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Concussion to groin pain: BJSM editors and authors contribute to a 200-strong clinician education event

17 May, 14 | by BJSM

BJSM editors and authors contributed to a 200-strong clinician education event run by the Faculty of Sport and Exercise Medicine of Ireland on Tuesday April 29.

Andy Franklyn-Miller argued the ‘compartment pressure’ syndrome was a misnomer for pathology that relates to relative overuse. His article can be found HERE  (OPEN ACESS) in BJSM and his podcast on the topic is among the top 5 of all time on BJSM podcasts (LISTEN HERE).

BJSM concussion cover 2014Eanna Falvey addressed the challenges of deciding on return to play in concussion and he challenged what many US newspapers are taking as gospel – that repeated concussion leads to chronic traumatic encephalopathy (CTE). BJSM’s 4th issue of 2014 addressed this question and Paul McCrory is on BJSM podcasts (LISTEN HERE).

Senior Associate Editor Peter Brukner (@PeterBrukner) reviewed the challenges of managing groin pain in sport. He argues that Copenhagen’s Per Holmich’s ‘entities’ approach is a useful one. You can see watch Per Holmich talk about history and clinical examination on YouTube (HERE) and read about the entities (HERE).

To close off the educational event, BJSM Editor in Chief Karim Khan reviewed the pathogenesis of tendinopathy arguing that collagen failure and abnormal tendon cells/matrix needs to be respected even if there are some biochemical changes that have loosely been linked to ‘inflammatory’ pathways. The new BJSM paper ‘Time to revisit inflammation”  (OPEN ACCESS)  is a thought-provoking contribution to tendinopathy management science by UK Professor Jonathan Rees. If you are interested in tendon injuries and their quality management, go to Oxford in September (2014). International Scientific Tendinopathy Symposium.

This event was part of a 10-city educational tour of UK supported by BJSM, McGraw-Hill publishers, and Aspetar Orthopaedic and Sports Medicine Hospital, Qatar.

What do you think? Tweet @BJSM_BMJ or email us (karim.khan@ubc.ca)your thoughts.

IOC World Conference – Prevention of Injury & Illness in Sport: On the ground recap

24 Apr, 14 | by BJSM

By Liam West (@Liam_West)

IOC conference

For 3 years this conference has been firmly on my “SEM Bucket List” and it did not disappoint. Firstly, Monaco in the sun is a sight to behold and secondly to walk into a coffee break to see the “who’s who” of global sports medicine was simply inspirational. The numbers for the event were equally impressive;

  • 24 symposia
  • 5 keynotes
  • 34 workshops
  • 73 free communications
  • 233 poster presentations (unopposed in the time table)

The only downside was that I could not attend all of the sessions, although I guess that speaks volumes of the quality of presentations on offer. Below is a summary of the 3 days and some take home messages from the sessions I attended.

Dr. Richard Budgett, IOC Medical Director, reminded all the delegates at the opening ceremony that “It’s all about the athlete” and as a former Olympic gold medalist he knows this more than most! The next day the opening keynote lecture showcased a vigorous debate between Karim Khan (@BJSM_BMJ) and Dominic MacAuley (@DMacA) as to whether sports injury & illness prevention research has delivered. The answer? Yes in certain areas (e.g. ACL prevention), but there is much work to be done (or optimistically to be read as opportunities for research!!).

Using the #IOCprev2014, the interactivity between delegates and speakers both in attendance and across the globe was terrific. Perhaps this was triggered by the excellent symposium about “the power of social media” chaired by @CarolineFinch. Learning points? You can to use social media as a platform to market your message. It is now one of the best ways to signpost readers to scientific content and can improve citation rates although @DrJohnOrchard warned about the perils of engaging in non-academic discussions online. @clairebower explained the three top rules of twitter [slides can be accessed here]. 1) Know your audience, 2) keep it simple & 3) image is everything (use photos). @EvertVerghagen explained that using social media can increase subject recruitment for research and apps may be the future of sports injury prevention – you can find his talk here.

Sudden cardiac death (SCD) was an integral theme at the last IOC conference in 2011 and 2014 was no different – read the open access BJSM issue on Advances on Sports Cardiology here. After the overview by @Prof­_MatWilson, the issue of the optimum screening protocol for SCD was tackled – future efforts lie in detecting subclinical disease in older athletes. No guaranteed protocols were given by the experts but Michael Papadakis provided pro-ECG evidence and then educated delegates to the normal ECG changes associated with age, sex and ethnicity – read the Seattle Criteria here and do the online BMJ ECG interpretation module here. Shanjay Sharma (@SSharmacardio) talked about the importance of maintenance of left ventricular cavity size in the athlete’s heart that is lost in cardiomyopathy and that it isn’t the size of the heart that matters but the function. Screening will never pick up all athletes at risk of SCD – Jonathan Drezner (@AMSSM) preached the importance of sideline preparation and the role of the automated external defibrillator (AED) in preventing SCD. The big take home message – “A seizure or loss of consciousness should be assumed to be sudden cardiac arrest until proven otherwise”

Concussion is the current vogue in SEM and the keynote by Neurologist/Sports Physician & PhD Paul McCrory was well attended. He described that whilst technology has improved enabling us to measure impact & biomechanical forces, these show little correlation to rates and severity of concussion. The most recent Zurich guidelines were emphasized to be just that – guidelines. There are no definite answers so far in concussion and currently we are only looking into neurocognitive athletic function but McCrory explained that concussion is a complex systemic pathology with many components; consider mood, sleep, hormonal disturbances etc. – listen to his 4 recent BJSM podcasts on the topic here – 1,2,3, & 4. It is important to note that Chronic Traumatic Encephalopathy is a separate entity to concussion and as clinicians we must not let the media dictate the course of science – education in this area is key! You can access the BJSM journal dedicated to concussion and the 4th International Conference on Concussion in Sport (Zurich, 2012) here.

