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Concussion Management and Treatment Considerations
in the Adolescent Population
Rosanna C. Sabini, DO; Cara Camiolo Reddy, MD
Abstract: Over the past decade, significant advances have been made in understanding concussions. Information regarding proper
identification, pathophysiology, risks, outcomes, and management protocols has shifted the treatment paradigm from a generalized
grading system to an individualized approach. Early identification and timely management of a concussion is necessary to ensure
that patients minimize persistent post-concussive symptoms affecting the physical, behavioral, emotional, and cognitive domains.
Adolescents are particularly vulnerable to concussions, having greater susceptibility and more prolonged recovery after sustaining an
injury. This article aims to inform clinicians on how to improve symptom relief and functional outcomes for adolescent patients with
concussion via immediate intervention, neuropsychological management, and pharmacological treatment.
Keywords: concussion; adolescents; sports; diagnosis; management; traumatic brain injury
Rosanna C. Sabini, DO 1
Cara Camiolo Reddy, MD 1
1
University of Pittsburgh Medical
Center, Pittsburgh, PA
Introduction
Each year, 40 million children and adolescents participate in some form of organized sport.1 Although
estimates suggest 3.8 million sport- or recreation-related head injuries occur in the United States every
year,2 inconsistent data reporting, misdiagnosis, or patient’s failure to seek treatment likely lead to a gross
underestimation of the exact incidence of concussion. The concussion rate in high school and collegiate
football players is estimated to be responsible for 4% to 11% of all injuries.3–7 However, researchers
have shown that only 20% of these players were aware of having sustained a concussion,8 and only 35%
were aware of the need to seek immediate treatment.9 Moreover, McCrea et al9 determined that of the
15% of football players who sustained a concussion, less than one-half reported their injury.9 The most
common reasons for concussions being under-reported were players believing that the injury was not
serious enough to warrant medical attention, the injury would prevent them from playing, or because
they were unaware of having sustained an injury.9
Over the last decade, research investigating the pathophysiology, risk factors, and outcomes of
concussion has led to improvements in evaluation and treatment. This improved awareness, also spurred
by increased media attention, has helped shed light on the devastating consequences of concussions
in athletes, particularly adolescents. Early identification of the injury can help minimize the severity
of long-term physical, behavioral, emotional, and cognitive sequelae. Furthermore, evidence suggests
that adolescent athletes are a unique population that warrants a more conservative treatment than their
adult counterparts.10
Definition of Concussion
Correspondence:
Rosanna C. Sabini, DO,
University of Pittsburgh Medical Center,
1400 Locust Street, Suite 7203,
Pittsburgh, PA 15219.
E-mail: [email protected]
Various academic organizations, committees, and researchers have published different and often
conflicting definitions of concussion over the past decades. Inconsistencies in these definitions may have
possibly contributed to historically inadequate “on-the-field” identification, treatment, and return-toplay (RTP) guidelines. The International Conference on Concussion in Sport convened for the first time
in 2001 to review concussion standard of care. The panel’s most recent Consensus Statement published
in 2008 defines concussion as:
. . .a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.10
Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that
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Rosanna C. Sabini and Cara Camiolo Reddy
may be utilized in defining the nature of a concussive head
injury include:
1. Concussion may be caused by a direct blow to the head,
face, neck, or elsewhere on the body with an ‘‘impulsive’’
force transmitted to the head.
2. Concussion typically results in the rapid onset of shortlived impairment of neurologic function that resolves
spontaneously.
3. Concussion may result in neuropathologic changes, but
the acute clinical symptoms largely reflect a functional
disturbance rather than a structural injury.
4. Concussion results in a graded set of clinical symptoms
that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically
follows a sequential course; however, it is important to
note that in a small percentage of cases, post-concussive
symptoms may be prolonged.
5. No abnormality on standard structural neuroimaging
studies is seen in concussion.10
With this concussion definition, clinicians will be better
able to more accurately detect, diagnose, and treat a concussion
appropriately.
