Helmets Vs Concussion

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Bottom Line Up Front (BLUF): Helmets don’t stop concussion!

Working in a Sports Medicine Department for a collegiate athletics program and being a Soldier in the United States Army and Florida Army National Guard, I cannot begin to tell you how many times I have heard an athlete, coach, parent, Soldier, etc. make a statement along the lines of, “My helmet will keep me safe from concussion.” Image result for death

The sad part here, is that this bit of misinformation could be lethal

The National Athletic Trainers’ Association, in their Position Statement on Concussions (2014), has began pushing for Athletic Trainers to support the use of certified helmets. The go-to in the field now is the National Operating Committee on Standards for Athletic Equipment, or NOCSAE, and according to them:

“Serious brain and neck injuries leading to death, permanent brain damage or quadriplegia (extensive paralysis from injury to the spinal cord at the neck level) occur in football. The toll is relatively small but persistent, averaging 1.44 fatal or severe, nonfatal brain or spinal cord injuries annually for every 100,000 players. HELMETS DO NOT PROTECT THE NECK, and none of these injuries can be completely prevented due to the tremendous forces occasionally encountered in football collisions; but they can be minimized by manufacturer, coach and player compliance with published rules of play, proper coaching, and in the case of head and brain injuries, compliance with accepted equipment standards.”

It is safe to take this quote to the bank! NOCSAE takes on certifying athletic headgear for various sports in its ability to protect from skull fracture or other dangers to theImage result for concussion gif external portions of the head, it has no chance of protecting the brain against any of the proposed mechanisms of injury that have been known to cause concussion, the coup-contrecoup, axonal torsion, concussive blast, or even non/sub-concussive cumulative impacts. No matter how much padding you put around the head it wont stop a concussion!

So, where does this lead us? The 5th International Consensus Statement on Sports Related Concussions, held in Berlin (2017), addressed the use of protective equipment in an attempt to stop concussion. When it came to helmets, here is what they had to say:

“The evidence examining the protective effect of helmets in reducing the risk of SRC is limited in many sports because of the nature of mandatory helmet regulations.”

Further, compare this to the National Athletic Trainers Association’s Position Statement on Concussion, and here are their thoughts on helmets:

“…although such helmets help to prevent catastrophic head injuries (eg, skull fractures), they do not significantly reduce the risk of concussions”

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Looking at two predominant official statements by major players in concussion research and seeing what they think, It seems clear that super-sizing helmets or the wear of any headgear will not truly stop the frequency of concussions!

Another major concern, is that research suggests that athletes wearing protective headgear may have a false sense of security against injury or even be more prone to use their head as a weapon, a dangerous thing in sport that can put them in danger of far worse injury than a concussion (Swartz et al, 2015). Swartz’s research posed a training concept for tackling in practice only without headgear on, they designed a process of slowly increasing intensity from static training through walking to tackle, to full speed once ready, and their research showed great potential in decreasing head-down tackling in football athletes! The group with the helmet-less tackling training decreased their head impacts by 30%.

Knowing this information, we may start to ask, “Well, if helmets don’t protect against concussions, then why does my son/daughter need to wear one?” That is a valid question, but we must always remember that while helmets don’t protect against concussions, they do keep our children and Warfighters safer from skull fractures!

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In the end, helmets are a necessary evil. They may not prevent or reduce concussions, but they do help in decreasing skull fractures and lacerations. It takes proper training in tackling form, concussion education, rule enforcement, and good sportsmanship to limit the rate of concussions. Remember tackle with your head up!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

National Operating Committee on Standards for Athletic Equipment [NOCSAE]. (2011). Statement of shared responsibility. Retrieved from http://nocsae.org/nocsae-standard/statement-on-shared-responsibilities/.

Swartz, E.E., Broglio, S.P., Cook, S.B., Cantu, R.C., Ferrara, M.S., Guskiewicz, K.M., and Myers, J.L. (2015). Early results of a helmetless-tackling intervention to decrease head impacts in football players. Journal of Athletic Training, 50 (12), 1219-1222.

The Q-Collar for Concussion Reduction

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BLUF (Bottom Line Up Front): Concussion is an internal problem, not external.

Annual speaking, Sports Related Concussion, or SRC, occurrence rated are approaching endemic levels. With an estimated range of 1.6-3.8 million per year (Broglio et al, 2014) occurring in sport and 300,000 annual visits to the Emergency Department according to the CDC (1997), many researchers and clinicians have started looking at various preventative measures. Let me assure you there are some pretty wild concepts of Concussion Prevention being discussed and not all is legitimately supported by valid, unbiased, and peer-reviewed research. Image result for gif head airbag

The first approach most people think about addresses that often a concussion occurs from a blunt force trauma to the head (though there are other mechanisms of injury for concussion this is the most commonly known). Along this lines of thinking many of the concussion prevention products addressed are typically based on padding the head. An example is an air bag system developed for cyclists that deploys when a fall is sensed by the system.

Another external fix for the concussion endemic is the Full 90 Soccer Headgear. The link leads to YouTube where there is a video of an NBC News on the Full 90 headgear Image result for full 90 concussion bandfor Soccer. The designer posed the idea and claims that it will decrease concussions by something like 50%… Dr. Cantu (we will cal him the man when it comes to Concussion research), tears the product to pieces. Aside from Dr. Cantu’s expert opinion, just listen to the video and it is ripe with inconsistency on the product preventing concussion. The video highlights  Natasha Helmick, a women’s soccer player that played on the Olympic Development Team before being forced to quit the sport from a high frequency of concussions (5 after starting to wear the Full 90). Worse off… she had to drop out of college due to the long-term effects of her extensive concussion history.

But, why doesn’t this idea of throwing on padding to the head stop or decrease concussions? As I mentioned in the BLUF, concussion are an internal problem, they are caused when the brain either rotates and causes axonal torsion or from a coup-contra coup impact against the inside of the skull. The brain is not snuggly fit in the skull, there is room to move.

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Image result for gif brain movement in skull

 

But, if external padding doesn’t work… then what will? Well, I mentioned in the BLUF once again that concussions are an internal problem. While we cannot go in and screw down the brain we can work externally to address the internal problem. In-fact, Q30 Technology, has developed just such a promising product, the Q-Collar. According to Myer et al (2016), the inspiration for this product came with the realization that there are less concussions occurring at higher altitudes.

“We postulated that acclimatisation to altitude may have influenced an
increased intracranial blood volume, resulting in a tighter fit of the brain within the cranium. The proposed physiological response to decreased relative ambient oxygen (thus increasing intracranial flow and volume) was speculated to have protected the athletes at higher elevations against sports-related TBI. “

The product mimics these natural outcomes by placing pressure over the jugular vein, Image result for q-collarnot the artery, thereby increasing the density and viscosity of the fluids protecting the brain. The effects are less sloshing of the brain back-and-forth during impacts. This is an awesome idea when looking at the levels of G-forces experienced in sport during impacts. According to Broglio et al (2011), over an 8 year period of 4 years of starting high school football and 4 years starting college football, a player is expected to have over 8,000 head impacts, with a mean g-force of 20.9g-22.25g and a cumulative of 183,834g assaulting the brain. That’s a LOT of Gs!!!

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The Q-Collar address this concern, and the research by Myer et al (2016) stated that thy found promising outcomes in animal models:

“This approach demonstrated an 83% reduction in amyloid precursor protein positive axons—a widely accepted biomarker of TBI— during a 900 g impact protocol studied in animals.”

When conducted on human models, the study found positive outcomes to decreasing these cumulative loads being placed on the brain. After an intervention of the Q-Collar being placed on 32 athlete for a season of game play, they found that the intervention group of 32 (Q-Collar Football Players), had significantly less brain diffusivity (a marker of brain injury) than the control group (30 Football Players without Q-Collar), this was found to be rather accurate with statistical measurements. They concluded that the Q-Collar may help decrease potential for injury to the brain!

Right now, you cannot get your athlete or self a Q-Collar, they are still in the research phase and have not moved to mass sales and distributions, but go check out their pages to stay abreast in their outcomes: Facebook , LinkedIn, and Website.

