The CJSM blog, and more. Much more.

October 26, 2013 by

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

Filed under General Interest, Technology in Sports Medicine Tagged with ,

Return to Play Decisions

October 20, 2013 by 2 Comments

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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 my team’s performance, and then called in three directions at once, treating players and making decisions on whether they can get back into the game:  decisions that can have significant consequences for the player and the team.

I thought I would write somewhat extemporaneously today, and in sharing some of the more interesting cases I have seen of late think in a more structured way about how we primary care sports medicine physicians make return to play (RTP) decisions.

RTP decisions make the headlines all the time.  In the professional leagues of North American sports, in just the last two weeks, we have seen discussions about Kobe Bryant’s return to the NBA from late spring Achilles tendon surgery; Rob Grownkowski’s ‘delayed’ return from a surgically treated forearm fracture; the much anticipated return of Derrick Rose more than a year after his ACL reconstruction; debate over RGIII and whether he has come back too soon from his own multi-ligamentous knee injury…….the list goes on!

pos elbow disloc

The end of a season?

In my own practice, I have been trying to return players back to American football while they have recovered from a kidney contusion, a posterior elbow dislocation, a complete rupture of the ulnar collateral ligament, and a demyelination injury of the axillary nerve.  Of the four, two are back playing; the elbow dislocation is still rehabbing, and i hope to return in a hinged knee brace before the end of the year; and the axillary nerve injury continues to have pain and profound weakness of his deltoid, and his recovery will extend beyond the end of this season (much to the coach’s dismay).

Despite being one of the more important aspects of our job, there is very little in the way of evidence-based medicine to guide a clinician in these decisions. Read more of this post

Filed under General Interest Tagged with , , , , , , ,

League of Denial: A review of the PBS documentary

October 13, 2013 by

steve young

49ers legend Steve Young
one of the great interviews on the
documentary, “League of Denial”

I watched the PBS Documentary “League of Denial” this week, and I’m sure many of you did as well.

In one word:  Bravo.

I thought the folks at PBS’ Frontline did a fantastic job, touching on many facets of what is arguably the biggest sport public health story of the last two decades.  There were so many dimensions to the nearly two hour documentary, it’s hard to know where to begin my review.  In nearly two hours, PBS (with a ‘redacted assist,’ if that’s the phrase, from ESPN), covered a lot of ground.

I thought I would highlight some of the major personas that showed up, and divide them into the following four categories: “Winners,” “Losers,” “Meh,” and “In Memoriam”

Winners

Bennet Omalu, the neuropathologist who broke the story of chronic traumatic encephalopathy (CTE), is my pick for the most compelling figure in this documentary.  A physician of great training and accomplishment, he had the mixed fortune of conducting the post-mortem examination of Mike Webster, the Pittsburgh Steelers icon who died young and whose brain showed the pathologic changes of CTE, the first case documented in an NFL player and reported in this study.

Dr. Omalu’s story, both personally and professionally, is worthy of its own documentary.  Originally from Nigeria, he knows little about American fooball and nothing about the Steelers icon when he first meets the latter’s corpse and goes about his job.  He reports being thoroughly unimpressed with the gross morphology of the deceased’s brain:  how it looked ‘normal.’  It was only on conducting his histopathologic exam that he made his stunning discovery.

For this and further efforts in investigating CTE in deceased NFL players’ brains, he was smeared by the NFL and its affiliated physicians.  Omalu poignantly states as a result, he wished he had never ‘met Mike Webster.’

As an Associate Editor of a medical journal, I found the calls by some in the NFL medical community (see below) for Omalu to retract his CTE study and their ad hominem attacks to be the more egregious sins (among many) reported in the documentary.  The process of science, spearheaded by peer-reviewed literature, is one of openness; disagreements are cause for further study, not suppression.  Retraction should be reserved for outright fraud.  The calls for retraction in this case are shameful.

Ann McKee, another neuropathologist now with the Boston Center for the Study of Traumatic Encephalopathy, has picked up the baton and is continuing to carry on the research into CTE in former professional football players, despite further pushback from vested interests and more ad hominem attacks that insinuate that, as a woman, what might she know about football?

Steve Young who experienced five or six concussions in his career, is one of the former players interviewed for this documentary.  I remember Steve Young well, as I lived in the Bay Area for many of the seasons of his glorious career with the 49ers, and I remember too when he had his career-ending concussion. Read more of this post

Filed under Concussion in Sport, General Interest, Public Health in Sports and Exercise Medicine Tagged with , , , , , ,

Dr. Keith Yeates guests on “5 Questions with CJSM”

October 5, 2013 by 2 Comments

keith

Dr. Keith Yeates revs up the crowd at
the International Brain Injury Association meeting
in Edinburgh, Scotland

I live and work in Columbus, Ohio, United States, and I am privileged to be surrounded by many leaders in the field of sports medicine.  One such figure, who is doing great work advancing the evidence to support the diagnosis and management of sport-related concussions, is Keith Yeates, Ph.D.

Dr. Yeates and I work at the same institution, Nationwide Children’s Hospital; I have found him to be a great resource to turn to for questions regarding the sport-related concussions in kids that I manage as part of my clinical practice.  He is a prolific researcher and writer, who has been a contributor to the pages of CJSM and journals beyond.  He is a lead neuropsychologist for a multi-site study of traumatic brain injury in children and adolescents, funded by the CDC.

I just learned from a press briefing that Dr. Yeates has become a millionaire of sorts:  he has been awarded a prestigious R01 grant to continue his work in the field of traumatic brain injuries.   And so I had to try to catch up with him and have him sit for 5 questions before his various other commitments overwhelmed him!  I got lucky, and here are Dr. Yeates’ thoughts on the state of concussion research.

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CJSM asks Dr. Keith Yeates 5 questions

1) CJSM: Congratulations!!  We understand you just received a $3M R01 grant for ‘predicting outcomes in children with MTBI.”  What areas of research do you plan on pursuing with this grant?

KY: The grant will fund research to examine how well diagnostic methods commonly used for children with mild TBI can predict persistent postconcussive symptoms (PCS) and functional deficits. Various methods are recommended for the diagnostic evaluation of children with mild TBI, including assessment of presenting signs/symptoms, acute mental status examination and balance testing, neuropsychological testing, and neuroimaging. Although these methods discriminate between children with mild TBI and healthy children, we don’t know whether they predict outcomes such as persistent PCS and functional impairments among children with mild TBI. As a result, decision tools are not available to physicians and other health care providers to guide the disposition and care of children with these very common injuries. This comprehensive study of common diagnostic methods and their incremental utility in predicting outcomes should have a major impact on clinical practice, particularly in acute care settings, by helping improve prognostic determinations, develop decision tools, and focus treatment efforts. The study should also add substantively to the scientific understanding of the outcomes of mild TBI. Read more of this post

Filed under Concussion in Sport, Evidence-based Medicine in SEM, General Interest Tagged with

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