powerpoint presentation3/9/2017 1 linking physical therapy concussion management practice to...

3/9/2017

1

Linking Physical Therapy Concussion

Management Practice to Research

and Research to Practice

Catherine Quatman-Yates,PT, DPT, PhD

Jason Hugentobler, PT, DPT, SCS, CSCS

OPTA 2017 Annual Conference

March 24, 2017

Disclosures• Catherine Quatman-Yates

– Member of APTA sponsored Concussion CPG Development Team

– NIH KL2 grant, Ohio EMS Grant (2), Cincinnati Children’s Research in Patient Services PS2 Grant, Cincinnati Children’s Trustees Program Award (2), OPTA Research Grant

• Jason Hugentobler– Evidence in Motion Concussion Program Faculty

– Ohio EMS Grant (2), Cincinnati Children’s Trustees Program Award (2)

Acknowledgements• Brad Kurowski, MD, MS

• Shari Wade, PhD

• Richard Ittenbach, PhD

• Mark Paterno, PT, MBA, PhD

• Tracy Glauser, MD

• Michael Riley, PhD

• Annie Lennon, PT, DPT

• Meredith Vegh, PT, DPT

• Barbara Janiszewski, PT, DPT, SCS

• Katie Hugentobler, PT, DPT, MBA

• CCHMC OTPT leadership and staff

• CCHMC sports medicine physicians and staff

3/9/2017

2

Learner Objectives

• Identify at least one potential opportunity to

bridge the evidence practice gap for concussion

management within your clinical practice or setting.

• Identify at least one potential barrier and

corresponding strategy to bridge the evidence

practice gap for concussion management within

your clinical practice or setting.

INTRODUCTION

Infr

astr

uctu

re

TBI (starting with mild)

EBP in Healthcare• 1992: “Evidence based medicine” introduced by Guyatt to shift

emphasis in clinical decision making from “intuition, unsystematic, clinical experience, and pathophysiologic rationale” to scientific, clinically relevant research”

• 1996: Sacket et al.—Emphasis on a combination of clinical expertise and patient’s preferences

• 2008: US Congress asks IOM to undertake a study on best methods used in developing clinical practice guidelines; IOM report—standards should be created, mechanisms should be created to support EBP practices

• 2011: IOM publishes Clinical Guidelines We Can Trust; Guidelines.gov embraces the standards

• 2013/14: IOM standards revised with greater emphasis on better transparency of systematic review process and synthesis processes and the processes used to form guidelines

3/9/2017

3

Recognized EBP Barriers

• There is no adequate evidence available

– Or there is but clinicians may...

• Be unaware

• Disagree with it

• Have trouble accessing it

• Have trouble knowing how to apply it

• Experience cultural and/or system barriers

1990 1995 2000 2005 2010 2015 2020

1992: “Evidence-based medicine

introduced by Guyatt to shift

emphasis in clinical decision making from “intuition, unsystematic, clinical

experience, and pathophysiologic

rationale to scientific and clinically

relevant research.

2008: Congress asks

IOM to undertake study

on best methods for developing CPGs. IOM

reports standards

should be established

2011: IOM publishes

Clinical Guidelines

We Can Trust; Guidelines.gov

embraces the

standards.

2013/14: IOM standards were

revised with greater emphasis

on better transparency of evidence search, appraisal,

synthesis, and recommendation

formation.

2005: Leadership

made commitment

to cultivate EBP culture

Cincinnati Children’s Division of OTPTTR Evidence Based Practice Journey

2006: Division published

first CPG (followed by

nearly 40 more and counting)

2010: Embraced

improvement science

methods/projects

2013: Began work in

chronic care outcomes

improvement, registry creation, population

management.

Growing Recognition of Need for Implementation, Not Just Awareness

3/9/2017

4

Scientific Discovery and Dissemination

Discovery Identification

and Synthesis

(BESts and Guidelines)

Discovery Integration and Care Quality

Improvement

Practice-Based

Evidence Discovery

-7 PhD trained clinicians, more in

progress

-$$$ in Grant Funding

-70 peer-reviewed publications

-35 EBP Guidelines/BESt

Statements

- IRB Approved Registry and Pilot

Project Data Extractions in

Progress

10 RCIC Teams

8 I2S2 Projects

2 AIM projects

1 COI Success

Percentage of CMT Patients Achieving Full Resolution within 6 Months

Strenk, Kiger, Hawke, Mishnick, Quatman-Yates. Physical Therapy Journal. (In Press)

3/9/2017

5

Scientific Discovery and Dissemination

Discovery Identification

and Synthesis

(BESts and Guidelines)

Discovery Integration and Care Quality

Improvement

Practice-Based

Evidence Discovery

CHEAPER

BETTER

FASTER

3/9/2017

6

Self-Assessment Activity

Practice-Based

Evidence (PBE):

High capacity to

generate evidence

at the point of care

Practice

Research

How Can We Work Together to Build Evidence-

Practice Bridges?

Evidence-Based

Practice (EBP):

High capacity to

integrate evidence

at the point of care

Supportive

Infrastructure

(QI)

Supportive

Infrastructure

(Research)

3/9/2017

7

MOTIVATION ABILITY

Personal Personal

Social Social

Structural Structural

2016 © Cincinnati Children's Hospital Medical Center. All rights reserved.

James M. Anderson Center for Health Systems Excellence

Motivation Ability

Personal

Social

Structural

What is your practice setting already doing well in terms of bridging the evidence-practice gap?



Motivation Ability

Personal

Social

Structural

Opportunities for bridging the evidence-practice gap in your practice setting?

https://www.cincinnatichildrens.org/




3/9/2017

8



Key Limitations and Barriers

Brief Recap…

Infr

astr

uctu

re

TBI (starting with mild)

Way back when…



3/9/2017

9

Cultural Shifts and Study Boom

An estimated 1.6 - 3.8

million people sustain

TBIs each year in the

U.S.

The majority are mild

TBI or concussions.

Head injuries ≠ Brain injuries.

Conventional imaging may NOT

capture structural damage.

MOST mild TBIs result in only

short-term functional limitations.

10-30% of mild injuries result in

prolonged symptoms and

functional impairments.

For those with prolonged

symptoms—it can be very

DISRUPTIVE to the child’s and

family’s daily life.

3/9/2017

10

TBI is one of the most prominent known environmental risk

factors for long-term neurodegenerative sequelae…

Rebekah Mannix—Prognostic Biomarkers and Genetic Markers in Ped. Concussion (Figure courtesy of Ron Hayes)

Not just a “brain” injury

• Musculoskeletal system

• Vestibular system

• Oculomotor system

• Sensorimotor processing

• Motor coordination

• Exertional/autonomic adaptation

And these are just

the systems, PTs

are most directly

concerned with…

e.g., Ontario Neurotrauma Foundation Guidelines for Concussion 2013; Marshall et al.

Clinical Practice Guidelines for mild traumatic brain injury and persistent symptoms. 2012. Canadian Family Physician; Department of Defense Clinical Practice Guidelines

for Management of Concussion /Mild Traumatic Brain Injury 2009.

3/9/2017

11

Body of Evidence Surrounding

PT Concussion Assessments

All mTBI Studies

Diagnostic Evaluation

and Medical Management

PT Scope of Practice

Valid and Reliable for Our Needs?

If designed for the

sideline, how useful is

it for us in the clinic?

It may be able to capture

impairments acutely and at

a population level, but how

does this translate into

individual patients?

Is this truly within a PT’s

scope of practice?

Proliferation of options, but

very few direct

comparisons—can we really

say one is better than the

other?Can we simply borrow from

other PT assessment

techniques, even though

studies specific to

concussion have not been

done?

An assessment technique

may be more sensitive from

a research perspective, but

does the benefit outweigh

the cost of implementation?

Body of Evidence Surrounding PT

Interventions for Concussions

All mTBI Studies

Diagnostic Evaluation

and Medical Management

PT Scope of Practice

Valid and Reliable for Our Needs?

8 studies…a few

more since then

3/9/2017

12

2011 2013 2015 2017

PT Role: Call

Over BESS

Tests

PT Concussion

Evaluate and

Treat

Implementation

and Spread

TBI Identified as

Top Condition

with Formation

of Community of

Practice

Bi-annual Staff

Updates and

Training

First

Concussion

Publications

and Funded

Grants

2013:

30 Scheduled

PT Visits,

8 Completed

2016:

173 Scheduled

PT Visits,

168 Completed

-Katie invited to

join APTA CPG

-Jason invited to

join EIM Faculty

First PBE study

conducted and

submitted for

publication

2011 2013 2015 2017

PT Role: Call

Over BESS

Tests

PT Concussion

Evaluate and

Treat

Implementation

and Spread

TBI Identified as

Top Condition

with Formation

of Community of

Practice

Bi-annual Staff

Updates and

Training

First

Concussion

Publications

and Funded

Grants

2013:

30 Scheduled

PT Visits,

8 Completed

2016:

173 Scheduled

PT Visits,

168 Completed

-Katie invited to

join APTA CPG

-Jason invited to

join EIM Faculty

First PBE study

conducted and

submitted for

publication

7 years later

-8 published manuscripts

-1 more in press

-1 under review

-$811,000 in grant funding

-20+ National/International presentations

CCHMC PT Concussion

Management Program

3/9/2017

13

Evidence-based classification

system Ellis MJ Brain Injury 2015

Post-concussion classification

Ellis et al. 2015

• Physiologic post-

concussion

disorder (PCD)

• Vestibulo-ocular

PCD

• Cervicogenic PCD

Our proposal

• Physiologic

• Vestibulo-ocular

• Sensorimotor

• Cervicogenic/MSK

3/9/2017

14

What are we seeing?

