concussions; what we don’t know

Thursday, October 13, 2016

Carson Palmer: concussion

Cam Newton- concussion

Sydney Crosby: concussion

NHL: new concussion screening policy.

Donald Trump- NFL need to toughen up; concussions around so bad.

And then there’s the knowledge gap.

“I don’t know.” Not the best thing to hear from your doctor after you’ve been examined. The expectation is that you go to the doc, get examined, you’re told what’s wrong, how you’re going to be fixed and when you’ll get better. That drill breaks down when the doc says “I don’t know”. Welcome to world of concussion.

Players and fans appreciate a potential head injury may occur with every play, but nothing is worse for the fan when the commentator announces that your favorite player is being evaluated for a concussion or in the concussion protocol. Those words are probably worse for the player. Whether it’s the NFL, NHL, MLB, NBA or MLS, the concussion protocol usually means that the player is gone for the game and perhaps, at least another week. The good news is that it may protect athletes after a concussion (regardless of Trump’s medical expertise), but the bad news is that nobody knows exactly how long to protect an athlete. Carson Palmer, Cam Newton, Sydney Crosby and the many other players who get hit in the head every week need to be protected, sometimes even from themselves, but how that’s done is up for debate.

Diagnosis

Concussion diagnosis is defined as brain injury and it’s easy to diagnose easy if the athlete is knocked unconscious, has visible signs of confusion or behavior changes. But the Zurich consensus on concussion in sports doesn’t require head trauma to make the diagnosis. Instead, the diagnosis only requires the head to be shaken, and just one symptom. That symptom might be as non-specific as not feeling right, being tired and fatigued, or becoming more emotional or irritable. There is no finding on physical exam, brain imaging (CT/MRI) or psychologic testing that can confirm or rule out the diagnosis. It is all based on self-reported symptoms.

Treatment

Concussion treatment is not necessarily evidence based. We don’t know how long it takes for the brain to heal after being concussed and the assessment decisions to allow sport participation often depend upon the athlete self-reporting symptoms and healing. And since many elite athletes are motivated to play, there are no tests available to confirm that the athlete is telling the truth and the brain is actually better. Anecdotes exist that suggest some athletes try to do poorly on preseason brain testing, so that if a concussion occurs, they can “pass” a test that compare brain performance before and after the injury. They set the bar low early to be able to clear it later.

Return to Play

The protocols that allow return to play protocol are arbitrary and while most concussion may resolve within 7-10 days, there is no objective test to know whether complete healing of the brain has occurred. According to the Zurich consensus, after a concussion, the athlete moves from one activity level to the next, as long as they are symptom free. If symptoms occur, then the progression through the protocol is delayed:

  • Day 1     No activity
  • Day 2     Walking, swimming or stat8ionary bike to increase the heart rate but no too much (just 70% of max)
  • Day 3     Sport specific exercise but no head impact activities, like heading a ball in soccer, or leading with the head or tackle in football
  • Day 4     Noncontact training drills that require increase information processing of the brian like passing drills in football or hockey
  • Day 5     If medically cleared, full contact practice
  • Day 6     Return to play

The long term effects of a concussion are still unknown. Does it take just one? Are lots of “small” concussions as ominous as one “big’ concussion? Can the effects of concussion be reversed?

In the real world of concussion, there is a lot of “I don’t know”. While the NFL and the NHL have empowered referees to pull players out of the game and have independent spotters monitoring replay video, it’s important to remember that concussion symptoms can be delayed. The Zurich consensus states it plainly, “…that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage.”

The logical application should be that if a player is pulled out of a game for fear of concussion, regardless of the sideline testing result, that player should be done for the day, since the sideline medical crew “won’t know” if symptoms will progress over time and in medicine, erring on the side of caution is never a bad thing.

But logic and pro sports don’t always go hand in hand. What we see on any given Sunday tends to filter down to the college, high school and even middle school levels. Pro athletes get paid to abuse their body and should know the inherent risks of their profession. Amateurs are trying to grab the brass ring to compete at the highest level of their sport. Most won’t get there and it’s the medical and coaching communities’ responsibility to protect younger, more fragile brains from long term damage. The problem is that we don’t just don’t know how.

