Parkinson’s disease: Management-a quick one on one

In this blog post let us dwell on the management of Parkinson’s disease (PD). As stated earlier PD is a progressive neurodegenerative disease. This means that as of now PD CANNOT be cured. Once the disease begins it slowly but surely progresses. The rate of progression varies from patient to patient. While PD cannot be cured, there are a number of medications available which can control the symptoms of PD. At times the response with these medications is dramatic and very gratifying. A few salient points:

NOT every patient of PD needs to be treated. When PD initially begins the symptoms are usually mild and may cause minimal interference to the patient’s lifestyle. The mild tremor of PD might be dismissed by the patient as a mere nuisance. At this stage of the disease, the patient does not exhibit problems with his/her gait or balance. The rigidity, bradykinesia is not disabling. At this stage of the disease, the neurologist may opt to simply keep the patient under observation. The patient and the family are educated about the disease and instructed to remain in follow up (come for follow up appointments after very 3-4 months).

The most effective medication for the treatment of PD is LEVODOPA. Since PD is caused by deficiency of dopamine in the brain, the most effective way to treat it is to give dopamine from outside. So levodopa is administered in tablet form usually 3 times a day. Levodopa is combined with another chemical called carbidopa which helps to prevent the breakdown of levodopa in the stomach and thus ensures that high level of levodopa is absorbed and reaches the brain. This combination of LEVODOPA+CARBIDOPA is the main medication used to treat PD. LEVODOPA+CARBIDOPA combination tab is marketed by many different pharmaceutical companies under different names (Please check the common brand name of this combination in your country). The tablet is usually started at low dose three times a day. The neurologist then titrates the dose up based on clinical response and side-effects. The medication is usually well tolerated by most patients and the effect is gratifying. It is important to emphasize that this medication still remains the MOST effective medication for PD. LEVODOPA comes in many different formulations including now in an inhaled form. These formulations are prescribed as the disease advances. Please discuss the same with your neurologist.

DOPAMINE AGONISTS: is another class of medication commonly used to treat PD. As the name suggests medications in this class act by stimulating dopamine receptors in the brain. While not as effective as LEVODOPA+CARBIDOPA, dopamine agonists are commonly prescribed. Commonly used dopamine agonists include pramipexole (Mirapex), rotigotine (Neupro), and ropinirole (Requip). Some neurologists prefer to use a medication in this class as first line treatment and use LEVODOPA+CARBIDOPA when PD symptoms are more bothersome (PD is more advanced).

Amantadine is another medication used to treat PD. It is usually used in combination with either LEVODOPA+CARBIDOPA or DOPAMINE AGONISTS.

Anticholinergic drugs such as benztropine and trihexyphenidyl are also commonly used. These drugs are helpful in controlling symptoms such as tremor and muscle stiffness.

Drugs referred to as selective MAO B inhibitors such as selegiline are used by neurologists usually early in the disease course. There is limited evidence to suggest that medications in this class may be “neuroprotective”.

COMT inhibitors: another class of medications used in the treatment of PD.

Neurostimulator such as DEEP BRAIN STIMULATOR (DBS): A neurostimulator called DBS is sometimes implanted in PD patients. DBS is usually implanted in the brain of PD patients with advanced disease who are experiencing motor fluctuations, medication side-effects called dyskinesias and medication refractory tremor. Please discuss this further with your neurologist.

