Posts Tagged ‘concussion’

2017 NFL Pro Bowl Concussion Symposium and Health Screening

Tuesday, February 21st, 2017

Desi Rotenberg
MS, ATC

Posted February 21, 2017

By Desi Rotenberg, MS, ATC

The 2017 NFL Pro Bowl is a tradition that stems back to its inception in 1938. While the teams have changed drastically since then, the NFL Pro Bowl has become a tradition of competitive fun and entertainment for players, NFL front offices and fans. 2017 was the first year since 1980 (minus 2009) that the game was held within the continental United States. This venue change hoped to bring more fans, more attention and enhanced exposure of the game itself.

One of the attention grabbers for me during the Pro Bowl weekend occurred off the field. This year, The University of Central Florida (UCF) hosted the 2017 Pro Bowl Concussion Symposium and Health Screening. The purpose of this symposium was two-fold. First, retired NFL players were invited to partake in health screenings for free to help identify any neurological, cardiovascular or other issues plaguing them due to their playing time in the league. Second, the NFL Players Association partnered with the UCF Psychology Department to present all of the latest research and treatment options related to concussions in the world of sports, and more specifically, the game of football.

Here are a few of the highlights:

Following the U.S. Supreme Court settlement regarding previous NFL players and head injuries, the science has gained a significant amount of traction. As new empirical data emerges and technology continues to develop, more funding is becoming available to allow athletes to have increased access to neurological assessment and professional evaluation following head trauma. Interestingly, the Supreme Court settlement included a 65-year plan that will give retired NFL players and their families financial support if they experience symptoms of amyotrophic lateral sclerosis (ALS), dementia or any other life-altering behaviors or symptoms that may arise secondary to traumatic brain injury.

Furthermore, baseline testing is being made available to all retired NFL players and will be done immediately upon retirement. This will allow the players’ medical teams to identify any behavioral, cognitive or neurological changes that may arise over the remainder of the individual’s life.

The overarching goal is to have every college, high school and middle school offer some form of baseline testing in at least one sport for all student athletes. We are slowly, but surely, making our way towards that goal. However, there still remains room for improvement when it comes to baseline testing.

The areas of deficiency that were identified was a lack of baseline testing within recreational sports and ease of administration within middle schools and high schools. If we want to ensure the safety of all athletes, we must do what we can to have concussion education, a concussion protocol and return to play protocol in place.

At the academic levels, we must also ensure that we have a return to learn protocol in place. The question that acts as a defense for medical professionals responsible for the return to play decision is, “If you cannot learn new information, should you be returning to play?”

Emerging Technology

To this point, there are 2 questions that remain: 1) How do we diagnose Chronic Traumatic Encephalopathy prior to death, and 2) How do we avoid the high cost of imaging when it comes to concussion diagnostics?

There is by no means an answer to the first question as of yet, but I am hopeful due to the emergence of Diffuse Tensor Imaging (DTI). DTI has been around for roughly 20 years and has been mainly used in the diagnosis of strokes and other ischemic disorders of the brain.1 Within the past 10 years, research has shown that DTI can also be used to assess the integrity of the white matter in the brain.2 The goal of physicians at the symposium was to make DTI more streamlined and allow patients access to this form of diagnostic following head trauma.

In the image below, the varying colors represent the orientation of various white matter within the brain. In the second image, neurological specialists have the ability to zoom in on a specific location and can visualize a physical abnormality or disruption in neuronal activation due to a disturbance in neuronal integrity.

Images Obtained from Journal of Neuroradiology

So how do we lower the cost of imaging?

We start by locating private medical companies that offer this type of imaging. There were several speakers at the symposium who owned businesses that focused on the neurological diagnosis and treatment of individuals who suffered traumatic head injuries. The businesses offer consultations and diagnostics at a fraction of the cost of normal imagining techniques.

Cognitive and Behavioral Effects of Head Trauma 

Neuropsychologists want to make one thing very clear to all health practitioners: There is no such thing as the average TBI patient. While there are several concussion treatment protocols, it is paramount that each case be treated on an individual basis according to the needs of the patient and the underlying symptoms present. Cognitive changes following head trauma occur on a varying spectrum, and can include, but are not limited to: changes in vigilance, reaction time, mental tracking, verbal retrieval, mood and information processing.

Common symptoms that can be seen are the emergence of anxiety, depression, inability to focus and difficulty sleeping. Each symptom can lead to frustration, impatience and social disconnect. There is one congruity with all of these cognitive and behavioral changes: a concussion is a physiologic injury of the brain, where normal cerebral flow has been altered and the normal “algorithm” of information input and output has been compromised.

Unfortunately, head injuries cannot be cured; however, there is hope for individuals seeking refuge from this life-alerting injury. There are many clinics that exist, such as the UCF Psychology Clinic that can help patients learn to cope with the inhibiting effects of head trauma. Treatments include consultations with neuropsychologists, who walk patients through cognitive rehabilitative exercises and various forms of talk therapy. These treatments can help an individual compensate for the mental, emotional or physical deficiency that has arisen. The goal of treatment is to help the individual learn how to live within this new reality, and how to improve their overall quality of life.

The central message of the symposium is concussion research and concussion management are constantly changing. Unfortunately, policy change happens at an even slower rate. Due to this constant evolution, this is a topic All medical, fitness and cognitive specialists need to stay up to date on this topic due emerging information and the constant evolution of the topic. This can be accomplished by staying up to date on the latest research and emerging trends, in order to be able to follow “best practices” and avoid liability.