Pathophysiology
In response to a concussive injury, a biochemical cascade
triggers a dysregulation of ions and neurotransmitters,
which increases inflammatory mediators and free radicals.11
Excitatory neurotransmitters (ie, glutamate) cause an efflux
of potassium and an influx of calcium, leading to abrupt
changes in cerebral cellular physiology. In response, the
sodium-potassium pump attempts restoration of the membrane
potential, increasing the metabolic demand by utilization of
adenosine triphosphate. Simultaneously, a decrease in cerebral
blood flow ultimately leads to a metabolic mismatch of increased
energy use in the presence of decrease energy stores. With physical
exercise, higher energy demands are placed on the body secondary to increased glucose uptake and cortisol levels, placing further
stress on the metabolic mismatch already present.12 These effects
have been noted to last for up to 2 weeks in animal models, and
possibly longer in humans.11 It is hypothesized that until the metabolic dysfunction resolves, the brain is at risk for further damage.
The consequences of RTP before full recovery from a concussion
can be catastrophic, particularly in children and adolescents.13,14
140
Clinical studies have demonstrated that younger athletes
exhibit delayed recovery15,16 and decreased neurocognitive
performance.17 An immature brain is particularly at a greater
risk of injury secondary to having an underdeveloped skull,
larger head-to-body proportion, or weaker neck muscles that
can predispose the brain to increased force transmission.18
In addition, a child responds differently pathophysiologically
after a concussion.19 Notably, there is more prolonged and
diffuse cerebral swelling.20 As a result, young athletes should
spend a longer time in the resting stage compared with older
athletes.10 Because immature brains are potentially 60 times
more sensitive to the effects of glutamate, this energy crisis
may be linked to the devastating phenomena known as secondimpact syndrome.11 Although rare, and primarily seen in the
adolescent population, second-impact syndrome occurs when
an athlete sustains a second concussion before complete
resolution of the initial head injury.9 Neurological function
can rapidly deteriorate, leading to severe disability or death.
It should be noted that the second injury may require less force
because the concussed brain may be more vulnerable to injury
and therefore have a lower threshold for sustaining impact.13
Evaluation
Accurate on-field identification of a concussion requires proper
education of athletic trainers, coaches, parents, and athletes to
ensure that common acute symptoms are readily recognized
(Table 1). An athlete experiencing any symptom listed should
be removed from play and frequently evaluated for change in
neurological status. Any athlete who displays significant or
progressively worsening symptoms should be immediately
transported to a hospital. Athletes who experience concussive
symptoms should never be returned to the field on the same
day, even if the symptoms have resolved. Concussion severity
should not be graded on the field, nor should standardized
grading scales be used.21,22 Rather, assessment of concussion
severity should be conducted based on the individual’s clinical
evaluation, post-concussive signs and symptoms, performance
on neuropsychological testing, and length of time in which
post-concussive symptoms last, as advocated by the International Conference on Concussion Sport.10,23
For on-field assessment of injury severity, there are several
easy-to-use screening tools, including the Standardized Assessment of Concussion (SAC) and the Sport Concussion Assessment Tool (SCAT).10 These tools more accurately identify
deficits in attention, concentration, short-term memory, and
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Concussion Management in Adolescents
Table 1. Possible Presenting Signs and Symptoms in Concussions
Table 2. Post-Concussion Symptom Scale42
Signs of Concussion
Symptoms of Concussion
Dizziness
0123456
Confusion
Headache
Headache
0123456
Confusion about plays in game
Nausea/vomiting
Nausea
0123456
Forgetting plays
Difficulty with balance
Vomiting
0123456
Retrograde amnesia (forgets
events prior to game)
Dizziness
Balance problems
0123456
Trouble falling asleep
0123456
Post-traumatic amnesia (forgets
events after head trauma)
Fatigue
Drowsiness
Sleeping more than usual
0123456
Drowsiness
0123456
Mumbling
Sensitivity to light or noise
Sensitivity to light
0123456
Drowsiness
Visual difficulties (double or
blurriness of vision)
Sensitivity to noise
0123456
More emotional than usual
0123456
Irritability
0123456
0123456
Blank stares
Disturbances of vision
(seeing stars)
Change in affect or mood
(personality change)
Disturbances of hearing
(ringing in the ears)
Sadness
Nervousness
0123456
Irritable or labile mood swings
Irritability/nervousness
Numbness or tingling
0123456
Exaggerated emotions
Sadness/emotional
Feeling slowed down
0123456
Seizures
Feeling “slowed down”
Feeling “in a fog”
0123456
Poor performance on field
Feeling mentally foggy
Difficulty concentrating
0123456
Unsteady gait
Difficulty concentrating
Difficulty remembering