While medications form the cornerstone of treatment of PD, there are a number of other simple interventions which are very effective. It is important to remember that PD affects the motor system causing problems with gait and balance. Hence I make it a point to emphasize the importance of exercise to my patients and their family. Exercises which improve gait and balance are the most helpful.

dance is a good exercise for patients with PD. (USEFUL RESOURCE: https://danceforparkinsons.org/)

–many are surprised to find out that boxing is a good exercise for patients with PD (USEFUL RESOURCES: https://www.rocksteadyboxing.org/ and https://www.youtube.com/watch?v=XC1h4ygl878)

–yoga is also a good form of exercise-it improves balance and helps reduce the stiffness in PD patients)

Parkinson’s disease patients are prone to falling. Hence falls are an important cause of morbidity in patients with PD. So simple interventions designed to reduce the risk of falling are helpful. (USEFUL RESOURCE: NATIONAL INSTITUTE ON AGING: Fall proofing your home https://www.nia.nih.gov/health/fall-proofing-your-home#:~:text=Keep%20electric%20cords%20and%20telephone,your%20way%20when%20you%20walk.)

Nitin K Sethi, MD, MBBS, FAAN

Director and Chief Coordinator Brain Care Foundation (https://braincarefoundation.com/)

Please support ongoing research in PD and more importantly PD patients and their families. Source of image is http://www.outsourcestrategies.com)

Parkinson’s disease: a quick one on one

Parkinson’s disease (PD) is a common neurological disease. This disorder of the brain is seen in people of all races and both sexes. PD is caused by the deficiency of a neurochemical called DOPAMINE in the brain. In this blog post I shall discuss the clinical presentation and diagnosis of PD.

Parkinson’s disease is included under the category of neurodegenerative brain disorders. What that means is that the disease is progressive. Once the disease starts, it slowly progresses. The rate of progression though varies from patient to patient. The disease onset is usually insidious. Most people first exhibit signs of the disease after age 60 (in some people the disease may start in the late 40’s or in their 50’s-this is then referred to as Early Onset Parkinson’s).

Disease onset-onset of PD is usually insidious and at times may not be noticed by the patient or the family. Typical first symptom may be a slight tremor (shaking) in the thumb of one hand/finger of one hand, the hand itself or the chin. The tremor is not disabling at onset and hence ignored by the patient/family. It is important to emphasize here that NOT ALL TREMORS ARE PD. There are numerous causes of tremor, many which are benign (do not signify any serious disease). PD tremor has some special characteristics (features) which helps to distinguish it from other types of tremors.

CHARACTERISTICS (FEATURES) OF PD TREMOR

  1. The tremor is usually insidious in onset and of low amplitude.
  2. The tremor is usually asymmetrical at onset (one thumb/one hand). As the disease progresses the tremor becomes more prominent and may involve both the sides of the body.
  3. PD tremor is typically what is referred to as a RESTING TREMOR. What this means is that the tremor is most prominent when the hands are completely at rest (example-the tremor is noted when the patient’s hands are resting on his/her lap, resting on the driving wheel). This is an IMPORTANT distinguishing feature of PD tremor. Tremors which are more prominent when the hands are extended in front (POSTURAL TREMOR) or while in motion are usually not due to PD.

CLINICAL PRESENTATION OF PD (SIGNS AND SYMPTOMS)

PD initially presents with motor symptoms. Patients do not have sensory symptoms such as pain, numbness, tingling. The common motor symptoms of PD are the following:

  1. Tremor: tremor of PD is a resting tremor (see above).
  2. Bradykinesia: the word bradykinesia means “slowness of movement” and is one of the main symptoms of PD. The patient is slow to walk, slow to initiate movement. As PD progresses, the patient becomes more and more bradykinetic (slow). There is loss of spontaneous movements such as facial expressions, gesturing, eye blinks.
  3. Rigidity: rigidity is another cardinal symptom of PD and refers to the stiffness which PD patients feel in their muscles. Rigidity can be detected by the neurologist on clinical examination.
  4. Disturbance of gait and posture: patients with PD experience a disturbance in their gait (how a person walks) and posture. A patient with PD is usually stooped (bent) forwards and walks with short quick steps. This is referred to as the SHUFFLING GAIT OF PD. This disturbance of gait and posture makes PD patients more prone to falls. It is important to emphasize here that FALLS ARE AN INPORTANT CAUSE OF MORBIDITY IN PD PATIENTS.

