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Knock Knock Presenters INCIDENCE OF CONCUSSION Concussion Definition

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Knock Knock Presenters INCIDENCE OF CONCUSSION Concussion Definition Powered By Docstoc
					                 Knock Knock:                                                              Presenters
                                                                    Rosemarie Scolaro Moser, PhD
                                                                      RSM Psychology Center, LLC, Lawrenceville, NJ
                                                                    Mark Lovell, PhD
          Opening the Door
                                                                      University of Pittsburgh School of Medicine
                   to                                               Philip Schatz, PhD
 Youth Sports Concussion Services In Your                             St. Joseph’s University, Philadelphia, PA
                 Practice                                           Michael Collins, PhD
               NAN 2004                                               University of Pittsburgh School of Medicine




        MANAGEMENT OF SPORTS CONCUSSION
              A Focus on Youth Sports
                                                                                                      Field, Collins, Lovell et
                    MARK R. LOVELL, Ph.D., ABPN
     Director, University of Pittsburgh Sports Concussion Program                                                al.
          Director, NFL and NHL Neuropsychology Programs
             Consultant, NASCAR, IRL and CHAMP Racing
                                                                                                        Comparing recovery
                                                                                                                from
                                                                                                         concussion in High
                                                                                                               School
                                                                                                        and college athletes

                                                                                                       Journal of Pediatrics,
                                                                                                               2003




            INCIDENCE OF                                                      Concussion: Definition
             CONCUSSION                                                  A complex pathophysiological process
                                                                                    affecting the brain, induced by
 75 to 85 % of all head injuries                                                   traumatic biomechanical forces.
                                                                         Common features
 1.0 to 1.5 million cases per year in US                                   • Direct blow to the head or body
                                                                            • Rapid onset of short lived impairment (usually)
 300,000 from sports                 (an underestimate?)                   • Acute symptoms a result of functional rather
                                                                              than structural injury
                                                                            • Normal structural neuroimaging studies
      Most cases go unreported
               POST-CONCUSSION SCALE                                                                                   Emotionality
                                 Lovell et al., 1996                                                                   • Feeling more emotional
                                               SEVERITY                                                                • Sadness
           SYMPTOM
          Circle appropriate number   None             Moderate           Severe                                       • Nervousness
   Headache                           0      1     2     3        4   5     6                                          • Irritability
   Nausea                             0      1     2     3        4   5     6
   Vomiting                           0      1     2     3        4   5     6
   Balance Problems                   0      1     2     3        4   5     6
   Dizziness                          0      1     2     3        4   5     6         Somatic Symptoms                                                  Cognitive Symptoms
   Fatigue                            0      1     2     3        4   5     6         • Visual Problems                                                 • Attention Problems
   Trouble falling asleep             0      1     2     3        4   5     6         • Dizziness                                                       • Memory dysfunction
   Sleeping more than usual           0      1     2     3        4   5     6         • Balance Difficulties                                               Fogginess”
                                                                                                                                                        • “Fogginess ”
   Sleeping less than usual           0      1     2     3        4   5     6         • Headaches                                                       • Fatigue
   Drowsiness                         0      1     2     3        4   5     6         • Light Sensitivity                                               • Cognitive slowing
   Sensitivity to Light               0      1     2     3        4   5     6         • Nausea
   Sensitivity to noise               0      1     2     3        4   5     6
   Irritability                       0      1     2     3        4   5     6

   Sadness                            0      1     2      3       4   5     6                                       Sleep Disturbance
   Nervousness                        0      1     2      3       4   5     6
                                                                                                                    •Difficulty falling asleep
   Numbness/tingling                  0      1     2      3       4   5     6
                                                                                                                    • Sleeping less than usual
   Feeling slowed down                0      1     2      3       4   5     6
                      fog ”
   Feeling like “in a fog”            0      1     2      3       4   5     6
   Difficulty concentrating           0      1     2      3       4   5     6
                                                                                   Factor Analysis, Post-Concussion Symptom Scale
   Difficulty remembering             0      1     2      3       4   5     6
                                                                                   N=327, High School and University Athletes Within 7 Days of Concussion (Pardini et al, 2004)




        COMMONLY REPORTED SYMPTOMS                                                                      NEW MANAGEMENT STRATEGIES
High School/University Athletes within 3 days of injury
                                                                                                      CIS Group, Vienna (2001), Prague (2004)