0123456
Poor coordination
Difficulty remembering
Slow speech
Numbness or tingling
amnesia than standard orientation questions such as person,
place, and time.24,25
It is important to note that an athlete may sustain a concussion without having a direct injury to the head or experiencing loss of consciousness. In fact, ⬍ 10% experience loss
of consciousness26,27 and most loss of consciousness episodes
last ⬍ 60 seconds.27 Although loss of consciousness is a predictor
of outcome in moderate and severe traumatic brain injuries, it
is neither a measure of severity nor a predictor of outcome in
concussive injuries.28–30 On the other hand, on-field presence of
amnesia (either anterograde or retrograde), for even seconds,
has been correlated with worse neurocognitive deficits29,30 and
higher number and prolonged duration of post-concussive
symptoms.29 Anterograde amnesia is a loss of memory of events
occurring after a head trauma that persists until the athlete
can retain ongoing memories. Questions to test this include
recalling recent plays or conversations and should be repeated
at multiple time intervals (time: 0, 5, 15, and 30 minutes, and
every hour thereafter). Conversely, retrograde amnesia is failing
to remember events occurring prior to the head injury. Questions to ask include: What was the score before the hit? Do
Severity graded from (0 = none; 1–2 = mild; 3–5 = moderate; 6 = severe).
you remember the hit? What was the last play you remember?
Retrograde amnesia may also contribute to future neurocognitive deficits; however, if not carefully assessed at specific time
points, it can be a poor reflection of injury severity.31
With any suspected head injury, an athlete should be
reevaluated by a physician knowledgeable in the treatment of
concussions. The initial medical evaluation should involve a
comprehensive medical history, including a thorough examination of the neurological, cognitive, and vestibular systems.
Use of the Post-Concussion Symptoms (PCS) Scale (Table 2) is
helpful for tracking symptoms throughout the recovery period
and can be a valuable asset for determining symptom severity.
Questions regarding prior concussive injury, especially
if the athlete has participated in contact sports or has had a
history of trauma to the face or neck, should be asked in an
initial or preparticipation sport evaluation. Athletes with a
history of concussion have been found to be at an increased
risk of sustaining additional concussions,8,32 have more severe
on-field markers,33 and perform worse on neuropsychological testing when compared with athletes with no history of
concussion.34 Particular attention should be given to athletes
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Rosanna C. Sabini and Cara Camiolo Reddy
who sustain multiple concussions, especially athletes participating in soccer, football, and boxing.35–37 There is mounting evidence suggesting that a history of prior concussion may also be
related to prolonged recovery,32,38,39 and the cumulative effects
of concussive injuries may increase the risk of depression,
memory difficulties, and earlier onset of Alzheimer’s disease.35
A clinician must keep in mind that sex differences have
also been observed in high school athletes. Female athletes
have been found to have a higher incidence of concussion
than their male counterparts,4 which may be because of differences in head-neck dynamic stabilization, predisposing
females to more injury.40 In addition, females are also more
likely to report more symptoms during baseline screenings41
and after a concussion.34,42 Neuropsychological testing has
also found that females tend to score higher in verbal memory
and lower in visual memory than males.41 There is a need for
further investigation into sex differences, particularly when
considering how female sport participation has continued to
increase in the past decade.
In the presence of acute neurologic deficits or prolonged or
exaggerated symptomatology after a medical history and physical examination, neuroimaging tests should be performed.
Computed tomography (CT) is routinely employed to rule
out severe injury, notably intracranial hemorrhage; however,
after concussive injury, CT and the more sensitive magnetic
resonance imaging (MRI) are typically negative for acute
intracranial pathology. Diffusion tensor or gradient imaging
may increase the sensitivity to detect structural abnormalities
in concussions, especially when there is diffuse axonal injury;
however, clinical utility has yet to be explored. Functional
MRI, which evaluates blood perfusion, has been able to detect
reduced task-related activation patterns that correlated with
severity of concussions.43 In addition, electroencephalograms
synchronized with cognitive tasks can provide information
regarding neuronal damage in the absence of clinical symptoms
and normal neuropsychological testing,44 while minimizing
influential factors such as downplaying symptoms to return
to a game or decreased motivation.45 Although these imaging
tools are promising, they are not part of the current treatment
standards for concussion management and should be considered on an individual basis.
