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

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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

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.

Clock of the Week June 6

Westborough, MA June 6, 2017 The clock of the week is depicted below.  It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital.  I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine.  I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient.  It was drawn by a 93-year old male with congestive heart
 

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Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s.  This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient.  The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well.  I once had a patient draw and elaborate grandfather clock fit for a castle.  The clock face became secondary and insignificant – for him.  The clock is a regular feature here at Concussion Assessment and Management.  
Anyone can submit a clock for consideration of the clock of the week.  Upload to my email address: msefton@whittierhealth.com – No identifying HIPPA protected information please but a brief overview is always helpful. 

Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/pagets-disease-of-bone/home/ovc-20183843 Taken June 6, 2017

Multiple Sclerosis: And it’s insidious impact on thinking

WESTBOROUGH, MA May 15, 2017 Multiple Sclerosis is a demyelinating disorder that affects the brain and spinal cord of those so afflicted. MS is a disease that causes the immune system to attack the protective covering around the nerve fibers (Reference.com). Many of the nerves in the brain and spinal cord are covered with a myelin sheath – something like insulation on wire.  This permits the instantaneous transmission of nerve impulses from one part of the body or brain to another. In patients suffering with MS their myelin is deficient sometimes having reduced efficiency or not working at all. It is a condition that for many gets better and gets worse.  As you can see from this image taken from Google images the myelin sheath is the outer layer or membrane of fatty Schwann cells and other neuroglial support cells. MS may be linked to a virus and/or immunological compromise but its true etiology is not known.
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Google images
We see a fair number of persons afflicted with M.S. in the rehabilitation hospital here in Massachusetts. MS is known to be relapsing and remitting in its quality which adds to treatment complexity and frustration for patients. They are a fiercely independent group of people and I can certainly understand why that might be.  On some days they are able to get themselves out and into their cars for the drive to work something we might take for granted.  While on other days, they may have difficulty putting on their their shoes and making lunch.  Many are frustrated and angry that they cannot take care of themselves and sometimes wind up in our hospital getting physical therapy and other restorative therapies.  Aquatic therapy is a great resource we offer at Whittier in Westborough, MA.  I encourage people to become familiar with aquatic programs
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Clock drawing by patient with early onset MS
in their area. They can provide support, pain management and effective physical therapy for those who may have limited energy resources.  Fatigue becomes a problem in nearly all patients who suffer with multiple sclerosis.  Cognitive changes are common in patients who experience long-term MS that sometimes make subtle changes in personality and all higher order problem solving, reasoning, and other executive functions.  Some believe there are distinct personality features in those with MS
In addition to frustration and anger, some patients are resistant to restorative solutions suggested by rehabilitation team members who want to help.  Some say “they want to do things their way” and resist rehabilitative suggestions that might offer energy conservation strategies or innovative methods for greater independence.  Medication is used to reduce inflammation associated with MS and prevent relapse.

Reference.com. (2017) https://www.reference.com/health/treatments-multiple-sclerosis-2ed87c70dcd71896. Taken May 6, 2017

Leadership is … being a friend when necessary


“Mike, the way to get followers is to be clearly understood”

Brian Gagan,  Leadership Strategies of Phoenix Arizona

Michael Sefton and Brian GaganMarch 24, 2016 As a matter of practice I try and stay in touch with good friends as often as I can.  I have some very good friends in this life.  Some I have known for over 25 years.  We travel together and try to meet two or three times a year.  I am difficult to pin down on dates and arrival times, etc. I know this about myself.  But occasionally I am vague and my friends become frustrated with me.  Especially as our travel dates grow close.  Once I had to cancel a planned visit 2 days before hand because of something I had forgotten about that I could not miss.  My friend Brian and I have enjoyed a good friendship in spite of being quite different.  Our skill sets often complement one another. But in some ways I’d like to be more like him.

