THE IMPACT OF SPORTS INJURIES - MDAdvantage

A PUBLICATION OF MDADVANTAGE INSURANCE COMPANY

VOLUME 11 • ISSUE 3 • SUMMER 2018

MDADVISOR: A JOURNAL FOR THE HEALTHCARE COMMUNITY

PERSPECTIVES ON THE CHANGING TREATMENT PROTOCOLS OF CONCUSSIONS IN YOUTH SPORTS: AN INTERVIEW WITH ANTHONY ALESSI, MDInterviewed by Catherine E. Williams & Janet S. Puro, MPH, MBA

CME TENDINOUS CONDITIONS OF THE HIP AND PELVISBy Jennifer Kurowicki, MD, John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, & Anthony J. Scillia, MD

SPORTS-RELATED CONCUSSION: RECOGNIZE, REST, REHAB, RETURNBy Damion A. Martins, MD

CARTILAGE PRESERVATION AND REPAIR TECHNIQUESBy William H. Rossy, MD

THE IMPACT OF SPORTS INJURIES

What happens when physicians themselves create a liability insurance provider? You get very good liability insurance, but you get a lot more, too:

You get advocacy, you get preemptive counseling and education, you get a partner — one able to help physicians protect and build their practices. That’s what happened when we founded MDAdvantage 15 years ago.

Contact your broker for more information about MDAdvantage or call us directly at 888-355-5551.

www.MDAdvantageonline.com

WE ARE YOUR ADVOCATE, YOUR COUNSELOR, AND YOUR PARTNER.(We also provide medical professional liability insurance.)

THE TOOLS AND RESOURCES YOU NEED TO BETTER PROTECT AND MANAGE YOUR PRACTICE.

• The most comprehensive coverage for your premium dollars

• Education programs and risk management services

• Customized consultations

• Responsive, expert customer service

• MDAdvisor. Our journal, providing content and commentary on the most pressing issues in healthcare as well as CME credit opportunities

• Complimentary practice administration and cyber security coverage that provides protection against data breaches, HIPAA violations, billing errors and RAC audits

100 Franklin Corner Road Lawrenceville, NJ 08648-2104

888-355-5551

FROM THE DESK OF PATRICIA A. COSTANTE

Welcome to this issue of MDAdvisor—dedicated entirely to sports medicine. Our Editorial

Board agreed that it is important to offer you a look at the latest developments in sports

medicine and the treatment of sports injuries, as well as the regulatory and legislative

efforts that are being considered and implemented to improve safety across the nation.

While much of our knowledge about the treatment of sports injuries comes from

research and experience on the professional level, it is our young athletes who are at

the greatest risk. Youth sports are a $15 billion industry and growing, with elite teams

playing year-round, with no offseason. Approximately 36 million kids play organized

sports each year in the United States. The National Safe Kids Campaign asserts that

more than 2.6 million athletes under the age of 19 are treated in emergency rooms

for sports- and recreation-related injuries each year, and Nationwide Children’s

Hospital reports that in addition to the ER visits, 5 million children are seen

by their primary care physicians or in sports medicine clinics for injuries.

I wish to thank Contributing Editor Vincent McInerney, MD, for

providing the vision for this special issue. Dr. McInerney has

been at the forefront of the movement to educate physicians,

schools and parents about prevention of sports injuries.

We were also fortunate to interview Anthony Alessi, MD,

a renowned expert in the prevention and

treatment of concussions. I would like to

express my appreciation to all of the

authors included in this issue who are

recognized for their expertise in their

respective areas and who took the

time to share their insights. We also

include the latest updates on

cartilage preservation and repair,

complex hip pathologies and pain

management, return to play protocols,

as well as other sports-related topics.

Best wishes for a wonderful, safe and

injury-free summer.

Sincerely,

Chairman & CEO

MDAdvantage Insurance Company

1MDADVISOR

What happens when physicians themselves create a liability insurance provider? You get very good liability insurance, but you get a lot more, too:

You get advocacy, you get preemptive counseling and education, you get a partner — one able to help physicians protect and build their practices. That’s what happened when we founded MDAdvantage 15 years ago.

Contact your broker for more information about MDAdvantage or call us directly at 888-355-5551.


WE ARE YOUR ADVOCATE, YOUR COUNSELOR, AND YOUR PARTNER.(We also provide medical professional liability insurance.)

THE TOOLS AND RESOURCES YOU NEED TO BETTER PROTECT AND MANAGE YOUR PRACTICE.

• The most comprehensive coverage for your premium dollars

• Education programs and risk management services

• Customized consultations

• Responsive, expert customer service

• MDAdvisor. Our journal, providing content and commentary on the most pressing issues in healthcare as well as CME credit opportunities

• Complimentary practice administration and cyber security coverage that provides protection against data breaches, HIPAA violations, billing errors and RAC audits

100 Franklin Corner Road Lawrenceville, NJ 08648-2104

888-355-5551

WHAT’S HAPPENING IN SPORTS MEDICINEIf you tear a knee ligament, arthritis is likely to followHarvard Medical School orthopedics professor Dr. Mininder Kocher has determined that the chance of getting arthritis within a decade of tearing a tendon or ligament in the knee is greater than 50 percent. Kocher found that the number of anterior cruciate ligament surgeries at 26 children’s hospitals in 2004 was about 500; there were 2,500 such operations in 2014. A big reason for the increase is more children are playing sports that involve twisting the knee (such as soccer and basketball), and children often participate year-round.

Youth sport superspecialization leads to injuries and burnoutYoung athletes are specializing in a single sport at earlier ages in the belief that more hours focused on one sport will result in them becoming a better athlete. However, research has shown that putting more hours into a sport at a young age may cause burnout and overuse injuries. In fact, some data show that in college and professional athletes, the ones who are multi-sport athletes are more likely to succeed and play at those levels than the ones who focused on a single sport.

NEW

S &

ACKN

OW

LEDG

EMEN

TS

Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company and any affiliated companies (all as “MDAdvantage®”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage®, their directors, officers or employees or institutions affiliated with the authors.

The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage®. If MDAdvantage® ever endorses a product or program, that will be expressly noted.

Letters to the editor are subject to editing and abridgment.

MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage Insurance Company. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2018 by MDAdvantage®. Postmaster: Send address changes to MDAdvantage, 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104.

For advertising opportunities, please contact MDAdvantage at 888-355-5551.

WE WANT TO HEAR FROM YOU!We’d like to hear about your favorite or most memorable MDAdvisor issue or article. Or what topic have we not covered that we should include in a future issue? Send your comments, which we may edit before publication, to [email protected]. Please remember to include your name and location.


MDADVISOR | Summer 20182

MDADVISORA Journal for the Healthcare Community

PUBLISHERPatricia A. Costante, FACHE Chairman & CEO MDAdvantage Insurance Company

PUBLISHING & BUSINESS STAFFCatherine E. Williams Senior Vice President MDAdvantage Insurance Company

Janet S. Puro Vice President MDAdvantage Insurance Company

Theresa Foy DiGeronimo Copy Editor

Imbue Creative Design and Layout

CONTRIBUTING EDITOR Steve Adubato, PhD

EDITORIAL BOARDPaul J. Hirsch, MD, Editor-in-Chief Hon. Paul W. Armstrong, JSC (Ret.) Jon R. Bombardieri Donald M. Chervenak, MD Jeremy S. Hirsch, MPAP William G. Hyncik, ATC John Zen Jackson, Esq. Alan J. Lippman, MD Judith M. Persichilli, RN, BSN, MA

EMERGING MEDICAL LEADERS ADVISORY COMMITTEETara Beck Kimberly Choi Solimar Colon William Davis Sheila De Young Breanna Mesa

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY100 Franklin Corner Road Lawrenceville, NJ 08648-2104


Phone: 888-355-5551 [email protected]

Indexed in the National Library of Medicine’s Medline® database.

MDADVISOR 3

1 Letter from MDAdvantage® Chairman and CEO Patricia A. Costante

5 Perspectives on the Changing Treatment Protocols of Concussions in Youth Sports: An Interview with Anthony Alessi, MD| Interviewed by Catherine E. Williams & Janet S. Puro, MPH, MBA

10 Tendinous Conditions of the Hip and Pelvis| By Jennifer Kurowicki, MD, John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, & Anthony J. Scillia, MD

17 Cartilage Preservation and Repair Techniques| By William H. Rossy, MD

21 Legislative Update| By Jon Bombardieri

25 Sports-Related Concussion: Recognize, Rest, Rehab, Return| By Damion A. Martins, MD

32 A Paradigm Shift: Addressing Problems in Human Skilled Movement with the Observer-Performer System| By Robert P. Narcessian, EdM

35 The Role Physical Therapists Play in Post-Concussion Rehabilitation and the Return to Play Protocol for Athletes

| By Daniel Kane, PT, DPT

39 An Orthopaedic Surgery Resident’s Perspective on Team Physicians| By Nancy Moontasri, MD, MPH


SUM

MER

201

8 |

CO

NTE

NTS

CME

Online Articles: Visit our website for full articles at: www.mdadvantageonline.com/mdadvisor

E40 Youth Sport Injuries: An Interview with Vincent K. McInerney, MD | By Steve AdubatoE42 Pain Management and Sports Related Injuries | By Brett Gerstman, MD

THE IMPACT OF SPORTS INJURIES

RWJBarnabas Health, New Jersey’s leading cancer care

provider is partnered with the Rutgers Cancer Institute of

New Jersey, the state’s only NCI-designated Comprehensive

Cancer Center—universally recognized for its scientific

leadership. We stand behind our patients with an army

of the nation’s top specialists, pioneering research and clinical

trials, the most advanced genomic analysis available and the

state’s only hospital-based proton therapy program.

Together, we’re bringing the fight to cancer with endless

resolve—right alongside you and your family, right in your

backyard. Learn more at rwjbh.org/beatcancer

With world-class care in your corner,the odds are stacked in your favor.

I’m fighting cancer, but I’m not fighting alone.

Let’s beat cancer together.

MDADVISOR 5

PERSPECTIVES ON THE CHANGING TREATMENT PROTOCOLS OF CONCUSSIONS IN YOUTH SPORTS

Anthony G. Alessi, MD, is a board-certified Connecticut neurologist in private practice specializing in general neurology, neuromuscular diseases, electromyography (EMG) and sports neurology, and an Associate Clinical Professor of Neurology and Orthopaedics and Director of the UConn NeuroSport Program at the University of Connecticut. Dr. Alessi responded to questions posed by MDAdvisor, sharing his insights into the field of sports neurology and recent advances in treating sports injuries, particularly concussions.

An Interview with Anthony Alessi, MD

MDADVISOR: How did you get started in the field of sports injuries?ALESSI: My first interest in concussion and sports injuries developed when I was in high school. I was close with the ath-letic trainer, and I learned a lot from him about working around athletes. In college, I earned some extra money by working as an athletic trainer before going to medical school, so I always had an interest in sports medicine, even at a young age. Then I went off to medical school and became a neurologist and went into private practice from 1986 until about 1995, when I was given an opportunity to work with the New York Yankees AA affiliate in Norwich, Connecticut. I should say my history with the New York Yankees goes way back; my grandparents were always Yankees fans. They came from Italy. My mother’s favorite players were named DiMaggio and Berra. My own history with the New York Yankees dates back to 1968 when I sold peanuts at the stadium in the Bronx. So for me, going to spring training and working with the medical staff at the minor league level was a great opportunity.

About a year or so after I started working with the Yankees, I began to work with the Connecticut State Boxing Commission—although there were very few sports neurologists then. In fact, at that time, concussions were not a big deal. When I was in medical school and throughout my residency at the University of Michigan in neurology, I don’t think I heard the word concussion more than five times; it wasn’t a term that was commonly used in medicine. It was a vague term that

was, and still is, not very specific. It’s still an accumulation of symptoms after a blow to the head—quite vague from the idea of a defined entity. But then sports neurology gradually developed over time in the late 1990s and early 2000s.

MDADVISOR: Could you talk about how our awareness of the dangers of concussions has changed over time? ALESSI: There’s been an awareness evolution that people who hit their heads in sports are not able to perform up to their highest ability. When this became apparent at the higher-level sports, it became a big deal. That’s the irony: Most of every-thing that’s been done about increasing awareness of sports concussions has been done at the highest levels where we have the fewest number of participants. We have about 1,800 American professional football players. If you look at it like a pyramid, we’ve got about 54,000 college football players, more than a million high school players and more than three million youth-level tackle football players. It’s interesting that all our emphasis has been at the highest levels where the money is, but the real brain damage is occurring at the bottom of that pyramid. If you throw in soccer and hockey, you have about six and a half million children under the age of 13 playing a high-velocity collision sport.

It really is an irony that our awareness of concussion devel-oped out of money-making team sports when we’ve known that head injury has been a big part of boxing and combat sports for many years—certainly since 1928 when Dr. Harrison Martland

Interviewed by Catherine E. Williams and Janet S. Puro, MPH, MBA


published his paper called “Punch Drunk” in JAMA. We’ve known all along that getting hit in the head is not a good thing and that getting hit in the head repeatedly will result in brain damage. This is not a new concept; it’s just at a new level of awareness.

MDADVISOR: Do you think enough attention is being paid at the bottom of the pyramid?ALESSI: Absolutely not. However, that’s where we are focusing our efforts at the University of Connecticut in our NeuroSport program. We’re trying to get people at the lower levels to become more aware because it’s the young brains that are the most vulnerable to injury. As those neurons are being formed and those networks are maturing, that’s where the damage will have more long-lasting effects.

When you go to a National Football League game, you’ll see athletic trainers, the team doctor and a neurologist or neuro-surgeon on each sideline. You’ll see neurologists up in the sky-box watching the game as an eye in the sky. They’re watching players who have made a cognitive choice to play the game to earn their living. When you go to a youth tackle football game, you don’t see many medical personnel. There might be an EMT, maybe a parent. In a sports activity where there are no medical personnel and no training for coaches, we’re seeing a very dangerous level of concussion and brain injury and other injuries. No, we’re not paying enough attention at the lower levels.

MDADVISOR: What do physicians and other healthcare pro-fessionals still not know about concussions?ALESSI: I think one of the most misunderstood things about concussion and the brain is that no two concussions are the same. We tend to like to pigeonhole things; we like to have a standard protocol for someone with a concussion: You need two weeks of no activity and no phone or computer. But that shouldn’t be the case for everyone. In fact, within the first 48 hours, physicians try to get concussed patients back to some level of aerobic activity because we know that this helps the brain in terms of fighting off the concussion and improving the symptoms. The idea of shutting down concussed patients and putting them in a dark room is not the way to go.

Every concussion is different. If you’ve seen one concussion, you’ve seen only one concussion—because each brain comes into the situation with a different level of maturity and different things that develop the personality. So, for example, if someone who has a history of ADHD, or migraine headaches or epilepsy gets hit in the head, I can guarantee that those conditions are going to worsen, even if only temporarily. So you really need to understand that specific person’s brain before you can make an accurate diagnosis and set out a plan of treatment. This is not an easy diagnosis to make.

MDADVISOR: Do you think that the way physicians are diag-nosing and treating concussions today may be based on a misunderstanding of the injury itself? ALESSI: We’re learning something new every day about con-cussions. Hopefully, articles like this help healthcare providers become a little more aware and understand that the simplistic, pigeonhole approach is not helping the patient. You really have to treat each person as an individual. Just think about it. The human body loves homeostasis. The body loves to wake up at the same time every day, go to bed at the same time every day, eat at the same time every day. But that’s not the way we live our lives. We have stresses during the day. Some days we can eat, some days we’re not eating, some days we’re sleeping late, some days we’re getting up extremely early. For athletes, it’s even more difficult to find a steady pattern. Their schedules are so irregular, competing at night, competing in the day, competing on the West Coast. A college athlete has the pressure to produce not only athletically but also academically. If you add a concussion on top of that, you can imagine how big a challenge it is to treat that condition. There are so many challenges to treating someone who has had a head injury because of their individual responsibilities both athletic and otherwise. My point is: You need to take into consideration the athlete’s entire lifestyle.

MDADVISOR: What should a physician—who is not a neurol-ogist—do when presented with a concussed athlete? Should he or she refer out to a neurologist? ALESSI: Here’s the good thing about concussions. Ninety per-cent of all sports-related concussions get better within 10 days. We have good data to show that. Primary care physicians are perfectly qualified to treat these cases and monitor patients. We know that 90 percent of them will get better if you treat them properly. First rule, don’t let the athlete get hit in the head a second time. Get them adequate rest and some reasonable amount of activity, as well as a good diet and hydration. With this kind of care, the concussion is going to get better within 10 days in 90 percent of the cases.

It’s that 10 percent that are not getting better in those 10 days where you probably need to get a neurologist involved who has an interest in seeing athletes. That’s where the difference comes in because that’s where you really have to dig down and find out what else is going on. Is it because this child had some elements of ADHD that have suddenly gotten worse? Is it because there’s a family history of migraine headaches, and although this child never had migraines in the past, he now does—in which case, the concussion may be better. You just have to treat the migraine. It becomes somewhat compli-cated at that point. I hate to see young athletes out of action a month at a time, out of school, being tutored at home, missing their friends—all because they had a treatable problem that

MDADVISOR 7

was lumped in with the concussion. By the time they get to me, they may have been incapacitated for months when the solution was really quite simple. In those cases, they should have been referred out.

MDADVISOR: What are your thoughts about chronic traumatic encephalopathy (CTE)?ALESSI: First, you have to understand that CTE is a diagnosis that we make after someone dies. It has given us a new window into the brain and what happens eventually. The question becomes: Does that information help us in terms of making decisions today regarding the patient? I think that’s the debate. How do you make this diagnosis when someone’s alive, and how do you advise someone whether they should abandon their career? This is especially difficult for self-employed ath-letes, like combat sports athletes and professional bull riders. If these athletes don’t perform, they don’t get paid; they don’t eat. This situation presents us with a real ethical dilemma. For a neurologist to be working in a sport where the only objective of the sport is to neurologically impair an opponent, like in boxing, is a bit ironic and challenging. My job, and that of all sports medicine physicians, is to advocate for the athlete. Our only obligation is to the athlete—not the team, not the coaches, not the owner—it’s only to the athlete. That’s very important to understand and to always maintain.

