Repeated heading of the ball in soccer – is there a link to brain injury?

December 11, 2011 2 Comments

Another day, another article related to concussion and head injury in sport in the New York Times – this time, concerning a possible link between repeated heading of the ball in soccer and brain damage.

The article, ‘A new worry for soccer parents – heading the ball’ highlighted some new research recently presented at the Conference of the Radiological Society of North America.

Michael Lipton, associate director of the Gruss Magnetic Resonance Research Center at the Albert Einstein College of Medicine and medical director of MRI services at Montefiore Medical Center in New York, together with colleagues used diffusion tensor imaging (DTI) to study the effects of repeated heading of the ball in soccer, and found that players who repeatedly head the ball with a high frequency had brain abnormalities on scanning similar to patients with traumatic brain injury.

DTI was used to examine for areas of fractional anisotropy (FA) in the white matter of the subjects, which is thought to have a relation to healthy brain tissue – healthy white matter having a relatively high FA.

Dr Lipton and colleagues used DTI on 32 amateur soccer players who had played the sport since childhood, and estimated how often each player headed the ball on an annual basis based on a standardised questionnaire. They then ranked players based on estimated heading frequency.

The researchers went on to compare brain images of the players estimated to have executed the most frequent headers with those of the remaining players, and identified areas of the brain where FA values differed significantly in certain ‘regions of interest’ (ROI) in the brain responsible for attention, memory, executive functioning and higher-order visual functions.

Using statistical analysis, Lipton and colleagues found that greater heading frequency was associated with low FA. They concluded that exceeding a threshold for heading frequency (1000-1500) may result in brain abnormalities similar to those seen in TBI, and went on to suggest that ‘the exposure threshold we identify suggests public health interventions to minimize excess exposure and, thereby, the adverse outcomes.’

Critics of the study may wish to point out the possible issues of recall bias, plus possible errors in the estimates of frequency of heading and statistical analysis as weaknesses of the study.

For those who wish to read more, there is a great summary of the study on the Radiological Society of North America website. This includes links to video footage of Dr Lipton himself describing the study and related issues, together with the views of a participant in the study.

There have been other studies of heading in soccer related to brain injury, but most of these have been subject to methodological flaws making it difficult to draw conclusions. In addition, some studies have included subjects from the days before the modern soccer balls were used, when leather balls could weight considerably more and especially when wet.

Zetterberg and colleagues examined biomarkers for neuronal injury collected by lumbar puncture following repeated headings in a training session and found no significant changes in neurofilament light protein, total tau, glial fibrillary acidic protein, and albumin concentrations 7-10 days after the repeated headings, with only a mild elevation of CFS S-100B concentration. They concluded that repeated low-severity head impacts due to heading in soccer are not associated with neurochemical signs of brain injury.

Cognitive deficits have been associated with repeated headings in football by some authors such as Tysvaer, although others such as Janda and colleagues who studied a youth population found no abnormalities in cognitive function other than difficulty in learning new words.

The debate about heading in soccer and its correlation with brain injury seems set to rage on into the future.

In the meantime, what should we tell concerned parents requesting medical advice about the issue? Where do YOU stand on this? CJSM would like to know.

References :

Zimmerman M et al. 2011. Making Soccer safer for the Brain : DTI-defined Exposure Thresholds for White Matter Injury Due to Soccer Heading

Zetterberg H et al. 2007. No neurochemical evidence for brain injury caused by heading in soccer. Br.J.Sp.Med. 41:574-577

Tysvaer A & Lochen E. 1991. Soccer injuries to the brain. A neuropsychological study of former soccer players. Am.J.Sp.Med. 19:56-60

Janda D et al. 2002. An evaluation of the cumulative effect of soccer heading in the youth population. Inj. Control Saf.Promot.9:25-31

(Image – England v Scotland 1872 at The Oval, London at Wikimedia commons)

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National Collegiate Athletic Association targeted for legal action on the issue of concussions amongst student athletes

December 3, 2011

There was an interesting article in the New York Times this week highlighting a recent class action lawsuit aimed at the NCAA over alleged negligence in relation to prevention and treatment of brain injuries in athletes.

The action represents the first attempt to target the NCAA rather than individual colleges or schools, as pointed out by Nikki Wilson on the Collegiate and Professional Sports Law Blog. Four plaintiffs, three with a history of participation in College football and one who played soccer, have filed lawsuits alleging a ‘long-established pattern of negligence and inaction with respect to concussions and concussion-related maladies sustained by (the NCAA’s) student athletes.’

