NCAA’s dirty archives. Now what?

 

Here is an article, short and sour, about the NCAA’s history of its internal discussions on concussion management.  “The NCAA’s History with Concussions: A Timeline” is a quick primer and will jet you into the conversation about what the Association should be doing to support its athletes.  It will also make it clear why the NCAA is facing a lawsuit, possibly a class action one.

Compiled and written by Travis Waldron on thinkprogress.org, the brief piece is a shocking timeline of the paranoia and recklessness of the NCAA manifested in its hands-off approach to concussion management in its member schools. This is just the beginning of a much larger conversation that deserves to be in the public realm.

image from sportsonearth.com

Why are we seeing more concussions?

 

Friends and family who have been serious athletes their whole lives have been asking me: What’s this concussion stuff all about anyway?  Is this just another health fad like Omega 3 Fatty acid, Acai, gluten-free food, or yoga?

To help sort out some of this I recommend the article from January 2013 Rolling Stone magazine by Paul Solotaroff called This is Your Brain on Football.  

In addition to being beautifully and soulfully written and a real pleasure to absorb, it makes the following points about the dangers of long term damage and persistent symptoms from too much head trauma:

…PCS (post concussion syndrome) is a crisis of molecular scale, a firestorm of ions leaking in and out of neurons to wreak havoc on their tiny connections. You can’t catch that on an MRI and won’t be able to in the near future. The only way to detect it is through a thorough examination by a concussion-savvy doctor or neurologist.

By way of explaining the cumulative effects:

“.…every hit mattered, from peewees on, and counted toward an unknown threshold number past which brain cells began their die-off.”

 

By way of explaining why so many more now:

“Kids now play and practice one or more sports eight to 10 months a year, so there’s much more exposure to blunt-force trauma – and much less downtime to heal.”

 

By way of explaining how the rules of play themselves need amending:

“When eight-year-olds are hitting each other – in tackle practice – with roughly the same G-forces as college players, what’s badly needed is a paradigm shift, a universal up-draft in thinking.”

 

And the piece ends with a poignant and disturbing story of a “football dad” who is unconvinced by Dr Robert Cantu, considered the guru of concussion and a mom who lost her son to second impact syndrome, a devastating and fortunately rare sudden death following recent concussion. A major problem is a cultural one, acted out by parents,  “many of whom insist on toughening their sons for NFL careers they’ll never have.”

Do you have an NCAA athlete in the family?

What happens to a college athlete who sustains a head injury while playing for the school?With all of the recent publicity about concussions one might think these athletes would be protected and served the way most high school athletes are now mandated to be cared for by laws to that effect in almost every state in the Union.  But no.  The NCAA has long maintained that each school should develop its own policy rather than promulgate standard Association guidelines.  As a result NCAA athletes can really be “on their own” to figure out how to get the best care following a head injury.  And they may experience intense pressure from respected and beloved coaches to get back in the game much sooner than medical experts recommend.

In a remarkable short article on CBSSports.com, Mike Freeman reveals how resistant the NCAA has been to promulgating policy about head injury. He quotes from a recent survey of concussion management by the NCAA.

Most disturbing was that fewer than 50 percent of the NCAA schools, the NCAA’s own documents show, stated a physician was required to see an athlete post-concussion. Also, 39 percent of schools did not have an established return-to-play guideline.

 

Many NFL athletes are involved in a well publicized class action suit over their symptoms and dysfunction and since many of them probably concussed in high school and college before going Pro, Freeman contends that this  might create the thorny situation in which “the NFL could possibly be in an awkward position of attacking its feeder system.” Will the NFL blame middle age dementia, depression and cognitive dysfunction on college concussions rather than assume responsibility for their own poor care?  Will these two organizations duke it out or will they begin to recognize that they have both erred and begin to change their protocols, practices and patterns?

Until we have confidence that the NCAA is shouldering the responsibility for these young lives, every parent of an NCAA athlete needs to ask about concussion management in their child’s sport.  Here are some questions to consider:

Is an athlete allowed to return to the game after a head injury?

What are the sideline diagnostic tools used?

Who makes the call about a head injury and who can over-ride that call?

How does the team determine when an athlete is clear to play again?

Who makes that determination?

