Nick Mercer: Impromptu Expectations

The thing about expectations is that they presume a certain course of events. In July 2003, I assumed that I would start my co-op job in Ottawa in September and I based my expectations for the coming years on that presumption – my previous post, Finding yourself after a brain injury. First step: Recon. Brain injuries themselves are unexpected, so you don’t know what presumptions to make that will allow you to generate expectations. You’re already starting off on the wrong foot. It’s not so much the issue of living up to, not meeting, or exceeding expectations, it’s more about the expectations themselves that I will write about.

After considering a patient’s health/medical history, age, other essential factors and the severity of most injuries, conditions, or diseases, doctors can only base their ultimate prognosis on probabilities. This is where expectations begin to go awry. Not to get into statistics or anything, but if the probability of surviving a coma of a certain length and severity is low, it’s because it hasn’t happened very much, therefore there will be few cases upon which to build expectations. The fewer cases, the fewer reliable prognoses can be made, hence few, if any expectations.

Those are for others to make. The most important expectations are the ones you make for yourself. I had been making those ever since
I can remember. When I was a kid and used to catch insects, I had Continue reading

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Concussion Conglomeration “Road Marker” (UPDATED FREE ARTICLE LINK)

A paramount review of concussions and their “long-term” effects has been published (or soon will) in Nature Reviews Neurology that I certainly hope does not slip past the masses.  Not only is the information somewhat of a “where we stand”-moment of clarity, it is authored by a very underrated and proficient researcher; Dr. Barry D. Jordan.

Jordan, B. D. Nat. Rev. Neurol. advance online publication 12 March 2013; doi:10.1038/nrneurol.2013.33 (note you need a log in).  Here is the FREE DOWNLOAD LINK

Acute and chronic sports-related traumatic brain injuries (TBIs) are a substantial public health concern. Various types of acute TBI can occur in sport, but detection and management of cerebral concussion is of greatest importance as mismanagement of this syndrome can lead to persistent or chronic postconcussion syndrome (CPCS) or diffuse cerebral swelling. Chronic TBI encompasses a spectrum of disorders that are associated with long-term consequences of brain injury, including chronic traumatic encephalopathy (CTE), dementia pugilistica, post-traumatic parkinsonism, post-traumatic dementia and CPCS.

Dr. Jordan also discussed CTE in further detail including the limitations of possible antemortem detection; including imaging and categorization.

In this Review, the spectrum of acute and chronic sport-related TBI is discussed, highlighting how examination of athletes involved in high-impact sports has advanced our understanding of pathology of brain injury and enabled improvements in detection and diagnosis of sport-related TBI.

The overriding theme I gathered from this review article is one that I have been hammering home for a very long time: the mismanagement of the original sequale may be the largest factor in discussion the multiple faces of “chronic TBI” that result from concussion.  This paper is also very succinct in demonstrating the massive amount of work that still needs to be done.

I urge you to find a copy or pay for a subscription for this article, it should be one that we look back on in 5 years as the “where have we come from” moment in this issue, regarding chronic issues from sports related concussion.

Head Football Coach ‘X’: How to take a stand on player safety

Working on a cause is difficult, especially if you are trying to swim upriver. When the cause is in direct conflict with the juggernaut that is football it becomes even more difficult – even at the high school level. I received and provided counsel to this individual as he fights a good fight in regards to player safety, most notably concussions. I applaud this individuals effort, attention to detail, player first mentality, and his willingness to sacrifice his job. What we have below is a microcosm of the issues we face with concussions; detailed and beyond sufficient for action – that is not being taken except against this author.

This information was obtained mainly through email strings – all identifiable properties have been painstakingly scrubbed to the best of my knowledge. It has been understood and agreed upon by the author that publication of this information may identify him and place him in further jeopardy. He is willing to take that chance and I am willing to provide him a platform. Unless otherwise noted in the post with breaks all of this is his and his alone. We shall begin;

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A Little Context:

At the start of my advocacy for safer measures to be applied to the competitive arena in high school football, I involved many people who I trusted and cared for in helping find my voice. Those people usually ended conversations with the same question:

“Are you willing to Get Fired for this?”

I laughed at the question considering the fact that I am advocating on behalf of measures that enhance Student Athlete Safety. At no point was my advocacy meant to be an argument, so the extent in which there has been resistance to proactive thinking has been quite a disappointing surprise to me.

The last 3 months of my professional career have been a whirlwind as I have gone from Advocate to Agitator. When the time for action came to blaze a trail for the future, and promote all that can be good on behalf of our student athletes, we collectively passed as a school system, even though a safer future for the thousands of kids who choose to play football within it is still very attainable.

