these are the concussion guidelines?

Sunday, March 24, 2013

Being a sports fan is a reminder that two people can watch the same play and disagree about whether it was a charge or block under the basket, the ball was hit fair or foul, or if the receiver was in or out of bounds. Part of the experience for the fan is the ambiguity that exists and the hot stove arguments that can last for years. While controversy may make for good sport, it is less well appreciated in medicine. Trying to develop consensus guidelines on the “best” care requires political skills that can water down the end result to make them useless when applied to the individual patient. And so goes the concussion saga in medicine today.

This week, the American Academy of Neurology updated their guidelines on the evaluation and management of concussion in sport. It only took 16 years since their last attempt at consensus and while we think that doctors and researchers have come to understand the issues associated with head injury, perhaps we give them too much credit. The biggest takeaway point from these guidelines is that the symptoms at the time of injury cannot be used to predict the severity of the concussion nor how long it will take to recover.

Most of the guideline recommendations are common sense but reading into the fine print uncovers significant questions that remain unanswered.

“In order to diminish the risk of recurrent injury, individuals supervising athletes should prohibit an athlete with concussion from returning to play/practice (contact risk activity) until a licensed health care provider has judged the concussion resolved.”

This seems pretty common sense, except it requires knowing that a concussion occurred and that eventually the brain has healed and the concussion resolved. Think that’s easy? The Neurology guidelines suggest that a variety of checklists and scales are appropriate to use, including the Post-Concussion Symptom Scale, the Graded Symptom Checklist and the Standardized Assessment of Concussion exam. This last one takes a few minutes to do and was referenced by Mr. DeMaurice Smith of the NFLPA at its 2013 Super Bowl press conference: “we know that the sideline concussion protocol takes at least 7 minutes to give, if we then see that player put back in the game 45 seconds later, we’d know that the sideline doctors have failed to employ the very protocol that we agreed to use.”

It’s nice that the players want to be protected but a seven minute test may not be the answer. The neurology guideline specifically addresses the inability to make a diagnosis.

“None of these tools is intended to “rule out” concussion or be a substitute for more thorough medical, neurologic or neuropsychological evaluations”.

If any or all of those tests are done?

“There is insufficient evidence to determine the best combination of specific measures to improve identification of concussion.”

It must also be remembered that the player must be evaluated to have the diagnosis made. The athlete does not need to be knocked out or even hit in the head to sustain a concussion. A shaken head is enough to shake the brain. It may be up to teammates or coaches to realize that the athlete is not quite right.

And return to play? There is a difference in how a more mature brain responds to a concussion and therefore, high school athletes should be held away from the risk of contact, longer than college or pro athletes. Using school as criteria, please explain how a 19-year-old NBA rookie’s brain can tolerate much more trauma that an 18-year-old high school senior. Some of the other return to play recommendations makes more sense:

  • The first 10 days may be the most important to allow the brain to rest.
  • Each athlete is unique and their return to play decision should be individualized to their situation. Migraine-like headaches, dizziness and “fogginess’ predict a longer recovery.

Still, there is no test available that can tell when the brain has healed and when it is functioning normally. The decision by the licensed health care provider may be just a best guess.

In the midst of March Madness, with baseball’s opening day only a week away and the playoff races in the NHL and NBA heating up, it seems strange talking about football but the NFL is the 800 pound gorilla in the room. Head injuries occur in all sports and at all levels of competition, but as the NFL takes the lead in athlete safety, everybody else will follow. Hopefully, they will get past the headlines of the new concussion guidelines and read the fine print.

Reference: http://neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd.full.pdf+html

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when the brain dies

Thursday, November 22, 2012

No matter how athletic one might be, or not, there is but one prime purpose for the body. Its job is to provide a supportive environment for the brain to function at maximal capacity and perhaps to be a vehicle to take the brain to experience the world around it. When the body dies, when the lungs don’t work and provide oxygen and the heart no longer pumps blood, the brain dies as well. But what happens when the body is alive and well but the brain no longer functions. The plight of Hector Camacho illustrates how difficult it is for doctors to make the diagnosis of brain death and how hard it is for families to accept.

The Camacho family is split about whether to turn off the ventilator, the machine breathing for Mr. Camacho because his brain no longer sends signals for the lungs to work. The same fears strike families every day in the US and they are lean on the doctors at the bedside to explain what is happening. It is a tough explanation. While they can intellectually accept that the brain is not alive but with their eyes they see a warm body with a heartbeat and whose chest rises and falls with each cycle of the ventilator. What if the doctors are wrong and there is a flicker of a person alive deep inside that body? What happens if they shut off the machine and the body still lives? What if?

In response to the Uniform Determination of Death Act of 1993, the American Academy of Neurology developed guidelines to help physicians decide who was brain dead and who wasn’t. Without those guidelines, each hospital in the country had to develop their own standard. Those recommendations were most recently updated in 2010 and set standards for what patient was eligible, what needed to be found on physical examination and what tests needed to be performed before the patient could be declared brain dead. (http://www.aan.com/elibrary/neurologytoday/?event=home.viewArticleGraphic&size=full&id=ovid.com:/bib/ovftdb/00132985-201006170-00001&objectID=TTU1)

There are two parts of the brain that need to fail. The cortex, where body control and thought are located and the brain steam where automatic controls of the body (like breathing) are housed. Not only does the doctor need to establish that the whole brain no longer works, but that certain conditions (for example, high spinal cord injuries, fertilizer poisonings) that mimic brain death are not present.  The decision to declare a person brain dead is not taken lightly.

While the American Academy of Neurology has set its standards for the United States, other countries may have their own guidelines or none at all. All this does not help the Camacho family come together to decide who gets to decide whether the machines need to stop. Without an advance directive, sometimes called a living will, the wishes of the patient may not be known and the weight of the decision is borne by the family. Should families have end-of-life discussions when calm exists, it can be a blessing to the family in times of crisis. Knowing what the patient wants is better than guessing.

In the ideal world, everyone would pass away peacefully in their own bed, surrounded by loved ones. Unfortunately, the real world can get in the way.

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