What if recovery is prolonged?

How does the team coordinate with the academic community to help the athlete while his or her cognitive (thinking) skills clear up?

Sometimes those collegiate athletes who are on their own following injury need to have a helpful roadmap for recuperation.  My book It’s All in Your Head: Everyone’s Guide to Managing Concussions has proven time and time again to be helpful for people in recovery.  The anecdotes and stories ring true because they are.  Each concussed person knows that only he or she perceives what doesn’t feel right.  Although reading is never a recommended activity in the first few days, a caregiver can read the book aloud and learn at the same time what to expect in the days ahead.

Above all, loved ones need to advocate for the injured person.  This “invisible injury” will soon enough be on the radar of the NCAA in a way the organization may not even be able to imagine.  It’s a new ballgame and they better figure out the plays.

Warnings about using online testing for concussion management

Awareness about the dangers of concussion has spread around the country.  Over two thirds of school districts now are mandated by their state’s law to have a concussion policy in place.  Many of these schools have bought a Computerized Neuropsychological Assessment Device (CNAD) to aid in the difficult decision making about managing students with head injuries.  The most common and widely distributed CNAD is ImPACT, developed in Pittsburgh by the sports medicine department at the University of Pittsburgh.

These CNAD tests were recently described, dissected and analyzed in a joint position paper by the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology in the journal Archives of Nueropsychology.  The bottom line is a warning call to the developers of the CNAD as well as the end-users.

brief online article about the concern over “sandbagging” these tests points out some of the very real concerns:

in a practice known as “sandbagging,” athletes intentionally attempt to reduce their baseline scores in order to circumvent the guidelines. A lower baseline score may mean that a poor post-concussion score won’t reveal impairment and keep the injured athlete from being allowed to return to play. Quarterback Peyton Manning famously claimed he sandbagged a preseason CNAD test in 2011.

Although highly trained and experienced professionals claim to be able to detect intentional sandbagging, up to 35% of “sandbagged” tests were not detected in one study.

The authors of this post conclude that  “improperly used CNADs, both for baseline and post-concussion assessment, create the illusion that effective, scientifically valid measures are being deployed to combat the sport concussion problem. It’s a dangerous illusion that doesn’t serve the interests of athletes at risk of concussion.”

Sandbagging is only one of the concerns expressed by the joint statement in the Archives of Neuropsychology.  Other concerns addressed include:

  • technical (hardware/software/firmware) issues (different links, internet speeds and programs as well as laptops and mouse quality can affect test results)
  • privacy, data security, identity verification, and testing environment; (who holds the data? Are HIPPAA rules being observed? What is done with the data?  Are students and families fully informed?
  • psychometric development issues, especially reliability, and validity; (test interpreters need to understand the statistical issues of reliability, predictive value, sensitivity and specificity)
  • cultural, experiential, and disability factors affecting examinee interaction with CNADs; (students with certain disabilities or who need medication but are not taking it when tested will not give reliable results.  Test interpreters need access to all of this information.)
  • the need for checks on response validity and effort in the CNAD environment; (students are often left on their own in an unsupervised environment when taking the test: these factors should be taken into account when interpreting.)

An anecdote may suffice to clarify the delicacy and difficulty of interpreting CNAD or ImPACT tests;

As part of my work as a school medical director I review the ImPACT tests in my school.  A few years ago a student scored very low on her baseline test.  When I reviewed the test and the symptom checklist that is a part of the test, it was clear that this student was scoring very high on emotional and psychological issues (depression, sadness, irritablity, difficulty sleeping).  It is important for the test interpreter (me in this case) to follow up on such a test in the same way one would if the patient were in the office.  The athletic director sought out the student and after questioning her it was determined that many of her responses and low scores were due to the fact that she had just broken up with her boyfriend.  She was not sandbagging the test. This example just goes to show that multiple factors can affect test results and the interpretation of a CNAD is only one factor in understanding the complicated brain of a teenager, much less the brain of a concussed teen!

 

 

Pediatricians Get Heads Up on Liability in Concussion Management

Pediatricians are being warned not to stick their necks out too far in protecting the heads of their young patients.  And to put on their own helmets.  A recent article in the AAP News,  the official news magazine of the American Academy of Pediatrics, the major professional organization of US pediatricians, is cautioning providers about the long reach of new legislation around concussions into the private lives and lifestyles of parents and patients.

