Ohio Chapter Chiropractors, Concussions, and Return to Play: Myth s and Facts

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Harold Boyd
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1 Ohio Chapter Chiropractors, Concussions, and Return to Play: Myth s and Facts Last month the Ohio House of Representatives added language to House Bill 59, the State Operating Budget, to allow chiropractors to clear youth athletes to return to practice or play following a concussion. This amendment was in direct opposition to House Bill 143, which passed the General Assembly with near unanimous last year. It dangerously expands the scope of practice for chiropractors, is in conflict with established standards of care for concussion management, and puts youth athletes at risk. MYTH: Concussion Management is within the chiropractic scope of practice FACT: A review of chapter 4734 of the revised code and applicable administrative rules pertaining to the scope of practice for chiropractors finds no references to concussions and other traumatic brain injuries. In fact, a simple keyword search of terms like brain, concussion, neurology, and neurologic returns no results. ORC defines the chiropractic scope of practice as the following: As used in this chapter, the "practice of chiropractic" means utilization of the relationship between the musculo-skeletal structures of the body, the spinal column, and the nervous system in the restoration and maintenance of health, in connection with which patient care is conducted with due regard for first aid, hygienic, nutritional, and rehabilitative procedures and the specific vertebral adjustment and manipulation of the articulations and adjacent tissues of the body. 1 It is clear from ORC that chiropractors have never had the authority in their scope of practice to treat concussions and other neurologic injuries. Additionally, the American Chiropractic Association offers the following definition of chiropractic: Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches. 2 Chiropractors have never been authorized in the revised code to evaluate and clear athletes who have a concussion. Chiropractors are an important part of the healthcare system, but they must consult with a physician before clearing a youth athlete it is the medically appropriate course of action. MYTH: Prior to House Bill 143, chiropractors could clear youth athletes to return to play FACT: As referenced above, there is simply no section of the Ohio Revised Code or the Ohio Administrative Code that ever authorized chiropractors to clear athletes to return to the field of play. When organizations like the Ohio High School Athletic Association adopted their own concussion management programs, they required chiropractors to consult or collaborate with a physician since they have the necessary education and expertise to clear an athlete following a concussion. National standards adopted by the American Academy of Neurology and endorsed by the NFL and other leading organizations recommend that the return to play process by managed by health care providers who are both knowledgeable about sports concussion and practicing within the scope of their training and experience. 3 Chiropractors simply do not meet this standard. 1 ORC Evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology, May 2013

2 MYTH: Many professional and youth sports leagues allow chiropractors to clear athletes in their own concussion management programs FACT: Youth league and high school sports concussion management programs require non-physician clinicians to consult with a physician before clearing players to return following a concussion. In Ohio, the Ohio High School Athletic Association was the first entity to adopt a concussion management program for return to play, the OHSAA adopted the following requirement: Once a concussion has been diagnosed..only an MD, DO or LAT can authorize subsequent return to play, and such authorization shall be in writing to the administration of the school. 4 The OHSAA guidelines have been in place for 3 years and no problems have been reported. Allowing chiropractors to clear athletes undermines these programs and contradicts medical standards of care. MYTH: Chiropractors have the necessary education to evaluate and clear concussions FACT: Documentation from the Council on Chiropractic Education shows the core competencies that chiropractors should have the CCE is designated by the U.S. Department of Education as the accrediting body for any institution offering the doctor of chiropractic degree. CCE offers the following definition for clinical competencies related to chiropractors: The neuromusculoskeletal examination is the foundation of the chiropractic approach toward evaluating the patient. Doctors of chiropractic commonly provide care to patients with complaints or health problems associated with the spine and extremities. The spine and its relationship to nervous system function is also viewed as an important factor in the patient's general health. Because the traditional model of chiropractic care involves spinal adjustment, evaluating the spine and nervous system is a crucial component of the patient examination. 5 CCE accreditation standards published earlier this year require chiropractors to be proficient in neuromusculoskeletal evaluation, treatment, and management and to communicate effectively with patients, doctors of chiropractic, and other health care professionals, regulatory agencies, third party payers, and others as appropriate. 6 The written examination offered by the National Board of Chiropractic Examiners offers a comprehensive review of chiropractic medicine, with no testing on concussions, brain injuries, and neurology; below is a test summary from the NBCE 7 : Part I: Includes subject examinations in each of six basic science areas: general anatomy, spinal anatomy, physiology, chemistry, pathology, and microbiology. Each subject examination contains 110 standard multiple-choice questions and is allotted 90 minutes of testing time. Part II: Consists of 110 multiple-choice questions in each of six clinical science areas, including general diagnosis, neuromusculoskeletal diagnosis, diagnostic imaging, principles of chiropractic, chiropractic practice, and associated clinical sciences. Each Part II subject is allotted 90 minutes of testing time, with a 20-minute break between subjects. Part III: Addresses nine clinical areas: case history, physical examination, neuromusculoskeletal examination, diagnostic imaging, clinical laboratory and special studies, diagnosis or clinical impression, chiropractic techniques, supportive interventions, and case management. The Part III Examination consists of two books, with a total of 110 standard multiple-choice questions and 10 case vignettes. In the case of concussion management, it is not only appropriate, but medically necessary for chiropractors to consult a physician before authorizing a youth athlete to return to play. 4 OHSAA: Implementation of NFHS playing rules changes related to concussion and return to play protocol, CCE Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status, January CCE Accreditation Standards, January 2013 Principles, Processes & Requirements for Accreditation 7