• “Typical” Athlete vs Athlete with PCS– Typical athlete will progress through RTP stepwise progression

– Pass all Concussion Testing

• Athlete with Post-Concussion Syndrome– PCS can occur in up to 14% of athletes 6-18 – OLD DATA (pre 2010)

• Between 20-30% at CCHMC have prolonged recovery

• Zemek et al. 2016 – Pediatric Emergency Research Canada (PERC)

– 3063 pts from 8/13 – 10/14 883 (31%) had persistent post-concussion symptoms 28 days later

– WHO = 3 or more symptoms for > 6 weeks

• Headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, memory difficulty

– Predictors of protracted recovery (Lau, 2011)

Role of PT CCHMC Model

Call Over Tests

and Measures

Postural Control

• Why?– Control of posture requires the CNS to process

and integrate information from visual, somatosensory and vestibular systems to produce an appropriate and coordinated response

– Concussion injuries can often disrupt or lead to changes in these processes (Guskiewicz, 2011; De Beaumont et al., 2011;

Cavanaugh et al., 2006; Riemann, et al., 2000)

– Injury to corticospinal tract and corticoreticularpathway associated following mTBI (Lee HD, Jang SH 2015, Jang SH, Kim

SY 2015)

3/9/2017

15

http://instruct.uwo.ca/anatomy/5

30/motor.htm

Balance Error Scoring System

http://emt.bu.edu/em610/em610_ol_spring_2008/mtoda125/reco

very.html


• Equipment needs:– Foam pad

– Stop watch

– Spotter

– BESS testing protocol

– BESS score card

• Stance positions: bipedal, single limb, tandem– Floor/ground surface

– Foam surface

3/9/2017

16


• Each trial is 20 seconds

• Errors include:

– Moving hands off iliac crests

– Opening eyes

– Step, stumble or fall

– ABD or FLX of hip beyond 30º

– Lifting forefoot or heel off of the testing surface

– Remaining out of the proper test position for ˃ 5 seconds

Limitations to BESS

• Designed as a sideline test (3-5 days post-injury)

• Our patients are often 5+ days post-injury

• Tested with college athletes

• Hip strength had likely stabilized vs. maturational changes

• Pre-season baseline assessments vs. normative estimates

• Need for challenging stances

• More difficult for youth?

• Observer-rated

• Too subtle to detect with eye? Rater reliability issues?

• Learning Effects

Role of PT CCHMC Model

Call Over Tests

and Measures

Full Evaluation

and Treatment

Athletes with

Protracted

Recovery

• Activity/Exercise

Tolerance

• Balance Training

• Vestibular Therapy

• Gaze Stability

• Dual Tasking

3/9/2017

17

King-Devick (K-D) test

• Rizzo et al. “methodology for assessment of normative data for the king-devick test”

– Slowed reading times acutely concussed

– Looked at normal behavior of eyes

– 12 controls• K-D reading time 51.24 (+/- 9.7) seconds

• Total of 145 saccades (+/-15)

• Average peak velocity 299.5 deg/s

• Subjects with fewest saccades tended to blink more causing larger missed data/errors

History• Timeline of events (Pt and Parent)

– When did injury occur

– Injury mechanism

– Description of onset of symptoms

– Description of current symptoms

• Previous concussion/head injury history

• Previous lower extremity or spinal injury

• ADHD/other health-related concerns

• Activity level prior to injury (sports, school, etc)

• Pertinent family history

Rehab A Z

1. Symptoms/Vitals– Beginning and periodic

2. Aerobic Exercise

– Manual Therapy

– Stretching

– Strengthening/Resistance

– Sport-specific/Interval training

– Balance/Vestibular/Oculomotor

3. Patient Education

3/9/2017

18

http://max-form.com/a-simple-workout-intensity-scale-rpe/

Vitals are VITAL

Light Aerobic Exercise

• Growing literature

• Prolonged rest can lead to deconditioning, depression, and fatigue

• Sub-symptom exercise may be beneficial(Leddy, 2007, Leddy 2010, Vidal 2012)

• Consensus recommends intensity of < 70% of maximum predicted

heart rate (McCrory et al., 2012)

– Study by Leddy et al. used 80% of symptom threshold HR

Aerobic Exercise

• Mode of Exercise– Bike

– Treadmill

– Clinic Area

– Elliptical

– Swimming

• Intensity of Exercise– HR

– Perceived Exertion

• Time

3/9/2017

19

http://www.youthsportsny.org/injury-reports/

3/9/2017

20

Symptom Re-assessment within

session

Pay attention to:

• Headache

• Nausea

• Balance problems

• Dizziness

• Fatigue

• Sensitivity to light/sound

• Feeling slowed down

• Visual problems

Don’t pay attention to:

• Trouble falling asleep

• Sleeping more/less

• Irritability

• Sadness

• Nervousness

• Feeling more emotional

Cognitive Symptoms

• Attention Problems

• Memory dysfunction

• “Fogginess”

• Fatigue

• Cognitive slowing

Somatic Symptoms• Visual Problems

• Dizziness

• Balance Difficulties

• Headaches

• Light Sensitivity

• Nausea

Emotionality• More emotional

• Sadness

• Nervousness

• Irritability

Sleep Disturbance•Difficulty falling asleep

• Sleeping less than usual

Factor Analysis, Post-Concussion Symptom Scale (Pardini, Lovell, Collins, 2004)

N=327, High School and University Athletes Within 7 Days of Concussion

Rehab A Z

1. Symptoms/Vitals– Beginning and periodic

2. Aerobic Exercise

– Manual Therapy

– Stretching

– Strengthening/Resistance

– Sport-specific/Interval training

– Balance/Vestibular/Oculomotor

3. Patient Education

3/9/2017

21

Manual Therapy

• Joint Mobility– Upper vs Lower Cervical

– Upper Thoracic

• Soft-tissue Mobility– Suboccipital region

– Scalenes

– Upper Trapezius

– Levator Scapulae

– SCM

• Headaches

Cervicogenic Headache (CEH)

• Systematic Review 2012 (Chaibi)– 7 RCT’s

• Physiotherapy

• Cervical spinal manipulative therapy (SMT)

– RCT’s suggest that physiotherapy and SMT mightbe an effective treatment in management of CEH

• Other causes of headache– Tension-type

– Migraine

– Autonomic Dysfunction

Headaches

Mig

rain

e •Recurrent

•Lasts 4-72 hours

•Unilateral and usually frontotemporal (can be bilateral especially in children <18 y/o)

•Pulsating quality

•Moderate to severe intensity

•Aggravated by routine physical activity

•Often associated with nausea, photophobia, phonophobia

•With or without aura

•Premonitory and resolution symptoms can include neck pain and stiffness

Tensio

n H

eadache •Recurrent

•Lasts minutes to days

•Typically bilateral

•Pressing/tightening in quality

•Mild to moderate intensity

•Does not worsen with routine physical activity

•Not associated with nausea but photophobia or phonophobia may be present

•Associated with myofascial tender spots

Cerv

icogenic

Headache •Tension type headache

associated with pericranial tenderness

•Evidence that pain is attributed to a neck disorder or lesion within the cervical spine or soft tissues

•Clinical features may include neck pain, focal neck tenderness, hx of trauma, mechanical exacerbation of pain, unilaterality, shoulder pain, decreased cervical ROM, nausea, photophobia, phonophobia

•Pain resolves within 3 months of successful treatment of the underlying cause

*International Headache Society Classification of Headache Disorders 3rd ed.