 

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Too many tests

Monday, August 25, 2014

In our mind’s eye, we could all throw it like Peyton, hit like big Papi and be like Mike. But while we aspire to their greatness, we should not ask to have their medical testing inflicted upon us. Today’s elite athletes can no longer be content with medical opinion, rather they or their team management expect that the latest technology be used to help make the diagnosis.

The latest victim of this syndrome is Carolina Panther quarterback, Cam Newton, whose rib injury during a preseason game might have been diagnosed with a brief history and physical examination. Mere mortals might have needed a plain chest x-ray but Mr. Newton also got a CT and MRI of his chest. The verdict? He had a nondisplaced rib fracture. And how did those extra tests affect his care and treatment? They didn’t.

Medicine has gone high tech with imaging tests that can peer inside every nook and cranny of the body to find things that may or may not matter. Chest wall injuries area prime example of what if gone wild. The ribs and muscles that make up the chest wall serve a couple of purposes. Most importantly, they act as a bellows, swinging up and out to suck air into our lungs to help us breathe and then again squeezing back in to make us exhale. It doesn’t matter if a rib is bruised or broken, the pain of either injury makes it difficult to take a deep breath and that interrupts the mechanism of breathing. When the lung does not adequately expand with inspiration, the patient runs the risk of getting pneumonia, an infection of the lung, and that is the great complication of a rib injury. The ribs also protect those organs that are located beneath. The lungs are obvious but the lower ribs also protect the spleen and liver in the abdomen and lower chest trauma can cause damage to the upper abdomen.

This is where the art of medicine comes in. Taking a history allows the doctor or other care provider to understand how much force was inflicted upon the patient and understanding the patient appreciates how much force they can withstand. A frail elderly patient who falls against a countertop and injures ribs is perhaps more likely to have underlying damage than a padded quarterback being hit by a linebacker. The physical examination can help decide whether a small area of the rib cage is damaged or whether numerous ribs are injured. The larger the injured area, the more likely that the breathing mechanism is compromised and the potential for complication increases. For most patients, a plain chest x-ray is adequate to look not for rib fractures but for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Ordering rib x-rays to look for a fracture is a waste of time, money and radiation. Physical exam will also tell you whether there is enough abdominal tenderness to us CT to look for internal bleeding.

But the art of medicine is not infallible and perhaps that is feeds the fear of missing an injury. Green Bay Packer center TJ Tretter hurt his knee early in the game against Oakland but played on after doctors evaluated him on the sideline and cleared him. Unfortunately, he had a fracture that will sideline him for the next many weeks. The same fear also feeds the use of CT to routinely evaluate concussions when there are clinical guidelines that can help decide who needs a scan and who doesn’t.

One can appreciate the high medical tech approach to those athletes whose salaries run into the tens millions of dollars and those teams who market the player to their maximum advantage, yet the general population takes their cue from what they see on the field, on the sideline and in the training room. Ideally, regular folk should ask the doctor why a test is being ordered and what benefit it will bring. Sometimes, tests are ordered just because with little thought. Other times, the decision as to what test to perform takes great thought. Sometimes, there is risk management involved. The doctor doesn’t want to miss a diagnosis, not only for the patient’s sake but also for fear of being sued. In many situations, if the patient were asked, they might agree the risk of missing the diagnosis was not enough to perform an expensive or painful test.

This shared risk happens routinely when a diagnosis has been made and treatment options are being contemplated. The patient often helps decide if they want aggressive or more conservative treatment options or perhaps an operation now or later. There is no reason that the process of involving the patient cannot happen earlier in the diagnosis phase as well. The key is communication is to allow the patient to become a partner in the all decision making process and not the object of it.

For Mr. Newton, his ribs are going to hurt for the next few weeks, regardless of whether they are broken or bruised. It will hurt to take a deep breath or to twist to throw or hand off the ball. It won’t matter that it took a CT scan or MRI to make the diagnosis of the broken rib. A good physical exam might have been enough, but it wouldn’t have been perfect…but even the best rarely are.

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