Author: braindiseases

I am a qualified neurologist with sub specialization in the fields of epilepsy, clinical neurophysiology, sleep medicine and traumatic brain injury.

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

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                                                              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

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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

 

Can we afford not to afford treatment of multiple sclerosis in India?

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Can we afford not to afford treatment of multiple sclerosis in India?
Neha Pandita 1, MD, Anuradha Batra 1, MD, Prahlad K Sethi 1, MD, Nitin K Sethi 2, MD

1 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)
2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

Multiple sclerosis (MS) is a chronic neurological disease which affects men and women in the prime of their youth. The disease can present in relapsing-remitting, secondary progressive, progressive relapsing and primary progressive forms and leads to increasing disability during the course of the patient’s lifespan. Symptoms such as muscle weakness, gait and balance problems, coordination problems, visual impairment, diplopia, bladder and bowel disturbances, sensory symptoms, cognitive dysfunction and fatigue can be disabling at times and lead to poor health related quality of life, neurological disability and high health care costs. Progressive disease can be paricularly disabling leading to a wheel chair chair dependent on caregivers for activities of daily living. In India; till a few years ago, MS was thought to be rare and a disease of the Western hemispher. It is unclear why now we are seeing more and more MS patients in India. Is it because with advances in health care and diagnostics, we are diagnosing more cases which earlier remained undiagnosed or is the incidece of this disease actually increasing in the Indian population? This still needs to be determined and it would behoove us well to start a national MS registry and keep a track of MS cases and coregister with dietary and enviromental variables. Many low and middle income countres such as India have a huge population with limited accessibility and affordability to health care facilities. About 70% of India’s 1.3 billion population lives in rural areas with 30% living below the poverty line. In a country like India, a disease like MS can have a particularly devastating impact not just because of its chronicity and propensity to affect the young but also due to its high treatment cost burden. A study published in April, 2015 found that the cost of first generation disease modifying medications for MS increased from between $8000 to $11000 annually in the 1990s to approximately between $60000 to S90000 per year currently. Newer disease modifying MS drugs cost even more.In the west, patients with MS commonly pay for their MS treatment in one of the following ways:

1. Job (employer) based health insurance plan
2. Individual health insurance plan
3. Medicare
4. Medicaid or state children’s health insurance program
5. Other state and federal government funded programs for the uninsured and underinsured

In India, where illiteracy, unemployment and poverty remain major social problems, state and federal supported health insurance schemes benefit only a small fraction of the population. As in India at present there is no National Health Insurance program, patients have to pay out of pocket for health care. The purpose of writing this commentary is to draw attention to the cost burden associated with a chronic disease like MS and start a discussion on treatment solutions that may benefit our MS population without causing unbearable financial burden.
We calculated the average health care cost to a patient who is first time admitted for any demyelinating disease, in a corporate health care institution. A patient with spastic paraparesis was admitted to Sir Ganga Ram Hospital (SGRH) with provisional diagnosis of acute myelitis later confirmed as MS. We found that the entire hospitalization cost him around Rs. 1.8 lac ($2560).

Breakdown of costs:

Investigations:
–contrast enhanced MRI brain and cervical spine (Rs. 26000/ $ 416)
–visual evoked potential (VEP) (Rs. 2000/$ 32 )
–lumbar puncture (CSF analysis) (Rs. 8000/ $ 128)
–ancillary investigations like autoimmune encephalitis panel (Rs. 40000/ $ 464).
Treatment costs:
—pulse IV steroid therapy x 5 days (Rs. 70000/ $ 1120)
Hospital stay costs:
–room cost plus ancillary expenditure (Rs. 70000/ $ 1120)

It is important to remember that this is the financial burden borne out of pocket by an average middle class patient admitted to SGRH. Patients who live below the poverty line cannot afford such costs and the financial burden forces family members to take loans or at times sell their home and property to pay for the treatment. Unlike a case of post infectious myelitis, a patient with MS may suffer an acute exacerabation or relapse leading to another hospitalization and additional costs. The various MS disease modifying agents are so expensive that few patients in India can afford the drugs. Many as a result discontinue treatment regimens and self medicate with medications such as oral steroids.

We also calculated the average cost to the patient of various disease modifying agents available in India.

