News & Alerts
Concussion in Sports
The United States Bone and Joint Initiative (USBJI) works to advance the understanding and treatment of musculoskeletal conditions – bone and joint disorders – through research, prevention and education. It is the U.S. National Action Network of the worldwide Bone and Joint Decade, a multi-disciplinary initiative focused on improving bone and joint health, and quality of life for those afflicted with related disorders.
USBJI organizations are engaged in developing new research and education programs that will generate significant advances in the knowledge, diagnosis and treatment of musculoskeletal conditions, and increase the number of resources available to healthcare professionals and the public at large.
The goals of the Initiative are to:
• Raise awareness and educate the world on the increasing societal impact of musculoskeletal injuries and disorders.
• Empower patients to participate in decisions about their care and treatment.
• Increase global funding for prevention activities and treatment research.
• Continually seek and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.
The USBJI recognizes the unique needs of children as they grow and develop. The Initiative’s Pediatric Specialty Group focuses on identifying primary areas of concern with regard to the musculoskeletal health of children. The Pediatric Specialty Group develops programs and activities to increase awareness, provide education, and promote healthy living as a means of reducing the burden of disease. Priorities include healthy lifestyles; reducing infectious disease of the musculoskeletal system; trauma prevention; improving access to high quality, ongoing care for children with limb deficiencies; optimizing bone, joint and muscle function in children with chronic neuromuscular and musculoskeletal disorders; and successful transition from pediatric to adult care for childhood onset musculoskeletal disorders.
Specific subsets within these priorities are selected to receive universal attention and focus on World Pediatric Bone and Joint (PB&J) Day, annually observed on Oct. 19. The Pediatric Specialty Group instituted the first PB&J Day in 2012. This day occurs during Bone and Joint National Action Week, Oct. 12 – 20, a time of global awareness and education.
Injuries to the musculoskeletal system in children and adolescents, especially those involving trauma to the shoulder or neck often produce head injury in the form of a concussion along with the musculoskeletal trauma. Recognition of the co-morbid neurologic injury has critical
implications for musculoskeletal as well as overall recovery. The severity of neurologic symptoms as well as the sequelae of repeated trauma have far reaching implications for both the short term and long term recovery process. This can include exercise intolerance during the recovery process, impairment of activities of daily living, and impairment of musculoskeletal function as well. The following is a discussion of the common traumatic injury known as concussion; it is the hope that increased awareness of this condition as it relates to musculoskeletal trauma will only serve to aid the recovery of injured children and adolescents.
Description of Issue:
Concussion, a form of mild traumatic brain injury (TBI), is a common consequence of trauma to the head in contact sports. As many as 3.8 million sports-related concussions occur in the United States each year. While the majority of concussions are self-limited injuries, catastrophic results can occur and the long-term effects of multiple concussions are unknown. A history of prior concussion may increase the risk for recurrent concussions.1,2
The effect of concussion on developing brains is of particular concern. Children with concussion, particularly multiple concussions, are at high risk for developing headaches and suffering from impaired memory, cognitive function, attention, or other behavioral changes.1 Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer, and basketball.2
Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiologic process. Concussion is a subset of mild TBI that is generally self-limited and at the less severe end of the brain injury spectrum.2
Risk Factors for Sports-Related Concussion:
• A history of concussion is associated with a higher risk of sustaining another concussion.2
• A greater number, severity, and duration of symptoms after concussion are predictors of a prolonged recovery.2
• In sports with similar playing rules, the reported incidence of concussion is higher in females than males.2
• Certain sports, positions, and individual playing styles have a greater risk of concussion.2
• Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.2
• Preinjury mood disorders, learning disorders, attention deficit disorders (ADD/ADHD), and migraine headaches complicate diagnosis and management of concussion.2
‘Sideline’ Evaluation and Management:
• Signs and symptoms of suspected concussion include: headache, dizziness, confusion, feeling like "in a fog", difficulty concentrating, difficulty remembering, "don’t feel right", balance
problems, amnesia, feeling slowed down, "pressure in head", sensitivity to light or noise, fatigue or low energy, drowsiness, more emotional, nervous or anxious, irritability, sadness, blurred vision, neck pain, nausea or vomiting, seizure or convulsion, or loss of consciousness.3
• Any athlete suspected of having a concussion should be removed from play and assessed by a licensed healthcare provider trained in the evaluation and management of concussion.1,2,3
• Recognition and initial assessment of concussion should be guided by a symptom checklist, cognitive evaluation (including orientation, past and immediate memory, new learning, and concentration), balance tests, and further neurologic physical examination.2
Diagnosis of Concussion:
• Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.2
• Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations.2
• When premature cognitive or physical activity occurs before full recovery the brain may be vulnerable to prolonged dysfunction.2
• Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from concussion.2
• Concussion symptoms should be resolved before returning to exercise.2
• A return-to-play progression involves a gradual, stepwise, increase in physical demands, sports-specific activities, and the risk for contact.2
• If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step.2
• Return to practice/ play after concussion should occur only with medical clearance from a licensed healthcare provider trained in the evaluation and management of concussion.1,2,3
• Greater efforts are needed to educate involved parties including athletes, parents, coaches, officials, school administrators, and healthcare providers to improve concussion recognition, management, and prevention.2 This education should include risk factors for concussion such as prior history of concussion, with the number, severity, and duration of symptoms noted as they known factors in concussion recovery.
• Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.2
• Helmets, both hard (football, lacrosse, and hockey), and soft (soccer, rugby), are best suited to prevent impact injuries (fracture, bleeding, laceration, etc) but have not been shown to reduce the incidence and severity of concussions.2
1. American Academy of Neurology. Position Statement: Sports Concussion. http://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/6.Public_Policy/1.Stay_Informed/2.Position_Statements/3.PDFs_of_all_Position_Statements/sports.pdf. Updated March 2013, Accessed June 30, 2013
2. Harmon K, et.al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clin J Sport Med. 2013;23(1):1-18
3. McCrory P, et.al. Consensus Statement on Concussion in Sport – the 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clin J Sport Med. 2013;23(2)89-117
Submitted by Bridget Burke
Radio interview featured on local NE station KFAB
Transcription of the interview which was aired on KFAB in Nebraska:
Starting today, 20-plus million uninsured Americans will start entering the heath care system. Many of them will have access to the nation's healthcare system for the first time. With the new influx of patients the big question is who will care for all of these new patients? John McGinnity [ma-GINN-NUH-TEE) is President-Elect of the American Academy of Physicians Assistants and says along with doctors and nurse practitioners they are considered one of the three primary care providers in the Affordable Health Care Act.
[PA] John McGinnity, President-Elect of the American Academy of Physicians Assistants; "are in primary care."
McGinnity says physician’s assistants will help bridge the gap between doctors and patients and are a very important component of the health care team. He also urges more people to consider a career as a physician’s assistant and there are two colleges that offer the program. They are the University of Nebraska Medical Center in Omaha and Union College in Lincoln.
Affordable Health Care Act open enrollment starts today. There are 20-million plus Americans that will now be entering the health care system and there is a lot of worry that will put a strain on doctors. John McGinnity is President-Elect of the American Academy of Physicians Assistants and says that is where they come in. He says the need for health care providers is at an all time high and he encourages more Nebraskans to consider this career.
[PA] McGinnity; "in the P-A profession."
The two P-A programs in Nebraska are the University of Nebraska Medial Center in Omaha and Union College in Lincoln.
Who is going to care for American's newly insured patients? With Affordable Health Care's open enrollment starting today it is estimated that 20-million patients will be entering the system in the next six months. With the new influx of patients will the wait at doctor's offices be even longer? In many areas of Nebraska doctors are few and far between and will the new patient load be too much for them to handle? President-Elect of the American Academy of Physicians Assistants John McGinnity says that is where they come in.
[PA] McGinnity; "increase patient satisfaction."
McGinnity says more physician assistants will be needed and he encourages Nebraskans to check out two programs that are available in the state. They are at the University of Nebraska Medical Center in Omaha and Union College in Lincoln.
Wells Receives Distinguished Alumnus Award
At the recent UNMC PA Alumni Reunion in Omaha, July 19-20, Roger Wells, PA-C, received the PA Distinguished Alumnus Award. The UNMC PA Alumni Association selected Roger for this award following a nomination and selection process. Roger Wells, Class of 1987, has served patients in rural St. Paul, Nebraska, for decades and continues to devote himself to his clinical practice. That grassroots experience has served him well as he has held positions on the Board of Directors for the AAPA, and chaired committees for NAPA. He is a leader in promoting the effective utilization of PAs in rural health care, and serves on the Nebraska Rural Health Association in this capacity. He's been instrumental in the formative stages of the Nebraska Healthcare Workforce Center, which will help predict future shortages before they become crises.
