Vermont has joined the growing group of states that are weighing laws regarding student athletes returning to play after sustaining a concussion, according to the Rutland Herald.
http://www.rutlandherald.com/article/20100301/NEWS03/100229936/1004/NEWS03
The bill pending in Vermont was proposed by a lawmaker who is also a physician, Rep. George Till of Jericho, Vt. Till is particularly concerned about so-called “second-impact syndrome,” where a second head injury leads to permanent brain damage. His bill would bar athletes from coming back to the field any sooner than one day after any symptoms they have go away.
Till’s bill, which is aimed at sports and athletes in Vermont public schools, mandates that players who sustain a concussion would need to get a doctor’s note before returning to sports. Coaches would also have to take new medical training.
The bill has its opponents, including physicians and trainers who argue that the law shouldn’t be used to prescribe medical care. That objection is just ridiculous. Banning an early return is not practicing medicine. It is just making sure.
NFL, War and Brain Injury
My internet news today had an intersecting of two recurring themes in the brain injury world, with that of an unexpected death of a former NFL player. The first theme is the difficulties retired NFL players have with disability. The second theme the degree of depression found in post Iraq war veterans. What does the death of Curtis Whitley have to do with the other two themes? Perhaps nothing, but even if this case doesn’t, other similar cases could. For the full story on the death of Curtis Whitely, click here.
Anyone who works in the field of brain injury, has often turned the old cliché about mental illness “Its all in the head” on itself, because of course, anything to do with the brain, is in the head. But, the extent of the interplay between emotional problems and brain injury is never, and I repeat never, fully appreciated. As I sit here and write this, I can’t fully appreciate this interplay, because it involves the area of human emotions and function, that we are only scratching the surface in our capacity to understand and have no clue as to how to measure.
Brain injury deficits and emotional deficits are synergistic, meaning the whole of the problems when you combine these two, is greater than the sum of the parts. From a recent deposition I took of a defense neuropsychologist:
But perhaps, Iraq war veterans will have a better fate. A recent article in the Science Daily, promises more for them, and we will discuss such issues in our next blog. Click here for that story.
Anyone who works in the field of brain injury, has often turned the old cliché about mental illness “Its all in the head” on itself, because of course, anything to do with the brain, is in the head. But, the extent of the interplay between emotional problems and brain injury is never, and I repeat never, fully appreciated. As I sit here and write this, I can’t fully appreciate this interplay, because it involves the area of human emotions and function, that we are only scratching the surface in our capacity to understand and have no clue as to how to measure.
Brain injury deficits and emotional deficits are synergistic, meaning the whole of the problems when you combine these two, is greater than the sum of the parts. From a recent deposition I took of a defense neuropsychologist:
Q If I were going to use the term “synergistic” to apply to the cumulative effect of all of these multifactorial aspects of an outcome, is that a reasonable word to use to describe it.With respect to Whitley, the 39 year old was found face down in a bathroom in Fort Stockton, Texas. The local sheriff said there was no indication of foul play, but the case is under investigation. That investigation will likely look at Whitley’s history of drug and/or alcohol abuse. What won’t be examined is how many concussions he had, how his dependencies on substances might have interplayed with those concussions and how his emotional vulnerabilities from the combination of the two contributed to the end of his NFL career and his premature death.
A Can you define how you’re using synergistic?
Q Well, if synergistic means the total exceeds the sum of the parts, do you believe that post concussional deficits can be synergistic?
Q I’ll add to that. Do you believe that the cumulative disability from post-concussional deficits can be synergistic?
A I believe — I hope I’m answering this consistent with what you’re asking — but I believe that these factors can feed off of each other and result in a very complex, poor outcome.
But perhaps, Iraq war veterans will have a better fate. A recent article in the Science Daily, promises more for them, and we will discuss such issues in our next blog. Click here for that story.
Evolution of the Definition of Concussion
My last blog focuses the acute symptom of amnesia, the symptom that is now believed to be the most significant predictor of outcome after concussion. However, that is the modern way of looking at concussion, and unfortunately, not even all treatises or commentators on brain injury, are even willing to look at amnesia in absence of a documented loss of consciousness at the time of concussion.
I have a fairly extensive library of brain injury treatises in my library, something many of you who have seen my websites or brain injury videos will recognize. If we were going to look at those books, you might be surprised as to how different the definition of concussion is in those books from what is the current thinking about concussion.
