Team Physician's Corner

CONCUSSION

Micheal B. Minix, Sr., M.D. Research
http://www.cappaa.com

The Kentucky Traumatic Brain Injury Prevalence Study January, 2004 showed that sports and recreational activities were the second leading cause of Traumatic Brain Injuries (TBI) in Kentucky. Sports and recreational represents 17.1% of TBI. Automobile accidents were first at 34%. These two were by a considerable margin the leader categories.

American football athletes and coaches often suffer with mental illness and depression from concussions. Multiple head injuries have been shown to result in severe mental illness to football players later in their life. A traumatic brain injury is characterized by loss of consciousness, confusion, amnesia for the events, and other neurological signs. Concussion often results later with loss of mental functioning, memory, migraine, seizures, dizziness, and depression.

Charlie Pell, a Bear Bryant disciple, and an assistant to Charlie Bradshaw at University of Kentucky from 1965-1969 suffered with severe depression. Pell made a public service documentary about his depression for the state of Alabama. His documentary was a very noble achievement and an excellent source of public information.

Bear Bryant said he cried often when head coach at Kentucky. He would often stop and vomit on the way to football practice and games. “I’ll tell you I’ve cried, literally cried like a baby” over some minimal matters.

Bryant was a textbook example of depression. He felt hopelessness and insecurity. Bryant manifested the depressive symptoms of inappropriate crying, empty feelings, loss of confidence and loss of temper. He was irritable, felt miserable, had difficulty sleeping and awakened too early.

An investigation has been conducted concerning the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players. Depression is the most cited psychological disturbance after traumatic brain injury, with prevalence rates from 6% in cases of mild traumatic brain injury to 77% in more severe TBI within the first year after injury. Retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression.

“In 2001 Kevin Guskiewicz, research director of the Center for the Study of Retired Athletes at the University of North Carolina at Chapel Hill was surprised by the depression statistics. Athletes with no concussions had a lifetime depression diagnosis rate of 6.6 %. That is about the same as the general male population. Once they suffered three or more traumas, however, the rate skyrocketed to 20.2 %. The depressions, can interact with other health problems to destroy the former athletes’ lives. The depressions have a snowball effect. The football player is retired from football, overweight, has musculoskeletal problems like sore knees, ankles, hips, not exercising. and life begins to go downhill.”.

Concussions can trigger a chemical chain reaction in brain neurons that that can cause athlete disorientation, unconsciousness, or death. TBI can also impair learning over a period of years. Barret Robbins, Oakland Raiders Pro Bowl center, suffered from severe depression. “The demons running loose inside Barret Robbins’ head put the football player in a San Diego hospital on Super Bowl Sunday”. The physical power of his 6-foot-3, 320-pound body was no match for the illness.

Athletes can be devastated by emotional and physical changes that come with depression. Worse is the athletes’ unwillingness to deal with their condition. The tough-man football environment makes them ashamed of their supposed “weakness,” Physical side effects from medication and the depression are the most difficult opponents they will ever confront.

”As athletes, we are taught to be tough,” said former NHL all-star Pat LaFontaine, who has battled depression. “You get up and shake it off. But you can’t do that with depression”. Former U.S. Olympic diver Wendy Williams once collapsed in front of her refrigerator, overwhelmed by something as simple as deciding what to eat. She quit getting into her car for fear she would drive off a cliff to escape her misery. “For me, the harder I tried, the worse it got.” Spiraling into shadows so dark she thought she’d never get out.

Harry Carson, middle linebacker with the New York Giants was a renowned defensive football player, intelligent, athletic and forceful, selected for the Pro Bowl. He was known for aggression. After a collision a dazed, Carson got up and walked back into the Giants’ huddle. As he stood holding his teammates’ hands, everything went black. He didn’t faint or stop playing. He was unable to figure out his coach’s signals from the sidelines. He couldn’t call the next play, as the middle linebacker is expected.

Blackouts like these were becoming familiar sensations for Carson. Over 13 seasons, he estimates he received between 15 and 18 concussions. Toward the end of his career Carson began to exhibit the cumulative effects of all these hits. He developed post concussion syndrome.

