The state of knowledge and policy on concussion in Rugby Football Union

cropped-cropped-cropped-header3.jpg
Westborough, MA  August 15, 2017 Just as American’s have begun to understand the true impact of concussion and the risk associated with repeat concussion and other blows to the head, the Rugby Football Union has started to take a serious look at the problem with respect to the long-term consequence of brain injury.  According to the New York Times in April 2014 “a tidal wave of earnings” may confound the rightful medical response to concussion injuries and dominate the return to play decisions on behalf of athletes who are found to have concussion. The remove-from-competition protocol has not taken hold in European rugby where players are routinely returned to play after a 5 minute time out during which they are examined by team medical personnel. Most are back on the pitch within 5 minutes. I have seen college Rugby games where this precise “recovery” was the norm.  The NCAA has protocols for managing concussion but in some club sports these protocols are not followed.
In 2011, Ben Robinson, a 14-year old boy in Northern Ireland, died from second impact syndrome resulting from playing through a concussion. He returned to the game three times after first being injured in a high school rugby match.  Ultimately he died after collapsing on the rugby pitch. Second impact syndrome results from a repeat brain injury resulting in a metabolic “energy crisis” that interferes with brain function including maintaining homeostasis on a cellular level. I  have documented it in several published Word Press Human Behavior posts.
More recently Irish Boxer Mike Towell died from second impact syndrome hours after his fight much the same way as 14-year old Ben Robinson.  He was seriously injured early in the bout and knocked down.  His toughness and tenacity along with unacceptable referee decision making allowed him to return to the fight. “The assumption that rugby had a better handle on concussions than football, however, might have been flawed from the get-go. The most recent injury audit performed by England’s Rugby Football Union (RFU) established that concussions in elite-level professional games were occurring at a rate of 13.4 per 1,000 player hours.” Bandidi, 2016
The NCAA protocol is cited here.  “Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be “available” at all NCAA varsity practices in the following contact/collision sports: basketball; equestrian; field hockey; football; ice hockey; lacrosse; pole vault; rugby; skiing; soccer; wrestling.” Female athletes are particularly vulnerable to concussion and tend to have longer recover times. Concussion is sometimes considered an invisible injury largely due to the absence of frank signs of injury on the outside of the head.
According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  Michael Sefton blog 2016

Burns, J. NY Times, In Europe, Echoes of America as Concussions Spur Debate, April 5, 2014. https://www.nytimes.com/2014/04/06/sports/in-europe-echoes-of-america-as-concussions-spur-debate.html?_r=0  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. https://concussionassessment.wordpress.com/2016/10/03/second-impact-syndrome-rare-but-often-fatal/ Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out.  http://www.espn.com/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines https://www.ncaa.org/sites/default/files/2017SSI_ConcussionSafetyProtocolChecklist_20170322.pdf Taken August 8, 2017
Advertisements

What is PCS? And why do I care?

ART1WESTBOROUGH, MA  September 28, 2016 Postconcussion Syndrome is a complex disorder that can stymie many physicians because of the abundance of both physical and emotional symptoms. There are about 3-25 percent of patients who are diagnosed with concussion that go on to have a longer duration of symptoms – sometimes a year or more . That is quite a discrepancy in the prevalence of cases.
The PCS cases with whom I have worked having prolonged symptoms from concussion often experience both physical and emotional symptoms that can be debilitating. “Post-concussion syndrome is a complex disorder in which various symptoms — such as headaches, light and sound sensitivity and dizziness — last for weeks and sometimes months after the injury that caused the concussion.” (Mayo Clinic)  If someone you know suffers from PCS the effects to a family system can be dramatic especially when the head of household can no longer go to work.  Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.
Sometimes vague physical symptoms create an overwhelming emotional response that comes from the lingering resentment patients feel when seeing doctors who seem unable to understand their needs. Sometimes the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation.
In a blog published in December 2015, Concussion and PCS was discussed in some detail.  “Like concussion, it is an invisible injury that renders many people unable to work. Headaches, neck pain, fatigue, visual changes, irritability, sensitivity to sound and light, depression, and poor sleep hygiene were common” (Sefton, 2015).  The long-term impact negatively impacts both physical and emotional functioning by slowly increasing autonomic activation and impact sleep, appetite, and emotional well-being.
When I am working with someone who has been symptomatic for months or more it is quite apparent how frustrated they can become. It is important for the patient to feel they are believed in the story they are telling. Their symptoms are real and in many cases life changing.  I realize that they have never received the proper education from experts to understand their concussion and its potential recovery course.  Someone with prolonged PCS can be difficult to work with because symptoms can be refractory to traditional therapy. The last thing they may want is to sit with a neuropsychologist and retrace their steps all the way back to the beginning of their symptoms or personal injury. A multidisciplinary approach is best for all involved and should include physical exertion that does not exacerbate existing symptoms (Makdissi, et al, 2016).
Meanwhile, there is a growing body of literature that links prolonged symptoms of concussion to major life stress that can imprint psychologically – like PTSD when the timing is right.
References
Mayo Clinic Website, http://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/basics/definition/con-20032705. Taken September 28, 2016
Sefton, M. Concussion: physician’s once espoused a link to unresolved litigation. Blog post: https://wordpress.com/stats/insights/concussionassessment.wordpress.com Taken October 1, 2016.
Makdissi, et al. The difficult concussion patient. Br J Sports Med. 2013 Apr;47(5):308-13. doi: 10.1136/bjsports-2013-092255 Taken October 1, 2016