Through my advocacy I have felt empowered by the leading researchers in the field of sports injury supporting these ideas. Support from the actual people who could make these changes has been “Hot & Cold” in a way that led to me presenting to the Athletic Administration of our entire school system and then being handed a letter of reprimand. At the current time I am labeled as a “Demanding” Coach and a person “Searching for a Cause”.

What follows is a chronological story of advocacy on behalf of player safety at the high school level as well as an example of how far away we actually are from a safer future for the student athletes who choose to play the sport of football.

Authors Note:

Some of the Main Points of Resistance in this philosophy have been diffused by simple logic when it comes to providing a safer arena for competition.

—–

ORIGINAL LETTER TO RAISE CONCERNS & TO START MY ADVOCACY
January 8th 2013
To: (School System) Director of Athletics ————————
CC: (School) Principal —————–, (School) Athletic Director ———————, (School) Assistant Athletic Director ——————

Subject: Public Health Issue regarding (School System) Cross-District Scheduling of Football Competition

I am writing to make you aware of a safety issue that our county has unknowingly placed many of our student athletes in through our recent scheduling for football. (School System) Athletics cross district scheduling policy for teams in the newly formed ——– District, while making sense from a convenience and perhaps even a cost basis, exposes athletes at certain smaller schools to a greater risk of serious injury. I share these concerns with other Head Football Coaches within (School System) as was voiced at the —————- 2012 All-District meeting.

(School System) scheduling policy requires each (Small School) District football team, which is made up of schools that have been classified at the 3A and 4A level in the (State League) to compete with three schools at the 5A classification from the (Big School) District for the 2013-2014 scheduling cycle. The 2013-2014 scheduling cycle determines opponents for each school’s next two (2) seasons. ——————— High School (——) is a 3A school that, based upon the recent scheduling for the 2013/14 seasons, is expected to compete with schools classified at the 5A level on six (6) separate occasions, schools at the 4A level 12 times, and similarly sized 3A classified schools 2 times in our next 20 scheduled games.

A schools classification is predicated upon the (State Association) account for each school’s student enrollment. That enrollment produces the available population to field athletic teams. (State Association) has outlined parameters identifying like-sized enrolled schools to view as competition throughout the state. (School System) scheduling policy has ignored these guidelines in which the (State Association) believes our schools can equitably, and safely, compete in the sport of football.

Current scheduling policy lacks the awareness of a significant and measurable increased risk of injury to the players at (School) and similar sized schools. What is alarming, and requires immediate awareness, are the findings of the most recent and advanced studies related to head injuries. These studies strongly suggest that (School System) scheduling policy as currently constituted, subjects student-athletes of the smaller schools, not only to a greater risk of injury but to a greater risk of serious head trauma Continue reading

International Boxing to BAN Headgear…

Discuss…  (LINK)

A major sports federation has mandated banning headgear in amateur boxing competition in an effort to reduce concussions and head trauma, a decision that is thought to be a first in the sports world.[…]

Removing the use of helmets or headgear has been discussed as a counterintuitive way to decrease brain injuries, with the idea being that athletes wouldn’t use their heads as weapons or hit as hard if they didn’t feel as protected. In boxing, there also is the belief that headgear makes it harder to see to the side to avoid blows, and makes the head a bigger target.

There has been limited research to support this change, but fresh data, still unpublished, suggests the removal of headgear in elite, male amateur boxing reduces the incidence of concussion, according to the chairman of the AIBA medical commission, Charles Butler, a retired cardiac surgeon and ringside doctor, who spearheaded the study that served as part of the basis for the recommendation.

AAN Concussion Guidelines – One Stop Post

Here is the presser for the updated AAN Sports Concussion Guidelines; their guidelines are simple and to the point, via YouTube;

  • No Grading System of concussion
  • 10 day rest period – “key” – Dr. Jeffrey Kutcher
  • Greater risk if you have had a concussion
  • Addressing of youth and recovery
  • Helmets are not the full answer
  • Licensed Health Care Providers should be clearing
  • Repetitive head injuries are bad
  • The discovery and annotation of “Chronic Cognitive Impairment”
  • No single test, CLINICAL assessment
  • “Kids are not little adults.” – Dr. Christopher Giza

Here is the LINK to the Updated Guidelines (can someone give me permission to post it here?)