3/9/2017

22

Stretching/Strengthening Exercise

• NO Evidence in Concussion– Ylinen et al. 2010 RCT – Neck Ex and CEH

• Stretching was LESS effective alone than when combined with muscle endurance and strength training

• Focus on DNF’s and Scapula

• Mechanism of Injury:– Whiplash

– Rotational

• Posture Presentation

http://ptjournal.apta.org/content/ptjournal/85/12/1349/F2.small.gif

Deep Neck Flexor Endurance Test

• Range of norms

– 20-40 seconds

• Neck pain

– 20-25 seconds

3/9/2017

23

Strength Training

• Follow stepwise progression– Light resistance initially

• Set parameters– Sets, reps, resistance, rest times

• If asymptomatic during ex progress– Need to account for cumulative effect of exercise

• Collins et al 2014 6600 HS athletes– Concussed vs uninjured

• Smaller mean neck circumference

• Small mean overall neck strength

Vestibulo-ocular dysfunction in

pediatric SRC Ellis MJ, et al. J Neurosurg Pediatr 2015

• 76% acute SRC (less than 30 days)

– 29% criteria for VOD

• 24% post-concussion syndrome

– 63% criteria for VOD

• Evidence of VOD acutely greater

chance of developing PCS

VOMS

• Designed for use with subjects ages 9-40

– When used with patients outside this age

range, interpretation may vary

• Abnormal findings or provocation of

symptoms with any test may indicate

dysfunction

– Help to guide treatment

3/9/2017

24

VOMS Equipment

• Tape measure (cm)

• Metronome

• Target w/ 14 point font print

– Provided to each of the satellites

– Re-usable tongue depressor with “E”

• Scoring sheet

• Instruction reference sheet

VOMS

• Baseline symptom assessment 0-10 scale

– Headache

– Dizziness

– Nausea

– Fogginess

VOMS

Smooth Pursuits

• Test the ability to follow a slowly moving target

• The patient and the examiner are seated

• The examiner holds a fingertip at a distance of 3 ft. from the patient

• The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft. to the right and 1.5 ft. to the left of midline

• One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed

• The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left

• The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions up and down

• Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward

• Record: Headache, Dizziness, Nausea & Fogginess ratings after the test

3/9/2017

25

VOMS

• Smooth Pursuit PRACTICE

VOMS

• Saccades- horizontal and vertical

– Test the ability of the eyes to move quickly

between targets

– Patient and examiner are both seated for

testing

VOMS

• Horizontal saccades– The examiner holds two single points (fingertips)

horizontally at a distance of 3 ft. from the patient, and 1.5 ft. to the right and 1.5 ft. to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right

– Instruct the patient to move their eyes as quickly as possible from point to point

– One repetition is complete when the eyes move back and forth to the starting position, and 10 repetitions are performed

– Record: Headache, Dizziness, Nausea & Fogginess ratings after the test

3/9/2017

26

VOMS

• Vertical saccades– Repeat the test with 2 points held vertically at a

distance of 3 ft. from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient must gaze 30 degrees upward and 30 degrees downward

– Instruct the patient to move their eyes as quickly as possible from point to point

– One repetition is complete when the eyes move up and down to the starting position, and 10 repetitions are performed


VOMS

• Horizontal and Vertical Saccade

PRACTICE

VOMS

• Convergence– Measure the ability to view a near target without double vision

– The patient is seated and wearing corrective lenses (if needed)

– The examiner is seated front of the patient and observes their eye movement during this test

– The patient focuses on a small target (approximately 14 point font size) at arm’s length and

slowly brings it toward the tip of their nose

– The patient is instructed to stop moving the target when they see two distinct images or when

the examiner observes an outward deviation of one eye

– Blurring of the image is ignored

– The distance in cm. between target and the tip of nose is measured and recorded

– This repeated a total of 3 times with measures recorded each time


– Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose

• ≥ 4 cm for measurement of true change + symptom ↓

3/9/2017

27

VOMS

• Convergence

VOMS

• Vestibular-Ocular Reflex (VOR) Test

– Assess the ability to stabilize vision as the

head moves

– The patient and the examiner are seated

– The examiner holds a target of approximately

14 point font size in front of the patient in

midline at a distance of 3 ft

VOMS

• Horizontal VOR Test– The patient is asked to rotate their head horizontally

while maintaining focus on the target

– The head is moved at an amplitude of 20 degrees to each side and a metronome is used to ensure the speed of rotation is maintained at 180 beats/minute (one beat in each direction)

– One repetition is complete when the head moves back and forth to the starting position, and 10 repetitions are performed

– Record: Headache, Dizziness, Nausea and Fogginess ratings after the test is completed

3/9/2017

28

VOMS

• Vertical VOR Test– The test is repeated with the patient moving their

head vertically

– The head is moved in an amplitude of 20 degrees up and 20 degrees down and a metronome is used to ensure the speed of movement is maintained at 180 beats/minute (one beat in each direction)

– One repetition is complete when the head moves up and down to the starting position, and 10 repetitions are performed

– Record: Headache, Dizziness, Nausea and Fogginess ratings after the test

VOMS• Near Point Convergence and VOR (vertical and horizontal) practice

VOMS

• Visual Motion Sensitivity (VMS) Test– Test visual motion sensitivity and the ability to inhibit vestibular-induced eye

movements using vision

– The patient stands with feet shoulder width apart, facing a busy area of the clinic

– The examiner stands next to and slightly behind the patient, so that the patient is guarded but the movement can be performed freely

– The patient holds arm outstretched and focuses on their thumb

– Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left

– A metronome is used to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction)

– One repetition is complete when the trunk rotates back and forth to the starting position, and 5 repetitions are performed


3/9/2017

29

VOMS

• VMS Test PRACTICE

Sports Specific Return

to Play

IJSPT article May et al. 2014

• Football

• Gymnastics

• Cheerleading

• Wrestling

• Soccer

• Basketball

• Lacrosse

• Baseball

• Softball

• Ice Hockey

3/9/2017

30

3/9/2017

31

Sport-specific/Interval Training

• Criteria

– Steady decline in symptoms

– Able to remain symptom free during aerobic

portion of exercise

– Increasing resistance levels with strength

exercise

• Begin with appropriate work:rest ratio

– Example: 10 seconds on: 50 seconds off

• Wrestling

• Lacrosse

• Soccer

• Football

• Baseball

• High Intensity

• Lower Intensity

Registry Research

• 175 patients (108 females, 67 males;

mean age 14.2 years; range, 6-21 years)

• November 1, 2014 to January 31, 2016

• Tolerability

• Outcome

3/9/2017

32

Tolerability

• Tolerability was measured in two ways: – 1) symptom changes between the beginning and end

of initial evaluation session measured by the Post-Concussion Symptom Inventory (PCSI)

– 2) an unplanned visit to an emergency department, urgent care, or pediatrician’s office for symptom exacerbation any time during the PT episode of care

• Initial exam session PCSI changes were categorized into: – improved/no symptom changes

– mild increase (1-10 points)

– large increase (11 or more)

Tolerability

• Mean duration of care 53.7 days (about 8 weeks)

• No patients needed emergent care during or immediately following an in-clinic or home exercise session

• Seven patients (4.0%) sought additional care due to symptom exacerbation at some point prior to discharge

• Changes in PCSI during the initial evaluation session were as follows: – 31 (17.7%) patients reported improvement or no change

– 106 (60.6%) reported a mild increase

– 38 (21.7%) reported a large increase in symptoms.

• Safety and tolerability indicators did not differ between the early, middle, or late cohorts (p < .05).

Impairments

• Classify the type of impairments present– Musculoskeletal

– Physiological

– Vestibulo/Ocular

– Sensorimotor???

• Impairment classifications were based on a set of pre-determined criteria relative to the standardized assessment and documentation protocols used by physical therapists at the institution.

3/9/2017

33

Outcome

• Outcome– Good

– Fair

– Poor

– Unable to be determined

• Outcome classifications were based upon a predetermined set of

criteria relative to:– Post-Concussion Inventory Symptom Scale (PCSI) scores

– Outcome measures

– Resolution of documented physical exam impairments

– Return-to-pre-injury activity

Impairments

• Impairments identified

– 86.3% had musculoskeletal impairments

– 74.7% had physiologic impairments

– 87.9% had vestibulo-ocular impairments

Impairments and Outcomes

• Outcome classifications resulted in:

– 108 (61.7%) GOOD outcome

– 48 (27.4%) FAIR outcome

– 6 (3.4%) had poor outcomes or showed no

improvement

– 13 (7.4%) had outcomes that were unable to

be determined due to no follow-up after initial

evaluation

3/9/2017

34

Outcomes

• A subset of 137 patient records had both PCSI from initial and final visits assessments available

• 85 female, 52 male (mean 14.38 ± 2.46 years)

• There was a statistically significant decrease in PSCI scores from initial visit (22.1 ± 20.86) to the final visit (9.15 ± 15.35) (p < .001).

• The mean decrease in scores was 12.95 with a 95% CI ranging from (CI of 9.6 to 16.28).

References

1. Holm L, Casidy JD, Carroll LJ. Summary of the WHO

collaborating centre for neurotrauma task force on mild traumatic

brain injury. J Rehabil Med. 2005; 37: 137-141.2. McCarthy MT, Kosofsky BE. Clinical features and biomarkers of

concussion and mild traumatic brain injury in pediatric patients.

Ann N Y Acad Sci. 2015; 1-11.

3. Schneider KJ, Meeuwisse WH, Nettel-Aguirre, et al.

Cervicovestibular rehabilitation in sport-related concussion: a

randomized controlled trial. Br J Sports Med. 2014; 48: 1294-

1298.

4. Hugentobler JA, Vegh M, Janiszewski B, Quatman-Yates C.

Physical therapy intervention strategies for patients with

prolonged mild traumatic brain injury symptoms: a case series.