Photo source: *photo: https://www.labiotech.eu/medical/axovant-parkinsons-disease-gene/ (the above image has been edited)

DIAGNOSIS OF PD

The diagnosis of PD is predominantly clinical and has not changed much since the disease was first described by James Parkinson, an English surgeon in his now famous 1817 work AN ESSAY ON THE SHAKING PALSY.

PD is diagnosed in the following way:

  1. Clinical examination by a neurologist: neurologists are able to diagnose PD after taking a history and doing a neurological examination in which they assess for tremor, bradykinesia, rigidity and gait/posture.
  2. Neuroimaging: it is important to emphasize that neuroimaging studies such as CT scan head and MRI brain are usually reported normal in patients with PD.
  3. New imaging modalities: DaT scan is a new imaging test which uses a small amount of a radioactive tracer drug to determine how much dopamine is available in a patient’s brain. It is important to emphasize that DaT scan is neither needed nor a definitive test for PD diagnosis. It is primarily helpful in differentiating Parkinson like diseases (Parkinsonian syndromes) from a more benign condition called essential tremor (ET).

DISCLAIMER: The information in this blog is for educational and informational purposes only. It does not constitute medical advice. Use of the site content does not establish any patient-doctor relationship. If you choose to write to me or post a comment on this blog, please do not divulge any personal medical information.

Nitin K Sethi, MD, MBBS, FAAN

Transgender athletes in Combat Sports: To fight or not to Fight?

Should transgender athletes be allowed to participate in combat sports? Will this be a fair bout and more importantly a safe bout (from the perspective of health and safety of both the combatants)? Attached is a PowerPoint presentation where in I discuss this polarizing topic.

Helping the helpers…preventing burnout in caregivers of patients with dementia

Burnout rates are high in caregivers of patients with dementia. India currently lacks services such as day care centers, specialized nursing homes or availability of home health aides to address the needs of dementia patients. In this blogpost we highlight this problem and offer some innovative solutions to address this issue. P K SETHI, MD & N K SETHI, MD

Image source: Alzheimer’s Association of North CA.

Me and my migraine headaches

Migraine is one of the most common neurological disorder which a neurologist encounters during his or her practice. It is not without reason that it is often referred to as the bread and butter of neurological specialty. My parents are both physicians. My father is a neurologist and mother a pediatrician. Growing up I remember my mother coming back from the hospital and complaining of a throbbing migraine. She would lie down in a quiet dark room and ask me or my sister to press her head. Sometimes she would ask me to tie a “dupatta” (a shawl-like scarf worn by Indian women) tightly around her head in a vice-like grip. She never threw up during a migraine attack, but I remember she was always drained afterwards. My sister is 4 years older than me and when she entered high school and later medical college she too complained of severe migraines.

Following my father’s footsteps, I chose neurology as my specialty. My first recollection of getting migraine headaches is when I was in medical school. During residency training it was not uncommon for me to have a throbbing unilateral headache after an overnight call. By 10 am I would sign-out to my co-resident and head home. I would feel sick and realized quickly that if I ate a good breakfast, took an over the counter non-steroidal anti-inflammatory drug and fell asleep, I would wake up later that afternoon migraine free. I am now in my mid 40’s. As an academic neurologist, I see a wide variety of neurology patients including those who suffer from migraines. I am now able to better appreciate and characterize my own headache disorder. I suffer from common migraines. My typical migraine attack has no preceding visual aura. Just like the textbook description my headache is throbbing, pulsatile with pain radiating to the ipsilateral eye. I am light sensitive though sounds do not bother me as much. Most of my migraine attacks are left temporal. My migraine attacks share some characteristics which have been reported in the scientific literature. Professor Lance famously described the Red Ear Syndrome in migraineurs. Just as he described it, my ipsilateral ear becomes red and burns when I get a migraine attack. Sometimes both my ears become red and the red ear precedes the headache. I do not suffer from the Red Forehead Dot syndrome, a syndrome which I described along with my father. I have noticed things which have not been described in the migraine literature such as that I tend to tolerate my left temporal migraines better than the rarer right temporal ones. When I do get right temporal headaches, I feel very uneasy and irritable. On those occasions you may find me a bit short-tempered. When my migraine does not abort and persists for a long period of time, I develop subtle signs of cerebral dysfunction. I subjectively feel that my speech is off and that I am slurring, my typing skills deteriorate, and I frequently hit the wrong key. Very rarely I feel my balance off.

