Delaware Youth Concussion Summit – Wrap Up

A regular reader and a very good friend to The Concussion Blog was fortunate enough to attend the Delaware Youth Concussion Summit the past week.  I had asked her to write-up a report and she kindly and succinctly did that for TCB.  Because of Dorothy Bedford I can bring you this information, thank you.  This is also a reminder that if you attend a conference, symposium or summit and feel the information would good for the readers you are more than welcome to submit it so us in a .doc or .docx form and we will publish.  Without further ado here is Dorothy’s contribution;

The Delaware Youth Concussion Summit, an initiative organized by the State Council for Persons with Disabilities Brain Injury Committee, Nemours/Alfred I. DuPont Hospital for Children, and the Brain Injury Association of Delaware, yesterday released its three-point Action Plan regarding the diagnosis, management, and return to activity for the rising number of young people sustaining concussions in sports activities. Participants in the summit and action work groups include leaders and experts in medicine, neuro-psychology, education, sports, advocacy, state agencies, and elected officials.

The Summit aims to further the aims of Delaware’s concussion legislation, signed in August 2011, which mandated both concussion training for all DIAA coaches and awareness training for parents and athletes, and set some rules around written medical clearances before returning to play.

After convening in May 2013, the Summit divided itself into working groups and today announced three focus areas for further action:  Continue reading

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Interesting Find This Morning

NFL Screen Shot 9.17.13The title and the article is nothing new, we have known for some time that computer based neurocognitive testing is not perfect.  Some have even concluded that these type tests are not worth the time and money.  More and more I am hearing from professionals that feel that they HAVE to give this tests or others like it, even though it’s not precise enough in cases.

What is interesting to me is the website it appeared on, NFL.com, the one league that has propelled this product more than any other.

The timing of this article is also curious to me as well.  Lately I have been getting many emails regarding computer based testing and the need for it and my overall thoughts on them.  Perhaps there is a wave of skepticism regarding this tool, which is nothing new, or perhaps there have been more and more issues with these tests, now that they are being used by so many.

There is no doubt there has been an impetus upon Continue reading

Next Level… In Concussion Care

As an athletic trainer – an opinionated one at that – I struggle with all the “bells-and-whistles” in this conundrum that is the concussion issue.  If you have visited here or heard me speak you undoubtedly know that mismanagement of concussions is the true issue of this complex paradigm.  Yes, we need to know when a concussion occurs to begin the process in the right direction; however, this can be accomplished by simply making sure you have a trained medical professional on hand when the need arises.  Getting an athletic trainer to cover the most at risk sports at the most at risk times is a great start (and in the authors opinion is the only choice if you want to have collision sports).  Short of that, education over-education is necessary for everyone: players, coaches, parents, officials, teacher etc. to properly identify and accept the nature of concussion in sport – it is a risk.

Even having an allied medical professional, like an athletic trainer (AT) at practices and games does not stop the injury from occurring.  In fact, many products that may claim reduction in concussions or “possible concussions” are toying with fraud; at the very least they are practicing deceptive marketing.  The point being, once we identify a concussion how do we and who do we send the injury to, to avoid the rest of the iceberg lurking under the surface of the water?  Moreover, what tools do we have that can help get the right prognosis, treatment and recovery for the injured (and there are many out there)?

I feel there is a new product (I am not a paid endorser, nor have I been given compensation for this article/opinion) now hitting the market that may get us closer to the panacea that we are all hoping for (note I said “closer”).  Although it may have been presented as some big secret; the C3 Logix: Comprehensive Concussion Care system is not a secret rather it is something I feel is a “game changer” for concussion care.  It is Continue reading

Why Are We Here? Confusion and muddy water

With all the work that has been done up to this point with concussions I truly believe that we should have a better grasp on this injury.  Recently, we have seen some very confusing information come forward, I feel the message has been mixed and may lead to further issues when handling concussions.  Patrick Hruby, in his article on Sports on Earth, takes a very critical look at the Collins research as well as other studies that have pointed to the players being the problem in this concussion issue.

It is not the players fault, it’s not the referees fault, it’s not the coaches fault, it’s not the sports fault.

