This is Interesting. Share Your Thoughts

6 Mar

I just saw this on Twitter from @NSAFitness, Time to Re-think the Zürich Guidelines? appearing as an editorial in the Clinical Journal of Sports Medicine March, 2014 issue.

I can think of many reasons to re-think Zurich; the two biggest is no inclusion of return-to-learn/work and the obvious lack of coalition in concussions.  It may be a “consensus” but really its a compromise, AT BEST.  Here are some excerpts;

The problems with the guidelines include a lack of diagnostic specificity, management strategies that are not evidence based, and rehabilitation goals that are not attainable. Given these problems, the Zürich Guidelines cannot be endorsed.

Don’t know why we have to be more specific, rather more global would make sense: ANY DISRUPTION OF NORMAL BRAIN FUNCTION AFTER AN UNNATURAL TRAUMATIC FORCE IS APPLIED TO THE PATIENT, would fit just fine.  I will defend the non-evidence based management strategies; how can they be evidence based if we are just now getting to this part of the puzzle (SPOILER ALERT: the concussion problem is due to the mismanagement of the injury, not the injury itself).

Another major problem with the Zürich Guidelines relates to the management algorithm. The authors continue to state that the cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve.  As in previous iterations of the consensus statement, the authors do not have a citation for their recommendation. Physical and cognitive rest are not defined. The notion of cognitive rest is not intuitively obvious. Rest and the initiation of worklessness have known deleterious consequences.

I happen to agree with the issue of what “rest” is, but how do we even quantify that?  I think there has been good strides on that, meaning we have tried to hammer home the need for complete cognitive and physical rest.  This includes anything that would require brain power; in other words one should sleep.  Refer back to the snow-globe analogy if you will.

I think this is a good discussion point, so please chime in if you will!

 

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6 Responses to “This is Interesting. Share Your Thoughts”

  1. Dwight March 6, 2014 at 13:22 #

    Seems I’ve heard this before…oh wait yea from you. One thing I can note is that within our concussion program the take on sleep is that the patient should try to maintain a normal sleep schedule and if necessary take short naps. Our physicians are trying to avoid having the patients sleep too little obviously but also too much. In the acute phase more sleep is common but as the recovery progresses we recommend a normal 8-10 hours of sleep for the patients.

    • Some of the editirial comments are not “new info” and one is quite befuddling:

      ===================================

      Since a concussion IS operationally defined as a brain injury.. .

      I am rather confused and bewildered by the following statement found in the Critique of the Zurich Guidelines.. :

      ” A good place to start would be acknowledging that the current syndrome defined as a concussion need not involve injury to the brain.”

      Concussion and the corresponding notion of the post concussion syndrome has been recognized for at least a few hundred years (Evans, 1992)

      =====================================

      2- Since the mid-1990s, the use of the term Traumatic Brain Injury (TBI) rather than head injury has been encouraged by a growing number of professionals and the Brain Injury Association of America. In 1996 the construct was also introduced into federal law (Kelly, 1999).

      The term Traumatic Brain Injury is viewed as a more precise explanation for the effects of a concussion.

      =============================

      3- The gathering of accurate epidemiological information pertaining to TBI is not an easy task due to such variables as:

      - differing definitions for the term brain injury (Cantu, 1996; Kelly, 1991; McCrory, 2002);

      - a lack of uniform medical/hospital documentation of its occurrence (Kraus & Nourjah ,1989);

      – under-reporting of injuries by physicians because a large percentage of athletes do not utilize health care providers when injured (McCrea, Kelly, Kluge, Ackley, & Randolph, 2002);

      - and an under-reporting of injuries by the athlete ( Echemendia & Julian, 2001; Lovell & Collins, 1998; Wills & Leathem, 2001; & Kelly, 2003).
      ==========================

      4- Vague and inconsistent definitions of the constructs used to explain aspects of brain injury, coupled with confusion and misunderstanding of brain injury symptoms, create further problems in the study, assessment and management of sports-related concussions.

      This fundamental concern / notion has been acknowledged for a significant period of time.

      For example, Wills and Leathem (2001) amplify this concern:

      “The quagmire created by the use of inconsistent, overlapping and poorly defined terminology relating to brain injury research [assessment and management] is exacerbated in sport-related research” (p. 646).