Over the years I have identified my migraine triggers. Stress at work especially when I am pressed for time and miss a meal is my most common trigger. Others include lack of sleep, dehydration, and red wine. An unusual one is perfumes with strong fruity fragrance. Recently an article highlighted the link between smartphone use and primary headache.  Smartphone use does not trigger my typical migraine attack but when I am having a migraine attack, I am quite sensitive to my iPhone screen and ringtone. Multitasking on the computer and iPhone apps such as answering multiple text messages, e-mails and phone calls all increase the severity of my migraine attack. Overtime I have learnt to adapt to these necessary technological evils. My office computer and iPhone screen brightness are set to low, ringtone to Chimes and the Night Shift turned on from 7:00 pm to 7:00 am. I have my office lights dimmed at all time. Doctors are said to make the worst patients. I am guilty as charged and have resisted a drug for migraine prophylaxis. Recently due to an increase in the frequency of migraine attacks, I started amitriptyline 10 mg at night. The results have been gratifying. My migraine frequency has dramatically decreased but I wake up feeling groggy. My illness has made me better appreciate the impact of this chronic common neurological disease. 

Nitin K Sethi, MD, MBBS, FAAN

COVID-19 and combat sports: when and how to begin bouts again?

COVID-19 and combat sports: when and how to begin bouts again?

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.

 

Professional boxing and mixed martial arts (MMA) are popular sports with a worldwide fanbase. COVID-19 (coronavirus disease 2019) is the infectious respiratory disease caused by SARS-COV 2 virus (Severe Acute Respiratory Syndrome coronavirus 2). On March 11th,2020 The World Health Organization (WHO) declared COVID-19 a pandemic considering the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread. 1 In order to control the spread of COVID-19, heath care authorities in different countries recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing. 2 Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. Widespread cancelation or postponement of sporting events including boxing and MMA bouts followed. The most common sited cause for cancelation was fear of contagion. The encyclopedia describes contagion as the communication of disease from one person to another by close contact. By canceling events, State Commissions, promoters and combat sport’s governing bodies made the tough but responsible decision to protect all the concerned parties namely the athletes, their camps, Commission officials, production crews and the fans at the venue.

 

The global death toll from COVID-19 has been devastating. COVID-19 has infected more than 2 million people and killed at least 132,276 worldwide as of April 15th 2020 according to the coronavirus resource center at Johns Hopkins University. 3 The pandemic affected each and every one of us fundamentally changing the way we live our lives. The pandemic has peaked in many European countries and the United States. While deaths continue to mount, new cases and admissions are declining. Governments are now turning to the complex question of how and when to open different states and countries to business and normal life. For combat sports to resume this summer we should explore the possibility of initially holding events “behind closed doors”. Only the athletes, cornermen, referee, judges, Commission officials, ringside physicians and TV production crew would be present at the venue. The rationale for holding an event behind closed doors will be to reduce the risk of COVID-19 transmission from person to person by restricting the number of people at the venue to under 50. In the past month many SARS-COV 2 diagnostic test kits have become available. Some of these can be administered at the point-of-care with a turnaround time of 24 hours. It is proposed that all (not just combatants) present at the closed door event undergo a coronavirus screening questionnaire and be tested for SARS-COV 2 in the week leading up to the event. Social distancing should be practiced at the time of the weigh-ins and also the event itself. Corner men, referee, judges, Commission officials, ringside physicians and TV production crew should wear a surgical face mask (N 95 respirator is not warranted), gloves and eye-protection during the course of the event.