Carson developed headaches and muscle twitches. He grew sensitive to bright lights and loud noises, making it difficult for him to sit in a busy restaurant or do a television interview. He’d lose track of time. Athletes like Carson were not studied by scientists until recently. Because of the numerous football fatalities each year in the 1960s, particularly at the high school level, researchers were much more concerned with on-field catastrophes.

“When someone dies, that catches everyone’s attention,” says neurosurgeon Robert Cantu, medical director of the National Center for Catastrophic Sports Injury Research. “It’s not surprising that fatalities in football have been tracked since 1931.”

“Thanks to better protective equipment and safer coaching techniques, football deaths have now dropped to single digits each year. The decline has allowed scientists to focus on more subtle traumas, and concussions are chief among them. Neurosurgeons have shown that even a minor ding can trigger a neurological cascade that can eventually cause cognitive dysfunction and mental illness. Among retired football players who have sustained three or more concussions, 20 percent have been diagnosed with clinical depression—more than three times the rate of players who never got a concussion.”

Half of those players are taking antidepressant medications. Most report that the condition impedes their normal daily activities, such as shopping for groceries and going to work. At the UCLA Brain Injury Research Center, neuropsychologist David Hovda has studied the cascade of these injuries. An injured athlete may be oblivious to the neurochemical cascade inside his brain. “You can see a broken arm,” says Carson. “You can see a torn ligament in the knee. But with a concussion, you don’t see it.” The effects show up in statistical research.

Many other sports other than American football have frequent concussions. Soccer, hockey and baseball are examples. Matser and Lezak compared the results of swimmers and runners and found the soccer players were three to four times more likely to show deficits in memory and planning skills. The more concussions players suffered, the lower their scores on three of the 16 tests. Lezak is unsurprised. “I know what happens when you bat on the brain,” she says. “Given what we know about boxing, it would have been surprising if we hadn’t found anything. In soccer, people are punishing themselves in much the same way boxers do.”

The athletic community has developed a heightened awareness concerning traumatic brain injury and concussion. Scientists are researching concussion pathology. Manufacturers are developing better protective helmets. Taking the head out of football during blocking and tackling is an extremely important technique that should be instructed and enforced.

References:
1. University of Kentucky Center on Drug and Alcohol Research KENTUCKY TRAUMATIC BRAIN INJURY PREVALENCE STUDY January 2004 Prepared For The Kentucky Traumatic Brain Injury Trust Fund Board and The Kentucky Department of Mental Health and Mental Retardation, Brain Injury Services Unit, Colleen A. Ryall, Ed.D, Director Report Prepared by: Robert Walker, M.S.W., L.C.S.W., Assistant Professor TK Logan, Ph.D., Associate Professor Carl Leukefeld, D.S.W., Professor and Director Erin Stevenson, M.S.W., Research Coordinator CDAR TECHNICAL REPORT NO. 2004-01
2. Recurrent Concussion and Risk of Depression in Retired Professional Football Players MedScape Posted 06/19/2007 Kevin M. Guskiewicz; Stephen W. Marshall; Julian Bailes; Michael McCrea; Herndon P. Harding Jr; Amy Matthews; Johna Register Mihalik; Robert C. Cantu
3. Fearsome opponent By Patrick Saunders Denver Post Sports Writer Monday, March 10, 2003 - Bipolar disorder.
4. Discover Science, technology, the future Lights Out Can contact sports lower your intelligence? by Barry Yeoman December 3, 2004
5. SIVAULT August 15, 1966, “I'll Tell You About Football” by Paul Bryant and John Underwood