 

Specifically, at least forty of the fifty US states have passed legislation which mandates medical clearance following a sports related head injury before a child may return to school sponsored physical education and sports.  By giving this authority to physicians, says the author, William McDonnell, a physician and lawyer who is the chair of the AAP committee on medical liability and risk management, the law also hands over responsibility for the consequences of lifestyle choices which the physician may actually have little control over.

 

Let’s imagine for instance that a family decides on its own to allow their recuperating child to play in a recreational soccer league even though the physician only has purview to  recommend that the child be barred from play at school according to the school’s policy. Parents need a great deal of education to understand that any subsequent head injury may require a longer recuperation period than the first one.  Just how long a student is vulnerable is a currently hotly debated and researched question.

 

Dr McDonnell has the following tips for practicing pediatricians in order to reduce their liability:

  • Follow a defined concussion protocol
  • Follow a clear Return to Play (RTP)clearance policy
  • Give clear discharge instructions
  • Document that RTP clearance is a relative issue, is not a guarantee and can change
  • Resist pressure to give RTP before a student is really ready
  • Follow up is critical
  • Facilitate follow-up with specialists if symptoms do not clear as early as expected

 

What Dr McDonnell does not emphasize in his AAPNews article is that Return to Learning is equally important and that many concussions occur outside of the sports world.  Much of the morbidity of  concussions is seen in the classroom and emerges as absenteeism, and presents as psychological, emotional, cognitive, and academic symptomatology.  It is these more “silent” issues  that must be attended to in the athlete and non-athlete alike. Not every state mandate is addressing these.  But these, too remain the responsibility of every good pediatrician.

 

 

 

 

The unspeakable “C” word

What do I know about hockey players?  A few things because I raised one through high school.  They get up too early in the morning to get to practice; their gear bags smell terrible; they skate like the wind; the elegance of a goal well played can be breath taking; they are rugged and rough and resistant.

But under the gear and the helmets and the speed are flesh and blood human beings with brains that look like jello, just like yours and mine.  And those brains are just as susceptible to concussion as anyone’s.

So it is dismaying that the hockey world seems resistant to the reality of what can happen on the ice.  While other sports and schools across the country are grappling with the right way to prevent and manage head injuries given that we are just beginning to understand them, the NHL is demurring. According to Roy Macgregor of Canada’s Globe and Mail (http://bit.ly/Y5yUJ6):

The NHL has increasingly shown a reluctance even to use the word “concussion.” A player is described as “dizzy” or suffering “whiplash,” anything to avoid using the word that is increasingly regarded as a stigma.

It has become the game’s “C” word.

 

This attitude not only does a disservice to every player who sustains an injury but it trickles down to the middle and high school players who emulate and admire their professional hockey heroes.  Slowly but surely the world is learning that one cannot diagnose a concussion right away but that each person’s head injury may take a different trajectory and show its severity over the hours or even days and weeks that follow the event.  Just last week a Kazakh player, Dmitry Uchaykin, died after taking a hard hit to the head even though he went home to sleep after the game only to suffer an unexpected cerebral hemorrhage. This terrible event made some waves on Twitter but it was underplayed elsewhere in the face of March Madness.  But the madness lies in skipping over the very serious reality of this condition, known as second impact syndrome.

To deny a head injury or its importance and subtlety is to collude in a dangerous game of putting the brains, minds, lives and souls of players and their fans at risk.

 

 

Why I admire Athletic Trainers

 

 

ath trainerMarch is National Athletic Training month. In a world filled with bad news, trainers are the deliverers of good news:

 

• Come on, you can do it!

• Let me help you!

• No pain, No gain!

• Sorry. You will need to sit out now but you will be back in the game as soon as it’s safe to play.

 

These are the messages athletic trainers send to athletes every day in order to keep them safe and playing the sports they love.

 

For over five years I have had the privilege of working with athletic trainers in Westchester County where I am the medical director for two districts. These professionals are in the trenches, watching our student athletes through all kinds of uncomfortable weather, at all times of the week and all hours of the day. Early morning practices and late, overtime games, seven days a week. The athletic trainers are there.