Brian is a leader. Intelligent, concise, unwavering. I admire him very much. We worked together as police officers and later by contributing to the domestic violence literature by investigating a horrific case of domestic violence in northern Maine.  His decisions are usually sound, forthcoming and without regret. In preparation for our upcoming trip Brian had asked that I confirm plans with him no later than Saturday.  I forgot to do this.  As a result Brian made alternative plans to meet with other friends who could be more concise and unwavering than I am able to be.  The remarks above were made to me during my telephone apology for being late and missing the deadline.  “The way to get followers is to be clearly understood.” He is correct as usual.  I missed that message in the lead up to the Saturday deadline which I now regret.  Clearly Brian had grown tired of my yammering.  I wanted to meet him for a few days of R & R but was prototypically vague.  By the time my plan crystallized Brian had moved on to other friends and activities – in the lead.  My bad.  I will miss seeing him next month in Maine along with other friends.  But I will be ready for our next visit and I will endeavor to be clearly understood in my communication with him.  Perhaps he will follow me next time.

The way to get followers is to be clearly understood.  I get it.  Thank-you for that lesson in leadership.  You are a good friend.

Is there risk associated with valve replacement surgery?

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Clock drawing of 66-year old patient who was recent recipient of prosthetic aortic valve. Premorbid health was otherwise excellent.

WESTBOROUGH, MA  March 28, 2016 Whenever surgery is recommended there are inherent risks that should be understood. The  fast answer is “yes, there are risks when you replace someone’s aortic valve.” But not so fast.

Cardiac surgery has become almost commonplace in the current medical society.  Here in the Boston area there are several heart centers providing surgical treatments and risks have been greatly reduced in the past 25 years. Procedures are now minimally invasive and require much less recovery time than the former procedures.  Many centers are also using robotic assistance in valve replacement.  There are at least 3 major centers in Boston with excellent surgical teams.  Your physician will discuss these with you but the patient must understand the risk versus reward conundrum.  You can read the list below for a bullet point visual.  This is the case whenever one embarks on treatment – “what are the risks of taking one drug over another?” or “is there a risk when I undergo surgery to replace a stenotic heart valve?

One’s heart valves are meant to last a lifetime.  The heart valves are paper thin and amazingly flexible and strong. The majority of people are born with the valves they will have at the end of life – 5-6 billion beats later. Arguably the greater risk associated with valve replacement surgery may be linked to the pre-surgical health of the recipient of the valve.  It is common that patients have multiple comorbid medical conditions such a diabetes, poor cardiac health, hypertension, and obesity.  The outcomes become only slightly murky with the host of illnesses I just cite.

My role in the cardiac rehabilitation is to assess cognitive functions when necessary. This includes concentration, attention, S-T memory, problem solving, and higher order thinking skill.  It is not uncommon for patients to have altered mental status following surgery.  Sometimes this is simply the result of pain cocktail and anesthesia but other conditions can contribute to changes in one’s cognition as well.  Sometimes I am asked to provide support and counseling for those few patients who exhibit affective changes or frank signs of depression. On occasion behavior therapy is needed to redirect idiosyncratic motor restlessness or agitation.  In general the goal of cardiac rehabilitation is to enhance functional capacity in the areas of endurance, physical fitness and activities of daily living to regain their independence.  Full recovery requires a change in habits and lifestyle. This takes time.

The rehabilitation process is a continuum of care provided to those recovering from surgery who may be ready for the changes that will take them forward.  This includes physical exercise and the nutritional support needed to enhance patient outcome.

The vast majority of patients who undergo valve replacement surgery sail right through it and never come to hospital acute rehabilitation.  Most are referred to outpatient rehabilitation where they stay at home and attend rehabilitation during the day.  For those who are sent for inpatient rehabilitation they wrestle with fatigue as much as anything.  Many were in poor physical shape prior to surgery because of the insidious impact of declining cardiac health in the months or years prior to the procedure.  Post surgical depression is common in as many at 25-40 % of cases. Psychotherapy and coaching can assist in the management of feelings that are sometimes present during recovery.  I have heard “why am I doing this…” just as much as: “I can do this and have a second chance for health…”.

Risks of valve replacement

  • Infection
  • Blood clots
  • Cardiac arrhythmia – atrial fibrillation
  • Excess bleeding
  • Transient ischemia or stroke
  • Kidney failure
  • Death – 1-2 %
NHS – UK website – taken 3-10-2016

The Cleveland Clinic has a wonderful video that is attached.

Cleveland Clinic Cardiac – Valve Replacement video

NFL yields to pressure acknowledging link to CTE

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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.