ACE Care Plan - Returning to Work

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ACE Care Plan - Returning to Work
Acute Concussion Evaluation (ACE)
Patient Name:
DOB: Age:
Date of Injury:
Care Plan
Gerard Gioia, PhD1 & Micky Collins, PhD2
Children’s National Medical Center
University of Pittsburgh Medical Center
You have been diagnosed with a concussion (also known as a mild traumatic brain injury). This personal plan is based on
your symptoms and is designed to help speed your recovery. Your careful attention to it can also prevent further injury.
Rest is the key. You should not participate in any high risk activities (e.g., sports, physical education (PE), riding a bike,
etc.) if you still have any of the symptoms below. It is important to limit activities that require a lot of thinking or concentration (homework, job-related activities), as this can also make your symptoms worse. If you no longer have any symptoms
and believe that your concentration and thinking are back to normal, you can slowly and carefully return to your daily activities. Children and teenagers will need help from their parents, teachers, coaches, or athletic trainers to help monitor their
recovery and return to activities.
Today the following symptoms are present (circle or check).
____No reported symptoms
Sensitivity to light
Feeling mentally foggy
Sensitivity to noise
Problems concentrating
Sleeping more than usual
Problems remembering
Feeling more emotional
Sleeping less than usual
Visual problems
Feeling more slowed down
Trouble falling asleep
Balance Problems
RED FLAGS: Call your doctor or go to your emergency department if you suddenly experience any of the following
Headaches that worsen
Look very drowsy, can’t be awakened
Can’t recognize people or places
Unusual behavior change
Repeated vomiting
Increasing confusion
Increasing irritability
Neck pain
Slurred speech
Weakness or numbness in arms or legs
Loss of consciousness
Returning to Daily Activities
1. Get lots of rest. Be sure to get enough sleep at night- no late nights. Keep the same bedtime weekdays and weekends.
2.Take daytime naps or rest breaks when you feel tired or fatigued.
3.Limit physical activity as well as activities that require a lot of thinking or concentration. These activities can
make symptoms worse.
• Physical activity includes PE, sports practices, weight-training, running, exercising, heavy lifting, etc.
• Thinking and concentration activities (e.g., homework, classwork load, job-related activity).
4.Drink lots of fluids and eat carbohydrates or protein to main appropriate blood sugar levels.
5.As symptoms decrease, you may begin to gradually return to your daily activities. If symptoms worsen or
return, lessen your activities, then try again to increase your activities gradually.
6.During recovery, it is normal to feel frustrated and sad when you do not feel right and you can’t be as active as usual.
7. Repeated evaluation of your symptoms is recommended to help guide recovery.
Returning to Work
1. Planning to return to work should be based upon careful attention to symptoms and under the supervision of an
appropriate health care professional.
2.Limiting the amount of work you do soon after your injury, may help speed your recovery. It is very important to get a lot
of rest. You should also reduce your physical activity as well as activities that require a lot of thinking or concentration.
___Do not return to work. Return on (date).
___Return to work with the following supports. Review on (date).
Schedule Considerations
___Shortened work day _____ hours
___Allow for breaks when symptoms worsen
___Reduced task assignments and responsibilities
Safety Considerations
___No driving
___No heavy lifting or working with machinery
___No heights due to possible dizziness, balance problems
This form is part of the “Heads Up: Brain Injury in Your Practice” tool kit developed by the Centers for Disease Control and Prevention (CDC).
Returning to Sports
1.You should NEVER return to play if you still have ANY symptoms – (Be sure that you do not have any symptoms
at rest and while doing any physical activity and/or activities that require a lot of thinking or concentration.)
2.Be sure that the PE teacher, coach, and/or athletic trainer are aware of your injury and symptoms.
3.It is normal to feel frustrated, sad and even angry because you cannot return to sports right away. With any injury, a full
recovery will reduce the chances of getting hurt again. It is better to miss one or two games than the whole season.
The following are recommended at the present time:
___ Do not return to PE class at this time ___ Return to PE class
___ Do not return to sports practices/games at this time
___ Gradual return to sports practices under the supervision of an appropriate health care provider.
• Return to play should occur in gradual steps beginning with aerobic exercise only to increase your heart rate (e.g., stationary cycle); moving to increasing your heart rate with movement (e.g., running); then adding controlled contact if appropriate; and finally return to sports competition.
• Pay careful attention to your symptoms and your thinking and concentration skills at each stage of activity. Move to the next level of activity only if you do not experience any symptoms at the each level. If your symptoms return, stop these activities and let your health care professional know. Once you have not experienced symptoms for a minimum of 24 hours and you receive permission from your health care professional, you should start again at the previous step of the return to play plan.
Gradual Return to Play Plan
1. No physical activity
2.Low levels of physical activity (i.e., symptoms do not come back during or after the activity). This includes walking, light
jogging, light stationary biking, light weightlifting (lower weight, higher reps, no bench, no squat).
3.Moderate levels of physical activity with body/head movement. This includes moderate jogging, brief running,
moderate-intensity stationary biking, moderate-intensity weightlifting (reduced time and/or reduced weight from
your typical routine).
4.Heavy non-contact physical activity. This includes sprinting/running, high-intensity stationary biking, regular weightlifting
routine, non-contact sport-specific drills (in 3 planes of movement).
5.Full contact in controlled practice.
6.Full contact in game play.
*Neuropsychological testing can provide valuable information to assist physicians with treatment planning, such as return to play decisions.
This referral plan is based on today’s evaluation:
___ Return to this office. Date/Time
___ Refer to: Neurosurgery____ Neurology____ Sports Medicine____ Physiatrist____ Psychiatrist____ Other____
___ Refer for neuropsychological testing
___ Other
ACE Care Plan Completed by:_____________________________ MD RN NP PhD ATC
© Copyright G. Gioia & M. Collins, 2006
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