Resources

1. Hagmann, P., Jonasson, L., Maeder, P., Thiran, J. P., Wedeen, V. J., & Meuli, R. (2006). Understanding diffusion MR imaging techniques: from scalar diffusion-weighted imaging to diffusion tensor imaging and beyond 1. Radiographics, 26(suppl_1), S205-S223.

2. Le Bihan, D., Urayama, S. I., Aso, T., Hanakawa, T., & Fukuyama, H. (2006). Direct and fast detection of neuronal activation in the human brain with diffusion MRI. Proceedings of the National Academy of Sciences, 103(21), 8263-8268.

3. Rutgers, D. R., Toulgoat, F., Cazejust, J., Fillard, P., Lasjaunias, P., & Ducreux, D. (2008). White matter abnormalities in mild traumatic brain injury: a diffusion tensor imaging study. American Journal of Neuroradiology, 29(3), 514-519.

About the Author

Desi Rotenberg, originally from Denver, Colorado, graduated with his bachelor's degree in 2012 from the University of Northern Colorado. He has been a BOC Certified Athletic Trainer since 2012 and earned his master's degree in Exercise Physiology from the University of Central Florida in 2014. He currently is a high school teacher, teaching anatomy/physiology and leadership development. Along with being a teacher, he wears many hats, such as basketball coach, curriculum developer and mentor. He has been a contributor to the BOC Blog since the summer of 2015. 

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Discussion and Research on Concussion Management

Thursday, October 6th, 2016

Posted October 6, 2016

Diane Sartanowicz,
MS, LAT, ATC

By Diane Sartanowicz, MS, LAT, ATC

With the start of the fall athletic season, much has been written about concussions. In the news and media, concussions are referred to as a public health crisis due to the increase in the number of diagnosed cases.  As Athletic Trainers (ATs), we are called upon as experts in the field of concussion management and are driving the research and discussion around this very hot topic. So why are there so many unanswered questions?

Some of it has to do with the definition of a concussion. The term concussion (or commotio cerebri) has been used for centuries to imply “a transient loss or alteration of consciousness without associated structural damage.”1 It is also known as a mild traumatic brain injury (mTBI) and can cause a variety of physical, cognitive and emotional symptoms. In recent years, concussion has been used most frequently in reference to sport-related head trauma.

Along with the struggle to come to a unified definition of concussion, another set of questions relates to the diagnosis of a concussion and the reporting rates. An estimated 1.7 million concussions occur each year in the United States as a result of sport and physical activity, and of those, 80 percent  are seen in an emergency room department. These numbers are staggering when almost half a million visits for mTBI are made annually by children aged 0 to 14 years.2  Many more concussed youth seek treatment through physicians’ offices or not at all.  So are these statistics accurate? We need to understand exactly what we are diagnosing in order to collect and track the data. Education on the signs and symptoms of a concussion is the key to successful outcomes for the athlete.

As a consequence of the multi-faceted issues facing youth sports concussions, programs like the Massachusetts Concussion Management Coalition (MCMC) are being established to address this issue.  MCMC is a group of individual stakeholders who are dedicated to the health and safety of our student-athletes. The broad range of groups like the Massachusetts Interscholastic Athletic Association (MIAA), Massachusetts School Nurse Organization, Athletic Trainers of Massachusetts (ATOM), Department of Public Health and the Brain Injury Center of Boston Children’s Hospital are represented and their top priority is to prevent and manage concussions.

MCMC is a pioneer in concussion research and education outreach bringing everyone together to collaborate on the best way to tackle the many issues surrounding concussions. Due to the generous funding by the NHL Alumni Foundation, MCMC has been able to provide free ImPACT™ neurocognitive testing to all MIAA member schools that enroll in the program. Along with the free testing, MCMC provides secondary schools with concussion education presentations to their communities. It is our goal to ensure tools are readily available for all secondary schools to be knowledgeable in the recognition, management and treatment of concussions. We hope to create a legacy of concussion education in the Commonwealth of Massachusetts which reflects these goals. For more information on our program or how to get involved, please visit our website at www.massconcussion.org.

As I write this blog, we have just completed a successful Concussion Awareness Week in Massachusetts. It is through the collaborative efforts of the Think Taylor Foundation and the MIAA that 86,000 student-athletes have become more engaged in the discussions surrounding concussions. Think Taylor was founded by Taylor Twellman, star forward for the New England Revolution soccer team. His career-ending concussion left him seeking answers and wanting to make an impact on the lives of student-athletes.

During Concussion Awareness Week, all student-athletes were encouraged to turn their school orange, the color of healing, and to take the TT Pledge. This pledge states, “I will become more educated on the signs and symptoms of concussions, I will be honest with my coaches, and Athletic Trainers, parents and teammates, and that I will be supportive of anyone with a concussion.” These 3 words – education, honesty, support – are what ATs embody every day. Our combined efforts lead the way to increased awareness and expanded concussion education across the state. I would encourage each of you to get involved in a movement like ours.

Resources

1 Charles H. Tator. Concussions and their consequences: current diagnosis, management and prevention, CMAJ. 2013 Aug 6; 185(11): 975–979

2 Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.

About the Author 

Diane Sartanowicz, MS, LAT, ATC is the Director of the MCMC.  She was president of ATOM from 2006-2008, past-president of Eastern Athletic Trainers’ Association from 2011-2012 and is currently the NATA District One Treasurer.

Concussion Baseline Assessments: What Should Clinicians Capture?