Int J Sports Phys Ther. 2015; 10(5): 676-689.

5. Gagnon I, Gril l i L, Friedman D, Iverson GL. A pilot study of

active rehabilitation for adolescents who are slow to recover from

sport-related concussion. Scand J Med Sci Sports. 2016; 26(3):

299-306.6. Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of

subsymptom threshold exercise training for refractory post-

concussion syndrome. Clin J Sport Med. 2010; 20(1): 21-27.

7. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation

of concussion and post-concussion syndrome. Sports Health.

2012; 4(2): 147-154.

8. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled

exercise in concussion management. PM R. 2016; 8(3 Suppl):

S91-S100.

9. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and

cervicogenic post-concussion disorders: an evidence-based

classification system with directions for treatment. Brain Inj.

2015; 29(2): 238-248.

10. Kurowski BG, Hugentobler J, Quatman-Yates C, Taylor J,

Gubanich PJ, Altaye M, Wade SL. Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain

injury: an exploratory randomized clinical trial. J Head Trauma

Rehabil. 2016.

Conclusion and Clinical Relevance

• In the initial PT session, many patients experienced a worsening of symptoms,

particularly for those whom PT was initiated

earlier in the recovery process. Even so,

nearly 20% reported an improvement in

their symptoms by the end of their first PT

session.

• Over 60% of the patients were identified as

having a complete or near complete

resolution of symptoms and return to pre-injury functional levels following completion

of the PT episode of care. Approximately

30% more experienced at least some

degree of progress in function and return to

pre-injury activity levels.

• These results indicate that PT interventions

are generally safe and tolerable regardless

of the timing of initiation.

• These results suggest that patients who

receive PT interventions typically have a

good prognosis for symptom improvement

with over 90% reporting fair to good

outcomes over the course of their PT

treatment sessions.

• The results of this study suggest that

multimodal PT interventions are safe and

associated with improvements in symptoms and function within as few as three

weeks post-concussion. Future research

should aim to identify optimal time points

for initiation of a supervised active

rehabilitation plan, particularly in those

patients who may be susceptible to

development of prolonged symptoms.

Results

Patient Profiles:

• 175 patient records (108 females, 67

males) met the inclusion criteria for the

study.

• Fifty-two (29.7%), 56 (32.0%), and 67

(38.3%) individuals were categorized under

the early, middle, and late intervention

cohorts, respectively.

Safety:

• Seven patients (4.0%) made an unplanned

visit to a healthcare provider for symptom

exacerbation within one week of a PT

session.

• There were three unplanned visits in both the early and middle intervention cohorts

and one in the late intervention cohort.

• No visits were immediately associated with

a PT-related exercise bout, and all

occurred at least two days after an in-clinic

PT visit.

Tolerability:

• 102 out of 136 patients (75.0%) reported a

worsening of symptoms, 9 (6.6%) reported

no change in symptoms, and 26 (19.1%)

reported an improvement in symptoms from

the beginning compared to the end of the

initial PT session.

• One way ANOVA indicated no

statistically significant differences in

tolerability between the cohorts (p =

.128). Descriptive and graphical

analyses indicated that the early

intervention patients generally

experienced a greater worsening of

symptoms in the initial PT session.

Outcomes:

• 108 (61.7%) and 48 (27.4%) were

classified as having good and fair

outcomes, respectively. Six (3.4%)

individuals were classified as having poor

outcomes or showed no improvement, and

13 (7.4%) were classified as having

outcomes that were unable to be determined.

• There was no statistically significant

association between intervention cohort

and outcome.

Materials/Methods

Patient Profiles: The following information was obtained:

• Demographic information: age, gender,

and mechanism of injury

• Mechanism of injury: sport, motor

vehicle accident, fall to the ground, and

other activity

• History of prior concussions

• Timing of PT implementation: within 0-

20 days following injury (early

intervention), 21-41 days following injury (middle intervention), and 42 or more

days following injury (late intervention).

Safety: Medical records were screened for

unplanned visits to a healthcare provider, urgent care

center, or hospital emergency room due to symptom

exacerbation.

Tolerability: Scores on the Post-Concussion

Symptom Inventory (PCSI) were extracted. • The Post-Concussion Symptom

Inventory (PCSI) is a self-reported

measure of 21 post-concussion

symptoms on a 7-point Likert scale. A

symptom change score was computed

by calculating the difference between

the patient’s score at the beginning and

the end of the initial PT session.

Outcomes: Outcomes following completion of PT were classified into the following:

Statistical Analysis:

• Descriptive statistics: computed for the

sample as a whole and for each cohort

to provide a robust representation of the

features of the data.

• Chi Square tests of Independence: analyzed demographical information,

safety, tolerability, and outcomes

between cohorts.

• Analysis of Variance: compared number

of sessions, duration of PT care, and

the change in PCSI scores from the

beginning to the end of the first PT

session between cohorts.

• An a priori alpha level was set at .05 to

make determinations for statistical significance between the cohorts.

Purpose/Hypothesis

The primary purpose of this study was to explore and describe the safety, tolerability, patient profiles, and

preliminary outcomes for patients who received post-

concussion PT interventions at varying time points

after injury.

Introduction

Medical management of children and adolescents following concussion has commanded the attention of

health care providers and researchers alike.

The majority of concussed individuals recover quickly

and spontaneously, but a concerning minority

experience persistent symptoms and deficits after the

injury.1

Prolonged impairments following concussion result

from disturbances of the body’s physical, cognitive, emotional, and sleep domains, and can range from

mild and temporary to severe and longstanding in

nature.2

In unresolved cases, individualized management

plays a crucial role in the resolution of symptoms,

return to daily function, and improvement in patients’

and families’ quality of life.

Introducing physical therapy in a monitored progression may help accelerate the recovery

process, lessen the likelihood for secondary effects,

and facilitate safe and tolerable re-integration into

pre-injury activities. 3-10

Although PT interventions have become recognized

as an important avenue to consider when managing

individuals with concussion, the appropriate timing of

implementation of such services remains unknown

and controversial.

Safety and tolerability of physical therapy following concussion: a retrospective analysis

Anne Lennon, PT 1, Jason A. Hugentobler, PT, DPT, SCS, CSCS 1,2, Mary Claire Sroka, BS, 1,2,3, Brad Kurowski, MD 4, Isabelle Gagnon, PT, PhD 5, Catherine Quatman-Yates, PT, DPT, PhD 1,2,3

1Divis ion of Occupational and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

2 Divis ion of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

3Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

4Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

5The Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada

Materials/Methods

Data were extracted from a departmental database at a children’s hospital for patients who received

outpatient PT services.

Inclusion criteria = formal medical diagnosis of

concussion or presentation of signs and symptoms

associated with concussion following head or neck

trauma.

References

1.Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular

and cervicogenic post-concussion disorders: an evidence-based

classification system with directions for treatment. Brain Inj.

2015; 29(2): 238-48.

2. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus

statement on concussion in sport: the 4th International

Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013; 47(5): 250-58.

3. Schneider KJ, Meeuwisse WH, Nettel-Aguirre, et al.

Cervicovestibular rehabilitation in sport-related concussion: a

randomized controlled trial. Br J Sports Med. 2014; 48: 1294-

1298.

4. Hugentobler JA, Vegh M, Janiszewski B, Quatman-Yates C.

Physical therapy intervention strategies for patients with

prolonged mild traumatic brain injury symptoms: a case series.

Int J Sports Phys Ther. 2015; 10(5): 676-89.

5. Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of

active rehabilitation for adolescents who are slow to recover from

sport-related concussion. Scand J Med Sci Sports. 2016; 26(3): 299-306.

Conclusion and Clinical Relevance

• A majority of patients following concussion presented to physical

therapy with a combination of

musculoskeletal, physiologic,

sensorimotor and/or vestibulo-ocular

impairments.

• A significant improvement in PCSI is

found for those individuals from their

initial visit compared to their final, as

well as an ability to achieve good and fair outcomes with treatment.

• Physical therapists are well-suited to be

among the providers of care for

pediatric patients with persistent post-

concussion symptom deficits.

• Patients who underwent physical

therapy services can achieve

satisfactory outcomes.

• Future studies should examine other

potential variables that contribute to

patient outcome (co-morbidities, family

burden)

Results

• A subset of 137 patient records had both PCSI from initial and final visits

assessments available (85 female,

52 male mean 14.38 ± 2.46 years).

• There was a statistically significant

decrease in PSCI scores from initial

visit (22.1 ± 20.86) to the final visit

(9.15 ± 15.35) (p < .001). The mean

decrease in scores was 12.95 with a

95% CI ranging from (CI of 9.6 to 16.28).

Methods

• Data were extracted from outpatient physical therapy medical records of

a large, metropolitan pediatric

medical center from November 1,

2014 to January 31, 2016. Patient

records were eligible for analysis if

the patient was referred to physical

therapy for post-concussion

interventions.

• Patient records were then categorized into three cohorts based

on the timing of PT implementation:

within 0-20 days following injury

(early intervention), 21-41 days

following injury (middle intervention),

and 42 or more days following injury

(late intervention).

