1. Michael J. O’Brien, MD, Director William P. Meehan III, MD Sports Concussion Clinic Division of Sports Medicine Boston Children’s Hospital

2. Disclosures No conflicts of interest related to this discussion to disclose Royalties: O’Brien and Meehan - Up to Date® (Sections on Pediatric Concussion Evaluation and Management) Meehan Only – Royalties from Praeger publishing for the book, Kids, Sports, and Concussion: A guide for coaches and parents. Receives grant funding from the NFL Players Association, Center for the Integration of Medicine and Innovative Technology, American Medical Society for Sports Medicine, and American College of Sports Medicine

3. Overview Read the existing literature Establish treatment algorithm Get out into the community Availability

4. Overview Read the existing literature –Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport. McCrory P, Meeuwisse W, Johnston K, et al. J Athl Train 2009;44(4):434-48 –Benefits of Strict Rest After Acute Concussion: a randomized control trial. Brown, NJ et al. Pediatrics 2015 –The Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Brown, N, Mannix, R, O”Brien, MJ, et al. Pediatrics. Vol 133. Number 2. Feb 2014 –Medical therapies for Concussion. Meehan WP. Clin Sports Med 30 (2011) 115– 124 –Assessment and Management of Sport-Related Concussions in United States High Schools. Meehan WP, dHemecourt P, et al. AJSM Vol 39. Number 11. 2011 –KNOW THE SPORT!

5. Overview Read the existing literature Establish treatment algorithm –Returning to Learning. Halstead M, McAvoy M, et al. Pediatrics Vol 132. Number 5. Nov 2013. –Benefits of Strict Rest After Acute Concussion: a randomized control trial. Brown, NJ et al. Pediatrics 2015 –CHOA Concussion Consensus: establishing a uniform policy for academic accommodations. Popoli DM, Burns TG, Meehan WP 3rd, Reisner A. Clin Pediatr (Phila). 2014 Mar;53(3):217-24 –Headsmart™ from SouthShoreHospital.org and “Heads Up” from CDC.gov

6. Consideration for RTP Consistent Message Resolution of symptoms at rest Academic tolerance Exercise tolerance Neurocognitive test results (where applicable)

8. Prolonged Recovery (Beyond 4 to 6 weeks) Consider other causes of headache Sleep regulation –Sleep Hygiene –Melatonin PT, Acupuncture, Trigger point injections Possible need for neuropsychological evaluation (pre-existing disability?) Medications are considered* : *Note: using meds for concussion management is “off label”

9. Overview Read the existing literature Establish treatment algorithm Get out into the community –Deliver lectures –Build referral relationships Referral base PT / Vestibular therapists, Psych, Pain Management, Neuropsych, Neurosurgery. Acupuncture

10. Overview Read the existing literature Establish treatment algorithm Get out into the community Availability –New appointments <1-2 weeks –Computerized testing –Evening and weekend appointments

11. Billing Prepare for longer appointments E and M Coding based on time –Where more than 50% of the appt is spent on face to face counseling Neurocognitive testing –Cost and reimbursement

12. Computerized Neurocognitive Testing: Buying in bulk decreases cost per test –($10-20 for al a carte testing, as low as $1.50 -$3 in bulk) Some suggest using the appropriated E&M code with a -25 modifier and use CPT 96120. Non-neuropsychologists are typically not being reimbursed in Massachusetts, but varies by state Be aware that bills may be passed onto patients, and trend of higher deductibles will lend to higher out of pocket expenses for the patient

13. Getting the Word Out Background knowledge Care plans Neurocognitive testing Athletic Trainers/Athletic Directors Volunteering

14. Getting the Word Out Potential referring providers Parent/school groups Media Advertising

15. 9 Hope Ave, Waltham319 Longwood Ave, Boston Michael J. O’Brien, M.D. Injury Prevention TheMicheliCenter.com (781) 373-2760 Sports Concussion Clinic (781) 216-1328 Sports Medicine Appointment Line (617) 355-3501 Sports.medicine@Childrens.Harvard.edu Michael J. O’Brien, M.D. William P. Meehan III, MD

16. References and Further Reading Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport. McCrory P, Meeuwisse W, Johnston K, et al. J Athl Train 2009;44(4):434-48 Assessment and Management of Sport-Related Concussions in United States High Schools. Meehan WP, dHemecourt P, et al. AJSM Vol 39. Number 11. 2011. The Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Brown, N, Mannix, R, O”Brien, MJ, et al. Pediatrics. Vol 133. Number 2. Feb 2014 Returning to Learning. Halstead M, McAvoy M, et al. Pediatrics Vol 132. Number 5. Nov 2013. Benefits of Strict Rest After Acute Concussion: a randomized control trial. Brown, NJ et al. Pediatrics 2015 CHOA Concussion Consensus: establishing a uniform policy for academic accommodations. Popoli DM, Burns TG, Meehan WP 3rd, Reisner A. Clin Pediatr (Phila). 2014 Mar;53(3):217-24 Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion. McGrath, N. J Athl Train. 2010 Sep-Oct; 45(5): 492–498. Medical therapies for Concussion. Meehan WP. Clin Sports Med 30 (2011) 115–124 Kids, Sports, and Concussion: A guide for coaches and parents. Meehan WP III. Praeger Publishers 2011 Traumatic Brain Injury Center from CDC.gov and Headsmart™ from SouthShoreHospital.org