WARNING some content may be considered “nerdy”, as there are very big words, even words I had to look up (OK you got me I have to look up many words longer than 5 letters). I may even go on a diatribe that may lose you. I do feel it is important for athletic trainers to read as well as our educators.
Awareness is the key with concussions – as I see it in this moment in time – understanding what one is and the proper management are probably the biggest issues we can educate on currently. That does not mean the rest of the information is forgotten or omitted rather, grasping the nature of concussions is of special attention. Once people start to understand/respect concussions some of the fear will be removed and fewer people will brazenly dismiss this brain injury. Decisions need to be made about exactly what to educate each audience about; granted it would be nice to explain all of it – every minute detail – to every audience, that is unlikely to get people to understand. The information about concussions – while remaining consistent – must be tailored to each subset for better understanding. One can always go out and find more information, but the basics must be the same for everyone. For example; disseminating the general signs and symptoms of concussion, the appropriate definition of a concussion, and immediate management of a suspected concussion. This information should be the same for everyone.
And I think we are doing a good job all around on this; from the CDC, to NFHS, to state level, to this blog.
Last night was an opportunity to learn more about concussions and the thought process of teaching about concussions, to at least athletic trainers, on twitter. During Thanksgiving I mentioned – and was pushing people – to understand what the Fencing Response is (pubmed) as Julian Edelman of the New England Patriots demonstrated this after getting hit in the game (
unfortunately I cannot get a film/.gif of this currently) (thanks to a reader here is the LINK to the video).
It was then suggested to me by fellow athletic trainer and current educator Dr.Theresa Miyashita (@DrMiyashita) that I should “be careful-the fencing response is not yet a proven neurological response to concussions.” To which began the debate as I clearly stated – and have done so since the beginning – we should be teaching people the recognize the Fencing Response as I feel it is another sign to warrant immediate removal for evaluation. Apparently Dr. Miyashita has and issue with this because it is not “evidence based” (EBP) or proven in research.
Through this debate I learned where I think we are possibly failing the athletic training students and possibly all medical providers. I learned that to teach something to others it MUST be evidence based and proven in research… when it fits the educators parameters. People will often overlook the EBP to support their beliefs – I do it – however they cling to EBP when they don’t agree with something – I don’t do that.
Last night I used this example; rest after a concussion. In Zürich we were told that there has been zero evidence based (EB) research on the type and duration of rest following a concussion (FTR I support rest). Therefore there is NO EBP on this, rather the general acceptance of this management technique based solely on the body’s general physiological response after injury and a bazillion anecdotal cases. Now I was being told that the Fencing Response should not be taught just yet because there was not EB research on it.
This is where I began to get frustrated. All I was trying to convey and continue to do – to the best of my ability – is inform those who come to this website about concussions, everything possible in a way that is understandable. The Fencing Response is a SIGN produced after a traumatic event usually involving the head (although I have been told this can also be described as forward tonic labyrinthine reflex). We should be educating the public, athletic trainers, doctors, lawyers, aliens, the POTUS about overt signs and get a player removed for evaluation. We have done it with loss of consciousness and balance disturbance, we are even beginning to accept the “gazed look” as a possible sign for removal and evaluation. However, I was being told by Dr. Miyashita that she would not be teaching her students about the Fencing Response because it was not in the research or was clearly evidence based research. I took umbrage with this and thus the debate – a good, heated and respectful one – raged on.
As good as I like to think I am at discussing concussion and educating about them I could not grasp why a fellow AT and someone who has an interest in concussions was not willing to teach about the Fencing Response as a sign for potential concussion. It has been my experience – therefore MY EBP – every case of the Fencing Response has been a concussion, in fact every case of transient posturing has resulted in concussion. Not unlike loss of consciousness (LOC), where even though every case of concussion does not have nor require LOC, every case of LOC following a traumatic event is at least a concussion. Why? Simple it’s an overt sign that we are not relying upon the athlete to tell us about. Because of concussion and its subjective nature, finding ways to possibly detect them without the need of a possibly “lying” athlete telling us, helps.
Thanks to @the_jockdoc he put it much more succinctly; the Fencing Response is not pathognomonic (to which I agree). FURTHERMORE – there is no pathognomonic sign or symptom for that mater of concussion. Basically what he is saying is that if we were to base everything on EBP and pathognomonic responses in concussions we would be omitting much of what we know.
I do believe we came to our own little consensus last night; the Fencing Response is a transient posturing state that when seen directly after a traumatic event that would include the head the player should be removed for a concussion evaluation.
Further comment from me: I also believe that if we would accept and use the definition of concussion as “disruption of normal brain function/activity following a traumatic event” (whether that be complex or simple, regardless of pathophysiology) and keep things simple we would get further. At times being too specific and grasping onto certain beliefs (getting tunnel vision) can lead us down the wrong path. A concussion is a BRAIN INJURY; any symptoms or sign in research that is associated with brain injury (including posturing) can and should be adapted to concussions as well. Just because it may be present does not make it a concussion, rather it makes it a possible brain injury.