 

We should acknowledge that even if an event is held behind closed doors and all those present (not just the athletes) are tested for the coronavirus, the risk of transmission from person to person remains. Controlling the spread of the COVID-19 pandemic is far bigger than any boxing or MMA event. It is a matter of social responsibility and an obligation to act for the benefit of the society at large. By adopting some of the above practices a cautious start to combat sports events can be contemplated.

 

 

COVID-19 and telemedicine: old barriers come down and new ones come up

COVID-19 and telemedicine: old barriers come down and new ones come up

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

In the space of a few weeks the COVID-19 pandemic has changed the way medicine is practiced in the United States. In order to control the spread of COVID-19, the Centers for Disease Control and Prevention (CDC) and department of health (DOH) of various states recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing.  Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. All non-essential staff were advised to stay home and work remotely if the facility to do so was available to them. Hospitals across the country were forced to make some drastic changes in order to prepare for the expected surge of COVID-19 patients. In New York City, hospitals canceled all elective surgeries, closed in-patient epilepsy and stroke units and canceled all outpatient clinics. Patients were discharged from the hospitals. Beds especially ICU beds and other resources such as ventilators were reserved for COVID-19 patients. Physicians working in these hospitals were advised to adopt telemedicine in order to primarily maintain continuity of care for their existing patients. Barriers which over years had started to shackle the physician-patient relationship and physician autonomy in the practice of medicine came tumbling down. The Health Insurance Portability and Accountability Act (HIPAA), a US law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers was relaxed to state that covered health care providers will not be subject to penalties for violations of the HIPAA Privacy, Security, and Breach Notification Rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency.   While physicians were encouraged to practice telehealth through their existing electronic health record (EHR) software, other modalities for pursuing telehealth were approved. Telehealth could be pursed via Zoom, WhatsApp or FaceTime. For physicians and patients who are unable to use any of the above modalities, a telephone encounter could be carried out. The above measures are a welcome relief to both physicians and patients as it helps maintain continuity of essential medical care during the COVID-19 pandemic. But just as the old barriers seem to come down, new ones started to come up. The HHS Office of Civil Rights (OCR) recommended the following: “OCR expects health care providers will ordinarily conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic. Providers should always use private locations and patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances. If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI.”  Overnight it seems new documentation guidelines came out with respect to televisits. We were told that physician documentation should include time start/end, participants on call and physical location of the patient at the time of the televisit. There had to be documentation of verbal consent that the patient understood that this is a billable visit. Patient could not have a phone visit within 7 days following last evaluation and could not be scheduled for an in-patient visit within 24 hours after a telephone visit else the physician could not bill for the televisit. We were informed of new billing codes and Medicare and Commercial Insurance rates for different time duration visits (5-10 minutes, 11-20 minutes, >21 minutes). A flurry of e-mails from the compliance specialists, medical billing specialists and office managers followed informing us of what we could or could not do.  It has been said that the COVID-19 pandemic is going to change the world as we knew it. When it comes to the practice of medicine the rules are expected to change too. While some old barriers have thankfully fallen, unfortunately new barriers have come up. It seems removing the shackles is easier said than done.

 

 

COVID-19 and combat sports-to fight or not to fight?

COVID-19 and combat sports: to fight or not to fight?

Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.

 

Professional boxing and mixed martial arts (MMA) are popular sports with a worldwide fanbase. COVID-19 (coronavirus disease 2019) is the infectious respiratory disease caused by SARS-COV 2 virus (Severe Acute Respiratory Syndrome coronavirus 2). On March 11th,2020 The World Health Organization (WHO) declared COVID-19 a pandemic considering the over 118,000 cases of the coronavirus illness in over 110 countries and territories around the world and the sustained risk of further global spread.  In order to control the spread of COVID-19, heath care authorities in different countries recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing.  Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. Widespread cancelation or postponement of sporting events including boxing and MMA bouts followed. The most common sited cause for cancelation was fear of contagion. The encyclopedia describes contagion as the communication of disease from one person to another by close contact. By canceling events, State Commissions, promoters and combat sport’s governing bodies made the tough but responsible decision to protect all the concerned parties namely the athletes, their camps, Commission officials, production crews and the fans at the venue.