The recent IOC Consensus Statement “Beyond the Female Athlete Triad – Relative Energy Deficiency Sydrome (RED-S)” was presented and discussed in a fantastic stream led by @margomountjoy – this work has moved on from the Female Athlete Triad and the journal can be read here. RED-S acknowledges this condition affects both genders and has multisystem involvement with more complex pathophysiology than previously described. It’s all about the energy. RED-S describes the imbalance between training load and recovery as the imbalance between energy availability and expenditure. With low energy availability comes susceptibility to short term risks to illness, infection, fatigue etc and long term risks such as decrease in performance and overall health. The paper proposes a traffic light system to RTP issues for athletes with this condition – useful for clinicians.

Some other short take home messages;

  • The legend of running biomechanics, Benno Nigg, spoke on the evolution of footwear and the prevention of running injuries. He concluded from his years of research that the only thing that actually confers injury protection is the ability of athletes to use a “comfort filter” to choose the shoe/insole that works for them.
  • Injury prevention – @benclarsen presented on the difficulty with recording overuse injuries. He stated that we need to move away from the trend of only measuring time loss injuries and look to include injuries that can lead to overuse pathologies.

I’d like to thank the organisers for putting on such a fantastic event that enabled delegates to meet old friends whilst making new connections that will hopefully last for many years to come. I look forward to seeing many of you at the next IOC Conference in 2017!

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Dr. Liam West BSc (Hons) MBBCh is a junior doctor at the John Radcliffe Hospital, Oxford. He is a founder and current President of USEMS and is also the founder of Cardiff Sports & Exercise Medicine Society (CSEMS). In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series. He has a passion for developing the SEM movement amongst undergraduates and sits on the Council of Sports Medicine for the Royal Society of Medicine as Editorial Representative and on the Educational Advisory Board for the British Association of Sport and Exercise Medicine. His Twitter handle (as above) is @Liam_West and you can find Liam on Facebook as well.

Sports-Related Concussion in Youth- Improving the Science, Changing the Culture: Book review by Dr. Michael Turner

9 Apr, 14 | by Karim Khan

Book review by Dr. Michael Turner

Sports-Related Concussion in Youth- Improving the Science, Changing the Culture (336 pages)

sports related concussion cover.phpThis is essentially the 2012 Zurich Concussion Consensus process applied to research in youth sport – a great summary of the topic but not an easy read.

For anyone versed in concussion the themes will be familiar:

  • A very high profile topic
  • Very few good quality articles published in the recent literature relating to concussion in youth sport
  • Epidemiology data non-existent for grass roots sport
  • The culture in youth sport is to play down concussion and avoid letting the team down
  • A single definition of concussion is not universally applied so data gathering is a mess
  • Little research has taken place on the molecular changes that occur in the young brain when a concussion occurs
  • Mixed findings on the long term effects of repetitive concussions and sub-concussive episodes
  • Risk factors for post-concussion syndrome and CTE have not been identified
  • No studies on the pre-high school group have tracked the post-concussion changes found in the following activities – physical, cognitive, emotional or sleep
  • There is no data to establish a threshold for concussion in young athletes
  • The is no equipment that can mitigate or prevent concussion, despite the manufacturers claims to the contrary
  • There is currently inadequate information to establish what combination of tests is best to identify and monitor concussion in youth sport (using hospital based or non-hospital based assessment tools)
  • Despite the consensus agreement that concussion should be treated with physical and cognitive, there is little empirical evidence to establish what is the optimal degree and duration of physical rest and if cognitive rest is necessary

The authors explore these problem areas and offer a detailed review of the published literature:

  • Neuroscience, biomechanics and risks of concussion in the developing brain
  • Concussion recognition, diagnosis and acute management
  • Treatment and management of prolonged symptoms and post-concussion syndrome
  • Consequences of repetitive head impacts and multiple concussions
  • Protection and prevention strategies
  • Conclusions and recommendations

 The authors make 6 recommendations:

  1. Surveillance – establish a national surveillance program for children aged 5-21
  2. Evidence based guidelines for concussion diagnosis and management – should be established and research supported
  3. Short and long term consequences of concussion and repetitive head impact – should be evaluated using a controlled, longitudinal, large scale study
  4. Age appropriate rules and playing standards – should be rigorously evaluated by sports associations, schools and national governing bodies of sport
  5. Biomechanics, protective equipment and safety standards – should be evaluated by research funded by the National Institutes of Health and the Department of Defence
  6. Culture change – the NCAA and other organisations should develop, implement and evaluate the effectiveness of the large scale efforts to increase knowledge about concussion and change the culture surrounding concussion (among elementary school through college-age youth, their parents, coaches, sports officials, educators, athletic trainers and health care professionals)

The book costs just US$64-00; the recommended research will cost a great deal more

Sports-Related Concussion in Youth – Improving the Science, Changing the Culture (336 pages)

Institute of Medicine and National Research Council of the National Academies

ISBN – 13: 978-0-309-28800-2

ISBN – 10: 0-309-28800-2

http://0-www.ncbi.nlm.nih.gov.elis.tmu.edu.tw/books/NBK169016/

http://www.nap.edu/catalog.php?record_id=18377

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Dr. Michael Turner, MB BS, FFSEM is the Chief Medical Adviser for the Lawn Tennis Association, London

Listen HERE to the BJSM podcast interview about his time as chief medical adviser of the Lawn Tennis Association, including the medical scandals that have cropped up and the advances he’s seen in the game’s sports medicine.

 

Coaches and doctors need to recognise when they are vulnerable to “win or else” pressure.