For example, one of the treatises that is on more neurologists shelf than almost any other, Adams and Victor, Principles of Neurology- that books says that you can not have a mild brain injury, you can not have a concussion, without a loss of consciousness.
That frankly is wrong.
But this book has been restating that basic principle since it was originally published in 1977. The copy on my shelf was printed in 1997, and the most recent version says the same thing. That is not the current thinking about concussion, not the thinking of the CDC, not the thinking of the American Academy of Neurology. But because it is content on one of the leading treatises in neurologist’s own libraries, it is the thinking of a far greater percentage of neurologists than should in fact be the case.
The definition of concussion really started to change about 1992, even though the research behind that change dates back at least as far as 1971. What happened in 1992 is that there was the American Congress of Rehabilitation Medicine’s (“ACRM”) published its definition of “mild traumatic brain injury.” In that definition, the ACRM abandoned the absolute requirement that you had to have a loss of consciousness to be diagnosed with a brain injury. The ACRM definition substituted this requirement with four different, alternative, what I describe on my website as acute events. Those events were Loss of Consciousness, a Change in Mental State, Amnesia, and Focal Neurological deficits. Source: Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, published at J Head Trauma Rehabil 1993:8(3):86-87 For the full context of the ACRM definition, click here.
The only one of those that really adds a significant amount to the diagnostic picture is amnesia. But because amnesia is one of those things that doesn’t have a true objective measure and something that is not particularly sensitive to be identified in the emergency room, amnesia has not helped us define mild brain injury/ in the cases where people are long term disabled as much as it should. See the previous blog on Amnesia, and the blogs that will follow later this week.
The 1992 ACRM definition of concussion was ultimately followed by the American Academy of Neurology’s work with concussion in sports. Those two movements had a major impact on changing the definition of concussion. That has ultimately lead to the extremely important “Heads Up Brain Injury in Your Practice “ which is published and distributed by the CDC. For those materials, click here.
Tomorrow: Concussion in Sport and How Relevant that is to Other Concussions
I have a fairly extensive library of brain injury treatises in my library, something many of you who have seen my websites or brain injury videos will recognize. If we were going to look at those books, you might be surprised as to how different the definition of concussion is in those books from what is the current thinking about concussion.
For example, one of the treatises that is on more neurologists shelf than almost any other, Adams and Victor, Principles of Neurology- that books says that you can not have a mild brain injury, you can not have a concussion, without a loss of consciousness.
That frankly is wrong.
But this book has been restating that basic principle since it was originally published in 1977. The copy on my shelf was printed in 1997, and the most recent version says the same thing. That is not the current thinking about concussion, not the thinking of the CDC, not the thinking of the American Academy of Neurology. But because it is content on one of the leading treatises in neurologist’s own libraries, it is the thinking of a far greater percentage of neurologists than should in fact be the case.
The definition of concussion really started to change about 1992, even though the research behind that change dates back at least as far as 1971. What happened in 1992 is that there was the American Congress of Rehabilitation Medicine’s (“ACRM”) published its definition of “mild traumatic brain injury.” In that definition, the ACRM abandoned the absolute requirement that you had to have a loss of consciousness to be diagnosed with a brain injury. The ACRM definition substituted this requirement with four different, alternative, what I describe on my website as acute events. Those events were Loss of Consciousness, a Change in Mental State, Amnesia, and Focal Neurological deficits. Source: Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, published at J Head Trauma Rehabil 1993:8(3):86-87 For the full context of the ACRM definition, click here.
The only one of those that really adds a significant amount to the diagnostic picture is amnesia. But because amnesia is one of those things that doesn’t have a true objective measure and something that is not particularly sensitive to be identified in the emergency room, amnesia has not helped us define mild brain injury/ in the cases where people are long term disabled as much as it should. See the previous blog on Amnesia, and the blogs that will follow later this week.
The 1992 ACRM definition of concussion was ultimately followed by the American Academy of Neurology’s work with concussion in sports. Those two movements had a major impact on changing the definition of concussion. That has ultimately lead to the extremely important “Heads Up Brain Injury in Your Practice “ which is published and distributed by the CDC. For those materials, click here.
Tomorrow: Concussion in Sport and How Relevant that is to Other Concussions