I went to a baseball game and a football game broke out?

Interesting article in today's NY Times about Mets'player Ryan Church, who has sustained two concussions this year, the most recent one 8 days ago. It appears he has been "cleared to play" by the trainers/medical staff, even though he is still experiencing symptoms such as dizziness, lethargy and headaches. Church has played since the concussion, going 1-4 as a pinch-hitter, but the manager and GM appear to have no idea how to manage a concussed player (citing CT and MRI results, which are negative in Mild TBI, and relying solely on subjective reports by the concussed player):

Minaya emphasized that a CT scan of Church the night of his injury showed no damage, and that a magnetic resonance imaging test Tuesday was also negative. Minaya and Manager Willie Randolph said the club had relied principally upon Church’s reports to trainers about how he felt before each game, and sometimes during it, in deciding if he was available to play.

“It’s his call,” Randolph said. He added: “He’s been feeling a little bit groggy, and most of what he feels is that uneasiness with his total, you know, mind. It’s kind of weird because he feels like he’s kind of foggy. He says he can hit, he can do that. But in the outfield, he’s unstable out there.” Randolph added: “When you’re talking about head injuries, I’m pretty lame on that. I don’t even know how to respond to, you know, when we can put him out there.”

Before almost every game, he has told reporters of symptoms. At one point he said, “I’m just sick of feeling like this.”

Further, The GM does not understand concussion testing, calling a 30-minute test "time consuming":

The Mets began having players take baseline neuropsychological tests in spring training so that they could be tested against them after an injury; however, Church did not take a test, Minaya said, because of time restrictions.

“My understanding is that it’s a long test,” he said. “If I’m not mistaken, it’s about a half-hour or more.”

Concussion experts commented on the case:

Dr. Mickey Collins: "That’s a situation that could be very dangerous... I haven’t examined this player personally, but if there were a second trauma to a person still experiencing symptoms, the risk could be much higher to a player’s health because he hasn’t healed from the first concussion."

Dr. Robert Cantu: "You’re playing roulette with your patient. You know the chances of him having another concussion are low, but you’re running the risk of exacerbating the symptoms that he does have. Now a person who would be asymptomatic in a week or two can have those symptoms go on for many months."

Perhaps most relevant is the comment of Corey Koskie of the Brewers who sustained a concussion in 2006, experienced prolonged symptoms, and eventually had to retire:

"That’s pretty much the reason I’m here today (retired) — thinking I could play through it... I think he’s nuts. He doesn’t want to get to the point where he’s not going to get better. Tell him to call me. It’s not worth it."

Back from Disney: Roller Coaster mania

Took a vacation with the family to Disney World, and went to Epcot, Magic Kingdom, MGM/Hollywood Studios, and Animal Kingdom.

Rode lots of great high-speed rides, including Space Mountain, Everest, Tower of Terror, and Rock 'n' Roll Roller Coaster. My 8-year-old, Ben, was so excited about Everest and RnR Roller Coaster, that I decided to look their stats up online and also found many YouTube online videos. (Everest, RnR, ToT)

So, it turns out the RnR Coaster is "one of the most powerful coasters in North America" accelerating 0-57 in 2.7 seconds, generating G-forces of 4.5 to 5 depending on where you are seated (stats from here).

A long time ago, I was inteviewed on the dangers of roller coasters (with respect to head trauma, which there appears to be none), but I was naturally interested in the possible dangers of such a fast acceleration. Fortunately, UPenn researchers had answered this question back in 2002:

They acquired G force data from three of the most popular and powerful roller coasters in the country: the "Rock 'n' Roller Coaster" at the Disney-MGM Studios in Orlando, Florida; "Speed -- The Ride" at the Nascar Café, in Las Vegas, Nevada; and "Face-Off" at Kings Island, Ohio. Using this data, they calculated peak head accelerations in three directions, assuming the head did not strike a surface. Even considering the worst-case scenario, the researchers found that the largest forces experienced on roller coasters were far below those that are known to cause injury.

I wish I could prove it was my line, but when I was interviewed by the Boston Globe I said "it is more dangerous to drive to the amusement park than to ride the roller coaster" but they didn't include that in the article. However, someone quoting the UPenn study, concluded:

It does not appear that roller coasters produce high enough forces to mechanically deform and injure the brain...