 

But it’s not just that they show up. They also do a tremendously important job, watching out for unsafe turf conditions, calling athletes out if they appear to have a concussion, and even saving the lives of referees and spectators who may get into medical trouble themselves. They are exceedingly well trained and have personalities that match their jobs. They do not give up. They may make it look easy to make the tough decisions as they sometimes need to stand their ground against opinionated coaches, referees, parents, athletes, bystander-doctors and others.

 

I am looking forward to a long collaboration with these professionals. And it would be my hope that every secondary school employs one. And that every medical director of school health has such a teammate. It’s hard for me to imagine a safe high school athletic program without one.

 

A Story of Post Concussion Syndrome from the Frontlines.

Rachel’s story is a cautionary tale that teaches us the importance of the Four Rs: Recognize, Respond, Rest and Reassess.  After her first hit to the side of her face during a game on September 22, 2010 which produced headaches and dizziness, she continued to play with severe symptoms for the next three days. The First Three Rs tell us that she did not Recognize the hit to be a concussion, that she did not Respond and leave the game and that she did not followup with Rest. Would the outcome have been different if Rachel had known about concussions? I am sure she wonders herself.

Dr Engelland

My name is Rachel Abrams and I am a junior in college. In high school I played soccer, softball and basketball. I went to college and was set out to play soccer and softball there. To anyone else September 22 is any other day, for me it is forever etched in my mind; I call it the devil’s day. I never thought anything of concussions; I was uneducated of this injury. I was one of the goalkeeper’s on the women’s soccer team and was having the time of my life. Then came September 22, 2010, when my life changed.

I received my first concussion on this day, during one of our soccer games at college. It was during one of our games, I was in goal and I received a corner kick from the opposing team. I misjudged it a little bit, caught it against the side of my face and continued playing. After the game I had headaches, I didn’t think anything of it and practiced the next three days, even with the headaches getting worse. Our athletic trainer then diagnosed me with a concussion and I was kept from playing. Then it got worse, my symptoms got worse, now experiencing nausea and increased headaches. I went to the emergency room at a local hospital where they did a MRI or CAT scan, I don’t remember exactly. From there on my symptoms got worse, with the addition of fatigue and I had to see a neurologist just to be completely checked out. I was suffering from fatigue, headaches, nausea, and had a slight hearing loss in one of my ears. My neurologist diagnosed me with a mild concussion and said I was out indefinitely. I had to take a week off of going to classes and in the next few weeks I was diagnosed with post concussion syndrome.

For the next nine months I experienced severe headaches every day, almost all day long. I couldn’t do any physical activity for about 90% of that time. I had many symptoms, most of all it was headaches. I was also nauseous almost every day for the first three or four months. I was always tired; I experienced a great deal of fatigue, but could never sleep. I had a lot of memory issues and I had a little bit of balance problems. I was on many different medications during these months, probably fifteen or more. At one time, I was taking twelve pills a day, a few in the morning but most at night. The medications were for all of my different symptoms. I was taking sleeping pills that could have side effects of hallucinations, which of course I had when I would wake up at night. My neurologist and I were trying all kinds of medications; with stopping ones that weren’t working I had to deal with rebounding. With going through this for so long, I believe I became slightly depressed because these headaches mess with your mind and you don’t think they will ever end. I had some nights where I would pray that either the headaches were gone in the morning or that I wouldn’t wake up. I finally got through this; I believe that I was finally 95% headache free by mid June.

I decided to go back to playing soccer in the fall of 2011, with headgear to protect my head. September 22, 2011 came around; I was warming up in goal, my teammate took a shot, it hit the side post, came back and hit me on the side of my head. I became very fatigued and slow thinking, I was diagnosed with a concussion. I then went back on some medication. I experienced a lot more memory problems and I had very bad balance. I began taking ImPACT tests. I started off doing horrible on these tests and almost always came out of them slow thinking, with a bad headache and completely exhausted.

This time around I dealt with the concussion better, I knew how to make the headaches decrease. I came off of the medications within the first few months. This concussion also lasted around 9 months also but I finally got through it. My neurologist and I figured out that I have probably had at least four very mild concussions before these two but never thought about it. So it is determined that I have had six concussions in my life. The hardest but easiest decision I have ever made was to never play competitive sports again. My sports career is over, it was hard to deal with but I can’t risk my health, which is most important.

