Return to Play Decisions: The hits and the HIT (system).

It’s October, and I thought I’d share a blog post I previously wrote about return to play decisions (see below). The football teams I cover are smack dab in the middle of their seasons; I, like all my colleagues covering teams this fall, have been busy making plenty of ‘return to play decisions.’

What do you all do with your 7 and 8 year olds? Yes, your 7 and 8 year olds……little did I know when I started my career that I would be making ‘return to play’ decisions for this age group, but that is among my duties here at Nationwide Children’s Hospital in Columbus, Ohio. How about you?

With that sort of return to play decision in mind, I could hardly find a more relevant piece of original research than the study on head impact exposure in youth football in the September 2014 CJSM.  The authors–a group from Virginia Tech and Wake Forest–are well known for recently publishing various studies on head  impact exposure using the ‘Head Impact Telemetry’ (HIT) system.   The HIT system is being used more regularly at various levels of football in helping to determine when an athlete may need a sideline evaluation.  As we all know, athletes in the heat of competition are not always the most forthcoming in sharing when they may have had a symptomatic hit; for that matter, the collective body of sideline physicians, athletic trainers and coaches don’t always pick up on the hits that occur right in front of our eyes:  just ask Brady Hoke and the Michigan Wolverines.

Returning to youth sport…..as my friends at MomsTeam have written, “the day when monitoring of head impact exposure in football and other contact and collision sports becomes commonplace is closer at hand than one might think.”  Here’s a list of what’s available right now for players from youth level on up to the pros (again, thanks MomsTeam for the reference).

I can forsee the time when I will integrate head impact exposure data along with what I find with my other concussion assessments to determine when I will release one of my youth athletes back to the field.  Next season, I will likely be involved with coverage of a high school which uses “Shockbox” technology.  However, I don’t currently use such systems; that is to say, none of the teams I cover, high school or university, use the HIT system or any other impact exposure technology.  Are you already using such technology in your determinations? Let me know if you are.  I’d like to learn more.

Enjoy the reblogged post below.

 

Clinical Journal of Sport Medicine Blog

535001_10201384038456502_1470889600_n Though a beautiful time of year, fall is not
the most idyllic for a sports medicine clinician

Like many of the readers out there, my colleagues and I are deep in a football season, where we are managing various teams and their mounting injuries.  For a sports medicine physician, fall in America must be a bit like early spring for an accountant (tax day = April 15):  it’s the time to buckle down and crank through patients, the time, from a certain perspective, to see the volume of patients that will sustain the business through leaner times of the year.

When I’m out of the clinic and on the sidelines, I’m also doing one of the parts of my job that is the most fun, and I’m sure my colleagues out in the blog sphere will agree.  But I wouldn’t describe the work as an idyll.  I can be enjoying…

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The CJSM blog, and more. Much more.

Presa_de_decissions

Interactivity: The Holy Grail
of On-Line Media

The CJSM blog was started by my predecessor and now CJSM Executive Editor, Chris Hughes, in June 2011.  We just passed the ‘century mark’ (this is the 103rd post for the blog) and, on a personal note, I am hitting the ‘half century’ mark:  this is the 50th post I’ve authored since taking over the reins in April of this year.  My first post, just over six months ago, was on the forthcoming 2013 AMSSM conference in San Diego.

Oh, and yes, I hit that half century mark earlier this year, but I hardly find that cause for celebration……

These blog post numbers have put me in a reflective mood, and I thought I might go over some of the ground we have covered and talk a little bit about where we might be going with our various on-line CJSM offerings in the world of Sports and Exercise Medicine (SEM).

If you look at the ‘word cloud’ in the right hand panel of the blog site, the largest phrase will be “Concussion in Sport.”  We’ve posted frequently on this topic, justifiably so given the breadth and the public health implications of the issue.  We’ve discussed the use of neuropsychological testing in concussion management in 2011 and more recently again in 2013. I recently reviewed the powerful PBS documentary “League of Denial,” which I think is one of the better produced analyses of the issue in the popular media.  We brought to you the Zurich Consensus statement in the journal earlier this year and discussed it on the blog as well as on YouTube.  Chris explored the issue of repetitive heading and it’s putative link to long-term neurological damage in a 2011 post.  There will be more posts on this topic coming, and the phrase in the word cloud will surely enlarge:  the more we learn about this issue, the more questions there are to answer, and that, of course, drives the sorts of research that will find its way on to the CJSM pages.