Here is the LINK to the Sports Concussion Toolkit from AAN

Here is the LINK to the Concussion Quick Check from AAN

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What does this mean in comparison to the Zurich Statement?  That is a great question; both groups used “consensus” however this group is much more centered on American practices.  Both have similar approaches, both advise nearly the same thing; but which one carries more weight.  I have been told the AAN will be much more “powerful”, respected and learned than Zurich.

This is a good debate, regardless, there is ample evidence to sit kids and any concussed individual.  This statement also continues the wave of information that cumulative and repetitive trauma to the brain (still figuring out thresholds) is not good.  Based on this and the Zurich statement the only way that we can collectively abate concussions at this point is exposure limitation.  No where in that last sentence does it state “stop playing sports,” or “get rid of football”.

When dealing with the brain and the injury of the brain less is better, which is ironically simple and a “no brainer”.

2013 Concussion Tracking – Need Help

Looking for some help out there…  Due to a myriad of factors I have let time slip away from me and have gotten behind the seasons for concussion data collection.

I am looking to keep current the NBA, NHL, MLB and AFL concussion lists; as of right now I have the AFL taken care of, the rest, not so much.

I have virtually missed the hockey season, I am hoping you all can fill me in with that.

I have a list of NBA concussions, but it seems that there has not be a single concussion in nearly a month;

Brea JJ MIN
Davis Anthony NO
Zeller Tyler CLE
Kidd-Gilchrist Michael CHA
Kaman Chris DAL
Gasol Pau LAL
Williams Marvin UTA
Melo Fab BOS
Shengalia Tornike BRO
Sanders Larry MIL

And the MLB season is in spring training and have caught only Steven Drew’s concussion to this point.

I am asking for all of your help.  If you wouldn’t mind posting a comment to catch me up (NHL send me an email), or tweeting concussions I would be very appreciative.

If anyone is going to have the time to be the “keeper” of the stats you may also email me your information and we can discuss how best to achieve the most complete lists.

Thanks again!

Nick Mercer: Finding yourself after a brain injury, first step – Recon

As has been said countless times in countless articles about brain injury, “every brain injury is different”. I don’t know and don’t care to know how many times I’ve heard or read it. That phrase is used primarily for the benefit the general public to explain or define a lasting injury about which little is known. Although geared towards people who have – seemingly – little or no experience with brain injury, the statement should still be understood as fully as possible by those of use who have such experience.

In 2003, until making a hard and fast right turn on my bike on a hill in Victoria, BC, I had every intention of completing my upcoming 8 month MPA work term with the Auditor General in Ottawa, and while there, continuing to ride my bike and join a local water polo club. When I finished my MPA I would work somewhere for a few years, then, hopefully, pursue a PhD.  The next morning, all that changed. Two weeks later, when I woke from my coma, I was a different person. Not completely different – I was lucky – but different enough that I had to change my plans for my future.

My focus wouldn’t be on finding an apartment in Ottawa or impressing my Continue reading

Capt. Peter Linnerooth – US Army

I was just minding my business reading the news and getting lost in my Sunday mindless exercise, when I came upon a news story that shook me – on many levels.  This story is about Captain Peter Linnerooth; a story worth noting and sharing.  Does it have to do with concussions, I don’t know and I don’t care, it has to do with the well-being of humans – a plight that is part of the concussion story.

Regardless the Sharon Cohen authored story on Capt. Linnerooth is well worth your time;

He had a knack for soothing soldiers who’d just seen their buddies killed by bombs. He knew how to comfort medics sickened by the smell of blood and troops haunted by the screams of horribly burned Iraqi children.

Capt. Peter Linnerooth was an Army psychologist. He counseled soldiers during some of the fiercest fighting in Iraq. Hundreds upon hundreds sought his help. For nightmares and insomnia. For shock and grief. And for reaching that point where they just wanted to end it all.

Linnerooth did such a good job his Army comrades dubbed him The Wizard. His “magic” was deceptively simple: an instant rapport with soldiers, an empathetic manner, a big heart.

The man knew how to handle others and create an atmosphere for helping on a battlefield and beyond;

He was, as one buddy says, the guy who could help everybody – everybody but himself. […]

“There’s no cavalry to save the day,” McNabb explains. “You ARE the cavalry. There was no relief.” […]

For about half his tour, Linnerooth’s office was a 12-by-12 trailer. His heavy-metal soundtrack – he banned the Beatles and Pink Floyd, deeming them too sad – provided a sound buffer. A thermal blanket serving as a makeshift room divider also provided a modicum of privacy.

