Alphabet Soup: Concussion Assessment in Youth

alphabet soup 1

Chicken soup: good for the soul….good for concussion? Photo: strawberryblues Wikimedia

SCAT2, SCAT3, Child-SCAT 3, SAC, BESS…….as those of us in sports medicine know, concussion assessments have become an alphabet soup!

Our July 2015 edition of CJSM contains an interesting study looking at baseline SCAT2 assessments of healthy youth student-athletes; it also included some preliminary evidence for the use of the Child-SCAT3 in children younger than 13.

The 4th International Consensus Statement on Concussion in Sport introduced the SCAT3 and Child-SCAT3 instruments.  The Child-SCAT3, in particular, was a significant advancement as there had been no pre-existing instrument for pediatric concussion assessments prior to the 2012 Zurich conference.  If you have not ever looked the Child-SCAT3 over, take the chance now by going to the freely available consensus statement–the Child-SCAT3 PDF is readily downloadable.  Among the differences between the SCAT3 and Child-SCAT3:  a different set of Maddocks questions (is it before or after lunch?); days of the week (as opposed to months of the year) in reverse order; a parent- as well as a self-assessment of symptoms (and the self-assessment is written in more age appropriate language).

Throughout the year, but especially at this time of year (late summer–football has begun) we do assessments like this for the large number of kids we see with concussions or suspected concussions.   Read more of this post

‘Energy Balance’ in the news

coke workout

He ain’t heavy, he’s my brother…..

The ‘Coke Wars’ have been raging for a week.

I read with great interest a recent piece in the New York Times – “Coca Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets.”  It’s been making the rounds on mainstream and social media–there has been a vigorous back and forth on Twitter.  You may already be very familiar with the story.  The ‘Letters to the NY Times Editor’ were overwhelmingly negative, suggesting that the researchers in the article were in the pockets of industry.

There were several dimensions to this story that intrigued me, and so I thought it would be a good piece to discuss here on the blog.  Reading Brian McFadden’s Strip in the Sunday’s NY Times, the ‘Sugar Water Workout,‘ finally got me on the laptop.  I’m a big fan of McFadden’s irreverent strips, though in this case I think– as i do about several of the discussions I’ve seen regarding this issue in the media–he has over-simplified a contentious issue to get some laughs.

Up front, let me share with you my opinions about this matter.  Then I’ll wend my way back to some of these comments to touch on what I think is a valid point the article makes and some thoughts about transparency in health care research.

My thoughts on reading the NY Times story:

  1. To achieve weight loss, an individual must restrict caloric intake.  There is a great deal of discussion about the ‘ideal diet,’ but the key is reducing calories–vegan, paleo, low carb, however one does it, reduce the ‘calories in’.   The history of dietary fads is a long one, but the most important principles are not the choice of diet as much as i)reducing intake and ii) maintaining these new habits over time.  To the extent my patients may consume a lot of carbonated soda, I have them identify that as the source of their unessential ‘extra’ calories and eliminate that from their diet while they work on other lifestyle changes as well.
  2. That said, there is an overwhelming body of evidence that ‘Exercise is Medicine.’*  Put another way, achieving weight loss is many people’s goal.  But it is usually not their only health goal, nor should it be the sole goal we clinicians in sports and exercise medicine will be working on with our patients.  Increasing physical activity and exercise has a host of benefits that cannot be achieved by diet alone.  For instance, improvements in knee osteoarthritis are seen more with diet change and weight loss than exercise; but the combination of exercise and dietary changes provides the most benefit to these patients.  And to pick one more of several studies I could point out, our ‘fellow travelers’ at BJSM recently published a meta-analysis on HIIT in adolescents and found these exercise interventions (not accompanied with dietary changes) can achieve significant improvements not only in cardiorespiratory fitness but also body composition (BMI and body fat).
  3. Therefore, I think it is something of a ‘Hobson’s choice’ to ask which is more important:  diet or exercise?  It’s not a ‘zero sum’ game. Diet & Exercise go hand in glove, they are complementary.  Most of us, and most of the patients we care for, need to address both parts of the equation.  The sedentary lifestyles we increasingly lead are one of the great public health crises of our time. With some irony, I think a debate that pits diet vs. exercise is a bit like the fanciful argument Lite beer used to have with itself:tastes great….no, less filling!  Tastes great!  Less Filling!!!!


    The stairs can be lonely in the modern world.

  4. The biggest misstep the scientists made as described in the article was an initial lack of transparency.  The Global Energy Balance Network (GEBN) with which the researchers are affiliated gets substantial funding from Coca Cola. There is clear potential for bias.  Scientists affiliated with this Network must be as transparent as possible.  On the GEBN website, this at first, apparently, was not the case.
  5. Finally, Social media can ramp things up to a fever pitch–it births viral memes and creates chatter that can overwhelm rational discussion.  Some of the criticism of the scientists and the science in the NY Times article is valid; much of it has descended to ad hominem attacks and is not constructive.  As someone who is involved both in the research and social media ends of clinical sports medicine, I would say the social media aspects of this story have overwhelmed rational discussion.

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Team Physicians: On your mark, get set….go!



The sidelines–where so many of us like to be.

It’s still full-on summer in North America. The temps can exceed 40 C (104 F) in some parts, and the geese haven’t flown anywhere…..but fall is in the air, as team sports are in the midst of two-a-days and the hitting has begun! My clinics have shown an uptick in patient numbers, as the injured are trickling in. I have yet to stand on a sideline, but will do so in two weeks. It’s a good time to review the Team Physician Consensus Statement (see below) published a couple of years ago.