Concussion is thought to be a functional rather than a
structural injury. To that end, neuropsychological testing
has emerged as the cornerstone of concussion evaluation
and management,10,21,23 further emphasizing the need for an
142
individualized approach to care. These neuropsychological
tests evaluate multiple cognitive domains, including visual
and verbal memory, processing speed, and reaction time.
Computerized neuropsychological testing is sensitive and
specific46 and can reveal neurocognitive deficits present despite
reported symptom resolution by the athlete.30 Multiple tests
are preferred to ensure adequate assessment of a patient’s
difficulties and should be interpreted by those who can
appropriately assess the data for any given age. The International
Conference on Concussion in Sport recognized the importance of neuropsychological testing in the assessment and
management of concussive injury, and recommended baseline
testing before participation in sports.10,21,23 Today, the most
commonly used computer-based neuropsychological testing
modules include Immediate Post-concussion Assessment and
Cognitive Testing (ImPACT), Automated Neurocognitive
Assessment Matrices (ANAM), Headminder Concussion
Resolution Index (CRI), and CogSport, all of which have
been validated for use in concussion evaluation. Compared
with traditional pencil-and-paper neuropsychological testing, computerized tests allow for easy administration to large
groups of athletes and provide a means to gather and store data
that can be used for future data collection and interpretation
while minimizing practice effects.47 Of note, cross-cultural
differences should be taken into consideration when interpreting
neuropsychological tests, and an individualized interpretation
is necessary for accurate assessment of the test results.48
Symptom Management and Treatment
Approximately 80% of high school athletes who sustain a
concussion recover within 3 weeks.49 The current mainstay
of treatment is physical and cognitive rest until symptoms
resolve, followed by a guided, gradual reexposure to exertion
prior to medical clearance for RTP.10 Physical and cognitive
rest includes abstaining from aerobic activity, scholastic work,
and computer or other electronic device usage. The demands
placed on an injured brain by these activities can exacerbate symptoms and prolong recovery. Studies with animal
models have found that physical exercise performed too soon
after a brain injury may result in a loss of neuroplasticity.50
However, if exercise was delayed by a few weeks, there were
increases in neurotrophins and an improvement in cognitive
performance.50 Such concepts have been demonstrated in
human models as well. A study of adolescent athletes found
that worsening post-concussion symptoms, visual memory,
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Concussion Management in Adolescents
and reaction times were related to overexertion.17 On the other
hand, adolescents with a protracted recovery who participated
in a gradual and closely supervised rehabilitation program
during the post-acute period were able to return to normal
lifestyle and sport participation.51
The remaining 20% with postconcussive symptoms lasting
longer than 3 weeks are considered to have a protracted recovery.
Such athletes were more likely to have a preexisting learning
disability,38 amnesia, and loss of consciousness associated with
their injury,32,33 or be younger in age.15 Post-concussive symptoms can be divided into 4 categories: somatic, cognitive, emotional, and sleep disturbances.47 Each category will be discussed
in detail, but it is important to recognize the inherent overlap
between these symptoms. For example, sleep disturbances
may cause irritability, headaches, or diminish cognitive speed;
however, these symptoms may result directly from the injury
itself. The overlap of post-concussive symptoms with other
pathologic processes, such as depression, post-traumatic stress,
and chronic pain have been the source of much debate, which
is beyond the scope of this article. In this article we consider
post-concussive symptoms as a direct result of a concussion.
The somatic category of symptoms includes headaches,
nausea, vomiting, dizziness, balance difficulty, light and sound
sensitivity, numbness, and tingling. Headaches are the most
commonly reported symptom following concussion, occurring in 70%38,42 to 86%27 of athletes. The presence of headaches
has been associated with amnesia, poor reaction time and
memory, and an increase in reported symptoms on the PCS
scale.38 Successful treatment depends on accurate diagnosis, as
post-traumatic headaches can have various etiologies (tension
or cluster-type, fatigue-related, migrainous, or rebound).
Cervicogenic headaches can also be present in the setting of
a whiplash injury. In addition, pre-morbid or family history of
headaches or migraines can further complicate management
and treatment.
