Two more states, New Jersey and Virginia, are weighing legislation relating to sports and concussions.
In the Garden State, Sen. Richard Codey (D-Essex) Monday introduced a bill that mandates that licensed athletic trainers take 24 hours of continuing education in sports medicine as a condition of their biennial license renewal. And four hours of that education would have to relate to concussions and brain injuries.
http://blog.nj.com/hssportsextra/2010/02/new_bill_targeting_concussion.html
But the proposed law drew criticism from the Athletic Trainers Society of New Jersey, which complained that it had not been consulted on the legislation. The group said that trainers are already required to take 75 hours of continuing education during a three-year period in order to retain their licenses.
Then in Virginia, a House of Delegates subcommittee Thursday passed a bill that will make the state Board of Education develop guidelines to identify and treat concussions in student athletes.
http://www2.wsls.com/sls/news/state_regional/govtpolitics/article/bill_on_student_athletes_concussions_advances_in_house_of_delegates/83790/
That bill was sponsored by Sen. Ralph Northam (D-Norfolk), and now will go to the full House of Education Committee. Northam is a pediatric neurologist.
The legislation mandates that student athletes who are suspected of having a concussion be benched during practice or a game, and get approval from a licensed health-care professional before coming back to play.
It will be interesting to see what each state comes up with for the definition and risks factors for concussion.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Super Bowl Coverage And the Concussion Issue
Better late than never. The NFL seems to have finally figured out that its sport’s future depends on protecting its most important asset, the players. It may be a little naive, but from this perspective, it seems that NFL Commissioner Roger Goodell really gets it. Concussions involve brain injury. Brain injured players aren’t very good players and have lots of problems after they retire.
With the Super Bowl just hours away from starting, Goodell told “Face the Nation” Sunday that the league was still studying ways to make the game safer and cut down head injuries in particular.
Goodell said that the so-called “three point stance,” where players square off with one hand on the ground, could eventually be barred, according to a New York Times story on his interview with Bob Schieffer. The article was headlined “Commissioner Stresses New Culture of Safety.” http://www.nytimes.com/2010/02/08/sports/football/08nfl.html?ref=sports
On the “Face the Nation,” Goodell said that for years “the culture” at the NFL was that concussions weren’t serious injuries.
“I think we have changed that culture and made sure that people understand they are serious and they can have serious consequences if they’re not treated seriously,” he told Schieffer.
On Super Bowl Sunday both The Philadelphia Inquirer and The Washington Post weighed in on the concussion issue.
In an editorial, http://www.philly.com/inquirer/currents/83742022.html
The Inquirer cited a Time magazine issue with a cover story on “the most dangerous game,” pro-football, which The Inquirer said “has crippled retirees mentally and physically.”
Young players sustain 140,000 concussions a year, and half of them return to the field so soon they may suffer permanent braind damage, The Inquirer warns.
And Washington Post columnist Leonard Shapiro complained that the Super Bowl pregame show and telecast made no mention of the concussion issue. http://www.washingtonpost.com/wp-dyn/content/article/2010/02/07/AR2010020703736.html
It is an interesting question, whether football is really the most dangerous sport. Boxing will always be on the top of my list even though it involves far fewer participants. The goal of boxing is to cause a brain injury to one’s opponent. Much of the impetus behind the growing movement to forbid return to play on the day of a concussion comes out of concern for the “second impact syndrome.” In second impact syndrome, the brain’s ability to regulate cranial blood pressure is impaired by the first concussion. When a second concussion occurs there can be a resulting catastrophic increase in intracranial pressure, ICP. It was such injury that caused Zachery Lystedt’s brain injury. Well how does one reconcile no return to play rules, when the injured person continues to box?
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
With the Super Bowl just hours away from starting, Goodell told “Face the Nation” Sunday that the league was still studying ways to make the game safer and cut down head injuries in particular.
Goodell said that the so-called “three point stance,” where players square off with one hand on the ground, could eventually be barred, according to a New York Times story on his interview with Bob Schieffer. The article was headlined “Commissioner Stresses New Culture of Safety.” http://www.nytimes.com/2010/02/08/sports/football/08nfl.html?ref=sports
On the “Face the Nation,” Goodell said that for years “the culture” at the NFL was that concussions weren’t serious injuries.
“I think we have changed that culture and made sure that people understand they are serious and they can have serious consequences if they’re not treated seriously,” he told Schieffer.
