Too often, concussed children and teens receive little besides unnecessary CT scans in emergency departments and concussions go undiagnosed. And when concussions are diagnosed, discharge instructions are poor and “kids are sent out into a no-man’s land” where recovery is often poorly managed, she said.
When Dr. Ho and his colleagues opened their concussion center in March 2013, they began seeing patients who remained symptomatic after concussions that had occurred 6-12 months ago, and longer. “It was almost like a silent epidemic,” he said. “We had one young woman who’d been injured in her senior year of high school and was still symptomatic after 2 years.”
To build the program at Fairfax Family Practice, Dr. Ho and his colleagues, Dr. Thomas Howard and Dr. Marc Childress (who, like Dr. Ho, are board certified in sports medicine as well as family medicine), capitalized on what they saw as a valuable synergy with high school athletic trainers.
Dr. Ho had worked closely with athletic trainers as a volunteer medical adviser to the Fairfax County Public School System’s athletic training program, which provides care to student-athletes in 25 high schools. He drew on his relationships to recruit three athletic trainers who were at transition points in their careers and who had both experience and “passion” in the treatment of concussions.
One of them, Jon Almquist, VATL, ATC, had led the development of return-to-learn protocols and other management practices for the high schools. He had also partnered with investigators at MedStar Health Research Institute in Baltimore on research that documented a 4.2-fold increase in concussions among the school system’s high school athletes between 1997 and 2008 (Am. J. Sports Med. 2011;39:958-63).
More surprising than this increase, however, were some data collected after the study period ended. When Mr. Almquist looked at recovery times for the concussions reported between 2011 and 2013, he found that about 25% of concussions took 30 days or longer to recover – a portion greater than he’d seen anywhere in the literature.
According to the 2014 IOM report, youth athletes typically recover from a concussion within 2 weeks of the injury, but in 10-20% of cases the symptoms persist for a number of weeks, months, or even years.
“Families would come to us for advice,” Mr. Almquist recalled. Other than referring them to the University of Pittsburgh Medical Center’s (UPMC) Sports Medicine Concussion Program, there were few local providers whom they believed offered comprehensive care and had experience with prolonged impairment.
Mr. Almquist and his fellow athletic trainers, and Dr. Ho and his physician colleagues, all had been following developments at UPMC’s Sports Medicine Concussion Program since it was established in 2000. The program had evolved to assess and manage diverse facets of concussions, including vision, vestibular, exertion, and medication components—not all of which are fully addressed in clinical practice guidelines and position statements. By 2010, the program was drawing 10,000 patients a year.
Care at UPMC is guided by a clinical neuropsychologist who assesses head injuries and then refers patients on as needed to other members of the team – like a neurovestibular expert for vestibular assessment and therapy, a neuro-optometrist for vision therapy, a physical therapist for exertion training, or a sports medicine physician for medication.
In planning their own concussion center, Dr. Ho and his team visited various programs in the country but homed in on UPMC. They decided to mimic several aspects of UPMC’s approach by providing comprehensive and individualized care, and by having the certified athletic trainers serve as the “quarterbacks.”
“The athletic trainer in our center does all the symptom inventories and history taking, a concussion-focused physical exam, vestibular-ocular-motor screening, and neurocognitive tests if appropriate,” said Dr. Ho.
Dr. Ho or one of his sports medicine physician colleagues then discusses results with the athletic trainer and completes the patient visit – with the trainer – by asking any necessary follow-up questions, probing further with additional evaluation, and writing medication prescriptions when appropriate.
Throughout the course of care – visits occur weekly to monthly and often last 30-90 minutes – the athletic trainer and physician work together on clinical issues such as sleep and mental health and on subtyping headaches (cognitive fatigue, cervicogenic, or migrainelike) and “determining where the headaches lie relative to other areas of dysfunction,” said Dr. Ho.
Much of the individualized counseling, monitoring, and coordination that’s required to address sleep hygiene, rest, nutrition, and graded return to physical and cognitive activity can be led by the athletic trainer, he said.
For the first year or so, patients were referred out for such special services as vision or vestibular therapy. But there were problems with this approach: One frequent issue was poor insurance coverage for these therapies. Another was the stress involved in getting to additional appointments on Fairfax’s congested roads. “Traffic and busy environments aren’t always tolerable for a concussed patient,” Dr. Ho said.