Monday, August 1st, 2016

Posted August 1, 2016

Nicole T. Wasylyk,
MSEd, LAT, ATC

By Nicole T. Wasylyk, MSEd, LAT, ATC

Traumatic brain injuries (TBIs) are an ever-prevalent topic in our society today, in part due to their high incidence rate. It’s estimated that 1.7 million Americans sustain a TBI each year.1 Diagnosing and managing TBIs can be a complex pathway. Clinical assessment of patients is key to diagnosis since there is currently no objective diagnostic tool to identify whether a patient has sustained a TBI.  Assessing a patient’s baseline is also key in the post-injury assessment and management process.

In order to craft the best clinical assessment to identify TBIs, we need to understand the key components that make up the assessment toolkit. A baseline assessment should consist of the following key components.2

Clinical History and Self-Reported Symptom Assessment

There are many useful tools clinicians can use to assess symptom number and severity. The most frequently used and researched tools include the Standardized Assessment of Concussion (SAC), Head Injury Scale, Graded Symptom Checklist, Brief Symptom Inventory 18 (BSI-18), Sport Concussion Assessment Tool Version 3 (SCAT3)3 and the Concussion Symptom Inventory. The SCAT, now in its 3rd version, is a useful tool that incorporates more than just a self-reported symptom scale. In 2012, a consensus statement was released by the International Conference on Concussion in Sport4 supporting the use of the SCAT3 and the Child SCAT3 (ages 5-12). 5

Physical Motor Control Testing

Assessing motor control can include any number of functional tests to assess gait, postural control, fine motor control or hand control and proprioception. Most commonly utilized tests include simple heel-toe gait observation and the Balance Error Scoring System (BESS). The BESS is a quick, portable and cost effective way to evaluate motor control. Although there is variability, the BESS has been found to be both a valid and reliable tool to assess motor control.6

Neurologic Exam

A neurologic exam should certainly be completed post injury. Baseline assessments most often do not demonstrate deficits but are helpful to perform for completion and practice’s sake.

Neurocognitive Testing

Computerized testing is the most frequently utilized form of neurocognitive testing. This type of testing is a comprehensive evaluation of specific domains such as memory, attention, problem solving, language, visuospatial and motor processing speed. Commonly used tests include the ImPACT test, Wisconsin Card Sort and King-Devick. There are numerous computerized tests to assess patients; it’s important to review and understand each of the domains the test seeks to evaluate and ensure it meets your patient population needs.

This leads us to the following question: What makes up the best baseline concussion assessment?

We do not yet have strong evidence to suggest the gold standard for clinical assessments. However, we do know that a combination of assessment tools, such as the SCAT3, which incorporates both a clinical history and self-reported symptom assessment and physical motor control testing, along with ImPACT testing is a robust way to evaluate patients. Almost all of the tests, aside from the computerized ones, are low cost, reliable, valid and easily implemented. They also carry little burden on both the clinician and the patient.

Recently the National Collegiate Athletic Association (NCAA) and the Department of Defensehave partnered together on a comprehensive study of concussions. This multi-center center study titled Concussion Research Initiative of the Grand Alliance7 will seek to answer questions on the etiology, evaluation, diagnosis and prevention of concussions. The study has 3 aims: to create a sustainable framework to achieve clinical and scientific research, to investigate the natural history of concussions, and to conduct advanced research that will integrate biomechanical, clinical, neuroimaging and genetic markers of injury to advance our understanding of TBIs.8

Hopefully there will be more information in the coming years regarding evidence based management of concussions. Currently, best practice is to utilize a multimodal approach to assess and manage concussions. This includes symptom assessment, physical motor control testing, neurologic exam and neurocognitive testing if available.

Resources

1. Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med. 2011 Jan;30(1):1-17, vii.

2 .https://www.nata.org/sites/default/files/Concussion_Management_Position_Statement.pdf

3. 4. SCAT3: http://bjsm.bmj.com/content/47/5/259.full.pdf

5. McCrory P, Meeuwisse WH, 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 Apr;47(5):250-8.

6. Child SCAT3: http://bjsm.bmj.com/content/47/5/263.full.pdf

7. Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health. 2011 May;3(3):287-95. PubMed PMID: 23016020;

8. http://www.careconsortium.net/research/

9. http://www.cdc.gov/traumaticbraininjury/basics.html

About the Author

Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection. 

 

After a Concussion, Watch for Red Flags

Friday, May 6th, 2016

Posted May 6, 2016

By Mackenzie Simmons, ATC

Over the past decade, there has been increased awareness about concussions in sports and other athletic activities. As the number of Athletic Trainers (ATs) has grown in a variety of settings, the rate of concussions has gradually increased as well. This is partially due to the fact that ATs are educated extensively in concussions, including baseline testing, diagnosis and return-to-play protocols. We are on the sidelines at many sporting events, which allows us to witness the traumatic impacts that cause concussions. We are trained in multiple testing systems that allow us to compare baseline scores to post-impact scores and educated in return-to-play guidelines that gradually allow an athlete to increase activity without stressing the brain.

Concussion symptoms will differ from athlete to athlete. While there are standard signs and symptoms for concussions, there are certain symptoms that warrant a more serious injury. There are several red flags that will indicate that the injury is more than just a concussion:

- Deterioration of neurological function

- Decreasing level of consciousness

- Decreasing or irregular respirations or pulse

- Unequal, unreactive, or dilated pupils

- Skull fracture (including cerebrospinal fluid from the nose or ears)

- Decreasing mental status and seizures

If an athlete presents with any of these aforementioned behaviors, he or she needs to immediately be referred to a physician. The athlete may have a secondary injury, including subdural hematoma, epidural hematoma, skull fracture or a cerebral contusion. Be thorough when evaluating for a concussion to ensure that these life-threatening injuries are handled appropriately.