On Super Bowl Sunday both The Philadelphia Inquirer and The Washington Post weighed in on the concussion issue.
In an editorial, http://www.philly.com/inquirer/currents/83742022.html
The Inquirer cited a Time magazine issue with a cover story on “the most dangerous game,” pro-football, which The Inquirer said “has crippled retirees mentally and physically.”
Young players sustain 140,000 concussions a year, and half of them return to the field so soon they may suffer permanent braind damage, The Inquirer warns.
And Washington Post columnist Leonard Shapiro complained that the Super Bowl pregame show and telecast made no mention of the concussion issue. http://www.washingtonpost.com/wp-dyn/content/article/2010/02/07/AR2010020703736.html
It is an interesting question, whether football is really the most dangerous sport. Boxing will always be on the top of my list even though it involves far fewer participants. The goal of boxing is to cause a brain injury to one’s opponent. Much of the impetus behind the growing movement to forbid return to play on the day of a concussion comes out of concern for the “second impact syndrome.” In second impact syndrome, the brain’s ability to regulate cranial blood pressure is impaired by the first concussion. When a second concussion occurs there can be a resulting catastrophic increase in intracranial pressure, ICP. It was such injury that caused Zachery Lystedt’s brain injury. Well how does one reconcile no return to play rules, when the injured person continues to box?
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Connecticut Considers ‘Concussion’ Bill To Protect Student Athletes
Connecticut is the latest state to be weighing a law that would protect student sports players from the after effects of concussions.
Democratic lawmakers in the Nutmeg State have proposed the legislation, according to The Hartford Courant. http://www.courant.com/sports/other/hc-concussions0126.artjan26,0,93453.story
The law’s slogan is “When in doubt, sit it out.”
So far two states, Washington and Oregon, have already passed laws protecting student athletes from the effects of concussion. California has similar legislation pending.
The proposed Connecticut law mandates that student athletes who are believed to have suffered a concussion wait a day until they return to play their sport. The law also requires that coaches be educated about concussions.
The Connecticut bill is being sponsored by State Sen. Majority Leader Martin Looney of New Haven and Sen. Thomas Gaffey of Meriden.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Democratic lawmakers in the Nutmeg State have proposed the legislation, according to The Hartford Courant. http://www.courant.com/sports/other/hc-concussions0126.artjan26,0,93453.story
The law’s slogan is “When in doubt, sit it out.”
So far two states, Washington and Oregon, have already passed laws protecting student athletes from the effects of concussion. California has similar legislation pending.
The proposed Connecticut law mandates that student athletes who are believed to have suffered a concussion wait a day until they return to play their sport. The law also requires that coaches be educated about concussions.
The Connecticut bill is being sponsored by State Sen. Majority Leader Martin Looney of New Haven and Sen. Thomas Gaffey of Meriden.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Ex-Washington Football Player Sues School District, Chiropractor Over Concussion-Related Brain Injuries
A former high school football player in Washington State is suing his old school district and a local chiropractic clinic for brain injuries he received in 2006.
Adrien Gault alleges in his lawsuit that the Sequim School District didn’t follow protocol by allowing him to come back and play football after sustaining multiple concussions, according to a story, http://www.komonews.com/news/local/82474567.html,
from the Peninsula Daily News that KOMO-TV ran on its Web site.
Sequim Chiropractic Clinic owner Robert Bean and his wife were also named in the suit, which seeks unspecified damages. The lawsuit was filed in Clallam County Superior Court.
According to the story, Bean wasn’t qualified to clear Gault to resume playing football, which he did despite the fact that the young player had received multiple concussions, and had to be taken from the field on a stretcher in one instance.
When he was a senior for the Wolves high school team Oct. 20, 2006, Gault went into a coma on the sidelines shortly after he had collided with a teammate during warm-ups. He had suffered a subdural hematoma.
The suit charges that the school district knew that Gault had suffered numerous concussions prior to the Oct. 20 incident, according to the story.
Gault claims that he has problems stemming from his brain damage, including a memory lapses and headaches.
Brain injury and chiropractors should never mix. No one suspected of a concussion should be seeing a chiropractor, not just because of something like this that could go wrong, but because of the risk of an artery dissection from neck manipulation.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
The Near-Fatal Football Injury That Lead To California’s Proposed Laws on Concussions
We recently wrote that California is considering new legislation that would impose strict guidelines on when high school athletes can return to the field after sustaining head injuries. Only three other states have policies as strict as the one California is considering.