For healthy people who meet the size requirements for the ride, you are probably safer on the average roller coaster than driving to the amusement park,

Playoff Hockey

Last night's Dallas-San Jose game had a hit frighteningly reminiscent of the hit Eric Lindros took from Scott Stevens.. head down, both players moving fast, attacking player hits the opposing player in the head with his shoulder.

One day later, the video is displayed on "NHLFightClub.com", and the spin from the coach is soberingly realistic:

Michalek hit hard. Michalek had his head down tracking a puck, when Morrow crushed him with a shoulder check. Morrow did not hit Michalek’s head, but there was a whiplash effect that could have caused a concussion by jarring the brain against the inside of the skull.

"Obviously, when Milan got hurt at the end of regulation, we played the overtime without him," Wilson said. "A whole game with a short bench, and our guys just kept going."

When asked if he could update Michalek’s health, Wilson replied: "It’s irrelevant. It’s over, so we have to move on."

Back from a brief break, finals looming

Not much "new" by way of news, but the semester is coming to a close and one colleage tells me of college students attempting to schedule formal neuropsychological evaluations to be completed before the end of the semester to document learning disabilities.

This got me reading, and this article mentions student grades being affected by concussion:

...who is enrolled in honors courses, is concussed, he suffers from headaches and a lack of concentration. "It feels like you have a haze over you, a fog, kind of," he said, adding that his grade-point average dipped from about a 3.57 to a 2.71 in the fall when he had trouble focusing after his football concussion.

"He's in all really, really intense classes, so concussions have much more effect there than on the field," said his mother...

Luckily, the focus on professional athletes denying concussions has raised awareness at the lower, youth, levels (ref), or so says a prominent sports agent:

Steinberg, who helped organize the summit along with the Sports Concussion Institute, is sponsoring a California program that will institute so-called "baseline testing" in 1,400 high schools, where athletes are given a cognitive exam that can be repeated after injuries to measure brain impairment.

or, as David Hovda so aptly stated:

"I don't know what's so mild about mild traumatic brain injury," said David Hovda, director of the UCLA Brain Injury Research Center.

Hidden Wounds of War

I guess I am in a political mood as of late, as this article caught my eye this morning:

Some 1.6 million Americans have served in Iraq and Afghanistan, more than 31,000 have been wounded in action and many more have sustained non-combat injuries or illness. TBI has been called the "signature injury" of this war, and the improvised explosive device (IED) is the leading cause of fatalities and brain injuries..

These powerful devices inflict severe damage and blast shock waves through the body, including sudden and violent impact to the skull causing damage to brain tissue. The resulting TBI can be fatal, or require immediate hospitalization. But more often the result of exposure is a less obvious concussion.

Despite the high incidence, there is little by way of diagnosis, let alone treatment:

Current estimates are that 10 percent to 20 percent of all U.S. military personnel in Iraq suffer concussion. Army studies show less than half of those exposed to IED blasts receive any evaluation.

In the environment of war, such symptoms can go unnoticed and unreported. Experience from sports and other noncombat injuries has shown that if an injured individual sustains a second concussion before resolving symptoms from a previous injury, a "second impact syndrome" can occur with dire, even life-threatening consequences. Repeated concussions cause cumulative damage and slow recovery.

It's a concussion; take it seriously.

Two articles showed up recently, both related to concussions and kids.

Dr. Michael Stuart writes an excellent primer for parents, and Dr. Gerard Gioia is mentioned in a press release about his "SCORE Program:

The program is one of the first of its kind. Currently, most concussion management programs for youth sports lag behind collegiate and professional sports, despite the serious consequences of brain injury on a developing brain.

"Implementing an effective sports concussion management program is essential to safeguard young participants and reduce long term risks,” writes Dr. Gioia. “Management of this serious injury must consider the various effects in the home, school, social and sports environments.”

Consider these "must-read" resources for someone new to concussions.

Interesting Logic

Pardon the brief political slant, but it appears that returning Vets from Iraq did not receive evaluations to diagnose Mild TBI:

"The fear of discovering a massive war syndrome among American troops returning from Iraq was the cause of Pentagon's postponement of routine brain screening among American soldiers for mild brain injuries.