Headaches may be precipitated by light or sound sensitivity,
crowded areas, or increased visual stimulation; therefore,
limiting exposure is the best treatment. Sunglasses or ear plugs
can also be useful to minimize exacerbating sensory inputs.
As part of a structured physical therapy program, cervicogenic
headaches should be addressed. Massage and other manual
therapies, such as craniosacral therapy, may also help with pain
relief and improved range of motion. The patient should particularly take an active role in performing daily neck exercises
and use modalities (heat, cold, etc.) to maintain mobilization
and decrease pain. A short course of over-the-counter or prescription anti-inflammatory medications may be warranted.
If contraindicated or ineffective, opiate medications can also be
considered, but should be used with caution because sedation
and impaired cognition may result.
Migraines, which are often associated with nausea,
vomiting, photophobia, and phonophobia, can be particularly
detrimental, as patients with coexisting concussions may have
more significant cognitive deficits and a prolonged recovery.52
Medications approved for the treatment of migraines, such
as triptans, can be considered. Tricyclic antidepressants and
β-blockers are frequently used for headache prophylaxis and
can be helpful for daily post-concussive headaches. When cognitive exertion causes or exacerbates a headache (often referred
to as cognitive-fatigue headaches), neurostimulants may be
considered to improve cognitive processing speeds and focus.
Dizziness and balance disorders are also common after
concussion and have been documented as high at 77% in
college athletes.32 Vestibular dysfunction can be evaluated by
testing ocular movements in all planes. Balance difficulties
can be tested by having the patient perform single, double,
and tandem stance, both on firm and foam surfaces, with eyes
opened and closed. The Balance Error Scoring System (BESS),
which uses these stances to provide objective information, is
easy to perform and is considered a valid assessment tool.53
Evidence of significant vertigo or balance dysfunction warrants
a referral to a trained vestibular therapist.
The cognitive category of post-concussive symptoms
includes “fogginess,” difficulty concentrating or remembering,
memory deficits, and cognitive fatigue. The term “foggy” is a
reported sensation used to describe feelings of slowness, being
out of touch with oneself, or a “head-in-a-fishbowl”-like experience. In high school athletes, complaints of fogginess have
been associated with a higher number of reported symptoms,
decreased memory, slower reaction times and processing
speeds, incomplete recovery, and worse outcomes.54 Such
symptoms can be associated with cognitive fatigue and headache, as noted previously. Neurostimulants such as methylphenidate, amantadine, and atomoxetine have shown to improve
cognitive deficits in patients after traumatic brain injuries and
warrant consideration in the treatment of these symptoms.55
Mood disturbance is the third subset of post-concussive
symptoms. Patients will often report irritability, anxiety, sadness, or
nervousness. Family or friends may describe a change in personality,
noting mood lability, short-temperedness, or aggression as an atypi-
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Rosanna C. Sabini and Cara Camiolo Reddy
cal response to even trivial circumstances. It should be noted that
slowed cognitive processing may be a potential cause of this trigger
and therefore addressing the ill effects of cognitive overstimulation
is important. If depression or anxiety is prolonged and begins to
interfere with a patient’s daily function, a psychiatric evaluation
should be considered. Selective serotonin reuptake inhibitors such
as citalopram, fluoxetine, and sertraline, or norepinephrine inhibitors such as venlafaxine can be used in the treatment of depression.
In the presence of mood lability, mood stabilization with valproic
acid or carbamazepine should be considered.
The final category of post-concussive symptoms consists
of sleep dysfunctions. Sleep dysfunction can have significant
consequences on one’s ability to concentrate, their behavior,
and their sense of well-being. Patients may complain of hypersomnia, usually seen early after injury, and/or insomnia. Sleep
assessment should include determining whether a patient has
difficulty falling or staying asleep. Initial treatment is aimed
at educating a patient on proper sleep hygiene. A strict sleep
schedule should be maintained by going to bed and waking up
at the same time every day. The patient should be instructed
to get out of bed if unable to sleep within 30 minutes. Napping during the day should also be restricted to ⱕ 30 minutes.
Eating, reading, or watching television while in bed should
be avoided. Caffeine should not be consumed in the late
afternoon, nor should exercise be performed in the evening,
because both can increase wakefulness. Intervention with
medication is warranted when sleep hygiene measures fail to
improve sleep duration. In these cases, melatonin, trazodone,
amitriptyline, nortriptyline, or ramelteon may be considered.