Linnerooth brought hope to those gripped by hopelessness. In a desert, he could always find the glass half full.

He turned tragedies into cathartic moments: When a platoon lost a member, he’d encourage the survivors to deal with their grief by writing letters to the children of the fallen soldier, recounting the great things about their father.

Then the pressures were too much; Continue reading

Opinion on Zurich Statement

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 Continue reading

Zurich 2012 In Writing

If you all recall I went to Zurich in November to attend the “Concussion Conference”; mainly as an observer, but there was enough time and opportunity to impart my questions/knowledge as a practicing athletic trainer.  Here are the links to DAY 1 and DAY 2 of my live blogging.  By the way, the live blogging was WELL received and continues to provide great insight into what went on.  I hope that I am asked back for the next conference, or any other conference that wouldn’t mind my attendance.

Now the information gathered at the conference has been hashed and rehashed and now appears as the 4th Consensus Statement (tweeted previously).

As part of the initiative the Standardized Concussion Assessment Tool (SCAT) was looked at and changes were made to the 2nd version from 2008.  You can now find the new version by clicking SCAT3.

A new wrinkle was an assessment tool for the younger ages, the group decided on the “Child” version of the new SCAT3, that can also be found by clicking Child SCAT3.

Also included in the addendum of the Consensus Statement was a recognition pocket card, found by clicking Recognition Pocket Card.

All of the above is free and intended to be used as a resource for better concussion assessment and even early management of concussion.  Please read the Statement regarding best practices.  As always this blog is NEVER to be used to diagnose or treat a concussion.  There is a lot to be absorbed and read; one thing is for sure we as athletic trainers and concerned/educated individuals now have the most recent information at our fingertips.  I guess this blog is actually doing some good work 🙂  A side note; how about this appearing during National Athletic Trainers Month?  It might be a coincidence, but I find it serendipitous.

Moorad Sports Law Symposium: Concussion Conundrum

The concussion issue has permeated every facet of life and sport.  Now policies, products, rules and law are starting to address the issue head on (pun intended), and one of the most renowned groups is taking a look at this issue as well;

The 2013 Jeffrey S. Moorad Sports Law Journal Symposium—Concussion Conundrum—explores, debates, and informs on the key issues facing players, teams, leagues, doctors, and lawyers regarding head injuries and brain trauma in sports.

Panels include commentary from well-known retired professional athletes about concussion awareness and prevention amongst players; an examination of both sides of the NFL Concussion Injury Litigation—the concussion injury class action suit brought by former NFL players against the league; an exploration of the science and concussion-related liability facing professional and amateur sports; and a look at where we are and where we are going with media personalities commenting on the state of sports and concussions.

Andrew Brandt, Director of the Jeffrey S. Moorad Center for the Study of Sports Law and NFL Business Analyst, has covered the concussion issue for ESPN and moderates all panels.

The Symposium takes place on Friday, March 15, from 9 a.m. to 12 p.m., in the Arthur M. Goldberg Commons at Villanova University School of Law. This program is approved by the Pennsylvania Continuing Legal Education Board for 2 substantive CLE credits. The event is free for non-CLE attendees.

The panel and the topics are top notch; this event should be on the “to-do” list of  anyone interested in sports law.  Below is the topics and panels (check the website for more deets – also notice our partners at stopconcussions.com (Keith Primeau) and our good friend Paul Anderson);

  • Panel 1: Framing the Issue
    • Keith Primeau
    • Jim Nelson
    • Taylor Twellman
    • Brian Westbrook
  • Panel 2: Building the Case — A Legal and Medical Background of Concussions  Continue reading

Anyone Want Money?

Basic RGBWell according to our comment section there are many of you out there looking for solutions; along with the efforts of established companies, like the helmet makers.  Now you can draw up and submit any ideas to the efforts of General Electric and the National Football League;

GE and the National Football League’s Head Health Challenge I aims to develop new solutions to help diagnose mild traumatic brain injury and invites proposals for scanning technologies and biomarkers that can accelerate growth. This four-year, $60 million partnership aims to improve the safety of athletes, members of the military and society overall.

The above is only step one, you have 111 days left to complete step 2;

We are seeking viable technologies for detecting early stage mild traumatic brain injuries at all stages of development for Challenge I. Ideas are welcome from all industries, organizations, and technical fields.

Visit the above linked website for further details and required forms.  I implore those that feel they have a technological solution to make the effort.  I will say this as candidly as possible; you cannot do it alone, you WILL and MUST have the resources and “blessings” of the NFL to get things done in the concussion effort.