Some promoters have explored the possibility of holding a combat sports event “behind closed doors”. Only the athletes, cornermen, referee, judges, Commission officials, ringside physicians and TV production crew would be present at the venue. The rationale for holding an event behind closed doors is to reduce the risk of COVID-19 transmission from person to person at the venue. It was further proposed that all athletes be tested for SARS-COV2 before entering the ring or cage. The term “behind closed doors” is used primarily in association with football (soccer) to describe matches played where spectators are not allowed in the stadium to watch. Soccer matches are played behind closed doors to punish a team when its fans display rowdy behavior and clash with the rival team supporters and is included in the FIFA Disciplinary Code. 3

Amid the COVID-19 pandemic should combat sports events be held behind closed doors? Crowd less bouts are rarely heard of in combat sports. Passionate frequently blood hungry fans vociferously and voraciously support their prizefighter and are as much a part of the sport as the athletes themselves. Combat sports athletes fight not just for fame and money, they fight for their fans in the venue. Holding a crowd less event takes the very essence and vibe out of a combat sports event. Just like water is the elixir of life, so is the combat sports fan to the sport itself. Even if an event is held behind closed doors and all those present (not just the athletes) are tested for the coronavirus, the risk of transmission from person to person remains. Controlling the spread of the COVID-19 pandemic is far bigger than any boxing or MMA event. It is a matter of social responsibility and an obligation to act for the benefit of the society at large.

 

The stunned brain: neuroanatomical correlates of an acute concussion in boxing

 

                                                              The stunned brain: neuroanatomical correlates of an acute concussion in boxing

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

 

 

 

 

 

Abstract

 

 

A concussion can be defined as a transient alteration of mental status due to biomechanical forces affecting the brain. Concussions are common in contact sports like boxing and mixed martial arts (MMA). In boxing frequently the goal is to win by causing a knockout (KO)/concussion though a fight may also be won by a body shot if the boxer is unable to continue. This is then ruled a technical knockout (TKO). In the case report that follows, the clinical semiology of an acute concussion in boxing is described and a speculative hypothesis about the neuroanatomical correlate of the syndrome is postulated.

 

 

 

 

Case Report

 

A-32-year old right handed professional male boxer with a record of 20 wins, no losses with 10 of the wins coming by way of knockout suffered a brutal KO during a high profile televised bout. The boxer went down with the head striking and then bouncing off the ring canvas. Immediately on impact with the ring canvas the boxer exhibited decerebrate posturing followed by a 20 second convulsion characterized by stiffening of the arms and low amplitude clonic jerks of the legs. The referee immediately signaled an end to the fight and motioned the ringside physician to enter the ring to tend to the downed fighter. Examination inside the ring revealed a conscious boxer (eyes open) with unresponsiveness (no response to commands). This conscious unresponsiveness state lasted for about one minute. Pupils were midsize, equal in size with sluggish response to light. The emergency medical service (EMS) personnel stationed ringside were summoned into the ring by the ringside physician. While maintaining spinal fixation, the boxer was placed in a hard cervical collar and lifted on to and strapped on a hard backboard. As this was been accomplished, the boxer suddenly became responsive and started punching the air with his gloved hands as if he was back in the midst of the bout. He was combative and attempting to get up from the board. He was restrained by the medical staff. After about 1 minute, he calmed down and became fully alert and oriented. He realized that the fight had been stopped because of a KO and requested the medical staff to allow him to get up. At the post-fight medical evaluation he was determined to have suffered an acute concussion and administered a 90 day medical suspension. A neurology clearance was also requested prior to return to competitive boxing.

