I had faded away to a place I thought I may forever stay.
I was aware enough to understand what others would say.
I took notes, I existed, I took medicine, I was given no hope.
For many years I was injured and just too unaware.
Many that I loved left and I handled it like I didn’ care.
I did care but I innately understood something was not fair.
I suspected it was me, so I was quiet and would not share.
I watched, I evaluated and this is what I realized was so hard to bear.
We departed without warning, and many loved ones missed us as well.
They knew we were injured, they had lives and stressors and they wanted to yell.
They realized they had lost us to an injury and another easier day.
I had faded away I thought to a place I was destined to stay.
I kept fading away, having non stop seizures and feeling in the way.
I took notes, I started taking baby steps forward sure that if I persevered
there could be a new day someday some way! I did not continue to fade away!
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
SAN DIEGO — Although athletes with suspected concussions should be benched immediately, their return to play may be handled flexibly according to symptoms and risk of further injury, according to new guidelines from the American Academy of Neurology.
The revision — the first in more than 15 years — does away with the previous version’s concussion grading system as well as a set 10-day period before a participant could return to active play, according to Christopher Giza, MD, of the University of California Los Angeles, and colleagues.
Their evidence review did not support the fixed rest period, they indicated. Therefore, the new guidelines allow concussed players to resume at least some sports activities at any time, as long as they do not worsen symptoms or offer potential for a repeat concussion.
The new guidelines were released at the AAN’s annual meeting here, and also published online in the group’s journal, Neurology.
“We’ve moved away from the concussion grading system we first established in 1997 and are now recommending [that] concussion and return to play be assessed in each athlete individually,” Giza and colleagues wrote. “There is no set time line for safe return to play.”
On the other hand, athletes should return to play gradually and only after all acute symptoms have disappeared, according to the guideline.
Another key recommendation was that evaluation of suspected concussions in athletes should be conducted by a licensed professional with specific training in concussions.
And, the guideline emphasized that concussion is a clinical diagnosis. Various sideline and clinical assessment instruments “may be helpful tools in diagnosing and managing concussions,” the AAN said in announcing the guideline, “but should not be used alone for making a diagnosis.”
At a press conference held to announce the guideline, co-author Jeffrey Kutcher, MD, of the University of Michigan in Ann Arbor, reiterated the importance of recognizing that no single diagnostic test is reliable for a concussion diagnosis.
“There is not a diagnostic tool that is supported in the literature that can diagnose an injury, or that can diagnose when an injury is over,” he said.
In an editorial published in Neurology with the guideline, Anthony Alessi, MD, of the University of Connecticut in Farmington, Conn., and two NFLPA officials — including its executive director, DeMaurice Smith, JD — called it “reassuring” that neurologists were seeking to help in attempting to keep sports concussions from becoming lifelong and perhaps life-shortening problems for young athletes.
They noted that “much had changed” since 1997 when the AAN’s guidelines were last updated. “It was rare to see a neurologist on the sidelines or at ringside, Alessi and colleagues wrote.
Now, they indicated with approval, “sports neurology is now on its way to becoming a recognized subspecialty.”
According to the AAN panel’s evidence review, risks in males are greatest among football and rugby players, followed by hockey and soccer. In women and girls, most concussions occur in soccer and basketball.
Signs and symptoms of a concussion include headache; light and sound sensitivity; changes in reaction time, balance, coordination, memory, judgment, speech, and sleep; and loss of consciousness or blackout. Headache and “fogginess” are two ongoing symptoms that should be monitored closely after a concussion.
A previous history of sports concussion is a significant risk factor for another concussion, and the greatest risk for a second concussion is within 10 days of the first. Other risk factors include time spent playing a sport and an APOE4 genotype.
What the panel didn’t find was evidence suggesting that any particular type of football helmet was better than others in preventing concussions. (Recently, in fact, a study suggested that helmets are not particularly effective at preventing concussions at all, although they may protect against other types of head injuries.)
Nor did it find any specific interventions that clearly speed recovery or prevent long-term consequences of concussions.
In the absence of effective treatments, the panel’s recommendations focused on measures to prevent re-injury.
Kutcher said a major take-home message from the group’s evidence view is “a lack of data …. We need to do more science and the right kind of science.”
Along that line, he indicated that the research into chronic traumatic encephalopathy (CTE) — an emerging concept that repeated mild brain injuries eventually produce serious brain pathologies resembling Alzheimer’s disease — is not yet mature enough to be addressed in an evidence-based guideline. Kutcher called CTE “an anecdotal diagnosis” at this point, so far supported only by case reports.
Giza, also speaking at the press conference, said research was under way to better understand the molecular physiology of mild brain injuries, which must be monitored noninvasively.
“The resolution of the biochemical cascade [following concussion] is the holy grail,” he said.
Another important research need relates to the risk and consequence of concussion in youth sports, he added, noting that previous research has tended to focus on college and professional athletes, not to mention concussions in nonsports settings such as the military.
Kutcher addressed concerns that the new flexibility in when concussed athletes can return to play would be exploited by coaches — or the players themselves — as a loophole for early and dangerous resumption of contact sports.
He argued that the recommendation that management be led by a licensed and experienced healthcare professional would make such abuses extremely rare.