• Two trained, independent reviewers

evaluated each identified patient record to classify the type of

impairments present

(musculoskeletal, physiological,

sensorimotor, and/or vestibulo-

ocular) and outcome (good, fair,

poor/no change, or unable to be

determined).

• Impairment classifications were

based on a set of pre-determined criteria relative to the standardized

assessment and documentation

protocols used by physical therapists

at the institution. (see Table 1)

• Outcome classifications were based

upon a predetermined set of criteria

relative to Post-Concussion

Inventory Symptom Scale (PCSI)

scores, outcome measures, resolution of documented physical

exam impairments and return-to-pre-

injury activity. (see Table 2)

• For all records with initial and final

PCSI total symptom scores

available, a paired samples t-test

comparing initial to final scores was

performed.

..

Number of Subjects

• A total of 175 patients (108 females, 67 males)

• Mean age is 14.2 years ± 2.62 (range,

6-21 years)

• Early (0-20 days) Cohort: 52 patients

• Middle (21-41 days) Cohort: 56 patients

• Late (42 days or more) Cohort: 67

patients

Introduction

A majority of individuals will recover quickly following a concussion, however a subset will go on to have

persistent deficits following injury.

Physical therapists are recognized as an important

part of the multidisciplinary care team for

management of patients with persistent deficits after

concussion.

Studies investigating PT interventions, when both

individually implemented and when incorporated into multimodal programs, have shown promising results

for expediting recovery in individuals with persistent

symptoms and deficits associated with concussion.

Impairment-based systems have been proposed to

guide management of persistent symptoms following

concussion.

Physical Therapy Service Utilization and Outcomes for Youth with Concussion at a Metropolitan Pediatric Medical Center

Jason A. Hugentobler, PT, DPT, SCS, CSCS 1,2, Anne Lennon, PT 1, Mary Claire Sroka, BS, 1,2,3, Brad Kurowski, MD 4, Isabelle Gagnon, PT, PhD 5, Catherine Quatman-Yates, PT, DPT, PhD 1,2,3

1Division of Occupational and Physical Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

2 Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

3Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

4Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

5The Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada

Acknowledgements

The authors would like to thank the Division of Occupational Therapy and Physical Therapy at

CCHMC for their support of this project, as well as

students Ryan Dudziak and Katharine Nissen.

Outcome Criteria

Good Improvements OR lack of deficits in impairment domains

AND improvement in PCSI from initial to final session

AND improvement in PedsQL (if available)

Fair Improvements OR lack of deficits in at least one domain from

initial to final session

AND/OR improvement in PCSI from initial to final sessionAND/OR improvement in PedsQL (if available)

Poor/No Change No improvement in any domain initial to final

AND no improvement in PCSI total score from initial to final

AND no improvement in PedsQL (if available)

Unknown Inability to grade outcome due to lack of follow up

Purpose

The purpose of this study was to describe the dominant impairment domains and outcomes of

patients presenting to outpatient physical therapy.

System Pathophysiologic Basis Classification Criteria

Musculoskeletal -malalignment of cervical

spine

-poor postural muscle endurance

-soft tissue damage/spasm

-proprioception dysfunction

-report of neck pain

-reproduction of neck/HA

pain with ROM-reproduction of neck/HA

pain with palpation

-indication of manual

therapy noted for c-spine

Sensorimotor -diminished sensorimotor

integration

-slower sensorimotor integration

-diminished sensorimotor

processing

-tBESS score abnormal

-self-report of balance

issues on PCSI-self-report of movement in

clumsy manner on PCSI

Vestibulo-ocular -altered oculomotor control

-altered processing and

integration of VO input-BPPV

-deficiency with NPC

-abnormal/symptom

provocation with gaze stabilization

-permanence of those

symptoms at f/u and/or

exercises used to address

Physiologic -autonomic dysfunction

-altered cerebral perfusion

-altered cerebral metabolic function

-inability to perform aerobic

exercise at level 13 on

BORG-self-report of fatigue on

PCSI

-resting HR value ≥ 100

bpm

Table 1

Table 2

3/9/2017

35

Improvement Planning Activities



Process: Beginning Boundary: Ending Boundary: Customers: Outputs/Outcomes:

Start Stop

High-Level Process Map Worksheet



Process: Staff “Productivity” Reports Beginning Boundary: Staff treat patients/complete projects Ending Boundary: Goal setting and action planning for next year Customers: Frontline Clinicians Outputs/Outcomes: Quantitative Dashboards of Individual, Team, and Divisional

“Productivity”

Staff treat

patients and

complete

projects

Goal setting

and action

plan for

next year

Start Stop

Monthly

Productivity

Reports

released

Staff

members

respond in

written

form

Supervisor

and staff

members

meet for

quarterly

rounding

Annual self-

recall

performance

reports

Supervisor

and staff

member

meet for in-

person

review






3/9/2017

36

Map Your Chosen Process



Process: Beginning Boundary: Ending Boundary: Customers: Outputs/Outcomes:

Start Stop




Process Name _________________________________

FA

ILU

RE

MO

DE

SIN

TE

RV

EN

TIO

NS

FA

ILU

RE

MO

DE

SIN

TE

RV

EN

TIO

NS

CU

RR

EN

T

PR

OC

ES

S





3/9/2017

37

Process Name: Staff Productivity Reports

FA

ILU

RE

MO

DE

SIN

TE

RV

EN

TIO

NS

CU

RR

EN

T

PR

OC

ES

S

No data for how

time is spent

outside of direct

patient care

No data for how

time is spent

outside of direct

patient care

Many staff do not

work at the same

site as

supervisors, and

therefore find it

difficult to convey

how hard they are

actually working

and the barriers

they are facing

Find it difficult to

set new, realistic

and time-based,

clinical excellence

goals for

upcoming year

due to poor sense

of how their time

is spent beyond

direct patient care

Dependent on

staff member to

have the time and

ability to recall all

non-billed

activities they

participated in

over the last 12

months

No systematic

way to think

about and

discuss clinical

excellence

activities

Those meeting

billing goals, feel

good (but

sometimes like

they have too

much on their

plates)

Those not, can

feel under

appreciated,

performance is

outside of their

control. and

question value of

non-billed

activities

Monthly Billed

Productivity

Reports

Supervisor-Staff

Performance

Review Meeting

Supervisor-staff

member

quarterly

rounding

meetings

Annual Self-

Recall and

Report of

Clinical

Excellence Work

Staff responds to

billed

performance

report in written

form

Those not

“meeting” billing

goal have to

retrospectively

give reasons why

and an

improvement plan

with no data to

support

assessment

Frustration

because some of

not meeting goal

is outside of the

control of clinician

(low census, low

site volume)

“I’m more than

what I bill”

“I can’t control

many of the

things that lead to this number”

“I can’t

remember why

my numbers were low”

“I used my

unbilled time

wisely but get no ‘credit’ for that” “I struggle to know

how to tell my

supervisor about the time barriers I am

facing”

“It takes a lot of

time to put the

report together, and I forget a lot”

“My supervisor

rarely sees me,

how I can he know how much

non-billed work I

do?

Process Name: Staff Productivity Reports

FA

ILU

RE

MO

DE

SIN

TE

RV

EN

TIO

NS

CU

RR

EN

T

PR

OC

ES

S

No data for how

time is spent

outside of direct

patient care

No data for how

time is spent

outside of direct

patient care

Many staff do not

work at the same

site as

supervisors, and

therefore find it

difficult to convey

how hard they are

actually working

and the barriers

they are facing

Find it difficult to

set new, realistic

and time-based,

clinical excellence

goals for

upcoming year

due to poor sense

of how their time

is spent beyond

direct patient care

Dependent on

staff member to

have the time and

ability to recall all

non-billed

activities they

participated in

over the last 12

months

No systematic

way to think

about and

discuss clinical

excellence

activities

Those meeting

billing goals, feel

good (but

sometimes like

they have too

much on their

plates)

Those not, can

feel under

appreciated,

performance is

outside of their

control. and

question value of

non-billed

activities

Monthly Billed

Productivity

Reports

Supervisor-Staff

Performance

Review Meeting

Supervisor-staff

member

quarterly

rounding

meetings

Annual Self-

Recall and

Report of

Clinical

Excellence Work

Staff responds to

billed

performance

report in written

form

Those not

“meeting” billing

goal have to

retrospectively

give reasons why

and an

improvement plan

with no data to

support

assessment

Frustration

because some of

not meeting goal

is outside of the

control of clinician

(low census, low

site volume)

Weekly reports

Built Daily

Tracking system

that accounts for

non-billable

activities

Map Your Failures and Brainstorm

Some Solutions

3/9/2017

38

Langley et al. 2009. The Improvement Guide: A Practical Approach to

Enhancing Organizational Performance. Jossey-Bass: San Francisco, CA.