1. Injectable DMTs like Avonex (beta interferon) given at a dose of 30mcg I/M once a week costs Rs. 30000/ $ 480 dollars monthly.
2. Copaxone (glatiramer acetate) Rs. 20000/ $ 320 monthly.
3. Mitoxantrone Rs. 400/ $ 5 per vial
4. Tysabri (natalizumab) costs a whopping Rs. 1,40,800/ S 2184 monthly.
5. Oral DMTs like fingolimod costs around Rs. 3,00,000/ S 4790 dollar for 30 capsules, teriflunomide Rs. 2,90,000/ $ 4500 for 1 month supply, and dimethyl fumarate Rs. 3,40,000/ $ 5300 for 1 month supply.
6. Azathioprine costs Rs. 600/ $ 9.6 per month

The per capita income in India is estimated at just short of Rs. 6000 per month which equals $ 90 per month. That means the per capita income for a family of 4 would be less than $ 400 a month, but the reality is that most people live on much less than that and struggle to provide for the basic needs of food, clothing and shelter. Both the interferons and the oral DMTs are accessible to only a few in India due to their exorbant cost. As a result, many Indian MS patients cannot afford treatment and are left behind untreated with significant neurological disability impairing their quality of life. In India, where it is estimated that around 100,000-200,000 people have MS, finding cost effective treatment options is very important.

What are the solutions?

1. Methylprednisolone (Solumedrol) is an effective drug used to treat an acute attack of MS. Once the diagnosis of MS is confirmed, and patient presents to the hospital with an acute exacerbation, first dose of methylprednisolone can be administered in the emergency department followed by rest of the doses at home. The outpatient administration can be carried out by trained nurses via patient outreach programs. This will greatly reduce the cost of treating an acute attack of MS without requiring admission.

2. An initial MS diagnostic and treatment package should be constituted, including all the necessary initial investigations and treatment. This shall help drive down the initial costs incurred by patients and family members.

3. A MRI package should be constituted. This should include the cost of MRI brain and cervical spine imaging at least once a year and help in reducing the diagnostic cost associated with repeated neuroimaging in patients with MS.

4. A National Health Insurance scheme geared towards chronic neurological diseases such as MS should be formulated. While many good insurance schemes have been recently launched by the government, unfortunately they remain on paper only.

5. Pharmaceutical companies manufacturing and marketing MS drugs should be approached by the government and the cost of MS drugs should be negotiated so that more patients can afford these medications and avail their benefits. Recently 3 Indian pharaceutical companies have launched generic versions of Tecfidera (dimethyl fumarate) costing under Rs.4000/month. Intas pharmaceuticals generic version of Aubagio (teriflunomide) costs only Rs. 2000/month.

6. There are various studies documenting the effectiveness of azathioprine in MS patients. A multicentre randomized non inferiority trial was conducted comparing azathioprine vs beta interferons for relapsing remitting multiple sclerosis and it was found that efficacy of azathioprine is not inferior to that of beta interferon for patients with relapsing remitting multiple sclerosis 1. Massacesi et al conducted a study evaluating the efficacy of azathioprine therapy on new brain lesions evaluated using magnetic resonance imaging and concluded that azathioprine administered at lymphocyte suppressing doses, is effective in reducing MS new brain inflammatory lesions and is well tolerated 2. In a study by Casetta et al in 698 patients with MS, it was concluded that azathioprine is a fair alternative to interferon beta for treating MS patients 3. In SGRH, we have around 20 patients with MS who are on azathioprine for the past 10 years, doing well and tolerating the medication well. Considering the convenience of oral administration, low cost and good efficacy, azathioprine may represent an alternative to interferon and oral DMTs. This should be studied further in the Indian context.

Conclusions

In India, there is a large unmet disease burden of MS. We can’t afford not to afford the treatment of MS in India as it affects our young population who are the backbone of our nation. To tailor to the requirements of the Indian population, drug trials with large sample size using cheaper drugs such as azotioprine are needed. Large academic medical centers in India should take the lead in this initiative and run head to head trials of azothioprine against more established injectables and oral DMTs.