3 Feb, 14 | by BJSM

 By Drs. Lynley Anderson and Brad Partridge 

John Orchard’s recent blog On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinician’s hands’, raises some interesting points for debate. Dr Orchard laments that decisions regarding return to play following concussion were made by a coach who is ‘forced by the nature of the job to think in the short term’. Orchard says that coaches are under “ridiculous pressure to win”, and so cannot be trusted to have the long term welfare of players in mind. Furthermore, he believes that the typically short term nature of a coach’s job (that is, they may be sacked if their team is not successful) compromises their decision-making about issues of player safety – as a result, Orchard believes that coaches should not be involved in decision making about return to play from concussion lest they put players at risk of long term harm.

We wish to expand upon Orchard’s useful and provocative contributions by making several points for consideration. Firstly, we think that Orchard gives the impression (perhaps unintentionally) that coaches such as Andreas Vilas-Boas can either try to win, or can be concerned about player safety – but are unable to do both. We believe that this describes a false dilemma for coaches. The pressure to win is certainly a factor that places coaches in a potentially vulnerable state when it comes to player safety – there are going to be circumstances where this vulnerability is heightened and, if not managed appropriately, lead to harm. But implying that the “win or else” pressure precludes coaches from having any concern about player health and welfare is perhaps not the most accurate or useful way of viewing things. Giving the impression that it is not within the scope of a coach’s obligations to care about player safety may be even more detrimental to player safety. If coaches are absolved of any obligations to the health and safety of players they may see this as encouragement to push the envelope further in their decision making in the belief that it is simply someone else’s job to tell them when they’ve gone too far.

Secondly, it is not surprising that Orchard thinks return to play decisions should be the domain of the team doctor because they ‘are in a position to think longer term with respect to the player’s health later in life’. Those in charge of football teams (and perhaps even those in charge of entire football leagues) could be accused of wanting to have it both ways when it comes to team doctors. On the one hand they want access to medical expertise when it comes to optimising performance and treating injuries because such expertise may facilitate winning. Furthermore, cynics might consider that the involvement of medical professionals allows coaches and administrators to trot out the well-worn line that “the player’s welfare and safety are paramount” – if nothing else, it makes for good PR to concerned mums and dads. But in the event that those medical professionals provide recommendations that do not facilitate the team achieving its goals (or may hinder their achievement), then some coaches and administrators may be apt to ignore such expertise or seek to circumvent it. This appears to be Orchard’s concern too.

Our point is that, team doctors can’t have it both ways either. Given the obligations and goals of coaches, Orchard says that team doctors need greater scope to say who can and can’t play, and that there is a need to redress “the power imbalance on match day between the coaching and medical staff”. In other words, doctors should be the ones with the final say on return to play, and doctors should be the ones to tell coaches when they’ve gone too far. There may be good reasons for this, but we can’t forget that team doctors (like coaches) have many conflicting pressures too – from their patient, the coach, their employer, and perhaps even their medical colleagues.1,2  Not all of these stakeholders necessarily have aligning interests when it comes to each case of injury. Orchard’s call for allowing team doctors longer assessment times seems like a sensible proposal, but it doesn’t eliminate the potential for the assessor to be swayed by these conflicting pressures – just like coaches. So Orchard’s solution is fairly neat, as long as we assume that team doctors are the only stakeholders who are immune to external pressures on decision making! Player welfare is a stated priority for all stakeholders, but Orchard’s most recent post creates the impression that coaches will always lean towards winning over player safety, but no team doctor ever will. We saw this as curious because we agreed with Orchard’s earlier blog post ‘Concussion, risk assessment, and practical steps to reform’, where he suggested that doctors are indeed at risk of losing their job if they do not toe the party line.

In that post, Orchard calculated the chance of the Tottenham medical team being sacked at 1 in 5 to 1 in 20, noting that the risk is ‘demonstrably lower than the manager but far higher than a colleague working in the NHS’. He goes on to state that:

… this level of risk becomes lower if they all “stick solid” with the manager on the decision to return the player to the field and much more likely if a public statement was made to the media along the lines of “the medical team requested that the player be substituted for safety reasons but the manager over-ruled us.”

The message is that members of the medical team are also vulnerable to losing their job and might tailor their medical advice or decision-making to please those who determine whether or not they retain their job.  Doctors are best placed to medically assess a concussion injury, BUT team doctors may not always feel able to make a call that goes against the wishes of the coach and their decision making may involve a compromise between what is in the athlete’s best interest and what is in their own. This raises doubts about the independence of team doctors and places them in a similar position to coaches – a point that seemed lost in Orchard’s most recent blog post.

Furthermore, in a blog post from March 2012 Orchard relayed how coaching staff at the NRL club he was working for made it clear that they would not refer potentially concussed players to him for assessment if there was a chance he would exclude them from further play. Whether or not this ever occurred is unclear, but it clearly made Orchard uncomfortable. Interestingly, when interviewed in 2012, the chief medical officer of the National Rugby League (NRL) implied that team doctors do not have any conflicts of interest affecting their decision-making about concussion:

“There have been questions about whether club doctors have a conflict of interest because they are being paid by the clubs … their number one priority is the welfare of the player. They will always make the right decision by him.” (quoted in Prichard 2012).

Echoing this sentiment, a co-author of the Australian Football League’s concussion management guidelines also appeared to discount the influence of third parties by claiming that team doctors only ever make clinical decisions with their obligation to the player in mind:

”I may be idealistic, I may be wrong, but my feeling is that the guys are going to follow what they’ve been doing which is making sure players are safe. … You have very experienced doctors working in the AFL … we’re not going to be doing anything that compromises or risks player welfare.” (quoted Lane 2011).

Orchard has raised some important concerns for the care of athletes and been refreshingly frank in confronting ethical issues facing team doctors – in this post we have sought to clarify some of these issues. There is a need for good research to elucidate the mechanisms that make coaches and medical support staff more vulnerable to decisions with the potential to compromise the wellbeing of players.  This will help develop strategies for managing these issues.