SMART Aim

Key Drivers Interventions (LOR #)

Note: LOR # = Level of Reliability Number, e.g., LOR 1

Project Leader(s):

Global Aim

Population

Revision Date: mm/dd/yyyy (v#)

Key Driver Diagram (KDD)

Potential Intervention (LOR #)

Intervention (LOR #)

Abandoned: Intervention (LOR #)

Potential intervention

Active intervention

Adopted/Abandoned intervention

Legend

Intervention (LOR #)


Adopted: Intervention (LOR #)




3/9/2017

39

Inpatient

Sports/Ortho Outpatient ND

Division of OTPT Structure

200+ OTs, PTs, TRsOutpatient Neurodevelopmental (150+ therapists)Sports/Orthopedic (28+ therapists)Inpatient (18+ therapists)

Target Testing Population

• Sports/Ortho PTs (~28 FTE)

• Highly motivated to perform well in patient care and value-added activities

• Similar style of patient flows

• 2-3 visits per week

• High volume during “Family Friendly Hours”

• Lower volume during school day

• Seasonal ebbs and flows in volume

• Design and implement at Winslow then spread to other Sports/Ortho sites

• Eventually spread to inpatient and outpatient ND teams

W

A

M

L

GB

N

Sports/Ortho

Inpatient

Outpatient ND

How do CCHMC PT clinicians spend their time?

Billed Units Partial Transparency

Non-Billed Time Utilization ?

3/9/2017

40

I²S²

Billed Time + Non-Billed Tracked Time

Total Hours Paid for the Week

Operational Definition

Transparent Time Utilization =

1. We know how time was spent2. Able to aggregate for individual

and group levels Original System

I²S²

SMART Aim


Increase the transparency of

time utilization for CCHMC

sports and orthopaedic

physical therapists from 70%

to 90% by January 11, 2017.

Standardized process for tracking non-

billable time utilization that is well-

integrated into clinicians’ daily workflow

Timely accountability reports of tracked

non-billable time utilization

Useful and actionable metrics for

operationalizing time utilization

Engaged and motivated culture to track

activities and continually optimize time

utilization

Shared communication stream and decision-making

supervisor/staff

(LOR #1)

Effective data extraction and aggregation

system for non-billed tracked time

Key

Gray shaded box = completed intervention

Green shaded box = what we’re working on right now

LOR # = Level of Reliability Number, e.g., LOR 1

Increasing the Transparency of OT and PT Clinicians’ Clinical Excellence Activities


Project Leader(s): Catherine Quatman-Yates

Revision Date: 1/9/2017 (v4)

Establish a sustainable

culture and system for

optimizing the engagement

of CCHMC’s front-line

occupational therapists,

physical therapists, and

therapeutic recreation staff

in impactful, value-added

and value-enabling activities.

Global Aim

Tracking tool exploration, selection, optimization

(LOR #3)

Integration into productivity dashboards (LOR #2)

Long-Term Tracking goals/expectations (LOR #2)

Extraction tests and simulations

(LOR #3)

Standardized nomenclature/codes (LOR #3)

TEST 1

What: Excel Feasibility

Who (population): CQ

When: 7/6/16 – 7/6/16

Act: Abandon

P D

S A

TEST 2

What: Access Feasibility

Who (population): CQ

When: 7/8/16 – 729/16

Act: Abandon

P D

S A

TEST 3

What: Outlook Feasibility

Who: CQ

When:8/8/16 8/15/2016

Act: Adapt

P D

S A

TEST 4

What: Outlook Categories Codes

Who (population): CQ, MP, CZ, JH

When: 10/3/2016 – 10/3/2016

Act: Adapt

P D

S A

TEST 1

What: Outlook appt subject lines

Who (population): Team leader

Who (executes): Team leader

When: 7/7/16 – 7/15/16

Act: Adapt

P D

S A

TEST 2

What: Outlook theme builds

Who (population): Winslow PTs

When: 7/11/16- 7/25/16

Act: Adapt

P D

S A

TEST 3

What: 3 non sports clinicians

Who (population): AB, JL, KH

When: 7/27/16 – 8/3/16

Act: Adapt

P D

S A

TEST 4

What: Tracking Tip Sheet

Who (populations): Mason team

When: 11/7/2016 – 11/12/2016

Act: Adopt

P D

S A

TEST 1

What: Tracking consistency self-report

Who (population):CQ

When: 8/9/16 – 8/9/16

Act: Adapt

P D

S A

TEST 2

What: Self-report consistency aggregated

Who (population): 6 participants

When: 8/9/16 – 8/10/16

Act: Abandon

P D

S A

TEST 3

What: Evaluate current billed time tracking

Who (population): Sports/ortho team

When: 9/8/16 – 9/10/16

Act: Adapt

P D

S A

TEST 4

What: Metrics for billed time simulations

Who (population): Sports/ortho team

When: 9/12/16 –9/20/16

Act: Adapt

P D

S A

Quality Transformation

April 6, 20071-Tracking System 2-Habit of Tracking 3-Data Aggregation

3/9/2017

41

System for Tracking Non-Billed Activities

Category Description

Administrative Random activities

Commute/Travel Time Commuting

Direct Patient Care Patient care.

Documentation Notes completed outside of clinic

EBP/QI/Registry/Outcomes Activities related to EBP, QI, Registry, or Outcome efforts

Educator/Mentor Efforts Activities that involve the act of teaching or mentoring

Indirect Patient Care Activities other than notes associated with patient care

Lunch/break Break and no other activity occurs during this time

On-field For sports residents

Outreach Community outreach

Professional Development… CEUs, trainings

PTO PTO time

Required Meetings… Mosby, etc

Research Activities associated with grant funded research projects

Service Time spent on meetings or deliverables pertaining to service role

Training Room Sports resident training room time

Unknown 15 min or greater slot of time in which you cannot recall what occurred

Outlook Aggregator

Trackers Share Calendar with Full Details

3/9/2017

42

Staff perceptions of new system…

126

Getting a 2nd parking pass, saves me 6

hours of commuting per week

I had to do a lot of tracking for my residency hours

anyway—this system got all my tracking in one place and allows my mentors to view it

in real-time

Putting a few minutes each day allows me to see that I am making progress, even

when it doesn’t feel like it…

Keeping track encourages me to use my time wisely…I want my calendar to be full

of productive time

In just the first week, I realized about 20 tasks I

should have delegated or said no to doing…I won’t be

making those mistakes again!

I enjoy tracking as it shows me where my time

is spent and honestly I think it keeps me on task!

3/9/2017

43

Draft a SMART Aim and Key Driver

Diagram


SMART Aim


Note: LOR # = Level of Reliability Number, e.g., LOR 1

Project Leader(s):

Global Aim

Population

Revision Date:


Abandoned: Intervention (LOR #)

Potential intervention

Active intervention

Adopted/Abandoned intervention

Legend

Adopted: Intervention (LOR #)

Plan your first small test of change

• Plan– What will you do and which driver will it target?

– Who will be in your testing group?

– When will you do it and for how long?

– How will you assess whether change is helpful or not?

– What do you predict will happen?

• Do– Carry out the test

• Study– How did your results align with your prediction?

– What went well?

– What did not work well?

• Act– Will you adopt, adapt, or abandon the change?

3/9/2017

44

Questions?

• Follow-up contact information

– [email protected]

– [email protected]

Appendix

Deliverable Selection

What are you hoping to

accomplish?

What expertise and motivation

elements do you need?

What resources do you have available?

Evidence Awareness:

- Evidence summary

- Annotated bibliography

- Narrative

Review/Commentary

- Systematic Review

- Meta-Analysis

- Clinical Practice

Guidelines

Evidence Integration:

- Education

- Visual cues or alerts

- Care algorithms

- Tracking/audits for

care bundle

completion

- QI projects/PDSA

ramps for

improvement

Evidence Generation:

- Case studies or small

scale retrospective

case series

- Prospective small,

scale studies

- Prospective large,

scale studies

- PBE/registry studies

mailto:[email protected]

mailto:[email protected]

3/9/2017

45


What are you hoping to accomplish?

What expertise and motivation elements

do you need?


Evidence Awareness:

- Evidence summary (no plan to publish)

1 or more people, systematic search of literature, table for relevant studies

- Annotated bibliography (no plan to publish)

1 or more people, evidence summary table expansion focused on direct utility

and take home points, gaps in knowledge

- Narrative Review/Commentary (plan to publish)

1 or more people, writing skills, large blocks of dedicated time

- Systematic Review (plan to publish)

3 or more people, methodological expertise, large blocks of dedicated time,

writing skills

- Meta-Analysis (plan to publish)

3 or more people, methodological expertise, large blocks of dedicated time,

analytics skills, writing skills

- Clinical Practice Guidelines (plan to publish)

Team of experts, methodological expertise, large blocks of time, experience

with CPG publication, writing skills, project management skills




do you need?



- Education

1 or more people with domain expertise

- Visual cues or alerts

low technology (e.g., visual signs in clinic space)

alerts in electronic documentation system, informatics collaboration

design of documentation (e.g., docflow sheet)

- Care Algorithms

knowledge of evidence, knowledge of systems

team of domain experts, dedicated time, methodologist/QI consultant

- Tracking/Audits/Optimization*

objective: to test, optimize, publish = QI expertise, analyst, writing skills

objective: to publish = + writing skills in health delivery systems research

*Sustainability will necessitate infrastructure that rewards and motivates

clinicians to adhere to the model




do you need?