 

Top 5 Hockey Injuries

Thursday, February 18th, 2016

Posted February 18, 2016

Mike McKenney
MS, ATC

By Mike McKenney, MS, ATC

Ice hockey is a sport often defined not only by its fast-paced action, but also by the injuries that result from contact between players or being hit into the boards. Specific injuries and their occurrence vary between men’s and women’s hockey, youth hockey compared to adult and professional compared to amateur levels of play. However, there are common injuries that routinely occur at all levels of play.

Groin Strains

One of the most frequently encountered injuries in ice hockey is groin strains. Numerous pre-disposing factors for this condition have been suggested in the literature.   However, there seems to be more widespread agreement that they are a result of imbalances between abduction and adduction muscle strength at the hip, in addition to having a prior history of adductor injury.1 Skating in hockey is unique and unlike any other athletic movement in sports. As a result, the demands placed on the pelvis and hip are often difficult to manage once injury has occurred. Adductor strength and control are needed in order to help support the pelvis through the transition of one leg to the other while skating. During a stride, players will briefly load both hips simultaneously as they are transitioning from one leg to the other for their next stride. Loss of pelvic control through the adductor will result in injury during this transitional movement.

Structural knee injuries

In a contact sport such as ice hockey, knee injuries are bound to happen. However, it is rare that these injuries result from non-contact activity as seen in other sports like basketball or soccer. If a ligament is involved, it is typically the result of someone falling on an opponent’s leg, sustaining knee-on-knee contact or a player’s skate being caught on the ice as they are hit in their upper-body. The exception to these occurrences are goaltenders who can experience medical collateral ligament (MCL) and meniscus injuries due to the unique nature of their position and the commonly used butterfly style of goaltending, which puts additional stress on those structures.

Acromioclavicular Joint Injury

Similar to other contact sports, injury to the Acromioclavicular joint or AC joint is a common occurrence in ice hockey, and tends to happen more when players are old enough to begin body-checking.2 What is deemed a legal body-check at most levels of play subsequently places the AC joint in a position to absorb a significant amount of force with shoulder to shoulder contact. This is especially true when a player is hit into the boards with their arm positioned across the body. For hits that are more straight-on, the clavicle is placed at a higher risk with the possibility of disrupting its role in the AC joint should a fracture occur.

Concussion

Even though leagues at all levels are taking steps to remove intentional head-contact from the game, the risk of concussion is still present. Interestingly, according to NCAA injury surveillance data for women’s ice hockey, concussions account for up to 22% of injury in games and 13% of injuries sustained in practice.3 This is much higher than what is reported for men at the same level.4 However, the inverse is true at the youth levels where the occurrence of concussion in boys’ high school hockey is only second to high school football.5 This widespread occurrence supports the continued need for Athletic Trainers to be vigilant in their recognition and appropriate treatment of athletes who sustain a concussion.

Contusion

In a sport where a frozen rubber disk routinely travels at high rates of speed, it is not surprising that contusions are a common injury, particularly to the lower extremity, foot and ankle when the puck is shot into a crowd of people. Additionally, upper extremity contusions are often the result of players getting cross-checked or slashed by another player’s stick. For those who don’t watch hockey regularly, this behavior is supposed to be penalized, but far too often is not.

Resources:

1. Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.

2. Hagel BE et al. Effect of bodychecking on injury rates among minor ice hockey players. Can Med Assoc J. 2006;175(2):155-160.

3. Agel J, Dick R, Nelson B, Marshall SW, Dompier TP. Descriptive epidemiology of collegiate women’s ice hockey injuries: national collegiate athletic association injury surveillance system, 2000-2001 through 2003-2004. J Athl Train. 2007;42(2):249-254.

4. Agel J, Dompier TP, Dick R, Marshall SW. Descriptive epidemiology of collegiate men’s ice hockey injuries: national collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. J Athl Train. 2007;42(2):241-248.

5. Marar M, Mcllvain N. Fields SK, Comstock RD. Epidemiology of concussions among united states high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747-755.

“Concussion” – A Movie Review from an Athletic Trainer’s Perspective

Friday, February 12th, 2016

Posted February 12, 2016

By Claudia Curtis, MS, LAT, ATC

As a moviegoer, I found “Concussion” to be very well done. The plot flowed well, did not feel too drawn out and the acting was superb. Will Smith did an excellent job portraying the main character, Dr. Bennet Omalu, taking you on his journey and making you feel what he felt.  It gave insight into what was happening behind the scenes for years regarding chronic traumatic encephalopathy (CTE) before the American public was aware of the situation. The movie was produced in a way to keep all kinds of viewers engaged, science for the healthcare professionals, game footage for the sports enthusiasts. The footage shows a lot of big hits, frequently without proper technique. In terms of a cinematic experience, I was pleased with my movie choice.

However, as an Athletic Trainer (AT), how did I feel watching “Concussion?” First and foremost, I was horrified at the way  ATs were portrayed in the movie. This movie focused mainly on the neuroanatomy and the discovery of CTE, not necessarily something  Athletic Trainers have a role in. However, there is one scene where “trainers” are mentioned, and it is done in a rather ignorant way. The scene discusses the fact that the NFL did research prior to Dr. Omalu regarding the presence of CTE.  However, the “researchers” named on the study were a rheumatologist, an equipment manager and a “trainer.” The response to that comment was, “Don’t they just tape knees?” This is a pretty large stage for our profession to be improperly represented, leaving a bitter taste in my mouth that lingers even now.