References

1.              Partridge, B. (2013). Dazed and confused: Sports medicine, conflicts of interest and concussion management. Journal of Bioethical Inquiry. DOI: 10.1007/s11673-013-9491-2

2.              Anderson, L., & Jackson, S. (2013). Competing loyalties in sports medicine: Threats to medical professionalism in elite, commercial sport. International Review for the Sociology of Sport, 48(2), 238-256.

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Dr Lynley Anderson is a Senior Lecturer at the Bioethics Centre, Division of Health Sciences University of Otago

Dr. Brad Partridge is a NHMRC Research Fellow at the UQ Centre for Clinical Research, The University of Queensland

 

 

Paediatric concussion…….must try harder!

31 Dec, 13 | by Karim Khan

By Dr James Thing

paedetric concussionThere has been plenty of discussion lately on the topic of sports concussion and its mismanagement at an elite level. This was most recently and infamously highlighted when Hugo Lloris was allowed to continue playing for Tottenham after a period of clear loss of consciousness following a traumatic collision with an opponent.

In addition to this a recent $765 million out-of-court NFL settlement has prompted other sports to raise their game and introduce new standards of management for players with suspected concussion, however concussion diagnosis and management at a paediatric level in the UK remains worryingly inadequate.

In the UK there are, to my knowledge, no specific referral pathways or specialised clinic services for young individuals who have sustained a sport-related concussive injury.

By comparison the US has widely and wisely invested in concussion management for adolescent athletes, ensuring that young brains are closely monitored and optimally protected.

I recently travelled to the Sport and Exercise Medicine Department at Boston Children’s Hospital where I observed the true scale of attention currently being offered to young concussed athletes.

The clinic was set up in 2007 in response to the growing number of sport-related paediatric concussion presentations.  The clinic is available to local children aged 8 and over and caters for the broader Massachusetts area, covering 1.04 million 5-18 year old’s [2].

The clinic receives over 1000 new referrals per year, and deals with mostly complex or prolonged concussive cases [1].  The clinic integrates successfully with local schools and colleges in the Massachusetts area, enhancing effective communication and facilitating requests for school absences and ‘accommodations’ as required.  The state is enviably designed for concussion management with almost every school or college employing an athletic trainer who is able to undertake baseline computerised neurocognitive testing (most commonly ImPACT) in 95% of educational establishments [1].

This structure offers the clinician a huge advantage as they can easily access baseline test reports and make an informed and evidence based decision regarding return to play for the individual.

The clinic has standardised the management for adolescent athletes with concussion and relies on self-developed clinical protocols to facilitate optimal outcomes, utilising a team of experienced psychologists, neuro-psychologists, athletic trainers, psychiatrists, neuro-radiologists and research coordinators.

Numerous research articles have stemmed from the novel clinic, helping to shape the care of paediatric concussion around the globe.  The clinics provide the perfect environment for research generation, which has recently focused on predictors of symptom duration in paediatric concussion [3], the prevalence of undiagnosed concussion in paediatric athletes [4] and the use of computerized neurocognitive testing in sport-related paediatric concussion [5].

In the UK at present there is no standardisation of management for paediatric athletes suffering from concussion.  Management depends on the individual clinician’s understanding and interest in sports concussion.  Algorithms do not exist and treatment is generally delivered on an ad hoc basis.

It is now time to resolve this issue by establishing specialist services and starting to provide the necessary care that our young athletes deserve.

References

[1] Verbal correspondence with Dr William Meehan, Director, Sports Concussion Clinic, BCH SEM Dept.

[2] US Department of Commerce/US Census Bureau, State and County QuickFacts: Massachusetts.

http://quickfacts.census.gov/qfd/states/25000.html

[3] Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013 Jul;132(1):8-17.

[4] Meehan WP 3rd, Mannix RC, O’Brien MJ, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med. 2013 Sep;23(5):339-42.

[5] Meehan WP 3rd, d’Hemecourt P, Collins CL, Taylor AM, Comstock RD. Computerized neurocognitive testing for the management of sport-related concussions. Pediatrics. 2012 Jan;129(1):38-44.

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Thanks to Drs William Meehan, Michael O’Brien, Pierre d’Hemecourt, Andrea Stracciolini and Michael Beasley at Boston Children’s Hospital.

Dr James Thing is a final year Sport and Exercise Medicine registrar with an interest in paediatric sports medicine and concussion.  He provides match day cover at Harlequins Rugby Club and Cranleigh School.  He was awarded the Bauerfeind travel fellowship, which funded his trip to Boston.

Guest post by @DrJohnOrchard. On Andre Villas-Boas, the unreasonable pressure on coaches/managers, and why player health should be in clinicians’ hands

18 Dec, 13 | by Karim Khan

 

A month is a long time in football

OrchardPICOn November 21st, I was one of three sports physicians who wrote a Blog at BJSM on the topic of concussions in football & managerial interference in medical decisions. I tried to assess the risks involved for all of the participants in the Hugo Lloris concussion incident. Perhaps controversially, I estimated that the (then) Tottenham manager, Andre Villas-Boas, had between a 1 in 3 and 1 in 5 chance of being sacked this season. Well as it turns out if I had have offered to hold bets at these apparently meagre odds I would have been taken to the cleaners, as he didn’t survive the calendar year, let alone the remainder of the football season.

Which begs the question, why should someone (an EPL manager) with a job expectancy of roughly a year – give or take – have any role in decisions which may have an impact on the health of the player 20 years down the track? The answer is that of course they shouldn’t, but of course they do. If there was one thing that AVB made very clear in his short tenure, it was that he and he alone decided when players were substituted off the field. Other managers have said that they respect the opinion of their medical staff, but those at the coalface know of pressure to not be “too conservative” in a cut-throat world with limited substitutions.

It’s not surprising that a manager would put ‘team performance’ ahead of ‘long-term player welfare’. (We are not pointing any fingers – we are just drawing a logical conclusion).