Sports 911 Emergency Action Plan

Micheal B. Minix, Sr., M.D. Research

BOY SCOUT MOTTO: BE PREPARED

• Assessment: evaluate level of consciousness, orientation in time, place and person, respiration/breathing, pulse, blood pressure, temperature.
• Try to determine the Cause, signs, symptoms and types of emergencies: Emergencies include injuries and illnesses such as diabetic hypoglycemia, dehydration, heat stroke, cardiac arrest, heart attack, seizure, cerebral vascular accident/stroke, hemorrhage, lacerated liver, ruptured spleen, collapsed lung and broken ribs, traumatic brain injury, concussion, fractured skull, cervical, thoracic and lumbar spine injuries All categories must be included in the plan.
• Try to determine the Cause, signs, symptoms and types of emergencies: Emergencies include injuries and illnesses such as diabetic hypoglycemia, dehydration, heat stroke, cardiac arrest, heart attack, seizure, cerebral vascular accident/stroke, hemorrhage, lacerated liver, ruptured spleen, collapsed lung and broken ribs, traumatic brain injury, concussion, fractured skull, cervical, thoracic and lumbar spine injuries All categories must be included in the plan.
• Team of responders: includes the Athletic Team Internal Responders: coaches, trainers, team physician / nurse, designated AED responder, record keeping responder to record emergency event, communication-telephone operator responder, maintenance responder to open door or gate and meet the EMS and the External Responders: EMS, police, fire department, hospital and physician / nurse.
• Proper training of the responders and ability to use the equipment
• Properly functioning equipment for the emergency event that has been satisfactorily maintained. An emergency station area must be designated. All working, maintained equipment must be at the emergency station. The minimal equipment must be: tourniquet, first aid kit, eye wash, flashlight, seizure bite block, variety of splints, icy kitty pool for water with hose and 2 large chests of ice, automated external defibrillator, and fire extinguisher.
• Communication among responders: A working phone must be kept at the emergency station on the practice field, stadium, or arena. The entrance for EMS should be designated and keys to that entrance, if applicable, kept with the phone. Emergency numbers for EMS, Team physicians and family numbers should be kept with the emergency phone. The phone communication-telephone operator responder should call all the External Responders including the family.
• Follow up: the record keeping responder should complete a form and self report the emergency event to school officials. Name, address, family phone numbers, mother and father’s name, injury, response, transport of athlete and result.
• All emergency records and sports related injuries must be reported to Authorities.
• Continuing Education for responders. All responders must have continuing education about the Sports 911 Emergency Action Plan.
• THE PLAN MUST BE PRACTICED AND DRILLED FREQUENTLY JUST LIKE THE SCHOOL FIRE DRILL.
• Athletes who suffer Exertional Heat Illness or Exertional Heat Stroke must be submerged in the icy kiddy pool of water as soon as possible after suspected.

Reference: National Cheer Safety Foundation

HOW HOT IS HOT ENOUGH FOR HEAT STROKE

December 7, 2009 by Micheal B. Minix, Sr., M.D. Research

How hot is hot enough to cause a heat stroke is variable because Primary and Secondary Predisposing Risk Factors contribute to Death from heat illness and abnormal body heat balance or abnormal thermoregulation.

There are reports of death from heat illness with temperatures in the 70's, because of Primary and Secondary Predisposing Factors often come into play.

Core Body Temperature above 104° alone from dehydration from insufficient water consumption might not be the sole cause of heat illness. An athlete patient might have one of the following associated with body heat imbalance and lethal body temperature while practicing, playing or exercising in the heat. Water consumption errors do not always account for all heat illness deaths.

PREDISPOSING RISK FACTORS AND HEAT ILLNESS

I. PRIMARY RISK FACTORS FOR HEAT STROKE AFFECT THE AIRWAY, BREATHING AND CIRCULATION/CARDIOVASCULAR SYSTEMS DIRECTLY.

1. Inadequate Oxygen and/ or Inadequate Airway

2. Breathing Difficulty. Can’t Breathe on their own.

3. Circulation Compromise and Cardiovascular Pathology

Athletes can have a Heat Stroke at 70° Fahrenheit if other Risk Factors are in effect, most notably the Primary Risk Factors. A dangerous Air Quality Index (AQI) is a Primary Risk Factor. It directly affects the Airway, Breathing, Circulatory and Cardiovascular systems, the ABC’s of Resuscitation. Medications and infections are Secondary Risk Factors. They are less fast fatal Risk Factors.