Col. Kenneth Cox, head of Pentagon's medical assessment division, explained the Department of Defense delayed the conduct of brain screenings to steer clear of another potential Gulf War syndrome discovered among American soldiers in the 1990s."

On the bright side, the DOD has granted significant funds to researchers studying Mild TBI:

The Department of Defense has awarded a consortium of Houston institutions a $33 million grant to investigate mild traumatic brain injury, or concussion, the potential severity of which has long been underappreciated.

The grant, an unusually large amount for the government, targets better understanding and treatment of the injury that afflicts about 1.5 million Americans a year and is considered one of the Iraq war's signature wounds.

Valadka said one emphasis of the research will be to determine if the mild traumatic brain injury suffered in blast explosions is similar to such civilian injuries. If so, the research will have great applicability, he said.

However, the project will not end until 2013, so it willbe a long while before these efforts translate into results.

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Research reveals brain changes from concussion

Dr. Erin Bigler, from BYU, has identified "subtle but significant" brain changes that normally go undetected using traditional imaging techniques. In this article they explain the benefits of using diffusion tensor imaging (DTI to look at what he calls "the microenvironment" of the brain, an analysis not provided by traditional MRIs:

The researchers found differences in the appearance of the corpus callosum, which separates the right and left sides of the brain, in 10 teenagers who had sustained concussions one to six days previously and who suffered symptoms such as headaches. The study compared these to the brain images of 10 uninjured teens.

The study found that the concussion patients with the worst symptoms had the most substantial changes on the DTI images. Because the DTI imaging is still "several steps removed" from looking at actual brain tissue, Bigler explains, it's hard to tell if those changes represent swelling.

This story will likely hit the AP and Reuters in the next few days, and should span a tremendous amount of new research.

What is a Concussion Worth?

On Wednesday (March 12th) Buffalo defenseman Nathan Paetsch was knocked unconscious by a "cheap shot" elbow (see the video here). The offending player, Georges Laraque, was suspended for 3 games, while Paetsch remains out "indefinitely".

Interestingly, if you watch a hit Paetsch took only two days ago in a game against the Rangers, you can see that he was clearly concussed as he lay motionless on the ice. In fact, in this ESPN article referring to his condition in the Pittsburgh game, they say:

"Paetsch was already sore, playing with a stiff neck after he was checked heavily into the boards by New York Rangers' Sean Avery during Buffalo's 3-2 shootout loss on Monday."

Not to suggest that Paetsch could have avoided the elbow, but it is possible that he not only shouldn't have been on the ice, but the fact that it appears to have been his 2nd concussion in 3 days may have contributed to the severity.

Recovery times

Conventional wisdom states that athletes tend to recover in 7-10 days, with some requiring up to 30 days, and only a select few experience lingering symptoms akin to "post concussion syndrome".

Let's see how concussed athletes in the recent limelight fared:

Some players are out for their season:

Tiffany Roulhac (NCAA-W-Basketball) - out for the season following 2nd concussion.

Mark MacDonald (NCAA-M-Basketball) - Missed 10 games so far (2 months+)

Simon Gagne (Professional Ice Hockey) - Out for the season after suffering 3rd concussion.

Some players miss extended playing time:

Taylor Procyshen (Minor League Ice Hockey) - Missed 21 games (approx. 2 months)

Tracey Kelusky (National Lacrosse League) - Missed 8 games (Approx 2 months).

Other Players miss only a few games:

Tyler Morris (NCAA-M-Basketball) - Misses 2 games (approx 1 week), now practicing.

Chris Higgins (NCAA-M-Ice Hockey) - Missed one game

And some players don't even leave the game in which they sustained the concussion:

Kate Lance (High School Girl's Basketball) - Returned to the same game after falling face-first during overtime, but returned to hit the game-winning shot, then was examined by doctors to determine if she suffered a concussion and, possibly, a broken nose.

Concussions and then some!

Looking at concussion-related news articles for months and months has revealed that concussions do not always happen in isolation, often with other secondary injuries, some of which could be expected:

Concussion and shoulder separation (Hockey):

"Smyth suffered a concussion and a minor shoulder separation after Kings defenseman Jack Johnson checked him into the padded glass partition near the Colorado bench. The Avalanche said Smyth won't return to the ice until he shows no lingering signs of the concussion.