Here is a key take-away though, concussion cannot be prevented! What we can work on is reduction of occurrence of the injury through proper concussion education, form training, rule enforcement, rule change to protect the athletes, training on peripheral vision, and items such as the Q-Collar. Internal interventions to internal problems!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Broglio, S.P., Eckner, J.T., Martini, D., Sosnoff, J.J., Kutcher, J.S., & Randolph, C. (2011). Cumulative head impact burden in high school football. Journal of Neurotrauma, 28(10), 2069-2078.

Kelly, J. (1997). Sports-related recurrent brain injuries — United States. CDC Morbidity and Mortality Weekly Report, 46(10), 224-227. Accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/00046702.htm

Myer, G.D., Yuan, W., Foss, K. D. B., Thomas, S., Smith, D., Leach, J., Kiefer, A.W., Chris, …, & Altaye, M. (2016). Analysis of head impact exposure and brain microstructure response in a season-long application of a jugular vein compression collar: a prospective, neuroimaging investigation in American football. British Journal of Sports Medicine, 0, 1-11.

Concussions and the Classroom

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The uniqueness of the brain, its developmental process, and its functions are not lost on healthcare providers when it comes to concussion. Concussions are defined as a traumatic brain injury (TBI) which impair neurological and cognitive (mental) functions (McCroy et al, 2017). Youth-athletes that sustain a concussion have been a recent area of focus in concussion research due to the nature of the developing brain at those ages and the unknown long-term consequences that could be associated to sustaining a brain injury at that young age (McAbee, 2015).

Traditional treatment options for concussed student-athletes asked for a 24-48 hour rest period to allow for symptoms to lessen then once the patient had returned to their baseline on neurocognitive tests (ImPACT, ANAM, CRI, etc.) they could initiate a graduated return-to-play (RTP) protocol that over six steps slowly exposed the patient to increasing levels of physical stress to see if symptoms could be elicited to qualify the patient to be fully returned to activity.

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However, more recent research has looked at the importance of slowly re-integrating the patient into the classroom. As an example of this, Halstead et al (2013), as part of the American Academy of Neurology, suggested that premature return to the classroom for a concussed student could present with major cognitive difficulties including learning new tasks or remembering old tasks. This is of major concern for any student-athlete or parent of a student-athlete as there is potential for decline in GPA associated to these issues. Decline of GPA can affect acceptance to college/university for a high school student, potentially throw off SAT/ACT scores, and have the ability to disqualify a student for potential grants and scholarships!  For the collegiate student-athlete, a decline in grades and GPA could affect their eligibility to play, standings on the team, and Image result for concussion learningboth athletics and academic scholarships. All of these potentially affect the long-term goals of student.

This concern for the student-athlete has become such a major issue in the field that for the first time in 20 years of international consensus statements being published, the fifth consensus statement in Berlin published an example Return-to-School graduated protocol (McCroy et al, 2017). This example protocol, shows potential academic accommodations that can be given to a student-athlete to facilitate the best possible environment for their recovery and long-term health and well-being. However, each concussion is unique, in-fact, research in 2014 suggested that there are actually six different clinical trajectories, of which each have different academic accommodation needs specific to the trajectory (Collins et al, 2014).

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I know you may be thinking, “What about 504 Accommodations?” Well, TBI is one of the 13 qualified disabilities for an official 504 academic accommodation to be set into Related imagemotion. The issue surrounding this is that the symptoms associated to a concussion typically subside after 7-10 days (McCroy et al, 2017), and due to state-variance in the 504 process the student-athlete may already be recovered by the time the official 504 is put into effect to protect their recovery needs. Further, collegiate student-athletes do not fall under the 504 or IEP process, these student-athletes have a separate process at the institution of learning.

Where do we go from here? In the case of the process taking far too long to be beneficial for the student-athlete’s recovery, there can be developed a local policy to abbreviate the process or establish a collegiate level process unique to the student-athletes. Administrators can work together to establish a plan of action, if your high school, college, university, or academy has an Athletic Trainer then they should be involved in the process, along with a Team Physician, Neurologist, Pediatrician, Guidance Counselor, Academic Advisor, School Nurse, Teachers/Professors, intervention specialist, etc. All of these stakeholders can bring a unique approach/intervention to the care of the concussed student-athlete and pre-establishing this group can lead to an effective abbreviated process.

From the Athletic Trainer’s perspective implementation should look like this:

  1. Concussion Diagnosis
  2. 24-48 Hours of Cognitive and Physical RestImage result for concussion learning
  3. Notify Team of Concussion Players
  4. Implement Academic Accommodations
  5. Daily Symptom Checks
  6. Full Return to School/Learning/Academics
  7. Baseline on Computerized Neurocognitive Test
  8. Initiate Return to Play Protocol
  9. Return Athlete to Sport

As can be seen, the student-athlete must complete their academic accommodations and be fully returned to school prior to initiating the graduated Return to Play Protocol. This is important as the use of academic accommodations should be seen as the patient still being technically symptomatic for concussion. Overall, we must put in the due diligence to take care of this vulnerable population. The research still is unsure of what potential long term effects could come with a history of concussion, particularly when referencing the youth-athlete population. It’s always better to play it safe then to risk the health and well-being of the student-athlete!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

 

References

Collins, M.W., Kontos, A.P., reynolds, E., Murawski, C.D., & Fu, H.H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA, 22 (2), 235-246.

Halstead, M.E., McAvoy, K., Devore, C.D., Carl, R., Lee, M., & Logan, K. (2013). Returning to learn following a concussion. Pediatrics, 132(5), 948-957.

McAbee, G.N. (2015). Pediatric concussion, cognitive rest and position statements, practice parameters, and clinical practice guidelines. Journal of Child Neurology, 30(10), 1378-1380.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

 

Eenie, Meenie, Miney, Tau

Mike Webster, a celebrated Hall of Fame center for the Pittsburg Steelers, played in 245 NFL games, including his time with the Kansas City Chiefs, and was hit in the head thousands of times. “Iron Mike” died 24 September 2002 at the age of 50. Dr. Bennet Omalu, a neuropathologist, was assigned to perform the autopsy on the body and the brain. Omalu made a groundbreaking discovery, seeing something in Webster’s brain that had never been found in a football player’s brain before and should never have been present in the brain of a 50-year-old man (Breslow, 2013; Concussion Legacy Foundation [CLF], 2017).

 

 

If you’ve read at all about concussions you’ve probably come across the term Chronic Traumatic Encephalopathy (CTE). CTE is a progressive degenerative disease of the brain found in athletes, military veterans, and others with a history of repetitive brain trauma. The repetitive brain trauma causes a buildup of a protein called tau.  The aggregation of tau is toxic, slowly killing cells of the brain, as also seen in Alzheimer’s disease (CLF, 2017; Lerner, 2016; Mandelkow & Mandelkow, 2012).

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The tau protein in itself is not inherently dangerous. Tau is a protein in the brain which helps stabilize brain cell structure and internal transport system (CLF, 2017; Lerner, 2016). Tau links microtubules that run through axons of the brain, two tau proteins in each link; the heads of the tau proteins are each bound to a microtubule, and the tau tails meet in the middle and are bound together, but this bound isn’t permanent (Lerner, 2016). Because of its hydrophilic nature tau does not adopt the typical compact, folded structure of most proteins. Instead, it is “natively unfolded” and “intrinsically disordered”, meaning its highly flexible and mobile, kind of like pipe cleaners you use in arts and crafts  (Mandelkow & Mandelkow, 2012). Motion within the brain easily detaches the tail ends of the tau protein and causes them to reattach to a new tau protein tail. This binding and unbinding allow for easy sliding between microtubules without damage (Lerner, 2016).

repetitive trauma

However, repeated injury to the brain causes neurons to stretch and tear.  Rapid jolts in concussive episodes do not allow the bound portions of tau tails to untangle and bond with a new tau partner. High-velocity forces of a concussion do not allow to tail ends of the tau proteins to unbind and the forces are exerted on the microtubules instead, causing damage (Lerner, 2016). The tau protein then changes its shape, clumps together with another tau, and spreads while slowly killing neurons. In CTE, clumps of tau tend to first appear around blood vessels within the brain sulci (valleys between brain cortical folds), and then spreads to other areas of the brain (CLF, 2017).

