Tag: football

Making sports safer- concussion evaluation, management and return to play decision making for the non-neurologist

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Nitin K Sethi, MD, MBBS, FAAN

sethinitinmd@hotmail.com

Background

American football, soccer, rugby, ice hockey, boxing, mixed martial arts, and wrestling are popular contact and combat sports both in the United States and in countries around the world. In these sports head impact exposures resulting in concussions are common. In American football, rugby and soccer, concussive injuries to the brain occur accidently when there is contact of the player’s head with the opposing player(s) head, torso, turf or as occurs in soccer with the ball while heading. In boxing every punch thrown at the head is thrown with the intention of winning by causing a knockout. As a result, concussions, and acute traumatic brain injuries such as subdural and epidural hematoma are common. Subdural hematoma is the most common cause of boxing related mortality. In recent years, the risk of chronic traumatic encephalopathy (CTE), a chronic neurodegenerative disorder associated with contact and combat sports has garnered the attention of physicians, players, and fans.

Concussion definition and evaluation

Concussion is defined as a clinical syndrome characterized by immediate and transient alteration in brain function, including alteration of mental status and level of consciousness, resulting from mechanical force or trauma. It is important to remember that loss of consciousness is not required for a concussion. Concussions are informally and non-scientifically graded into mild, moderate, and severe based on the duration of loss of consciousness and post traumatic amnestic period. Concussive properties of any head impact exposure depend upon the force, velocity, and angle of the hit to the cranium and how the mechanical forces are transferred and absorbed through the intracranial cavity. Both linear and rotational (angular) acceleration forces play a role as does impact deceleration occurring when the athlete falls and strikes the head against the ground.

Image Credit: Patrick J. Lynch, medical illustrator – Modified version of Image: Skull and brain normal human.svg by Patrick J. Lynch, medical illustrator (Source Wikipedia). The image is solely for educational purposes only.

The nature of many contact and combat sports is such that head impact exposures cannot be altogether avoided. Abundant medical literature highlights the long-term health significance of multiple head impact exposures. Minor concussions (sub concussive injuries) contribute to the development of CTE, a neurodegenerative disorder presenting with a constellation of cognitive, mood, and behavioral changes along with motor system dysfunction (Parkinsonism) usually after the athlete has retired. The symptoms of concussion are predominantly subjective such as headache, dizziness, nausea, light sensitivity, sound sensitivity, and cognitive dysfunction. Frequently, when athletes sustain head impact exposures, they themselves are unaware that they are concussed and continue to play. As a result, it is important that when an athlete sustains a head impact exposure, a standardized concussion evaluation be conducted. While this can be conducted on the sidelines, evaluation in the locker room where the athlete is less likely to be distracted is more ideal. Since some athletes exhibit motor signs such as impaired coordination, balance, and stance after a concussion while others exhibit only cognitive dysfunction, it is important that multimodal concussion evaluation be conducted. This includes use of Maddocks questions to gauge awareness, standardized concussion assessment tools such as SCAT5, King Devick test and Balance Error Scoring System (BESS).

Concussions are common in soccer especially during heading the ball.

Management of concussive injury

The athlete’s mentality is to never quit. Hence many athletes will deny symptoms of a concussive injury to the brain. Physicians should be aware of this. An athlete who has suffered a concussion should be pulled out of play and “benched.” This is done for two main reasons. A concussed athlete with impaired attention, concentration, balance, and coordination is more prone to a second head impact exposure. The other reason is that if the concussed athlete continues to play, it is likely that he or she will exhibit more profound and prolonged post-concussion symptoms. The benched athlete is advised a period of cognitive and physical rest. The rationale for this is that a concussed brain is in a state of energy crises and fares better when the cognitive and physical demands on it are less. Cognitive rest entails pulling back from cognitive activities such as team meetings, college work, screen time (amount of time spent using devices with screens such as a smartphone, computer, television, or video game console). Physical rest entails pulling back from normal physical activities such as running and jogging. Here it is important to emphasize that complete cocooning is ill-advised with recent research work showing that it may in fact be detrimental and lead to prolongation of symptoms. The concussed athlete should be evaluated by a physician skilled in concussion management. In most cases neuroimaging with computed tomography or magnetic resonance imaging is not warranted and if conducted comes back negative. There is currently no validated imaging or biofluid (blood or cerebrospinal fluid) biomarkers for concussion. In the absence of biomarkers, the diagnosis of concussion is made clinically based on history of head impact exposure followed by characteristic symptoms (post-concussion symptoms). The concussed athlete is advised to drink adequate water and to avoid alcohol intake and sudden inversions till symptomatic. The role of supplements such as magnesium, vitamin B2 (riboflavin), vitamin B12, fish oil among other remains unclear but these are frequently prescribed. There is no treatment for the head injury itself. Treatments for symptoms of concussion such as headache, dizziness, cognitive impairment, poor sleep, mood, and behavioral disorder involves a multi-disciplinary team consisting of neurologists, neuropsychologists, neurosurgeons, neuroradiologists, neuro-ophthalmologists, physical therapists, occupational therapists, and vestibular therapists with expertise in concussion management.