Concussion and spinal contusion (Hockey):

"Lupul returned to the lineup Feb. 9 after missing 14 games with a concussion and spinal contusion."

Concussion and broken nose (Hockey):

"Bergeron was leveled from behind by Flyers' defenseman Randy Jones and went head first into the boards. He suffered a serious concussion and broken nose and has been absent from the Bruins lineup since late October."

Concussion and brain tumor? (Rugby):

"Wallaby fullback Julian Huxley discovered he had a brain tumor after undergoing medical scans following a concussion in a weekend Super 14 match. Huxley was cleared in preliminary scans after he was carried from the field after having convulsions following a head knock in win over Queensland on Saturday night."

It's not very often that neuroradiological studies are positive, so this would definitely be a case of a concussion being a good thing!

Athletic Trainers vs. Trainers

Athletic trainers affiliated with the National Athletic Training Association (NATA) are distancing themselves from Brian McNamee, who has admitted to injecting Roger Clemens with HGH:

The guy who works with boxers is referred to as a trainer, and though he trains boxers, per se, he's a far cry from an athletic trainer who is focused on injury management and injury prevention. We have medical backgrounds and training. And we know the limits of what we can do. We can evaluate and treat an injury, but we never give injections, and we do not prescribe medicine."

Sheridan, 38, first heard the word trainer while watching the 1976 movie Rocky as a youngster. "Did Mick know how to prepare Rocky for the fight? Yes," Sheridan said. "But did Mick know if Rocky had a concussion? Did he know how to evaluate it and treat it? No. But that wasn't his concern. His concern was to prepare Rocky to fight, not medically manage him."

I can imagine a scene in the politically correct version of Rocky 2012:

INT: BOXING RING: CORNER: ROCKY JR. SLUMPS IN THE CORNER

Rocky Jr.: "I can't think out there Mick, I see double, the lights bother me, I have a headache"

Mick Jr.: "What month is it? Snap out of it Rock! What's the date, the day, the year? Tell me the damned months in reverse order Rock!

How to recover from concussion

Some folks require "peace and quiet to recover from a severe concussion", others are able to "shake off a mild concussion", while others simply "brave a concussion".

Cumulative Effects=Get it Right the First Time

So, Flyers' forward Simon Gagne is out for the season after returning too early following a concussion this season:

"James Kelly, a concussion specialist at the University of Colorado department of neurosurgery, told Gagne on Wednesday that his initial brain injury had never healed. Consequently, it got progressively worse with subsequent blows to the head.

"It's one concussion," Gagne said Kelly told him. "It got worse and worse. Every time I was getting hit to the head, the symptoms were coming back."

This does not bode well for players like Gerald Wallace, who suffered his 4th concussion in four years:

"Wallace visited a neurologist Tuesday, four days after the forward was knocked unconscious when he was hit in the face with an inadvertent elbow from Sacramento's Mikki Moore. It was Wallace's fourth concussion in four years, an all-too-familiar statistic for football players, but almost unheard of in basketball.

While Wallace is out indefinitely, there are concerns about his long-term health and questions about what can be done to protect him when he returns.

Let's hope that Wallace takes his time coming back. Concussion testing guidelines can only take you so far, but if the players are going to deny symptoms, there isn't much to protect them.

Concussion becoming an common adjective?

Concussions have become so commonplace, the term is being used as an analogy outside of the sports pages. From food descriptions:

"The cucumber was crisp and juicy. Above the sweet, fresh, salty, marine taste of the geoduck, other flavours spun around like the stars of a cartoon concussion"

...to veterinary diagnoses:

"...the owl had been hit by a car about three weeks ago and was sitting on the side of the road with a concussion and an eye injury.

Even in the sports pages, the term needs creative modifiers, as in this minor league re-cap:

"Bell was later taken from the arena on a stretcher, and was hospitalized overnight with what Phoenix coach Brad Church called "an extreme concussion."

Extreme concussion?

Off the Beaten Path

Concussions come from a variety of sources:

Ice-dancing:

"That performance came first despite Chris dropping Frankie on her head while attempting a difficult manoeuvre during training on Friday. "I was really embarrassed. She said it wasn't my fault but she has mild concussion and her neck's been hurting ever since so I still feel like an idiot.:

Acting like a Jackass (link warning: TMI):

"This is not the first time father-of-one Johnny has been taken to hospital following a botched stunt.... while filming Jackass: The Movie in 2002, he was knocked out by one of his castmates and had to be treated for concussion.