There are a wide range of claims made, including allegations that the NCAA has failed to implement :

– A support system for players unable to continue to play or lead a normal life after sustaining concussions

– Legislation addressing treatment and eligibility of players who have sustained multiple concussions

– Guidelines for screening and detection of head injuries

– Return-to-play guidelines for players who have sustained concussions

– Effective ways of addressing or correcting coaching of tackling methods that cause head injuries

One plaintiff, Adrian Arrington, claims to have suffered ‘numerous and repeated concussions’ during his playing time at Eastern Illinois and now is alleged to suffer from memory loss, depression, and near-daily migraines as a result. The lawsuit claims that the NCAA ‘..has failed its student-athletes choosing instead to sacrifice them on an altar of money and profits.’

Perhaps unsurprisingly, Donald Remy, the NCAA General Counsel and Vice President for legal affairs, has called the lawsuit ‘wholly without merit.’

The organisation responded by stating that ‘..the NCAA has been concerned about the safety of all of its student-athletes, including those playing football, throughout its history,’ and claimed that ‘..we have specifically addressed the issue of head injuries through a combination of playing rules, equipment requirements, and medical best practices.’

The NCAA and the CDC have collaborated to create educational resources for coaches, student-athletes, medical staff and college sports supporters. The NCAA Sports Medicine Handbook has 4 pages on concussions including information on symptoms, and has a revised management plan for all athletes with concussion.

The outcome of the legal actions will no doubt be watched closely by all former college athletes who believe that they may be suffering from ongoing symptoms as a result of repeated concussions during play.

For a further discussion on the lawsuit issues, readers can listen to the EDUsports podcast on the subject.

In the meantime, CJSM would like to hear your thoughts.

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Pro-bowl picture by Cpl. Michelle M.Dixon

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Team Doctor AND fan? Avoiding conflicts of interest and issues affecting clinical judgement in Sports Medicine

November 27, 2011 3 Comments

This weekend was one of the weekends that I both look forward to and dread at the same time, in equal measure – when ‘my’ team play the team with whom I am currently working as team doctor.

I started supporting Sheffield Wednesday Football Club when I was around 5 years old, spurred on by my father who was, and still is, an ardent fan. He took me along to my first game against Peterborough United on a cold winter’s day and an exciting game led to a 3-3 draw. However, by all accounts, I was not particularly engaged with the game itself, choosing instead to run amok up and down the gangways of the main stand and only becoming particularly focussed at half time when I was given a bag of sweets to demolish.

Nevertheless, I grew into a diehard Wednesday fan myself and became a regular season ticket holder, attending games regularly with my father. Much of my childhood conversation at home and at school was on the topic of how the Owls were performing each week. I still remember well the first day that I became a member of the Young Owls Club, proudly sporting my Club badge, shaking hands with some of the players and collecting autographs. One of the players whose autograph I still have from that day was Gary Megson, an honest and hard-working midfielder. He was later to become Club Manager, having been appointed just last year to the role with the Club. I still have a close affiliation with the Club as a fan, and those conversations about the team with my father still remain as regular as they were over 30 years ago.

Although I have looked after several different teams in the past and have been involved in lots of different sporting events, the first time I was called to be involved in any sort of Professional capacity at an event at which ‘my’ team were playing was last year when Leyton Orient were due to face Sheffield Wednesday in Sheffield at Hillsborough, the ground in which I had spent so much of my time over the years watching my team.

In Football League 1 in the UK, it is standard practice for the home team doctor to care for both the home and away teams during the game itself, so there was no requirement for me to attend that day as club doctor for Leyton Orient. However, I was very keen to go along as a football fan, at least. Despite being invited to take up my usual position on the bench with Leyton Orient, my instincts told me that I would be much better off in the stands with my father and brothers watching the game as a fan. It was with a strange mix of emotions that I watched the match that day, feeling a desire for both teams to do well and certainly not feeling like a team doctor. Being up in the stand, I could enjoy the game as a spectacle rather than approaching the game as I usually do when I am on duty as team doctor.

Later on in the season, Leyton Orient played Sheffield Wednesday in London. Although I approached the game with a little trepidation at first, I felt much more professionally detached and objective on the day which was perhaps down to the familiarity of my usual working environment. I found it relatively easy to concentrate on my club doctor role and to care for both sets of players on the day.

There are a number of possible ways in which being a fan might potentially cause a conflict of interests or influence the clinical judgement of a team physician both in a conscious or  in a subconscious manner. Perhaps the most difficult situation is when a clinician is both team physician and a fan of the same team – a situation perhaps not as uncommon as one might think. The team physician may or may not start out as a fan of the team, but they may develop into a fan without being truly aware of this such that objective clinical judgement may be affected and insight might be poor. A decision might be taken, for example, to ‘patch up’ an important player in a vital game and let them continue to play rather than taking a different view.

Whilst conflicts of interest between what might be best for a player and what might be best for a team are not so uncommon and are well known to team doctors, matters of clinical judgement related to a doctor’s ‘fan status’ may not be so apparent, and there may be a lack of awareness on all sides.

Perhaps the most important requirement for a team physician in order to prevent any potential adverse effects on objective clinical judgement alongside a Professional approach is the capacity for self-reflection and insight.