  1. Headache (71%)
  2. Feeling slowed down (58%)
                                                                                                   Removal of symptomatic athletes from play
  3. Difficulty concentrating (57%)
  4. Dizziness (55%)                                                                                 Graduated return to play
      Fogginess”
  5. “Fogginess” (53%)
                                                                                                     Neuropsychological testing recommended
  6. Fatigue (50%)
  7. Visual Blurring or double vision (49%)                                                                                         Management”
                                                                                                        “One of the Cornerstones of Management”
  8. Light sensitivity (47%)
                                                                                                Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell,
  9. Memory dysfunction (43%)                                                                   McCrory, Meeuwise, Schasmasch, 2001. Clinical J. Sports Med .

  10. Balance problems (43%)




      Evaluation Timeline                                                                Summary of What We Have Learned From
                                                                                               Traditional Testing Projects


                                                                                         Testing yields useful information

                                                                                                           because…
                                                                                         Testing difficult because…
         BASELINE                     Sideline  NP
                                                     RETURN TO
            NP                        Testing Testing PLAY?
         TESTING                                                                                     Difficult to evaluate large numbers of athletes

                         INJURY
                                                   1-2 DAYS
                                                                                                     ? sensitivity of tests to cognitive speed
        PRE-SEASON
                                                 AFTER INJURY
        COMPUTER BASED TESTING                        COMPUTER-BASED TESTING
          Currently Available Programs
                                                                          Advantages
                                                     Promotes Group Testing
               Cogsport                            Accurate Evaluation of Reaction Time

               Headminders (CRI)                   More Cost-Effective

                                                    Minimizes Practice Effects (randomization)
               ANAM
                                                    Automatic Scoring and Display of Results

               ImPACT                              Transmission of Test Results Via E-Mail




    COMPUTER-BASED TESTING                                     Current Large-Scale Programs
                                                                Neuropsychological Testing
                   Disadvantages?                          20 NFL Teams                    Ontario Hockey League
                                                           IRL, F1, CHAMP Car              New Zealand Rugby
                                                           NASCAR                          S. African Rugby
                                                           USA Olympic Hockey
   Difficulty in Presentation of Some Tests
                                                           USA Hockey
                                                                                            World Cup Soccer
                                                                                            150 + Universities in US
                                                           400 + High Schools in US
 Presentation of Instructions Requires Reading                                             Many Neuropsychology
                                                           60 Sports Medicine               Clinics in US
 Less Direct Interaction with Examiner?                    Clinics in US
                                                                                            Major League Baseball
                                                           Pro Boxing in California
                                                                                            Major League Baseball
                                                           USA Ski Team
                                                                                             Umpires
                                                           USA Soccer Juniors




                                                          UNIQUE CONTRIBUTION OF
 WHY USE NEUROPSYCHOLOGICAL TESTING?                    NEUROPSYCHOLOGICAL TESTING
                                                        TO CONCUSSION MANAGEMENT
    Unique Contribution To The Diagnostic Puzzle
                                                                           Symptomatic      Asymptomatic   Control

                                                                               100
                                                                                95
     Testing Provides Unique Information                                        90
                                                     Testing reveals            85

    Concussed Athletes Often Deny Symptoms
                                                     cognitive deficits         80
                                                                                75
                                                     in asymptomatic            70
    Athletes May Lack Awareness of Symptoms          athletes within 4          65
                                                                                60
                                                     days post-injury           55
                                                                                50
                                                                                     Verbal        Visual
                                                                                     Memory        Memory
                                                   N=215, MANOVA p<.000000
                       UNIQUE CONTRIBUTION OF                                                                            VALUE ADDED OF
                     NEUROPSYCHOLOGICAL TESTING                                                                    NEUROPSYCHOLOGICAL TESTING
                     TO CONCUSSION MANAGEMENT

                                                                                                                                         100
                                                                                                                                          95                         88
            Symptomatic   Asymptomatic   Control                   Symptomatic   Aysmptomatic   Control                                   90
      0.8                                                     50                                                  NP testing              85
                                                                                                                                          80                   82
                                                                                                                  increases
      0.7                                                     45
      0.6
                                                              40                                                                          75
                                                                                                                  Diagnostic
      0.5

      0.4
                                                              35                                                                          70
                                                                                                                                                                                EITHER
                                                                                                                                           65
                                                                                                                  yield to
      0.3                                                     30