Did AVB’s stance on concussion have a role in his downfall? I suspect not; my experience in professional sport is that managers are judged primarily on (poor) results. If Tottenham were leading the EPL then he would have been getting praised for being a strong leader who made tough decisions. Since my November blog, the Australian cricket coach Darren Lehmann has talked about batting on after being knocked unconscious by a ball the first time he batted at the WACA. No one talked about this being an inappropriate thing to say, possibly because cricket has fewer incidences of concussion but – more pragmatically – because coaches are fair game for criticism when they are losing but almost immune to criticism when they are winning. Darren Lehmann has just presided over a 3-0 Ashes win for Australia that – like AVB getting the sack – would have seemed impossible a month ago.

The ‘must win’ culture for coaches is unfair

The deal which coaches get – “win or else” – is unfair, but all in sport need to understand this deal and then question whether those under such ridiculous pressure to win should have the health and welfare of players in their hands? How can AVB be asked to think about Hugo Lloris’ health 20 years hence when the coach might only be in the job another month? Given the manager is NOT well placed to consider a player’s long-term health, how are sports administrators redressing the imbalance of power on match day between the coaching and medical staff? Note that the NFL paid out close to 800 million $US to football players who felt their long-term health was not a club priority during their playing years. NHL players are now seeking a similar payout. (Of course the NFL did not acknowledge ‘guilt’ of any kind).

Is there time for doctors to make an accurate concussion diagnosis pitchside?

A further development from my Blog, but relating to a different game (i.e. NOT the Tottenham doctors) is that a team doctor who has been accused – by the press – of allowing a concussed player to stay on the field wrote to say that in the incident in question he didn’t believe the player to have been concussed (despite what the press wrote). He admitted that the rules of football meant that his assessment was unfortunately a brief one on the pitch and that he supported a rule where he could more thoroughly assess the player on the sideline. Rugby Union has introduced Pitchside Concussion Medical Assessment. Doctors are thus under conflicting pressure from their teams (to err on the side of leaving the player on the field) and their medical colleagues (to err on the side of taking the player off, permanently if this is all the rules allow). It is a hard time to be a team doctor.

Legislate to be allow doctors to make additional concussion assessments and require player substitution as needed.

The bottom line is that in almost every professional sport the decisions on which players to substitute are primarily controlled by coaching staff who are forced by the nature of the job to think in the short term. Witness AVB’s sacking. Doctors are in a position to think longer term with respect to a player’s health later in life. The rules of sport need to change to allow doctors to have the power to make (additional) assessments and substitutes in the case of potentially concussed players.

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Dr. John Orchard @DrJohnOrchard is an Australian sports physician, injury prevention researcher, Cricket NSW doctor, and BJSM Associate Editor.

Concussion, risk assessment, and practical steps to reform: Learning from the Hugo Lloris example

21 Nov, 13 | by Karim Khan

By Dr. John Orchard (@DrJohnOchard)

sideways pitchAnother month in professional sport and we have another (few) concussion management controversies in multiple sports and multiple countries. Although we respect the fundamentals of the original van Mechelen injury prevention paradigm [1] it is clearer than ever that “real-world implementation” is at least half the battle [2].

This BJSM Blog [3 4] and multiple newspaper columnists on both sides of the Atlantic have tipped a bucket on the Tottenham manager Mr Villas-Boas’ apparent actions in overriding his medical staff and allowing the concussed goalkeeper Hugo Lloris to return to the field in a Premier League match. However as a departure from the Zurich guidelines [5], it was not an isolated incident, simply the most blatant disregard for them in the last few months given that the player was incontrovertibly unconscious and amnesic.

Bearing in mind the lesser degrees of certainty (but high degree of probability) the following additional teams (at least) stand somewhat accused of letting potentially concussed players continue in the game in the time since the Zurich meeting: along with Tottenham, EPL teams Arsenal , Everton, Stoke and probably the majority of the league; the Australian Rugby Union , NSW Waratahs team; the South Sydney & Canberra Raiders NRL teams; the Leeds Super League team; the South African and South Australian cricket teams; and probably the entire NFL.

When one team or doctor isn’t following the 2013 Zurich guidelines you can put it down to intransigence or incompetence. When there is a widespread failure to adhere, then the office-based experts need to look further as to why the coalface implementers aren’t complying.

Let’s try to estimate some of the risks related to the Tottenham / Lloris incident:

(1)   The additional risk that by staying on, Lloris would have suffered a second head injury with a catastrophic outcome – probably in the vicinity of 1 in 500 to 1 in 5000 (i.e. higher than baseline but possibly still a risk that a professional athlete might find acceptable, even when assessing the risks whilst not concussed!).  It is worth noting that our assessment of the likelihood of this risk (i.e. very low but possible) hasn’t changed in recent years.

(2)   The additional risk that by staying on and suffering further incidental contact (on this and other occasions) that the player might suffer a premature neurodegenerative condition such as Alzheimer or motor neuron disease – possibly in the vicinity of 1 in 20 to 1 in 200 although these odds are not well known and the lag time is probably 10-30 years. However this is the additional risk which we now appreciate is much higher than what we thought a decade ago. It is why the 2013 publication of the 4th Zurich Concussion in Sport Guidelines are more conservative than the first.

(3)   Let’s compare the risk that the manager, Andre Villas-Boas, will get sacked at some stage during the 2013-14 season – possibly in the vicinity of 1 in 3 to 1 in 5. Although he may not be doing these actual calculations in his head, let’s assume that he thinks or realises that these odds will increase if his team loses the game against Everton, and that he thinks or realises that the chances of losing the game materially increase if he “wastes” one of his three substitutes on a (relatively unfatigued) goalkeeper instead of using it, like his opponents probably will, on a fatigued midfielder.