Some of the more popular posts have been about such wide-ranging issues as the effect of Ramadan on sports performance; the medical coverage of the 2013 Boston Marathon, which riveted the world; and Novak Djokovic’s gluten-free diet:  performance enhancing or not?  If you have an opinion on the matter, go to that link, where you will find a poll along with the blog post.  Such polls are just another of the interactive media we use here at CJSM. Read more of this post

William P. Meehan III, M.D. guests on “5 questions with CJSM”

bill m stanley cup

Bill Meehan & The Stanley Cup
One of the few awards he has
not garnered in his career.

Readers of the blog will remember in August I was able to interview Dr. Jason Mihalik, University of North Carolina, about his work while using the ‘5 questions with CJSM’ format.  I’m happy to say I have another willing victim for this format.

I have known William P. Meehan III, M.D. for several years; we both did our sports medicine training in Boston under the illustrious doctors Lyle Micheli, M.D. and Pierre d’Hemecourt, M.D., authors whose names will be familiar to readers of the journal as they have both been published in CJSM numerous times.

Bill, as I know him, is likewise establishing his own enviable track record in the clinical management and study of sport-related concussions.    I have mentioned some of the work he has done in a recent blog post, and so in the spirit of brevity let’s get right to the interview.

_______________________________________________________________________

Five Questions with CJSM

WM:  Thanks so much for inviting me to be part of your blog, Jim.  You do great work here at the Clinical Journal Sports Medicine I appreciate your including me.

1)    CJSM:  Thanks for those kind words Bill, and congratulations on your receipt of the first AMSSM-ACSM Foundation’s Clinical Research Grant for your project titled “A Randomized, Double-Blind, Placebo-Controlled Trial of Transcranial Light Emitting Diode Therapy for the Treatment of Chronic Concussive Brain Injury.”  Can you tell us what potential you see for LED therapy in this arena

WM:  The idea of using light emitting diodes (LEDs) to treat concussive brain injury was brought to my attention by Margaret Naeser, PhD, who works at the VA Boston Healthcare System and Boston University School of Medicine. Dr. Naeser approached me one day after a lecture and suggested that perhaps LED therapy could help people suffering from concussive brain injury. To be honest, I was a bit skeptical at first. But she was passionate and convincing about it.  After reading some of the previous medical and scientific literature about light therapy, my mentor in the laboratory, Michael Whalen, MD at Massachusetts General Hospital conducted some experiments on mice that had suffered a traumatic brain injury.  The results were promising.  So the three of us, together with Rebekah Mannix, MD, MPH, Alex Taylor, PsyD, and Ross Zafonte, DO set out to conduct the study.

As you know, the current hypothesis of concussion is that a rapid rotational acceleration of the brain leads to changes in the ionic gradients across the axonal membrane. Those ionic gradients are restored to homeostasis by the action of the sodium-potassium pump. The sodium-potassium pump operates on adenosine triphosphate (ATP). It turns out that light in the red and near infrared spectrum when applied to cells in culture increases the activity of cytochrome C oxidase. This results in further ATP synthesis. Thus, some very astute researchers hypothesized that shining light in the red/near infrared spectrum on the brain would result in an increase in ATP production and perhaps decrease the healing times after certain brain injuries, including traumatic brain injury.

Dr. Whalen was nice enough to conduct an experiment in his laboratory using mice that had sustained brain injuries when we first heard about this.  Those experiments showed that treatment with laser in the red/near infrared spectrum resulted in better outcomes on measures of cognitive functioning, specifically the Morris water maze. After considering all of the evidence I followed up with Dr. Naeser. She informed me that she had an ongoing trial of light emitting diode therapy for people suffering from chronic traumatic brain injury. She had also published a case series of two patients who sustained concussions during motor vehicle collisions, athletic participation, and military service, who showed improvements of their cognitive functions after LED therapy. So we decided to conduct a randomized, double-blinded, placebo-controlled trial of LED as treatment for concussion.  Thus far, we have recruited half of our estimated sample size of 48 patients.