      0.2                                                     25
                                                                                                                                           60            65                NEUROPSYCH
                                                                                                                  88%
                     Reaction Time                                      Processing Speed
                                                                                                                                           55
                                                                                                                                                                      SYMPTOMS
                                                                                                                                           50
                                                                                                                                                 % DECLINED
                                                                                                                                                  FROM BL

                                                                                                                 201 concussed High School and collegiate athletes tested with 2 days of injury.
        MANOVA p<.000000 (ImPACT Test Battery)                                                                   Abnormal performance determined by RCI’s (van Kampen, 2004).




 WHY USE NEUROPSYCHOLOGICAL TESTING?
                                                                                                          Concussion and Memory Dysfunction
            Ding”
   Mild or “Ding” Injuries May be Significant                                                              64 high school athletes with Grade 1 concussion
                                                                                                           24 Non-injured control subjects
  Cannot gauge severity of injury based on initial                                                                                          ding”
                                                                                                              All athletes diagnosed with ”ding”
symptoms                                                                                                        Confusion, amnesia, signs/symptoms cleared
                                                                                                                     within 15 minutes
                                                                                                                No athlete in sample sustained LOC
 Acute recovery may not be a linear process
                                                                                                           No athlete returned to contest
                                                                                                           ImPACT evaluation obtained at baseline, 36 hours,
                                                                                                            4 days and 7 days post-concussion

                                                                                                                                           Lovell et al., J. Neurosurgery, 2003.




                Memory Impairment Following
                     “Mild Concussion”
                           Concussion”                                                                                                    Summary
                                              CONCUSSED            CONTROLS

                90
                                                                                                                 Current research supports the use of
                85                                                                                              neuropsychological testing following concussion

                80                                                                                               Relying on symptoms alone may be dangerous

                75                                                                                               Attentional processes, memory, and cognitive
                                                                                                                    speed are key elements of testing
                70
                           Baseline                36 Hours           Day 4                 Day 7                Younger athletes deserve particular attention
                                             Time of Evaluation
     Lovell, Collins, Iverson et al., J. Neurosurgery, 98 ,                      2003
    Thank You!
    LovellMR@UPMC.edu                                     Concussion in Youth Athletes




                                                                           Philip Schatz, PhD
                                                               Saint Joseph’s University, Philadelphia PA
                                                                         http://schatz.sju.edu/nan/




              Cerebral Concussion                            Post Concussion Symptoms
• Mild traumatic brain injury                             “Oh man… I was licking the dreamcicle”
• Alteration in consciousness due to a blow to the
                                                          -- Professional wrestler, reflecting on a concussion
  head or acceleration/deceleration/rotational force
• Does NOT imply/require loss of consciousness.
• Usually temporary changes in mental status,
  temporary changes in somatic functioning
• May produce a wide range of symptoms




         Post Concussion Symptoms                              Physiological Changes
•   Pressure in head           •Feeling like in a “fog”
•   Headache                   •Difficulty                             •    Shearing or strain injury of axons
•   Balance troubles            concentrating                          •    Diffuse microscopic changes to axons
•   Visual Disturbance                                                 •    Microscopic tearing of small blood vessels
                               •Difficulty                             •    Metabolic cascade resulting in imbalance
•   Numbness
                                remembering                                 between glucose demands and regional CBF
•   Tingling                                                                supply (vulnerable to SIS)
                               •Irritability
•   Feeling slow                                                                Giza & Hovda, JAT, 36(3), 228-35
•   Sensitivity to light/noise •Sadness
                              • Nervousness
                                     Epidemiology                                                         Epidemiology

     • High School                                                               • College: NCAA Injury Surveillance System
           – 20% or 250,000 per year in football (Gerberich, et al. 1985)             –   1.6 to 6.4% of all injuries
           – 25,520 per season (Powell, 1995)                                         –   Ice Hockey - 4.5% of all injuries (.56 per 1,000 AE)
           – NATA High School Study                                                   –   Football .43 per 1,000 AE
                         –   57,716 occurrences of mTBI per year
                         –   5.3% of football injuries                                –   Wrestling .49 per 1,000 AE
                         –   4.4% of wrestling injuries                               –   Soccer (Men = .35/Women=.58)
                         –   3.4% of boys soccer
                         –   2.6% girls soccer                                        –   Lacrosse (Men= .33/Women=.62)
                         –   2.3% girls basketabll                                    –   Basketball (Men=.16.Women=.29)