Is it time for clear ethical guidance on this issue?

Should we have a section on a team doctor’s annual appraisal on probity issues related to ‘fan versus doctor’ to facilitate and encourage reflection?

CJSM would like to hear your views.

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Working in teams – what about learning in teams? Interprofessional Education in Sports Medicine

November 20, 2011 3 Comments

There are a wide variety of healthcare professionals working in the sports medicine environment, whether that be in primary or secondary care, or within a sports team.

These might typically include physiotherapists, physicians, massage therapists, strength and conditioning coaches, nutritionalists, biomechanicists, sports psychologists and others.

Most of us working as healthcare professionals in a sports medicine environment are no strangers to the multidisciplinary team way of working, but how often do we think about how we learn together, and from each other, in teams?

The term ‘Interprofessional Education (IPE),’ as suggested by the Centre for the Advancement of Interprofessional Education (CAIPE), may be used to define a process that ‘occurs when two or more professions learn with, from and about each other to improve collaboration and quality of care.’ CAIPE go on to state that ‘IPE includes all such learning in academic and work-based settings before and after qualification, adopting an inclusive view of ‘professional.’

The unique concept of IPE is one of deliberately bringing together a group of heterogeneous healthcare practitioners to discuss educational topics. As a consequence of this, it is hoped that the diversity amongst the group together with effective knowledge sharing will allow for better learning for all within the group. Hopefully, this goes on to lead to improved patient care and patient outcomes.

IPE approaches to learning have been studied extensively, and Freeth (5) noted that some have indeed led to improved outcomes for patients, including improved preventative care, screening effectiveness and immunisation rates (1), improved teamwork and less perceived errors occurring in an emergency department (2), and increased interprofessional participation in planning and reviewing care (3, 4). However, there is a paucity of research on the implementation of IPE in a sports medicine environment, let alone on whether it leads to the outcomes we all desire for our patients and for our teams.

Whilst IPE can be delivered in formal settings, it is perhaps the informal settings where its practicability can be demonstrated., for example, during MDT assessments of athletes with injuries where complex contributing factors need to be assessed as part of the overall picture. Most of us involved in sports medicine will be familiar with MDT assessment in this way, and if an effective learning environment is created, then this represents a wonderful opportunity for each of the participants to learn from each other. I wonder how often we consciously think of MDT assessments as a real opportunity for learning, and treat them as such?

There are a number of possible barriers to the implementation of effective IPE. These include tensions between different professional groups such as negative stereotypes, status or salary differences, and demotivating and derogatory feedback between groups within the learning environment.

To some extent, these barriers can be avoided if one adopts appropriate ground rules. As mentioned by Freeth (5), these might be extrapolated from the ‘Contact hypothesis’ which suggests that one can reduce hostility amongst different groups by creating a learning environment where everyone has equal status, interaction is co-operative, participants are working towards a common goal, the ‘authorities’ support the initiative (eg Club management and Professional bodies), participants are made aware in advance of each others’ differences and similarities, participants share positive expectations, and participants from different groups perceive each other as typical of their group (6).

The extent to which these precedents are achievable is open for debate, and one might question whether with the wide range of healthcare practitioners involved in Sport and Exercise Medicine this might ever be achieved, or might even be desirable.

It is not uncommon to experience formal and informal IPE in the sports medicine environment, whether that may be at conferences, as part of social learning platforms such as blogs and twitter feeds, or within the workplace. In addition, formal postgraduate degree courses such as the MSc in Sport and Exercise Medicine at William Harvey Research Institute, Queen Mary University, London which I lead often have a student base made up of a wide complement of healthcare practitioners who participate and learn from each other. This is regarded as a real strength of the course.

CJSM would like to hear your views on IPE in the world of Sports Medicine– does it work for you, your colleagues, and perhaps more importantly for your patients?

 

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1) Shafer M-A et al. 2002. Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls. JAMA 288:2846-52

2) Morey J et al. 2002. Error reduction and performance improvement in the emergency department through formal teamwork training:evaluation results of the MedTeams project. Health Services Research 37:1553-81

3) Berman S et al. 2000. Assessment training and team functioning for treating children with disabilities. Arch.Phys.Med.Rehab.81:628-33

4) Walsh P et al. 1995. An impact evaluation of a VA geriatric team development program. Gerontology and Geriatrics Education 15(3):19-35

5) Freeth D. 2010. Interprofessional education. In Swanwick T (Ed.) 2010. Understanding Medical Education : Evidence, theory and practice. ASME, Wiley-Blackwell, London

6) Hewstone M and Brown R. 1986. Contact is not enough: an intergroup perspective on the ‘contact hypothesis.’ In: Hewstone M and Brown R (Eds) Contact and Conflict in intergroup encounters. pp.1-44. Blackwell, Oxford

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