2) CJSM:  Congratulations as well for becoming Director for the Micheli Center.  If you had to compose a 140 character tweet to tell the world about the work you expect to accomplish there, what would it say?

WM:  Thank you.  I was delighted to become director of the Micheli Center for Sports Injury Prevention. We believe we are the first center in the world where athletes can come and learn which injuries they are at highest risk of sustaining, and what steps they can take to reduce the risk of those injuries.  The full Injury Prevention Evaluation takes about 3-3.5 hours.  It starts by collecting historical information, such as what sports the athletes play, what injuries the athletes have previously suffered, how many hours per week the athletes train, etc.   Then the athletes move out to the assessment floor where we measure bony angles, flexibility at the joints, strength in various muscle groups, speed, power, agility, and many other factors that are associated with the risk of injury.  The full evaluation includes over 300 data points, all based on the available medical and scientific evidence.  At the end of the evaluation, athletes are given a list of the injuries for which they are at highest risk, and an individualized prescription that outlines the steps they can take to reduce their risk of sustaining those injuries.

Our goal is to encourage safe participation in athletics while simultaneously decreasing the risk of injuries sustained during sports.

Although I don’t have twitter account, if I had to put out a 140 character tweet to the world I would say, “Our goal is to reduce the risk of sustaining sports injuries while simultaneously encouraging athletic participation.”

(CJSM:  21 characters to spare with that tweet!  Hey, Bill, with a name like yours, you can imitate RG3 and see if the twitter handle WM3 is available.  You can make the Micheli Center go viral!) Read more of this post

Computerized Neurocognitive Testing in the Management of Concussions, Part 2

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Concussion management for football,
c. 1930

I woke up this morning to my usual Sunday routine:  the New York Times Sports page and coffee.

Today’s sports section–and I don’t think the Times is alone in this regard–is devoted to the subject of the forthcoming American college football season.  The first games of the season will take place this Thursday, August 29.  As the Times puts it, “The nation’s annual rite of mayhem and pageantry known as the college football season begins this week…..”

When I’m not doing work with the Clinical Journal of Sports Medicine, I’m taking care of youth, high school and college athletes; for my colleagues and me, the football season has already begun, with the various teams we cover already having had weeks of steady, increasingly intense practices and scrimmages.  And we’re seeing the injury results of the sport, including an increase in volume of concussions.

I’ve mentioned this in my blog posts for this month, where the theme has been ‘concussions.’  Last week I wrote about the special set of CJSM concussion research articles we have made freely available for a limited time.  At the beginning of the month, I authored a post on the subject of computerized neurocognitive testing (e.g. ANAM4, CNS-Vital Signs, AxonSports,  ImPACT, etc.) and their use in managing concussions.  I want to return to that subject in today’s post.

axon sport macdonald

The author’s baseline AxonSport report

A recent article from the Archives of Clinical Neuropscyhology was especially interesting, I thought. The authors looked at a military population while evaluating the test-retest reliability of four computerized neurocognitive assessment tools (NCATs):  Automated Neuropsychological Assessment Metrics 4 (ANAM4), CNS-Vital Signs, CogState (available now in the U.S. as ‘Axon Sports’), and ImPACT).  I’m familiar with these products, but most especially ‘know’ CogState, as this is the NCAT we use in our clinic.

The authors correctly assert that test-retest reliability is one of the “…fundamental psychometric characteristics that should be established in each NCAT,” and that “….reliability should be established before making conclusions about a test’s validity,” which is the psychometric construct that can indicate whether a test measures what one is truly trying to measure (for instance, ‘reaction time,’ or ‘memory’).  Reliability, is the “…extent to which the test produces consistent results across multiple administrations to the same individual.”

In this study of 215 individuals (mean age 34, range 19 to 59), Read more of this post

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