From the challenges of making real-time, sideline decisions regarding our athletes to the development of emergency action plans, those of us in clinical sports medicine will find a lot to help us in this statement.  In CJSM we have published over the years several manuscripts of great importance to the team doc.  We have explored whether return to play decisions are the responsibility ultimately of the team physician to variation in physician practice in those return to play decisions to more.  On this blog, we’ve covered the spectrum with interviews of team physicians from the Ohio State Buckeyes (Jim Borchers) to the Michigan Wolverines (Bruce Miller)…….

The health and welfare of our athletes is our primary obligation; in keeping our eye on this ‘ball’ there are several others we need to juggle–the needs of the team, the decisions of coaches and managers, the desires of parents if we are taking care of youth athletes……As our seasons progress, be sure to follow us here on the blog and on twitter @cjsmonline. And stay tuned to for studies released ahead of print, our ever-growing body of podcasts. We will try to help you navigate this juggling act.  All the best!

Originally posted on Clinical Journal of Sport Medicine Blog:

Earlier this week, several sports medicine organizations released a statement with which all sports medicine clinicians should familiarize themselves:  the “Team Physician Consensus Statement:  2013 Update.”

The Statement represents, in its own words, “…an ongoing project-based alliance” of the major professional associations associated with sports medicine  in the United States.  These include the American Academy of FamilyPhysicians (AAFP), the American Academy of Orthopaedic Surgons (AAOS), the American College of Sports Medicine (ACSM), the American Orthopaedic Society for Sports Medicine (AOSSM), the American Osteopathic Academy of Sports Medicine (AOASM), and this journal’s affiliated professional group, the American Medical Society for Sports Medicine (AMSSM).

This is an update of a statement first published in 2000.  It includes sections which define the role of ‘team physician’;  describe the requisite education and qualifications; enumerate the medical and adminstrative duties and responsibilities; and explore the relevant ethical and medicolegal issues.

The entire statement is worth a read, but I find…

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Football. Texas style.

grand prairie texas weather

It’s big–and HOT–in Texas.

The Lone Start state, in August.  Grand Prairie, Texas–next to Arlington, within sight of Cowboy Stadium (alright, so it’s officially AT&T stadium).  Deep in the heart and soul of American Football, that’s where my month began.

In addition to being an Associate Editor of CJSM, one of the hats I wear is as a Director sitting on the Board of a non-profit youth sport safety advocacy group, MomsTeam Institute. Yesterday, I participated in the group’s outreach to a youth football organization in Texas:  the Grand Prairie Youth Football Assocation (GPYFA).  The Chief Executive of MomsTeam, Brooke deLench, has organized a week long session to address issues of football and cheerleading safety; this week is preparatory to longitudinal work including injury surveillance to determine if certain interventions can lower injury rates in the 1000+ youth athletes participating in GPYFA sports.  Brooke has coined the term “SmartTeams, PlaySafe” to emphasize the important role education, knowledge transfer, and implementation can play in the world of youth sports.

Yesterday, I was one of a few individuals speaking to the coaches and parents of GPYFA.  My charge was to talk about preventing and identifying heat illness and overuse injuries, and review the pre-participation evaluation (PPE) with the assembled crowd.

s grand prairie hs weight room

The weight room in South Grand Prairie High School It’s superior to a lot of college facilities I have seen.

The venue was South Grand Prairie High School, a magnificent structure with a beautiful, large auditorium, and just around the corner a magnificent and huge weight room and indoor turf facility. Boy, they do things big in Texas, they really do.

As I prepared for this talk, I found myself time and again dipping into the CJSM well–on the subject of youth overuse injury, I leaned heavily on the AMSSM position statement from Di Fiori et al. published in the January 2014 CJSM. When I touched on the topic of Exercise-Associated Hyponatremia, I turned to the 3rd International Consensus Statement and the podcast I just conducted with lead author, Dr. Tamara Hew. The PPE?  Of course, I would consult the joint ACSM/FIMS statement (CJSM Nov. 2014) and the podcast I conducted with its lead author, Dr. William Roberts.

It does indeed excite me to share with you all the resources this journal has.  As an educator and public health advocate, as well as a clinician, I use CJSM in a very real and practical sense.  Day in, day out.

My time in Texas was brief, but MomsTeam’s work will continue.  I am hopeful that our work will help these children and their families navigate some of the risks that are associated with the many, many benefits of youth sports such as football and cheer.  For one, I hope my talk helps prevent any cases of exertional heat illness (EHI) in this group. The forecast for  this week in Grand Prairie has the thermometer hitting 106F (41C)!!!  At least I think the humidity on an August day in Texas may be a little bit less than that seen in, say, Qatar, site of the 2022 World Cup.

As I flew home, I read the recent Sports Illustrated story on the 25 anniversary of the release of the iconic book,’ Friday Night Lights.’  I mused on the importance of youth football not just in Texas, but in the United States in general.  With 3.5 million players age 6 – 13 in this country (CJSM 2013), the sport keeps a LOT of kids active.  With the season now upon us, let’s all keep working on making this sport, and all sports, safer for our young athletes.  With the work done in this and other journals of sports medicine, we’ll continue to generate the evidence to support the decisions that will further this cause.


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