The impressions I took from this movie span far beyond that one scene though. This movie made me feel a variety of emotions: sympathy, anger, fear and confusion to name a few, alternating throughout the scenes. The person I saw the movie with, a non-healthcare professional, after the movie said, “I wish they had given us more information about what’s been learned since this all started.”

What I realized is that there aren’t a lot more answers right now, but rather that more questions have developed with time and research. How many years of impacts might cause CTE? Does it matter the level of sport played (high school vs. college or professional sports)? Does it matter if consciousness was lost? Are we doing the right thing to prevent this in our concussion recovery programs? Will these concussion return protocols prevent CTE?

I could probably fill an entire page with questions. There is one I’m still asking myself: Is this movie enough to convince high school kids of the real danger that concealing concussions could have long term?

I am Thankful to be an Athletic Trainer – Part 3

Wednesday, December 30th, 2015

Editor’s Note: Being thankful and celebrating the good things in life are very much a part of this time of year.  As year-end approaches, it’s important to look back and review your achievements and be proud of your accomplishments.  In this series, our BOC guest writers take a look back to at their career as Athletic Trainers and share their stories on what makes them feel thankful to be in this profession. 

 

Amazing Experiences as an Athletic Trainer

By Brian Bradley, MS, LAT, ATC, CSCS

I am thankful to be an AT because of all of the amazing experiences I have had throughout the years.  I have worked at a professional baseball game in Fenway Park, covered NCAA National Championships and worked at other events while watching Olympic athletes compete.  I have been able to share in a team’s state championship success and console an athlete after a devastating defeat.  I have helped patch an athlete up, so they can play one last time on Senior Night.  I have also helped to rehab a grandmother so she can play with her grandson.  I have had a lot of amazing experiences thanks to the athletic training profession.

 

A Moment of Gratitude

Claudia Curtis, MS, LAT, ATC

Claudia.curtis@phci.org

As a ATs, we take pride in seeing our athletes return from significant time loss injuries to compete and have success, even win state or national championships.  We rejoice with them in their successes, and we share in their sorrow when success isn’t achieved.  We’re used to delivering the news that their season may be over, but what do we do when we fear their career might be over?

In the fall of 2013, I found myself in unfamiliar territory.  The starting quarterback on the team had suffered a concussion ending his previous football season.  This one presented with neurological symptoms that particularly concerned me, leading me to push him toward a specialist.  After further referrals, he was cleared, and his role on the field changed to protect him.  However, the first day of contact in the season, the neurological symptoms came back on a routine tackle.  As quickly as they presented, they resolved, but they sent my mind reeling.  What if the next hit leaves him paralyzed? What if one seemingly routine football play changes his life forever?

So he and I sat down in the athletic training facility and talked one on one.  He had aspirations of being a police officer but thought his only way of getting into college was through football.  We discussed all of the risks and consequences football could have not only on his future goals, but also in his everyday life, his relationships and his independence.  I thought he understood the potential danger that playing football with his diagnosis, cervical spinal stenosis, could have on his life.  I felt I may have eased his mind about ways to achieve his professional goals without football.  However, I didn’t feel that I was really able to empathize with what he was going through in the best way possible, only sympathize.  So I took a giant leap of faith.

This situation came up at the same time ESPN ran the special “The Book of Manning.” Those familiar will remember that Cooper Manning, the one Manning to not play professional football. Manning had the same diagnosis as my patient and has been highly successful in his post-football professional career.  So, I did some internet digging and sent him an email, looking for guidance on how to support my athlete.  I sent the email on a Friday evening: a desperate plea for any advice.  I knew it was a long shot and didn’t anticipate any response.  However, Monday morning when I got to work, I already had a voicemail on the phone in the athletic training facility.  It was Cooper Manning, calling to discuss the situation.  After a short phone call with Cooper, he asked me if I thought the athlete might like to talk to him on the phone, which I knew he would. The call was then scheduled for that evening.

The next day, the athlete came into the athletic training room and immediately gave me a huge hug, saying the words “Thank you so much. That’s the nicest thing anyone has ever done for me.”

That moment, one of gratitude in what may have felt like the worst of situations at the time, was the moment for me when I forgot all of the negatives about my job and remember exactly why I got into athletic training in the first place … and why I continue to have the passion for it every day.

Our Brain is the Key to Longevity: Sub-concussive Force and Chronic Trauma

Friday, October 16th, 2015

By Desi Rotenberg, MS,  LAT, ATC

The human brain is one of the most studied aspects in existence today, and yet, we are only able to scratch the surface of how it really works.  With its overwhelming complexity, researchers are constantly on the lookout for methods to understand, treat and predict the various symptoms that can be associated with disruption of normal cerebral and neurological functioning.  What we do know is the human brain is vulnerable and fragile.  While the brain may hold the secrets to our existence and can take a lifetime to develop into its full potential, it only takes a momentary physical trauma for everything to change.

Concussions and traumatic brain injuries continue to be a hot topic amidst the athletic population and will continue to be on the forefront of research and medicine, as long as human beings strive to test the limits and durability of the human body.  The ugly truth about athletics and sports as a whole is the risk of altered cognitive functioning following a hit to the head. While most athletes will tell you the consequences of brain damage are unlikely, as a professional, I believe is it our responsibility to educate and prepare for these unlikely events.