I do think that football and collision sports do require some sort of “full” practices in a controlled environment.  Although the actual speed of a game is difficult to replicate in a practice, full-go is needed for players to understand the closing speeds, angles and decision-making of the sport.  Without a full grasp on this the player may be at further risk for overall injury in sport.  It would be insane to have a football, hockey Continue reading

Downplaying brain injury is not the way to attack this

Concussions have gained so much attention that the news is almost inundated with story-after-story of occurrences, recovery, litigation and people trying to mitigate the injury.  There seems to be a shortage of press clipping and stories on how to handle this injury.  More often I have witnessed stories downplaying the injury or the oft cited “Heads Up Football“.

The former, downplaying the injury itself, is not a good thing it is exactly what put us in the spot we are in now.  Patrick Hruby also took note of this while reading an article from Andrew Wagaman in the Missourian;

Still, when it comes to the single most head-scratching public statement I’ve seen regarding brain trauma and football, University of Missouri neuropsychologist Thomas Martin takes the pole position. Hands-down. In a piece about youth football and cognitive risks published this week in the Columbia Missourian, Martin compares brain damage to … knee injuries[…]

This blew my mind. I had to read it twice. And then a half-dozen more times. It still blows my mind as I’m typing this. Here’s why people react differently to brain and knee injuries, and why football is in a world of potential trouble: because the potential harm resulting from a brain injury is nothing like that resulting from a knee injury.

If you read Hruby’s article you will see he makes a strong case for this analogy being utterly false; Continue reading

Archaic Thinking/Management of Concussion Not Just a N. American Issue

I have cataloged this problem many times in many sports across the world.  It seems that perhaps the focus and glare is greatest here with North American sports (mainly football and hockey), but this problem extends further.  This issue perhaps came to a head in the UK over the past week with this article by Tom English;

Barry O’Driscoll played rugby for Ireland in the Five Nations championship of 1971.

As a respected doctor (whose son was team doctor for Ireland and the Lions in the recent past) with a background as an international full-back he became an important figure on the International Rugby Board where for 15 years he held positions on the medical, anti-doping and disciplinary committees. Until late last summer, when he resigned.

Dr. O’Driscoll left his post because of the way the International Rugby Board (IRB) was/is handling concussions on the field and in general.  As an aside, the IRB is a founding partner of the Zurich statement as well.

What would make a highly trained and well-respected doc – with rugby in the blood – step away?  Take a look, specifically at what happened to his nephew;

After one collision too many that day Brian O’Driscoll lost his bearings, was clearly unsteady on his feet and had to be helped from the field, like a boxer assisted from the ring. You did not need experience in pathology to know that the great man was out of it for a moment in time. Yet a few minutes later he was back on the pitch, supposedly as bright as a button and fully recovered.

He was back on the field because ?????;

There is an accompanying rule now – still on trial – and it states that if a player with suspected concussion can pass a series of tests lasting five minutes then he can be allowed back into the fray: the Pitch Side Concussion Assessment (PSCA) – or the five-minute rule.

Even worse the “new” rule was not even in place when his nephew sustained his concussion, leading the good doc to question what the sanctioning body and the medical board was doing;

“Rugby is trivialising concussion,” he says. “They are sending these guys back on to the field and into the most brutal arena. It’s ferocious out there. The same player who 18 months ago was given a minimum of seven days recovery time is now given five minutes. There is no test that you can do in five minutes that will show that a player is not concussed. It is accepted the world over. We have all seen players who have appeared fine five minutes after a concussive injury then vomiting later in the night. To have this as acceptable in rugby, what kind of message are we sending out?

“If a boxer cannot defend himself after ten seconds he has to have a brain scan before he comes back. And we’re not talking ten seconds for a rugby player, we’re talking maybe a minute that these guys are not sure what’s going on. They don’t have to have a brain scan, they have to have five minutes where they have to stand up straight without falling over four times, they have a basic memory test – ‘What’s the score? Who are you playing against? Which half did it happen in? And do you have any symptoms?’