Disseminated cysticercosis (tapeworm)in a vegetarian male

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Disseminated cysticercosis (tapeworm) in a vegetarian male

 

Prahlad K Sethi, MD and Nitin K Sethi, MD,

 

 

A 35-year-old vegetarian man presented with a generalized convulsion. MRI brain showed extensive cysticerci lesions involving the bilateral supra and infra-tentorial brain parenchyma, myofascial planes of the face, neck, floor of mouth, parotid glands and left orbital extraocular muscles (figure 1). MRI thigh showed diffuse cysticerci involving multiple muscles (figure 2). Disseminated cysticercosis can occur in vegetarians and non-pork eaters due to fecal-oral contamination of food with Taenia solium eggs from tapeworm carriers1.

The conflict between combat sports and ethical medicine: can they co-exist?

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The conflict between combat sports and ethical medicine: can they co- exist?

N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America
Corresponding author: N K Sethi (sethinitinmd@hotmail.com
Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.

Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065
Email: sethinitinmd@hotmail.com
Tel: + 212-746-2346
Fax: + 212-746-8845
Even after so many years, there are times when my love and passion for combat sports collides head on with my love and passion for medicine and protecting athletes health.

One would assume that these 2 passions would not cause any conflict in me and for a while it never did. On many weekends, I would be at Mendez Boxing hitting the bag while wearing my favorite T-shirt proudly emblazoned “Neurologist-because awesome is not a job description”. My friends at Mendez know me and call me simply “doc” and some of my most memorable moments have been spent in their company discussing combat sports.

I once gave a lecture to a body of my peers at my hospital. The topic I chose was “Neurological injuries in boxing”. I spoke passionately about the topic. To my dismay, many of my colleagues disagreed with my involvement in combat sports and got up and left midway. I felt hurt but my passion and love for both combat sports and Neurology remained unchanged. But recent events have forced me to come to terms with my involvement as a ringside physician in combat sports.

One principle has always helped me when I find myself struggling and that is that I am there ringside or cage side for only one thing. To stop a fight once I feel the threshold has been reached beyond which I cannot guarantee a fighter’s health and safety.

The fighters are professionals skilled and trained to do their job. They always command my greatest respect. I too am a professional skilled and trained to do my job. My threshold of stopping a fight may differ from a fighter or a fan’s threshold of stopping a fight. It may also differ from a referee’s threshold of stopping a fight. As a physician one cannot defend combat sports by saying that boxing or MMA is good for the brain or the body. No amount of boxing or MMA is good for the brain-not one round, not even one punch to the head or to the body. Ringside or cage side I need to remain objective, completely free of any bias and make a call to stop a fight based solely on the medical facts in front of me not the fighter’s fight record and certainly not based on how big the fight is and how much money is at stake. The minute I do that, I fail to remain an objective doctor and I rather be a spectator occupying a seat at the venue rather than wasting a seat ringside or cage side. My judgement is going to be biased and I am now primed to fail in my only duty which is to protect the athlete’s health.

Do I have all the answers? No. But sometimes under tremendous pressure I must make a call. It does not matter whether the setting is the ER, the ICU or the bright lights of a combat sports arena. Why would I treat a patient that I am seeing in the ER after an assault on the street differently from an athlete who has sustained similar injuries inside a ring or a cage? If I am concerned about an assault victim, I am not going to tell him all is well and just discharge home from the ER. No, I shall admit him and do the necessary medical evaluation and management. Why should my approach be different cage side or ringside just because it is a big fight? If it is, I have no right to be present there for I am failing my patient (the athlete) who has trusted me with his/her health on entering the cage or the ring.

The ringside/ cage side setting is far more challenging to practice medicine than the controlled environment of the ER or the hospital. I must make a call and I must make it fast. I do not have the luxury of doing labs or a CT scan. It is all clinical with only the athlete in front of me. And yes, contrary to some people’s view it does take 15 to 18 years of intense medical training to make this call-which athlete has only suffered a concussion and can be discharged home versus one who may be about to develop a far more serious traumatic brain injury. You only have to encounter an unconscious person on the street to realize how tough it is and how helpless you feel without a doctor on hand. And I need to make the right call for there may never be a second chance for me to re approach my patient and change my decision.

It is unfortunate and dangerous when an experienced referee, inspector, judge or ringside physician is afraid to make a call because he/she is worried how the decision shall be viewed by the public and other parties. When they are worried whether their decision is going to cost them the opportunity of working the next “big” fight. Would you (if you were a patient) trust this doctor with your most precious possession of good health?

