immediate Post-concussive Assessment and Cognitive Testing), a computerized test for measuring memory, reaction time and processing speed. Many athletes now take the test before the start of their season to have a personal baseline if they suffer a head injury.

Concussion patients must rest in order to fully recover, so the team developed a set of discharge instructions that emphasizes physical and cognitive rest.

“Younger individuals are at higher risk for post-concussion syndrome,” Rang said. “That’s why there’s been such a push in recent years to protect student athletes, and make sure their symptoms have completely cleared before going back to sports.”

Sleep and inactivity are essential, Lavallee noted. “We’re talking about letting the brain rest. Not playing video games, not doing calculus, just letting the brain rest.”

With their algorithm, the team hopes to raise public awareness of proper concussion treatment.

“We’re seeing the long-term effects—at the highest level of sports—of not managing concussions appropriately,” Rang said. “Now, regardless of the simplicity or complexity of your case, you’re going to be getting the appropriate level of care.”

Acute concussion care - symptoms/signs of concussion

On field evaluation (ATC, team physician, coach) immediate medical evaluation requested/indicated (if not, 48-72 hour PCP evaluation)

Option 1: Ready Care, Care Express, Quick Care (Utilize head injury decision rules to determine need for ER referral)

Standard concussion evaluation completed (no “red flags”)

  • Standard recommendations made
  • Task to PCP
  • Follow-up PCP 48-72 hours

Option 2: Emergency Dept.

Standard concussion evaluation

  • Work up determined
  • Concussion diagnosed
  • Standard concussion recommendations
  • 48-72 hour follow-up - PCP

48-72 hour PCP follow-up

  • ImPACT as indicated
  • Balance testing
  • Exam
  • Return to work/school/physical activity decision analysis
  • Recommendations -options
  • Return to work/school/physical activity
  • Ongoing concussion management
  • Office or phone follow-up as indicated

Neurology or Sport Medicine consultation

  • 48-72 hour follow-up if no PCP (Primary Care Sports Medicine)
  • Persistent symptoms >7-14 days
  • Parent concerns at any time
  • Provider concerns (return to play in the multiply concussed, unexplained findings on examination)

Post concussion rehab:

  • Persistent symptoms at 30 days
  • Should have prior neurology consultation

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