“These questions should serve as a landmark for when you examine them six hours later to see if they’re getting worse or if they’re bleeding into their brain. That’s why you ask them, not to see if they can go back on. They are already concussed at that point. You don’t need to ask questions to find that out. If six hours later their responses are worse than they were earlier you say ‘Wait a minute, this shouldn’t be the case, is this guy going to bleed?’ That’s why you ask the questions and so it has always been. But we’re going in the other direction now. We’re going from being stood down for three weeks to one week to five minutes with players who are showing exactly the same symptoms. The five-minute rule came out of the blue. I couldn’t be a part of it so I resigned from the IRB. It saddened me, but I couldn’t have my name attached to that decision.”

As you can clearly see some places are not quite ready to accept the real issue of concussions – not the actual injury – the mismanagement of the injury once it occurs.  If the IRB places the new “five-minute pitch side rule” into place they are going in the absolute wrong direction.

If any player in any sport shows clear signs of concussion they should be removed and not allowed back in, period.  Even Zurich, which the IRB is part of states this.  Dr. O’Driscoll is merely saving his reputation by stepping aside, and in my opinion it is the exact correct move.

 

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.

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”.

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

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

Team Gleason PSA – Hey NFLPA Please Read

I received this from an anonymous source and was asked to spread this news, hopefully it will reach those it is intended for…  How bout you watch the video first then go to the Team Gleason website;
Subject: PSA release: NFL Players and Coaches stand together to cure ALS
Hi everyone…I hope this email finds you well…
Just wanted to let you know that beginning today, we at Team Gleason are rolling out a new ALS awareness campaign to be introduced this week in New Orleans for the Super Bowl.
Here’s a link to the video, which takes viewers directly to the Team Gleason website:
This is important, please spread if you get the chance…  This is NOT JUST A FOOTBALL PROBLEM, this is a problem for everyone!

NFLPA News

So at 3:15pm EST the NFLPA will hold a news conference to discuss some “goings on”; the biggest nugget in this presser will be the announcement of a 100 million grant for Harvard over 10 years to study them.  All aspects of player health is the word I seem to be getting.  Which is good, because for a long time the former player has been neglected and has led to current and future players taking risks their bodies will not be able to cash in down the road.  I believe you can catch it live on YouTube as well, perhaps someone can provide the link in the comments…

In other NFLPA news, Deadspin and Barry Petchesky wrote about how players are overwhelmingly disenfranchised with the medical care they receive as a big-bad NFL player;

An NFLPA study, the results of which were obtained by the Washington Post, finds that the vast majority of players have serious doubts about the care they’re provided.

The NFLPA asked its players to gauge on a one to five scale how much they trust their team’s medical staff. Seventy-eight percent of respondents said five, meaning they’re not satisfied at all. An additional 15 percent said four, and just three percent responded to the question with a one or a two.

“The most troubling aspect of the survey for me is that lack of belief that the doctors are treating them for their players own health, safety and wellness reasons,” DeMaurice Smith said.

Perhaps this is why the NFL is entrusting the elite Harvard to study such things and happenings to players over a long-term time frame.  Petchesky  also takes part of the article to touch on the conflict of interest (COI) that is VERY rampant on the NFL sidelines concerning medical care.  If you have followed and read here long enough you will know it is something that we have been harping on for over two-year and one of our illustrious commentators, Don Brady, has written a dissertation that includes this problem.

Simple facts are that the team athletic trainers are paid by the team, not the players, and in a majority of NFL clubs the “team doctor” is actually paying for the privilege.  In a business model, it would appear – in my humble opinion – that the teams are making sure their priorities are met when it comes to injuries.  NOW HOLD ON…  There are some very outstanding athletic trainers and doctors that roam the hallowed sidelines of the National Football League, and they are VERY VERY VERY good at what they do, but the appearance – TO THE ACTUAL PLAYERS – is that their medical care may not be in their best interest.