Latest Research on Concussions; Rather No Concussions = Changes

Certainly the research is flying in; mostly the investigations are now looking at either ways to detect the injury or objective ways to determine recovery.  There are a bunch of other designs and angles out there but the most important are the above.  Although it would be great if we had an objective way of determining concussion, it is really not the pressing issue (with solid education and conservative approach to injury – sit them out).

As I have stated over and over, the BIGGEST issue we face with concussions is the mismanagement of concussion from the beginning; therefore the need to identify when it is safe to return is more paramount in my opinion.

The newest research is out from the Cleveland Clinic, it looked at 67 college football players, more specifically it looked at their blood, report from WKYC;

In a study of 67 college football players, researchers found that the more hits to the head a player absorbed, the higher the levels of a particular brain protein that’s known to leak into the bloodstream after a head injury.

Even though none of the football players in the study suffered a concussion during the season, four of them showed signs of an autoimmune response that has been associated with brain disorders.

There we go again, telling and showing people that the hits that don’t elicit a concussive response are also a culprit in the brain injury crisis we are facing.  Coaches, particularly in soccer and football, will tell us that we are wrong and that it is either unproven or not a possibility because of how “safe” they practice or the equipment they have.

Back to the research, the group looked for the S100B protein that should only be in the brain;

Typically, S100B is found only in the brain; finding S100B in the blood indicates damage to the blood-brain barrier. While the exact function of S100B is not known, it is used in many countries to diagnose mild traumatic brain injury when other typical signs or symptoms are absent.

Studies in Janigro’s lab revealed that once in the bloodstream, S100B is seen by the immune system as a foreign invader, triggering an autoimmune response that releases auto-antibodies against S100B. Those antibodies then seep back into the brain through the damaged blood-brain barrier, attacking brain tissue and leading to long-term brain damage.

They also did some PET scans to Continue reading

Athletic Trainer Removed from Post for Standing Ground on Concussions

This is one heck of a way to start out National Athletic Trainer Month…

Paul Welliver, a name that should be remembered and learned about.  Welliver is a certified athletic trainer in Maryland and was until a few weeks ago the athletic trainer at Winters Mill High School.  The only one the school has ever known; being outsourced from Maryland SportsCare & Rehab.  The admin at the High School asked his employer to have him no longer provide service for them.  Welliver (at time of post) has not been fired from Maryland SportsCare & Rehab.

Why, you ask?

Because this athletic trainer stood up for what he believed and knows about concussions.  Unfortunately, this scene is all to familiar with us high school athletic trainers.  The story is from Carroll County Times;

The Carroll County Public Schools Supervisor of Athletics Jim Rodriguez and Winters Mill High School Principal Eric King told Welliver’s boss at Maryland SportsCare & Rehab that they did not want him to continue his position at Winters Mill, according to Welliver. After 10 years as the school’s athletic trainer, his last day was Feb. 12. […]

Welliver said on four different occasions in the last 18 months, he refused to begin the protocol that is meant to gradually release student-athletes back into sports participation after a concussion. The protocol, also known as Return to Play, is supposed to begin once a student-athlete returns a medical clearance form after their injury has been classified as a concussion.

In this school district they have a pretty solid concussion policy and protocol  highlighted in the story, however when the one person – and last line of defense for the student-athlete – stands up for the protection of the children he is summarily dismissed;

He said the athletic trainer has to sign off on a student-athlete’s return to full contact and competition following a diagnosed concussion.

Welliver’s refusal to start the protocol all four times was because he was concerned about the safety of the student-athletes, he said. He is worried about their short- and long-term health, he said.

“There are times when I do not believe they should return to the sport,” Welliver said. “It is not safe.” […]

“I treat all those athletes like they are my children,” he said. “Sometimes I spend more time with other people’s children than my own.”

He is exactly correct!  As if he had to really explain it to people who should not be part of the process he did for the article;

“I take into account many factors, including the number and severity of previous injuries and the age and grade of the student,” he wrote on Facebook. “It would be much easier to go along with the pressure of returning the student A.S.A.P., but I have seen way too many poor outcomes after multiple head injuries.” […]

In addition to his decision to keep student-athletes from playing their sport after a concussion based on age, grade and the severity and number of previous concussions they have experienced, he also takes into consideration the sport or sports the athlete would return to. Their return could take longer if they play high-collision sports.

Shockingly, the school district and those that put the separation is motion had no comment.

Welliver did and does it right based on all accounts, the man – athletic trainer – father Continue reading