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axons under stress

The danger of chronic brain injury is the guaranteed risk for memory loss, confusion, impaired judgment, paranoia, impulse control problems, aggression, depression, and eventually progressive dementia (CLF, 2017).

A study by Shahim et al. (2014) looked at blood biomarkers after a concussion in professional ice hockey players and found that the highest concentrations of total tau were measured immediately after injury, tau levels declined after the first 12 hours, and a second peak of tau levels occurred between 12-36 hours post-injury. Most importantly, tau levels 1 hour post-concussion concussion predicted the number of days it took for the concussion symptoms to resolve and the players to have safe return to play. This suggests that total tau levels may potentially be a way to monitor recovery in patients with brain injury (Shahim et al., 2014)Since diagnostic imaging is not able to help health care professionals predict concussion outcomes and recovery, perhaps these findings with help pave the way for more efficient, more informed, and

Since diagnostic imaging is not able to help health care professionals predict concussion outcomes and recovery, perhaps these findings with help pave the way for more efficient, more informed, and better-monitored recovery and return to play.

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Author: Alyssa Reidy, LAT, ATC, CCTP

References

Breslow, J. (2013). The Autopsy That Changed Football. [online] FRONTLINE. Available at: http://www.pbs.org/wgbh/frontline/article/the-autopsy-that-changed-football/

Concussion Legacy Foundation [CLF] (2017). What is CTE?. [online] Concussion Legacy Foundation. Available at: https://concussionfoundation.org/learning-center/what-is-cte

Lerner, E. (2016). Penn study determines breakaway protein is critical in concussions. [online] Penncurrent.upenn.edu. Available at: https://penncurrent.upenn.edu/2016-01-14/latest-news/penn-study-determines-breakaway-protein-critical-concussions

Mandelkow, E. and Mandelkow, E. (2012). Biochemistry and Cell Biology of Tau Protein in Neurofibrillary Degeneration. Cold Spring Harbor Perspectives in Medicine, 2(7), p.a006247

Shahim, P., Tegner, Y., Wilson, D., Randall, J., Skillbäck, T., Pazooki, D., Kallberg, B., Blennow, K. and Zetterberg, H. (2014). Blood Biomarkers for Brain Injury in Concussed Professional Ice Hockey Players. JAMA Neurology, 71(6), p.684

 

 

The Blue Light Spectrum Concussion

How many times have you stared at your cell phone screen since waking up this morning? How long will you look at after getting in bed tonight?

 

Patients with concussion present with varying symptoms: headaches, dizziness, and vertigo, amnesia, depression, irritability, word-finding difficulty, impulsiveness, difficulty sleeping, difficulty concentrating, sound sensitivity and visual symptoms. These visual symptoms might include photosensitivity and photophobia, wherein “photo-” equates to light. Photophobia translates to “fear of light”, but it is actually a neurological condition affecting how the light receptors in the eye transmit information to the brain. Generally, it refers to exposure to light that exacerbates pain (Digre & Brennan, 2012). Light and sound tolerance decrease in patients with head injuries compared to control subjects (Magone et al., 2013). Light sensitivity after a concussion in the absence of ocular inflammation is a common complaint and effects 40-50% of patients with brain injury.

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The increased sensitivity to light occurs in the subacute period (7-21 days) after a head injury, and although most patients/athletes report improved symptoms after 6 months, patients/athletes with post-concussive syndrome continue to report increased photosensitivity (Digre & Brennan, 2012). Research suggests the cause is cortical and subcortical lack of inhibitory control (Magone et al, 2013), as also seen in other brain disorders, such as migraines and epilepsy. These abnormal responses may include non-uniform cortical excitability and cortical hyper-responsiveness, which may interfere with visual perception to cause photophobia. A study of patients using resting state functional magnetic resonance imaging (fMRI) in patients with closed head injuries showed a cluster of increased functional connectivity in the right frontoparietal lobe as compared to and a matched control group (Shumskaya et al., 2012). This increased activity may cause increased awareness of one’s external environment resulting in cognitive fatigue with headache and increased sensitivity to light and sound. Digre and Brennan (2012) provide a more extensive description of the pathophysiology of photophobia. I have included the link below for your reading pleasure.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3485070/

Computer Vision Syndrome occurs in 75% of computer workers who view a video display for 6-9 hours per day. Ocular complaints include eye fatigue, burning, redness, blurred vision, and dry eyes, as well as non-ocular symptoms (headache, neck/shoulder pain)(Loh & Redd, 2008; Lynch et al., 2015). Viewing a digital screen is different that reading printed material; the letters on a screen are not as sharply defined, contrast of letters to the background is reduced, and glare and reflection on the screen making it difficult to read, forcing increased visual demand by the reader (AOA, 217; Loh & Redd, 2008).The normal human blink rate of 10-15 times per minute is significantly reduced while using digital screens, causing poor tear film quality, stressing the cornea. Prolonged use of a digital screen (i.e. computers, cell phones, television, tablets, e-readers, etc.) causes transient deviation of phoria (visual alignment), transient myopia (nearsightedness), and diminished accommodation to changing visual stimuli (Loh & Redd, 2008; Lynch et al., 2015).

melatonin

Digital screens emanate a lot of low wavelength light, what the science world would call blue light. The eyes’ exposure to blue light suppresses the body’s ability to produce melatonin, the hormone produced by the pineal gland when light receptors in the eye detect darkness, helping to regulate the body’s circadian rhythm and make you fall asleep. Ergo, people who are glued to their digital screens, especially in the evening when the body should begin melatonin production, delay this mechanism or even prevent the body from making melatonin the entire night.

blue light frequency

Recent research supporting the use of bright light therapy in the morning to help improve sleep, cognition, emotion and brain function in patients with concussion (Stone, 2013).

Add all of that to concussion symptoms and an athlete/patient is guaranteed to hinder the healing process and delay their return to play/work.

big picture

Now, in a world that runs on screen time, it’s not realistic to completely cut out all electronics from our daily routines. What we as health care professionals can do it educate our athletes/patients and their parents/guardians on how to modify. First and foremost, limit screen time. The American Optometric Association recommends following the 20-20-20 rule for people without concussions; take a 20-second break to view something 20 feet away every 20 minutes (AOA, 2017).

202020

 

Again, it’s not realistic to micromanage one’s screen time when it’s dark outside, but we’re fortunate enough to live in a time where blue light is able to be eliminated without turning off our screens. Software engineers have created a plethora of apps and settings on our devices that automatically eliminate blue light from our devices at a set time, usually sunset, or a specified time set by the user. Below are just a few of many device applications that can be downloaded to help the concussed patient manage their light exposure.

 

flux

F.Lux (I personally use this for my computer) – this app reduces blue light after the sun sets in your specific location https://justgetflux.com/

 

twilight

Twilight – for Android users, this app is similar to f.lux, although it doesn’t have a particular blue light filter, you can control the color temperature and intensity https://play.google.com/store/apps/details?id=com.urbandroid.lux&hl=en

midnight

Midnight– you control the black, yellow, blue and red light, you can schedule to start and stop time of the filter, but it doesn’t automatically change based on your location’s sunrise/sunset. However, it can determine ambient light and dims the screen in dark environments.

This list is not exhaustive, all anyone needs is an internet search engine to compare and contrast apps.

 

Author: Alyssa Reidy, LAT, ATC, CCTP

 

 

References

American Optometric Association. (2017). Computer Vision Syndrome. Aoa.org. Retrieved 17 June 2017, from https://www.aoa.org/patients-and-public/caring-for-your-vision/protecting-your-vision/computer-vision-syndrome?sso=y

Digre, K., & Brennan, K. (2012). Shedding Light on Photophobia. Journal Of Neuro-Ophthalmology, 32(1), 68-81. http://dx.doi.org/10.1097/wno.0b013e3182474548

Greenbaum, D. (2017). 5 Best Android Apps that Reduce Eye Strain for Night Reading. Guidingtech.com. Retrieved 17 June 2017, from http://www.guidingtech.com/60491/best-android-night-filters/

Loh, K., & Redd, S. (2008). Understanding and Preventing Computer Vision Syndrome. Malays Fam Physician, 3(3), 128-130.