MDADVISOR: There was a blood test called Banyan BTI approved by the Food and Drug Administration (FDA) to assess brain trauma. Do you believe that this is helpful to evaluate brain injury?ALESSI: The blood test has proven to be helpful to evaluate brain injury, but I don’t think it has a very big application in sports because you don’t get results until hours later, which doesn’t help us on the sideline. I think its application is going to be for motor vehicle accidents and liability cases that go to the emergency room. It’s being marketed as something that will eliminate the need for a CT scan, but that’s not the case at all. If you suspect an athlete was struck in the head so badly that he needs an imaging study, it’s because you think he bled into the brain. In that case, you’d better get the CT scan right away because you can get an immediate result as opposed to waiting around for a blood result. Also, the blood test is approved only for adults. It doesn’t help us in youth or high school sports. I think it’s going to be a helpful test for brain injury, but it will help us in sports only to a very limited extent.

MDADVISOR: Which sports do you believe pose the greatest risk for concussion? Is there a difference by age or gender?ALESSI: If we look at statistics, the greatest number of concus-sions overall is in women’s soccer. We know also that it takes young women—women of childbearing age—longer to recover after a concussion. And it does take longer for children’s brains to recover after a concussion.

American professional football players

College football players

High schoolfootball players

Youth-level tacklefootball players

≈1,800

≈54,000

1 million +

3 million +

…All our emphasis has been at the highest levels where the money is, but the real brain damage is occurring at the bottom of that pyramid.


MDADVISOR: Has there been any progress in reducing the number of youth concussions?ALESSI: The only youth sport where we’ve been able to reduce the number of concussions is youth hockey. Why? Because they changed the rules. No checking until age 13. Suddenly, the number of concussions dropped. Yes, we’re changing the rules of the game to avoid head injury as best we can, but the intense focus of rule change has been at the NFL level. We really have to get it down to youth sports.

Some states now have pending legislation to ban youth foot-ball before the age of 12. I have a problem with legislating com-mon sense. But if that’s what we need to do, maybe we should do it. But it would be better if families changed their beliefs about youth sports. When you talk to accomplished NFL foot-ball players, you’ll find that so few of them played youth foot-ball. Tom Brady never played youth football. Archie Manning never let his children play youth football. Why? Because he was afraid they were going to get hurt at that stage—even though he knew they had skills. Look at the recent NFL draft: 29 of the 32 first-round draft picks played multiple sports as children and in high school. They didn’t specialize in one sport, and many did not play youth football. They developed other athletic skills. That’s how they became accomplished athletes. When parents think youth tackle football is the ticket to the NFL, they’re very wrong statistically.

The goal of youth sports is to get children running around rather than sitting in front of a TV or computer getting obese and diabetic. The goal is to learn what it’s like to work as a

team, to learn skills like running, throwing, catching—and you can do that all with flag football. That’s why flag football is the fastest-growing youth sport in this country today. With those skills, children can become accomplished players of contact football in high school.

Instead of using legislation to address the problem, I would rather see us devote time, effort and money to education. As with any public health problem (and I think concussion is a public health problem), whether it be AIDS or cholera, we solve the problem by teaching the people it affects most. That means the athletes themselves or their parents. By educating them, we begin to regulate the problem. I think that’s where we need to devote our efforts right now.

MDADVISOR: Where will that education and regulation come from?ALESSI: Somebody needs to regulate leagues. These youth leagues—premier, travel, AAU and more—just crop up and start collecting money. High school sports are regulated by

The greatest number of

concussions overall is in

women’s soccer.

Some states now have pending legislation to ban youth football before the age of 12.

MDADVISOR 9

the state. But these other leagues are not regulated in any way. Many of the AAU teams I’ve worked with have taken a lead in creating regulations, but they’re under no obligation to do that. Their only obligation is to collect money from the parents for uniforms, travel and other things, which has become a very profitable segment of sports these days. I think the education and regulation need to occur at the league level, especially with the coaches and parents who are involved.

MDADVISOR: It sounds like an exciting time for sports neurology and for you and for the University of Connecticut.ALESSI: It is. What’s interesting is that the treatments for neuro-logic conditions like multiple sclerosis (MS), epilepsy and even stroke have now changed so much that we have athletes with these conditions competing at the highest levels of their sport. Teddy Bruski of the New England Patriots, for example, had a stroke. They actually repaired the hole in his heart, and he went back to playing football. That’s what sports neurologists do. We have athletes competing at the highest professional level with severe migraines and with a valid diagnosis of multiple sclerosis—again, being managed by a sports neurologist. Teams need a sports neurologist because the physician has to have a clear understanding of how to treat that athlete within the confines of best athletic performance. Even prescribed med-ications have to be carefully chosen to ensure the drug won’t limit the athlete’s performance. That’s the real challenge in sports neurology, and that’s what we bring to the table for the management of athletes and their various injuries.

People are starting to ask me when I’m going to retire. I just can’t see retiring—this is too much fun right now. I get to work with young professionals who are so energetic and passionate about being involved in sports and athletics. We talk about the high level of burnout for physicians, but I’ve never seen burnout in a sports neurologist. The day is so varied. You don’t know when the phone is going to ring, and you’re going to be faced with a new challenge from an athlete somewhere in the world. At the University of Connecticut, we’ve developed a HIPAA-secure Internet channel so that at any point I can do an exam and support another physician or athletic trainer who’s in a training room with an athlete to answer their questions and actually see the athlete and conduct an interview and document in the record what they should or shouldn’t be doing. This week alone, I’ve cleared three athletes to return to their sport while they were on the road. Instead of waiting until they come back home for an exam, they can play that night because I can do an exam over the Internet. It’s fascinating from that standpoint. The University of Connecticut is truly dedicated to developing a sports medicine team. At the facility where I work, we have sports orthopedists, sports primary care and physical therapists, all under one roof. That’s key to allowing us to consult with each other on every athlete who comes in.

MDADVISOR: Where do you think you’ll see the greatest advances in sports neurology in the next 5 to 10 years?ALESSI: I think we’re going to see the ability for more ath-letes who have either chronic neurologic conditions or head injuries to recover appropriately and return to their sport. I’m not just talking about the highest level of sports. I’m talking about other athletes who, after having suffered conditions like stroke or having MS, will get back out and participate, whether it be something like playing golf or tennis or running marathons. We’ve seen this already with Paralympians. We’ve seen someone who’s lost limbs compete at a high level. Sports are becoming much more inclusive, and that inclusiveness is extending more and more to people who’ve had neurologic conditions. That’s what we want to emphasize to our patients.

MDADVISOR: What would be your advice to medical students entering the neurology field? ALESSI: I tell young medical students to take a good, hard look at neurology. In the past, there were so many conditions we couldn’t do anything about. Stroke, for example. People would say, “You can’t do anything for a stroke.” Now, with neuroplas-ticity we know the brain is always developing and continuing to repair itself. I encourage young people to look at as many fields of neurology as possible, whether it be epilepsy, mus-cular dystrophy, Lou Gehrig’s disease. Neurology is so exciting because every day there’s something new about it. I encourage young neurologists to look at all the different aspects, including sports, and really develop a repertoire of skills to go forward. There are so many opportunities for young men and young women in neurology that make it a tremendous field.

Catherine E. Williams is Senior Vice President, Business Development and Corporate Secretary at MDAdvantage Insurance Company. Janet S. Puro is Vice President, Business Development and Corporate Communications at MDAdvantage Insurance Company.

In order to obtain AMA PRA Category 1 Credit™, participants are required to:

1. Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully.

2. The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form.

3. Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete.

4. Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or complete online at www.surveymonkey.com/r/Summer2018CME

Or fax to: 978-367-9148

5. Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again.

6. Mail the Registration and Evaluation Form on or before the deadline, which is August 1, 2019. Forms received after that date will not be processed.

Tendinous Conditions of the Hip and PelvisBy Jennifer Kurowicki, MD, John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD

Authors: Jennifer Kurowicki, MD (orthopaedic surgery research fellow with St. Joseph’s Healthcare System in affiliation with Seton Hall University-School of Health and Medical Sciences, Orthopaedic Surgery Residency Program); John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD (New Jersey Orthopaedic Institute (Wayne, NJ) and St. Joseph’s Healthcare System (Paterson, NJ).Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and through the Joint Providership of Health Research Education and Trust of New Jersey (HRET) and MDAdvantage. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity.

CME

11MDADVISOR

LEARNING OBJECTIVESAt the conclusion of this activity, participants will be able to:

1 Identify intra-articular and extra-articular causes of hip pain.

2 Understand the anatomy and associated physical exam findings in evaluation of hip pathology.

3 Describe the utility of diagnostic imaging.

4 Discuss the operative and non-operative management of these disorders.

INTRODUCTION Hip pain is among the most common complaints seen in an orthopedist’s office. Historically, hip pain has been attributed to osteoarthritis and treated conservatively with physical therapy and corticosteroid injections until definitive treatment with hip arthroplasty was indicated. However, technological innovations, including arthros-copy and ortho-biologics, combined with improved con-ceptual understanding of hip pathology, have improved a physician’s ability to diagnosis and treat a plethora of complex hip pathologies. Thus, a non-specific com-plaint such as hip pain has an ever-evolving differential diagnosis and requires physicians to have a firm grasp of possible sources.

Obtaining a comprehensive history, physical exam and appropriate imagining studies can help categorize hip pain into its two major causes: intra-articular or extra-ar-ticular pathologies. Intra-articular hip pain typically pres-ents with pain that radiates anteriorly to the groin and is associated with mechanical symptoms, such as clicking or catching.1 Common intra-articular producers of pain can include osteoarthritis, labral tear, femoroacetabular-impingement (FAI) or loose bodies.1–3

Conversely, extra-articular pathologies may mimic hip pain but are associated with the surrounding muscles, tendons, bursae, bones or nerves. Core muscle injury, also known as sports hernia, is a common mimicker of anterior groin pain seen in high-level athletes and should be differentiated from labral tears, FAI or osteoarthritis. Patients with lateral hip pain should be evaluated for greater trochanteric pain syndrome, which encompasses the trifecta of trochanteric bursitis, external snapping hip (coxa saltans) and abductor tendinopathy.2, 4, 5 Last, the main etiologies of posterior hip pain are extra-articular, including piriformis syndrome or a tear of the proximal hamstring.3, 6, 7

This article provides a general overview of the anatomy, diagnostic testing and treatment strategies for the man-agement of the most common cause of anterior/groin, lateral and posterior hip pain.

Anterior/Groin PainAnterior/groin pain may be the result of core muscle injury, femoroacetabular impingement or osteoarthritis.

Core Muscle Injury. The abdominal conjoined tendon is formed from the fibers of the internal oblique and transver-sus abdominis as the tendon inserts on the pubic tubercle. This tendon merges with fibers of the rectus abdominis and external oblique to form the pubic aponeurosis and meets at the origin of the adductor longus and gracilis muscles on the pubic symphysis. Core muscle injury, com-monly referred to as “sports hernia,” occurs when shearing forces are applied across the pubis during simultaneous trunk hyperextension and thigh hyperabduction resulting in a tear of the conjoined tendon insertion of the adductor longus and rectus abdominis on the pubis.3, 8-11

This injury is commonly seen in male athletes, particu-larly in sports with an abundance of kicking and twisting, such as soccer, hockey or rugby.12, 13 Typically, there is an insidious onset of symptoms that are relieved with rest and aggravated by sneezing, coughing or activity.11, 14 Physical exam will be devoid of true hernia and demon-strate tenderness to palpation of the adductor insertion on the pubis. Pain can also be elicited with resisted sit-up or resisted hip adduction.

Plain radiographs can demonstrate bone resorption and widening of the pubic symphysis (indicative of osteitis pubis) as well as rule out possible fractures or avulsions.1 Magnetic resonance imaging (MRI) of the pelvis demon-strating increased signal at the pubis and high-intensity signal at the groin muscles is considered the gold standard for diagnosis15 (see Figure 1).

Conservative management with activity modification and rest for 6 to 12 weeks, cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy aimed at core and adductor strengthening are the first line of treatment.16 For patients who fail a minimum of three months of non-operative therapy, surgical inter-vention using a mini-open approach to repair the rectus abdominis to the periosteum of the pubis and adductor lengthening has been described.17 Operative management in athletes has demonstrated a full return to play in up to 97 percent of patients.11


CME

Femoroacetabular Impingement (FAI). Femoroacetabular impinge-ment (FAI) is a result of abnormal articulation between the acetabu-lum and the proximal femur due to abnormal variants in anatomy. Pincer impingement occurs due to acetab-ular overcoverage of the proximal femur, while cam impingement is a result of an aspherical femoral head-neck junction.1 As a result, impinge-ment can cause decreased range of motion, pain, labral tears and an increased incidence of osteoarthri-

tis.18, 19 Commonly seen in hockey, golf, dance, soccer and football, patients complain of pain with prolonged sitting, rising from a seated position or lateral, cutting-type action.20 The flexion-abduction-external rotation (FABER) maneuver is considered positive for FAI if the maneuver elicits pain.

Plain anterior-posterior (A/P) and cross-table pelvic radio-graphs can be utilized to evaluate acetabular overhang and head-neck femoral anatomic variants, respectively. MR arthrog-raphy can evaluate for concomitant labral pathology in which an increased signal within the labrum and extension of contrast into the labrum indicates tearing21 (see Figure 2).

Conservative man-agement with NSAIDs, physical therapy and intra-articular cortisone injections is the primary treatment. Hip arthros-copy including femoro-plasty for cam lesions, acetabuloplasty for pin-cer lesions and labral repair have demon-

strated excellent results and high rates of return to play.22 Osteoarthritis. Hip osteoarthritis (OA) is a degenerative

disease causing progressive loss of cartilage and joint space, resulting in pain, stiffness and mechanical symptoms, such as catching or locking. In patients 30 years and older, the prev-alence of symptomatic hip OA is 3 percent with prevalence increasing with age, female gender and obesity.23 A physical exam is significant for decreased hip flexion and extension with limited internal rotation. Standing AP pelvic or AP/lateral hip radiographs demonstrate joint space narrowing, osteophytes, subchondral sclerosis and cysts.

First-line treatment for all patients is NSAIDs, weight loss (particularly in patients with BMI >40 kg/m2) and intra-ar-ticular hip injections. Corticosteroids, hyaluronic acid and

platelet-rich plasma (PRP) injections have all demonstrated functional improvement and pain reduction similar to one another.24, 25 In patients refractory to conservative treatment, total hip arthroplasty (THA) may be considered. The direct anterior approach has recently been popularized utilizing an internervous, intermuscular plane at the interval between the tensor fasciae latae and the sartorius muscle.26 This approach has been linked to less muscle damage and pain, quicker hospi-tal discharge and better functioning at short-term follow-up.27-30

LATERAL HIP PAIN CAUSED BY GREATER TROCHANTERIC PAIN SYNDROMEGreater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain due to inflammation of the trochanteric bur-sae, external snapping of the hip and tendinopathy of the glu-teus medius and minimus.31 While all three of these pathologies may be seen individually, it is common to see these diagnoses concomitantly. There are three bursae in the peritrochanteric space that aid in the smooth motion of the gluteus tendons, iliotibial band (ITB) and tensor fascia lata (TFL); these bursae often become inflamed, inciting lateral hip pain.

External snapping hip is the audible snapping sensation caused by a tight or thickened ITB as it slides over the greater trochanter during hip flexion and extension.32, 33 This is com-monly seen in middle-aged women and is often asymptomatic; however, in the setting of trochanteric bursitis, patients report lateral pain.1 Snapping is often reproducible on exam, and a positive Ober test indicates ITB tightness.

Conservative management with rest, core and abductor strengthening and stretching, NSAIDs and ultrasound-guided injections should be trialed initially. In external snapping hip refractory to non-operative management, surgical techniques, including open lengthening or release of the ITB, versus arthroscopic techniques may be explored. Regardless of open or arthroscopic technique, 98 percent of patients in pooled data were able to return to pre-activity levels.5

Abductor tendon tears of the gluteus medius and/or minimus present as lateral hip pain that is worsened by climbing stairs and a positive Trendelenburg gait.34 Pain on physical exam is exacerbated by resisted hip external rotation or abduction.34

MRI demonstrates a 73 percent sensitivity and a 95 percent specificity for hip abductor pathology, with high signal intensity superior or lateral to the greater trochanter, gluteus medius tendon elongation and tendon discontinuity, all correlated to a tear of the hip abductor.36

Use of steroid injections guided via ultrasound, fluoros-copy or palpation has been shown to provide equivocal pain relief.37-40 Surgical management is reserved for patients who fail three months of conservative treatment. Operative techniques continue to evolve from open to arthroscopic, demonstrating satisfactory outcomes regardless of technique.

Anthony J. Scillia, Copyright 2018. Reprinted with permission.


MDADVISOR 13

CME

Posterior/ Gluteal PainPosterior/gluteal pain is often caused by piriformis syndrome or proximal hamstring tear.

Piriformis Syndrome. The piriformis muscle courses in close proximity, just superior to, the sciatic nerve. Anatomic variations in the muscle or nerve, muscular hypertrophy or trauma may result in irritation and compression of the sciatic nerve and result in posterior hip and gluteal pain.41 Patients typically describe pain that radiates from the hip down to the ankle and is worsened by sitting for long periods.42 A physical exam will demonstrate pain on palpation of the greater tro-chanter, a negative straight leg test and reproducible pain on resisted abduction of flexed, internally rotated hip.41 There is MRI utility in ruling out possible lumbar disk herniations and demonstrating piriformis hypertrophy.