The ABC’s of Resuscitation are a mnemonic used in the care of the unconscious or unresponsive patient. It is used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations. Airway, breathing, and circulation are vital for life, and each is required, in that order, for the next to be effective. The Heat Stroke Patient must have the ABC’s attended and stabilized first in that order:

SECONDARY RISK FACTORS

I. MEDICATIONS

A. Sympathomimetics (alpha adrenergic agonists)
1. Amphetamines
2. Epinephrine
3. Ephedrine
4. Cocaine
5. Norepinephrine

B. Anticholinergics
1. Atropine
2. Scopolamine
3. Benztropine mesylate
4. Antihistamines

C. Diuretics
1. Caffeine
2. Alcohol
3. Furosemide (Lasix)
4. Hydrochlorothiazide
5. Bumetanide (Bumex)

D. Phenothiazines
1. Prochlorperazine
2. Chlorpromazine hydrochloride
3. Promethazine hydrochloride

E. Butyrophenones
1. Haloperidol (Haldol)

F. Tricyclic Antidepressant
1. Amitriptyline (Elavil)
2. Imipramine
3. Nortriptyline
4. Protriptyline

G. Monoamine Oxidase Inhibitors
1. Phenelzine
2. Tranylcypromine

H. Recreational and Illicit Drugs
1. Alcohol
2. Lysergic Acid diethylamide (LSD)

I. Other Medications
1. Beta Blockers
2. Calcium Channel Blockers
3. Lithium

Heat Illness Prevention

II. Pathophysiology Predisposing conditions alter heat balance

1. Increased Endogenous heat load
1. Vigorous Exercise or overexertion
2. sympathomimetic drugs

2. Increased Exogenous Heat load
1. Sun Exposure
2. Increased Heat Index

3. Decreased Heat Dissipation

a. Exogenous cause
1. Humidity
2. Occlusive or excessive clothing

b. Endogenous cause
1. Dehydration
2. Lack of acclimatization
3. Healed burns
4. Sunburn
5. Dermatitis
6. Sweat Gland Dysfunction

4. Other predisposing factors for abnormal heat balance

a. Prior Heat Stroke

b. Concurrent infection
1. Upper Respiratory Infection
2. Gastroenteritis

c. Elderly
1. Myocardial dysfunction
2. Decreased muscle mass
3. Decreased skin blood supply
4. Renal insufficiency
5. Chronic illness

d. Comorbid medical condition
1. Anorexia
2. Cystic Fibrosis
3. Diabetes Insipidus
4. Poorly controlled Diabetes Mellitus
5. Obesity
6. Hypokalemia

References:

William O. Roberts, MD, sports medicine MinnHealth in White Bear Lake, Minn Czerkawski (1996) Your Patient Fitness 10(4): 13-20

Sandor (1997) Physician SportsMed, 25(6):35-40

Barrow (1998) Am Fam Physician 58(3):749

Hett (1998) Postgrad Med 103(6):107

Wexler (2002) Am Fam Physician 65(11):2307

Heat Illness

Promoting athlete’s safety is essential. Youth athlete injuries and heat illness have significantly increased during the last decade. Safe sports supervision and environments are imperative.

Coaching athletes in the 21st Century is unlike coaching them in the 20th Century, because today’s youth are different. First and foremost they are not as acclimatized to outside heat as athletes were 50 years ago, when central air conditioning wasn’t standard equipment, and indoor games and computers were non-existent. Athletes played outside many hours each day.

This fall before schools begin, youth athletes will begin conditioning and practicing for their fall schedules. Intense conditioning and practice will require replacement of water and salt because of loss from sweating.

The signs and symptoms are headache, dizziness fainting, weight loss, increased body temperature, thirst, muscle cramps, nausea and maybe seizures and unconsciousness.

Reference: American Academy of Pediatrics Committee on Sports Medicine, heat related illnesses are all preventable. (Sports Medicine: health Care for Young Athletes, American Academy of Pediatrics, 1991.)

"1. Each athlete should have a physical examination with a medical history when first entering a program and an annual health history update. History of previous heat illness and type of training activities before organized practice begins should be included. State High School Associations recommendations should be followed.