After a few days of cognitive and physical rest when the acute concussion symptoms have abated, the athlete begins a graded and gradual return to play (RTP) program preferably under the guidance of an athlete trainer with expertise in concussion management. Nowadays most contact and combat sports have sport specific return to play (RTP) protocols. Despite individual variations, the basis tenant remains the same and involves the athlete progressing from light aerobic activity (walking or stationary bike for 10 minutes, no resistance training) to sport-specific activity/drills to non-contact training drills to contact practice and if asymptomatic return to play after a release has been signed by the treating physician.

Conclusion

Concussion is a common head injury in contact and combat sports. Timely identification of the concussed athlete, removal from play and medical management usually results in a good outcome. Closer medical supervision of sports and education of all concerned parties on concussion recognition and management remains the need of the hour.

Chronic traumatic encephalopathy-making the games we play safer

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New data indicates the ever present danger of chronic traumatic encephalopathy (CTE) in contact sports such as boxing, mixed martial arts (MMA), football, ice-hockey and even soccer.  Contrary to popular belief it is now felt that it is just not concussive injuries but even sub-concussive injuries which can predispose an athlete to CTE. This may be of importance to a soccer player who repeatedly heads the ball during play. There are other questions for which we still do not have a good answer.

1. How many concussions are needed and how severe they need to be for CTE to develop? Is there a limit beyond which the brain loses its capacity to compensate for chronic trauma and signs and symptoms of CTE appear? If so what is this limit? Can it be defined? If a player stops playing before this limit is reached would CTE be aborted?

2. Once CTE develops can it be reversed?

3. Is there a way to protect the brain from developing CTE apart from changing the way the games are played. Changing the rules of the game (such as avoiding head butts during football, heading the ball in soccer, direct blows to the head in MMA, wearing safety gear/helmets) shall certainly help but are there other neuroprotective strategies such as medicines (antioxidants, anti-inflammatory drugs) which can be given to prevent the onset and progression of CTE?

As you can see there are many questions for which we still lack good answers. Making the games we play safer certainly sounds a logical principle and hence the thrust to identify concussions in a timely fashion on the playing field and rest the player till complete recovery is documented. Neurologists, neurosurgeons and other physicians skilled in neurosciences by virtue of their training are better equipped to identify concussions and thus there is a growing call to have them by the side of the playing field in every professional and now even college level game. Biomakers and imaging markers to identify CTE in the living brain are also been explored.

Till more is known about CTE and more importantly on how to prevent and reverse it, making the games we love and play safer should be the goal.

 

Nitin K Sethi, MD

Head injuries sustained while playing contact sports such as boxing, ice-hockey and football—how concerned should we be about chronic traumatic encephalopathy?-A neurologist’s viewpoint

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Head injuries sustained while playing contact sports such as boxing, ice-hockey and football—how concerned should we be about chronic traumatic encephalopathy?-A neurologist’s viewpoint

Nitin K Sethi

 

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

Address for correspondence:

Nitin K. Sethi, MD

ComprehensiveEpilepsyCenter

New York-Presbyterian Hospital

WeillCornellMedicalCenter

525 East, 68th Street

New York, NY10065

Tel: + 212-746-2346

Fax: + 212-746-8845

 

 

The problem

Head injuries frequently occur while playing contact sports such as boxing, ice-hockey, American football, mixed martial arts (MMA) and even soccer. In sports such as boxing and MMA the goal is to knock out your opponent by causing a concussion. The perils of boxing are thus well recognized by the medical community especially by neurologists.  Boxer’s encephalopathy, punch-drunk syndrome and dementia pugilistica are terms used to describe the neurodegenerative changes seen in professional boxers as well as athletes in other contact sports who suffer repeated concussions during their professional careers. There is now increasing evidence that repeated concussions sustained by a boxer or an athlete in his or her professional career predisposes them to memory problems later on in life (says in their 40’s and 50’s) and Alzheimer’s disease (dementia) like pathological changes are visible in the brain on histopathology. These athletes are also plagued by neuropsychiatric disorders such as anxiety and depression in their later years. Parkinsonian features (problems with gait and balance) may appear later in life due to damage to the deep grey nuclei of the brain.