      ===========================

      5- Consistent with numerous past sport-related concussion guidelines, the Zurich guidelines are also not supported via evidence based research ; they are CONSENSUS guidelines that must be cautiously read as being valid and relaible.

      Furthermore, growing apprehension has been proclaimed that members of such concussion committees fail to clearly share with readers their personal conflict of interests / “entanglements”

      ====================================

      6- Excerpt from Brady, D; 2004:

      … just as specific sources and amounts of funding for drug-related research and other secondary interests need to be clearly enunciated (Lemmens et al., 1998), sources and amounts of funding for sports-related concussion research, multiple relationships, and other secondary gains should also be openly acknowledged and clearly described in all research presentations and corresponding journal articles.

      This is so that the audience/reader may become fully aware of possible health care provider biases that may have adversely impacted the research findings being reviewed.

      Such a perspective is similar to Krimsky and Rothenberg’s (1998) view that authors’ COIs should be shared with readers so that they may become aware of, and personally judge, the credibility of the article’s contents..

  2. Tom March 7, 2014 at 20:06 #

    Another area to consider is the comment that 80-90% of concussions resolve within 7-10 days, but the CIS’s continue to cite study which only utilize BESS, SAC, and self-reported symptoms. The list of limitations of those tests are long enough to form their own lengthy blog entry. At this point there are dozens and dozens of studies (start with Chou’s gait studies and Slobounov’s work), using diverse research paradigms, that show lingering deficits for weeks or months post-concussion. At some point the athletic medicine community and athletic environment overall is going to have to acknowledge that a concussion doesn’t just mean you might miss 1 week, but that it’s normal to take weeks to recovery.

    Dustin – a question for you. The problem with your description is how do operationally define (with good specificity and sensitivity) “disruption of normal brain function”? I think pretty much everyone reasonable with agree with that description, but identifying this disruption is the problem.

  3. Daniel Gallucci March 8, 2014 at 07:54 #

    Great Post!
    As a clinician in the trenches dealing with concussions, PCS etc etc on a daily basis, the ambiguity and non specificity is of great concern and a hinderance in the rehabilitation process.

    The fact is we do have better diagnostic capabilities. In clinic we use Videonystagmography, Saccadometry, Computerized posturography and other evidence – based strategies to indentify and then rehabilitate dysfunction. No matter what we want to call it.

    When we can capture baseline data from a number of these measures we have a more solid foundation on which to base our rehab strategies if an injury were to occur.

    We are often asked “well where’s the research?” While this is currently being accumulated it is still tough to take a problem that is so inter disciplinary in nature and put it into a purely research based environment.

    Then again where is the research supporting physical and cognitive rest and what does that mean?

    Am I ” resting” physically and cognitively lying on the couch while my wife is watching an episode of Girls? Absolutely not! My CNS is taking a beating.

  4. Scott L. Bruce March 9, 2014 at 18:04 #

    Is it possible the author of the editorial is referring to no “objective” bio-marker for the definitive diagnosis of concussion? I agree with the definition of a concussion, but the bottom line is that because concussions are like snow flakes the likelihood of missing concussions or players not reporting them remains a very real problem. I am aware of some preliminary work being done look at enzymes and proteins that are released and/or produced as a result of the head trauma which shows promise of developing a bio-marker. But until then, the subjective nature of this injury continues to be a problem.

  5. Mike Hanika (@brainologymikey) March 22, 2014 at 10:37 #

    Underreporting is a good excuse, but not a valid one. As a player (football) in high school and college, I had 15-20 concussions. All were performance limiting head injuries. whether I was staggering or laying on the field, everyone knew what happened. Now I suffer from the long term effects of the mild head trauma i received when i was younger. I wear leg braces and use a wheelchair because my brain signals will not tell my legs what to do. My body tempature cannot regulate itself, tremors, muscle pain and cramps constantly. Cognitive and executive skills have slowed significantly. I am on disability as I previously was a tax accountant and a Construction management professions. i am unable to concentrate for any length of time and i cannot workout because of my intolerance to heat that makes me physically ill. I am not writing this for pity, but merely as another testimonial that it is real and as the many neurologists i have seen do not want to acknowledge it. Thanks for getting the word out and let me know if I can help you in any way. @brainologymikey Mike Hanika

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