I am reminded of the story of Pat Grange, a professional soccer player who was diagnosed with Chronic Traumatic Encephalopathy (CTE) at age 29, and subsequently lost his life to amyotrophic lateral sclerosis (ALS).  His brain was later donated to the Boston University VA.  Analysis revealed stage 2 (out of 4) on the CTE Severity Scale.  Up until his death, no one really considered soccer a high-risk sport when it came to chronic brain injuries.  From this examination and that of the countless others who donated their brains to science, medical research continues to raise the understanding that the human brain can only handle a certain amount of trauma on a day-to-day basis before it begins to degenerate from the inside out.

Occasionally, a player will suffer a concussion from knocking into an opponent’s head while going up for a ball.  However, what we seem to overlook is the number of times soccer players may use their heads during a single practice.  Is it possible that sub-concussive, low-force hits to the head may cause CTE?

A soccer player practicing headers through the course of a single season may have knocked their head over a thousand times.  Similarly, an offensive lineman who undergoes sub-concussive hits to the head for 4 straight months may not understand the damage that is occurring.  While these blows to the head may not produce clinically positive concussive symptoms, further research may reveal sub-clinical, chronic trauma to the head that could elicit long-term breakdown and scarring of brain tissue.  While correlation does not equal causation, we cannot overlook the fact that the human brain may be susceptible to long-term, low-force trauma.

As Athletic Trainers working at the high school level, we simply cannot take any chances when it comes to the developing brain.  Student athletes have their whole lives ahead of them, and while athletic competition is important, we must always remember the future of our athletes should never be sacrificed for a single practice or game.

Source: Johna Register-Mihalik, PhD, ATC, LAT

Instead, when it comes to head injuries, we must take into account the aspects of life that are going to be affected by the injury.  While the academic and extracurricular effects are obvious, we must not overlook the social and behavioral changes that also can occur.

Behavioral changes can affect interactions with family and friends and can often affect an individual’s ability to feel connected at home, at school and in the locker room.  Additionally, if an individual has any type of anxiety disorder or cognitive disorder, the individual’s recovery time may be slowed, or even negatively affected.

As medical professionals on the front lines, we are the first line of defense when it comes to protecting the futures of young athletes.  If a student athlete were to come to me in the middle of a game and say, “I was hit in the head and I have a headache,” concussion protocol states  the athlete should be removed from play.  However, I would continue to hold the athlete out of the game, regardless if the athlete were to tell me that their headache has remitted.

The brain is malleable and delicate, and we must do our part to ensure young athletes are not being exposed to chronic, sub-concussive blows to the head at a time when the brain is still developing.  As we saw in the case of Pat Grange and many other individuals before him, long term, low-force trauma to the head may prove to be disastrous later in life.

Resources

Branche, J. (2014, February 26). Brain Trauma Extends to the Soccer Field. The New York Times. Retrieved from http://www.nytimes.com/2014/02/27/sports/soccer/researchers-find-brain-trauma-disease-in-a-soccer-player.html?_r=0

McKee, A. C., Cantu, R. C., Nowinski, C. J., Hedley-Whyte, E. T., Gavett, B. E., Budson, A. E., ... & Stern, R. A. (2009). Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. Journal of neuropathology and experimental neurology, 68(7), 709.

Register-Mihalik, J., Guskiewicz, K. M., Mann, J. D., & Shields, E. W. (2007). The effects of headache on clinical measures of neurocognitive function. Clinical Journal of Sport Medicine, 17(4), 282-288.

In-Depth Look: Meet an Athletic Trainer for an NFL Team

Thursday, September 24th, 2015

T. Pepper Burruss is the Director of Sports Medicine Administration and Athletic Trainer/Physical Therapist for the Green Bay Packers.

Describe your setting:

Our athletic training facility was recently renovated, and we have only been in it since July.  It includes an expanded treatment area, functional rehabilitation area, recovery room, examination rooms, GE iDXA body scan room, digital X-ray room, 4 Athletic Trainer offices, conference room, hydrotherapy room with 2 walk-in hot tubs and a walk-in 4 x 16 cold tub, and a SwimEx rehabilitation pool - all surrounded by 11-foot tall walls of glass.  You can never have enough storage space, but we’ve been very fortunate to have an attached 2-level stock/work room that accommodates all of our supplies as well as our array of travel trunks, last but not least, an ice machine/cooler storage room.

In 2013, we were fortunate to have an addition to our building that houses a 10,000-square-foot weight room and an adjacent regulation width indoor 35-yard in-filled field. The addition, called the Conditioning, Rehabilitation and Instructional Center (CRIC), is a valued adjunct to our strength and conditioning program and to our rehabilitation regimes.

How long have you worked in this setting?

This is my 39th season in the National Football League (NFL). I spent the last 23 seasons with the Green Bay Packers and the first 16 with the New York Jets.  I trace my career path to the choice to move from New York state to attend Purdue University under the legendary NATA Hall of Famer, William “Pinky” Newell.

As I was leaving high school in 1972, a chance encounter made me aware of the many Purdue graduates with influential athletic training jobs all across the country.  Several of those were in the NFL, which I had my sights set on at a very early age.  With that, I decided I needed to be mentored by the best; after all, Pinky was known to have the most high profile job opportunities come across his desk.

It was 800 miles from my New York state hometown to Purdue University.  Pinky wrote to me (I think I still have the hand written letter) that it was an awful long way for an out-of-state student, and he couldn’t guarantee me a spot in the athletic training facility.  I wrote back that I was coming.  Years later Pinky confided that my decision to make the trek showed I was determined and willing to put my money where my mouth was.

