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.


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.


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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lymphoma and why statistics lie

Monday, October 26, 2015

Numbers lie and cancer isn’t fair. Those two truths cannot ease the passing of Flip Saunders this past weekend as he lost his battle against Hodgkin’s lymphoma. Mr. Saunders was diagnosed just a couple of months ago and initially planned to continue his job running the NBA’s Minnesota Timberwolves. Sadly, complications of chemotherapy kept him hospitalized until his death.

Lymphoma is a disease of the lymph system, where mutation makes normal white blood cells abnormal, causing them to become malignant and grow out of control. The lymph system attacks and protects the body against infection. B-lymphocytes (a type of white blood cell) make antibodies that kill bacteria, while T-lymphocytes act as messengers to help turn on the immune system against a variety of invaders and predators. The cells are born in the bone marrow, mature in he spleen but are activated in the lymph system, the lymph nodes and lymphatic vessels that help scavenge the body for waster products and debris. Arteries and veins get all the press, but the lymphatics do the dirty work.

Lymphomas are categorized as either Hodgkin’s or non-Hodgkin’s lymphoma based upon what type of white ell is involved and what the cells look like under the microscope. Hodgkin’s affects the B cells and can start anywhere within the lymph system from the lymph nodes, (the swollen glands that can be felt in the neck after a throat infection but that also exists everywhere in the body and enlarge when the body fight infection) to the spleen to the bone marrow.

Symptoms may be few initially, like a virus that doesn’t get better or a backache or swollen glands that don’t go away, so the diagnosis may not be made in its early stages. Lymphoma tends to spread through the lymph system and does not invade the blood stream until later stages of the disease, and for a time spares organs like the liver, lung or brain.

Treatment is individualized to the patient, and depends upon the patients underlying physical health and the stage of the cancer. Chemotherapy, radiation therapy, immunotherapy, monoclonal antibody use, stem cell transplantation and surgery are in the armamentarium that doctors have access to in treating this canner. But this is where numbers matter.

For all comers, the prognosis for surviving Hodgkin’s lymphoma is pretty good. There is a 92% one-year survival rate after the cancer is found and 85% of patients are alive at 5 years. But every patient is unique, and while the statistics say that the odds favor survival, those same numbers also say that 15% will die within 5 years.

There are prognostic factors that adversely affect survival including being male, being older than 45, red blood cell, white bod (including lymphocyte levels) and the cancer stage (whether it has spread). Regardless of the blood test results, Mr. Saunders had the deck somewhat stacked against him just being male and 60 years old. Just those two statistics may have dropped his 5-year survival rate to 67%


All those who surround him, just as other families and friends will mourn other cancer victims, will miss Mr. Saunders. It is a disease that doesn’t play fair, that ignores the numbers and that ignores the rulebook. And regardless of the statistics and percentages, whatever happens to the individual patient 100% happens. They don’t 85% survive or have a partial complication. Life happens in whole numbers and isn’t always fair.

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