Physical therapy should be aimed at stretching the piriformis, stabilizing the lumbosacral joint and strengthening the hip abductor through exercise. Injections under fluoroscopic guid-ance should be targeted to the origin of the piriformis muscle and have demonstrated therapeutic relief.43 If a patient fails to improve following six months of conservative therapy, surgical intervention by open or arthroscopic technique is indicated. In a case series of 60 arthroscopic piriformis releases with a two-year follow-up, there was significant improvement in pain and function.44

Proximal Hamstring Tear. Injury to the proximal hamstring usually occurs during eccentric lengthening, resulting in a par-tial tear to complete avulsion of the hamstring from its origin on the ischial tuberosity. On a physical exam, posterior thigh ecchymosis is typically present when a complete proximal hamstring rupture has occurred. Additionally, tenderness to palpation of the ischial tuberosity, pain with knee flexion at 45 degrees hip flexion, hamstring weakness and a palpable defect may be present on physical exam. MRI can be used to detect tears in the bone-tendon interface. However, studies have demonstrated correlation between asymptomatic ham-string tendinopathy and increasing age; thus, care must be taken to differentiate acute versus chronic injury.45

Non-operative treatment with rest, ice, compression and elevation or ultrasound-guided injections may be indicated for patients with partial tears of one or two tendons. Patients

with greater than 2 cm retraction, involvement of semimem-branous, semitendinous and biceps femoris tendons or failed conservative management may benefit from surgical repair (see Figure 3).46 Repair of proximal hamstring ruptures has demonstrated high rates of return to play, greater restoration of hamstring strength and higher patient satisfaction compared to those treated non-operatively.47, 48 The evolution of surgical techniques to arthroscopic has begun to gain popularity and has demonstrated satisfactory mid-term results.49

CONCLUSIONAs our knowledge of the anatomy surrounding the hip con-tinues to develop, paralleled with the introduction of innova-tive diagnostic and surgical techniques, physicians can readily manage a multitude of hip pathologies. Conservative manage-ment with ultrasound-guided injections and physical therapy remain the first-line treatment options; however, in the event of refractory pain, minimally-invasive arthroscopic surgical options are available demonstrating excellent outcomes.

Jennifer Kurowicki, MD, is an orthopaedic surgery research fellow with St. Joseph’s Healthcare System in affiliation with Seton Hall University-School of Health and Medical Sciences, Orthopaedic Surgery Residency Program. John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD, practice at New Jersey Orthopaedic Institute (Wayne, NJ) and are affiliated with St. Joseph’s Healthcare System (Paterson, NJ).

1. Karrasch, C., & Lynch, S. (2014). Practical approach to hip pain. Medical Clinics of North America, 98, 737–754, xi.

2. Redmond, J. M., Chen, A. W., & Domb, B. G. (2016). Greater trochanteric pain syndrome. Journal of the American Academy of Orthopaedic Surgeons, 24, 231–240.

3. Tibor, L. M., & Sekiya, J. K. (2008). Differential diagnosis of pain around the hip joint. Arthroscopy, 24, 1407–1421.

4. Pierce, T. P., Issa, K., Kurowicki, J., Festa, A., McInerney, V. K., & Scillia, A. J. (2018). Abductor tendon tears of the hip. Journal of Bone and Joint Surgery Reviews, 6, e6.

5. Pierce, T. P., Kurowicki, J., Issa, K., Festa, A., Scillia, A. J., & McInerney, V. K. (2018, June). External snapping hip: A systematic review of outcomes following surgical intervention. Hip International. [Epub ahead of print.] www.ncbi.nlm.nih.gov/pubmed/29902932.

6. Scillia, A., Choo, A., Milman, E., McInerney, V., & Festa, A. (2011). Snapping of the proximal hamstring origin: A rare cause of coxa saltans: A case report. American Journal of Bone and Joint Surgery, 93, e1251–1253.

7. Jankovic, D., Peng, P., & van Zundert, A. (2013). Brief review: Piriformis syndrome: Etiology, diagnosis, and management. Canadian Journal of Anesthesia, 60, 1003–1012.

8. Akita, K., Niga, S., Yamato, Y., Muneta, T., & Sato, T. (1999). Anatomic basis of chronic groin pain with special reference to sports hernia. Surgical and Radiologic Anatomy, 21, 1–5.

9. Joesting, D. R. (2002). Diagnosis and treatment of sportsman’s hernia. Current Sports Medicine Reports, 1, 121–124.

10. Meyers, W. C., McKechnie, A., Philippon, M. J., Horner, M. A., Zoga, A. C., & Devon, O. N. (2008). Experience with “sports hernia” spanning two decades. Annals of Surgery, 248, 656–665.



CME

11. Meyers, W. C., Foley, D. P., Garrett, W. E., Lohnes, J. H., & Mandlebaum, B. R. (2000). Management of severe lower abdominal or inguinal pain in high-performance athletes. American Journal of Sports Medicine, 28, 2–8.

12. Santilli, O. L., Nardelli, N., Santilli, H. A., & Tripoloni, D. E. (2016). Sports hernias: Experience in a sports medicine center. Hernia, 20, 77–84.

13. Ahumada, L. A., Ashruf, S., Espinosa-de-los-Monteros, A., Long, L. N., de la Torre, J. I., Garth, W. P., & Vasconez, L. O. (2005). Athletic pubalgia: Definition and surgical treatment. Annals of Plastic Surgery, 55, 393–396.

14. van Veen, R. N., de Baat, P., Heijboer, M. P., Kazemier, G., Punt, B. J., Dwarksing, R. S., … van Eijcket, C. H. J. (2007). Successful endoscopic treatment of chronic groin pain in athletes. Surgical Endoscopy, 21, 189–193.

15. Albers, S. L., Spritzer, C. E., Garrett, W. E., & Meyers, W. C. (2001). MR findings in athletes with pubalgia. Skeletal Radiology, 30, 270–277.

16. Larson, C. M. (2014). Sports hernia/athletic pubalgia: Evaluation and management. Sports Health, 6, 139–144.

17. Scillia, A. J., Pierce, T. P., Simone, E., Novak, R. C., & Emblom, B. A. (2017). Mini-open incision sports hernia repair: A surgical technique for core muscle injury. Arthroscopy Techniques, 6, e1281–e1284.

18. Beck, M., Kalhor, M., Leunig, M., & Ganz, R. (2005). Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. British Journal of Bone and Joint Surgery, 87, 1012–1018.

19. Ganz, R., Parvizi, J., Beck, M., Leunig, M., Notzli, H., & Siebenrock, K. A. (2003). Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research. www.ncbi.nlm.nih.gov/pubmed/14646708.

20. Philippon, M., Schenker, M., Briggs, K., & Kuppersmith, D. (2007). Femoroacetabular impingement in 45 professional athletes: Associated pathologies and return to sport following arthroscopic decompression. Knee Surgery, Sports Traumatology, Arthroscopy, 15, 908–914.

21. Czerny, C., Hofmann, S., Neuhold, A., Tschauner, C., Engel, A., Recht, M. P., & Kramer, J. (1996). Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology, 200, 225–230.

22. Schallmo, M. S., Fitzpatrick, T. H., Yancey, H. B., Marquez-Lara, A., Luo, T. D., & Stubbs, A. J. (2018). Return-to-play and performance outcomes of professional athletes in North America after hip arthroscopy from 1999 to 2016. The American Journal of Sports Medicine. http://journals.sagepub.com/doi/abs/10.1177/0363546518773080.

23. Nho, S. J., Kymes, S. M., Callaghan, J. J., & Felson, D. T. (2013). The burden of hip osteoarthritis in the United States: Epidemiologic and economic considerations. Journal of the American Academy of Orthopaedic Surgeons, 21, S1–6.

24. Battaglia, M., Guaraldi, F., Vannini, F., Rossi, G., Timoncini, A., Buda, R., & Giannini, S. (2013). Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis. Orthopedics, 36, e1501–1508.

25. Levine, M. E., Nace, J., Kapadia, B. H., Issa, K., Banerjee, S., Cherian, J., & Mont, M. (2013). Treatment of primary hip osteoarthritis for the primary care physician and the indications for total hip arthroplasty. Journal of Long-Term Effects of Medical Implants, 23, 323–330.

26. Post, Z. D., Orozco, F., Diaz-Ledezma, C., Hozack, W. J., & Ong, A. (2014). Direct anterior approach for total hip arthroplasty: Indications, technique, and results. Journal of the American Academy of Orthopaedic Surgeons, 22, 595–603.

27. Martin, C. T., Pugely, A. J., Gao, Y., & Clark, C. R. (2013). A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. Journal of Arthroplasty, 28, 849–854.

28. Bremer, A. K., Kalberer, F., Pfirrmann, C. W., & Dora, C. (2011). Soft-tissue changes in hip abductor muscles and tendons after total hip replacement: Comparison between the direct anterior and the transgluteal approaches. British Journal of Bone and Joint Surgery, 93, 886–889.

29. Meneghini, R. M., Pagnano, M. W., Trousdale, R. T., & Hozack, W. J. (2006). Muscle damage during MIS total hip arthroplasty: Smith-Petersen versus posterior approach. Clinical Orthopaedics and Related Research, 453, 293–298.

30. Barrett, W. P., Turner, S. E., & Leopold, J. P. (2013). Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. Journal of Arthroplasty, 28, 1634–1638.

31. Strauss, E. J., Nho, S. J., & Kelly, B. T. (2010). Greater trochanteric pain syndrome. Sports Medicine and Arthroscopy Review, 18, 113–119.

32. Allen, W. C., & Cope, R. (1995). Coxa Saltans: The snapping hip revisited. Journal of the American Academy of Orthopaedic Surgeons, 3, 303–308.

33. Brignall, C. G., & Stainsby, G. D. (1991). The snapping hip: Treatment by Z-plasty. British Journal of Bone and Joint Surgery, 73, 253–254.

34. Twair, A., Ryan, M., O’Connell, M., Powell, T., O’Byrne, J., & Eustace, S. (2003). MRI of failed total hip replacement caused by abductor muscle avulsion. American Journal of Roentgenology, 181, 1547–1550.

35. Domb, B. G., Nasser, R. M., & Botser, I. B. (2010). Partial-thickness tears of the gluteus medius: Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy, 26, 1697–1705.

36. Cvitanic, O., Henzie, G., Skezas, N., Lyons, J., & Minter, J. (2004). MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). American Journal of Roentgenology, 182, 137–143.

37. Cohen, S. P., Strassels, S. A., Foster, L., Marvel, J., Williams, K., Crooks, M., … Williams, N. (2009). Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: Multicentre randomised controlled trial. BMJ. www.bmj.com/content/338/bmj.b1088.

38. McEvoy, J. R., Lee, K. S., Blankenbaker, D. G., del Rio, A. M., & Keene, J. S. (2013). Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: Greater trochanter bursa versus subgluteus medius bursa. American Journal of Roentgenology, 201, W313–317.

39. Brinks, A., van Rijn, R. M., Willemsen, S. P., Bohnen, A. M., Nerhaar, J. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2011). Corticosteroid injections for greater trochanteric pain syndrome: A randomized controlled trial in primary care. Annals of Family Medicine, 9, 226–234.

40. Labrosse, J. M., Cardinal, E., Leduc, B. E., Duranceau, J., Remillard, J., Bureau, N. J., … Brassard, P. (2010). Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. American Journal of Roentgenology, 194, 202–206.

41. Windisch, G., Braun, E. M., & Anderhuber, F. (2007). Piriformis muscle: Clinical anatomy and consideration of the piriformis syndrome. Surgical and Radiologic Anatomy, 29, 37–45.

42. Reus, M., de Dios Berna, J., Vazquez, V., Redondo, M. V., & Alonso, J. (2008). Piriformis syndrome: A simple technique for US-guided infiltration of the perisciatic nerve. Preliminary results. European Radiology, 18, 616–620.

43. Byeon, G. J., & Kim, K. H. (2011). Piriformis syndrome in knee osteoarthritis patients after wearing rocker bottom shoes. Korean Journal of Pain, 24, 93–99.

44. Park, M. S., Yoon, S. J., Jung, S. Y., & Kim, S. H. (2016). Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: Mean 2-year follow-up. BMC Musculoskeletal Disorders, 17, 218.

45. De Smet, A. A., Blankenbaker, D. G., Alsheik, N. H., & Lindstrom, M. J. (2012). MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy. American Journal of Roentgenology, 198, 418–422.

46. De Smet, A. A., & Best, T. M. (2000). MR imaging of the distribution and location of acute hamstring injuries in athletes. American Journal of Roentgenology, 174, 393–399.

47. Bodendorfer, B. M., Curley, A. J., Kotler, J. A., Ryan, J. M., Jejurikar, N. S., Kumar, A., & Postma, W. F. (2017). Outcomes after operative and nonoperative treatment of proximal hamstring avulsions: A systematic review and meta-analysis. American Journal of Sports Medicine. www.ncbi.nlm.nih.gov/pubmed/29016194363546517732526.

48. Shambaugh, B. C., Olsen, J. R., Lacerte, E., Kellum, E., & Miller, S. L. (2017). A comparison of nonoperative and operative treatment of complete proximal hamstring ruptures. Orthopaedic Journal of Sports Medicine. http://journals.sagepub.com/doi/full/10.1177/2325967117738551.

49. Lindner, D., Trenga, A. P., Stake, C. E., Jackson, T. J., El Bitar, Y. F., & Domb, B. G. (2014). Endoscopic repair of a chronic incomplete proximal hamstring avulsion in a cheerleader. Clinical Journal of Sport Medicine, 24, 83–86.

MDADVISOR 15CME

TENDINOUS CONDITIONS OF THE HIP AND PELVIS

CME QUESTIONSDeadline for Response: August 1, 2019

1 All patients with hip pain should be managed conservatively until definitive treatment with total hip arthroplasty is indicated.a. Trueb. False

2 In a patient with suspected diagnosis of core muscle injury (sports hernia), which of the following is considered the gold standard for confirming diagnosis?

a. Plain radiographs b. Magnetic resonance imaging (MRI) of the pelvisc. Computed tomography (CT) scan of the pelvisd. Ultrasound

3 Which of the following is the best physical exam maneuver to evaluate femoroacetabular impingement (FAI)?a. Resisted sit-up b. Ober’s test c. Flexion-abduction-external rotation (FABER) maneuverd. Trendelenburg sign

4 Patients with intra-articular hip pathology are more likely to present with mechanical symptoms, such as clicking, catching or locking.

a. True b. False

5 Which of the following is true regarding the direct anterior approach for total hip arthroplasty?a. Recommended for obese patients (BMI >40 kg/m2) b. Requires longer hospital length of stayc. Incurs less muscle damage d. Increases time under anesthesia

6 Which of the following diagnoses should be considered in a patient with lateral side hip pain?a. Greater trochanteric pain syndromeb. Hip osteoarthritisc. Piriformis syndrome d. Core muscle injury

7 External snapping hip refractory to conservative treatment can be treated surgically with iliotibial band lengthening or release.a. Trueb. False

8 Which of the following is an indication for surgical repair of a proximal hamstring tear?a. <2 cm of retractionb. Involvement of semimembranous and semitendinous femoris only c. Involvement of semimembranous and biceps femoris onlyd. Involvement of semimembranous, semitendinous and biceps femoris

9 Compared to conservative treatment, patients managed surgically for proximal hamstring tears demonstrate: a. Decreased hamstring strengthb. Higher rates of return to playc. Decreased range of motiond. Higher rate of recurrence

10 Which of the following is not a component of greater trochanteric pain syndrome?a. Gluteus medius tendonb. Gluteus minimus tendonc. Gluteus maximus tendond. Tensor fascia lata

This post-test may also be completed online at www.surveymonkey.com/r/Summer2018CME

MDADVISOR | Summer 201816CME

REGISTRATION FORM

First Name Middle Initial Last Name Degree

Address

City State ZIP

Phone Email Address Specialty

ANSWER SHEET Circle the correct answer.1) A B 2) A B C D 3) A B C D 4) A B 5) A B C D

6) A B C D 7) A B 8) A B C D 9) A B C D 10) A B C D

Number of hours spent on this activity (reading article and completing quiz)I attest that I have read the article “Tendinous Conditions of the Hip and Pelvis” and am claiming 1 AMA PRA Category 1 Credit.™

Signature Date

EVALUATION Completed by Physician Non-Physician

1. The content of the article was: Excellent Good Fair Poor

2. The authors’ writing style was: Excellent Good Fair Poor

3. The graphics included in the article were: Excellent Good Fair Poor

4. The stated objectives of this article were: Exceeded Met Not met

Was this article free of commercial bias? Yes No

If not, why not

Please share your name and contact information so that we may investigate further.

Participant Name Telephone/Email:

5. Will the knowledge learned today affect your practice? Very Much Moderately Minimally None

6. Based on your participation in the CME activity, describe ways in which you will change the way you practice medicine.Yes Describe

No Why not?

N/A Were you the wrong audience for this activity?

7. Did this CME activity change what you know about:• Intra-articular and extra-articular causes of hip pain. Yes No• The anatomy and associated physical exam findings in evaluation of hip pathology. Yes No• The utility of diagnostic imaging. Yes No• The operative and non-operative management of these disorders. Yes No

8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:

TENDINOUS CONDITIONS OF THE HIP AND PELVIS

REGISTRATION AND EVALUATION FORM(Must be completed in order for your CME Quiz to be scored)

Deadline for Response: August 1, 2019

17MDADVISOR

By William H. Rossy, MD

Cartilage Preservation and Repair Techniques

rticular cartilage injuries are particularly difficult injuries to treat. These injuries

are especially challenging when present in the young, active patient. Normal

cartilage is comprised of a specialized and intricately complex scaffold made up of hyaline cartilage, collagen, proteoglycans and other complex structures that optimize joint function by creating a near frictionless environment. The uniqueness of this tissue is further demonstrated with the understanding that it promotes the distribution of forces within a joint evenly during activities in order to self-protect and optimize joint biomechanics. This factor is crucial in an environment where the forces can often reach eight times a person’s body weight.

The same characteristics that make this specialized tissue unique also make it very difficult to replicate in the face of injury. Over the last several years, much research has been done, and a multitude of cartilage repair techniques have been described. As our understanding of the basic science and biologics of cartilage evolves, so do our treatment algorithms. Consequently, active patients who have cartilage injuries today have many surgical and non-surgical options available to them that were not available 5 to 10 years ago. As the practice of medicine evolves, patient-centered experiences, as well as patient-specific outcomes, become more and more relevant. It is now more important than ever for the patient to be educated on different treatment options.