Benzodiazepines, antihistamines, and anticholinergic medications should be avoided because they have unwanted side
effects and can worsen cognitive function.
Pharmacological treatment for post-concussive symptoms should always be considered judiciously in the setting
of protracted symptoms, and length of treatment is based on
resolution of symptoms.10 Ideally, clinicians with expertise in
brain injury and neuropharmacology will work closely with
neuropsychologists in the evaluation and treatment phases of
injury, collaborating to determine safe RTP recommendations.
Return to Play
Return-to-play decision making is the most difficult and often
the most controversial aspect of concussion management. The
risk of prolonged symptoms with overexertion can lead to
significant morbidity, adversely affecting the athlete’s ability to participate in sports and have a detrimental effect
on schoolwork. Children between the ages of 5 and 18 years
are often considered a special population in concussion treatment and RTP decisions. However, all athletes must be treated
conservatively and should not be allowed to return to sport
participation on the same day after sustaining a concussion.10
Return to play has been historically guided by standardized grading scales. However, these scales have been criticized for assuming identical RTP criteria for all ages and do
not take into account the full spectrum of post-concussive
symptomatology. An individualized approach to concussion
management is now advocated as standard of care. As noted
previously, the Consensus Statement by the International
Table 3. Graduated Return-to-Play Protocol10
Rehabilitation Stage
Functional Exercise at Each Stage of Rehabilitation
Objective of Each Stage
1. No activity
– Complete physical examination and cognitive rest
Recovery
2. Light aerobic exercise
– Walking, swimming, or stationary cycling keeping
intensity ⬍ 70% of maximum permitted heart rate
– No resistance training
Increased heart rate
3. Sports-specific exercise
– Skating drills in ice hockey, running drills in soccer
– No head impact activities
Add movement
4. Noncontact training drills
– Progression to more complex training drills (eg, passing
drills in football or ice hockey)
– May start resistance training
Exercise, coordination,
and cognitive load
5. Full-contact practice
– Following medical clearance participate in normal
training activities
Restore confidence and assess
functional skills by coaching staff
6. Return to play
– Normal game play
Reproduced with permission from Br J Sports Med.10
144
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Concussion Management in Adolescents
Conference on Concussion in Sport also declared that RTP
should only be considered when post-concussive signs and
symptoms have resolved (both at rest and with full noncontact
exertion) and performance on neuropsychological testing has
returned to baseline.10
With resolution of symptoms and normalization of
neuropsychological testing, a rehabilitation protocol for a
graduated RTP protocol should be implemented (Table 3). If
an athlete has no symptoms within a 24-hour period in one
stage, they may advance to the next stage. However, if postconcussive symptoms do occur at any stage, the athlete is to
return to the previous asymptomatic level of activity and be
reassessed after 24 hours.10 When the athlete has progressed
through these stages and remains asymptomatic, RTP may be
recommended.
Prevention
Education is the best form of concussion prevention and
management. Schools should take advantage of internet-based
and multimedia resources to teach students, faculty, coaches,
medical personnel, and parents about concussion prevention
and identification. In addition, rules that help minimize
aggressiveness and prevent head injuries should be enforced.
The adolescent population is known for having risk-taking
behaviors and should be educated on use of appropriate protective gear for sports, bikes, and skateboards. Although mouth
guards and helmets can reduce the incidence of external injuries such as a skull fracture and oral and facial injuries, there is
no definitive evidence that wearing protective equipment will
prevent a concussion. This is possibly because of the acceleration/deceleration and rotational forces that the brain experiences during a head injury. The limitations of this equipment
should also be well known to the athlete because protective
equipment has been theorized to increase the rate of injuries
as athletes adopt more risk-taking behaviors.56
Conclusion
Effective management and treatment of concussion in adolescents is best accomplished when a team approach is implemented. Clinicians should maintain open communication
between the athlete, the athlete’s parents, coaches, and teachers
regarding physical, behavioral, emotional, and cognitive effects
of the injury. The individualized treatment approach, based on
an understanding of the history and nature of the symptoms
experienced by a concussed athlete, ensures the most successful
treatment outcomes.
Conflict of Interest Statement
Rosanna Sabini, DO and Cara Camiolo Reddy, MD disclose
no conflicts of interest.
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