Said Nebraska Rural Health Association Executive Director John Roberts: "He's been an unwavering protector of the health of rural Nebraskans."
Roger continues to mentor PA students and individuals pursuing the PA profession. "More PAs than I can count," said Michael Huckabee, Ph.D., director of physician assistant education, "would say that they became a PA because of their connections with Roger."
Union College PA Program Open House
You are invited to the Ribbon Cutting Ceremony and Grand Opening of the new academic facilities for Physician Assistant Studies and International Rescue and Relief at Union College.
Monday, October 7, 2013
3800 South 48th Street
1:30 – 4:00 p.m.
Tour the new offices, classrooms and labs and enjoy refreshments
Remarks begin at 1:45 p.m. at Center Campus
Parking available across the street at College View SDA Church, Prescott and 49th Streets or
in the lots to the north off Prescott and 51st Streets.
PA Week Proclamation Week Signing
Nebraska Governor Dave Heineman recognized October 6-12 as Physician Assistant Week in Nebraska and presented an official proclamation to representatives of the Nebraska Academy of Physician Assistants. A large group of Physician Assistants and PA students gathered at the State Capitol in Lincoln to accept the proclamation. NAPA President Sandy Lloyd addressed the crowd and thanked the Governor for his support.
Thank you to all the dedicated Physician Assistants across the state for providing excellent care to the citizens of Nebraska.
Governor Signs New PA Regulations
NEW PA REGULATIONS EFFECTIVE September 3, 2013
In 2009 the law relating to PA practice was changed. These are found in the statutes relating to the Practice of Medicine and Surgery, sections 38-2001 to 38-2062. New regulations, primarily regarding physician supervision of PAs with less than 2 years of experience, were written and approved by the Governor August 29, 2013. They became effective September 3, 2013. The following is a synopsis of law and regulation changes that affect all PAs. Some of these law and regulation changes were put in effect late summer of 2009 (1-6, 10 & 11), others just recently (7-9).
1. Credentialing of supervising physicians and their biennial fees were eliminated.
2. Increased the number of PAs that one physician may supervise from two to four.
Physicians may have practice agreements with more than 4 PAs, but only 4 may be providing
medical services at any given time. Waivers to this ratio may still be requested.
3. Only the PA’s name needs to be on the prescription label unless the physician’s name is needed
for reimbursement reasons. (Nebraska Medicaid no longer requires MD name because PAs are
4. PAs may pronounce death and sign death certificates and other forms not otherwise prohibited
5. PAs must have a Scope of Practice agreement with each supervising physician. They may sign the
same one or have individual agreements. A copy of these agreements must be kept at each PA
practice site and the primary practice site of the supervising physician. A sample Scope of
Practice agreement can be found on NAPA’s or the Nebraska Department of Health and Human
6. PA regulations states “Supervision means the ready availability of the supervising physician for
consultation and direction of the activities of the physician assistant. Contact with the supervising
physician by telecommunication is sufficient to show ready availability.”
7. Temporary licensed PAs with less than 2 years of experience must have the supervising physician
physically present 100% of the time at all practice sites . Cannot provide medical services at a
at any practice site without physician presence. No chart review/co-signing required at any site
because the supervising physician must be present .
8. Permanent licensed PAs with less than 3 months of experience must have the supervising
physician present a minimum of 20% of the total time the PA is practicing. May provide medical
services at any practice site without physician presence. If so, a minimum of 20 patient medical
records per month must be reviewed by the supervising physician. If less than 20 patient per
month seen by the PA without physician presence then 100% of the medical records shall be
reviewed by the supervising physician. There are no time constraints for these reviews to occur.
9. Permanent licensed PAs with more than 3 months but less than 2 years of experience must
have the supervising physician present a minimum of 10% of the total time the PA is practicing.
May provide medical services at any practice site without physician presence. If so, a minimum
of 20 patient medical records per month must be reviewed by the supervising physician. If
less than 20 patient per month seen by the PA then 100% of the medical records shall be
reviewed. There are no time constraints for these reviews to occur.