I am not saying that medical decision making in combat sports should not be critically appraised. Every medical stoppage should be looked at, studied and learnt from. Was it right or was it wrong? But there is a way to do this and it is not online. Telling a doctor that he is a “fucking scum”, screaming for his blood so that he fears for his own health and safety as he heads out of the arena is certainly not the way. Thrashing his reputation online is also not the way. Most ringside physicians practice ringside medicine a mere 1% of their total time practicing medicine. We work in hospitals and we have regular jobs. We do not do ringside medicine for the money. We are paid anywhere between $200 to $400 for the night, a night where we tirelessly work upto 12 hours under exceptionally difficult circumstances. That is below minimum wage. We do what we do because we care.

It is understandable why even my own peers in Neurology and Medicine do not support the work of ringside physicians and call for a ban on all combat sports. Combat sports and ethical medicine cannot co-exist without conflict. The gap is too large to bridge.

Today, I again struggle to bridge my love for medicine and combat sports.

Making boxing safer: when to stop a fight on medical grounds

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Making boxing safer: when to stop a fight on medical grounds
N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America

Corresponding author: N K Sethi (sethinitinmd@hotmail.com

Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.

Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065

 

 

 

Recently the boxing world was heart broken by the untimely demise of boxer Patrick Day. By the accounts of all who knew him, Patrick was an intelligent well-spoken young man who was loved by all. He died at the tender age of 27 after suffering devastating traumatic brain injury (TBI) during the course of a professional boxing bout. Patrick was no rookie stepping into the ring for the first time. He was an accomplished boxer with a record of 17 wins and 4 losses in professional boxing. His amateur record was 75-5.

Following Patrick’s death, the boxing community has been looking inwards and searching for answers on what went wrong that eventful night and what can be done to prevent such tragedies in the future. Unfortunately, there are no easy answers. In a sport where every punch thrown at the head is thrown with the intention of winning by causing a knock-out (KO) (aka a concussion); the risk of TBI lurks all the time. Many still do not understand that deaths when they do occur in the ring are not the result of a single blow (punch) to the head; rather it is the culmination of multiple head shots which the fighter sustains during the course of the bout. Importantly the initial signs of a concussion/TBI are subtle and wholly subjective. The fighter may experience a headache, subjective feeling of dizziness or imbalance, vision problems and difficulty in focusing. There are no objective signs which can help the ringside physician, the referee, the inspectors and the corner men identify the concussion/TBI with confidence. By the time objective signs such as gross motor instability (GMI) (obvious balance problems, lack of coordination or inequality in pupil size) appear, the TBI is usually well evolved and precious little can be done ringside to save the boxer’s life except to transport him to the hospital in an emergent fashion for life saving brain surgery. Usually a decompressive hemicraniectomy is carried out for evacuation of the blood clot and to reduce the intracranial pressure. Even though surgery in some of these cases may save the boxer’s life, he is usually left behind with significant and permanent neurological deficits such as motor weakness, speech and cognitive deficits and problems with coordination and gait. Hence the goal should remain to stop a fight early rather than late. A good stoppage done by the referee or the ringside physician on medical grounds is one which is done for the right indication such as concern for TBI and at the right time (neither too early, certainly never too late!).

Standardizing medical stoppages in the ring is no easy task but certainly something which we all should be paying closer attention to. One approach which can be adopted is to establish NO-GO criteria in boxing. If any of the NO-GO criteria are encountered during the course of the bout, the bout should be stopped on medical grounds to protect the health and safety of the boxer. Ringside physicians, referee, the Commission officials, the corner men and most importantly the two boxers should be aware of these NO-GO criteria.