A


EPIDEMIOLOGYFocal cartilage defects are typically the result of high impact or repetitive loads to the articular surface. The knee is the most common joint affected, followed by the ankle.1-3

Symptomatic cartilage injuries tend to cause swelling, pain, mechanical symptoms and overall joint dysfunction. Previous studies have shown that the incidence of cartilage injuries iden-tified at the time of knee arthroscopy is more than 60 percent, making these injuries a common problem faced by the general orthopaedic surgeon.3 Biomechanical testing demonstrates the detrimental effects of neglecting these lesions since sig-nificant increases in peak forces are found in the surrounding, normal cartilage. This can lead to chronic pain, limitation of joint motion, swelling and progressive arthritis.4

NON-OPERATIVE TREATMENT OPTIONSNon-operative treatment options include physical therapy, injections and biologics.

Physical Therapy. Physical therapy is the mainstay treat-ment of all orthopaedic injuries and ailments. It is typically the first line of treatment, and, if surgery is ultimately required, it is crucial post-operatively for optimal outcomes. Immediately following a cartilage injury, implementing physical therapy that optimizes joint mobilization and kinematics by strengthening surrounding muscles will often improve the biomechanics of that joint and lead to decreased inflammation and improved function. Because of this, it is almost always recommended that physical therapy should be attempted before invasive or more aggressive treatments.

Injections. A number of injections can be employed by the orthopaedic surgeon to help address the pain and swelling associated with cartilage injuries. The most common and first-line treatment is a cortisone injection. Cortisone injections act as strong anti-inflammatory agents to diminish pain and swelling. Combined with a numbing medicine, cortisone can provide short-term pain relief that is substantial and imme-diate. A cortisone injection does not address the underlying pathology or injury other than by offering pain relief. Thus, this treatment should not be considered a definitive therapeutic treatment, but it remains a powerful diagnostic tool for the orthopaedic surgeon.

Viscosupplements, commonly referred to as “gel injections,” are longer acting agents used to treat degenerative changes and early arthritis. In addition to increasing joint lubrication and shock absorption, more recent studies have shown vis-cosupplements stimulate cells within the joint to produce hyal-uronic acid and block certain cell mediators responsible for the inflammatory process and pain.5 Current outcome studies assessing the effects of viscosupplementation and cortisone report on patients with knee osteoarthritis. Therefore, treating acute cartilage injuries in younger patients with cortisone or gel should be done with extreme caution.

Biologics. The use of biologics has become an increasingly popular option for multiple orthopaedic injuries, including articular surface cartilage injuries. Platelet-rich plasma (PRP) and stem cell injections are the two major biologic treat-ments that have become the focus in cartilage restoration and preservation.

When PRP is utilized, a patient’s blood is drawn in the office and then placed in a centrifuge, creating a suspension of plate-lets, growth factors and biomarkers. This PRP is then reinjected back into the affected joint with the goal that the growth fac-tors and associated platelets will promote healing due to the innate regenerative properties they possess. A growing body of evidence suggests that these growth factors can be effective in treating symptomatic cartilage lesions and osteochondral defects.6, 7

Stem cell treatment has gained the most attention with regard to non-operative management of cartilage injuries due to cells’ ability to differentiate into mature cells and potentially replace previously damaged cartilage cells, known as chondrocytes. Mesenchymal stem cells (MSCs) are the precursors of bone and cartilage cells and have been the most thoroughly stud-ied. Although there is mounting evidence in animal studies to indicate the efficacy of stem cells,1 the evidence in humans is minimal to date and, as such, is still considered experimental.

OPERATIVE TREATMENT OPTIONSOperative options for cartilage repair fall into two categories: 1) non-cell based and 2) cell-based.

Non-Cell Based Operative Options. Non-cell based options include bone marrow stimulation (microfracture), osteochon-dral autograft (OATS) and osteochondral allograft.

Bone Marrow Stimulation (Microfracture). Microfracture is an arthroscopic technique for cartilage repair that is carried out with an arthroscopic awl or motorized pic that is used to penetrate the subchondral bone of the cartilage lesion. Following this penetration, local bleeding occurs into the car-tilage defect, leading to migration of stem cells and growth factors into the area from the underlying bone marrow. The congregation of these factors at the base of the cartilage defect promotes the formation of reparative fibrocartilage. Although this tissue is not as resilient as the typical hyaline cartilage that makes up a joint surface, it has been shown to offer signifi-cant improvement in function in short-term follow-up studies.8

Unfortunately, multiple long-term studies have shown that the positive effects of this technique tend to deteriorate after two years.8, 9

Osteochondral Autograft (OATS). Autologous osteochondral transplantation utilizes a patient’s own bone and cartilage in order to address a known injury. This technique involves taking a predetermined size plug of bone and cartilage (osteochon-dral) from a non-weight-bearing portion of the patient’s knee and transplanting it to the injured area. The main advantage

MDADVISOR 19

of this procedure is that it transfers a patient’s own tissue and potentially restores hyaline cartilage, as opposed to repara-tive, less-resilient fibrocartilage. This is associated with a rela-tively brief rehabilitation and healing process since it involves a patient’s own bone-to-bone healing.10 The major limitation of this procedure is the limitation in graft size. The harvesting of an osteochondral graft from the patient’s own articular surface inherently limits the graft size available for transplantation.

Osteochondral Allograft. Osteochondral allograft is a method and technique similar to the autograft previously described; however, instead of using a patient’s own cartilage, the cartilage and bone from a fresh cadaver are transplanted into the affected knee (see Figure 1). This is ideally suited for the management of larger articular cartilage injuries (>2.5 cm2). In previous years, this technique was thought of a second-line, salvage procedure; however, as current studies are demon-strating its outstanding outcomes, it is becoming more com-monly utilized as the first line of treatment. Outcomes of this procedure have shown graft survival rates to be as high as 95 percent at 5 years and 85 percent at 10 years, with subjective improvements in 75 to 85 percent of patients.11-13

Cell-Based Operative Options. Over the last several years, significant advances in surgical treatment options have arisen as our understanding of the biology of cartilage and its intricate workup has evolved. Many of these new techniques focus on addressing the cartilage injury on a cellular level. These cell-based treatments aim at growing cartilage that closely mimics the natural hyaline cartilage found in joints. Treatments include autologous chondrocyte implantation (ACI), particulated juve-nile articular cartilage allograft and BioCartilage.

Autologous Chondrocyte Implantation (ACI). The autol-ogous chondrocyte implantation (ACI) technique was first described in 1994.14 Multiple iterations and advancements over the years have improved the outcome and reliability of

this technique. Currently, the most recent generation of ACI includes using a specialized collagen matrix to promote growth and healing of a patient’s own cartilage cells and is known as matrix induced autologous chondrocyte implantation (MACI).

MACI is a two-stage procedure that requires a knee arthros-copy at the first stage to obtain a patient’s own cartilage cells from a portion of the knee that is non-weight bearing and therefore, non-essential. Once this stage is completed, the cells are placed into a sterile medium and sent to a lab, where the chondrocytes are isolated and expanded in culture. After three to four weeks, the cells reach a certain concentration and are ready to be re-implanted in the second stage of the procedure (see Figure 2).

In the second stage, the cells are placed on the specialized collagen matrix and mailed to the surgeon’s hospital, at which point they are placed back in the patient’s knee over the previ-ously injured area. The collagen matrix promotes the growth of the patient’s own chondrocytes into mature cartilage that fills the prior defect and closely replicates native hyaline car-tilage. This technique has a more prolonged post-operative rehab compared to the previously discussed osteochondral transplantation techniques; however, results and follow-up studies demonstrate excellent long-term outcomes.15

Particulated Juvenile Articular Cartilage Allograft. Despite improving outcomes with MACI, a major drawback is that it requires two separate surgeries. The particulated juvenile articular cartilage allograft technique, utilizing cartilage cells, obviates the need for the second surgery. In this procedure, the cartilage defect is filled with particulate juvenile (donor’s age <13 years) articular cartilage cells that have 100-fold higher

Figure 1. (a) Focal cartilage defect after it has been reamed and prepared for graft implantation. (b&c) Osteochondral graft harvested from a cadaver after the graft has been measured and contoured to fit the defect. (d) Graft inserted into patient’s knee, filling the previous defect. By William H. Rossy, Copyright 2018.

Figure 1. Osteochondral Allograft

a

c

b

dFigure 2. Demonstrates the process of autologous chondrocyte implantation. The new MACI techniques utilize a collagen bi-layer and no longer utilize a periosteal patch. Reprinted from “Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation,” by M. Brittberg, A. Lindahl, A. Nilsson, C. Ohlsson, O. Isaksson, and L. Peterson, 1994, The New England Journal of Medicine, 331, p. 999.

Figure 2. Diagram of Chondrocyte Transplantation in the Right Femoral Condyle

Copyright 2018 by the Massachusetts Medical Society. Reprinted with permission.


growth potential to differentiate into mature hyaline cartilage.16 As this technique is slightly newer than ACI, long-term studies analyzing its results are lacking at this time.

BioCartilage. An additional option for treatment of cartilage injuries has recently been popularized that combines both non-cell mediated and cell mediated cartilage restoration techniques. A product, known as BioCartilage (Arthrex Inc, Naples, FL), utilizes micronized allogenic cartilage with a PRP adjunct. It can be used to augment a cartilage defect following a bone marrow-stimulating (i.e., microfracture) procedure. The extracellular matrix is placed over the microfractured defect. Before placement, the allograft matrix of minced cartilage cells, containing multiple growth factors, is infused with PRP (see Figure 3). A recent study has shown that combining these two techniques has resulted in significant improvement in cartilage repair when compared to microfracture alone.17

CONCLUSIONCartilage injuries are difficult injuries to treat. If left alone, they can lead to significant impairment, loss of function, inability to participate in sports and, ultimately, post-traumatic arthritis. In the young active patient who is not an ideal candidate for total knee replacement or partial knee replacement (due to age and activity level), cartilage preservation and restoration techniques can be employed.

As our understanding of the biology of these injuries evolves, so do our treatment options. Injuries that were once debil-itating and potentially career ending for athletes now have viable treatment options, both surgical and non-surgical, that

have been shown to improve function, restore cartilage and potentially prevent the need for total joint replacement in the future. Knowing the various options, and having injuries addressed by specialists who are specifically trained in cartilage restoration techniques, further optimizes patient outcomes and satisfaction following treatment.

William H. Rossy, MD, is a sports medicine specialist at Princeton Orthopedic Associates in Princeton, New Jersey.

1. Mall, N. A., Harris, J. D., & Cole, B. J. (2015). Clinical evaluation and preoperative planning of articular cartilage lesions of the knee. Journal of American Academy of Orthopaedic Surgeons, 23, 633–640.

2. Murawski, C. D., & Kennedy, J. G. (2013). Operative treatment of osteochondral lesions of the talus. The Journal of Bone and Joint Surgery, 95, 1045–1054.

3. Curl, W. W., Krome, J., Gordon, E. S., Rushing, J. Smith, B. P., & Poehling, G. G. (1997). Cartilage injuries: A review of 31,516 knee arthroscopies. Arthroscopy, 13, 456–460.

4. Guettler, J. H., Demetropoulos, C. K., Yang, K. H., & Jurist, K. A. (2004). Osteochondral defects in the human knee: Influence of defect size on cartilage rim stress and load redistribution to surrounding cartilage. American Journal of Sports Medicine, 32, 1451–1458.

5. Levy, D. M., Petersen, K. A., Scalley Vaught, M., Christian, D. R., & Cole, B. J. (2018). Injections for knee osteoarthritis: Corticosteroids, viscosupplementation, platelet-rich plasma, and autologous stem cells. Arthroscopy, 34, 1730–1743.

6. Leitner, G. C., Gruber, R., Neumuller J., Wagner, A., Kloimstein, P., Hocker, P., … Buchta, C. (2006). Platelet content and growth factor release in platelet-rich plasma: A comparison of four different systems. Vox Sanguinis, 91, 135–139.

7. Patel, S., Dhillon, M. S., Aggarwal, S., Marwaha, N., & Jain, A. (2013). Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: A prospective double-blind, randomized trial. American Journal of Sports Medicine, 41, 356–364.

8. Gobbi, A., Nunag, P., & Malinowski, K. (2005). Treatment of full thickness chondral lesions of the knee with microfracture in a group of athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 13, 213–221.

9. Gobbi, A., Karnatzikos, G., & Kumar, A. (2014). Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 22, 1986–1996.

10. Cole, B. J., Pascual-Garrido, C., & Grumet, R. C. (2009). Surgical management of articular cartilage defects in the knee. American Journal of Bone and Joint Surgery, 91A, 1778–1790.

11. Driesang, I. M., & Hunziker, E. (2000). Delamination rates of tissue flaps used in articular cartilage repair. Journal of Orthopaedic Research, 18, 909–911.

12. Ebert, J. R., Robertson, W. B., Woodhouse, J., Fallon, M., Zheng, M. H., Ackland, T., & Wood, D. J. (2011). Clinical and magnetic resonance imaging-based outcomes to 5 years after matrix induced autologous chondrocyte implantation to address articular cartilage defects in the knee. American Journal of Sports Medicine, 39, 753–763.

13. Farr, J., Tabet, S. K., Margerrison, E., & Cole, B. J. (2014). Clinical, radiographic and histological outcomes after cartilage repair with particulated juvenile articular cartilage: A 2-year prospective study. American Journal of Sports Medicine, 42, 1417–1425.

14. Brittberg, M., Lindahl, A., Nilsson, A., Ohlsson, C., Isaksson, O., & Peterson, L. (1994). Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. The New England Journal of Medicine, 331, 889–895.

15. Bartlett, W., Skinner, J. A., Gooding, C. R., Carrington, R. W., Flanagan, A. M., Briggs, T. W., & Bentley, G. (2005). Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: A prospective randomised study. British Journal of Bone and Joint Surgery, 87, 640–645.

16. Adkisson, H. D., Martin, J. A., Amendola, R. L., Milliman, C., Mauch, K. A., Katwal, A. B., … Buckwalter, J. A. (2010). The potential of human allogeneic juvenile chondrocytes for restoration of articular cartilage. American Journal of Sports Medicine, 38, 1324–1333.

17. Forier, L. A., Chapman, H. S., Pownder, S. L., Roller, B. L., Cross, J. A., Cook, J. L., & Cole, B. J. (2016). BioCartilage improves cartilage repair compared with microfracture alone in an equine model of full-thickness cartilage loss. American Journal of Sports Medicine, 44, 2366–2374.

Figure 3. BioCartilage Utilizing Both Non-Cell Mediated and Cell Mediated Cartilage Restoration Techniques

Figure 3. (a) 15cc of blood in a double syringe before being placed in a centrifuge (b) PRP after it has been centrifuged with PRP found on top of the suspension. (c) The mixture of minced allogenic cells (MACs) with PRP being placed in the bed of the cartilage defect. (d) The mixture after it has filled the defect. Reprinted from “Arthroscopic Management of Isolated Tibial Plateau Defect with Microfracture and Micronized Allogeneic Cartilage-Platelet Rich Plasma Adjunct,” by K. C. Wang, R. M. Frank, E. J. Cotter, D. R. Christian, and B. J. Cole, 2017, Arthroscopy Techniques, 6, p. e1613. Copyright 2017 by the Arthroscopy Association of North America. Open access article license http://creativecommons.org/licenses/by-nc-nd/4.0/.

a b c

d

MDADVISOR 21

As concerns continue to mount about the long-term health impacts of playing football and other contact sports, lawmakers have turned their attention to leg-

islation aimed at protecting young athletes. New Jersey, along with several other East Coast states, has introduced bills spe-cifically targeting protocols for preventing, diagnosing and treating concussions and other head injuries.

NEW JERSEYAssembly Bill No. 3760: Sponsored by Assemblywoman Valerie Vainieri Huttle (D – District 37), this legislation would prohibit children under the age of 12 from participating in organized tackle football. New Jersey is now the fourth state (behind California, Illinois and New York) to propose legislation to restrict or ban tackle football in youth sport organizations.1

The legislation further provides that a school district may not permit a student under the age of 12 to participate in tackle football during interscholastic athletics, intramural athletics, physical education programs or any athletic activity offered to students.

The Assemblywoman notes in her legislation that chronic traumatic encephalopathy (CTE) is caused by repetitive hits to

the head sustained over a period of years. Athletes who begin playing contact sports at younger ages are at a greater risk for neurological impairment later in life, including CTE. Studies show that exposure to tackle football before the age of 12 is associated with a greater risk of neurological impairment than exposure to tackle football starting at or after the age of 12.2

Whether Assemblywoman Huttle’s legislation gains support among her fellow lawmakers remains to be seen. None of the four other states with similar proposals has passed legislation to date.

Assembly Bill No. 1837: Sponsored by Assemblywoman Pamela R. Lampitt (D – District 6) and Assemblyman Daniel R. Benson (D – District 14), this legislation provides that an enrolled student who sustains a concussion must receive an evaluation by a licensed healthcare professional and written clearance from the licensed healthcare professional to return to school.3

In the event that the licensed healthcare professional pro-vides notice that the student requires restrictions or limitations, school officials must immediately implement the restrictions or limitations and notify all teachers and staff who have con-tact with the student of the restrictions or limitations. The school district’s 504 team would promptly identify the manner in which the restrictions or limitations would be provided to the

Legislative Update:CONCUSSION LEGISLATIONBy Jon Bombardieri


student during recovery and the need for the continuation or adjustment of the restrictions or limitations; the team would also determine the duration of the restrictions or limitations.

The bill also provides that a student who sustains a con-cussion is prohibited from engaging in any physical activity at school, including, but not limited to, recess or physical education. The student may not participate in any physical activity until he or she is evaluated by a licensed healthcare professional and receives written clearance to participate.

As defined in the bill, “licensed healthcare professional” means a healthcare provider whose scope of practice includes the ability to diagnose and treat concussion.