- Case Studies

1 or more people with domain expertise, well documented case data

- Prospective small, scale studies

1 or more people (typically need to be CITI trained), have skills to apply for

and adhere to IRB compliance regulations

Participant recruitment infrastructure

Analytics, writing support

- Prospective large, scale studies

Study team with ability to pull off large-scale project

Often a need for grant funding, which entails higher level expertise and grant

management skills

Data management, analytics, and writing expertise

- PBE/Registry studies

knowledge of evidence, knowledge of systems

high fidelity data collection processes

analytics and writing expertise

3/9/2017

46

Enablers

Evidence Awareness:

- Librarian

- Software to help

support management

of process

- Distiller SR

- RevMan

- Endnote

- Webinars and training

sessions

- Grants to support

process

- E.g., APTA CPG

grants


- QI/Improvement

Science webinars and

texts

- QI consultants

- Informatics support


- Informatics support for

medical record

extraction

- Data management

support for building

data warehouses for

prospective data

collection

- Statistics/Analytics

support

Infrastructure References:

1. Merriam S, Tisdell E. Qualitative Research: A Guide to Design and Implementation. San Francisco Jossey-Bass;

2016.

2.Denzin N, Lincoln Y, eds. The Sage Handbook of Qualitative Research, Third Edition. Thousand Oaks, CA: Sage

Publications; 2005.

3. Richardson L. Evaluating Ethnography. Qualitative Inquiry. 2000;6(2).

4. Sartore-Baldwin M, Quatman-Yates C. Utilizing ethnographic projects within sport management curriculum: Bridging

the gap between research and practice through personal knowledge. Sport Management Education Journal.

2012;6(1):42-52.

5. Duckworth A. Grit: The Power of Passion and Perseverance. New York, NY: Scribner; 2016.

6. Sinek S. Start with Why: How Great Leaders Inspire Everyone to Take Action. New York, NY: Portfolio/Penguin;

2009.

7. Attiyah R. The Fearless Front Line: The Key to Liberating Leaders to Improve and Grow Their Business. Brookline,

MA: bibliomotion; 2013.

8. Kotter JP, Cohen DS. The Heart of Change: Real-Life Stories of How People Change Their Organizations. Boston,

MA: Harvard Business Review Press; 2002.

9. Senge PM. The Fifth Discipline: The Art & Practice of the Learning Organization. New York, NY: Random House,

Inc.; 2006.

10. Brownson RC, Colditz GA, Proctor EK. Dissemination and Implementation Research in Health: Translating Science

to Practice. New York, New York: Oxford University Press; 2012.

11. Grant A. Give and Take: Why Helping Others Drives our Success. New York, NY: Penguin Books; 2013.

12. Dweck CS. Mindsets shape consumer behavior. Journal of Consumer Psychology (Elsevier Science).

2016;26(1):10p.

13. Savani K, Chugh D, Dweck CS. Leveraging Mindsets to Promote Academic Achievement. Perspectives on

Psychological Science. 2015;10(6):6p.

14. Walton GM, Romero C, Smith EN, Yeager DS, Dweck CS. Mind-Set Interventions Are a Scalable Treatment for

Academic Underachievement. Psychological Science (0956-7976). 2015;26(6):10p.

Infrastructure References:

15. Johnson YR, Spitzer BJ, Trzesniewski KH, Powers J, Dweck CS. The Far-Reaching Effects of Believing People

Can Change: Implicit Theories of Personality Shape Stress, Health, and Achievement During Adolescence. Journal of

Personality & Social Psychology. 2014;106(6):18p.

16. Langley G, Moen R, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing

Organizational Performance. San Francisco, CA: Jossey-Bass; 2009.

17. Collins J. Good to Great: Why Some Companies Maek the Leap...and Others Don't. New York, NY: Harper

Business; 2001.

18. Maslow A. A Theory of Human Motivation. Psychological Review. 1943;50:370-396.

19. Patterson K, Grenny J, Maxfield D, McMillan R, A. S. Influencer: The Power to Change Anything. New York, NY:

McGraw-Hill; 2008.

3/9/2017

47

Concussion References:

1. Ellis MJ, Cordingly D, et al. Vestibulo-ocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr.

2015:16;248-255.

2. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based

classification system with directions for treatment. Brain injury. 2015 Jan 28;29(2):238-48

3. Quatman-Yates CC, Cupp A, Gunsch C, et al. Physical Rehabilitation Interventions for Post-mTBI Symptoms Lasting

Greater Than 2 Weeks: Systematic Review. 2016; 96 (11): 1753:1763.

4. Gagnon, I, Galli C, Friedman D, et al. Active rehabilitation for children who are slow to recover following sport-related

concussion. Brain Inj. 2009;23:956–64.

5. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a

randomised controlled trial. Brit. J. Sport Med. 2014:48;1294–1298.

6. Kurowski BG, Hugentobler JA, Quatman-Yates C, et al. Aerobic exercise for adolescents with prolonged symptoms after

mild traumatic brain injury: an exploratory randomized clinical trial. J Head Trauma Rehab. 2016

7. Leddy JJ, Baker JG, Willer B. Active rehabilitation of concussion and post-concussion syndrome. Phys Med Rehabil Cli.

2016:27;437–454.

8. Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate

Concussions. Am J Sports Med. 2014:42(10);2479-2486.

9. Grady MF. Concussion in the adolescent athlete. Curr Probl Pediatr Adolesc Health Care. 2010;40(7):154-169.

10. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on

Concussion in Sport held in Zurich, November 2012. British journal of sports medicine. 2013;47(5):250-258.

11. Broglio SP, Puetz TW. The effect of sport concussion on neurocognitive function, self-report symptoms and postural control :

a meta-analysis. Sports Med. 2008;38(1):53-67.

12. Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following

sport-related concussion: a systematic review of the literature. British journal of sports medicine. 2013;47(5):304-307.

13. Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression in retired professional football

players. Med Sci Sports Exerc. 2007;39(6):903-909.

14. Baugh CM, Stamm JM, Riley DO, et al. Chronic traumatic encephalopathy: neurodegeneration following repetitive

concussive and subconcussive brain trauma. Brain imaging and behavior. 2012;6(2):244-254.

Concussion References

Concussion References

Ellis MJ, Cordingly D, et al. Vestibulo-ocular dysfunction in pediatric sports-related

concussion. J Neurosurg Pediatr. 2015:16;248-255.

Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-

concussion disorders: an evidence-based classification system with directions for

treatment. Brain injury. 2015 Jan 28;29(2):238-48

Quatman-Yates CC, Cupp A, Gunsch C, et al. Physical Rehabilitation Interventions for

Post-mTBI Symptoms Lasting Greater Than 2 Weeks: Systematic Review. 2016; 96 (11):

1753:1763.

Gagnon, I, Galli C, Friedman D, et al. Active rehabilitation for children who are slow to

recover following sport-related concussion. Brain Inj. 2009;23:956–64.

Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in

sport-related concussion: a randomised controlled trial. Brit. J. Sport Med. 2014:48;1294–

1298.

Kurowski BG, Hugentobler JA, Quatman-Yates C, et al. Aerobic exercise for adolescents

with prolonged symptoms after mild traumatic brain injury: an exploratory randomized

clinical trial. J Head Trauma Rehab. 2016

Leddy JJ, Baker JG, Willer B. Active rehabilitation of concussion and post-concussion

syndrome. Phys Med Rehabil Cli. 2016:27;437–454.

Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening

(VOMS) Assessment to Evaluate Concussions. Am J Sports Med. 2014:42(10);2479-2486.

Grady MF. Concussion in the adolescent athlete. Curr Probl Pediatr Adolesc Health Care.

2010;40(7):154-169.

McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport:

the 4th International Conference on Concussion in Sport held in Zurich, November 2012.

British journal of sports medicine. 2013;47(5):250-258.

Broglio SP, Puetz TW. The effect of sport concussion on neurocognitive function, self-

report symptoms and postural control : a meta-analysis. Sports Med. 2008;38(1):53-67.

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The

effects of rest and treatment following sport-related concussion: a systematic review of the

literature. British journal of sports medicine. 2013;47(5):304-307.

Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression

in retired professional football players. Med Sci Sports Exerc. 2007;39(6):903-909.

Baugh CM, Stamm JM, Riley DO, et al. Chronic traumatic encephalopathy:

neurodegeneration following repetitive concussive and subconcussive brain trauma. Brain

imaging and behavior. 2012;6(2):244-254.

McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes:

progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol.

2009;68(7):709-735.

Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic

traumatic encephalopathy in a National Football League player. Neurosurgery.

2005;57(1):128-134; discussion 128-134.

