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Managing Patients with Sports Related Concussion

Giza, Chris MD; Kutcher, Jeffrey MD

doi: 10.1097/01.NT.0000388167.72327.e8
Letters to the Editor

We were pleased to see your recent article regarding the incidence of concussions in youth ice hockey (“Three-Fold Fewer Concussions in Youngest Hockey Players When Body Checking is Barred,” July 15). It is encouraging to see the neurological community taking interest in this topic. With our unique set of skills and experience, neurologists should be leading the efforts to better understand this injury. Unfortunately, our field has not fully engaged itself in the conversation, until recently.

The AAN Sports Neurology Section was founded to raise the awareness of sports specific issues within the field of neurology and to promote the involvement of neurologists in clinical care, education, and research. One of the most urgent actions of the section was to address the outdated AAN Practice Parameter for Concussion Management. Published in 1997, this parameter was relevant at the time and represented the best possible approach to these patients based on the published literature.

Since 1997, however, concussion management has evolved as the result of advancements in basic science as well as a growing body of clinical literature and consensus in the Sports Medicine field. Effectively, there are several aspects of the AAN 1997 document that are in direct opposition to more recently published guidelines, such as the consensus statement from the 3rd International Conference on Concussion in Sport held in Zurich in 2008.

Most notably, there is now wide consensus that grading a concussion at the time of injury, as directed by the AAN's 1997 parameter statement, does not allow the clinician to accurately predict the injury's duration or severity. Also, concussion symptoms are now understood to frequently develop or worsen up to several hours after a hit. Therefore, the recommendation to return an athlete to play if they are asymptomatic after 15 minutes is flawed. If followed exactly, therefore, the 1997 document puts athletes at risk of returning to their sport too early, which is why we are concerned that it was included in your story of July 15.

The AAN began the process of developing a new parameter statement in the fall of 2009. As the co-leaders of this effort we are striving to produce the most up to date and scientifically accurate document on the topic. Until its completion, likely in the spring of 2012, we urge all clinicians to follow the guidelines outlined by the Zurich conference.

Chris Giza, MD,

Los Angeles, CA

Jeffrey Kutcher, MD

Ann Arbor, MI

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Regarding “New Law Mandates Disclosure for Neurology Imaging” (June 17), it seems provisions of the health care reform law have brought to the forefront the longstanding turf-battle between radiologists and clinicians who perform in-office imaging. But some underlying facts are missing in the heated discussion generated by the spokespersons for the two sides.

The longstanding “Stark” legislation — which aims to minimize the conflict-of-interest dangers that exist when professionals refer for technical services to a facility in which they have an ownership interest — has long had a loophole permitting referral for in-office procedures.

The new law attempts to narrow the loophole by compelling clinicians to reveal their ownership interest, and to inform patients of other possible locations where the procedure might be performed.

William G. Preston, MD, chair of the AAN Neuroimaging Section, points out what he perceives as burdensome and impractical aspects of this rule, and names a non-radiologist group, the Coalition for Patient Centered Imaging, as intervening with the CMS in the effort to clarify the situation.

The article points out the position taken by the American College of Radiology that “non-radiologists who own imaging equipment are a primary source of inappropriate use,” a position strongly contested by the neurologists cited.

None of the participants in this debate consider the possible value of research. Given the huge amounts of money involved, it would be worthwhile to fund some studies. It might be possible to quantify the financial significance of self-referral, for example, by looking at the Medicare database and correlating the neurology-related coding for CT and MRI performed by radiologists on referral by neurologists, and those performed in-house by neurologists.

The issue of overutilization is extremely complex, and involves many other factors, including referral for “neurologic” indications by other practitioners, such as primary care physicians and orthopedists, but a focused study such as I propose might reveal whether excessive self-referral really exists.

The article also notes that in 2008 the AAN issued a position paper “opposing any restrictions on self-referred imaging practices and equipment ownership. No citation was given as to the authorship, but one wonders if this position was taken in view of any considerations other than financial. Do all training programs require adequate time for expertise in neuroradiology? Do clinicians who practice in-office imaging have fellowship training? If not, who certifies their qualifications? Should there be a certifiable subspecialty in the neurology boards?

The issue of uncritical use of high-tech imaging the subject of an editorial by Bruce J. Hillman, MD, and others in the July 1 New England Journal of Medicine is a matter of national signi-fi-cance, certainly more than a relatively parochial problem affecting the economic interests of neurologists.

Robert Jaffe, MD

New York, NY

EDITORS' RESPOND: Thank you for writing. For the AAN position statement, “Principles of Neuroimaging Training, Guidelines, and Practice (March 2008),” visit Look for an article about the “uncritical use of high-tech” imaging in an upcoming issue of Neurology Today.

© 2010 American Academy of Neurology