Opinion on Zurich Statement

13 Mar

I think I have had enough time to digest the information in the 4th Consensus Statement; it is enough time for me to give an opinion.  WARNING: My opinion may differ than yours and you may even take umbrage with what I say.  However I am going to give my honest opinion.  To keep it as succinct as possible I will go in bullet form along with the statement itself.

In general I feel that we as the community in the “know” are muddying the waters more when it comes to concussions.  I think there are reasons for this; litigation and emotion mainly.  I still strongly feel that concussion identification and immediate assessment by trained personnel is non-complex; its simple.  Sure others may think it is hard; I think changing the oil in the car is hard and complicated – a mechanic would find that a mundane task.

Secondly, the now undeniable MASSIVE issue with concussions is not the injury itself, rather, the mismanagement of concussion; which includes but not limited to assessment, rest, rehabilitation, return to learn and return to play.  The newest consensus statement address some of this for the first time.  Now, the paper…

SECTION 1: SPORT CONCUSSION AND MANAGEMENT

  • The definition of concussion is more clear for the practitioner.
  • Starting to address the psychological aspects of concussions – about time.
  • Clearly states if no trained health care provider present that if any signs/symptoms present players must sit out.
  • Clearly states that if concussion present, no RTP same day for ANYONE!
  • Not really a fan of all the sideline assessments out there.  No where does it say its mandatory for any of these; rather they are tools at our disposal to help identify concussions.
    • Here is a novel approach people: use your training and ability to be in-tune with the athletes to make a solid clinical judgement.  Oh, wait, not every sport team has an athletic trainer available?  <–THIS IS THE PROBLEM WITH IDENTIFICATION AND ASSESSMENT.
    • The Statement also clearly makes it a point that clinical judgement is the standard of care when it comes to all of this.
  • Although currently there is not an objective measure of the injury on the brain they have opened the idea it may be coming.
  • Neuropsych testing was a good section, the take-home point here is that baselines are not part of best practices and that they should not be used as a clearance device, except in the case of a trained neuropsych using the information.
  • Loved the discussion on “rest”, really thought about it a lot since it came up in Zürich.  The term “rest” is so subjective as well, but the Statement made a good effort in trying to convey what most of us already did.  Concussions are like orthopedic injuries; we still have a 72 hour window where the inflammation response is active.
  • The graduated RTP protocol remains unchanged – which I am most upset with.
  • However, the inclusion of (although almost in passing) of return to learn was good to see.
    • In the RTP steps all the group had to add was a step between 1 & 2; where it is return to school/work/cognitive activity without symptoms.  That was obviously too much to ask, because I asked it be included many times while in Zürich.
  • Still no solutions for the 10-15% of “difficult” patients.
  • Addressed pharmacological aspects of concussion for the first time, good idea.
  • The concussion modifiers are a good point for all of us to consider.
  • Special populations or as I call it – “enhanced muddying of the water” – just gives everyone more loopholes to expose and ways to explain down a concussion.  A concussion is a concussion is a concussion is a concussion.  Now management of said concussion may be different, but the damn injury is the same across the board.  Why can we not grasp this?
  • Prevention section was refreshing and gaining the most traction early on.
  • Yes the way the games are being played is a big contributor to concussions.  Remember my quick rant about the sports we play?
    • These sports/games were designed for a different human being in the late 1800’s.  The size and speed has drastically changed in the athlete, while the game has seen slow and reactive changes that still lag in effectiveness.
  • Probably the most overlooked portion of Section I is the “Knowledge Transfer” portion.  This is absolutely key, this is exactly why the blog exists.

SECTION 2: STATEMENT ON BACKGROUND TO THE CONSENSUS PROCESS

Perfectly honest, didn’t read much of it, mainly because I was in Zürich and witnessed the process.  What you basically need to know here is that the authors of the paper were the ones that came to “consensus” and in some cases they did a tremendous job of getting somewhere without getting anywhere – making us aware; CTE is the example of this good team work.  Yet the select group didn’t hear nor heed the concerns of many regarding return to learn (only casual mention).

A lot of the researchers/practitioners in the “consensus” group are very good and nearly void of massive conflict of interest.  We must realize that almost everyone there has some “skin in the game”.  Unfortunately, most if not all of the “good” guys are non-US-based.  I can count on one hand the US based authors I trust on this subject, sorry fellas.  This sets up my rant.

In the US the concussion issue is not only overly complex in terms of ID and management, it is overly political; too often the pursuit of money or “fame” gets in the way of solid science.  There are “elite” groups of researchers that have the proper connections and pull to get the lion share of grant money and innovation money.  And more often than not independent voices/views or decent is met with immediate scoffing from the ivory towers.

Also in the section was the medical-legal concerns, worth the read but also worth nothing, because this does nothing for setting the standard of care we all can be protected by.