De Beaumont L, Lassonde M, Leclerc S, Theoret H. Long-term and cumulative effects of

sports concussion on motor cortex inhibition. Neurosurgery. 2007;61(2):329-336;

discussion 336-327.

3/9/2017

48

Guskiewicz KM, Marshall SW, Bailes J, et al. Recurrent concussion and risk of depression

in retired professional football players. Med Sci Sports Exerc. 2007;39(6):903-909.

Baugh CM, Stamm JM, Riley DO, et al. Chronic traumatic encephalopathy:

neurodegeneration following repetitive concussive and subconcussive brain trauma. Brain

imaging and behavior. 2012;6(2):244-254.

McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes:

progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol.

2009;68(7):709-735.

Omalu BI, DeKosky ST, Minster RL, Kamboh MI, Hamilton RL, Wecht CH. Chronic

traumatic encephalopathy in a National Football League player. Neurosurgery.

2005;57(1):128-134; discussion 128-134.

De Beaumont L, Lassonde M, Leclerc S, Theoret H. Long-term and cumulative effects of

sports concussion on motor cortex inhibition. Neurosurgery. 2007;61(2):329-336;

discussion 336-327.

De Beaumont L, Mongeon D, Tremblay S, et al. Persistent motor system abnormalities in

formerly concussed athletes. J Athl Train. 2011;46(3):234-240.

Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic

brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378.

Faul M, Xu L, Wald MM, Coronado V.G. Traumatic Brain Injury in the United States:

Emergency Department Visits, Hospitalizations, and Deaths 2002-2006.: Centers for

Disease Control and Prevention, National Center for Injury Prevention and C-|؊,x;2010.

CDC. Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities

Among Persons Aged 19 Years or Less--United States, 2001-2009. Morbidity and

Mortality Weekly Report. 2011;60(39):1337-1342.

CDC. Report to Congress on mild traumatic brain injury in the United States: Steps to

prevent a serious public health problem. Atlanta, Georgia: Department of Health and

Human Services, CDC, National Center for Injury Prevention and Control.

o ; 2003 2003.

Guskiewicz KM, Valovich McLeod TC. Pediatric sports-related concussion. PM R.

2011;3(4):353-364; quiz 364.

Kirkwood MW, Yeates KO, Taylor HG, Randolph C, McCrea M, Anderson VA.

Management of pediatric mild traumatic brain injury: a neuropsychological review from

injury through recovery. Clin Neuropsychol. 2008;22(5):769-800.

Sigurdardottir S, Andelic N, Roe C, Jerstad T, Schanke AK. Post-concussion symptoms

after traumatic brain injury at 3 and 12 months post-injury: a prospective study. Brain

injury. 2009;23(6):489-497.

Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology

of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics.

2010;126(2):e374-381.

Yeates KO. Mild traumatic brain injury and postconcussive symptoms in children and

adolescents. Journal of the International Neuropsychological Society : JINS.

2010;16(6):953-960.

DeMatteo C, McCauley D, Stazyk K, et al. Post-concussion return to play and return to

school guidelines for children and youth: a scoping methodology. Disabil Rehabil.

2015;37(12):1107-1112.

Hingley S, Ross J. Guidelines for diagnosing and managing paediatric concussion: Ontario

Neurotrauma Foundation guideline. Archives of disease in childhood. Education and

practice edition. 2016;101(2):58-60.

McAbee GN. Pediatric Concussion, Cognitive Rest and Position Statements, Practice

Parameters, and Clinical Practice Guidelines. Journal of child neurology.

2015;30(10):1378-1380.

Marshall S, Bayley M, McCullagh S, et al. Updated clinical practice guidelines for

concussion/mild traumatic brain injury and persistent symptoms. Brain injury.

2015;29(6):688-700.

Leddy JJ, Kozlowski K, Fung M, Pendergast DR, Willer B. Regulatory and autoregulatory

physiological dysfunction as a primary characteristic of post concussion syndrome:

implications for treatment. NeuroRehabilitation. 2007;22(3):199-205.

Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation of Concussion and Post-

concussion Syndrome. Sports health. 2012;4(2):147-154.

Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-

concussion disorders: an evidence-based classification system with directions for

treatment. Brain injury. 2015;29(2):238-248.

Leddy J, Hinds A, Sirica D, Willer B. The Role of Controlled Exercise in Concussion

Management. PM R. 2016;8(3 Suppl):S91-S100.

Gagnon I, Grilli L, Friedman D, Iverson GL. A pilot study of active rehabilitation for

adolescents who are slow to recover from sport-related concussion. Scand J Med Sci

Sports. 2015.

Clausen M, Pendergast DR, Willer B, Leddy J. Cerebral Blood Flow During Treadmill

Exercise Is a Marker of Physiological Postconcussion Syndrome in Female Athletes. J

Head Trauma Rehabil. 2015.

Hugentobler JA, Vegh M, Janiszewski B, Quatman-Yates C. Physical Therapy

Intervention Strategies for Patients with Prolonged Mild Traumatic Brain Injury

Symptoms: A Case Series. Int J Sports Phys Ther. 2015;10(5):676-689.

Griesbach GS, Gomez-Pinilla F, Hovda DA. The upregulation of plasticity-related proteins

following TBI is disrupted with acute voluntary exercise. Brain research.

2004;1016(2):154-162.

Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pinilla F. Voluntary exercise

following traumatic brain injury: brain-derived neurotrophic factor upregulation and

recovery of function. Neuroscience. 2004;125(1):129-139.

Jeter CB, Hergenroeder GW, Hylin MJ, Redell JB, Moore AN, Dash PK. Biomarkers for

the diagnosis and prognosis of mild traumatic brain injury/concussion. Journal of

neurotrauma. 2013;30(8):657-670.

45. Giza CC, Hovda DA. The Neurometabolic Cascade of Concussion. J Athl Train.

2001;36(3):228-235.

48. Tavazzi B, Vagnozzi R, Signoretti S, et al. Temporal window of metabolic brain

vulnerability to concussions: oxidative and nitrosative stresses--part II. Neurosurgery.

2007;61(2):390-395; discussion 395-396.

Maugans TA, Farley C, Altaye M, Leach J, Cecil KM. Pediatric sports-related concussion

produces cerebral blood flow alterations. Pediatrics. 2012;129(1):28-37.

Choe MC, Babikian T, DiFiori J, Hovda DA, Giza CC. A pediatric perspective on

concussion pathophysiology. Curr Opin Pediatr. 2012;24(6):689-695.

Gall B, Parkhouse W, Goodman D. Heart rate variability of recently concussed athletes at

rest and exercise. Med Sci Sports Exerc. 2004;36(8):1269-1274.

Hilz MJ, DeFina PA, Anders S, et al. Frequency analysis unveils cardiac autonomic

dysfunction after mild traumatic brain injury. Journal of neurotrauma. 2011;28(9):1727-

1738.

Polak P, Leddy JJ, Dwyer MG, Willer B, Zivadinov R. Diffusion tensor imaging alterations

in patients with postconcussion syndrome undergoing exercise treatment: a pilot

longitudinal study. J Head Trauma Rehabil. 2015;30(2):E32-42.

Makdissi M, Davis G, McCrory P. Updated guidelines for the management of sports-

related concussion in general practice. Australian family physician. 2014;43(3):94-99.

West TA, Marion DW. Current recommendations for the diagnosis and treatment of

concussion in sport: a comparison of three new guidelines. Journal of neurotrauma.

2014;31(2):159-168.

3/9/2017

49

Silverberg ND, Iverson GL. Is Rest After Concussion "The Best Medicine?":

Recommendations for Activity Resumption Following Concussion in Athletes, Civilians,

and Military Service Members. J Head Trauma Rehabil. 2012.

Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom

reporting in high school athletics. The Journal of adolescent health : official publication of

the Society for Adolescent Medicine. 2013;52(3):330-335 e333.

Tremblay S, Beaule V, Proulx S, et al. Multimodal assessment of primary motor cortex

integrity following sport concussion in asymptomatic athletes. Clinical neurophysiology :

official journal of the International Federation of Clinical Neurophysiology.

2014;125(7):1371-1379.

Stein CJ, MacDougall R, Quatman-Yates CC, et al. Young Athletes' Concerns About

Sport-Related Concussion: The Patient's Perspective. Clinical journal of sport medicine :

official journal of the Canadian Academy of Sport Medicine. 2015.

Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity

levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43(3):265-274.

Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH. The difficult

concussion patient: what is the best approach to investigation and management of persistent

(>10 days) postconcussive symptoms? British journal of sports medicine. 2013;47(5):308-

313.

Foley C, Gregory A, Solomon G. Young age as a modifying factor in sports concussion

management: what is the evidence? Curr Sports Med Rep. 2014;13(6):390-394.

Gioia G, Janusz J, Isquith PK, D V. Psychometric properties of the parent and teacher Post-

Concussion Symptom Inventory (PCSI) for children and adolescents. Journal of the

International Neuropsychological Society : JINS. 2008;14(204).

powerpoint presentation3/9/2017 1 linking physical therapy concussion management practice to...

Documents