(4)   Now let’s compare the risk that a member of the Tottenham medical team will get sacked at the end of the 2013-14 season – possibly in the vicinity of 1 in 5 to 1 in 20 (demonstrably lower than the manager but far higher than a colleague working in the NHS). It’s not being unrealistic to assume that this risk becomes lower if they all “stick solid” with the manager on the decision to return the player to the field and becomes much more likely if a public statement was made to the media along the lines of “the medical team requested that the player be substituted for safety reasons but the manager over-ruled us”.

(5)   Finally, for a player in a specialist position like the goalkeeper, the risk of losing the status and salary of being the team’s first choice in this position is up there with the risk that the manager will get sacked. If he is replaced, even for half a game, it allows his understudy the chance of making a match-winning save that could mean the manager decides to make the substitution a permanent one.

So if we ask why the Zurich guidelines aren’t being followed it is clear that all agents – the players, coaches/managers and even medical staff might be making ‘rational’ choices (see Thaler and Sunstein in ‘Nudge’ about ‘Econs’ how make rational decisions). Clearly the concrete high risks of bad outcomes in the short term (i.e. losing one’s job) are greater than nebulous long-term risks to the player’s future health, even though we are now certain that these long-term risks exist.

Substitution rules provide a solution

A common denominator for many of the team sports is that substitutions are limited and represent an important currency or resource that teams do not want to waste [6]. Managing concussion or suspected concussion according to the Zurich guidelines can cost teams some of this limited commodity (and potentially reduce the chances of the team winning the game).

The most restrictive of sports with respect to substitution is Test cricket, which is played over 5 days, and which only allows substitution for fielding (but not batting or bowling). Many traditionalist cricketers are proud that this sport is the last bastion in which a fatigued player cannot be replaced by a fresh one [7]. It is a separate debate as to whether – in an age of a ridiculously cluttered cricket calendar and high rates of fast bowler injuries [8] – bowlers should be able to be ‘subbed’ out of Test matches to prevent injury.

It is serendipitous that Graeme Smith the South African captain, one of the traditionalists who argued the opposing case to me in a recent debate on this issue, recently suffered a concussion from being hit in the head by a bouncer in a Test match. He was not allowed a substitute at the time of this injury and continued to perform well — he scored a double century which helped South Africa level the series. However he then needed to leave the same Tour early after complaining of post-concussive symptoms. Once the dust settles on this incident, it would be pertinent to ask Smith whether he still believes that it is important that the rules of Test cricket encourage players to continue on with injuries such as concussion? He has a one year old daughter & hopefully will not suffer a neurodegenerative consequence that would stop him enjoying his retirement with his children. But if his daughter decides as an adult to herself play cricket and gets hit on the head by a bouncer, would he encourage her to sit the rest of the game out for her own safety or continue on to help her team win the match? If he now thinks that he would advise her to sit out, how would he respond if she asked why she couldn’t continue to play just as he did in the Test match of 2013 against Pakistan? When and if he contemplates these scenarios, he again should be asked if it is a wise and good thing that Test cricket encourages players to ignore injury, including concussion, and stay on the field, or whether he accepts that there needs to be an elevation of safety concerns in determining the rules of cricket.

If it indeed were the case that his recent concussion has changed his views then it would be tempting to conclude that the cricket ball had actually knocked some sense into him. It is more accurate to conclude that it is not only medical staff but also rule-makers who owe a duty of care to the future health of players. The “culture” of cricket is that a player must be tough enough in a Test match scenario to push through injury. There are occasions when it becomes reckless to do so – concussion is one of them – and authority figures need to temper the player’s natural desire to push through.

At the moment, players, coaching staff and even medical staffers appear to be ignoring the 2013 Zurich guidelines, but the guidelines don’t prescribe consequences for doing so and recommendations as to how the widespread non-adherence can be resolved. In football, rugby league and cricket, extra substitutions (in the event of concussions) have been proposed even by the coaching staff. This would create further issues for the various sports. In football, where players are prepared to fake shin contact to be awarded penalties, it may be considered fair gamesmanship to fake a concussion in order to get the team an additional substitute. Something similar has happened before in the rugby union Bloodgate incident. But the question needs to now be asked – would it be a worse problem to have uninjured players faking that they are concussed to leave the game or to have concussed players faking that they aren’t injured to stay in the game? (..given that we now appreciate that premature neurodegenerative disease is a consequence of the latter). In the Bloodgate incident, the RFU were prepared to hand out far stricter punishments than any administrative body has managed to contemplate for breach of concussion laws. Further safeguards can be instituted around “free” substitutes by prescribing minimum stand-down periods for an athlete’s 1st, 2nd and subsequent seasonal and career concussions to encourage conservative management and discourage rorting of the system.

An early suggestion for the 2016 Concussion in Sport Meeting

If the next round of the Concussion In Sport Group Consensus statement (planned for 2016) actually recommended, for example, that FIFA institute an additional free substitute for a concussed player,  and if other sports were to follow suit,  then one of two things would happen. If the rule changes were instituted there would almost certainly be a more substantive move in the direction of safer management.  If they weren’t instituted then it would be the entire sport, rather than just the coalface individuals, who would be in breach of those 2016/17 Concussion In Sport Guidelines.

 References

1. van Mechelen W, Hlobil H, Kemper H. Incidence, Severity, Aetiology and Prevention of Sports Injuries: A Review of Concepts. Sports Med 1992;14(2):82-99

2. Finch C. A new framework for research leading to sports injury prevention. J Sci Med Sport 2006;9:3-9

3. Brukner P. http://blogs.bmj.com/bjsm/2013/11/07/guest-blog-peterbrukner-some-further-thoughts-on-the-hugo-lloris-concussion-incident/: BJSM Blog, 2013.

4. Khan K. http://blogs.bmj.com/bjsm/2013/11/07/mr-villas-boas-stands-by-his-concussion-call-if-the-manager-says-its-not-concussion-its-not-concussion-mr-villas-boas-its-time-to-apologise-for-the-sake-of-hugo-lloris-and-players-the/: BJSM Blog, 2013.

5. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 Br J Sports Med 2013;47:250-58

6. Orchard J. More research is needed into the effects on injury of substitute and interchange rules in team sports. Br J Sports Med 2012;46(10):694-5

7. Brettig D. To sub, or not to sub? Secondary To sub, or not to sub?  http://www.espncricinfo.com/australia-v-south-africa-2012/content/story/594154.html November 28 2012.

8. Orchard J, James T, Portus M, et al. Changes to injury profile (and recommended cricket injury definitions) based on the increased frequency of Twenty20 cricket matches. Open Access Journal of Sports Medicine 2010;1:http://www.dovepress.com/changes-to-injury-profile-and-recommended-cricket-injury-definitions-b-peer-reviewed-article-OAJSM May 2010

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Dr. John Orchard @DrJohnOrchard is an Australian sports physician, injury prevention researcher, Cricket NSW doctor, and BJSM Associate Editor.

Suspected Concussion? There’s a mobile app for that

12 Nov, 13 | by Karim Khan

By Keara Hooi, Sarah Mackay, Jacqueline Mitchell, Anton Moshynskyy, and Jacky Shen

Imagine being the brand new student trainer on an athletic team. You are ambitious, keen and ready to embark on a dynamic and rewarding journey in the industry. You grin as you stare out onto the field of football players, with your brand new Apple iPhone 5S cradled in your back pocket.

sway-balance-1-3-s-386x470During a particularly brutal play, a burly linebacker takes one of your running backs down. You suspect a concussion; what are you to do? You fire up your ‘Sway Balance’ mobile application and give it to the player to hug close to their heart.

A concussion occurs due to rapid acceleration and resultant impact forces on the brain. The symptoms may last from several hours to several weeks, depending on factors such as age, physical condition and previous history of concussions (Brukner and Khan, 2012).  Trauma to the brain may cause symptoms such as headache, confusion and disorientation, dilation of pupils, amnesia, poor balance, and nausea and vomiting, the severity of which is dependent on the grade of concussion (CDC, 2010). A concussion can also incur serious long-term implications, even after an athlete has retired from sport.

The Sway Balance iOS mobile app provides a cost-effective method of evaluating balance in an athlete suspected of having a concussion. While the app is running, the player places the device to his or her chest, and is prompted to perform several balance assessments, similar to those you might see in a Balance Error Scoring System (BESS). The results are then compared to the athlete’s previously established baseline data set. This FDA-approved program is an important device in a trainer’s toolbox, mostly because it is less subjective than the BESS and more affordable than a force platform (Pogorelc, 2013). Nonetheless, there is potential for unnecessary harm; persons who are uninformed about the nature of concussion could easily be led to believe that balance is the only indicator in diagnosis.

Balance is somewhat variable and may change based on an athlete’s current physical and mental state, especially in athletic settings where factors such as stress and fatigue come into play. A fatigued athlete may score significantly different compared to his or her baseline values, consequently giving a false-positive. Conversely, allowing an athlete with concussive symptoms outside loss of balance could provide a false-negative. Without monitoring for delayed onset of symptoms, a concussed athlete thrown back into a game or competition could easily suffer significant long-term adverse effects. These effects and health risks further compound if the population involved is composed of youth or adolescent athletes.

The apps reliability was also questioned. Could the condition of the iPhone impact how accurate the calibration system is within the device itself? A study completed by Lee et al (2012) compared two different balance apps and they found no significant difference in calibration from the phone being dropped.

The Sway Balance mobile app, while pragmatic, accessible, and fitting with modern society’s need for instant gratification, should neither be the single deciding factor of whether a player suspected of concussion may immediately return to play, nor used in place of a qualified healthcare professional. A professional will be able to conduct a comprehensive, holistic assessment on an individual suspected of concussion. A conservative approach, rather than a diagnosis based solely on a balance evaluation, is crucial to ensure that the risk of further injury, particularly concussion sequelae, is minimized.

Disclaimer: The views of the authors do not necessarily constitute or imply product endorsement by BJSM. Neither the authors nor BJSM received financial support from the The Sway Balance iOS mobile app.

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Keara Hooi is a fourth year Kinesiology student at UBC in the health sciences stream. She is currently a competitive gymnastics and cheerleading coach, and hopes to further her passion for exercise and rehabilitation through a career in physical therapy.

Jacqueline Mitchell is a fourth year Kinesiology student at UBC in the interdisciplinary stream. She is from North Vancouver and originally transferred to UBC from Capilano University. Following graduation, Jacqueline is planning on applying to the Masters of Physical Therapy program to pursue a career in physiotherapy.

Sarah Mackay is a fourth year Kinesiology student at UBC in the health sciences stream. She is from Calgary, Alberta and came to UBC in 2010 to swim competitively for the Thunderbirds. Upon completing her undergraduate degree, Sarah plans on perusing a career in medicine.

Anton Moshynskyy is in his fifth year of interdisciplinary kinesiology stream with plans to apply to a graduate program at UBC.

Jacky Shen is a fourth year Kinesiology student at UBC in the interdisciplinary stream. He is from Burnaby, British Columbia and originally transferred to UBC from Capilano University. Following graduation, Jacky is planning to pursue a Doctor of Chiropractic degree. In his spare time Jacky enjoys weight lifting, watching sports and spending time with family and friends.

Mr Villas-Boas stands by his concussion call. “If the manager says it’s not concussion, it’s not concussion”? Mr Villas-Boas – It’s time to apologise for the sake of Hugo Lloris and players the world over.

7 Nov, 13 | by Karim Khan

I was really disappointed with what I saw in this report in The Guardian. To see the word ‘incompetent’ linked to the world experts on concussion including FIFA’s neurologist and sports medicine specialist Professor Jiri Dvorak. To the Concussion In Sport Group who has met 4 times over a decade to make concussion the most improved field of management in sports medicine. Mr Villas-Boas had a golden opportunity for good yet it looks like he is digging a bigger hole for himself.