                         Epidemiology: Gender                                                Understanding Base Rates
                                 Hillary, Mann, Schatz, ACN, 2002

Study                    Sport (% of All Injuries)      Males          Females
Powell, Barber-Foss      Soccer                         3.9%           4.3%
Powell, Barber-Foss      Basketball                     2.6%           3.6%      • History of Previous Concussion: 10-80%
Powell, Barber-Foss      Baseball/Softball              1.7%           2.7%
NCAA                     Soccer                         4.7%           4.4%      • Recent Trend Upwards:
                         Total % of all injuries        3.23%          3.75%          –   % with 1+ Previous Concussion
Study                    Sport (Injuries per 1000 AE)   Males          Females        –   Collins, et al (1999) 53%
Dick                     Soccer                         0.348          0.578
Dick                     Lacrosse                       0.334          0.618
                                                                                      –   Kaushik (2005) 75%
Boden, et al.            Soccer                         0.6            0.4            –   Moser & Schatz (2001) 97%
NCAA                     Soccer                         0.44           0.46
Powell, Barber-Foss      Soccer                         0.18           0.23
Powell, Barber-Foss      Basketball                     0.11           0.16
Powell, Barber-Foss      Baseball/Softball              0.05           0.1
J. Kelly, J. Rosenberg   Soccer                         0.25           0.24

                         Total Ave per 1000 AE          0.289          0.348
                         Soccer Ave per 1000 AE         0.364          0.382
                         Other Ave per 1000 AE          0.165          0.293




                      Understanding Base Rates                                               Understanding Base Rates

                                                                                 •   Sensitivity 78.9%
     • Sensitivity and Specificity of Test Measures varies                       •   Specificity 91.5%
       as a function of Base Rate (LaBarge, et al, 2003,                         •   PPV 90.9%
       ACN, 18)
     • Sample Data:
                                                     Concussed     Control
                                Test +                  60           6

                                Test -                    16         65
                                                                                     http://www.cebm.utoronto.ca/practise/ca/statscal/
                                                                                          Moser & Schatz (2001): High School
    Importance of Baseline Assessment
      “Nobody in football should be called                                          •    Youth Athletes
      a genius. A genius is a guy like Norman
                                                                                    •    College-prep boarding school
      Einstein.”
                                                                                    •    Mandatory participation in sports
      -- Football commentator and former player                                     •    Multiple sports over 5-10 years
                                                                                    •    No concussion program in place
                                                                                    •    Attempt to understand/replicate previous
                                                                                         findings




              Dependent Measure: RBANS                                                   Moser & Schatz (2001): Study Design
                Subtests measure multiple neurocognitive domains
•   Immediate Memory
    List Memory - recall of 10 words presented orally.
    Story Memory - recall of short story presented orally.
                                                                                    Youth athlete volunteers from a Private Boarding School, divided
•   Visuospatial/Contructional
    Figure Copy - Copy of multi-part geometric drawing.
    Line Orientation - identify lines from a drawing.
                                                                                    into independent groups on the basis of concussion history.
•   Language
    Picture Naming - Naming of pictures of objects.                                     • Zero or One Previous Concussion: 8 healthy volunteers with either no
    Semantic Fluency - Name examples from category in one minute.
                                                                                          history of concussion, or had sustained one previous concussion
•   Attention                                                                             (not within the past six months).
    Digit Span - Repeat a string of digits presented orally.
    Coding - Matches geometric shapes corresponding to numbers.
                                                                                        • Two+ Previous Concussions: 13 youth athletes who had sustained two
•   Delayed Memory
    List Recall - Recall 10 words learned in the List Learning subtest.                   or more previous concussions (not within the past six months).
    List Recognition - recognition of 20 words presented orally.
    Story Memory - Recall of short story learned earlier.
    Figure Recall - Draw, from memory, the figure shown earlier.                        • Recent Concussion: 13 youth athletes who had sustained a recent
                                                                                          concussion, with no identified medical or neuropsychological difficulties
                                                                                          related to concussion one week after testing.