I am not throwing anyone under the bus here, I am merely Continue reading

Quick Hits on a Cold Thursday

American Medical Society of  Sports Medicine Position Statement…

I had seen this but caught it again in a below article, the AMSSM released its position statement on concussions recently.  Most of those involved in writing this were in Zurich last November and this comes out about two months before the consensus statement is released in the British Journal of Medicine.  (pssssst – it is also going to have a release in Australia, in conjunction with the AFL Concussion Conference and first round of games and I am still looking for a sponsor)

I found one piece of this position statement very encouraging and made me smile for all the hard work others have done;

Return to Class

* Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from concussion.

The rest of the statement is not really “Earth shattering” but there are interesting points in there;

* In sports with similar playing rules, the reported incidence of concussion is higher in females than males.

* Certain sports, positions, and individual playing styles have a greater risk of concussion.

* Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.

* Balance disturbance is a specific indicator of concussion but is not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat type or surface, use of ankle tape or braces, or the presence of other lower extremity injury.

* Most concussions can be managed appropriately without the use of neuropsychological testing.

* There is increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae.

* Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale, epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment.

* Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.

* Helmets, both hard (football, lacrosse, and hockey), and soft (soccer, rugby), are best suited to prevent impact injuries (fracture, bleeding, laceration, etc) but have not been shown to reduce the incidence and severity of concussions.

* There is no current evidence that mouth guards can reduce the severity of or prevent concussions.

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X-Games, D on coverage…

Anyone catch the X-Games this past weekend?  Action sports are on the rise and the X-Games Continue reading

Matt Chaney – Tireless Worker

SpringGame1984Sideline
If you have been around enough you have seen the stylings of Matt Chaney on this blog, he is someone I call a friend.  In some circles that discounts me as a professional, which is both stupid and dumb.  I don’t always agree with Matt, heck him and I have been known to battle via electronic and phone communications.  However, his opinion is a valuable one – often his work is based in so much fact it makes your head spin as to why some of its missed.  Regardless, Matt has published two recent articles on his blog, for all to consume, here are some excerpts.

Part 1, published January 7th;

Historic football excuses thrive in modern debate over brutality

Lawsuits, criticism explode and officials project blame onto individuals

Old talking points of football apology resonate yet as officials tout anti-concussion measures like trainers along sidelines, new rules for safer play, injury reduction and expert consultation—same type of promises heard from gridiron leaders during the Victorian Era

American football gets lambasted in public for maiming and killing, denounced by an influential movement of critics, and game officials pledge safer play based on their new concepts of prevention, including:

*Qualified trainers and doctors will patrol sidelines.

*State-of-art medical response will treat the rare severe casualties.

*Limits will govern length of practices.

*Injury tracking will cut rates already on decline.

*Coaches will properly train players.

*Every player will undergo medical prescreening.

*Experts will lead safety reform in rulemaking and research.

*Referees and coaches will enforce new rules of experts.

*Players will follow new rules of experts.

Sounds familiar, these steps, a practical recitation of talking points for contemporary “safer football” promoted by the NFL and commissioner Roger Goodell, in face of lawsuit frenzy against the league and sport in general, along with festering disgust in the public.

Except the football rhetoric is 119 years old, from 1894, a packaged response during the game’s initial siege against formidable opposition seeking abolishment. Continue reading

Coach & AD Magazine Cover Story

cover picIn January’s edition of Coach and Athletic Director Editor-in-Chief, Michael Austin wrote the cover story on concussions; titled “What you’re missing when it comes to brain injuries”.  A very well researched and written article on concussion issues at the high school level.  Austin looked at the changing protocols, safety issues and legal concerns that will be facing the sports of our community schools now and in the future.  Here are some excerpts;

This isn’t just a football problem.  Media coverage focuses on the gridiron, but any time a player’s head is placed in harm’s way, a brain injury is a potential result.  “From what I see, football leads the pack by far but we’re also seeing more girls and boys soccer players sustaining concussions,” says Dr. Michael C. Koester, MD, ATC, who is the director of the Slocum Sports Concussion Program within the Slocum Center for Orthopedics and Sports Medicine in Eugene, Ore. “Interestingly this year, and this could just be a statistical blip, but it’s worth noting we are seeing more girls volleyball players as well.”

That comment struck me as in the fall I saw more junior high school volleyball concussion (5) than high school football concussions (4), I have no idea what that means.