 

 

Discussion

 

 

The 5th international conference on concussion in sport held in Berlin, October 2016 defined a sport related concussion (SRC) as a traumatic brain injury induced by biomechanical forces resulting in the rapid onset of short-lived impairment of neurological function that resolves spontaneously 1. However, in some cases, signs and symptoms may evolve over a number of minutes to hours. While SRC may result in neuropathological changes, the acute clinical signs and symptoms largely reflect a functional brain disturbance rather than a structural injury with no abnormality seen on standard structural neuroimaging studies such as CT or MRI.

 

The centripetal theory of cerebral concussion postulates that in a concussion there is a centripetal progression of strains from the outer surfaces to the core (midbrain and basal diencephalon) of the brain 2, 3, 4. The anatomical localization of memory is in the temporal lobes or orbitotemporal regions. As per the centripetal theory, less degree of force does not penetrate deep into the cortex and so while cognitive and memory dysfunction may result, consciousness is retained. Forces strong enough to penetrate through to the mesencephalic brainstem result in loss of consciousness. It is important to remember that the above theory and biomechanical concepts are largely based on primate research and not on humans. The observation that brainstem signs can occur in the absence of significant “cortical” symptomatology and that cortical signs can occur in the absence of significant “brainstem” symptomatology means that the centripetal theory explains some but not all of the varied clinical semiology of concussion. It is generally accepted that traumatic decerebration, short duration traumatic coma (loss of consciousness) and impact seizure are brainstem release phenomena in which cortical inhibition of normally suppressed brainstem activity is lost due to diffuse cerebral injury. It may also be that the above phenomena are primarily due to failure of activity in the mesencephalic reticular formation and with loss of brainstem reflex response without widespread cortical involvement.  The amnestic symptoms noted during a concussion have been postulated to be due to a transient interruption or disturbance in the ascending cortical projections at the level of the mesencephalon. It is hence intriguing to think of a “brainstem concussion” distinct from a “cortical concussion” each with different clinical semiology and symptom complex 4.

 

The above described clinical semiology of an acute concussion in boxing has not been described thus far in the medical literature. While this “stunned brain syndrome” is unnerving to witness as a physician neurologist because of its dramatic presentation and rapid evolution; the syndrome is self-limited with the boxer returning to baseline neurological function usually in the ring itself. It likely has the bulk of its anatomical focus in the brainstem with some cortical and subcortical contribution.

 

Understanding the neuroanatomical correlates of an acute SRC as in boxing has important implications for our conceptual understanding of concussion and acute management of these injuries in the ring.

 

References

 

  1. McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5thinternational conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017; 51:838-847.

 

  1. Ommaya A. Head injury mechanisms and the concept of preventative management: a review and critical synthesis. J Neurotrauma1995; 12:527–46.

 

 

  1. Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic unconsciousness. Correlation of experimental and clinical observations of blunt head injuries. Brain1974; 97:633–54.

 

  1. McCrory P. The nature of concussion: a speculative hypothesis. British Journal of Sports Medicine 2001; 35:146-147.

 

Ensuring and Maintaining Brain Health of the Combat Sports Athlete

Ensuring and maintaining brain health of the combat sport athlete

Nitin K Sethi, MD
Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

DISCLOSURES: NKS serves as Associate Editor, The Eastern Journal of Medicine and Editor-in-Chief, ARP Journal of Combat Sports Medicine. He also serves as Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed are his and do not necessarily reflect the views of the NYSAC.