Senate Bill No. 645: Sponsored by Senator James Beach (D – District 6), this legislation requires a public school student with concussion to be evaluated by a physician or other licensed healthcare provider before returning to school and returning to physical activity at school.4

This bill provides that a student enrolled in a school district who sustains a concussion must receive an evaluation by a physician or other licensed healthcare provider trained in the evaluation and management of concussions and receive writ-ten clearance from one of these healthcare providers in order to return to school. In the event that the physician provides notice that the student requires restrictions or limitations, the school district’s 504 team must immediately implement the restric-tions or limitations and notify all teachers and staff who have contact with the student of the restrictions or limitations. The school district’s 504 team, in consultation with the physician who provided notice, would promptly identify the manner in which the restrictions or limitations would be provided to the student during recovery and the need for the continuation or adjustment of the restrictions or limitations; the team would also determine the duration of the restrictions or limitations.

The bill also provides that an enrolled student who sustains a concussion is prohibited from engaging in any physical activity at school, including, but not limited to, recess, physical educa-tion or intramural sports. The student may not participate in any physical activity until he or she is evaluated by a physician or other licensed healthcare provider trained in the evaluation and management of concussions and the student receives written clearance to participate.

Senate Bill No. 2442: Sponsored by Senator Patrick J. Diegnan (D – District 18), this legislation provides that a student-ath-lete who sustains a concussion must return to regular school activities before returning to competition; the bill also requires school districts to implement a five-step return-to-competition process.5

The Centers for Disease Control and Prevention (CDC) has developed recommendations concerning a student-athlete’s return to sports and activities following a concussion or other head injury. According to the CDC, a student-athlete who sus-tains a concussion or other head injury should not return to competition or practice until he or she first returns to regular school activities and is no longer experiencing symptoms of the injury when conducting those activities. Once those conditions are met, the CDC recommends that the student-athlete engage in a graduated, five-step return-to-play progression to ensure the student-athlete’s safety and well-being. The CDC’s return-to-play progression recommendations address time frames for participating in 1) light aerobic activity, 2) moderate activity, 3) heavy, noncontact activity, 4) practice and full contact and 5) competition.6

The bill also requires the Department of Education to revise its athletic head injury safety training program to include infor-mation on the CDC’s graduated recommendations. The bill also requires a school district to revise its written policy concerning the prevention and treatment of sports-related concussions and other head injuries to include the CDC’s recommendations.

CONNECTICUTHouse Bill No. 5186: Sponsored by Representative Diana S. Urban (D – Assembly District 43), this legislation requires coaches of youth athletic activities conducted on fields, courts and recreational areas owned, operated or managed by municipalities to annually view an informational video regarding concussions.7

The bill exempts any person, organization or entity (including youth coaches, municipalities, businesses or nonprofit organi-zations) from civil liability due to a youth coach’s failure to take the online course. It sets no penalty for failing to take the course and does not designate an agency to enforce its requirements.

House Bill No. 5291: Sponsored by Representative Nicole Klarides-Ditria (R – District 105), this legislation (signed into law on June 6, 2018) creates a working group to develop rec-ommendations for creating a system for rating the safety of youth athletic protective headgear and for public disclosure of such protective headgear’s safety rating.8

The working group shall include at least three members cho-sen by the Commissioners of Consumer Protection, Education and Public Health or their designees, and may include a repre-sentative from the Connecticut Athletic Trainers’ Association; the Brain Injury Alliance of Connecticut; the Connecticut

MDADVISOR 23

Nurses’ Association; the Commission on Women, Children and Seniors; the Parents Concussion Coalition or a helmet manufacturer; a chiropractor licensed under chapter 372 of the general statutes; an orthopedic sports physician; or any other member the Department of Public Health deems neces-sary and relevant to carrying out the working group’s duties.

The working group shall recommend, based on performance standards for youth athletic protective headgear, the data that should be collected for purposes of 1) developing a safety ratings system to identify which youth athletic protective head-gear best protects against head injury and 2) determining the best way to make such safety ratings available to the public to allow consumers to easily compare overall performance among different models of youth protective headgear.

On or before January 1, 2019, the working group shall report to the joint standing committees of the General Assembly regarding the group’s findings and recommendations.

MARYLANDHouse Bill No. 552: Sponsored by Delegate Terri L. Hill (D – District 12A), this legislation, known as Youth Sports Programs: Concussion Risk and Management Training—Requirements, makes changes to the concussion risk and management train-ing requirements for sports programs at public schools and for specified recreational youth sports programs. The bill generally requires that an educated individual or a licensed healthcare provider must be at every practice and game and that that individual be responsible for final decisions regarding a stu-dent’s removal from or return to play. Local school systems must make specified training that is provided for local school system employees available also to coaches and other indi-viduals from youth sports programs. A reasonable fee may be charged for the training.9

House Bill No. 1210: Sponsored by Delegate Terri L. Hill (D – District 12A), this bill establishes a number of restrictions and requirements aimed at addressing child head injuries from sports, including 1) prohibiting physical sports, for elemen-tary- and middle-school-age individuals at public schools or as part of a youth sports program, 2) requiring high school students to complete a course regarding head injuries before participating in interscholastic athletics or a youth sports pro-gram involving “physical sports” on public school grounds, 3) requiring coaches of youth sports programs that involve “physical sports” to review information regarding head inju-ries and make that information available to high-school-age participants, 4) requiring the Maryland State Department of Education (MSDE), in collaboration with specified individuals and entities, to develop standards for treating head injuries that would require notification of a school nurse and specified academic accommodations for students with head injuries and

5) requiring generally that an educated individual or a licensed healthcare provider must be at every practice and game and that that individual be responsible for final decisions regarding a student’s removal from or return to play.10

PENNSYLVANIAPennsylvania has no significant leg-islation at this time regarding stu-dent-athletes, but the state passed a law in 2011 (SB 200) that established standards for managing concussions and traumatic brain injuries for stu-dent-athletes. The law requires the Department of Health and Education to develop guidelines to educate students participating in or desiring to participate in athletic activities, as well as their parents and coaches, about the nature and risk of concussion and traumatic brain injury. If a game official, a coach from the student’s team, a certi-fied athletic trainer, a licensed physician, a licensed physical therapist or other official designated by the student’s school determines that a student exhibits signs or symptoms of a concussion or traumatic brain injury while participating in an athletic activity, that student is required to be removed from participation at that time. The student may not return to play until the student has been evaluated and cleared for partici-pation by an appropriate medical professional.11

WEST VIRGINIA Senate Concurrent Resolution No. 51: Sponsored by Senators Kenny Mann (R – District 10), Robert Karnes (R – District 11) and Mike Hall (R – District 4), this resolu-tion requests that the Joint Committee on Government and Finance study all aspects of implementing Return-to-Learn protocols for elementary and sec-ondary education students and higher education students who have suffered a concussion.12

MASSACHUSETTS House Bill No. 1256: Sponsored by Representative Marc R. Pacheco (D – First Plymouth and Bristol District), this legislation directs the Department of Health to create, implement and maintain mandatory baseline concus-sion testing for all high-school-aged athletes enrolled in public school or any school, private or otherwise, that is subject to the Massachusetts Interscholastic Athletic Association rules.13

House Bill No. 1155: Sponsored by Representative Tricia Farley-Bouvier (D – Third Berkshire District), this legislation


established a special commission to study concussions that occur as a result of varsity sports in public and private high schools. The commission shall consist of nine members: one of whom shall be the Commissioner of Public Health or designee, who shall serve as chair; one representative each from the Brain Injury Association of Massachusetts, the Massachusetts Interscholastic Athletic Association and the Athletic Trainers of Massachusetts; and five representatives who shall be appointed by the Governor. Of this group of appointed five, one shall be a physician with expertise in the management of sports-re-lated concussions, one shall be a researcher specializing in the study of the long-term consequences of brain trauma, one shall be a professional whose primary responsibility is that of athletic director at a Massachusetts high school and one shall be a representative of private school athletic programs in Massachusetts. In appointing members of the commission, consideration shall be given to race, gender and geographic diversity.

The commission shall take on three tasks: 1) analyze current data on the prevalence and causes of sports-related concus-sions, 2) review the rules associated with each sport and the safety policies currently in effect with respect to each sport and 3) study the cost and effectiveness of baseline concussion testing of athletes.

The commission shall make four recommendations regarding the following: 1) methods of reducing and preventing concus-sions, 2) procedures to be employed by schools to identify and respond to occurrences of concussions, 3) the necessity of requiring baseline concussion testing for students participating in high school athletics and 4) any legislation the commission deems necessary to effect its recommendations.14

RHODE ISLANDSenate Bill No. 2050: Sponsored by Senators Frank S. Lombardi (D – District 26) and Erin Lynch Prata (D – District 31), this legislation would provide guidelines for concussions incurred during school and youth programs, requiring that an adult trained in recognizing the symptoms of a concussion be present during all events. All school districts would be required to have an athletic trainer, a nurse or a similarly trained person, who is trained in concussion symptom recognition and evaluation, at all recreational and athletic events addressed by this statute.

The legislation provides that a youth athlete who has been removed from play may not return to play until the athlete is evaluated by a licensed physician who may consult with an athletic trainer—both of whom shall be trained in the eval-uation and management of concussions. The athlete must receive written clearance to return to play from that licensed physician.15

DISTRICT OF COLUMBIABill No. 22-0688: Sponsored by Democratic Councilmembers Vincent C. Gray, Anita Bonds, Brianne Nadeau and Jack Evans, this bill calls for a public hearing regarding the Athletic Trainers Clarification Amendment Act of 2018. This amendment would allow athletic trainers to diagnose physical disabilities and to rehabilitate injuries resulting from concus-sions. It expands the scope of injuries that can be treated by athletic trainers and expands available methods of treatment. It increases the membership of the Board of Physical Therapy from 7 to 10.16

Jon Bombardieri is a Partner at CLB Partners, LLC, in Trenton, New Jersey.

1. Johnson, B. (2018, April 10). N.J. could soon ban tackle football for kids under 12. NJ Advance Media. www.nj.com/politics/index.ssf/2018/04/nj_could_soon_ban_tackle_football_for_children.html.

2. Vainieri Huttle, V. (2018, April 5). Assembly, No. 3760; State of New Jersey 218th Legislature. www.njleg.state.nj.us/2018/Bills/A4000/3760_I1.HTM.

3. Lampitt, P., & Benson, D. (Pre-filed for introduction in the 2018 Session). Assembly, No. 1837; State of New Jersey 218th Legislature. www.njleg.state.nj.us/2018/Bills/A2000/1837_I1.HTM.

4. Beach, J., & Ruiz, T. (Pre-filed for introduction in the 2018 Session). Senate, No. 645; State of New Jersey 218th Legislature. www.njleg.state.nj.us/2018/Bills/S1000/645_I1.HTM.

5. Diegnan, P. (2018, April 5). Senate, No. 2442; State of New Jersey 218th Legislature. www.njleg.state.nj.us/2018/Bills/S2500/2442_I1.HTM.

6. Centers for Disease Control & Prevention. (2015 [updated]). Returning to sports and activities. Heads Up. www.cdc.gov/headsup/basics/return_to_sports.html.

7. Urban, D. (2018, March 15). House of Representatives, No. 5186, File No. 9; State of Connecticut. www.cga.ct.gov/2018/FC/2018HB-05186-R000009-FC.htm.

8. Klarides-Ditria, N. (2018, June 6). Senate and House of Representatives, No. 5291, Special Act No. 18-15; State of Connecticut. www.cga.ct.gov/2018/ACT/sa/2018SA-00015-R00HB-05291-SA.htm.

9. Hill, T. L. (2018, January 26). House Bill, No. 552; State of Maryland. www.mgaleg.maryland.gov/2018RS/bills/hb/hb0552f.pdf.

10. Hill, T. L. (2018, February 8). House Bill, No 1210; State of Maryland. www.mgaleg.maryland.gov/2018RS/bills/hb/hb1210f.pdf.

11. Browne, P. (2011). Senate Bill, No. 200; State of Pennsylvania. www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?sYear=2011&sInd=0&body=S&type=B&bn=200.

12. Mann, K., Karnes, R., & Hall, M. (2017, March 31). Senate Concurrent Resolution, No. 51; State of West Virginia. www.wvlegislature.gov/Bill_Text_HTML/2017_SESSIONS/RS/Bills/scr51%20org.htm.

13. Pacheco, M. (2018, May 31). Senate, No. 1256; Commonwealth of Massachusetts 190th General Court. www.malegislature.gov/Bills/190/S1256.

14. Farley-Bouvier, T. (2018, February 7). House Bill, No. 1155; Commonwealth of Massachusetts 190th General Court. www.malegislature.gov/Bills/ 190/H1155.

15. Lombardi, F., & Lynch Prata, E. (2018, January 18). Senate, No. 2050; State of Rhode Island. http://webserver.rilin.state.ri.us/billtext18/senatetext18/s2050.htm.

16. DC State Legislature. (2018). Council Bill 220688. https://legiscan.com/DC/bill/B22-0688/2017.

I n the National Football League, right now, there is a lot of press and a lot of noise regarding the long-term dangers of concussions. This spotlight has begun to cast its light on the public health impact of sports-related concussions in all sports and at all levels.

Depending on which study you look at, there are approximately 3 million or so sports-related concussions a year in this country, with a significant increase over the last decade in emergency department visits for mild traumatic brain injury (i.e., concussion).1 With press attention and numbers like these, those involved in the care of athletes at all levels—physicians, athletic trainers, nurses, parents and the athletes themselves—are questioning the impact of concussions: How dangerous are concussions? How should they be treated? Are there long-term side effects?

These are questions that we in the healthcare community need to address by doing a better job of identifying concussions and taking advantage of some of the newer diagnostic and rehab protocols.

Sports-Related Concussion: RECOGNIZE, REST, REHAB, RETURN

25MDADVISOR

By Damion A. Martins, MD


OBSTACLES TO IDENTIFYING CONCUSSIONS Of major concern in the quest to diagnose and treat sports-re-lated concussions is the problem that many athletes don’t report concussions. Studies have shown that almost 50 percent of athletes don’t report their concussions.2 Sometimes, the athletes are just not taught how to recognize the signs and symptoms. In my experience the majority of athletes don’t report a possible concussion because they don’t want their coaches or athletic trainers to pull them from participation.

That is the double-edged sword of many rules and laws requiring appropriate assessment of concussions. New Jersey was one of the first states that came out strong on concussion legislation for high school athletes, which was a very positive decision. Unfortunately, now that the athletes know a concus-sion will pull them out of competition for a week or so, there is an inherent bias against reporting the concussion.

Encouraging athletes to self-report requires a lot of support from the parents, schools and medical community. But most importantly, it requires ongoing education of athletic trainers who are the first-line evaluators on the sidelines and in the training room. Athletic trainers should be able to recognize the signs and symptoms of concussions, regardless of what the athlete says. Accurately diagnosing concussions requires having the most up-to-date information on concussions—and this, currently, is an obstacle.

An additional obstacle is the pervasive and persistent reli-ance on only one test result for diagnosing concussions. Those diagnosing concussions need to know that no one test is per-fect. There are many on-field assessments and other cognitive concussion tests, but they are not all the same in terms of sensitivity and specificity. If you have a strep throat test, you want to know how sensitive it is—meaning how good is it at identifying the disease when it’s present and how specific the test is in terms of its true negative rate.

When assessing someone with a concussion, the healthcare professional has a choice of many different tools and tests. We have to know which test to use and then be able to interpret the results in light of the clinical situation. That is the art of medicine—documenting the patient’s signs and symptoms, obtaining an accurate history and physical exam, interpreting test results and then making a determination whether or not the person truly has a concussion and not just a neck sprain or a bruised jaw.

CONCUSSION TESTINGOvercoming the obstacles to an accurate concussion diagnosis requires willingness on the part of a practitioner to consider the following range of available tests and then determine which ones can be combined for a diagnosis that is sensitive and specific (see Figure 1).

PCS. The Post-Concussion Symptoms (PCS) scale is probably the most commonly used test. It is a Likert scale on which the

concussed individuals rate from 0 to 6 how they feel regarding common symptoms of concussion, such as headache, diz-ziness, fatigue, irritability, sadness and sleeping difficulties. Although the PCS is very sensitive at picking up a concussion, a patient who had the flu or had a bad night’s sleep may score positive on that test, so it’s not very specific for a concussion.

SAC. The Standardized Assessment of Concussion (SAC) test is a 30-point cognitive test that looks at memory, concen-tration and delayed recall. For example, part of the test asks the patient to say five words and repeat them a few minutes later, or to state the months backwards or to recall certain numbers in reverse order. However, because some people have good delayed recall and good concentration, this test is not very sensitive or very specific. Having a baseline test for comparison is valuable.

BESS. Balance Error Scoring System (BESS) is a simple bal-ance test. This test is not very sensitive, but it is very specific because people who have concussions almost always have some issues with balance or their vestibular system.

SCAT-5. The SCAT-5 incorporates several tests, including the PCS, the SAC and the balance testing, all in one. For most athletes and athletic trainers in schools, this is probably the test most commonly used to identify if a patient is concussed. Unfortunately, the SCAT-5 doesn’t help categorize the patient’s type of concussion, and we’re now learning that this categori-zation is vital (as explained later in this article).

VOMS. The Vestibular Ocular Motor Screening (VOMS) test, developed at the University of Pittsburgh, is a very good test for concussions because vestibular and ocular motor impair-ments and symptoms have been documented in patients with sport-related concussions.3 This test looks at eye motion, con-vergence, visual motion sensitivity and the vestibular ocular reflex system. The VOMS is one of the newer tests most helpful in examining patients who have balance and vestibular issues. A case in which the VOMS test is useful is a young athlete who

Figure 1. Diagnostic Tools: How Good Are They?