In the area of classification, Austin does a good job of trying to put ‘mild’ to rest with concussions;

Dr. Gerard Gioia, the director of the Pediatric Neuropsychology Program at Children’s National Medical Center and the director of the hospital’s Safe Concussion Outcome, Recovery & Education (SCORE) Program, says the medical community has “dropped the grading system” when it comes to concussions.  He adds a common misnomer is the
suggestion you must have loss of consciousness to sustain a concussion, which is not true.  “You can’t call a concussion
‘mild’ just because someone isn’t knocked out for 10 minutes. Most concussions do not involve a loss of consciousness,” Gioia says.

Regarding the state legislation and protocols;

“The No. 1 goal is to get the student-athlete back to school without symptoms or ramifications before even thinking about a return to the sport,” Fink says. For coaches anxious to have the player return to the field, Fink tells them every athlete Continue reading

Another Upcoming Concussion Symposium – January 25th

Time is short on this, I understand, but I just was dropped a note about this symposium being held in Chicago.  Once again yours truly has “commitments”, this time it is a wrestling dual tournament – where my services are needed more.  Regardless, when I looked at the faculty list and the speaking topics my interest was piqued.  BIG NOTE here it is only $25 for athletic trainers to attend ($60 for physicians).

The lecture is going to be directed by Julian Bailes, MD and David Firm, MD, PhD, both unheralded leaders in the field of brain injury.  What is more interesting than that is the fact that two relative “quiet” doctors will be presenting their information.  Both of these men are “controversial”; one is seen as an extreme outsider by the NFL and the powers that be in their corner – Dr. Bennett Omalu the other has had his share of issues, mainly in the press (see Irv Muchnick), for previous perceived mishandling of concussions in the NFL and WWE – Dr. Joseph Maroon.

Unlike the symposium I posted about yesterday, there are no athletic trainers on the speaking panel, to me that is a shame as the athletic trainer is the front lines on concussions in sports (mainly HS up).  Here are the topics, Continue reading

Concussion Symposium March 2nd

I received the following press release about a Concussion Symposium coming up in March.  The faculty is not your “usual suspects” rather some very good and known people in the medical field.  If you get the chance to head down to Texas for that Saturday I believe you will not be wasting your time or resources.  I would love to make it, however I have a prior commitment; that being said someone take good notes for me.

I would also like to add that having athletic trainers on the program list legitimizes this symposium in my mind.  Here is the presser;

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Austin, Texas (PRWEB) January 10, 2013

Concussion Compliance presents “Bridging the Gap on Best-Practices in Concussion Management.” This day-long exchange, sponsored by St. David’s HealthCare, brings together leading medical experts and practitioners to discuss the issues dominating today’s best-practice concussion management and how to incorporate the guidelines as well as the use of several tools into clinical practice.

The national symposium will be held March 2, 2013, at the Norris Conference Center, Austin. Registration is now open

“Communication and education that crosses traditional boundaries are key factors to providing good concussion treatment for our young athletes,” said Theodore Spinks, M.D., chair of the symposium program planning committee. He is a board certified neurosurgeon seeing patients in Austin, Round Rock, and Georgetown, Texas. Dr. Spinks currently serves on the CDC Expert Panel for Pediatric Mild Traumatic Brain Injury. He also served on the Texas Medical Association Committee on Concussions in Athletes during the last session of the Texas Legislature.

The symposium program provides an overview of the current best practices and consensus statements on concussion management, the latest scientific research, an update on tools available to practitioners, and perspectives from experts in concussion management.