Snowmobiling:

"A 13-year-old Mount Vernon boy who was unconscious for nearly 20 minutes after driving a snowmobile off a 20-foot waterfall Sunday was treated and released from St. Joseph Hospital the same day...Family members reported they could not awaken Janicki for nearly 20 minutes after the fall.... he was treated for facial injuries and a concussion

And just getting a cup of coffee:

"A visiting student from Rochester Institute of Technology slipped and fell on the sidewalk in front of the Starbucks Coffee on Saturday. The student hit her head and blood was seen in the snow where she fell... the report said she appeared to be visibly drunk, as were the other people with her, who were said to be extremely intoxicated and less than cooperative. The emergency medical technicians at the scene of the incident said she appeared to have a possible concussion and a small laceration on her head."

Be careful out there!

The "grim reality"

Being a Philly guy, I suppose I am partial to home-spun news.It may only be two sentences in an article, but Phil Sheriden doesn't waste a word:

"The concussion epidemic in professional ice hockey is another issue that forces us to question just how much we're willing to ignore to enjoy these sports. Watching Simon Gagne follow the path blazed by Eric Lindros and Keith Primeau is slow torture, if you're a fan. Imagine what it must be like for the players.

Getting the NHL On-board

There is an article on ESPN's web site (also referring to a really interesting video from CBC's Fifth Estate on Chris Benoit), calling on the NHL to "embrace concussion research":

"If the NHL proposed a study or investigation for such an effect, I'd be first in line," Keith Primeau, a 15-year NHL veteran who retired in 2006 because of post-concussion symptoms that still pop up from time to time in his life... "For me, for the day-to-day [post-concussion effects], I think I'm over the worst of it. I've been feeling really good in the last four months. It's been the most comfortable I've been in some time."

Referring to the possible long-term implications of his concussions, Primeau says:

"I've resigned myself to the fact I'm always going to have [symptoms] to deal with, and I hope that they'll be very intermittent, as they've started to become. But I know I'll always have these setbacks. They are a reminder of exactly the price I've paid."

"[Non-concussed players] can't possibly comprehend the severity and long-term ramifications of head injuries... as a sufferer, even I don't know what the ramifications are. I believe at some point in my life there's going to be a consequence; I just hope it's later rather than sooner."

While the NHL has a mandatory concussion testing program, there has never been any data released or published, although it is not known if the blame lies with the NHL or the NHL Players Association.

An Academic Injury

It is great to see a discussion of the social and academic changes following concussion, as found in Brown's newspaper:

Much as they would like to, they cannot treat concussions - the most common prescription is a healthy dose of rest. In time, patients recover on their own. But the meantime can be stressful for collegiate athletes in ways that have no relation to school or sport.

(One student) recalls his injury changing all aspects of his lifestyle - athletic, academic and social.

"I didn't watch TV without my sunglasses on for a month," he says. "You wouldn't believe how it affects your social life."

...one of the harshest symptoms of his concussion was a social awkwardness that accompanied him wherever he went. "It's something that not too many people around you understand," he says. "You don't walk around with a sign up saying, 'I'm concussed.'"

...an injury - especially one as private as a concussion - could intensify the already-demanding pressures of Brown's academic and social environment.

"I think they affect academics not only in terms of material retained, but there is a very real concern that any injury makes you feel very self-conscious, especially within the academic milieu of Brown. You worry you're going to appear dumber than everyone else," she says. "Many injuries are visual - someone's got a cast, someone's got an ice pack - and we have a certain amount of sympathy. But when you have an injury like a concussion, and it isn't necessarily explained to everyone, I think that itself becomes an embarrassment and a frustration."

Concussion Treatment?

Folks at the University of Buffalo have come up with a concussion treatment program:

"...the program entails controlled exercise at a level of stress that does not trigger the symptoms. Its effect is to correct imbalances in brain mechanism brought on by the initial blow, which cause the illness and headaches."

It isn't clear how exercise can alter the metabolic cascade following concussion, so it will be interesting to see if this paradoxical "treatment" is helpful.