In order to identify and prevent acute TBI in boxing, the following good practice guidelines and NO-GO criteria are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:

The fight should be stopped if the boxer voices any of these complaints or displays any of these signs at any time during the course of the fight:

1. If the boxer voices complaint of headache.
2. If the boxer is displaying overt signs of a concussion and gross motor instability (GMI). These signs include but are not limited to confusion and disorientation, impaired balance and coordination.
3. If the boxer suffers any duration of loss of consciousness after a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
4. If the boxer suffers an impact seizure or displays fencing responses at the time of a KO. This boxer should not be allowed to continue even if he gets up at the count of 8. It is good practice for the referee to waive off the count in these instances, signaling an end to the contest so that the fighter can immediately be attended to by the ringside physician medical team.
5. The boxer suffers loss of visual acuity during the course of a fight. This is usually on account of trauma to the eye. Loss of visual acuity results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer.
6. The boxer suffers loss or restriction of visual field during the course of a fight. This may be on account of trauma to the eye, neural mechanisms which control eye-movements or due to swelling around the eye (peri-orbital swelling). Restriction of visual fields results in an impaired fighter who cannot defend himself/herself effectively. Allowing the fight to continue risks the health and safety of the boxer
7. If the boxer becomes a physically compromised fighter during the course of a fight. This usually occurs on account of injury to the hands/shoulders or the lower extremity (knee or ankle injury) leading to inability to defend oneself from the opponent.
8. If the boxer starts to vomit during the course of the bout, the fight should be stopped (caveat is that boxers will sometime vomit after a hard body or liver shot).

 

Thyroid orbitopathy masquerading as late onset myasthenia gravis

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A 84-year-old right handed lady presented with 2 months history of diplopia on binocular vision worse on right gaze. On monocular vision, diplopia disappeared irrespective of which eye was closed. AchR binding Ab was 1.07 nmol/L (positive >0.5 nmol/L) and she was diagnosed with myasthenia gravis. Neurological examination was normal. Nerve conduction studies and needle EMG of all muscles was within normal limits. Repetitive nerve stimulation at 3 Hz of the left medial nerve/APB and accessory nerve/trapezius system, at rest and following 10 seconds and 60 seconds of exercise revealed no abnormal decremental or incremental response (figure 1). MRI brain revealed enlargement and abnormal enhancement of the muscle bellies of the bilateral superior, medial and inferior rectus muscles in pattern suggestive of thyroid orbitopathy (figure 2).TSH 3rd generation was 0.145 (range 0.550-4.780 uIU/mL. Thyroid associated orbitopathy, also known as Graves’ orbitopathy, is typically a self-limiting autoimmune process associated with dysthyroid states with clinical presentation varying from mild disease to severe irreversible sight-threatening complications. 1

Reference

1. Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol. 2012; 60: 87–93.

Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

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Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

Nitin K Sethi, MD, MBBS, FAAN
Chief Medical Officer, New York State Athletic Commission
Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY 10065 (U.S.A.)

Disclaimer: the views expressed in this article are mine and do not necessarily reflect the views of the New York State Athletic Commission (NYSAC).

 

In the ring and cage during a fight:

1. If concern for concussion or traumatic brain injury arises during the course of the bout, the ringside physician shall assess the combatant preferably between the rounds. The evaluation will be carried out by the ringside physician during the 1-minute break between rounds or after the 1-minute break but before commencement of the next round by requesting the referee to call a time out. The ringside physician shall assess the combatant with the use of Maddocks questions. Maddocks questions include but are not restricted to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

2. The ringside physician shall conduct a focused neurological evaluation of the combatant in the ring/cage. This evaluation shall include:

–asking the combatant if he/she has any subjective complaints such as headache, dizziness, visual disturbances, nausea, feeling off-balance.
–giving the combatant a two-step command (touch your right ear with your left glove).
–assessment of pupil size symmetry and reactivity (integrity of cranial nerves II and III)
–assessment of extraocular movements (integrity of midbrain and pons by assessment of cranial nerves III, IV and VI)
–assessment of cerebellar function and infratentorial compartment integrity by checking gait and stance (stand still with feet together and/or tandem gait).

The ringside physician should be aware of the NO-GO criteria. If any one of the NO-GO criteria is present, consult with Chief Medical Officer (CMO)/Assistant Chief Medical Officer (ACMO) and consider advising the referee to stop the fight on medical grounds.

The NO GO criteria are the following:

1. If the combatant exhibits any period of LOC or unresponsiveness after a KO.

2. if the combatant exhibits confusion (any disorientation or inability to respond appropriately to questions) at time of assessment by ringside physician.

3. If the combatant exhibits amnesia (retrograde / anterograde) when assessed by the ringside physician. The ringside physician shall assess for retrograde and anterograde amnesia in the ring/cage using Maddocks questions including but not limited to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

4. If the combatant voices to the ringside physician or his corner any new and/or persistent subjective symptoms such as headache, nausea, dizziness.