SCAT III (1 Class II study)> 3.5 decrease from baseline is 96% sensitive and 81% specific – value < 74.5 associated with 83% sensitivity and 91% specificity

PCS (Multiple Class III studies)sensitivity 91–100% – specificity 64–89%

SAC score (Multiple Class III studies)sensitivity 80–94% – specificity 76–91%

Neuropsychological test (1 Class II, multiple Class III studies)sensitivity 71–88%

Deficits in BESS (Multiple Class III studies)sensitivity 34–64% – specificity 91%

From “Summary of Evidence-Based Guideline Update: Evaluation and Management of Concussion in Sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology,” by C. C. Giza, J. S. Kutcher, S. Ashwal, J. Barth, T. S. Getchius, G. A. Gioia, … R. Zafonte, June 2013, Neurology, 80, pp. 2250–2257.

MDADVISOR 27

sustains a concussion and, although the student has no cogni-tive issues, has trouble returning to school. His brain works just fine, but he has trouble looking at the white board or computer screen because of his inability to focus his eyes. I spend a lot of time teaching our Sports Medicine Fellows at Atlantic Health System how to do this assessment. Today’s sports medicine practitioners need to learn how to administer the VOMS test because it helps identify a significant portion of concussions that we have probably missed in the past.

SUBTYPES OF CONCUSSIONS Once the concussion is diagnosed, there’s still a need to identify the subtype of concussion before determining the best treatment, because not all concussions are the same. Concussions can manifest predominant symptom patterns, such as headaches, neck pain, vestibular/balance issues or anxiety/depression. The treatment for various subtypes of concussions is different. For example, there is evidence that vestibular rehabilitation decreases vertigo and dizziness,4 while neurocognitive rehabilitation improves attention.5 Knowing the subtype of concussion allows us to more quickly and accurately treat the patient. (See Figure 2.)

TREATMENT

For years, we have used what I call the cocoon theory to treat people with concussions: Rest—cognitive rest and bed rest. This is similar to the way we used to treat back-pain patients 20 to 30 years ago—bed rest for a week until you feel better. But now we know that this treatment does not work and, in fact, makes the back pain worse. It is the same with concussions. There is no scientific evidence that prolonged rest is beneficial. The best available evidence suggests that complete rest exceeding three days is detrimental.6 There is minimal scientific evidence that medications speed recovery (although SSRIs and TCAs may help with depression and insomnia, and Aricept, lecithin and CDP-choline may alleviate cognitive deficits). In addition, there is limited evidence that psychological interventions are beneficial.7

Effective treatment for many types of concussions includes a brief period of rest during the acute phase (24 to 48 hours) after injury, followed by gradual/progressive activity. Concussed individuals should stay below cognitive and physical symp-tom-exacerbation thresholds so that their activity level does not bring on or worsen their symptoms.8 Aerobic exercises begun 14 to 21 days after concussion upregulate neurotrophins in association with improved cognitive performance.9

Cutting-edge research suggests that early return to exercise in patients with concussions has been effective. Dr. Leddy’s (University of Buffalo) protocols have been used at Atlantic Sports Health with a significant reduction in our patients’ symp-toms.10 Their controlled exercise program, called progressive sub-symptom threshold testing, is a modified version of the more commonly used Balke-C protocol used to determine endurance (VO2 max) in athletes and cardiac patients.

The Balke-C protocol has been modified by Leddy to speed up the return-to-exercise protocol.11 In its simplest form, the practitioner monitors heart rate and blood pressure while the patient uses a bike or treadmill to push their limits to the point that the exercise exacerbates symptoms. The patient then fills out a PCS symptom checklist. For example, if the primary symptom is headache, when the heart rate reaches 100 beats per minute, the headache worsens. The patient then

Figure 1. Diagnostic Tools: How Good Are They?

SCAT III (1 Class II study)> 3.5 decrease from baseline is 96% sensitive and 81% specific – value < 74.5 associated with 83% sensitivity and 91% specificity

PCS (Multiple Class III studies)sensitivity 91–100% – specificity 64–89%

SAC score (Multiple Class III studies)sensitivity 80–94% – specificity 76–91%

Neuropsychological test (1 Class II, multiple Class III studies)sensitivity 71–88%

Deficits in BESS (Multiple Class III studies)sensitivity 34–64% – specificity 91%

From “Summary of Evidence-Based Guideline Update: Evaluation and Management of Concussion in Sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology,” by C. C. Giza, J. S. Kutcher, S. Ashwal, J. Barth, T. S. Getchius, G. A. Gioia, … R. Zafonte, June 2013, Neurology, 80, pp. 2250–2257.

Figure 2. Newer Classifications: mTBI Signs and Symptoms

• Symptoms – Somatic (headache, nausea, dizziness, fatigue,

sensitivity to light and noise) – Cognitive (feeling slowed down, feeling

mentally “foggy”) – Emotional (sadness, nervousness, feeling

more emotional)

• Physical Signs (vomiting, balance problems, loss of consciousness, amnesia)

• Behavioral Changes (irritability, personality changes)

• Cognitive Impairment (slowed reaction time)

• Sleep Disturbances (change in sleep patterns, trouble falling asleep)

• Neuro-ophthalmological Abnormalities: – Saccades – Convergence – Accommodation – Vestibular-ocular/Vestibular-spinal

From “Consensus Statement on Concussion in Sport—the 4th International Conference on Concussion in Sport held in Zurich, November 2012,” by P. McCrory, W. Meeuwisse, M. Aubry, B. Cantu, J. Dvorak, R. Echemendia, … A. Sills, March 2013, Clinical Journal of Sport Medicine, 23, pp. 89–117.


exercises at 80 percent of the symptom threshold, reaching a heart rate of 80 beats a minute. Every day, the patient increases the time until he or she reaches 30 minutes of exercise at that 80 percent threshold. The practitioner retests to find the new symptom threshold. After the patient is asymptomatic from this method of slow progressive exercise, he or she then follows the progressive return-to-play protocol. Ninety-nine percent of our patients are able to exercise within two to three weeks without any symptoms.

By understanding the subtypes of concussions and the vari-ety of treatment tools available, we can return our concussed patients to exercise more rapidly and we can return them to sports in a safe manner.

POST-CONCUSSIVE DISORDERApproximately 90 percent of high school and college athletes diagnosed with concussions at our Atlantic Sports Health clinic improve their signs and symptoms within two weeks. There are some patients, however, who require many weeks or even months to recover.

In these cases, the practitioner must determine which subtype of a concussion is causing the delayed recovery. Physiologic types respond well to early exercise. Those patients suffering from depression, post-traumatic stress disorder or anxiety usu-ally require evaluation and treatment with a sports psychologist or a neuropsychologist. The presence of migraine headaches might require a neurologist to implement a migraine treatment program. Cervicogenic types of whiplash injuries should be evaluated and treated with physical therapy. Vestibular reha-bilitation is required for balance issues.

A significant portion of patients with delayed recovery have physiological concussions, meaning that the autonomic ner-vous system is disrupted, making it difficult to regulate blood pressure and heart rate after a concussion. We have found that Leddy’s progressive exercise protocol is very effective in reset-ting the autonomic nervous system and putting these people back into a regular exercise program.

Post-concussive disorders require a team approach, including neurologists, physiatrists, sports psychologists and neuropsy-chologists, such as the program at Atlantic Health System. These patients are the most time-consuming and difficult to handle.

THE FUTURE OF CONCUSSION PREVENTION, DIAGNOSIS AND TREATMENT There are quite a few new approaches to concussion manage-ment that hold promise for better prevention, diagnosis and treatment in the future.

Improved Head Gear. Manufacturing helmets that better protect the brain may prevent many future concussions. A lot of this work is coming out of National Football League (NFL) video game analysis. In real time, the videos help team physicians determine the mechanism of injury and see whether a player

shows any signs or symptoms of a concussion immediately after a hit. Long-term, as a research tool, the videos are being used to analyze the relationship between the players’ field position and the location of impact. The NFL has presented to its team physicians unpublished data showing that the majority of football concussions are caused by helmet-to-body blows and that the part of the head taking the hit varies by player position. This has helped the NFL pursue research looking at helmet contacts to identify exactly where the player is getting hit and how likely that is to lead to a concussion. That informa-tion will trickle down to helmet companies to make a better helmet and make the athletic trainers more aware of what to look for in these athletes.

Blood Test for Concussion. The Food and Drug Adminis-tration (FDA) approved its first blood test for concussions that allows for the possibility in the future of doing a blood test on the sideline to determine the presence of a concussion. This test checks the blood levels of S100B, a chemical released from nerves after injury. We don’t know what a patient’s baseline levels are for this chemical or how long it takes to become ele-vated after concussion. In the future, it’s likely that a pinprick on the sidelines may determine elevated S100B levels and confirm the diagnosis of concussion.

Diagnostic Testing. There’s a lot of time and energy being applied to the role of imaging and advanced testing to diagnose a concussion. Tesla, 3T, functional MRI (fMRI), diffusion tensor imaging (DTI), magnetic resonance spectroscopy (MRS), cere-bral blood flow (CBF), electrophysiology/quantitative electro-physiology (QEEG), fluid biomarkers and transcranial magnetic stimulation (TMS) are all being examined to see if they can better pinpoint brain changes caused by concussion.

Fish Oil. Interesting animal research is showing that the omega-3 fatty acids in fish oil may have a protective effect. Rat studies have shown that high levels of omega-3 have a protective effect on neurons, can prevent damage from a concussion and may quicken healing and decrease symptoms after concussion.12 This work is promising for future concussion management.

MDADVISOR 29

Pearls of Wisdom for How to Cut the Incidence and Severity of ConcussionBart Oates, President of NFL Alumni AssociationSuper Bowl Champion, NY Giants

• Genetic testing is available to give insight into athletes with a predisposition to suffering a concussion.

• Proteins have been developed that can be injected when someone has a concussion. The protein prevents some of the side effects, like memory loss, headaches etc., when someone suffers a concussion.

• Running in different ways can deflect the forces of concussion. For example, Walter Payton was able to deflect the forces of a tackle and exit the contact like a turbo charge and not get hurt.

• Prevent players from using straight arms, especially running backs. The straight arm technique pushes down the head of the tackler, which can increase likelihood of getting a concussion.

PARTING ADVICECertainly, it is difficult for primary care physicians to keep up with the changing landscape of concussion management. Given the increasing pressure from sports organizations and legislative directives, it is most often best for a primary care physician to refer these patients to concussion specialists. Some states, like New Jersey, require that physicians sign off on a return-to-play protocol stating that they have exper-tise in concussion diagnosis and treatment. Many physicians are concerned about the legal ramifications of signing off on a student’s return-to-play note, and instead opt to refer to experts who have a multi-modal, team approach concussion program.

Damion A. Martins, MD, is Director, Orthopedics and Sports Medicine, and Program Director, Sports Medicine Fellowship, at Atlantic Health System.

1. Centers for Disease Control & Prevention. (2017, April 27 [updated]). Traumatic brain injury: TBI: Get the facts. www.cdc.gov/traumaticbraininjury/get_the_facts.html.

2. Register-Mihallik, J. K., Guskiewicz, K. M., Valovich McLeod, T. C., Linnan, L. A., Mueller, F. O., & Marshall, S. W. (2013). Knowledge, attitude, and concussion-reporting behaviors among high school athletes: A preliminary study. Journal of Athletic Training, 48(5), 645–653.

3. Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., … Kontos, A. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: Preliminary findings. American Journal of Sports Medicine, 42(10), 2479–2486.

4. Alsalaheen, B., Mucha, A., Morris, L., Whitney, S., Furman, J., Camiolo-Reddy, C., Collins, M., . . . Sparto, P. (2010, June). Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy, 34(2), 87–93. [Available at https://journals.lww.com/jnpt/Fulltext/2010/06000/Vestibular_Rehabilitation_for_Dizziness_and.7.aspx]

5. Tiersky, L. A., Johnston, M. V., Kurtyka, J., Roosen, E., Schwartz, T., & Deluca, J. (2005, August). A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 86(8), 1565–1574. [Available at https://www.ncbi.nlm.nih.gov/pubmed/16084809]

6. Leddy, J., Cox, J. L., & Baker, J. G. (2013, July/August). Exercise treatment for postconcussion syndrome: A pilot study of changes in functional magnetic resonance imaging activation, physiology, and symptoms. Journal of Head Trauma Rehabilitation, 28(4), 250–259. [Available at https://journals.lww.com/headtraumarehab/Pages/toc.aspx?year=2013&issue=07000]

7. Al Sayegh, A., Sandford, D., & Carson, A. J. (2010, October). Psychological approaches to treatment of postconcussion syndrome: A systematic review. Journal of Neurology, Neurosurgery, and Psychiatry, 81(10), 87–93. [Available at https://www.ncbi.nlm.nih.gov/pubmed/20802219]

8. McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., … Vos, P. E. (2017). Consensus statement on concussion in sport—The 5th International Conference on Concussion in Sport. British Journal of Sports Medicine, 51(11), 838–847. [Available at http://bjsm.bmj.com/content/51/11/838]

9. Griesbach, G. S., Hovda, D. A., Molteni, R., Wu, A., & Gomez-Pinilla, F. (2004). Voluntary exercise following traumatic brain injury: Brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience, 125(1), 129–139.

10. Leddy, J., Sandhu, H., Sodhi, V., Baker, J. G., & Willer, B. (2012, March). Rehabilitation of concussion and post-concussion syndrome. Sports Health, 4(2), 147–154. [Available at https://www.ncbi.nlm.nih.gov/pubmed/23016082]

11. Leddy, J. J., Baker, J. G., Kozlowski, K., Bisson, L., & Willer, B. (2011). Readability of a graded exercise test for assessing recovery from concussion. Clinical Journal of Sport Medicine, 21, 89–94. www.buffalo.edu/content/dam/www/news/imported/pdf/May11/UBconcussionStudy.pdf.

12. Mills, J. D., Hadley, K., & Bailes, J. E. (2011). Dietary supplementation with the omega-3 fatty acid docosahexaenoic acid in traumatic brain injury. Neurosurgery, 68(2), 474–481.

Department of MedicineMarc Klapholz, MD, MBAChair

CongratulationsPranela Rameshwar, PhD

Edward J. Ill

Outstanding Scientist Award Recipient

2018


P i n n a c l e o f E x c e l l e n c e i n H e a l t h c a r e S o c i e t y $50,000+

E x c e l l e n c e i n M e d i c i n e S o c i e t y $15,000 - $24,999N e w J e r s e y O r t h o p a e d i c I n s t i t u t e &

V i n c e n t K . M c I n e r n e y , M D , A n t h o n y F e s t a , M D , A n t h o n y J . S c i l l i a , M D J o h n C a l l a g h a n , M D , & C r a i g Wr i g h t , M D

B D , I n c .

H e a l t h c a r e C h a m p i o n S o c i e t y $10,000 - $14,999Pa t r i c i a A . C o s t a n t e

D r. a n d M r s . G e o r g e F . H e i n r i c h

Pa u l J . H i r s c h , M D

N J M I n s u r a n c e G r o u pD r. a n d M r s . J e a n A n d e r s o n E l o y &

R u t g e r s N J M S D e p a r t m e n t o f O t o l a r y n g o l o g y - H e a d & N e c k S u r g e r y

H e a l t h c a r e I n n o v a t o r S o c i e t y $5,000 - $7,499C L B Pa r t n e r s

R o b e r t P. W i s e , FAC H E

R o m a B a n k C o m m u n i t y F o u n d a t i o n

W i n n i n g S t r a t e g i e s I T S

We’d like to say Thank you

MDADVISOR 31

H e a l t h c a r e A d v o c a t e S o c i e t y $2,500 - $4,999M DA d v a n t a g e I n s u r a n c e C o m p a n y E m p l o y e e s

Va s l a s L e p o w s k y H a u s s & D a n k e , L L P

D r. & M r s . H a r r y M . C a r n e sJ LT R e

P r i n c e t o n O r t h o p a e d i c A s s o c i a t e s , P. A .

S a i b e r , L L C

M DA d v i s o r E d i t o r i a l B o a r d

S e n a t o r C h r i s t o p h e r “ K i p ” & S u s a n B a t e m a n

D u g h i , H e w i t & D o m a l e w s k i , P C

L e e a n d M u r r a y K u s h n e r I n h o n o r o f S t e v e K a l a f e r

H e a l t h c a r e S u p p o r t e r S o c i e t y $ 1 , 0 0 0 - $ 2 , 4 9 9D r s . B e s s i e M . & E d g a r J . S u l l i v a n | C a t h e r i n e & E d W i l l i a m s | G e n n a r o ’ s I t a l i a n M a r k e t & C a t e r i n g |E i l e e n M . M o y n i h a n , M D | D r s . D o n a l d & R e n e e C h e r v e n a k , M o r r i s C o u n t y M e d i c a l S o c i e t y & P r o f e s s i o n a l H e a l t h C a r e A s s o c i a t e s | D a n i e l & N i n a G o w a t y | J e r e m y & L i s a H i r s c h |Pe r r & K n i g h t | G i b l i n , C o m b s , S c h w a r t z , C u n n i n g h a m & S c a r p a L L C | A l a n J . L i p p m a n , M D | D e l p h i Te c h n o l o g y | I n v e s t o r s B a n k F o u n d a t i o n | M a c N e i l l O ’ N e i l l & R i v e l e s , L L C | M a r s h a l l D e n n e h e y Wa r n e r C o l e m a n & G o g g i n | O r l o v s k y , M o o d y , S c h a a f f & C o n l o n , L L C | R u p r e c h t H a r t We e k s & R i c c i a r d u l l i , L L P | S t a h l & D e L a u r e n t i s , P C | R o w a n S c h o o l o f O s t e o p a t h i c M e d i c i n e | A l l i a n t / B o y n t o n & B o y n t o n | R o s e n b e r g , J a c o b s , H e l l e r & F l e m i n g , P C | Ve r i t e x t L e g a l S o l u t i o n s | A c a d i a P r o f e s s i o n a l , L L C | R o s a l i e G r e e n b e r g B a r e d e s | R y a n & M a t t h e w B a r e d e s | N i n e t t e & F r e d B o r d o f f , S y l v i a & A l a n G o l d b e r g , & C l a u d e t t e & M i c h a e l S p a n o | H a c k e n s a c k M e r i d i a n H e a l t h | M B S I n s u r a n c e S e r v i c e s |M DA d v a n t a g e I n s u r a n c e C o m p a n y B o a r d o f D i r e c t o r s | N A S I n s u r a n c e | N e w J e r s e y R i s k M a n a g e r s &C o n s u l t a n t s , I n c . i n h o n o r o f S t e v e K a l a f e r | N o r r i s M c L a u g h l i n & M a r c u s , PA | R e g i o n a l C a n c e r C a r e A s s o c i a t e s | S t a r r , G e r n , D a v i s o n & R u b i n , P C | D a v i d E . S w e e , M D |

T r i n i t a s R e g i o n a l M e d i c a l C e n t e r | Va n C l e e f E n g i n e e r i n g A s s o c i a t e s i n h o n o r o f S t e v e K a l a f e r |

to our New Jersey healthcare partners for their support of the Excellence in Medicine Scholarship Fund.