Lynch, J., Anderson, M., Benton, B., & Green, S. (2015). The Gaming of Concussions: A Unique Intervention in Postconcussion Syndrome. Journal Of Athletic Training, 50(3), 270-276. http://dx.doi.org/10.4085/1062-6050-49.3.78

Magone, M., Cockerham, G., & Shin, S. (2013). Visual Dysfunction in Combat-Related Mild Traumatic Brain Injury: A Review. US Ophthalmic Review, 06(01), 48.

Shumskaya E, Andriessen TM, Norris DG, Vos PE. (Jul 2012). Neurology, 10; 79(2):175-82.

Stone, P. (2013). Bright Light Therapy Relieves TBI Sleep Problems. Neurologic Rehabilitation Institute at Brookhaven Hospital. Retrieved 17 June 2017, from http://www.traumaticbraininjury.net/bright-light-therapy-relieves-tbi-sleep-problems/

Madden Football Vs Concussion

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In 2006 NBC ran an article citing that Madden NFL ’07 sold 2,000,000 copies in its opening week, they followed up with a stat that said today, as of September 1, 2006, the franchise had sold 53 million copies of the game (Wong, 2006)! Fast forward 10 years and a Fox Business article stated that EA projected, rather conservatively, that there would be 5.5 million copies of Madden NFL ’17 sold in the year (Barrabi, 2016).

Acknowledging those staggering numbers of the population playing the Madden franchise alone, not taking into account NHL, FIFA, or other sports games on the market, it isn’t hard to see how proper portrayal of concussions in these games could assist in concussion education by creating a cultural framework to build upon.

Concussions were not a potential injury in EA’s Madden franchise until the Madden ’12 edition (Good, 2011), which sold 5 million copies on its own (Zox, 2012). With sales estimates around that same 5 million units mark from that point on, we can make an educated guess that ~25 million Madden fans have been exposed to the video game’s portrayal of concussion!

Image result for nfl evil league of evilThis level of exposure is an amazing step in the right direction for concussion awareness worldwide. To further show that the NFL isn’t the evil creature that they are portrayed to be, Robinson (2014) in a Sports Illustrated article pointed out that while the NFL and EA decided to remove the fan-favorite and famous Madden Ambulance, the NFL also provided EA with Image result for madden ambulanceaccurate frequency data on concussions so they could properly include them for realism, as well as, using proper verbiage like head injury, over “Bell Ringer” or “Ding”.

These steps in the proper use of terminology of head injury, frequency rates of injury, and return to play time frames being passively exposed to the world’s sports ‘gamers’ and youth, are a key concept in establishing a culture of proper education as to what a concussion is and how it should be treated. We already know that there are major concerns in self-reporting of concussions and concussion-like symptoms, estimated that 40% go unreported (Meier, 2014); thus, this passive education could potentially lead to a world where under-reporting numbers of concussions are significantly lower! The game actually has the sportscasters talk about the injury and the evaluation accurately, check out this video of Madden ’15 portraying a concussion for reference.

Image result for football concussion meme

Madden is not the only sports game franchise to take on proper portrayal of concussions, FIFA and EA’s NHL games have taken this injury into account as well. This ensures a larger population is learning accurately about concussions and the passive culture change is occurring. All of this is wonderful, but it is important to ensure that accuracy is being taken into account and that there is no improper representation of concussion in these efforts. A mistake of that magnitude could spell disaster.

Image result for EA concussion video game injury

Overall, wonderful efforts are being made by video game organizations along with their represented sport league partners to ensure concussions are being properly acknowledged, portrayed, and treated to the level that they should be. All of these efforts can truly lead to a well-informed population and hopefully a decreased potential for future concussions!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Barrabi, T. (2016). Is ‘Madden NFL 17’ a touchdown for electronic arts?. Fox Business. Retrieved from http://www.foxbusiness.com/features/2016/08/25/is-madden-nfl-17-touchdown-for-electronic-arts.html.

Good, O. (2011). Madden concussions a teachable moment, says EA sports. Retrieved from http://kotaku.com/5787833/madden-concussions-a-teachable-moment-says-ea-sports.

Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S.F. (2014). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, XX, 1-6.

Robinson, J. (2014). It’s Not In the Game: Eight Features the NFL Made EA Sports Remove from “Madden”. Retrieved from https://www.si.com/extra-mustard/2014/03/12/ea-sports-madden-features-nfl-remove.

Wong, M. (2006). Madden video game post record sales: 17-year-old franchise takes in $100 million in first week. NBC News. Retrieved from http://www.nbcnews.com/id/14621205/ns/technology_and_science-games/t/madden-video-game-posts-record-sales/#.WURaAmjyvIU.

Zox. (2012). FIFA & Madden 12 series sales. Retrieved from http://www.vgstrategy.com/2012/02/15/fifa-madden-12-sales-totals/.

Concussions Kill

Image result for second impact syndromeAt this point most of us have seen either Will Smith’s Concussion movie or theImage result for dr. bennet omalu will smith PBS Frontline Special League of Denial on Dr. Omalu’s CTE story. However, CTE is not the only aspect of concussion that can kill, Second Impact Syndrome is another killer associated to concussion and is arguably a much bigger concern in our youth-athlete populations.

Second-Impact Syndrome, or SIS, is defined by Stovitz et al (2017) as follows: “Second-impact syndrome refers to a very rare, but usually fatal diffuse cerebral edema as a consequence of a mild head injury. This term is applied typically when an athlete develops diffuse cerebral edema from a second head injury while still symptomatic from a first concussion.’’

Another issue is that, according to the National Academies Committee on Sports-Related Concussions in Youth (2014), even though a patient may report having no concussive symptoms, they can still show cognitive deficits on a computer administered neurocognitive test (ImPACT, CRI, or ANAM as examples) for up to 3 days from the point of being asymptomatic. This means they patient may think they are no longer concussed but in reality, they still have brain damage from the initial injury. As a result of this finding, a patient may attempt potentially dangerous activities that could expose them to SIS and endanger their lives.  This fact stresses the importance of not only being asymptomatic but also being returned to baseline on neurocognitive testing prior to initiating a graduated return-to-play protocol.

With an estimated annual occurrence of concussions between 1.6 and 3.8 million incidents (Broglio et al, 2014), and when further examining only those aged 10-19 approximately 500,000 are referred to various emergency departments for their concussions (Gilchrist et al, 2011), then to top it off we know there is a major issue in underreporting of concussion and concussion-like symptoms in this population (Meier et al, 2014) we begin to see that there are the makings for a very dangerous situation in the youth-athlete population.

Not every concussion merits referral to the emergency department, Broglio et al (2014) suggests that this in only warranted when there are certain red flags present, such as:

  1. Decreasing Levels of ConsciousnessImage result for Sideline concussion
  2. Increasing confusion
  3. Increasing irritability
  4. Loss of or fluctuating level of consciousness
  5. Numbness in the arms or legs
  6. Pupils becoming unequal in size
  7. Repeated vomiting
  8. Seizures
  9. Slurred speech or inability to speak
  10. Inability to recognize people or places
  11. Worsening headache

The real worry exists in the combined concerns of the underreporting of concussions and the population vulnerable to Second-Impact Syndrome a controversial, infrequent, and potentially fatal outcome of mismanagement of concussion. Most patients that suffer from SIS are under the age of 18 (Cox, 2016), and with an estimated underreporting rate of 40% in concussed student-athletes combined with the 60% of athletes estimated to hide symptoms to return to play sooner (Meier et al, 2014) it can be seen how this has the makings for the perfect storm.Image result for perfect storm

SIS has a 50% mortality rate (Stovitz et al, 2017; Cox, 2016; ), that means of the 20 cases that have been discovered and diagnosed that half of them perished(Dessy et al, 2015) , of the 50% that lived many had significant changes in quality of life. Take for example the Preston Plevretes Story. Horror stories, such as Mr. Plevretes experience with SIS, could have been prevented through proper concussion education and management.

