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ACUTE CONCUSSION EVALUATION (ACE)

PatientName:
CARE PLAN
DOB: Age:
GerardGioia,PhD
1
&MickyCollins,PhD
2
1
ChildrensNationalMedicalCenter
Date: ID/MR#
2
UniversityofPittsburghMedicalCenter
DateofInjury:
Youhavebeendiagnosedwithaconcussion(alsoknownasamildtraumaticbraininjury).Thispersonalplanisbasedon
yoursymptomsandisdesignedtohelpspeedyourrecovery.Yourcarefulattentiontoitcanalsopreventfurtherinjury.
Restisthekey.Youshouldnotparticipateinanyhighriskactivities(e.g.,sports,physicaleducation(PE),ridingabike,
etc.)ifyoustillhaveanyofthesymptomsbelow.Itisimportanttolimitactivitiesthatrequirealotofthinkingorconcentra-
tion(homework,job-relatedactivities),asthiscanalsomakeyoursymptomsworse.Ifyounolongerhaveanysymptoms
andbelievethatyourconcentrationandthinkingarebacktonormal,youcanslowlyandcarefullyreturntoyourdaily
activities.Childrenandteenagerswillneedhelpfromtheirparents,teachers,coaches,orathletictrainerstohelpmonitor
theirrecoveryandreturntoactivities.
Todaythefollowingsymptomsarepresent(circleorcheck). ____Noreportedsymptoms
Physical Thinking Emotional Sleep
Headaches Sensitivitytolight Feelingmentallyfoggy Irritability Drowsiness
Nausea Sensitivitytonoise Problemsconcentrating Sadness Sleepingmorethanusual
Fatigue Numbness/Tingling Problemsremembering Feelingmoreemotional Sleepinglessthanusual
Visualproblems Vomiting Feelingmoresloweddown Nervousness Troublefallingasleep
BalanceProblems Dizziness
REDFLAGS:Callyourdoctororgotoyouremergencydepartmentifyousuddenlyexperienceanyofthefollowing
Headachesthatworsen Lookverydrowsy,cantbeawakened Cantrecognizepeopleorplaces Unusualbehaviorchange
Seizures Repeatedvomiting Increasingconfusion Increasingirritability
Neckpain Slurredspeech Weaknessornumbnessinarmsorlegs Lossofconsciousness
ReturningtoDailyActivities
1.Getlotsofrest.Besuretogetenoughsleepatnight- nolatenights.Keepthesamebedtimeweekdaysandweekends.
2.Takedaytimenapsorrestbreakswhenyoufeeltiredorfatigued.
3.Limitphysicalactivityaswellasactivitiesthatrequirealotofthinkingorconcentration.Theseactivitiescan
makesymptomsworse.
PhysicalactivityincludesPE,sportspractices,weight-training,running,exercising,heavylifting,etc.
Thinkingandconcentrationactivities(e.g.,homework,classworkload,job-relatedactivity).
4.Drinklotsofuidsandeatcarbohydratesorproteintomainappropriatebloodsugarlevels.
5.Assymptomsdecrease,youmaybegintograduallyreturntoyourdailyactivities.Ifsymptomsworsenor
return,lessenyouractivities,thentryagaintoincreaseyouractivitiesgradually.
6.Duringrecovery,itisnormaltofeelfrustratedandsadwhenyoudonotfeelrightandyoucantbeasactiveasusual.
7.Repeatedevaluationofyoursymptomsisrecommendedtohelpguiderecovery.
ReturningtoSchool
1.Ifyou(oryourchild)arestillhavingsymptomsofconcussionyoumayneedextrahelptoperformschool-relatedactivities.
Asyour(oryourchilds)symptomsdecreaseduringrecovery,theextrahelporsupportscanberemovedgradually.
2.Informtheteacher(s),schoolnurse,schoolpsychologistorcounselor,andadministrator(s)aboutyour(oryour
childs)injuryandsymptoms.Schoolpersonnelshouldbeinstructedtowatchfor:
Increasedproblemspayingattentionorconcentrating
Increasedproblemsrememberingorlearningnewinformation
Longertimeneededtocompletetasksorassignments
Greaterirritability,lessabletocopewithstress
Symptomsworsen(e.g.,headache,tiredness)whendoingschoolwork
~Continuedonbackpage~
ThisformispartoftheHeadsUp:BrainInjuryinYourPracticetoolkitdevelopedbytheCentersforDiseaseControlandPrevention(CDC).