2018 Excellence in Medicine Scholarship Honor Roll Members


There are multiple ways to perform a skilled movement involving control and coordination of various key pos-tures. Finding the best way to optimize the movement’s

trajectory requires the skillful linking of the body parts with the body’s environment, within the limits of ability. The goals of such optimization are dual:

1) exploiting momentum, utilizing the reliable conservative force of gravity and sparing muscle energy to optimize both mechanical and physiological power

2) assessing microtrauma injury risk, as well as performance readiness.

The observer of the movement (e.g., coach, physical edu-cation teacher or physical therapist) may attempt to change what is believed to be wrong in the movement, even when the performer (e.g., athlete or patient) feels it is correct. Or the performer may resist or feel unable to change something about the movement that the observer believes is correct. This dilemma to decide what to do requires applying knowl-edge to assess similarities and differences of these qualitative behaviors that risk errors of either accepting what is wrong or rejecting what is correct.

This situation encapsulates the major problems for any human attempting to enhance the performance of skilled movements, especially those that risk injury. Therefore, a word to the wise from Einstein, who said, “We cannot solve our problems with the same thinking we used when we cre-ated them.” Keeping this in mind, a new paradigm called Observer-Performer System (OPS) is being researched* and used, applying a new way of thinking to resolve these major issues that commonly occur when addressing problems inher-ent in enhancing human skilled movement.

THE HIDDEN SKILL: OPTIMAL TRANSFER OF MOMENTUM Observing highly skilled athletes is often accompanied by commentary describing its smoothness, grace, effortlessness, proficiency, expertise, qualifications etc. Time and again, the body positions are analyzed, their muscular contributions are evaluated, the mental fortitude is acknowledged; however, do these explanations tell the whole story, or does a hidden skill exist that is difficult to reveal?

When the stress of physical or mental pressure adversely alters an athlete’s performance, the perceived behavior is often referred to as a momentum shift. Rather than the shift, however, OPS seeks to first consider the role that momentum itself plays as it aids or harms an athlete.

From a mechanical perspective, momenta (mv) of a bodily system are defined as the mass (m) of their parts (e.g., seg-ments) times their respective velocities (v). It can be envis-aged as a resistance to change when the body 1) remains still indefinitely at a zero velocity and 2) moves at a constant speed in a given direction without letting up unless acted upon by some force—which is responsible for a change in the perceived behavior.

Optimal transfer of momentum between segmental masses occurs when the skilled performer intuitively learns to perceive and set the correct initial segment velocities in a few critical body configurations so that the motor task can be accom-plished by a small number of concatenated phases. During each phase, momentum and energy transfer between segments will occur and the motion will appear and be perceived as smooth and effortless. This may explain the paradox that the more skillfully a motor task is performed, the smoother and more effortless it appears to an observer and is felt by the performer. These observable fundamental shifts in behavior include starting movement, stopping movement and changing movement direction or magnitude (i.e., speed).

The human brain is capable of perceiving a change in momentum (i.e., a force); however, the brain lacks the ability to perceive momentum itself. Sitting in an airplane traveling at 500 mph would be perceived as stationary unless the plane experiences air turbulence (i.e., a force) or alters velocity (i.e., direction or speed). Thus, the athlete feels a change in momen-tum and the observer is its witness, unable to see the forces causing that change.

The hidden skill is the expertise and proficiency in timing a change in momentum (e.g., muscle contraction) either from a given stationary position or during a specific phase of the movement that exploits momentum and thus, spares muscle. This can be expressed in the simple power formula as shown in Figure 1.

A PARADIGM SHIFT: ADDRESSING PROBLEMS IN HUMAN

SKILLED MOVEMENT WITH THE OBSERVER-PERFORMER SYSTEMBy Robert P. Narcessian, EdM

* Narcessian and Leet have been conducting a series of OPS studies involving vol-unteers across grades K–12 with written parental consent and older subjects that were approved by St. Joseph’s Regional Medical Center’s Institutional Review Board.

MDADVISOR 33

SteveAdubatoPhD@SteveAdubato/SteveAdubatoPhDSteveAdubato.org

Weeknights

Figure 1. Power Formula

P = W/t = Fd/t = Fv = mav = mvaP = power v = velocityW = work F = ma F = force m = masst = time a = accelerationd = distance mv = momentum

DYNAMICS FUNDAMENTAL TO THE SKILLED ATHLETEIt is uncomplicated to intuit physiological power as work accomplished within a specific time; however, mechanical power is often expressed mathematically as a product of force and velocity. Noting that P = mva (Figure 1), one can intuit mechanical power as the interaction of the momentum (mv) of the body parts and their respective muscular contractions (a). Thus, timing muscular contractions at specific body configura-tions during starting, stopping or changing movement direction or speed are the dynamics fundamental to the highly skilled athlete. Adding muscular effort at the wrong time or from the wrong configuration can result in compensatory actions, poorer performance or risk harm of injury.

CONCLUSIONThe OPS provides each performer and their observer with both an injury risk assessment (IRA) and a performance readiness

evaluation (PRE) with two goals: to prevent injury and to enhance performance. The pending research projects with the schools and their students will consist of the following analytics:

• Learning measurement, collection, analysis and re-porting of data about performers and their observers with the objective of understanding and optimizing movement skills within its environment, as well as recognizing signs and symptoms of microtrauma

• Predictive use of statistics, multi-joint mechanisms (MJM) of fundamental two-joint systems that extend sin-gle-joint evaluations, and fundamental dynamic movement skills (FDMS) that involve multi-planar systems greater than two-joint systems to predict outcomes with the goal of guiding future IRA and PRE research

• Prescriptive extend the likely IRA and PRE outcomes to demonstrate suggested actions using computer-generated OPS algorithms that yield more successful and economi-cally efficient interventions that are responsive to the needs of each performer and to determine the effectiveness of those observers providing their care.

This ongoing research will test new injury prevention ap-proaches in sports medicine healthcare.

Robert P. Narcessian, EdM, is on the teaching staff and is a research consultant with the Department of Orthopaedics at St. Joseph’s Regional Medical Center, Paterson, New Jersey.

It’s the whir of the engine

and the blur of the trees.

It’s finding a new road to

get lost on.

For over a century, NJM has helped protect the things worth remembering by delivering service you won’t forget. Because this isn’t just a car. It’s your car.

Offer applies to qualified New Jersey and Pennsylvania residents. Coverage is subject to eligibility requirements, as well as underwriting guidelines, review and approval. Insurance underwritten by New Jersey Manufacturers Insurance Company and its wholly-owned subsidiaries, 301 Sullivan Way, W. Trenton, NJ 08628.

This isn’t just insurance.It’s NJM.

E S T. 1 9 1 3

njm.com | 1-800-232-6600

MDADVISOR 35

The treatment of sports-related concussions has been a hot topic for the past several years and continues to spark discussion as recommendations change.

Many New Jersey physicians are familiar with the return to play protocol that has been implemented by the New Jersey Department of Education, as a result of 2010 legislation (P.L. 2010, Chapter 94). As a result, physicians are used to working closely with athletic trainers in area schools. However, physi-cians are not always aware of the role physical therapists can play in implementing the protocol and the ways that their involvement can benefit young athletes.

In the past, cognitive rest was the main feature of concussion treatment, including the “avoidance of excessive neurometa-bolic processes associated with cognitive activities.”1 However, the latest research shows that prolonged rest can actually “lead to physical deconditioning, metabolic disturbances, and sec-ondary symptoms such as fatigue and reactive depression.”

In 2012, studies in animals showed that while exercise during the first week of a concussion can impair recovery, exercise 14 to 21 days after concussion improves cognitive performance and can decrease depression.2 The return to play protocol uses this information to move the concussed athlete back to health and active play with the input of a supportive concussion man-agement team, which ideally includes the physical therapist.

SEVEN STAGES OF THE RETURN TO PLAY PROTOCOL FOR CONCUSSIONS Once a concussion diagnosis is confirmed, the athlete is removed from participation in sports. When the athlete is symptom-free for at least 24 hours, he or she can begin the return to play protocol, a program that must be implemented and supervised by a healthcare professional. Stage 1: Physical and Cognitive Rest. This step requires removal of the injured athlete from sports, gym and all

The Role Physical Therapists Play in Post-Concussion Rehabilitation and the Return to Play Protocol for Athletes By Daniel Kane, PT, DPT


exertional activities, and possible removal from school or modified school attendance. Television, video games and cell phones are avoided during this time, along with an overall avoidance of any activities that reproduce symptoms. Stage 2: Light Aerobic Exercise. This stage involves light aer-obic exercise at less than 70 percent of maximum heart rate. (The maximum heart rate is 220 minus the athlete’s age.) The athlete typically does 20 to 30 minutes on a bike, ARC trainer or elliptical machine with heart rate monitoring throughout.

The physical therapist is involved throughout all of the stages. The athlete typically is seen in an outpatient physical therapy clinic during stages two through five. Stage 3: Increased Cardiovascular Training. This stage involves increased cardiovascular training, including a repeat of light aerobic exercise from the previous day, as well as the introduction of moderate activity, including jogging, sprinting and jumping and light weight lifting for a duration of 35 to 45 minutes at an intensity of 80 to 85 percent of the maximum heart rate. No change-of-direction drills are included at this stage.Stage 4: Strenuous Cardiovascular Training. This stage involves strenuous cardiovascular training and introduces strenuous exercise, such as agilities, plyometrics and change-of-direction drills, and then progresses to heavier

weights. These activities are performed at 90 to 95 percent of maximum heart rate for 45 to 60 minutes. Sport-specific drills are avoided at this stage.Stage 5: Sport-Specific Exercise. This stage introduces sport-specific drills that reproduce the demands of a prac-tice or game. They might include sprinting, cutting, dribbling, shooting, plyometrics and advanced resistance training at an intensity of 90 to 95 percent of maximum heart rate. Head and body contact activities are avoided at this stage.

In general, stages two through five are performed in four sub-sequent days. Each step throughout the protocol is designed to gradually increase the heart rate and blood flow to the brain to ensure that symptoms do not reappear. If symptoms arise at any time, the athlete must rest for 24 hours and then resume activity at a level one step below where the symptoms occurred. Once an athlete has passed through stage five, the physical therapist remains in contact with the physician, ath-letic trainer and parents as needed.Stage 6: Contact Practice. This stage can occur only following medical clearance from a healthcare professional trained in concussion management. In New Jersey, the medical clear-ance has to come from the physician who referred the athlete to physical therapy. Once the physical therapist signs off on the completion of stages two through five, the athlete can return to the field for contact practice with oversight from the athletic trainer and team physician. The athlete is then able to participate in a recommended 50 percent of practice, with progress to full practice depending on the severity and length of symptoms. Headers should be kept to a minimum and major collisions should be avoided.Stage 7: Full Return to Sport. After successful completion of all the previous stages without the return of symptoms, and with full medical clearance, the athlete can return to full practice and game play.

PHYSICAL THERAPIST TREATMENT DOMAINS IN POST-CONCUSSION SYNDROME TREATMENTNinety percent of concussions resolve within a 10-day period; the remaining 10 percent of concussions have persistent signs www.spsk.com | (973) 539-1000

Schenck Price’s Health Care Practice

Group provides corporate, litigation,

regulatory and compliance services

to medical professionals, health

care entities and hospital systems.

Our Firm’s recognized leaders include

former regulators and in-house counsel

as well as seasoned trial attorneys

who bring extensive experience to

one of the premier health care practice

groups in New Jersey.

Florham Park, NJ Paramus, NJ Sparta, NJ New York, NY

Seven Stages of Return to Play Protocol for Concussions

Stage 1: Physical and Cognitive Rest Stage 2: Light Aerobic ExerciseStage 3: Increased Cardiovascular TrainingStage 4: Strenuous Cardiovascular TrainingStage 5: Sport-Specific ExerciseStage 6: Contact PracticeStage 7: Full Return to Sport

MDADVISOR 37

and symptoms beyond two weeks.3 The three treatment domains in the physical therapist’s conceptual model for treat-ing these post-concussions (as illustrated in Figure 1) include 1) cervical and musculoskeletal rehabilitation, 2) physical exertion progression and 3) vestibular-ocular rehabilitation.4

Cervical and Musculoskeletal Rehabilitation Cervical and musculoskeletal rehabilitation focuses on head-ache and neck pain, as well as possible muscle tightness or spasm—all common post-concussion syndrome complaints. The therapist can perform manual physical therapy (soft tissue mobilization to upper trapezius/cervical paraspinals/levator scapulae) and manual stretching (upper trapezius/levator scapulae). The physical therapist can also address inherent muscle weakness that may have contributed to concussion susceptibility. Athletes perform TheraBand rows to improve rhomboid and other periscapular (trapezius/serratus anterior/levator scapulae) strengthening. These exercises improve cer-vical and scapular stability.

Physical Exertion ProgressionPhysical exertion rehabilitation includes light to moderate aerobic exercise, such as using an exercise bike, ARC trainer or ReACT trainer. With this type of rehab, the athlete can exercise at 50 to 60 percent of maximum heart rate, even when diag-nosed with post-concussion syndrome.

Vestibular-Ocular RehabilitationResearch has shown that physical therapists can be especially helpful with vestibular-ocular rehabilitation in patients with post-concussion syndrome. A study performed in 2017 showed sub-maximal cardiovascular exercise, cervical spine and vestib-ular-ocular rehabilitation decreased Post Concussion Symptom Scale (PCSS) scores significantly and decreased Balance Error Scoring System (BESS) scores by 53 percent.5 A randomized controlled trial also showed that cervical and vestibular therapy decreased time to return post-concussion players to sport.6 Vestibular-ocular rehabilitation consists of tests and treatments such as smooth pursuits, saccades, convergence, vestibular-ocular reflex and the visual motor sensitivity test. These treatments help decrease prolonged symptoms of diz-ziness, nausea, fogginess and vomiting, which helps put the athlete back on track for the return to play protocol.

CONCLUSIONPhysical therapists play an integral role on the concussion team: performing the return to play protocol in their clinics and progressing patients through a conceptual model that takes into account the recovery timeline, phases of recovery, progression of treatment and the treatment domains of cer-vical and musculoskeletal rehabilitation, physical exertion

progression and vestibular-ocular rehabilitation.4 They also play an important role in helping patients with post-concussion symptoms return to play. When referring to a physical therapist, it is beneficial to identify someone who has knowledge of the return to play protocol, as well as someone who knows about vestibular-ocular rehabilitation.

The physical therapist is an important member of the entire concussion team that should include the physician, athletic trainer, athlete/patient and parents, who all work together to ensure the best outcomes.

Daniel Kane, PT, DPT, is Clinical Director of Rehabilitation at JAG Physical Therapy, which has office locations in New Jersey and New York.

1. Valovich McLeod, T., & Gioia, G. (2010). Cognitive rest: The often neglected aspect of concussion management. Athletic Therapy Today, 15(2), 1–3.

2. Leddy, J., Sandhu, H., Sodhi, V., Baker, J., & Willer, B. (2012). Rehabilitation of concussion and post-concussion syndrome. Sports Health, 4(2), 147–154.

3. McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R. J., … Turner, M. (2013). Consensus statement on concussion in sport: The 4th international conference on concussion in sport, held in Zurich, November 2012. Journal of Athletic Training, 48(4), 554–575.

4. Lundblad M. (2017). A conceptual model for physical therapists treating athletes with protracted recovery following a concussion. International Journal of Sports Physical Therapy, 12(2), 286–296.

5. Grabowski, P., Wilson, J., Walker, A., Enz, D., & Wang, S. (2017). Multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: A retrospective analysis on safety and feasibility. Physical Therapy in Sport, 23, 22–30.

6. Pabian, P. S., Oliveira, L., Tucker, J., Beato, M., & Gual, C. (2017). Interprofessional management of concussion in sport. Physical Therapy in Sport, 23, 123–132.

From “A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery Following a Concussion,” by M. Landblad, 2017, International Journal of Sports Physical Therapy,12, pp. 286–296. Reprinted with the permission of The International Journal of Sports Physical Therapy.

Figure 1. Physical Therapy Conceptual Model

PREVAIL

STAHL & DELAURENTIS

PREVAIL

See we can put the odds on your side

With a better-than-90%success rate.

An exceptional record of success for clients since 1997.

WORKERS’ COMPENSATION

GENERAL LIABILITY

MEDICAL MALPRACTICE

10 E. Clements Bridge Road | Runnemede, NJ 08078(856)380-9200 | stahl-delaurentis.com | [email protected]

MDADVISOR 39

I never realized the importance of physician coverage during high school athletics until I was assigned to cover football games with one of my orthopaedic attendings.

Through this experience, I quickly learned the importance of team physicians with strong communication skills.

Initially, I did not fully understand how closely team physi-cians work with athletic trainers—the go-between individu-als who coordinate the needs of the injured athlete, parents, coaches, school administrators and physicians. When an injury occurs, athletic trainers are the ones who usually introduce the medical team to the player and the parents. The connection with the athletic trainer is so vital that I often gave my own cell phone number and contact information to the trainer in case he or she needed to reach me at any time during the game. The athletic trainer has an extremely important role in expediting patient care.