SECTION 3: QUESTIONS ADDRESSED

Good read

REFERENCES

This is worth the investigation people, read what they cited for a background on why certain things were written.

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13 Responses to “Opinion on Zurich Statement”

  1. Dwight Randall March 13, 2013 at 09:36 #

    I couldn’t agree more that the experts are firmly planted in a muddy gray area. We live in a litigious society. This issue is moving from medical to legal/political. The focus should be less on making laws and more on requiring schools to have trainer professionals available to CLINICALLY evaluate injured athletes. State and federal governments aren’t passing laws on how concussions from MVA are handled. Why? Because MVA have trainer professionals responding and taking patients for medical care. It’s an issue of access to care not the quality of care provided. Many of these new laws are taking clinical decision making out of the hands of trainer medical professionals (athletic trainers). It really frustrates me. One last comment on baseline testing. I totally agree wide spread baselines are not needed. There is plenty of normative data out there. I feel often times the presence or a baseline test and access to it results in non trained physicians clearing athletes based solely on scores on NP tests returning to baseline. They don’t have the clinical skills to do a good evaluation and rely on test scores just because we have them. I would rather not baseline athletes and then require they see a trainer neuropsych who has normative data and will perform a thorough exam including history symptoms vestibular and balance testing as well as the NP testing.

    • arlis2013 March 13, 2013 at 10:58 #

      Dwight,

      Psychometrics are bit more complicated than Mark Lovell and Ruben Echemendia would have you believe. There so-called normative database is a sample of convenience. it is not a controlled laboratory sample.

      Testing concussion resolution with The younger the subject the more variation one will see and therefore demands much tighter controls. Use patient as control, not Bobby has a B average and his mom helped him take a test at home. Do you think a B student at a New York City magnet school is the same a a B student in Pudukah, KY? Do you think children’s brains change at predictable rates between 5 and 13? Show me the data. Do you think two year baselines are suitable for teenagers? Show me the data.

      I realize Lovell and Maroon have made a career by selling simple solutions to complex questions but at some point when is the ATC community realize they have been suckered. Impact sells what ATCs want to hear not what is scientifically valid. It is all a wink and nob to provide the appearance of care and not care.

      Please look into the so-called authors backgrounds and their involvement with the disgraced NFL m-TBI committee. NFL players are suing the league because these clowns contributed to the poor diagnosis and treatment of players. When the case gets kicked out of Federal Court expect the lawyers to go after Team Pittsburgh.

      • Dustin Fink March 13, 2013 at 12:13 #

        I think I have realized that NP tests are a waste of time and resources for us at AT’s… One we are not qualified to read them, secondly too often I feel the parents/player put so much stock in it, it gives false sense of recovery… All that being said I still use them… I think simple SCAT3 or even connect the dots would be good for assessments purposes…

      • Michael Hopper March 13, 2013 at 12:24 #

        I have used ImPACT, I’ve used SCAT2. They all have uses, but the questions continues to remain what are their true benefits? And it’s hard to gain that research.

        ImPACT isn’t “selling what ATCs want to hear” and it upsets me that you would say something like that. Athletic Trainers are HEALTHCARE PROFESSIONALS and we want to protect our athletes.

        I am always analyzing how I proceed in event of concussion just like any other injury. Always learning more..

      • BryanATC March 15, 2013 at 12:55 #

        Dustin, what would you rather have us as ATC’s use instead of NP tests?

        Go back to no baselines at all and some abstract “normal” for athletes as they recover?

        Have nothing to show a physician that might be clearing an athlete too soon that shows depressed cognitive function?

        I am in no way defending ImPACT as it definitely has it’s flaws. With that being said, spending a couple hundred dollars a year to have 570 baselines done over the span of 7 hours can be a wonderful tool (even if flawed). Should we do SCAT2s instead? That’s 70 hours of 1 on 1 testing.

        Concussion treatment without baselines of some sort is essentially a crap shoot. Even after completing a 3 hour battery of NP tests interpreted by a highly trained physician, would clearing someone who scores at the 50th percentile be appropriate? What if that individual had been a prior straight-A/perfect GPA student? Maybe they would have scored 50th before the concussion, maybe they should be scoring in the 90th? 50th percentile is “WNL” and with nothing to compare it to could result in too early a clearance. (Actually happened in the town next to me).

        The cheap and easy NP tests have their flaws, but the alternative is essentially using nothing.

        You say you still use them even though they are a waste of time and resources. What would you use instead? As I see it ATC’s pretty much have a choice of using them and having baselines or not using them and not having baselines. I find that a step backwards in level of care and unacceptable.