3 MYTH: Chiropractors suffered an unintended consequence in House Bill 143 by having their ability to treat athletes with concussions limited FACT: Language in House Bill 143 required chiropractors and other non-physician practitioners to work in consultation with a physician, pursuant to the referral of a physician, in collaboration with a physician, or under the supervision of a physician when giving an athlete authorization to return to play. 8 As has been demonstrated above, this provision is in absolute agreement with current standards of care and the scope of education and expertise of MD s, DO s, chiropractors, athletic trainers, and other licensed healthcare providers. There was no unintended consequence. There is no prohibition against chiropractors being on the sidelines at a sporting event or being the first person on the scene when a player is injured. If a coach, referee, parent, chiropractor, or other healthcare provider notices signs of a concussion the player is removed from the field of play and cannot return. There is no requirement that a physician be present during practice or a game as the youth athlete cannot return for at least 24 hours, and only after being cleared by a physician or other healthcare professional working with a physician. Chiropractors can coordinate care and be the primary point of contact throughout the return to play timeline. As was stated in testimony before the Senate Finance Medicaid Subcommittee, chiropractors can order CT scans and other diagnostic exams. All of this is in agreement with the chiropractic scope of practice and is unchanged as a result of House Bill 143. When it comes time to evaluate a player to see if they are ready to return to the field of play, a chiropractor must consult or work with a physician. This is in the best interest of the athlete and in alignment with national standards of care. MYTH: Not all patients and school districts have access to physicians, so House Bill 143 limits patient access to concussion treatment FACT: Concussions are not simple injuries; they are complex traumatic brain injuries that vary from athlete to athlete. Ohio s concussion law is meant to encourage safety and ensure these types of injuries are evaluated by healthcare experts trained in concussions and other neurologic injuries. Chiropractors are not primary care providers; they do not perform basic primary care services such as vaccinations and physicals. If a player where to receive a cut or laceration during a game or practice, a chiropractor is not able to suture the cut and treat this simple injury it puts youth athletes at serious risk to allow chiropractors to treat concussions and other traumatic brain injuries without consulting a physician. The OHSAA concussion program has been in place for nearly 3 years, and no access problems have been reported. Most children have a family physician or pediatrician, or live in close proximity to one of Ohio s excellent children s hospitals. With so much emphasis on coordinated care models such as the patient centered medical home, it is a major step in the wrong direction to expand the chiropractic scope of practice instead of encouraging coordinated and patient-centered treatment for youth with concussions. With advances in telehealth and increased support for rural communities, there is no credible reason to think a chiropractor treating a youth athlete cannot consult or work with a physician. Allowing chiropractors to clear youth athletes after a concussion puts those youth at risk. It is an unwise and dangerous expansion of the chiropractic scope of practice. Appropriate concussion management requires coordinated care and the expertise of physicians and non-physicians alike. House Bill 143 was a major step forward in protecting children and ensuring that concussions are properly diagnosed and treated we should resist expanding the chiropractic scope of practice and continue to encourage patient-centered care. 8 ORC (E)(2) and ORC (E)(2)