(This is the same requirement as permanent licensed PAs with less than 3 months of
10. Permanent licensed PAs with more than 2 years of experience have no additional standards of
supervision for any practice site beyond having a Scope of Practice agreement and the ability to
contact a supervising physician at any time the PA is providing medical services. Supervising
physicians and hospital policy may require more.
11. Waivers may be requested for supervision standards for PAs with less than 2 years of
Appropriate Use Criteria for Coronary Revascularization Focused Update
In January 2012 the Journal of American College of Cardiology published the Appropriate Use Criteria for Coronary Revascularization Focused Update. According to the article, “This report is a focused update of the AUC for coronary revascularization published in 2009. The increasing prevalence of coronary artery disease (CAD), continued advances in surgical and percutaneous techniques for revascularization and concomitant medical therapy for CAD, and the costs of revascularization have resulted in heightened interest regarding the appropriate use of coronary revascularization (pg 3).” All PAs interact with patients who have been diagnosed with CAD or who are having symptoms that makes one suspicious they may have CAD in one setting or another. As the appropriate use criteria application becomes more common there are a few definitions, classifications, and scoring systems that one may be seeing more frequently and need to be understood. Risk stratification of stress tests, the Canadian Cardiovascular Society Classification System of Angina Pectoris (CCS), and the TIMI risk score will be discussed here.
A nuclear stress test, whether it be chemically induced or an exercise stress test, is a very common noninvasive imaging modality used today. One may soon see changes in the stress test report that need further clarification. More frequently the test results are now “risk stratified” into low risk, intermediate risk, or high risk categories based on the perfusion defect. A low risk study is defined as the patient having less than 1 percent risk of mortality in one year, intermediate risk a 1-3 percent risk of mortality in one year, and a high risk of greater than 3 percent mortality in one year. This information helps the cardiologist to determine whether or not the patient would be an appropriate candidate for a diagnostic left heart catheterization (LHC) and possible percutaneous coronary intervention (PCI).
One may also find the Canadian Cardiovascular Society Classification System of Angina Pectoris (CCS) used more often to aid in decision making. Class I includes no anginal symptoms with ordinary physical activity including: walking or climbing stairs. These patients’ symptoms begin when they are doing strenuous, rapid or prolonged exertion. Class II patients have angina with walking more than 2 blocks on level ground or after taking more than 1 flight of stairs (at a normal pace and in normal condition). This is considered slight limitation of ordinary activity. Class III are considered to have marked limitations of their activity and have symptoms when walking 1 or 2 blocks on level ground or after taking 1 flight of stairs (again in normal condition at a normal pace). Class IV patients may have symptoms at rest or may not be able to carry on any type of physical activity without presentation of their angina.
The guidelines also take into account a patient’s TIMI Risk Score used for individuals with suspected acute coronary syndrome (ACS). This is a scoring system in which each of the following variables receive one point: Age greater than or equal to 65, greater than or equal to 3 risk factors (hypertension, diabetes, family history of CAD, hyperlipidemia, or smoking), known CAD with a stenosis greater than or equal to 50%, severe angina (defined as greater than or equal to 2 episodes in the last 24 hours), aspirin use in the last 7 days, ST-segment deviation greater than or equal to 0.5 mm, and elevated cardiac biomarkers. A low risk score is 0-2 points and has a less than 8.3% event rate (death or ischemic event) in the next 14 days. Intermediate risk encompasses those who have 3-4 points. They have a greater than 19.3% risk in event in the 14 day window. The high risk category includes those patients who received a score of 5-7. These individuals carry a 41% event rate in the next 14 days.
Even though this information is helpful to all cardiologists when treating patients, the guidelines do state that it does not take the place of clinical judgment. Risk factors, a patient’s history and their symptoms must still be taken into account and each patient should be treated on an individual basis.
New studies are published daily concerning the benefits and risks of revascularization in patients with coronary artery disease and new treatment modalities and diagnostic testing are forever being developed. By being able to recognize the above terms and understand the definitions one is better able to educate their patients and understand information presented by consulting physicians. The full article can be accessed online at http://www.ncdr.com/WebNCDR/CathPCI/Home/auc.
Chelsie Doane PA-C
Nebraska Heart Institute
President Elect NAPA BOD
Patel, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/AFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update. Journal of American College of Cardiology January 30th 2012. http://www.ncdr.com/WebNCDR/CathPCI/Home/auc. Access date 7/1/2013.
National Registry of Certified Medical Examiners
Codeine and acetaminophen recommendations for children