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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the “official” doctor

Monday, February 18, 2013

The same day that Rajon Rondo of the Boston Celtics underwent successful knee surgery in Birmingham Alabama, the NFL Players Association was demanding reform in how doctors are chosen to look care for their members.  The link between the two stories is one that affects most people in the US, not just elite athletes, and has to do with trust and the patient-physician relationship. How do you decide what doctor will be the right one for you, whether it is a family physician, obstetrician or surgeon? Even the most restrictive insurance plans offer opportunities to choose but how?

Back to the NBA and the NFL.  Rajon Rondo went doctor shopping to find the surgeon he trusted to repair the torn ACL in his knee and decided upon Dr. James Andrews of Birmingham, Alabama one of the most renowned orthopods in the country. He has operated on some of the most accomplished athletes in the world and is team doctor for the Washington Redskins, but not the Boston Celtics. Their team physician is Dr. Brian McKeon of the New England Baptist Hospital but that relationship was not enough for Rondo to pick the doctor and hospital preferred by his team. It seems that many pro teams view the official hospital and doctor designation no differently than any other sponsorship deal. For millions of dollars, New England Baptist has the right to advertise itself as the “official and exclusive Celtics hospital” just like the Celtic deals made with Dunkin’ Donuts and Reebok. There are many quality hospitals in the Boston area, home to Harvard, Boston University and Tufts to name a few, but for marketing hops, only Baptist can claim to be the chose one for Celtic green. And yet, the hospital that was good enough for Larry Bird was bypassed by Mr. Rondo.

The NFLPA has been working hard to promote safe medical care for its players, especially on the concussion front, pushing to get an independent neurologist on the field to assess any player with a potential head injury. Never mind that neurologists tend not to deal with concussions routinely; it is the purview of sports medicine specialists, emergency physicians and neurosurgeons. The idea, however, was to have a doctor who has no affiliation with the team provide care, presuming that the team physician might have mixed allegiances, to both player and team, and the advice given may not always be in the player’s best interest. There has been precedent for conflict of interest and perhaps the most flagrant case occurred with Marty Barrett who played for the Boston Red Sox in the 1980s. His ACL injuries were misdiagnosed by team physician Arthur Pappas, who also happened to be a minority team owner. Mr. Barrett was awarded a $1.7 million judgment. The latest concern of trust with an NFL team doctor rests in San Diego, where team physician, Dr. David Chao, has been sued numerous times for medical negligence. By itself, this is not an issue since many well qualified physicians are sued, but much more worrisome is that the California State Medical Licensing Board has publicly reprimanded him and is in the process of seeking to suspend his license to practice medicine in the state.

When choosing a doctor, most people give it little thought and usually spend more time and energy researching mechanics, painters and tennis instructors.  Finding the right fit with a family doctor is a tough job.  The ideal candidate will become a life-long advocate for your care with disease prevention and routine screenings, as well as caring for the acute illnesses and injuries that can happen. In today’s mobile society, people often move to places where they to start a new physician-patient relationship and the process is like getting divorced and starting to date again. The first place to start is with family, friends and coworkers for their recommendations but then the hard work begins. A computer search of the American Medical Association doctor finder website can tell you about training and qualifications. After that, a search for the State Medical Association or the State Licensing Board may be appropriate to look for licensing issues, reprimands or practice limitations. But the big test happens when you make an appointment and decide whether you like that particular doctor. There is no shame in looking for a personality or practice style that satisfies your need. Most often, you want to develop a relationship that lasts years and not just a one night stand.

Years ago, the AMA stated that it was unethical for doctors to advertise. Unfortunately, that ethics were trumped by legal rights and there are plenty of radio, TV, newspaper and billboard ads to go around.  While it may be fine to choose your next donut or running shoe based upon your favorite player’s testimony, finding your doctor soul mate should take more time an effort than knowing about the official doctor and hospital status of New England Baptist and Drs. Andrews, McKeon and Chao. It’s a title likely bought and paid for, just like a Yellow Pages ad.

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