      • Dustin Fink March 16, 2013 at 10:22 #

        Bryan,

        I use them because I am told I MUST use them… I would prefer the following (laugh as you may); BESS baseline, toddler puzzles, connect the dots and simple reaction time testing… I even have been looking more into the King-Devick test as well…

        The key is communication, in my opinion… I don’t have MRI or XRAY eyes to tell you that a ligament in your ankle is messed up, we don’t run pretests on that, but I can certainly tell you when the injured is ready… The same is for concussions; I and many other practitioners don’t need objective tests to tell us you are concussed and if you are ready, heck we don’t have one now…

        I am merely apprehensive because we are now starting to RELY on these measures that tell us the same thing our clinical assessments are telling us. Rather than the NP tests being used to “clear” someone I rely upon these devices to confirm that my clinical assessment is accurate in holding the athlete out. They are VERY good for that, especially with parents and uninformed doctors…

        Too often I have had athletes not be “cleared” by the NP test but have performed all other tasks including the SCAT2 flawlessly, combined with clinical assessment and vigorous other testing by me and doctors players have been released by MD/DO’s even though the NP tests have said essentially “no go”… (I have also had the same in reverse, where the NP tests tell me the kid is OK, but clearly he/she is NOT)…

        My steadfast baseline for all kids in HS is the classroom and in school dynamics… I can only gauage this via communication with teachers, parents and other peers…

        I struggle with the thought of it being “too simple” but I think we are now in a position of too much minutia…

        The concussive injury, like all injuries, is not based on pure numbers/results on quasi-objective testing, nothing out there currently can assess each individuals brain fitness, our best is to take the WHOLE picture, with what ever you have in your tool box, and making the best clinical judgement… My over-riding concern is laziness, which leads us to the real issue of improper management…

        Bet that is as clear as mud! Great question…

      • Dustin Fink March 16, 2013 at 10:25 #

        Add to that the NP tests were designed and should be interpreted by a VERY educated person in the NP realm… Just like AT’s (or MD/DO’s) should be the first to assess the injury…

  2. stevie777587 March 13, 2013 at 09:46 #

    “more often than not independent voices/views or decent is met with immediate scoffing from the ivory towers”.

    Finally, from your own mouth even, I don’t believe it.

    • Dustin Fink March 13, 2013 at 10:44 #

      Oh Mark…. New readers above is Mark Picot who sells a mouth orthodontic that claims it can attenuate concussions… I loved your thoughts but your actions deserved scoffing, especially when you provide research that would be better used as kindling for a fire… Keep up the fight Mark!

      BTW, if you are insinuating that I am coming from an Ivory Tower… WOW!! Thanks for the compliment!!!

  3. Educator Mom March 13, 2013 at 11:50 #

    I would agree with many of your opinions. As a teacher and a mother of a concussed student, I was glad to see this statement: “Children with concussion should be managed conservatively, with the emphasis on return to learn before return to sport.” And I like the phrase “return to learn” over the more commonly used phrase “return to academics”. I would like to see concussion legislation the incorporates both return to play and return to learn in order to help schools and families make better decisions about the student athelete’s physical AND coginitive recovery.

    I was a bit dismayed to read the “Special Populations” section. What I have found is that those who are not familiar with the possible long term effects of concussions, often try to find other reasons for the ongoing symptoms. We personally have been questioned about ADD, TMJ, and a host of other issues by general practitioners, and pediatricians. We have been fortunate to live in an area where we have access to concussion specialists but there are many who do not. It would be unfortunate if that particular section of the statement offered the medical, athletic, and educational communities another opportunity to attribute long term symptoms to other conditions instead of facing the concussion issue head on.

  4. stevie777587 March 13, 2013 at 15:52 #

    “a mouth orthodontic that claims it can attenuate concussions”
    Shame on you Dustin.
    It’s been made clear that it’s an orthodontic appliance designed for athletic performance and may help with Tmd symtoms in those with Temporal mandibular joint dysfunction. There is no such thing as a mouth guard that prevents or mitigates cou contra cou concussion. The King of concussion has made this clear. ( this means you )

    • Dustin Fink March 14, 2013 at 04:33 #

      That’s not what your website nor your previous emails claim… Heck Mark you also claim that your product can even help with CTE? Why don’t you fill everyone in on that…

      Oh, I guess that you have changed your tune since the FTC and Udall have picked up the heat on companies that made such claims…

      And to be real clear there is no product, period, that can prevent concussions, let alone plastic in ones mouth…

      • A mentor of mine provided me with the following advice re expert panels and blue ribbon committees:

        ” A concern pertaining to COIs being exhibited by members of expert panels and blue ribbon committees was recently voiced by a clinical professor of medicine at the SUNY Upstate Medical University Hospital located in Syracuse, NY. Anton Joachimpillai (2004) stated that

        from his clinical perspective derived from almost 50 years of practicing medicine, expert panels and blue ribbon committee findings should be both cautiously accepted and critically reviewed as he has frequently found that committee members promulgate self-serving, and thus biased interests (personal communication, March 9, 2004). ”

        2- A readily accessible declared Conflict of Interest section for each of the panel members appears to be missing from this journal article.

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