I know what you are thinking, “But, how do we prevent this?” or maybe, “How can I make a difference in this?”. Well, it all starts with education and making subtle cultural changes to protect our youth-athletes from SIS. A great start is to stop referring to concussions as “Bell Ringers”, “Getting his/her bell rung”, or “Dings”. Referring to a concussion, which is actually a mild traumatic brain injury (mTBI), in such a manner as a ding or bell ringer down plays the severity of the injury. Combine that misuse of verbiage for a concussion with the glorification of playing through concussion, such as portrayed by NFL athlete Thomas Jones when he stated he felt playing concussed was when he played his best or that he felt in the zone, and you once more have that perfect storm for SIS.

In the end in order to make culture change we need to ensure we get our Student-Athletes/Youth-Athletes Baseline tested on Neurocognitive tests like ImPACT, ANAM, or CRI and ensure they follow the advice of Medical Professionals such as MD/DO/ATs. If we can shape culture change surrounding concussion, then we could likely prevent SIS from taking or affecting any more lives.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Bey, T. & Ostick, B. (2009). Second impact syndrome. Western Journal of Emergency Medicine, 10(1), 6-10.

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Cox, W.A. (2016). Second impact syndrome. Forensic Science Newsletter, September 15, 2016. http://www.forensicjournals.com/blog/wp-content/uploads/2016/09/Second-Impact-Syndrome.pdf.

Dessy, A.M., Rasouli, J., Yuk, F., & Choudhri, T.F. (2015). Second impact syndrome: A rare, devastating consequence of repetitive concussions. Contemporary Neurosurgery, 37(20), 1-5.

Gilchrist, J., Thomas, K.E., Xu, L., McGuire, L.C., & Coronado, V. (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged ≤ 19 years– United States, 2001-2009. Centers for Disease Control Morbidity and Mortality Weekly Report, 60(39), 1337-1342.

Meier, T.B., Brummel, B.J., Singh, R., Nerio, C.J., Polanski, D.W., & Bellgowan, P.S.F. (2014). The underreporting of self-reported symptoms following sports-related concussion. Journal of Science and Medicine in Sport, XX, 1-6.

National Academies Committee on Sports-Related Concussions in Youth. (2014). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK185340/.

Stovitz, S.D., Weseman, J.D., Hooks, M.C., Schmidt, R.J., Koffel, J.B., & Patricios, J.S. (2017). What definition is used to describe second impact syndrome in sports? A systematic and critical review. Current Sports Medicine Reports, 16(1), 50-55.

An Athletic Trainer’s view of The Concussion Legacy Foundation and Ambassadorship

Image result for concussion

It has been estimated that there are as many as 3.8 million reported and unreported concussions every year (Broglio et al, 2014); further, a study comparing 100 high schools and 180 colleges in the United States found that concussions made up 8.9% and 5.8% of the total injuries due to sports (Gessel et al, 2007). With occurrence numbers in those levels it is not a major reach to argue that concussions are approaching an epidemic level in sports. As an Athletic Trainer working in the Collegiate setting, I find these epidemiological findings concerning and disparaging at best.

Image result for the concussion legacy foundation non-profit

This information inspired me to seek out advocacy groups for which I could become involved. After a good deal of research I came across the Concussion Legacy Foundation, a non-profit organization co-founded two major players in concussion research Dr. Cantu (MD) and Dr. Nowinski (PhD). This organization, founded in 2007, has taken a three pronged approach to shaping change in regard to the concussion crisis:

  1. Education through running Advanced Concussion Training (ACTs) clinics and conducting various conferences and coalitions in concussion education
  2. Policy through advocacy for state concussion laws and accurate video game representation of concussions
  3. Research through driving multiple published research articles in various journals, involvement in position/consensus statement development, and league driven research.

This organization has been a driving force behind much of the Image result for brain bankadvancement in concussion research and policy. Currently, there is a large push for donations to the VA-BU-CLF Brain Bank this national initiative allows researchers access to brains after the patient has passed away, currently the only way to diagnose CTE or research long-term effects to multiple brain injuries. The Brain Bank currently has been pledged brains from famous athletes the likes of: Brandi Chastain, Dale Earnhardt Jr., and Nancy Hogshead-Makar. As of 2014, they had been donated over 400 brains and of those 400 over 250 had tested positive for CTE!

Another national initiative this organization has taken on to herald takes place at the front lines of concussion in sport, the very athletic team. The Concussion Legacy Foundation advocates for teams and coaches to take the Team Up Speak Up Day Pledge, this annual pledge day is scheduled for September 12, 2017 and the organization is asking for volunteers to pledge that if they notice their teammate and friend is concussed that they will speak up and notify someone to get them help. These pledge drive days are designed to increase reporting of concussion, currently research suggests that only 47.3% of concussed athletes will report their symptoms (Gessel et al, 2007); further, we research has shown that, subject to motor vehicle accidents, sports is the second leading cause of concussion in the 15-24 year old age group (Marar et al, 2012). Knowing that the 15-24 year old age range is also susceptible or vulnerable to Second-Impact Syndrome this disparity in self-reporting could be the makings of the perfect storm… Thus, this advocacy at the front line is a much needed action!

Image result for stand up speak up concussion

 

Image result for ambassadorA third major action the Concussion Legacy Foundation is taking is their Ambassador program. This is a program that allows interested volunteers to get involved in the efforts and help shape change in the day-to-day concussion fight. Being an Ambassador to the Concussion Legacy Foundation allows mom, dad, sister, brother, cousin, athlete, coach, student, medical professional, or basically anyone with a vested interest to join the efforts in stopping the concussion crisis through raising awareness about concussion or raising funds for the non-profit to bankroll it’s research and education efforts.

I could not be more excited to announce that after much research on the foundation’s efforts and accomplishments to ensure their goals are in line with my own, I have personally taken the pledge to be a Concussion Legacy Foundation Ambassador. If you have a friend, child, or loved one that participates in sports or you care to help make a difference in the world’s concussion crisis then I highly recommend taking the pledge to be an ambassador, Donate your Brain to the Brain Bank, or get your team to take the Team Up Stand Up pledge on the day.  Every effort helps and the numbers don’t lie.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P, Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., & Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., & Comstock, R.D. (2007). Concussions among United States high school and collegiate athletes. Journal of Athletic Training,42(4), 495-503.

Marar, M., McIlvain, N.M., Fields, S.K., & Comstock, R.D. (2012). Epidemiology of Concussions Among United States High School Athletes in 20 Sports. The American Journal of Sports Medicine, 1-9.

 

 

 

Siri, Alexa, & “Ok, Google” Vs Concussion Education

Image result for concussion siri Image result for just ask alexa amazonImage result for ok google

Arguably and anecdotally speaking, a large portion of today’s student-athletes and parents of student-athletes fall under the Millennial generation, being born between 1982 and 2000 (Roberts, Newman, & Schwartzstein, 2012), and other researchers have taken the time to establish that Millennials are a technologically driven population when it comes to education and learning (Desy, Darcy, & Wolanskyj, 2017).

With the recent research focus, hype, discussions, and debates being built around sports related concussion, or SRC as the 5th International Conference on Concussion in Sports Consensus Statement held in Berlin (2017) coined as an abbreviation, thanks to Will Smith’s movie Concussion and the PBS Front Line Special League of Denial it seems that many parents and student-athletes would seek to find education on what a concussion in fact is and the potential long-term effects associated to such an injury.

As mentioned above we know that Millennials are technologically driven and as Desy et al mentioned in their 2017 research article, technology even plays a necessity in this generation’s education. So, it seems a fair and logical conclusion that a Millennial with a question on education would reach for the quickest and closest media to answer their questions. The concern is if the Millennial posing the question is receiving their information from a legitimate resource or are they receiving miss information and is that driving dangerous actions?

