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.
Keep up the good work, Dustin. My personal opinion is that nobody ever suffered from overkill. Even if we treated every single person that exhibited the fencing response as having a concussion and then mandated full cognitive rest, I’d be happy to have a debate about whether or not the rest protocol was overkill 2 weeks later when (hopefully) that person felt fine. The inverse of specialists hemming and hawing about whether or not that person was fully concussed could mean the difference between prolonged suffering in terms of post-concussive symptoms.
A person feeling great and thinking, “Gee, I don’t know if I really needed to be shut down for those few weeks” is a situation I’d much prefer over a person in agony later on wishing that their doctor was more proactive about telling them what they needed to do.
Yes Jay, I agree… We look at LOC much the same way…
Here’s a link I found of the hit. Looks like posturing to me. http://www.nfl.com/videos/nfl-game-highlights/0ap2000000099425/Julian-Edelman-injury
EBP is sound, is needed and is a standard for which all medical professionals should aspire. But EBP can also be extremely binding. For a practitioner in the clinical setting (especially traditional AT settings of sports), EBP will be an incredible hindrance. Those of us in this setting can’t wait for EBP to catch up with what we are doing in the real world. But, those of us in the “real world” can’t just do things based on gut feeling or “that’s the way we have always done it.” We must base our clinical practice on science, EBP principles and questioning why we do what we do. But there are so many injuries and situations that walk into our clinical practice for which there is no EBP. Every situation, every injury, every athlete, every concussion especially, is different. This truth is why an experienced AT is so valuable. This truth is what separates the great ATs from the bad ones – their ability to assess and treat everything that walks in the door.
EBP is needed, more research should be consistently performed, but the clinician can’t limit themselves to the current body of knowledge. ATs constantly push the envelope of accepted practice. It is called innovation!
I understand that MASH units in the field are constantly pushing the envelope and establishing new protocols from the intense experiences in the real world. A lab will never reproduce real life experience.
BAM!!! Another home run from another “in the field AT”… I wish academics would please listen to us and make changes that will work for the new incoming AT’s…
Today’s graduating AT’s unfortunately are closer to “paper AT’s” than field AT’s… This is my opinion of course, but today’s AT’s are NOT ready to be thrown into full coverage of a high school just after graduation… I find that sad…
EBP is needed for basics, fundamentals, position statements, and radical changes… But clinical experience and clinical evaluations are what this profession is based on…
Unfortunately EBP is needed for credibly, and some times those in charge are too concerned with what others think, instead of letting our actions speak for themselves…
Dustin, being certified for all of 23 months, I definitely understand what you’re saying. Young ATs are lacking plenty, but I think some of it has to simply be learned in the field and even in our clinicals we couldn’t do that. One thing was I knew I had a safety net onsite in that situation. Guess what– today I AM the safety net.
Regarding concussions, we’re constantly playing catch-up. What I learned about concussions in the classroom were being thrown out the window that afternoon in the clinical setting. Basically I learned Cantu’s Grading Scale and use it today only when somebody asks me specifically about a grade. But I don’t use it. And I explain to them why I don’t use it.
Not to hammer on the new AT’s just getting out of school (because I don’t think it’s COMPLETELY their fault), but the regulations put in place through the accreditation process has limited AT’s to what they can do in school today. I went through the old school internship route. My hands on experience came first, then my “book” experience followed. Young AT’s are definitely lacking the experience when dealing with “real world” coaches, parents, and administrators. You can’t learn that in the classroom. I know of one new AT who is being eaten alive by everyone around him because he doesn’t quite have the backbone to stand up to the coaches in the appropriate way because they know he is green. I hate to see it. But the handcuffs are put on in the classroom and it doesn’t help these folks one bit moving forward.
I know this post wasn’t originally meant as an AT topic, but good important discussion nonetheless.
No it was a side ways angle into the AT stuff… I agree… I did the internship route…
I got in the program, was given a stocked bag, practice schedule and was told “don’t kill anyone”… Seriously…
Looking back that type of education has really made me into what I am…
Maybe I’m looking at this from the high school teacher perspective but as a “teacher” I didn’t learn how to actually teach or how to deal with parents and administrators until I actually became a teacher. As an AT, it was much the same way…I missed the internship route by a year or so. While new ATs struggle–I don’t think it matters what route you did on that aspect, I do think that some of the “new” or newish ATs are much better at saying no, when needed, than some of the old school ATs I have worked with. For too many years we have been about the “for good of the athlete” to the extent of way too much personal sacrifice and that is something I’ve seen change to some extent with some of the newer ATs that I’ve worked with.
Back on topic, the fencing debate certainly is interesting and not something I’ve seen much of as a practicing athletic trainer.
One citation here from pubmed.com, (which apparently many of you have already been searching):
“Brain injury forces of moderate magnitude elicit the fencing response” (2009)
Examines YouTube videos and reports of rat experiments.
The rest us need to compile game film clips into a research project, in cooperation with team physicians. Or maybe we just start with weekly NFL clips of hits evidencing the fencing response and combine that data with the weekly concussion report..
It seems like I’ve seen the fencing response often in hockey and non-helmeted sport collisions. Wonder if it is more common in certain sports than others. It would be interesting to see the types of clips that could be collected.