                 Moser & Schatz (2001): Results                                                               Follow-up Study
                                                                                                           (Moser, Schatz & Jordan, In Review)



                                                    RBANS Mean Raw Scores        238 youth athlete volunteers ... divided into four independent
             Concussion Group        n           Total     Coding    Attention
             _____________________________________________________________       groups on the basis of concussion history.
             0-1 Previous            8 Mean 252.63            63.88      77.38
             Concussion                   SD     14.10          7.18      9.59    • No Concussion: 82 healthy volunteers with no history of concussion.
             _____________________________________________________________
             2 or More Previous     13 Mean 240.54            55.92      68.69
             Concussions                  SD     14.85          6.68      8.10    • One Previous Concussion: 56 youth athletes who had sustained one
             _____________________________________________________________          previous concussion (not within the past six months).
             Recent                 13 Mean 233.77            53.15      65.38
             Concussion                   SD     15.92        10.71       9.20
             _____________________________________________________________        • Two+ Previous Concussions: 51 youth athletes who had sustained two
                   Total RBANS:   [F(2,31)=3.86; p = .032; r = .53]                 or more previous concussions (not within the past six months).
                   RBANS Coding: [F(2,31)=3.98; p = .029; r = .50]
                   RBANS Attn:    [F(2,32)=4.59; p = .018; r = .55]
                                                                                  • Recent Concussion: 49 youth athletes who had sustained a recent
             Note: Higher Mean Scores = Stronger Cognitive Functioning.             concussion, with no identified medical or neuropsychological difficulties
                   Analyses are two-tailed; Effect sizes denoted by "r".            related to concussion within one week of testing.
                              Study Results-GPA                                                                     Study Results-RBANS
                                                                                                                                RBANS Subtest by Concussion Group
                                      GPA by Concussion Group

                                                                                              80
                                                                                                                                                                 No Concussion: (82)
 3.55                                                                                                                                                            One Previous: (56)
                                                                                              70                                                                 Two+ Previous: (51)

  3.5                                                                                                                                                            Recent: (49)

                                                                                              60
 3.45


  3.4                                                                                         50


 3.35
                                                                                              40

  3.3

                                                                                              30
 3.25


  3.2                                                                                         20


 3.15
                                                                                              10

  3.1

                                                                                               0
 3.05                                                                                                   *Attn            IMM             DEM             Lang           VisC
        No Concussion: (82)   One Previous: (56)       Two+ Previous: (51)   Recent: (49)                                           RBANS   Subtest
                                          Concussion   Group




                        Study Results-MANOVA                                                               Moser & Schatz: Group Means


                                                                                                   Effects of Previous Concussion on RBANS and GPA scores.
  • Multivariate Analysis of Variance (MANOVA) revealed a
    significant overall effect of concussion history on                                            Concussion                   RBANS Sub-Scales Student
    cognition [F(21,672)=1.8; p=.015].                                                             Group                *Attn      IMM         DEM      Lang     VisC     *Total        GPA*

                                                                                                   No Concussion: (82) 71.1          50.7        53.3     31.1     34.9         240.3   3.54
  • Univariate F-tests revealed significant main effects of
                                                                                                   One Previous: (56)     71.8       52.0        53.9     31.2     36.3         244.8   3.35
    concussion history on Attention [F(3,228)=4.72; p=.003]
    and GPA [F(3,228 =5.76; p=.001]. Means and standard                                            Two+ Previous: (51) 67.8          50.2        53.2     29.3     35.3         235.9   3.23
    deviations are presented in next slide.
                                                                                                   Recent: (49)           64.8       50.9        52.4     29.4     34.5         231.7   3.26




                                What we know:                                                                     What we think we know:

• Health non-concussed youth athletes with a history of                                     Contributing to these findings:
  concussion often show subtle deficits in attention and
  concentration at baseline assessment.                                                               A more vulnerable and susceptible youth brain

• These enduring effects of previous cerebral                                                         Participation in multiple sports over a large
  concussions can be detected using traditional and                                                   period of years.
  computer-based measures.
• Concussions occur in female athletes at a greater
  rate/frequency.
                  Future Directions:

• Baseline screenings for all athletes, but especially in
vulnerable youth athletes.
      -documenting pre-concussion status,                                  PRACTICE GUIDE
      -pre and post concussion comparisons
      -multiple “sliding” baseline.
                                                                                     CHECKLIST
• Involvement /awareness of pediatricians and family                             Are you ready to start a
practices = Neurop$ychology                                                 Youth Sports Concussion Practice?