Image result for concussion out of order

This clinical question lead me to think about what available and timely resources Millennials had to answer their questions. That thought process guided me to Personal Assistant Applications and Artificial Intelligence pieces that were commonly available, so here is a list of the available resources I queried as to define what a concussion is:

  1. Apple’s Siri Virtual Assistant/AIImage result for concussion misinformation
  2. Amazon’s Alexa/Echo/Tap Virtual Assistant/AI
  3. Android’s “Ok, Google” Virtual Assistant/AI

The results from each were vaguely shocking…

Leading off at bat for the Virtual Assistant and AI programs was Apple’s Siri, when asked to define a concussion Siri responded with:

“Temporary unconsciousness caused by a blow to the head. The term is also used loosely of the aftereffects such as confusion or temporary incapacity.” 

I was extremely unimpressed with this definition that Siri provided. Suffice it to say that Siri grounded out at first base. To breakdown the concerns with the misinformation in the definition of a concussion, let’s look at the 5th International Consensus Statement: “The majority of SRCs occur without loss of consciousness or frank neurological signs”; however, Siri’s definition stated that a concussion was a temporary unconsciousness. Referring one more time to the Consensus Statement: “SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.” Once again, Siri’s definition stated that concussion were only caused by a blow to the head. Siri’s definition was riddled with misinformation and this leads to a concern for those using that as a quick resource to know if a concussion has occurred. This Siri does not get the approval of this Sports Medicine professional!

Image result for no siri

On deck was Amazon’s Alexa Virtual Assistant/AI program, when asked to define a concussion Alexa responded with:

“Concussion has two different meanings. Noun. Injury to the brain caused by a blow usually resulting with loss of consciousness. Two, any violent blow.”

Once again, the virtual assistant/AI program failed to accurately define a concussion. In this case, Alexa hit a pop fly that got her to round first base before being caught for an out. She started off strong with her definition in that according to the 5th International Consensus Statement a concussion is in fact a brain injury, she avoided the common pitfall of referring to the injury as a “Ding” or “Bell Ringer”, which we know we should avoid because it down plays the severity of the brain injury (Broglio et al, 2014). The issue in Alexa’s definition of concussion was once again the statement of usually resulting in a loss of consciousness, which as previously mentioned according to the 5th International Consensus Statement is not a common occurrence in concussion. Thus, Alexa too does not receive approval from this Sports Medicine professional as a valid source or tool for concussion education.

Image result for amazon alexa failed

With our team of Virtual Assistants/Artificial Intelligence applications and programs currently sitting with two outs and no one on base, I queried Android’s “Ok, Google” Virtual Assistant/AI to see if we could at least get a base hit in concussion education sources/tools. When asked to define concussion, “Ok, Google” responded with:

“According to Mayo Clinic staff. Print. A concussion is a traumatic brain injury that affects your brain function. Effects are usually temporary but can include headaches and problems with concentration, memory, balance, and coordination. Concussions are usually caused by a blow to the head.”

Finally, a pretty decent swing and a hit. We will call this a definition a ground rule double in Millennial concussion education tools. While “Ok, Google” did a decent job in defining what a concussion is and by far it was the best of the three queried, there was still a shortcoming in the definition. “Ok, Google” hit the nail on the head with stating that a concussion is a traumatic brain injury, in-fact according to the NATA’s Position Statement on Concussion, concussions are a mild TBI or mTBI. So, that jumping off point in the definition was a great start. “Ok, Google” also took the time to reference its source, Mayo Clinic, which neither of the predecessors did. The only concern was once more the inclusion of the usual cause being associated to a blow to the head, while the research suggests that other causes include violent shaking, blows to the body translate movement to the head, or even explosions. Overall, “Ok, Google”‘s response was the strongest of the three Virtual Assistants/AIs, and while it is not the best definition it was a decent one. Thus, Android’s “Ok, Google” receives an acceptable status from this Sports Medicine professional.

Image result for android ok

The strongest definition to date for concussion can still be found in the 5th International Consensus Statement on Concussion (2017):

Image result for 5th international conference on concussion in sport

“Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:
►► SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
►► SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
►► SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
►► SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.”

As far as seeking out great information and concussion education for parents, coaches, or even student-athletes, there is a series of free courses that take approximately 15 minutes to complete that are offered by Sports Safety International, they are called the ConcussionWise course series and can be found at the following links:

Image result for concussion wise

  1. Athletes
  2. Parents
  3. Coaches

While there is no way to prevent every concussion from occurring, education on concussion and best practices in prevention can help minimize risk. Always ensure that any resource being used is one of quality and grounded in the proper research, so that you know you are receiving accurate and correct information, especially when concerning mild traumatic brain injuries and student-athletes.

Author: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

References

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Desy, J.R., Darcy, A.R., and Wolanskyj, A.P. (2017). Milestones and Millennials: A perfect pairing– competency-based medical education and the learning preferences of Generation Y. Mayo Clinic Proceedings, 92(2), 243-250.

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

Roberts, D.H., Newman, L.R., and Schwartzstein, R.M. (2012). Twelve tips for facilitating Millennial’s learning. Medical Teacher, 34(4), 274-278.

 

Referees Are Friends, Not Food

Be forewarned, this may not be the most “scholarly” article in terms of the use of the scientific method. It will probably consist of opinionated monologues and common sense. Believe me, as an athlete, and even as an Athletic Trainer for my team, I had my fair share of yelling matches and eye rolling with referee calls. But, the more I’ve worked as a PRN ATC as a completely neutral third party, I’ve seen with a clear eye why these “silly” rules are in place. Please be gentle with your opinions as I attempt to play Devil’s Advocate for a moment.

**Note: This post will focus on rules put in place to decrease the risk of head injury.

Like many authority figures, sports officials are targeted with a negative stigma and bad publicity. I think being shark bait is in their job description.

When it’s YOUR team playing, it seems to always be a bad call from the ref, not a poor play by the athlete. Our athletes are good, but you have to admit that there is a point at which some athletes are desperate enough to do anything to win, even if it accidental.

If you really, think about it, referees have to put up with a lot of crap. For instance, getting run over the players, and sometimes even the ATCs (guilty as charged)!

dont do this to your ref.gif

Stumbling, but having to recover immediately because no one cares about their boo boos;

ref recover.gif

Verbal abuse

verbal abuse.gif

And sometimes even physical abuse.

do not do this to your ref

So, instead of thinking “That was a terrible call ref! Just let them play the game!”, maybe we should think, “Okay, yeah I wish he would have just let that go, but he may have saved my kid from breaking his neck and never being able to play again.” Morbid, I know. If referees were not there to judge whether a play/player is safe or not, we’d have athletes doing all sorts of dangerously hooligan things on the field just to get that extra point. As much as I enjoy a good hockey brawl, that’s the player who takes a hit right to the temple and loses consciousness.  Enforcement of rules by officials, coaches, parents, and adherence to rules by athletes will reduce the incidence and severity of sports-related concussions (Committee on Sports-Related Concussions in Youth et al., 2017).

Let’s look at some rules that are in place to save your athletes’ lives:

Rule: Heads Up/Body checking

Sport: Ice Hockey, Football, Men’s Lacrosse

Rationale: Body checking is a tactic by defensive players to separate the carrying player from the object. It is a legal move if it is performed using the trunk (hips and shoulders), but the introduction of helmets and face shields to protect from facial trauma showed an increase in the number of serious head, neck, and spinal injuries related to body checking. Perhaps the helmets created a false send of safety, resulting in rule changes to prohibit head-first contact.  USA Hockey, as well as other hockey leagues, has banned body checking at the Pee Wee level.

(American Academy of Pediatrics, 2000; Peters, 2013)

 

Rule: Targeting/Launching

Sport: Football

Rationale: The  NFL implemented two rule changes to augment player safety. First, an offensive player who is attempting to catch a ball that’s been intercepted will be ruled defenseless and cannot be hit in the head or neck area by the intercepting team as possession changes. Also, the NFL has given certified athletic trainers who are stationed in sky boxes at each game the authority to stop play with the touch of a button if they see a player who is exhibiting notable signs of injury, even if he was hurt in a previous play. How exciting for us!!!!