  •     Featured Topics – The Physician’s Perspective; An Athletic Trainer’s Perspective; Head to Head: Cognitive Testing; Beyond Cognition: Balance Testing; A Look Into the Future: Vision Testing; Neurosurgical Management of Head Injuries and Concussion; Implementation of Best Practices Into Clinical Practice
  •     Keynote Speaker – Dr. Steven Erickson will present on the latest best practices in concussion management. Dr. Erickson is the medical consultant for Major League Baseball caring for the umpires and serves on the Major League Baseball Medical Advisory Committee and the Major League Baseball Mild Traumatic Brain Injury Committee.
  •     Reading of Proclamation from Governor Perry’s Office – March Concussion Awareness Month in Texas
  •     Exhibit Hall – Featuring the newest in technology, practice services, practice information, and pharmaceuticals

In addition, Governor Perry has Continue reading

National Concussion Awareness Tour

It is an idea that can catch on, real quick, it has the basic tenet of education/awareness at its core, with the right promotion and teaching/tools I am in agreement this will do some good.  The plan is to have a national concussion awareness month, September, and along with that have a tour across the United States.  Instead of me trying to explain it, here is a promotional video, geared to finding sponsors for this event;

I do not endorse the Shockwave System, I am only endorsing the idea of an awareness tour….  Heck I don’t even know about baseline and/or neurcognitive testing…  However the idea to inform everyone is sound…

Possible Biomarker? Possible Definitive Imaging?

Biomarkers are the next frontier in the concussion realm, really any specific and reliable objective measure to confirm a concussion.  Currently we can view concussion a “diagnosis in absence”; meaning if you have head trauma and there is no remarkable imaging the default diagnosis would be concussion.  This can be effective if there were enough signs that warranted the exam or the individual was truthful about symptoms; but what about the population that either does not respect/believe concussions or refuses to accept that they are a brain injury?

That is why the race is on to find either a biomarker or imaging technique that someone can say; “look, see these numbers/images, it means you have a concussion.”  This is great if the process of evidence based practices (EBP) was swift and widely accepted; the sub-issue is that there is ALWAYS “more research to be done”.  The first study deals with not a blood drawn biomarker, rather an imaging measured biomarker.

Dr. Michael Lipton of the Albert Einstein College of Medicine in New York presented this information recently;

In a single-center, case-control study, patients with mild traumatic brain injury (TBI) who had more abnormally high fractional anisotropy (FA) had fewer concussive symptoms and better quality of life a year after their injury than those who had less of the biomarker, […]

“If abnormally high FA represents neuroplastic effects, and if that’s how people recover from brain injury, it would be possible to use this in translational studies to identify the underlying mechanisms of pathology and to identify therapies that don’t look at how we fix the damage, but how we enhance the brain’s ability to compensate for that damage,” Lipton said during the briefing.

[…]
Overall, all patients had detectable areas of abnormally high FA: some had more, others had less, Lipton said.

But those who had higher levels of abnormally high FA had fewer post-concussive symptoms and better health-related quality of life a year after their injury, he reported.

Higher levels significantly predicted improvements in concussive symptoms (P=0.01), as well as better outcomes in terms of the quality-of-life outcomes of mobility control (P=0.024) and psychological functioning (P=0.007).

This suggests that the “brain is compensating for its injuries,” Lipton said, and that high FA “may be a manifestation of neuroplasticity.” Because the brain does not form new axons, he said, it could be that the connections between existing axons are changing or strengthening.

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At the same time  a group led by Dr. Yulin Ge found and published in Continue reading

Ding, ding, ding!

I recently read a story in the Globe and Mail, “Stampeders backpedal on concussion talk” about Calgary QB Drew Tate who was hit in a head-to-head collision in the 2nd quarter of play on Sunday, November 11. At halftime, Tate said that he had his “bell rung” and couldn’t remember the first half of play, generating this comment from Eric Francis of the Calgary Sun, “All the questions Monday will and should revolve around the apparent silliness of letting Tate play after his halftime admission to TSN.” (emphasis added) Not to worry though, according to Tate all that really happened is that he was “dinged” and “felt some fuzziness”, besides, as Tate says, “As far as talk about a concussion, I didn’t get what the fuss was because I felt fine and just wanted to play.” The Stampeders administered concussion tests during the game, after the game, and Monday morning. Tate was ruled to be symptom free.