2. It is clear that top physical performance can only be achieved by an athlete who is in top physical condition. Lack of physical fitness impairs the performance of an athlete who participates in high temperatures. Coaches should know the physical condition of their athletes and set practice schedules accordingly.

3. Along with physical conditioning the factor of acclimatization to heat is important. Acclimatization is the process of becoming adjusted to heat and it is essential to provide for gradual acclimatization to hot weather. It is necessary for an athlete to exercise in the heat if he/she is to become acclimatized to it. It is suggested that a graduated physical conditioning program be used and that 80% acclimatization can be expected to occur after the first 7-10 days. Final stages of acclimatization to heat are marked by increased sweating and reduced salt concentration in the sweat.

4. The old idea that water should be withheld from athletes during workouts has no scientific foundation. The most important safeguard to the health of the athlete is the replacement of water. Water must be on the field and readily available to the athletes at all times. It is recommended that a minimum of 10 minute water breaks be scheduled for every half hour of heavy exercise in the heat. Athletes should rest in a shaded area during a break. Water should be available in unlimited quantities. Check and be sure athletes are drinking the water. Cold water is preferable. Drinking ample water before practice or games has also been found to aid performance in the heat.

5. Salt should be replaced daily. Modest salting of foods after practice or games will accomplish this purpose. Salt tablets are not recommended. Attention must be directed to replacing water - fluid replacement is essential.

6.  Know both the temperature and humidity. The greater the humidity the more difficult it is for the body to cool itself. Test the air prior to practice or game using a wet bulb, globe, temperature index (WBGT index) which is based on the combined effects of air temperature, relative humidity, radiant heat and air movement. The following precautions are recommended when using the WBGT Index: (ACSM's Guidelines for the Team Physician, 1991).

There is also a weather guide for activities that last 30 minutes or more (Fox and Mathews, 1981) which involves knowing the relative humidity and air temperature:

  RH= Relative Humidity

One other method of measuring the relative humidity is the use of a sling psychrometer, which measures wet bulb temperature. The wet bulb temperature should be measured prior to practice and the intensity and duration of practice adjusted accordingly. Recommendations are as follows:

7. Cooling by evaporation is proportional to the area of the skin exposed. In extremely hot and humid weather reduce the amount of clothing covering the body as much as possible. Never use rubberized clothing.

8. Athletes should weigh each day before and after practice and weight charts checked. Generally a 3 percent weight loss through sweating is safe and over a 3 percent weight loss is in the danger zone. Over a 3 percent weight loss the athlete should not be allowed to practice in hot and humid conditions. Observe the athletes closely under all conditions.

9. Observe athletes carefully for signs of trouble, particularly athletes who lose much weight and the eager athlete who constantly competes at his/her capacity. Some trouble signs are nausea, incoherence, fatigue, weakness, vomiting, cramps, weak rapid pulse, visual disturbance and unsteadiness.

10. Teams that encounter hot weather during the season through travel or following an unseasonably cool period, should be physically fit but will not be environmental fit. Coaches in this situation should follow the above recommendations and substitute more frequently during games.

11. Know what to do in case of emergency and have your emergency plans written with copies to all your staff. Be familiar with immediate first aid practice and prearranged procedures for obtaining medical care, including ambulance service. Heat Stroke: This is a medical emergency - delay could be fatal. Immediately cool body while waiting for transfer to a hospital. Remove clothing and use cool water on body. An increasing number of medical personnel are now using a treatment for heat illness that involves applying either alcohol or cool water to the victim's skin and vigorously fanning the body. The fanning causes evaporation and cooling. (Source - the First Aider, September 1997) Heat Exhaustion: Obtain medical care at once. Cool body as you would for heat stroke while waiting for transfer to hospital. Give fluids if athlete is able to swallow and is conscious.

SUMMARY: The main problem associated with exercising in the hot weather is water loss through sweating. Water loss is best replaced by allowing the athlete unrestricted access to water. Water breaks two or three times every hour are better than one break an hour. The small amount of salt loss in sweat is adequately replaced by salting foods at meals. Talk to your medical personnel concerning emergency treatment plans.”