ReturningtoSchool(Continued)
Untilyou(oryourchild)havefullyrecovered,thefollowingsupportsarerecommended:(checkallthatapply)
__Noreturntoschool.Returnon(date)
__Returntoschoolwithfollowingsupports.Reviewon(date)
__Shortenedday.Recommend___hoursperdayuntil(date)
__Shortenedclasses(i.e.,restbreaksduringclasses).Maximumclasslength: _____minutes.
__Allowextratimetocompletecoursework/assignmentsandtests.
__Lessenhomeworkloadby________%.Maximumlengthofnightlyhomework:______minutes.
__Nosignicantclassroomorstandardizedtestingatthistime.
__Checkforthereturnofsymptoms(usesymptomtableonfrontpageofthisform)whendoingactivitiesthatrequirea
lotofattentionorconcentration.
__Takerestbreaksduringthedayasneeded.
__Requestmeetingof504orSchoolManagementTeamtodiscussthisplanandneededsupports.
ReturningtoSports
1.YoushouldNEVERreturntoplayifyoustillhaveANYsymptoms(Besurethatyoudonothaveanysymptoms
atrestandwhiledoinganyphysicalactivityand/oractivitiesthatrequirealotofthinkingorconcentration.)
2.BesurethatthePEteacher,coach,and/orathletictrainerareawareofyourinjuryandsymptoms.
3.Itisnormaltofeelfrustrated,sadandevenangrybecauseyoucannotreturntosportsrightaway.Withanyinjury,afull
recoverywillreducethechancesofgettinghurtagain.Itisbettertomissoneortwogamesthanthewholeseason.
Thefollowingarerecommendedatthepresenttime:
___DonotreturntoPEclassatthistime
___ReturntoPEclass
___Donotreturntosportspractices/gamesatthistime
___Gradualreturntosportspracticesunderthesupervisionofanappropriatehealthcareprovider(e.g.,athletictrainer,
coach,orphysicaleducationteacher).
Returntoplayshouldoccuringradualstepsbeginningwithaerobicexerciseonlytoincreaseyourheartrate
(e.g.,stationarycycle);movingtoincreasingyourheartratewithmovement(e.g.,running);thenaddingcontrolled
contactifappropriate;andnallyreturntosportscompetition.
Paycarefulattentiontoyoursymptomsandyourthinkingandconcentrationskillsateachstageofactivity.Move
tothenextlevelofactivityonlyifyoudonotexperienceanysymptomsattheeachlevel.Ifyoursymptomsreturn,
letyourhealthcareproviderknow,returntotherstlevel,andrestarttheprogramgradually.
GradualReturntoPlayPlan
1.Nophysicalactivity
2.Lowlevelsofphysicalactivity(i.e.,symptomsdonotcomebackduringoraftertheactivity).Thisincludeswalking,light
jogging,lightstationarybiking,lightweightlifting(lowerweight,higherreps,nobench,nosquat).
3.Moderatelevelsofphysicalactivitywithbody/headmovement.Thisincludesmoderatejogging,briefrunning,moderate-
intensitystationarybiking,moderate-intensityweightlifting(reducedtimeand/orreducedweightfromyourtypicalroutine).
4.Heavynon-contactphysicalactivity.Thisincludessprinting/running,high-intensitystationarybiking,regularweightlift-
ingroutine,non-contactsport-specicdrills(in3planesofmovement).
5.Fullcontactincontrolledpractice.
6.Fullcontactingameplay.
*Neuropsychologicaltestingcanprovidevaluableinformationtoassistphysicianswithtreatmentplanning,suchasreturntoplaydecisions.
Thisreferralplanisbasedontodaysevaluation:
___Returntothisofce.Date/Time
___Referto:Neurosurgery____Neurology____SportsMedicine____Physiatrist____Psychiatrist____Other____
___Referforneuropsychologicaltesting
___Other
ACECarePlanCompletedby:_____________________________
CopyrightG.Gioia&M.Collins,2006