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 4734.01 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 4734.01 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 4734.01 2 http://www.acatoday.org/level1_css.cfm?T1ID=42 3 Evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology, May 2013 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 NBCE7: 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, 2011 5 CCE Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status, January 2007 6 CCE Accreditation Standards, January 2013 Principles, Processes & Requirements for Accreditation 7 https://www.nbce.org/written/overview.html 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