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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lessons learned from the playing field

Monday, January 18, 2016

Learning about medicine from the playing field.

Randall Cobb of the green Bay Packers, leaps to catch a pass, lands awkwardly and sustains a pulmonary contusion, or bruised lung. After coughing up some blood, never a good thing but many times not disastrous, he is observed in hospital and is discharged home where his lung will slowly heal, just like any other bruise. The injury is a reminder that with chest trauma, and many people fall and hit their ribs, the x-rays done are to evaluate the lungs and not the bones. Doctors are more interested in whether there is a collapsed lung (pneumothorax) or lung contusion, while the patient is more interested in whether there is a broken rib. Regardless of whether the ribs are bruised or broken, the treatment is the same: pain control so that the patient can take a deep breath and expand the lung to prevent pneumonia, the most important complication of a minor chest injury.

Steeler receiver, Antonio Brown, suffered a concussion in the game against the Cincinnati Bengals and within 24 hours there were reports that he would be recovered within the week to play in the team’s next game. He did not. After his concussion, Green Bay Packer, Sam Shields took a month to recover before play9ing again. It is a reminder that there is no way to predict the brain’s path to recovery from concussion and there is no definitive test to determine that a brain has fully recovered and is able to withstand another blow. No matter the NFL protocols, concussion remains a diagnosis made at the bedside and return to play has no standard playbook to follow.

finger bony anatomy

Carson Palmer of the Arizona Cardinals had a new splint on the right index finger of his throwing hand to protect the PIP joint that had been dislocated. Fingers have three joints (the thumb has two), the metacarpophalangeal (MCP) that connects the finger to the hand, and the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joint. The PIP joint is commonly dislocated and can heal relatively easily but because of the complex anatomy of the hand, the bones can damage the tissues and tendons that surround the joint when they dislocate. Complications include a volar fracture of the thin plate of bone on the palmar surface of the joint can be broken, leading to joint instability and a boutonniere deformity where the tendons slide to the side of the joint and prevent the finger from completely straightening. It’s a reminder that hands are complicated and minor injuries may lead to major long term complications.

Joakim Noah of the Chicago Bulls dislocated his shoulder and will undergo surgery to stabilize the joint. In most people, surgery is not the first step in rehabilitation. They are allowed to undergo physical therapy to strengthen the shoulder and return range of motion before considering an operation. But in athletes or those who may not be able or willing to limit their activities, surgery is often the first and potentially curative step. Studies of young athletes and military recruits, that surgery after the first shoulder dislocation can prevent future dislocation 95% of the time. Without an operation only 5% will have stable shoulders. The reason has to do with the inherent instability of the shoulder. It is designed to have a wide arc of range of motion in all directions and for that reason, the surface area of bone in the joint is very small. The stability has to do with the soft tissues that hold the shoulder together from the capsule and the labrum to the ligaments and surrounding muscles.  When the shoulder dislocates, all these structures are damaged and stretched. Surgery, either arthroscopic or through an incision, is meant to tighten all the structures that have been torn apart. Rehabilitation takes months to return range of motion and power; Mother Nature does not like to be rushed when she heals soft tissues.

More lessons from the playing field next week.

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