After Purdue, I chose to attend Northwestern University Medical School to receive my second bachelor’s degree in physical therapy.  Then, eight weeks prior to my graduation from Northwestern, I received a call from Bob Reese, the new Head AT of the New York Jets and 1970 Purdue alumni. He asked if I wanted to be the Assistant Athletic Trainer of the Jets. Keep in mind, this is my home state and “my” team growing up. Bob and I had met in 1972 when I was considering attending Boston College, where he was employed as the youngest Head AT in Division 1 football. Years later, Bob made a call to Pinky seeking a recommendation of a Purdue grad he might hire, and as they say, “the rest is history.”

I spent 16 seasons with the New York Jets as an Assistant AT.  In 1991, the Jets Director of Player Personnel, Ron Wolf (2015 NFL Hall of Fame inductee) became the general manager of the Green Bay Packers.  He called me in early 1992 and asked me if I would be interested in becoming the Head AT of the Green Bay Packers after the late Dominic Gentile retired.  I wasn’t quick to jump at the offer, as the Packers had been through a rough stretch of 25 years of mediocrity.  (I also thought it was truly the “frozen tundra” with more snow than grass.)  Several months later, I decided this was the right decision for my family.  Dominic retired after the 1992 season, and I joined the Green Bay Packers January 1, 1993.

Describe your typical day:

My typical day is the same as most any full-time AT working the “daily grind.”  We come in when it’s dark, and we leave when it’s dark.  There is not a typical day as each has its varied challenges depending the time of year, intensity of the week and a never-ending administrative load.  I firmly believe all ATs feel an unceasing commitment to try to get the job done every day.  Over the years, I’ve learned that it is never done. We could work 24/7, and we’d never get everything done because healthcare is never done.  Sadly, athletic training is not a 9-to-5 job. It’s a serious commitment. Those who passionately embrace it succeed.

So many things are happening:

With the exponential pace of technological advancements, the athletic training world rides along.  It makes for an exciting time, and future, as the technological growth advances our techniques, overall attitudes and initiatives.

Technological advances become tangible through diagnostics, enhanced MRI and digital X-ray systems (now retrievable on the sideline), concussion and helmet studies, foot/ankle/turf interface advancements, computer enhanced modalities, infectious disease control, rehabilitation techniques, injury statistical/video analysis, bracing and protective gear enhancements, electronic health records (EHRs), telemedicine diagnostics and more.

National initiatives, by the likes of the Centers for Disease Control and Prevention (CDC) and multiple professional sports leagues, make us more introspective about how we go about our business.  Such initiatives address concussion care (as with the Zack Lystedt Law), acute spine injury protocol reviews and DEA enforcement of controlled medications with athletic teams. It is no longer “business as usual.”  We’re looking to evidence based research to refine everything we do in, and about, the athletic training facility.  It becomes evident athletic medicine is no longer just local, it is national and international.

In the early 70s, Pinky dreamed of an endowed NATA scholarship, and now there are dozens.  He was excited to welcome the first female member of the NATA, and now women are our majority. They are past presidents, executive directors and employed in many male-dominated sports.

To think, I look back at “computer, arthroscopy and MRI” as the major advancements in my time.  What will be your “computer, arthroscopy and MRI” to look back on and say, “Wow, how far have we come and how far will we go?”

Athletic Trainers contribute significantly to making football safer, but it is inherently a collision sport. We cannot eliminate injuries.  People say to me, “Keep ‘em healthy.”  I respond, “That’s God’s work; I just do the helpin’.” If we are going to take credit for a team being healthy, we better be ready to assume credit when they are not.  I choose not to take any credit.  If you are going to take credit for the good, you better take credit for the bad too.

What do you like about your position?

Game day is undoubtedly the “glitz and glimmer” of the NFL.  Game days are special. They’re electric. The more important the game, the bigger the “high” is of a win – or the lower the “low” of a loss.

For anyone who has ever been in a fraternal group – like with the military, police, firefighters or various teams – there is nothing compared to the relationships you build in the locker room.  There is not a player who retires from the game who says they miss lifting weights, being sore and getting beat up.  They always say, “I’m going to miss the locker room.”  You can’t help but appreciate the people and relationships.  I love being relevant and included as a part of the locker room.

I think there is an inherent ego that comes with the glitzy jobs, whether they are in with a big-time college, professional team or the Olympics. It’s just an honor to be a part of it.  There is something to be said for the NFL – the travel, resources, budget, glitz and glamour – and I believe it can become addicting.

You never grow tired of walking out of the stadium tunnel, listening to the home-field introductions and the national anthem being played. It’s a super rush if there is a military fly-over!  It wasn’t until last season, after 37 years in the league, that I realized something. Packers Equipment Manager Gordon “Red” Batty and I were out on the field during a timeout, when he said to me, “Pepper, think about this. None of those people on the sidelines can walk out into the middle of the field during a game, and you and I can. How fortunate are we?”  I had never thought of it that way before.  The assistant coach, video staff, security or ball boys cannot venture out into the middle of the field.  It falls under the moniker of nothing compares to game day.  Sometimes you fail to realize how good you have it; I’ve been very, very, very fortunate.

What do you dislike about your position?

I’ve said this a thousand times; my least favorite part of the job is the grind of the hours.  With the typical hours an Athletic Trainer works, it takes a concerted effort to maintain some normalcy to family/home and leisure life.

I would say another thing that I find challenging is the vast corporate world of the NFL.  The players have multimillion dollar salaries.  I struggle with the politics of dealing with all that comes from an entourage of agents, medical consultants and caregivers who advise and direct the players beyond our concerted efforts.  Many of these folks have nothing more than a business relationship with the player, yet, in season, we spend more waking hours with them than we do our own families.  The pressure on the players gives rise to a challenge of balancing the many outside influences their personal medical advisors bring to the table in relation to the care rendered in our facility.