5. If the combatant vomits during the course of the fight (this criterion should not be used in isolation to stop a fight on medical grounds).

6. If the combatant has an abnormal neurological examination (ataxia, impaired balance, pupil size asymmetry and/or reactivity) when assessed by the ringside physician.

7. If the combatant has a concussive seizure also at times referred to as an impact seizure (seizure occurring at the time the fighter’s head makes impact with the ring/cage canvas).

 

In the post-fight examination area/locker room after the fight is over

The ringside physician shall assess for the presence or absence of concussion/ traumatic brain injury with the aid of a multimodal concussion screening and assessment battery including but not limited to:

a) Glasgow Coma Scale Score (best motor response, best verbal response and eye-opening). CGS score less than 13 is mandatory transfer to the emergency department (ED) of the designated Level I Trauma Center via on-site ambulance for urgent CT scan head to rule out acute traumatic brain injury.
b) Detailed neurological examination including higher mental function testing, cranial nerve II to XII testing, pronator drift testing, assessment of motor function, finger to nose testing, tandem gait assessment and Rhomberg’s test.
c) Standardized Assessment of Concussion (SAC) test-check orientation, immediate memory, concentration, delayed recall (see attached SAC form).
d) Balance Error Scoring System (BESS) test-double leg stance, single leg stance and tandem leg stance (see attached BESS testing procedure).

Management of a concussed combatant is on a case by case basis with majority of combatants discharged from the venue with a medical suspension. Duration of the suspension may vary from 30 to 90 days with mandatory 90-day suspension and follow up with a neurologist if the concussion occurred by a KO. All combatants discharged home from the venue are instructed to remain in close observation of a family member/coaching staff for the next 24 hours with instructions to report to the nearest emergency department (ED) if any neurological symptom (headache, dizziness, blurred vision, vomiting, impaired balance) or sensorium (lethargy, unresponsiveness) is reported. All discharged combatants are educated about post-concussion symptoms with instructions to seek medical care if these are reported. A combatant may be referred to the ED of the nearest Level I trauma center for an urgent CT scan of the head and further evaluation if deemed appropriate by the ringside physician. Transport in these cases shall take place via on site ambulance.

References

 

1. Neidecker J, Sethi NK, Taylor R, Monsell R, Muzzi D, Spizler B, Lovelace L, Ayoub E, Weinstein R, Estwanik J, Reyes P, Cantu RC, Jordan B, Goodman M, Stiller JW, Gelber J, Boltuch R, Coletta D, Gagliardi A, Gelfman S, Golden P, Rizzo N, Wallace P, Fields A, Inalsingh C. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.Br J Sports Med. 2019;53(6):328-333. doi: 10.1136/bjsports-2017-098799.

2. Erlanger DM. Exposure to sub-concussive head injury in boxing and other sports. Brain Inj. 2015;29(2):171-4. doi: 10.3109/02699052.2014.965211.

3. Jayarao M, Chin LS, Cantu RC. Boxing-related head injuries. Phys Sportsmed. 2010;38(3):18-26. doi: 10.3810/psm.2010.10.1804.

4. Galetta KM, Barrett J, Allen M, Madda F, Delicata D, Tennant AT, Branas CC, Maguire MG, Messner LV, Devick S, Galetta SL, Balcer LJ. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology. 2011 Apr 26;76(17):1456-62. doi: 10.1212/WNL.0b013e31821184c9.

5. Potter MR, Snyder AJ, Smith GA. Boxing injuries presenting to U.S. emergency departments, 1990-2008.Am J Prev Med. 2011 Apr;40(4):462-7. doi: 10.1016/j.amepre.2010.12.018.

6. Sawauchi S, Murakami S, Tani S, Ogawa T, Suzuki T, Abe T. Acute subdural hematoma caused by professional boxing. No Shinkei Geka. 1996 Oct;24(10):905-11.