    Establish Knowledge & Expertise




                 Establish & Document
                 Knowledge & Expertise
                                                                                           DART
                                                                                         • Diagnosis:
                                                                 Symptom Severity Value (LOC, headache, amnesia)
                  1.Formal coursework                                       Grading System

                 2. Read Journals, Books                                                • Assessment:
                                                                                Test tools, alternate forms, how often?
                      3. Consultation                                                 • Return to Play:
                                                                                   Multifactorial & Multiperson
                4. Research/Publications                                      Consultation, Limitations, Documentation
                                                                                         • Treatment:
                  5. Interest in the Sport                                       REST! EDUCATE. SUPPORT.
                                                                                 HEADACHE MANAGEMENT
                  6. Knowledge base of                                      REFERRAL (Pediatric Neurologist in place??)

                working with/testing kids.




                 OFFICE SET UP                                     Identify Your Market Share
• Baselines not covered by insurance.
• Sometimes schools offer to pay for post-concussion services.
• Use Post Concussion Diagnosis. Avoid general dx like
  “encephalopathy” or “Unspecified”
• Billing: 96115-initial exam and
                      first (computerized) testing
          96117-followup/retesting
Need to inform school contacts & parents of costs up front.
• Releases/Record Forms
• Scheduling Accessibility
• Office Environment
       Identify Your Market Share                                                 Propose Baseline Programs
• Target populations:
  public/private schools, community/rec                                     •   Develop a plan.
  leagues, minor league teams                                               •   Market to local public/private schools.
• Target referral sources:                                                  •   Consider cost: data collection, bartering.
  ERs, pediatricians, neurologists, athletic                                •   Get your foot in the door as the school
  trainers, school nurses                                                       concussion consultant.




                           Bartering                                             Execute Marketing Strategies
•   Follow APA guidelines                                                   •   Website: www.rsmpsychology.com
•   Formal agreements/contracts                                             •   Brochure.
                                                                            •   Educational Materials.
•   Inform your accountant                                                  •   Mailings.
•   Items to consider:                                                      •   Talks to schools, teams, hospitals, associations.
    Use of private school’s gym, library,                                   •   Meet with local referral sources.
                                                                            •   Write articles for local venues.
    golf course; Tickets to games. Opportunities
                                                                            •   Partner in philanthropic activities.
    to be listed as supporters in programs,
                                                                            •   Place ads, Signage, PA Announcements
    school activities; tables at events.




       Sample PA Announcement                                                    Ethical/Legal Considerations
•   Ever feel like you’ve been cross-checked from behind into the boards?   • Competence
•   Is life an endless series of bad blue line calls?
•   Do most of the people in your life belong in the penalty box?
                                                                            • Informed Consent: data collection, limitations of
•   Let RSM Psychology Center conveniently located in Lawrenceville           screening, insurance.
•   Help you…                                                               • Parental consent in divorce.
•   Win the critical faceoffs                                               • Confidentiality
•   Score on the power play and
•   Make that game winning goal in overtime.
                                                                            • Dual relationships (school payment)
•   Look for RSM Psychology Center in tonight’s program.                    • Consultation without seeing patient
                                                                            • HIPAA
                                                                            • Bartering
              CASE: 17 yo Female
    Honors Senior Student Field Hockey Player                                          REALITIES
•   Stick to face. Fractured nose.                                        • You’ve got to spend money to make money.
•   Initial sx: nausea, vomiting, headache.
•   ER cleared. Return to school. No play.                                • It takes a while to develop and groom a
•   Persistent sx. Poor school work. Referred for neuropsych. by AT.
•   ImPACT screen. REST from school. Consult with school. Referral to       sports concussion practice.
    neuro. Sent for MRI.
•   ImPACT retest. Continued sx. Low scores, little improvement. MORE     • Become a part of the sports culture.
    REST from school. CANCEL SATs.
•   Headache stopped. Returned to school half day, then full day. Work    • It helps to be outgoing, gregarious.
    with teachers to reduce workload and modify expectations.
•   Monitor by phone consults with student, parent, school, MD. Out the   • It helps to be business-oriented.
    rest of the season.
•   Scheduled for followup visit and testing.




                                         Pain is temporary…
                                         Quitting lasts forever.
                                               Lance Armstrong

				
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