(National Football League, 2017; Reyes, 2015)

Good news is, the NFL will n linger penalize or fine most post- touchdown celebrations (Patra, 2017)

 

Rule: Head butting

Sport: Soccer

Rationale: A new rule in U.S. soccer limits the amount that youth players are allowed to head butt the soccer ball. For players 10 y.o. and younger, no head butting is allowed. Kids ages 11-13will head butt less during practice; players 14 years and older can head butt as always. “These new rules will resolve a lawsuit brought last year against U.S. soccer and others by a group of parents in California who argued the groups weren’t doing enough to protect kids from head injuries.” More importantly, brains in young children are not as myelinated as an adult’s brain, as they are still developing. When violently shaken, the unmyelinated nerve fibers in a child’s brain are more susceptible to trauma to the nerve fibers and disrupting the neural connections.  Also, the musculature surrounding a young child’s neck and trunk are less developed, meaning there is less support causing a blow to the head to cause more force and motion of the brain in the skull.

(Public Broadcasting Service, 2015)

 

Rule: Lane etiquette

Sport: Swimming

Rationale: When you enter a lane that already has a swimmer in it, you alert that person that you are entering the lane. When 2 swimmers share a lane, each person picks a side to swim laps and sticks to it. With three or more swimmers, everyone “circle swims”, meaning everyone stays to the right. If you must pass, alert the other person and don’t pass anyone who is near the end of the lane. This lane etiquette is important for lifeguards to enforce and for recreational swimmers to follow because the water inhibits out senses. Swimmer’s faces may be in the water, so they cannot see all of their surroundings clearly. Water distorts auditory stimuli. Bright sun may momentarily blind a swimmer. Different strokes cause different blind spots for a swimmer. Fifty percent of Olympic level synchronized swimmers have had a concussion. It is very difficult to control your body in the buoyancy of water, especially with current made by the waves of other team members. However, in competition it is ALL about the points, and teams gain more points the closer they move together and the ore complex their routines are, including throwing teammates into the air.

(Cimons, 2016; Gardner, 2016)

 

Rule: MLB 7.13 Home Plate Collisions- A runner attempting to score may not deviate from his direct pathway to the plate in order to initiate contact with the catcher; unless the catcher is in possession of the ball, the catcher cannot block the pathway of the runner as he is attempting to score

Sport: Baseball

Rationale: Catchers in baseball were beginning to suffer from concussions more than any other position on the field. Collisions at home plate are literally a blind crash between two opposing forces, and they can result in both concussion as well as traumatic fractures.

(Major League Baseball, 2014; Tribou, 2014)

So remember, sports officials are not there for kicks and giggles, they are there to make sure the game is played fairly and safely in order for people to continue to play the games they love. So smile,…..

 

 

and always remember to hug your Ref 🙂

hug your ref.gif

 

References

American Academy of Pediatrics (2000). Safety in Youth Ice Hockey: The Effects of Body Checking. Pediatrics, [online] 105(3). Available at: http://pediatrics.aappublications.org/content/pediatrics/105/3/657.full.pdf [Accessed 4 Aug. 2017].

Cimons, M. (2016). Swimming is supposed to be low-impact, so why the concussions?. [online] Washington Post. Available at: https://www.washingtonpost.com/national/health-science/swimming-is-supposed-to-be-low-impact-so-why-the-concussions/2016/12/09/aff3163e-b0d8-11e6-be1c-8cec35b1ad25_story.html?utm_term=.6dff5f9c8cef [Accessed 4 Aug. 2017].

Committee on Sports-Related Concussions in Youth, Board on Children, Youth, and Families, Institute of Medicine, National Research Council, Graham, R., Rivara, F., Ford, M. and Spicer, C. (2017). Sports-Related Concussions in Youth Improving the Science, Changing the Culture. Washington D.C,: National Academies Press (US), pp.17-19.

Gardner, D. (2016). Synchronized swimming bosses introduce new rules to prevent crashes. [online] Mail Online. Available at: http://www.dailymail.co.uk/news/article-3699412/Synchronized-swimming-bosses-forced-introduce-new-rules-prevent-crashes-emerges-HALF-competitors-suffered-concussion.html [Accessed 4 Aug. 2017].

Major League Baseball (2014). Orbit had one final prank for mortal enemy Chris Archer before the Rays left town. [online] Major League Baseball. Available at: http://m.mlb.com/cutfour/2017/08/04/246386032 [Accessed 4 Aug. 2017].

National Football League (2017). 2017 Rules Changes and Points of Emphasis | NFL Football Operations. [online] Operations.nfl.com. Available at: http://operations.nfl.com/the-rules/2017-rules-changes-and-points-of-emphasis/ [Accessed 4 Aug. 2017].

Patra, K. (2017). NFL relaxing touchdown celebration rules for players. [online] NFL.com. Available at: http://www.nfl.com/news/story/0ap3000000810537/article/nfl-relaxing-touchdown-celebration-rules-for-players [Accessed 4 Aug. 2017].

Peters, C. (2013). Peewee Body-Checking Ban: Why Hockey Canada, USA Hockey are Getting it Right. [online] The United States of Hockey. Available at: https://unitedstatesofhockey.com/2013/05/31/peewee-body-checking-ban-why-hockey-canada-usa-hockey-are-getting-it-right/ [Accessed 4 Aug. 2017].

Public Broadcasting Service (2015). U.S. Soccer rolls out new rules to prevent kids’ concussions. [online] PBS NewsHour. Available at: http://www.pbs.org/newshour/bb/u-s-soccer-rolls-new-rules-prevent-kids-concussions/ [Accessed 4 Aug. 2017].

Reyes, L. (2015). NFL reports reduction in concussions, new measures to protect players. [online] USA TODAY. Available at: https://www.usatoday.com/story/sports/nfl/2015/08/05/concussions-reduced-rule-changes-defenseless-injured-players/31189031/ [Accessed 4 Aug. 2017].

Tribou, D. (2014). New MLB Rule Cuts Home Plate Crashes, But Not Catcher Concussions. [online] NPR.org. Available at: http://www.npr.org/2014/11/09/362459949/new-mlb-rule-cuts-home-plate-crashes-but-not-catcher-concussions [Accessed 4 Aug. 2017].

 

 

 

 

 

CDC Concussion Game App

Image result for cdc rocketbladez

So, before I begin this blog I must admit that I am over the age of 6-8 and I know that may come as a surprise to some of you; however, I still downloaded this app to see how great the product was with regard to concussion education for children.Image result for cdc rocketbladez

The Center for Disease Control (CDC)’s HEADS UP created a great application for creating culture change in concussion education in our nation’s youth. The name of this application is Rocket Blades and its intent is to teach 6-8 year olds about:

  1. Different types of injuries that can lead to a concussion.
  2. The importance of self-reporting concussion symptoms.
  3. The importance of rest in concussion recovery.

The game opens with an introduction of the “team” of athletes and game’s explanation. It even stresses that though the team may wear helmets, they can still get a head injury if they fall. Then it shows an animation showing how when the head hits a surface that the  brain still shakes back and forth inside the skull. Let me start with this is an awesome learning point for the kiddoes, one of the biggest issues come across in the field is that most people, athletes, coaches, and even some healthcare professionals cannot identify the majority of concussion symptoms or believe that it either a concussion requires a hit to the head, requires being knocked out, or that helmets will protect from concussion (Sullivan et al, 2009).

Image result for cdc heads up rocketbladez

The game has various levels of play, it starts out easy… yes I know I am not a 6-8 year old kiddo, but the levels do get progressively harder! Once the skater gets going if he or she crashes then the game player has the option to select to sit out the team’s avatar to rest or to go on and play the concussed skater. What really stuck out to me in the game was that once the skater is concussed if the player chooses not to sit the skater and continue playing him or her, the screen begins to get blurry and react slower to the player’s commands. This is a great demonstration as to the effects of trying to play through a concussion.