UPDATE: This article, originally published on March 18, 2013 at 2:00 p.m., was updated with new material at 7:45 p.m.
The guideline development was funded by the AAN.
Members of the guideline development committee and Alessi reported relationships with the NFLPA, the National Basketball Association, the National Collegiate Athletic Association, other sports bodies, UptoDate.com, E1MindA, and a variety of publishers for educational and other materials related to concussion. Several reported serving as expert witnesses in litigation. Alessi’s two co-authors for the editorial were NFLPA employees.
Primary source: Neurology Source reference: Giza C, et al “Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology” Neurology 2013.
I missed gentle treatment as I
traveled with a brain injury.
I could not understand what had
happened to amiable and tender
treatment. Everyone seemed so short
and curt. I also noticed how bad it hurt.
I could not understand why so many
seemed to feel a need to be harsh and
severe. All I ever wanted was for people
to act gentle, soft. kind and fair.
I never forgot I was a human being.
I never thought that I deserved less.
I never understood why anyone would
intimidate, harass or harm any disabled person.
Yes, I missed gentle treatment as I
traveled along with a brain injury. Lets
all remember to treat others gently!
Among individuals at low-to-intermediate cardiovascular risk, coronary artery calcification (CAC) score predicts the occurrence of stroke, even after accounting for traditional risk factors, researchers found. After adjustment for variables in the Framingham risk score, calcification score was significantly associated with a greater risk of incident stroke overall (HR 1.52, 95% CI 1.19 to 1.92), although the relationship was not significant for those with a high cardiovascular risk at baseline, according to Dirk Hermann, MD, of University Hospital Essen in Germany, and colleagues. Further adjustment for atrial fibrillation weakened — but did not eliminate — the association, the researchers reported online in Stroke: Journal of the American Heart Association. “That CAC, as we now have shown, is able to predict stroke events independent of established risk factors, [makes] this marker promising for risk stratification not only in the hands of cardiologists but also in the hands of neurologists,” they wrote, adding that the radiation exposure involved in the assessment needs to be considered. Evan Muse, MD, PhD, of Scripps Health in La Jolla, Calif., said it was unclear whether this study will lead to a change in clinical practice “because it was known for quite some time that stroke and coronary artery disease exist along the same spectrum of disease process in terms of atherosclerosis [and] inflammation.” Muse, who was not involved in the study, told MedPage Today that clinicians may choose to perform a calcification assessment for an individual patient to help better convey that patient’s stroke risk and induce the changes necessary to manage it. Calcification measured by electron-beam CT has been shown to predict myocardial infarction (MI) in the general population and also has been shown to enhance the discrimination of cardiovascular risk, particularly in patients with intermediate risk. To examine its ability to predict stroke risk, Hermann and colleagues turned to the population-based Heinz Nixdorf Recall study, which enrolled a random sample of individuals ages 45 to 75 from three cities in the industrialized Ruhr area of Germany. The current analysis included 4,180 individuals (mean age 59) who did not have a history of stroke, coronary heart disease, or MI at baseline. They were followed for an average of 7.9 years. During that time, 2.2% of the study population had a stroke — 82 ischemic strokes and 10 hemorrhagic strokes. The median coronary artery calcification Agatston score at baseline was significantly higher among those who had a stroke during follow-up (104.8 versus 11.2, P<0 .001="" along="" and="" calcification="" category.="" each="" increased="" of="" p="" rate="" stroke="" successive="" the="" with="">In a multivariate analysis that included age, sex, systolic blood pressure, LDL and HDL cholesterol, diabetes, and smoking, calcification score was an independent predictor of stroke, along with age (HR 1.35 per 5 years, 95% CI 1.15 to 1.59), systolic blood pressure (HR 1.25 per 10 mm Hg, 95% CI 1.14 to 1.37), and smoking (HR 1.75, 95% CI 1.07 to 2.87). Calcification score also remained a significant predictor when hemorrhagic strokes were excluded. The score predicted stroke in both sexes. It was a significant predictor among individuals younger than 65 (HR 2.21, 95% CI 1.59 to 3.06) but not in the older age group (HR 1.11, 95% CI 0.80 to 1.54). When the study participants were divided into Framingham risk groups, calcification score predicted stroke only in those with low (less than 10%) or intermediate risk (10% to 20%). “These observations indicate that among cohorts without apparent risk, subjects exist that nonetheless exhibit a high stroke incidence,” the authors wrote. “On the basis of our data, CAC is suitable to identify those subjects.” The researchers noted that three previous population-based studies — the Cardiovascular Health Study (CHS), Rotterdam study, and Multi-Ethnic Study of Atherosclerosis (MESA) — failed to show a significant association between coronary artery calcification and stroke after adjustment for traditional risk factors. That was “most likely because of lack of power related to lower stroke numbers observed in the population sample,” they wrote. Total stroke numbers ranged from 28 to 59 in those studies, compared with 92 in the current study.
The study was supported by the Heinz Nixdorf Foundation in Germany, the German Ministry of Education and Science (BMBF), and the German Research Foundation (DFG). Sarstedt AG supplied laboratory equipment. The authors reported that they had no conflicts of interest.