NO-GO criteria in boxing

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NO-GO criteria in boxing

 

 

Nitin K Sethi, MD, MBBS, FAAN

Associate Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

Chief Medical Officer, New York State Athletic Commission

New York State, Department of State

 

The fight should be stopped if the boxer voices any of these complaints or displays any of these signs at any time during the course of the fight:

  1. If the boxer voices complaint of headache.
  2. If the boxer is displaying overt signs of a concussion and gross motor instability (GMI). These signs include but are not limited to confusion and disorientation, impaired balance and coordination.
  3. If the boxer suffers any loss of consciousness after a KO. This boxer should not be allowed to continue even if he gets up at the count of 8.
  4. If the boxer suffers an impact seizure or displays fencing responses at the time of a KO. This boxer should not be allowed to continue even if he gets up at the count of 8.
  5. The boxer suffers loss of visual acuity during the course of a fight. This is usually on account of trauma to the eye.
  6. The boxer suffers loss or restriction of visual field during the course of a fight. This may be on account of trauma to the eye, neural mechanisms which control eye-movements or due to swelling around the eye (peri-orbital swelling).
  7. If the boxer becomes a physically compromised fighter during the course of a fight. This usually occurs on account of injury to the hands/shoulders or the lower extremity (knee or ankle injury) leading to inability to defend oneself from the opponent.
  8. If the boxer starts to vomit during the course of the bout, the fight should be stopped (caveat is that boxers will sometime vomit after a hard body or liver shot)

 

Disclaimer: the views expressed above are those of the author and do not necessarily reflect the views of the New York State Athletic Commission.

THE TREADMILL OF LIFE

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THE TREADMILL OF LIFE

Prahlad K Sethi, MD1 and Nitin K Sethi, MD2

1 Department Neurology, Sir Ganga Ram Hospital, New Delhi, India

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

 

 

THE EPISODE

I go to the gym in Siri Fort Complex early morning as a part of my daily exercise routine. The goal is to remain fit and hopefully have a long innings in my life and continue to carry working in my profession as a physician neurologist.

One day when I was on the treadmill I realized that I was walking rather hurriedly with short quick steps. My goal was to reach my exercise target as fast as I could. Nothing else mattered to me at that moment. I happened to look towards my right and I found a friend of mine also walking on the treadmill.  He looked at ease, calm and peaceful taking long steady strides apparently enjoying his workout. On the way back home from the gym, my colleague’s calm peaceful face and long steady strides on the treadmill were itched on my mind. I tried to justify my hurried rushed style on the treadmill…I am not as tall as him nor do I have his long legs.  I felt satisfied that I had met my goal on the treadmill that day.

After a couple of days, I decided to try my friend’s “treadmill style of walking”. I punched in the same distance target on the treadmill, the same speed and incline but instead of taking rushed small steps, I began to walk with slow steady long strides. To my surprise after about 5 minutes, I began to feel calm and peaceful. A relaxed feeling enveloped me.

On my drive back home I kept thinking what had just transpired. How did this small change of walking style create such peace and calmness in my mind? I had walked on the same treadmill the same distance the same incline and the same length of time. I had reached the same target but the peace and satisfaction was so much more. Instantly I thought cannot we apply the same analogy to life?

 

 

 

LIFE IS A TREADMILL

 

 

Life is like a treadmill; call it the treadmill of life.  We all have to learn to wait patiently for our turn to get on this usually fast moving treadmill. During the waiting period one has to be patient. We need to remember that opportunities will come our way sooner or later. One needs to set ones goals in life: what you want to achieve, how you plan to achieve it and at what speed you plan to go about accomplishing those goals. These goals, the speed may not be clear to us at the start but the desire to achieve those goals should certainly be there. One needs to be passionate about it. But passionate does not mean desperate. One should enjoy the ride.

 

“A journey of a thousand miles must begin with a single step.”—Lao Tzu

 

“The journey not the arrival matters.”—T. S. Eliot

 

A wise man once said “If you don’t know where you are going, any road will lead you there.” So as we travel on the adventure called life we should enjoy the journey and the experiences which we encounter along the road.

 

 

 

The lyrics of the song “Wear Sunscreen” by Baz Luhrmann sum it up perfectly and I shall quote:

 

“Don’t worry about the future. Or worry, but know that worrying is as effective as trying to solve an algebra equation by chewing bubble gum. The real troubles in your life are apt to be things that never crossed your worried mind, the kind that blindside you at 4 pm on some idle Tuesday.

Do one thing every day that scares you.

Sing.