Because only the home team supplies a team physician, I soon realized the importance of engaging the athletic trainer and the parents of an injured athlete on the opposing team. Some come from a distance, and their treating physician back in their hometown needs to be alerted. When I could obtain contact information for that physician, I was able to implement an appropriate and informative transfer of care.

For effective communication, privacy is critical and yet dif-ficult in game situations. The tremendous noise makes the environment unprofessional, and therefore, a physician has to make an attempt to move away from the band, cheerleaders and boisterous fans to a quieter area of the football field to discuss the injured athlete’s situation. This task can be chal-lenging; however, it needs to be done.

If I decided that the student athlete should go to the emer-gency room, I learned that it is helpful to give my business card to the athlete and family. This gives them an immediate contact person to help navigate the diagnostic and therapeutic processes. I also learned that calling ahead to the receiving

emergency room or urgent care center physicians is most help-ful. I can pinpoint the x-rays needed or suggest certain tests, such as a stress x-ray or a certain view, to help the emergency physicians expedite the diagnostic and therapeutic measures.

Once off the field and in the office or hospital, the physician needs to engage the student and his or her parents. Using examples of injuries in famous athletes for comparison with the student’s injury is often helpful for the patient and the parents to have a better comprehension of the injury’s severity. Direct eye contact, a calm voice and simple terminology are critical for them to fully understand the scope of the injury and the appropriate diagnostic tests that may be necessary, including x-rays and possibly an MRI. I learned that it can be helpful to explain exactly what the abbreviation MRI means and how it works, as well as to assure the family that x-rays have minimal radiation and can be safely administered.

Treatment options also have to be explained in terms under-standable to the student athlete as well as to the guardians. I learned that giving the athlete and his parents a website, such as orthoinfo.org produced by the American Academy of Orthopaedic Surgeons, is a powerful tool for patient education.

During my time on the football field, I learned a tremendous amount about the vital role of clear, calm and accurate com-munication with all parties involved while providing care for an injured athlete—which certainly can be applied to other sports and other events. These experiences were eye-opening for me as an orthopedic resident and vital to my goal of becoming an informed and caring physician.

Nancy Moontasri, MD, MPH, is a PGY-3 orthopaedic resident at St. Joseph’s University Medical Center, Paterson, NJ, affiliated with Hackensack Meridian School of Medicine at Seton Hall University.

AN ORTHOPAEDIC SURGERY RESIDENT’S PERSPECTIVE ON TEAM PHYSICIANSBy Nancy Moontasri, MD, MPH

Steve Adubato, PhD, interviewed Vincent K. McInerney, MD, Orthopedic Surgeon and Director of Sports Medicine at Seton Hall University and St. Joseph’s University Medical Center, regarding the prevention, cause and treatment of sport injuries. Part of this interview in MDAdvisor is adapted from Dr. McInerney’s appearance on One-on-One with Steve Adubato.

Adubato: Do you believe that there are more sports injuries today than in the past? Or is it that we have become better at detecting these injuries? McInerney: I think it’s a combination of both. There are more injuries. Our players are bigger, taller and faster. And there have been some rule changes over the years that have invited more injuries. Too many safety rules are not enforced. Dribbling in basketball is a good example. Players are now allowed to palm the ball and run with it. This changes the speed of play and results in major knee injuries, especially with female athletes, jumping and twisting at higher speeds. Traveling with the ball is rarely called, even though players are taking two or three steps. We are also better at detecting injuries by more precise and thorough examinations performed by athletic trainers and orthopedic surgeons on the field of injury. The new generation of extremely accurate MRIs enhances our ability to detect subtle injuries previously unnoticed.

Adubato: What can the parents of young athletes do to reduce the potential for injury?McInerney: Parents have a great say in creating the rules and regulations of youth sports. They also have a strong voice when they see that the rules are not being enforced. I’m particularly nervous about young women, especially in girls’ soccer. With all the heading that’s allowed, subconcussive injuries to the head are too common. At a recent meeting of the New Jersey Athletic Trainers Society, we had several talks about the brain—about

how delicate those billions of cells and trillions of connections are to trauma. And yet, we’re allowing the brain to be struck on a repetitive basis—much more than you and I ever expe-rienced. Parents and student athletes should say: “No, we’re not going to allow it. We are going to go to governing bodies to demand changes in the rules.” Young children should chest the ball. No headers. Players still might get hit in the head accidentally if someone kicks the ball and they just can’t get out of the way. But if they intentionally head the ball, they’d be out of the game. That’s just one example in one sport. There are many other dangerous situations that parents have the power to change.

Adubato: Can you give us an example of officials being lax about enforcing the rules we do have and how that has caused injury?McInerney: Football is a particularly dangerous sport, and referees should be empowered, without jeers from the fans or coaches, to immediately penalize or suspend players who strike their opponent above the shoulder area. There must be a no-tolerance level for helmet to helmet contact.

Adubato: What role does the medical community—athletic trainers, school nurses, primary care doctors etc.—have when they see these injuries that result from lack of rule enforcement in youth sports?

By Steve Adubato, PhD

An Interview with Vincent K. McInerney, MD

Youth Sport Injuries:

MDADVISOR | Summer 2018E40

McInerney: The medical community needs to speak up with authority and conviction to promote sports safety at the high-est levels. We all have a great responsibility to change rules that permit dangerous play. Our children and grandchildren depend on us to provide safe competitive sports environments for everyone to enjoy and thrive in. Sports are for the develop-ment of humankind, not humankind is for the development of sports as they exist.

Adubato: There seems to be an intensity coming from the par-ents and coaches of these young athletes to push through the injuries. Why is that? McInerney: Many parents are living vicariously through their children. They can’t do that anymore. Children need to be empowered to say: “I don’t want to do that.” This is an import-ant step in reducing the number of concussions in youth sports. Children don’t like to get hit in the head. It hurts. It’s not fun. And it’s detrimental to these young children and their develop-ing brains. Some of these youngsters are injured for life by these concussive injuries. They’re dangerous. They can be stopped. Athletic trainers and physicians have the ultimate authority and responsibility to educate children and their parents about sports safety and injury prevention and treatment.

Adubato: How is medical care today changing the way sports injuries are treated? McInerney: Medical education is now changing rapidly due to advances in technology that reduce the need for highly invasive surgeries and long recovery time. Virtual reality technology and the use of surgical robotics have been game changers. Recently, I did four robotic surgeries on knees and hips at

St. Joseph’s University Medical Center in Paterson, New Jersey. The precision of the incisions and bone cuts is incredible—it’s like an old-fashioned diamond cutter who cuts the diamond perfectly, and now we can cut it a second time perfectly. You can barely see the incision—it’s that precise. We believe that this is going to lead to greater longevity in the total joint arena for our athletes and more precise graft placement for our ante-rior cruciate ligament (ACL) surgeries. The use of stem cells is also an upcoming treatment strategy that is changing sports medicine. Injection of platelet-rich plasma is here to stay. Although injury prevention and safety are most important, when an injury occurs, the ability of our healthcare providers to return the athlete safely and quickly to full function is just remarkable.

Evidence-based medicine is a powerful tool to guide unin-formed parents and help them to make the correct decision regarding their child’s treatment and return to play criteria. Scientific evidence is available today in many helpful and compelling formats.

Steve Adubato, PhD, is a four-time Emmy Award-winning anchor for Thirteen/WNET (PBS) and NJTV (PBS) and has appeared on the TODAY Show, CNN and FOX as a media and communication expert. Steve currently anchors three television series produced by the Caucus Educational Corporation (CEC) — Caucus: New Jersey with Steve Adubato, an Emmy Award-winning public affairs series; State of Affairs with Steve Adubato, a weekly program covering New Jersey’s most pressing policy issues; and One-on-One with Steve Adubato.

MDADVISOR E41

Sports participation has been increasing over the past two decades as our society becomes more active and health conscious.1 This trend can be seen throughout

all age groups and is encouraging. Although this should lead to general well-being for individuals, healthcare professionals must be aware that this trend may also precipitate a rise in sport-related injuries.2

APPROACH TO THE ACUTELY INJURED ATHLETEWhen approaching an acutely injured athlete of any age, it is essential to perform a comprehensive history and neurologic/musculoskeletal physical exam. It is important to make an accurate and specific diagnosis early on in the course of the injury. This specificity helps focus early diagnostic and thera-peutic plans and prevents acute injuries from developing into chronic pain syndromes.

As a physiatrist who practices pain medicine, I believe it essential to have a conservative and multidisciplinary approach when treating the injured athlete. This includes minimizing invasive procedures or surgery early in the treatment course while integrating healthcare professionals from different medical disciplines, such as athletic trainers and physical and occupational therapists. These providers commonly deliver the therapeutic treatment plan prescribed by the physician. They also spend the most time with the injured athlete. Making sure all providers are on the same page is essential so that the message to the patient is consistent and treatment efficient.

The early integration of mental health professionals, includ-ing sports psychologists, can also be extremely beneficial in maximizing recovery.3 After an acute injury, an athlete’s per-sonality, history of stressors and self-esteem can all positively and negatively affect injury recovery and subsequent sport performance. Additionally, an athlete’s anxiety, depression, adherence to rehabilitation and fear of reinjury can all nega-tively affect his or her rehabilitation.4

Medical treatment of the injured athlete can include the use of analgesics, but all come with potential risks. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in managing pain and inflammation in the acute phase but have known gastrointestinal, renal and cardiovascular side effects.5,6 NSAIDs also interfere with the acute phases of soft tissue and fracture healing.7 Muscle relaxants are commonly prescribed, but there are limited studies demonstrating the benefits after the first few days of injury.8 As a class, muscle relaxants are sedating, and the side-effect profile cannot be ignored. Opioid medications should be avoided in the treatment of an acute sports injury; however, if provided, minimal doses and quantities should be dispensed. Initial prescriptions should be for no greater than a five-day supply. Extensive patient and family education about the significant risks associated with opioid medications must be provided and documented.

Treatment plans should be provided to the patient in oral and written instructions. This has been shown to improve health literacy especially in orthopedic patients.9 It will not only help

MDADVISOR | Summer 2018E42

Pain Management and Sports Related InjuriesBy Brett Gerstman, MD

the patient better understand the expected plan but also limit post-visit patient confusion and frustration.

APPROACH TO THE CHRONICALLY INJURED ATHLETEUnfortunately, some athletes go through appropriate reha-bilitative and surgical regimens, and their pain persists. This can occur in the presence or absence of proper injury healing or surgical correction. Chronic pain is defined as pain that persists longer than the normal healing time.10 Athletes with chronic pain present a unique clinical challenge as their clinical outcome lags far behind their peers with similar complaints in the acute period after an injury.

When an athlete presents with chronic pain, the physician should treat the athlete similarly to those with acute injuries. The physician should perform a comprehensive history and neurologic/musculoskeletal physical exam, looking for undi-agnosed causes of the pain and potential flaws in previous treatment. For example, an athlete can be diagnosed with a chronic hamstring strain while having an underlying lumbar disc herniation, which refers pain into the posterior thigh. If these misdiagnoses are identifiable, corrective action and treatment can be made.

Many times, the physician agrees with the diagnoses made by previous providers, and the treatments appear appropriate. These are times when further examination of the athlete’s mental and general health must be made. Extended periods away from sport participation have been linked to athletes experiencing feelings of fear, irritability, hostility and anxiety.11 Athletes can also experience a sensation of isolation from being estranged from their team and sport.12 These psychological factors can severely impair an athlete’s recovery and must be addressed. The first and most effective step in reversing this trend is establishing effective physician–patient communi-cation.13 Simultaneous involvement of mental health profes-sionals is also prudent.

Further examination of an injured athlete’s general health and sleep habits can be informative as well. Deficiencies in certain hormonal or vitamin levels (thyroid, testosterone or vitamin D) can predispose individuals to chronic pain syn-dromes. These deficiencies can be readily corrected and lead to symptomatic improvement. Similarly, improving sleep habits can positively affect an athlete’s pain and performance levels within a short period of time.

GOING FORWARDSports medicine providers (physicians and non-physicians) should continue to focus on developing and implementing injury prevention programs at all levels of sport. This will limit our athletes’ exposure to the pitfalls of injury, and it will mini-mize absence from sport participation.

No matter how strong our prevention programs are, it will be difficult to prevent all injuries. Further research efforts must be made to identify modifiable risk factors in these acutely injured athletes that predispose them to developing chronic pain syndromes.

Brett Gerstman, MD, is a partner at New Jersey Spine Center and an Assistant Clinical Professor in the Rutgers New Jersey Medical School Department of Physical Medicine & Rehabilitation.1. Woods, R. A. (2017). BLS spotlight on statistics: Sports and exercise.

Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics.2. Sheu, Y., Chen, L. H., & Hedegaard, H. (2016, November). Sports- and

recreation-related injury episodes in the United States, 2011–2014. National Health Statistics Reports. Hyattsville, MD: National Center for Health Statistics.

3. Wiese-Bjornstal, D. M. (2010, October). Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: A consensus statement. Scandinavian Journal of Medicine and Science in Sports, Suppl 2, 103–111.

4. Covassina, T., Beidler, E., Ostrowski, J., & Wallace, J. (2015, April). Psychosocial aspects of rehabilitation in sports. Clinical Sports Medicine, 34(2), 199–212.

5. Momeni, M., & Katz, J. D. (2013, December). Mitigating GI risks associated with the use of NSAIDs. Pain Medicine, 14(Suppl 1), 18–22.

6. Bello, A. E., & Holt, R. J. (2014). Cardiovascular risk with non-steroidal anti-inflammatory drugs: Clinical implications. Drug Safety, 37(11), 897–902.

7. Su, D., & O’Connor, J. P. (2013). NSAID therapy effects on healing of bone, tendon, and the enthesis. Journal of Applied Physiology, 115(6), 892–899.

8. Chou, R., Peterson, K., & Helfand, M. (2004, August). Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: A systematic review. Journal of Pain Management Symposium, 28(2), 140–175.

9. Tsahaskis, J. M., Issar, N. M., Kadakia, R. J., Archer, K. R., Barzyk T., & Mir, H. R. (2014, April). Health literacy in an orthopaedic trauma patient population: Improving patient comprehension with informational intervention. Journal of Orthopaedic Trauma, 28(4), e75–79.

10. Bonica, J. J. (1953). The management of pain. Philadelphia, PA: Lea & Febiger.11. Udry, E., Gould, D., Bridges, D., & Beck, L. (1997). Down but not out: Athlete

responses to season-ending injuries. Journal of Sport and Exercise Psychology, 19, 229–248.

12. Mainwaring, L. (1999). Restoration of self: A model for the psychological response of athletes to severe knee injuries. Canadian Journal of Rehabilitation, 12, 145–154.

13. Stewart, M. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 1423.

MDADVISOR E43

New Jersey’s World Class, Award Winning Sports Medicine and Orthopaedic Specialists For over 36 years

Arthroscopic Knee, Shoulder, Hip, Elbow and Ankle Surgeries | Children’s Sports Injuries and Concussion Management | Fracture Surgeries | Total Joint Replacement

Vincent K. McInerney MD, Anthony Festa MD, Anthony J. Scillia MD, Robert M. Palacios MD Douglas J. Borkowski MD, Craig Wright MD, John J. Callaghan MD, Casey Pierce, MD, Erica Simone, ATC Colleen Joseph, PA-C, Rachel King, ATC, Kristen De Wilde, MS, Margeritte Carlson, ATC

Proud Healthcare Excellence Society Sponsor of the

Edward J. Ill Excellence in Medicine Awards® & Scholarship Fund

Wayne ~ Morristown ~ Butler ~ W. Milford Montclair ~ Bridgewater ~ ClarkMain & Business Office:504 Valley Road, Suite 200,Wayne, NJ 07470 973-694-2690 fax: 973-694-2692

www.njorthoinstitute.com

1st uncemented MAKO Robotic Assisted Total Knee Replacement in New Jersey1st Anterior approach MAKO Robotic Assisted Total Hip Replacement in North Jersey

Team Physicians and Consultants: Seton Hall University, Montclair State University, NJ Jackals and 18 High Schools

Largest Medical Malpractice Broker in the NationHealthcare Expertise Across the Continuum of Care Gallagher’s Healthcare Practice provides the unmatched expertise and ability to meet the unique needs of all types of healthcare providers— from physicians to facilities—and across the full continuum of care. Healthcare reform has forced the industry to focus more on collaboration, compliance and most importantly, integrated and accountable care. As your partner, we have the tools necessary to build creative solutions to address these challenges— for where you provide care today, and where you want to provide care tomorrow.

"Working with Gallagher over the past 10 years has saved our members millions of dollars in Medical Professional Liability Insurance premiums. I urge you to contact Gallagher for this important coverage."

—Anthony Alessi, MD, Chief Executive Officer, Colonial Cooperative Care, Norwich, CT

Bill Carey Managing Director Healthcare Practice 800.215.2707 [email protected]

John Moriarty Senior Vice President 860.885.0630 [email protected]

"World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC.

© 2018 BD. BD and the BD Logo are trademarks of Becton, Dickinson and Company. BDIG26188

LIFTING AND INSPIRING LIVES ACROSS THE WORLD. For generations, BD has made a profound impact on untold millions of lives. From helping enable the inoculation of children in the final fight against polio, to identifying infectious organisms and providing the research tools for the discovery of an AIDS vaccine, we take on the steepest health challenges with a powerful purpose: advancing the world of health. This is why we attract not only many of the most talented minds, but also many of the most committed. Because when the people in a company are working to do the right thing, challenged against great odds, there’s no telling how much good we can accomplish. With our extensive partnerships, depth of insights and exceptionally broad portfolio of solutions from discovery to the delivery of care, we have the talent and the tools to make an even greater difference in essential human health. Discover the difference one company can make. Discover the new BD.

Learn more about the Difference of One at bd.com

Date post:	16-Mar-2023
Category:	Documents
Upload:	khangminh22
View:	0 times
Download:	0 times

THE IMPACT OF SPORTS INJURIES - MDAdvantage

Documents