There Be Monsters

“In like a lion, out like a lamb,” that’s what they say about March.

To the extent that expression applies to the weather this month and to this blog, I think 2014 may be the exception that proves the rule!  We may be going out like a lion in both areas.

The east coast of North America is ready for spring, but this month that opened up with winter is ending the same way.  If there was an outdoor lacrosse game in Buffalo, New York this weekend, the players were dealing with snow!

More like a lion than a lamb: an NHL body check.

As for this blog, we opened the month with a post that had both sound and teeth, like the proverbial carnivore itself:  our first podcast was a discussion with Drs. Neil Craton and Oliver Leslie, the authors of the March 2014 CJSM lead editorial, Time to Re-Think the Zurich Guidelines: a Critique on the Consensus Statement on Concussion in Sport.  I continue to hear about this editorial, on social media, on the American Medical Society for Sports Medicine email ListServ, and most recently at a symposium on concussions held at Ohio State University (OSU).  It has stirred a tremendous amount of interest.  And so I thought it would be fitting to end the month where we started, with the subject of concussion in sport.

The featured speaker of the OSU symposium was Kevin Guskiewicz, who spoke about “Sports concussions: paranoia or legitimate concern?”  Both he and Dr. Jim Borchers, the Ohio State Team Physician, mentioned the editorial critique in their respective talks.

If you follow the literature on sport-related concussions, you most certainly will come across Dr. Guskiewicz’s name.  He has contributed mightily to the research on several dimensions of this injury.  And so it was a pleasure to hear him speak for an hour on the subject.

As the title of his talk would indicate, Dr. Guskiewicz took as his theme the fear surrounding sport-related concussion.  Dr. Guskiewicz did an admirable job underscoring the importance of both the injury (concussion) and the need to avoid throwing out the baby with the bathwater:  eliminating collision sports such as American football out of possibly misplaced concern over short- and long-term deleterious effects on the brain.  The high points of his talk focused on the various aspects of sport amenable to change which can minimize injury risk and maximize participation.

I especially enjoyed his approach because, in many respects, it is the work that he and a few others have done (amplified by the media) that has helped unleash the beast of “concussion fear.” Focusing his research on this injury for over 20 years, he was one of the first to alert clinicians and others to the seriousness of concussions.  With over 90 articles on the subject, it would be impossible in this space to give due credit to his contributions to the concussion literature.  He was lead author on the JAMA study I still refer to in discussions I have with patients and families:  Cumulative Effects Associated with Recurrent Concussion in Collegiate Football Players.  He has been an author in CJSM several times:  he has looked critically at  postural stability assessment following concussion, for instance, and more recently (September 2013)  he and others assessed The Effects of Sleep Quality and Quantity on Baseline Concussion Assessments.

TED should get Dr. Guskiewicz to deliver the sort of talk I was privileged to see….wait, it has!!  Take a look here at a ‘mini-version’ of what I got to witness.

To summarize, Dr. Guskiewicz called for the need to make sports safer rather than eliminating some, such as American football; and he emphasized the following points as a basis for where to go next:

Odysseus, sailing between the Sea Monsters Scylla and Charybdis

1) We need to better identify those individuals who may have risk factors for sports injuries and chronic neurologic impairment.  We might be able to alter those risk factors.  We may be better able to guide such individuals in making appropriate choices for sport if we better understand those risk factors.

2) We need to “modify the behavior and change the culture,” (for instance, considering rules changes regarding violence and ice hockey).

3) We need innovative scientific approaches to identify more specifically the injury (e.g. biomarkers, novel imaging); prevent the injury (e.g. using impact sensors to train individuals in proper tackling techniques); and treat the injury (e.g. we currently struggle to find evidence-based approaches to concussion treatment).

Dr. Guskiewicz did not answer his own question directly:  “Sports concussions:  paranoia or legitimate concern?”  The way he marshalled his arguments left me with the notion that the injury is a legitimate concern, while our society’s reaction to it has trended toward the paranoid.

I concur.  “Navigating the twin perils of brain injury and physical inactivity,” that’s how I phrase it in my own talks.  American football is the number one participant sport in high school students and other youth in this country.  If we eliminate it, with what do we replace it? Kids certainly would be safer in front of an iPad as opposed to an opponent twice their size in an Oklahoma drill.  But is the ‘clear and present danger’ to kids and others sport-related concussion;  or is it physical inactivity and consequent obesity?  There is some evidence that there is a decline in participation in organized youth sports.  This is concerning.

Odysseus famously survived his encounters with sea monsters, and other perils, by using his cleverness, his intelligence.  We, too, can navigate our course with science, with evidence-based research.  “There be monsters”–just look at how March is going out!

But we need not be afraid.