What advice do you have about your practice setting for a young AT looking at this setting?

Choose the best school that fits your circumstances.  Build an impressive résumé and network with people in your chosen field.  I started my career by choosing a school that featured a pioneer in the athletic training field.  I was able to build and develop the skill set that helped shape me for the profession and the career I sought.

I tried to never turn down an opportunity to build my résumé through volunteering, taking an additional class or seeking insightful experiences. Students and young ATs need to understand there is mega competition for the glitzy jobs. There are many bright, highly educated students, but so many of the résumés look exactly the same.  I think a goal for a young AT should be to make their résumé likely to move from the big pile to the small pile.  You have to seek people who can advise you how to best accomplish that.  It is not by having the fanciest paper with the designer font.  It’s by having loads of experiences in and out of your desired field/profession that makes your résumé pop.

Every year, we receive piles of résumés from students and professionals who are applying to be a summer or seasonal intern.  My preference is that the résumé not be in a tiny font to make it all fit on a page.  I am not a proponent of the 1-page résumé.  If your hobbies, interests and voluntary efforts could move your résumé from the big pile to the small pile, isn’t that worth an additional page?

Little mistakes can also make a big difference in the review of a cover letter and résumé.  We get letters via surface mail that have not been signed.  I understand that void with emails, but not taking the time to sign a hardcopy is a mistake.  Maybe it’s a small thing, but it is attention to detail and it catches my eye.  The ultimate transgression is a mismanaged mail merge that combines a staff member’s name with the wrong team name.  Proofread your letter and make sure you have the correct information included.

Certainly you can’t understate the need to network.  There is no better place to network than your local, state, district and national NATA meetings.  Realize the classmate or AT intern you sat next to in a lecture hall may one day be in a position to recommend, or even hire you, for a job. You cannot afford to be short-sighted about networking, meeting other students, competitors and show exhibitors. Take the time to put a name and handshake with a face.

Résumé references are important and especially good if they happen to be known to the staff you are applying to for a position or internship. For a potential employer to know a reference by name and reputation puts some “oomph” to their recommendation.  Some of the teams give preference and geographic loyalty to in-state institutions, whereas some offer opportunities to those from around the country.  Just take the time to construct your letter and résumé in such a way it has a better-than-average chance to move from the big pile to the small pile.

Don’t set your sights on attaining “average.”  That just means you are better than some folks, but a batch of folks are better than you.  Lastly, don’t set you goals too low; you are liable to reach them!

 

 

King-Devick Test Follow Up: Science vs. Media

Thursday, September 10th, 2015

Claudia Percifield, MS, ATC

The King-Devick Test for Concussion Evaluation has quickly been gaining popularity in the news.  A simple Google search for King-Devick Test will pull up pages upon pages of articles and blogs written just in the month of August alone.

Initially, media outlets were calling for it to be the answer to concussion testing. They sensationalized the speed and ease with which it could be administered, stated minimal training is involved in administering the test and boasted about the percentage of concussions it could correctly diagnose.  As a healthcare professional taught to critically evaluate research and not take things at face value, I was extremely skeptical.

My first thought was, “Would we as clinicians throw out every special test we had used for decades to evaluate ankle sprains if someone wrote a few news articles about 1 new quick test that could replace all ankle tests currently in practice?” This thought led to my first post, which can be found here.

News articles focused on promoting it as the test rather than as an additional resource. They promoted the use in situations where no Athletic Trainer may be present, while inferring those administering the test would in fact be diagnosing the test.  All of these things concerned me.

After my initial post, I was contacted by Danielle Leong, OD, FAAO, Senior Director of Research with King-Devick Test to discuss my article.  In light of our conversation, I was inspired to debunk myths and shine light on what may be a more scientific way to look at the test and the current research.  Leong spent time explaining from a neurological perspective the multiple cortexes the King-Devick Test evaluates during the exam, in addition to hitting the cerebellum and brain stem.

This test was previously used on military patients with traumatic brain injury (TBI). In this research, testers microscopically examined their patients’ eye movements and saw abnormalities in the movement patterns, leading to further research.  The size of the numbers used in testing are at a 20/100 level, minimizing the effect that not wearing corrective lenses could have on the exam.

Leong was quick to mention that while the King-Devick Test is able to be administered quickly and easily with minimal training, it is meant to be a screening tool, not a standalone resource for diagnosing concussion. She said non-healthcare professionals administering the test (especially in youth sports), should immediately remove these athletes from play and refer them to the appropriate healthcare professional for further evaluation, NOT diagnose these athletes as having a concussion.

Most notable to me, she cited a University of Florida study1 that examined the percentages of concussions captured using the King-Devick Test alone (79%); a modified SCAT3 that included the SAC, symptom checklist and the BESS alone (50%); and encompassing all testing (100%).  This study most directly addresses the call to incorporate both exams into our sideline arsenal to protect our athletes. Again, it’s one retrospective research study, but it is one with compelling results. Out of everything I’ve read and heard in researching for both of my posts, this is what stood out to me the most.  This is what calls me clinically to evaluate my methods of examination for concussion as I go forward in my clinical practice.

Science vs. Media. It’s a powerful thing these days; they can paint 2 different pictures.

Resource

1 Marinides Z, Galetta KM, Andrews CN, et al. Vision Testing is Additive to the Sideline Assessment of Sports-Related Concussion. Neurology: Clinical Practice. July 2014.