4 Cleveland Plain Dealer Ohio's new concussion law for youth sports is fine for now: editorial June 10, 2013 Last year, the Ohio General Assembly passed a law designed to protect young athletes from the perils of undiagnosed or mishandled concussions. The law requires that any youngster who displays symptoms consistent with a concussion -- dizziness, memory loss, disorientation, temporary loss of consciousness, nausea, etc. -- be examined by a physician before being allowed to return to competition or practice. For purposes of the law, "physician" is defined as a medical doctor or a doctor of osteopathy. Last week, the Ohio Senate passed -- in the proposed state budget, where such a provision clearly has no place -- a measure that would amend last year's law so that chiropractors would be included among the people empowered to make return-to-play decisions. The provision was shoe-horned into the budget in April on an amendment by State Rep. John Adams, a Republican from southwest Ohio, and was in the budget bill the House passed last month. The Ohio State Chiropractic Association notes that chiropractic training includes 149 hours of study in neurology. That's certainly more neurological training than the vast majority of coaches or referees have undergone, so it's possible that the chiropractors have a valid point. Still, two red flags arise. First, the proposal deserves debate and a vote as a stand-alone measure. It is simply not a budgetary matter. Second, and far more important, the intent of Ohio's new law is not merely to make sure that coaches, officials, athletes and their parents have at least a rudimentary knowledge of the symptoms and effects of concussion -- although that is a plus. The law, by design, makes it harder for a player who has suffered a concussion to get back into a game or practice, where the injury might be aggravated. If there's not a physician around when the questionable situation arises, the athlete is off the field until such time as a physician can examine him or her. That is a prudent reaction that recognizes that a young athlete's future is infinitely more important than today's game. There's no sense rushing an injured youngster back into a game. Just as there's no sense rushing through this change in Ohio law. The conference committee that resolves differences between the Senate and House versions of the budget should strip it out.

5 Akron Beacon Journal Editorial: Physicians only May 23, 2013 State lawmakers, the medical community and other stakeholders devoted much time and energy to crafting legislation involving the handling of concussions suffered by young people in school sports. The new law took effect a month ago. Yet already chiropractors are seeking to make a change, and they have been aided by a provision added to the House version of the state budget. A key element of the new law defines the procedure for allowing an athlete recovering from a concussion to return to play. It permits non-physician licensed health-care providers to give approval if they have been working closely in consultation with or under the supervision of a physician. Do chiropractors belong in the category of supervising physician, essentially with the authority to give the go-ahead to a young athlete? In a recent letter to Scott Oelslager, the chairman of the Senate Finance Committee, six leading health-care organizations answered with an emphatic no. They are the Ohio State Medical Association, the Ohio Children s Hospital Association, the Ohio Hospital Association, the Ohio chapter of the American Academy of Pediatrics, the Ohio Athletic Trainers Association and the Ohio Osteopathic Association. They stressed that all of this had been discussed at length and resolved, chiropractors without the authority of physicians because they don t have the same rigorous training and depth of expertise. That careful decision-making shouldn t be mischievously overturned. The Senate should remove the House provision from the budget.

(A) results from that individual's participation in or training for sports, fitness training, or other athletic competition; or

(A) results from that individual's participation in or training for sports, fitness training, or other athletic competition; or VT AT Act 12/04 Title 26: Professions and Occupations Chapter 83: ATHLETIC TRAINERS 4151. Definitions As used in this chapter: (1) "Athlete" means any individual participating in fitness training and conditioning,