Let’s keep the facts really clear before the ‘spin doctors’ take over.

1. Mr Villas-Boas alone made the decision for Hugo Lloris to stay on the field. Mr Villas-Boas said “He (Lloris) doesn’t remember it so he lost consciousness” (Sunday!). The call always belongs to me is a quote from Mr Villas-Boas. There was no reference to the medical team clearing the player. Mr Villas-Boas specifically made the point that this was ‘his call’. This cannot be undone – no matter how much spin follows now. Mr Villas-Boas claimed it was his responsibility. The critical point. IT’S NOT THE MANAGER’S CALL.

2. Medical teams use a ‘SCAT3′ test to diagnose concussion – Mr Villas-Boas did NOT administer this short test before taking responsibility to keep Hugo Lloris on the field.

3. The call always belongs to me” is a quote from Mr Villas-Boas. That is the thinking that needs to be changed.

4. Great people apologise when they are wrong. “The call belongs to THE DOCTOR is what Mr Villas-Boas needs to say. Mr Villas-Boas has a golden opportunity to prioritise Hugo Lloris’ health and to influence the health of footballers the world over.  That should be the priority.

5. Abraham Lincoln: “How many legs does a dog have if you call the tail a leg? Four. Calling a tail a leg doesn’t make it a leg.”

6. I’m not going to comment on Tottenham’s football operations. I’m not trained in football or football club operations. On that, I defer to experts such as Mr Villas-Boas. It’s the principle of ‘scope of practice’. Doctors, and other clinicians, are trained in concussion assessment and management. That’s why concussion management is their call. #Lawyer’sFieldDayWhenManagersMakeConcussion”MyCall”.

7. A reminder for Tottenham Risk Management Department. The NFL just settled a concussion suit for $765 million. Can you imagine the court case in 2025….

Lawyer: “Mr Lloris, you say you have persistent headaches and your career was cut short after the game at Goodison Park in 2013. Who made the call for you to keep playing in that game?”

Hugo Lloris: “Well that was Mr Villas-Boas”.

Lawyer: “I see, Mr Villas-Boas was a neurologist, a sports physician, someone well versed in concussion management?”.

Hugo Lloris: “Uhh…no, he was our manager, a very good manager.”

Lawyer: “No further questions your honor”.

I hope, for Hugo Lloris sake, that a poor process (Mr Villas-Boas making the call) leads to no harm. But this is a watershed issue for the future Hugo Lloris’ and every woman, man and child who plays football. It’s the health professional’s call.

Come out and share that with the world Mr Villas-Boas. Great men have made important apologies. Football has been good to you. It’s time fpr you to be good for football.

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Here’s the link for folks who care about the health of players….

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Sorry Mr Villas-Boas. “Concussion call ALWAYS belongs to Doctor.”

4 Nov, 13 | by Karim Khan

AVB

 

 

The BJSM represents an authoritative voice in sports medicine so it would be negligent if BJSM did not comment on the widely-reported ‘Loris concussion’. We begin by emphasizing that BJSM knows the Tottenham medical team and they are excellent. In 2012, they helped saved Bolton’s Fabrice Muamba’s life on field – and provided a global illustration of world’s best practice.

In my editor in chief role, I also underscore that this blog comment comes without having been at the game between Tottenham and Everton, without having watched the footage, and without having assessed the player.

The focus of this letter is on a media report, with the caveat that media reports can be wrong.

If the media reports are accurate, my respectful point Mr Villas-Boas, would be - ‘Please learn from this incident that the concussion call does NOT belong to you.’  Mr Villas-Boas, the  world concussion experts, including FIFA representatives, met in Zurich in 2012 and agreed that potential concussion incidents need medical assessment. This is in the best interests of player and of coaches. Imagine how a coach would feel if he or she were to overrule a doctor, insist a player return to play, and then watch helplessly as that player bled to death later in the game, or that night at home.

Letting a concussed player return to sport is not validated by how the player performs later in that game; nor does a normal MRI scan mean it was safe for the player to return. An MRI only visualises structure – it cannot measure the complexity of brain function. Many former NFL players with chronic headaches, depression, and suicidal ideas had normal MRIs shortly after their concussion episodes.

An entire BJSM issue, supported by various sporting bodies including FIFA and the IOC is freely available by clicking here.

I cannot pretend to imagine the pressures of being an Premier League coach and I apologise for writing in a public forum. But as BJSM editor, I have a responsibility to my constituency as you do to yours.

This open letter/blog merely comments on what has been attributed to you – “the call always belongs to me”. If this was an inaccurate quote, or out of context, I apologise sincerely in advance. If you agree that medical decisions should be made by your expert medical team then you and I  agree. If you believe that you, as coach, have ultimate medical authority, over and above the medical team, I have a professional responsibility to disagree vehemently. Given how widely this incident has been reported, your quote “the call always belongs to me” needs to be countered strongly in a public forum.

I have worked with many excellent coaches/managers – coaches who have reached the pinnacle in professional and Olympic sports. They unequivocally support the position that the medical team must have the final say in the concussion decision. In other clinical settings, such as after a hamstring strain, ‘return to play’ and ‘availability’ decisions are ‘joint decisions’. The medical team provides input to the player and the coaches/manager make a decision. The very crux of ‘evidence-based practice’ has the ‘patient’ at the centre of decision-making model with options explained by the clinician.

But concussion is different. Because of the player’s mental state, he/she is not any position to make a call. Coaches are not trained to make the call. World Cup Final. Champions League Final. Premier League clincher. It matters not. In suspected concussion Mr Villas-Boas, “the call always belongs to the doctor”.

I’m signing my name as a professional responsibility and I’m happy to discuss this if you feel anything I have said is not respectful or not true. I wish you and your team every success and I underscore what a great medical team you have.  Most respectfully, karim khan.

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