Showing these effects of trying to play through a concussion are ideally meant to build a strong culture around concussion education. This will hopefully help with the major issue in underreporting of concussions, some estimates are that only 33.5% of concussed athletes will report their symptoms (Llewellyn et al, 2014). This underreporting issue can lead to major concerns for potential Second Impact Syndrome, a pathology that kills 50% of those who get it. See our blog on Second Impact Syndrome to learn much more.

Image result for second impact syndrome

I truly do not know what is worse, the issues surrounding Second Impact Syndrome in our youth population or the fact that there is still so much unknown about the long term effects of a concussion in the developing brain of a youth-athlete.

Overall, I think to advise parents I would suggest to have your kids download the app Image result for cdc heads upand play it to learn. The game is actually even fun for us older folks! The only issue I have with regard to this game is that it is currently only available for the IOS (apple) platform. So, us Android fans will have to wait until it is available for our platform too.

But there is still hope for all of us who use the Android platform, the CDC does have other applications or even online courses designed to help educate all levels (parents, kids, and practitioners) on concussions. Here is a link if you would like to reference those:

https://www.cdc.gov/headsup/youthsports/training/index.html

Overview of the App:Image result for cdc heads up

Pros

  • Fun
  • Educational
  • Captivating
  • Free!

Cons

  • IOS only 😦
  • That’s it

 

My take away for any parent in this post, is that education is important for our kiddoes to ensure a culture change occurs surrounding concussions symptom identification and self reporting of symptoms to someone who can help. After all, 33.5% is unacceptable, that’s 66.5% of unreported concussions…

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

 

References

Llewellyn, T., Burdette, G.T., Joyner, A.B., & Buckley, T.A. (2014). Concussion reporting rates at the conclusion of an intercollegiate athletic career. Clinical Journal of Sports Medicine, 24(1), 76-79.

Sullivan, S.J., Bourne, L., Choie, S., Eastwood, B., Isbister, S., McCrory, P., & Gray, A. (2009). Understanding of sport concussion by the parents of young rugby players: A pilot study. Clinical Journal of Sports Medicine, 19, 228-230.

Williamson, I.J.S. & Goodman, D. (2006). Converging evidence for the under-reporting of concussions in youth ice hockey. British Journal of Sports Medicine, 40, 128-132.

Concussions and Diagnostic Imaging

Image result for gif brain

BLUF (Bottom Line Up Front): No standard diagnostic imaging can be used to diagnose a Concussion!

Often as a healthcare practitioner, myself or my peers have been asked by athletes, coaches, and/or parents why we couldn’t just send the student-athlete out for imaging to see if they have a concussion. The answer is simple, according to the definition of Sport Related Concussion, or SRC, offered in the 5th International Consensus Statement on Concussion in Sport, held in Berlin (2017),

”  SRC may result in neuropathological changes, but the acute
clinical signs and symptoms largely reflect a functional
disturbance rather than a structural injury and, as such, no
abnormality is seen on standard structural neuroimaging
studies.”

This means that no Radiograph (X-Ray), Magnetic Resonance Imaging (MRI), or other Image result for dollarstandard forms of diagnostic imaging will detect the presence of a concussion! Further, even if they did detect the presence of a concussion this would not be a fiscally responsible diagnostic process. Let’s look at the range of costs according to Healthcare Bluebook (2017):

  • Radiographs (X-rays) of the skull range in price from $88-$275
  • Computerized Topography of the brain range in price $561-$1,765
  • MRIs of the brain and skull range in price from $924-$2,890

Image result for money flying away gif

With 1.6-3.8 million sports related concussions occurring a year (Broglio et al, 2014), it is safe to suggest that prices in those magnitudes being charged at those frequencies would significantly drive up the cost of insurance and decrease sports participation. Having said that, we cannot put a price on our brain’s health, but there are easier ways to diagnose the presence of a concussion. The current ‘gold standard’ does not exist, but according to the research a clinical evaluation, particularly on the sideline by a trained healthcare provider, such as an Athletic Trainer (ATC), is the best practice in identifying concussions.

An Athletic Trainer’s comprehensive sideline evaluation typically addresses the following areas:Related image

  • Cervical Spine Screening
  • Cranial Nerve Screening
  • Cognitive Screening
  • Memory Screening
  • Balance Screening
  • Vestibular Ocular Motor Screening
  • Exertional Testing (if all else fails)

Sideline evaluations and assessment batteries are considered to be an essential component of concussion screening (McCroy et al, 2017), and a comprehensive battery of tests such as what is listed above, significantly increases the potential of identifying a concussion by addressing the functional deficits associated to a concussion and simultaneously ruling in or out more major injuries, such as subdural or epidural hematomas. Top all of that off with the fact that these tests listed are free to conduct, makes this approach ideal.

But, a discussion on diagnostic imaging and concussions would not be complete without addressing the elephant in the room, Chronic Traumatic Encephalopathy or CTE by its more common moniker. This degenerative disease of the brain has been posed to be related to a history of concussions and has potentially lethal outcomes, such as increased risk of suicide.

Image result for CTE

The issue with CTE, is that it currently can only be diagnosed through autopsy, meaning we do not know until after the death that the person was suffering from this level of degeneration. This concern has lead to an increase in research around a more timely identification and diagnosis of CTE before the person takes their life.

Image result for tau protein

Research by James et al (2015) has focused on using positron emission tomography or PET scans to identify TAU protein, the hallmark of CTE as it forms in the brain. Though their research focused on Alzheimers, there is similarity in the lesions.

But where does this leave us? PET scans still run around $7,000.00, and that is significantly higher than previously listed imaging sources. Other research looked at the use of functional MRI or fMRI in the use of identifying the damage done during concussion (McDonald et al, 2012). Their research looked at <20 published research articles over a 10 year span of research using fMRI on concussed patients and they concluded that:

“…fMRI is ideally suited for noninvasive analysis of the impact of mTBI on both regional vulnerabilities to injury and on key functional circuits (e.g., memory, attention, emotion regulation) both shortly after injury as well as during recovery.”

According to the Yale School of Medicine’s Magnetic Resonance Research Center Image result for fMRI(2017), the current rate for an fMRI is $510 per hour with most imaging times taking around 1.5 hours, totaling $765.

While, $765 to scan the brain for concussion is far easier to bite off and chew than the PET Scan’s $7,000 fee, it is still a pretty big number when addressing the 1.6-3.8 million incidents of concussion per year in the United States (Broglio et al, 2014). The only issue is that the fMRI is best suited for establishing the sequela of concussion (McDonald et al, 2012), or the consequences of the mTBI occurring. While the clinical and sideline evaluations are still the best practice there is clearly increasing future potential in imaging. Once we can truly identify an ideal method combining a clinical application at high schools and colleges with a high sensitivity and specificity, while keeping the cost low, then we will truly have created the ideal diagnostic and potential ‘Gold Standard’ evaluation for concussion. Just remember, currently, standard and affordable imaging cannot diagnose a concussion!

 

By: Jeremy D. Howard, MS, LAT, ATC, CSCS, CES, PES, ITAT

 

 

Reference

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

Healthcare Bluebook. (2017). Retrieved from  https://healthcarebluebook.com/page_ProcedureDetails.aspx?cftId=136&directsearch=true.

James, O.G., Doraiswamy, P.M., & Borges-Neto, S. (2015). PET imaging of tau pathology in alzheimer’s disease and tauopathies. Frontiers in Neurology, 6(38).

McCroy, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., …, and Vos, P.E. (2017). Consensus statement on concussion in sport– the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of  Sports Medicine, 0, 1-10.

McDonald, B.C., Saykin, A.J., & McAllister, T.W. (2012). Functional MRI of mild traumatic brain injury (mTBI): progress and perspectives from the first decade of studies. Brain Imaging Behavior, 6(2), 193-207.

Yale School of Medicine. (2017). Magnetic Resonance Research Center. retrieved from http://mrrc.yale.edu/users/charges.aspx.