 

Combat sports such as professional boxing and mixed martial arts (MMA) are popular sports with high risk for both acute and chronic traumatic brain injuries (TBI). Unfortunately, combatants have died in the ring or soon after the completion of a bout usually due to an acute catastrophic neurological event such as an acute subdural hematoma (SDH); which has been documented to be the most common cause of boxing related mortality. Acute TBI is just the tip of the iceberg when it comes to neurological injuries caused by combat sports. Hidden under the surface and away from the eyes of the public and media are the equally devastating chronic neurological sequelae of boxing and MMA including but not limited to chronic posttraumatic headache, chronic posttraumatic dizziness, posttraumatic cognitive impairment, posttraumatic Parkinsonism, posttraumatic dementia, dementia pugilistica, punch drunk syndrome, chronic traumatic encephalopathy (CTE) and neuropsychological sequelae such as mood, behavioral changes and depression.

At present there are no validated imaging or bio fluid (blood, cerebrospinal fluid) biomarkers for concussion and many of the above chronic neurological sequelae of boxing and MMA. In the absence of biomarkers; prognostication of the brain health of a combat sports athlete is inherently difficult. Most combatants undergo neuroimaging at the time of applying for initial licensure to compete in combat sports. This entails a magnetic resonance (MRI) scan of the brain without contrast usually carried out on a 1.5 or 3 Tesla strength magnet. In some countries and Commissions in the United States, a computed tomography (CT) scan of the head is acceptable in lieu of the MRI brain. While neuroimaging prior to licensure helps detect incidental clinically silent structural lesions with a high risk of bleeding such as aneurysm, arteriovenous malformation, large cavernoma, vein of Galen malformation and brain tumors, it does not yield any useful information about the function of the brain. Hence combining structural imaging with a functional study of the brain such as a formal neurocognitive evaluation should be considered at the time of initial licensure. Neurocognitive testing is a way to measure brain function non-invasively. It uses paper-and-pencil tests or computerized tests to assess important aspects of cognition such as attention, memory (immediate recall, short-term, long-term, auditory, visual), language, reaction time, perception and so on after factoring in the IQ and formal education of the examinee. A formal neurocognitive evaluation carried out by a qualified neuropsychologist is extremely helpful to formally assess the function of the brain as well as the mind and to grade/score it. The above test combo carried out at the time of the initial licensure serves as the baseline against which future test results are compared.

The average professional career of a combat sports athlete spans 10 years. During their active career most combatants fight on an average 2-6 times per year. It is recommended that a combat sports athlete undergo repeat MRI brain and neurocognitive evaluation after every 3 years. If the MRI shows evidence of prior TBI such as an area of encephalomalacia or gliosis, diffuse axonal injury, micro hemorrhages and the neurocognitive scores show a demonstrable decline, the combatant should be flagged. These combatants may need further tests such as PET scan of the brain, an electroencephalogram (EEG) and referral to a neurologist. On a case by case some may be allowed to proceed with their career under close observation while others may be counseled to hang up their gloves in order to prevent further and at times irreversible brain damage.

The brain is like a muscle and needs to be exercised, nourished and nurtured. The more it is exercised the stronger it becomes. Use it or lose it has scientific validity. Combat sports athletes should be counseled about brain health and how to build their cognitive reserve by doing exercises such as crossword puzzles, playing chess, reading, writing, listening to music or learning a new language or musical instrument. Supplements such as magnesium oxide and vitamin B12 are generally acknowledged to be brain healthy. A brain healthy Mediterranean diet which entails cooking food in extra virgin olive oil, less of dairy, less of red meat, more fish, more nuts should be promoted.

It is further recommended that the various sports commissions in the United States and abroad and combat sport’s governing bodies coordinate to assist with the setting up of an online central neuroimaging and neurocognitive database so that neuroimaging and neurocognitive data can be shared in the different countries where the combatant may compete.
The above interventions shall help to maintain the brain health of the combat sports athlete.

Reference

 

1. Sethi NK. Neuroimaging in contact sports: Determining brain fitness before and after a bout. SA J. Sports Med. 2017. vol.29 n.1 http://dx.doi.org/10.17159/2078-516x/2017/v29i0a2390