How am I now? I still get headaches at least once a week, my balance is much better, I have a slight memory problem and I am not on any medication. I am a stronger person, having gone through this. What I want to do is educate people and support people who may be going through something like this. There is no reason that concussions should be put on the back burner.

Kobe Bryant Speaks Out

Kobe BIt’s one thing when a state law or a policy that comes down from above says that resting is the best treatment for concussion. But it’s another when a star player like Kobe Bryant has something to say about it.

Commenting in the LA Times and re-quoted on Slamonline.com, Bryant said of his teammate, Paul Gasol who has missed five games due to a concussion:

“I was a little angry with him the other day because he’s coming to practice and coming to the games,’ Bryant said. ‘Stay home. Cut all the lights off. Just rest. Let your brain rest. But he wants to be around [the team]. That’s the type of teammate he is.”

What Bryant is recognizing is that healing from a concussion requires athletes, especially at the NBA level to do something that often runs counter to who they are. That’s to withdraw from the limelight, the locker room, the home territory with the friends and teammates and be quiet and REST.

According to the basketball blog site TrueHoops, the NBA has gotten serious about concussion management. Even though the degree and frequency of hits may not be what we see in the NFL, they are implementing a multistep protocol to keep players safe in the short and, maybe most importantly, the long run. Under the guidance of Dr Jeffrey Kutcher, the program is taking hold. Kutcher is quoted on Slamonline as saying: “the policies need to reflect the fact that it’s a team effort to diagnose concussions and look out for injuries, because the injured athletes oftentimes don’t know they’re injured.”

It does seem surprising that we have very little to offer injured players other than vigilance—no medication, no shots (meaning vaccinations), no therapy of any kind. But as Bryant says: ‘It just takes time. There’s nothing you can do really to expedite it. It’s not a muscle. You can’t massage it. There’s nothing you can do. You just rest.’”

photo from superbwallpapers.com via Googleimages

How Long Will Concussion Symptoms Last?

37EEG_mit_32_ElectrodenThose of us on the front line in the concussion world and certainly all injured people would like to know if it will take a few hours, or days, or if the debilitating symptoms of concussion are likely to persist. For some recovery can take many months. For some life is never quite the same. Ever.

A fascinating if somewhat disheartening study was published online this week showing us just how much we really don’t know about concussions.

In the revamped JAMA Pediatrics journal online, Drs. Zemek and others from Canada published their ambitious review of the literature to see if they could define the predictors (or “prognosticators”) of prolonged recovery from concussion in pediatric (ages 2-18) patients. The murkiness starts with the fact that there is not a consistent definition of concussion, post-concussion syndrome (PCS) or full recovery. So with these limitations in mind, the researchers did their best to determine what we know about predicting.

They culled fifteen studies that met strict criteria after a review of over 500 published papers in the world literature. In sum their findings show that in large studies the risk of PCS (defined as more than a month of symptoms following injury) was increased in older children who had sustained loss of consciousness, headache and/or nausea/vomiting. In smaller studies there appeared to be some correlation between initial dizziness after the injury and prolonged recovery (PCS).

Another soft finding from the review that many “feel” is true is that certain conditions predispose to prolonged recovery. Those include children and teens who have had a previous head injury, learning difficulties, or behavioral problems. However, none of these associations with prolonged recovery were strong predictors.

The authors conclude that “because there is no method to predict which children will experience prolonged symptoms vs which will have a rapid recovery, clinicians must continue to recommend conservative management including both cognitive and physical rest, followed by a stepwise return to activities for all children.”

We remain without a good “test” or means to determine whether a concussion is mild, moderate or severe until we see how long the process of recovery will take. No estimation of severity can be made at the time of the injury. We still do not have a clue about who will recover when.

But we have a fantastic opportunity to do some good research to try to find out. Now that the majority of the states in the US have mandated some sort of concussion protocol and management program at the middle and high school levels, there is a tremendous opportunity to collect solid data. And we also need to keep looking for and tracking markers (biological or behavioral tests) that might help predict who will play the next season and who cannot.

image from curebird.com via Googleimages