It seems fairly clear that Tate was concussed. However, not according to Dave Dickenson, Calgary’s offensive coordinator and a former QB, whose diagnosis was that  he “can tell when I look into someone’s eyes if they are concussed or not,” and he didn’t see any symptoms. Nevertheless, Chris Nowinski knows a thing or two about concussions, concussion management, and the Continue reading

NFL Makes Case For No Indpendent Neuro

Finding a true “independent” health care provider for concussions in the NFL is a sticky situation; the NFLPA says they want one and the League is saying no.  Of course there are various reasons as to why the League would not want an independent neuro there; cost being one issue, the other issue is that the players may actually be in greater peril – and I agree.  Dr. Richard Ellenbogen co-chair of the NFL Head, Neck and Spine Committee explained this in an article in USAToday;

“No one knows the players as well as the athletic trainers, period.

“Having said that, some teams already have neurosurgeons on the sidelines. Having a doc show up just for a game takes away from the all-important baseline exam and continuity of care. It would be like getting operated upon by a surgeon who did not see you pre-operatively. Is that safer than having someone who saw you beforehand? The baseline is all important in making an assessment if a player is OK after a hit.”

Concussion are so subjective, most cases do not involve overt signs and it is incumbent upon the player to report what is going on.  Trust is a HUGE factor for players – of all ages – but more so in the NFL where they are making a living by playing football.  Although the tests are there and meant to be as objective as possible it is still a clinical diagnosis overall.  The only health care professional Continue reading

Good Reminder About Rest After Concussion

This blog post was made a while back, from time-to-time I will republish them with associated comments that resulted.  This topic is about “rest” after the injury.  Most if not all medical professionals now prescribe this method, but as we found out in Zurich recently, the research behind exactly what “rest” is and for how long is unknown.  What is known allowing the brain to settle down for a period of time is highly beneficial.

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Although most point to physical rest as the major component of concussion management the truth of the matter is that all activity that affects brain activity needs to be limited after a concussion.  If we use the “snow globe” analogy; all the flakes in the globe must come to rest before exposing it to further activity.  What excites the “flakes” or brain, honestly, just waking up does this.  That is why I have been hammering on the need for COMPLETE rest after a concussive episode.  It is also why I am a firm believer in getting kids out of school while the brain injury heals.

This information is not new to you that read the blog, but it seems that this management technique is just catching on as a principal protocol, rather than using it if there are setbacks;

“There is so little we really know about concussions,” said Dr. Mary Dombovy, vice president of Unity Neurosciences, which includes physical medicine and rehabilitation, neurology and neurosurgery. “We’re learning more as time goes by. What we’re learning is it’s not just physical exertion that is making the brain work harder. School tasks, studying for tests, trying to write a paper, these things are very stressful for people who’ve had a concussion.”

It is not that it is stressful, per se, it is that the brain is FUNCTIONING to do those tasks and like getting on crutches for a broken leg, the only way to get the brain on “crutches” is to not give it any stimulation.  Along with that comes how long and what to do when symptoms have gone, to me it is obvious that this is where you then begin the Zurich RTP protocol (the current concussion management protocol I use).

What I am having a hard time fathoming is Continue reading

Hammering Home The Need For Athletic Trainers

I published this 10/22…  Since there has been higher volume as of late, I feel it is a good time to repost.  There is also another article by John Doherty that supplements this, HERE.

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In findings released today in New Orleans it is becoming more clear that athletic trainers play a vital role in secondary level athletics.  Using reports from 2006-2009 in various injury reporting systems there has been significant findings about injuries and concussions;

Overall injury rates were 1.73 times higher among soccer players and 1.22 times higher among basketball players in schools without athletic trainers. Recurrent injury rates were 5.7 times higher in soccer and 2.97 times higher in basketball in schools without athletic trainers. In contrast, concussion injury rates were 8.05 times higher in soccer and 4.5 times higher in basketball in schools with athletic trainers.

Not having an athletic trainer predisposes the athletes to greater risks, not from the usual sporting activity, but playing with injuries that can develop into greater problems.  Athletic Trainers also have the educational background and grasp of prevention of injury; either through (but not limited to) nutrition/hydration or conditioning of the body.

Athletic Trainers are also on the forefront for concussion awareness, education and assessment, often the first allied health care professional to see the problem and identify it.  As much as I hammer home Continue reading