Don’t waste your time on jealousy. Sometimes you’re ahead, sometimes you’re behind. The race is long and, in the end, it’s only with yourself.

Don’t feel guilty if you don’t know what you want to do with your life. The most interesting people I know didn’t know at 22 what they wanted to do with their lives. Some of the most interesting 40-year-olds I know still don’t.

Maybe you’ll marry, maybe you won’t. Maybe you’ll have children, maybe you won’t. Maybe you’ll divorce at 40, maybe you’ll dance the funky chicken on your 75th wedding anniversary. Whatever you do, don’t congratulate yourself too much, or berate yourself either. Your choices are half chance. So are everybody else’s.

Dance, even if you have nowhere to do it but your living room.”

 

 

 

 

 

 

 

 

 

WAITING FOR YOUR TURN

Sometime when I go to my gym I find all the ten treadmills occupied. I have learnt to wait for my turn. There is a card posted on the fall which requests the members to be considerate of others and not to use the treadmill for more than 15 minutes at one stretch. Often I find people ignore that sign. I have learnt to be patient and wait for my turn.

“When I Consider How My Light is Spent” is one of the best known of the sonnets of John Milton. The last three lines are particularly well known, although rarely quoted in context.

 

“When I consider how my light is spent,
Ere half my days, in this dark world and wide,
And that one Talent which is death to hide
Lodged with me useless, though my Soul more bent
To serve therewith my Maker, and present
My true account, lest he returning chide;
“Doth God exact day-labour, light denied?”
I fondly ask. But patience, to prevent
That murmur, soon replies, “God doth not need
Either man’s work or his own gifts; who best
Bear his mild yoke, they serve him best. His state
Is Kingly. Thousands at his bidding speed
And post o’er Land and Ocean without rest:
They also serve who only stand and wait.”

 

Once your time comes and you are on the treadmill, you can choose your style (run versus walk) and your speed. If you choose to run , run only as fast as you need to. Be kind to your knees, you shall need them when you get old!

 

 

 

 

 

 

 

 

GETTING ON A MOVING TREADMILL

 

Once when I entered my gym, I found only one treadmill unoccupied. I ran to occupy it before anyone else could. To my surprise it was still running. In my haste I had jumped on to a running treadmill and nearly fell. This is true for life too. Running to achieve your goals, taking short cuts does not always yield the desired results. Sometimes one falls and falls hard.

 

 

 

 

 

SUDDEN STOPPING OF A TREADMILL

 

In Delhi, power cuts are frequent and unexpected. My gym lacks a back-up generator. Sometimes I will be walking on the treadmill and it will come to a sudden unexpected stop when we suffer a power outage. I have learnt to be aware of this and have avoided a couple of nasty tumbles. Life too sometimes throws lemons at us, curveballs which strike us when we least expect them. A sudden unexpected loss in business or a sudden unexpected health emergency like a heart attack or stroke. Be aware of this, be humble for the higher we rise the harder we fall.

 

 

 

 

COOLING OFF PERIOD

 

The cooling off period is a very important part of my treadmill routine. The treadmill slowly decelerates, the incline gradually declines to baseline.  After a vigorous work-out the cooling off period is intended to gradually lessen the impact on the muscles and the heart and to return them to their pre-exercise physiological state. One feels relaxed and has a feeling of “that was a great workout”. Similarly in life, one day retirement looms. One should anticipate this and be prepared for it. It is time to mentally and physically step off the treadmill of life but not leave it altogether! We each have to find hobbies and tasks to keep our brains occupied so that we do not slip into the throes of depression. Some among us shall choose to mount the treadmill again and find a new job, others shall dismount from the treadmill completely and choose to spend time with family and friends.

 

 

 

TREADMILL OF LIFE-THE CONCLUSION

 

The humble treadmill which we encounter in our gyms can teach us many valuable life lessons.

 

 

 

 

 

 

In the words of Frank Sinatra:

 

“And now, the end is near
And so I face the final curtain
My friend, I’ll say it clear
I’ll state my case, of which I’m certain
I’ve lived a life that’s full
I traveled each and every highway
And more, much more than this, I did it my way”

(Song: “My Way” by Frank Sinatra)

 

 

 

 

(Source: http://embercoaching.com/2015/05/avoid-the-treadmill-of-life/)