My own love for boxing

With this increased awareness about the perils of repeated concussions there is a thrust to make these sports safer. But can boxing, MMA and American football be made safer? It is ironic that I was personally drawn to boxing near about the time I started my neurology residency in Saint Vincent’s Hospital and Medical Center in New York.  Prior to that I knew little if anything about this sport. I had just joined a new gym and happened to walk into a boxing class. I was standing outside peeping in when Tyrone the boxing coach yelled out at me across the room. The first class is free come in he said. There and then my love for boxing was born. Since that fateful day 7 years ago, I have grown to love this sport. I have been boxing on and off since then, yes at times I spar usually with boxers who I know won’t throw a wild punch. For one to really understand this sport and the men and women behind it, one needs to spend time in a boxing gym. New York can boast of some world famous boxing gyms such as Gleason’s gym, I call Mendez boxing on 26th Street and 6th Avenue home. There I am known simply as doc. I see the passion and discipline in the men and women who train there especially the ones who are fighting on the amateur and professional circuits. Most of them are in the age range of 16-25. During my time at Mendez I have had the opportunity to closely observe how these men and women train and I tell you it is grueling. Most start with jumping rope for about 10-15 minutes. Then shadow boxing, a few rounds on the heavy bag and pad work. Then come the sparring sessions which can be highly entertaining to watch.  Most boxers end their work-out by going a few rounds on the speed bag. I can honestly say that boxing has changed me for the better; both in mind and in body. So I recently applied and got accepted to be a panel physician for the New York Athletic (boxing) Commission. I feel this shall accord be a unique opportunity to closely observe professional boxing from a neurologist’s point of view.

Making boxing and football safer

So how can we make boxing and other contact sports safer? Some say the best way is to change the rules that govern these sports. In the case of American football one option would be to limit aggressive and hard tackles that encourage helmet to helmet collisions. There has been a healthy debate on this subject. Some have advised better quality helmets the kind worn by soldiers in the battlefield to prevent traumatic brain injury (TBI). The new military helmets (advanced combat helmets) are especially designed to prevent TBI following an improvised explosive device detonation though it is still debatable whether the helmets actually do achieve this objective. The players helmets can be further fitted with a sensor which records the force of impact. This data can then be readily accessed by a physician on the sideline and a timely decision can be made to either pull a player out of play or allow him to continue after a concussion. We certainly have the technology to do this at present but do we know how to analyze the data? Like for example how much should the concussive force be to warrant pulling a player out of a critical game? Some advocate that the rules be amended more drastically such as a complete ban on head to head collisions be enforced. Players should be taught to tackle leading with their shoulder and not using their head as a battering ram. Or that helmets be taken away completely so that players and coaches are forced to switch to “safer” tactics. The main problem with some of these rather novel ideas is that you risk changing the very nature of the sport and driving away the fans. Coming back to boxing you all would agree that most of us go to a boxing match to see a hard knockout. Any Iron Mike fan shall testify to that! Boxing would not be boxing if the rules were amended so that blows to the head were not allowed and professional boxers were forced to wear protective head gear.  So when it comes to boxing and MMA a more “practical” solution would be to enhance our ability to detect concussions in a more comprehensive and timely fashion. But this itself is no easy task. Anyone can identify a concussion when the boxer is knocked out and suffers prolonged loss of consciousness (>5 minutes). Over and out! However it is the minor/subtle concussions which are harder to detect. At present this is what happens. A boxer goes down and a ring side physician like me jumps into the ring to assess him. Are you Okay? Do you want to go on? Raise your gloves for me. Track my finger with your eyes. If he is able to answer my questions and follow my commands, I clear him to fight further. Studies though show that many concussions are missed if examined in this rudimentary fashion. Grossly the boxer looks fine but he is not. There are a few well documented cases where in the boxer has gone on to fight after sustaining a concussion and even win the fight only to be found dead in his bed the next day (second impact syndrome). So is there any better way to identify concussions in a timely fashion?