Worthwhile educational video brings concussion to life

 

WESTBOROUGH, MA These educational videos are posted by the National Academy of Neuropsychology and offer viewers the personal stories of elite athletes – many of them are nationally

Dr Sefton
Michael Sefton (right) with former Boston Bruins player teaching young hockey players about concussion

known.  In my practice I have learned that concussion impacts the younger athlete with more unpredictable outcomes and a longer recovery.  I have worked with professional and college athletes and have come to know that management of these players is important.  Light exertion should be part of their recovery.  Individualized return to play protocols are designed for those who suffer a second or third concussion.  If this occurs within a single season most athletes are encouraged to shut it down allowing time for complete recovery before competing at 100 percent.

See these videos and Concussion 101 – Dr. Mike Evans interesting take of this injury.

 


cropped-ball-in-air.jpg

National Academy of Neuropsychology posts educational video

 

NFL yields to pressure acknowledging link to CTE

Omalu
Bennet Omalu, M.D. a pathologist who is given credit for first identifying the signs of CTE in brain of NFL player  (PHOTO Google images)

WESTBOROUGH, MA March 15, 2016 In a published article headlining the BBC web pages the NFL has acknowledged that a link exists between repeated concussion and chronic traumatic encephalopathy – a deadly brain disease resulting in depression, memory loss, and erratic behavior. Only 50 days ago the NFL’s hired “expert” Mitch Berger, M.D., a neurosurgeon claimed that no link had been established between hits in football and the chronic brain disease leading to death.

This is the first time the NFL has acknowledged that such a link exists. Why are they now acknowledging what science has accepted years ago?

In Boston, neuropathologist Dr. Ann McKee unequivocally states that a correlation between concussive and subconcussive blows to the head has resulted in CTE in 90 of 94 brains she has examined – all from NFL players who have died and donated their brains to the Boston University Brain Bank. “The Boston Globe features this story as well today” according to Michael Sefton, Ph.D. “I have heard Dr. McKee and her colleagues report these findings since they examined the first series of brains including the brain of former N.E. Patriot Junior Seau who committed suicide shortly after his retirement from football.” The link has been well established for over 5 years but denied by NFL medical experts and league president Roger Goodell.  The NFL Player’s Association sued Goodell and the NFL for hiding the dangers associated with concussion in 2014.  The major motion picture Concussion starring Will Smith as real life physician Bennet Omalu was overlooked for an Oscar nomination in 2015.  Nevertheless, the movie brought many of the NFL’s secrets about concussion out for all to see.


This link will take the reader to the BBC report.

Concussion night 2016 at Bruin’s game

206982_1037539872681_50_nThe Children’s Hospital of Boston is participating in the special night at the Boston Bruin’s game on March 10, 2016.  The Bruins welcome Rebekah Mannix, M.D. a physician spokesperson at Children’s Hospital.  She acknowledge that brain injury is a silent injury often overlooked.  She described the importance of brain injury awareness including concussion prevention. Dr. Mannix talked about the silent injury that is concussion.  As an emergency room physician she noted that most injuries do not show up in the computerized tomography (C-T scan).  Athletes should rest following injury but recovery is different with all athletes – especially the younger players. Treatment options were discussed with Dale Arnold – NESN Sport Bruins Face-Off Live host.

Concussion and ImPACT

WESTBOROUGH, MA This video shows Michael “Mickey” Collins, Ph.D. provide information about concussion and the ImPACT Baseline concussion program he helped create at the University of Pittsburgh – Sports Medicine.  ImPACT is the gold standard for measuring preseason cognitive functioning and post-injury changes.  “Using ImPACT has allowed physicians and concussion experts to measure and track neurocognitive changes after injury.  Its reliability and validity in measuring the cognitive impact of brain trauma is second to none” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological Service at Whittier Rehabilitation Hospital in Westborough.

 

Contact Dr. Sefton at WRH – 508-870-2077 with questions about using ImPACT for baseline cognitive testing and its utility in measuring recovery from concussion. For a parent meeting please contact WRH or MSefton directly.