The Kind Devick test (www.kingdevicktest.com) has been found to be quite sensitive in identifying concussions. It basically involves the testee reading a set of numbers off a card. The number of errors and time taken to accomplish this task is recorded and can be used to assess if a concussion has occurred. This test can be administered to boxers and other athletes prior to the fight or game and these scores serve as the baseline scores. If the boxer gets hit during the fight or a football player suffers a concussion on the field, the test can be administered on the sidelines and a decision to either pull the player/boxer or to let him continue can be made. The Kind Devick test has some inherent advantages. It is easy to administer by anyone (not just a physician), the test can be administered through hand held cards or on the Ipad, quick to administer (this is very helpful when it comes to boxing since the decision to stop or continue the fight has to be made in a matter of minutes), finally it can be administered ringside or on the sidelines.

Other ways to make boxing, American football and MMA safer include yearly neuropsychological testing of all participants to identify deficits in memory, cognition and other neuropsychiatric morbidities such as anxiety and depression. Serial  MRI scans of the brain should be carried out during the athletes career and a physician trained in the neurosciences such as a neurologist or neurosurgeon should be present ringside in all professional and amateur fights/ games (I agree this is not a very practical solution).

Final thoughts

Finally knowledge is power and all athletes, their coaches, parents of children who indulge in contact sports should be made aware of the perils of repeated concussions, how to identify and avoid them. Working together we can certainly making boxing and American football safer.

Concussion during sports and return to play decisions

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                                      Concussion during sports and return to play decisions

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

I recently read an article in the Archives of Neurology ( Vol 65, Sep 2008) by Dr. Lester Mayers about return to play (RTP) criteria after athletic concussion. As concussions are relatively common sport related injuries (especially in contact sports like football, rugby and boxing) I thought it would be a good idea to review some of the salient points of the article in this forum.

Concussion is a common type of traumatic brain injury and has been referred to by other names such as mild traumatic brain injury, mild head injury and minor head trauma. No good defination for concussion exists though it is frequently described as head injury with transient loss of brain function (usually a short period of loss of consciousness occurs).

Let me explain with the help of an example. I love to box (true one of the few neurologist who actually likes boxing). Lets assume I am going a couple of rounds in the ring with another guy.  A southpaw with a mean right hand. First round here we go!!!. I got my right and left combinations going. Hmmm feeling good and then it happens. I walk into his right. BOOOOOM!!! My knees give in and I hit the canvas. I see stars shining and birds twittering. The referee is asking me “Are you okay? Are you okay?” I look dazed and then slowly come around and answer I am fine. I am helped out of the ring, the fight is over!!! THERE I JUST HAD MY FIRST CONCUSSION!!!

Can I return to play/ box after a 10 mins break?

 Or rather should I return to play after a break?

Is it safe?

 Am I okay?

All these questions are addressed by Dr. Mayers in his review. Traditionally return to play decisions are made by the field side by the team physician or in the case of boxing by the doctor at the ringside. This is usually a clinical judgement with doctors relying on the documentation of resolution of symptoms at rest and during exertion to provide an estimate of the appropiate time for the athletes to resume practice and play (return to play).

A stepwise process was outlined by the Canadian Academy of Sports Medicine:

Step 1: no activity, no play and complete rest till asymptomatic and with a normal neurological examination–if your clear this then Step 2: light aerobic exercise permitted, no resistance training–if you clear this then Step 3: can return to sports specific training and resistance training—if patient remains asymptomatic then can be cleared for Step 4: non-contact training can begin–if patient remains asymptomatic then he is cleared for Step 5: full contact training —if he still remains asymptomatic then he is cleared for Step 6-full play!!! (As you can imagine these criteria are for professional atheletes but also apply for others)

As you can see there are steps to be followed before return to play can be allowed. If you fail one step you go back to the previous step and remain there till you feel better and are ready to proceed further.

Why is this important? Studies have shown that even simple concussions cause cerebral dysfunction (reflecting damage to the brain at the celluar level) and that it takes a minimum of 4 weeks for the brain to revert back to normal. If RTP occurs earlier, the athlete is at risk for a recurrent concussion and further brain damage. Even death can occur (we have all heard of boxers who die during or shortly after a bout).

Learning points from Dr. Mayers review:

1) Concussions are common.

2) Concussions can be serious and even fatal.

3) Concussions lead to cerebral dysfunction and damage to the brain at the cellular level.

4) Return to play decision should be made by a doctor skilled in this task.  A postconcussion RTP interval of at least 4 weeks is imperative (Dr. Mayers takes pain to point out that even more time may be needed to permit complete brain healing and recovery).

My advise to you:

1) Treat a concussion with respect and see a doctor if you suffer one.

2) You may feel you are okay but you are not. The brain takes time to heal completely from a concussion.

3) Do not return to play. See a doctor and get his advise. Let him decide what the return to play interval should be.