The San Francisco Chronicle today has a detailed story, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/24/MN6V1BM6OR.DTL, on
the young man whose near-fatal football injury lead to the proposed legislation.
Blea was playing for San Jose Academy High when he was hit in the chest during a play at a Thanksgiving Day game last year. He got up from the field, got to the sidelines and then collapsed. He was put in a drug-induced coma for a week, spent almost a month in hospitals and lost 31 pounds, according to the Chronicle.
The story cites a number of statistics regarding high school injuries. For example, about 68,000 concussions were sustained during the 2008 high school football season, according to the National High School Sports-Related Injury Surveillance Study.
And the man who helped organize that study, Ohio State associate professor Dawn Comstock, said that in 2008 16 percent of high school football players who had concussions where they lost consciousness went back to play that same day.
Blea played as a running back and linebacker, positions that one study found are most likely to get concussions.
Two U.S. high school players died as a direct result of football injuries last year, the Chronicle story says.
Physicians say Blea’s outlook is good, but he can’t play football again.
When he was hit, Blea fell and his head hit the turf, with his brain “slamming against his skull,” according to the Chronicle.
The story then describes his surgeries and recovery.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
The San Francisco Chronicle today has a detailed story, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/24/MN6V1BM6OR.DTL, on
the young man whose near-fatal football injury lead to the proposed legislation.
Blea was playing for San Jose Academy High when he was hit in the chest during a play at a Thanksgiving Day game last year. He got up from the field, got to the sidelines and then collapsed. He was put in a drug-induced coma for a week, spent almost a month in hospitals and lost 31 pounds, according to the Chronicle.
The story cites a number of statistics regarding high school injuries. For example, about 68,000 concussions were sustained during the 2008 high school football season, according to the National High School Sports-Related Injury Surveillance Study.
And the man who helped organize that study, Ohio State associate professor Dawn Comstock, said that in 2008 16 percent of high school football players who had concussions where they lost consciousness went back to play that same day.
Blea played as a running back and linebacker, positions that one study found are most likely to get concussions.
Two U.S. high school players died as a direct result of football injuries last year, the Chronicle story says.
Physicians say Blea’s outlook is good, but he can’t play football again.
When he was hit, Blea fell and his head hit the turf, with his brain “slamming against his skull,” according to the Chronicle.
The story then describes his surgeries and recovery.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
California Weighs Strict Laws To Protect Student Athletes With Concussions
Momentum for the Lystedt Law which prevents a concussed scholastic athlete to return to the game in which he or she receives a concussion continues to grow. California, often on the vanguard of American culture and society, has joined the movement to impose tough laws to protect young sports players from concussions.
California is considering new legislation and a proposal from the state’s high school sports federation that would mandate that physicians have a say before an injured can return to play, according to a story Friday in the San Bernardino County Sun.
The story, http://www.sbsun.com/sports/ci_14244046, says that only three other states have policies as strict as the one California is considering.
The legislation was proposed after the near-death of San Jose High Academy Football player Matt Blea, according to the story.
California Assemblywoman Mary Hayashi has introduced two bills. The first would require coaches to become familiar with the symptoms of head injuries. The second would require a physician to give an OK before an injured player could get back on the field.
That second bill is similar to a proposal that the California Interscholastic Federation, which governs sports at about 1,500 schools, is considering.
Currently many California school districts mandate that injured student players must get a physician’s release before resuming play, according to the story. But not all schools have such a policy.
Zachery Lystedt was a high school football player in Washington who suffered a mild concussion early in a game but continued to play. Near the end of the game he suffered another concussion, which resulted in a severe brain injury. His injury became the impetus for a law in his home state of Washington prohibiting any return to play of a scholastic athlete after a concussion.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
California is considering new legislation and a proposal from the state’s high school sports federation that would mandate that physicians have a say before an injured can return to play, according to a story Friday in the San Bernardino County Sun.
The story, http://www.sbsun.com/sports/ci_14244046, says that only three other states have policies as strict as the one California is considering.
The legislation was proposed after the near-death of San Jose High Academy Football player Matt Blea, according to the story.
California Assemblywoman Mary Hayashi has introduced two bills. The first would require coaches to become familiar with the symptoms of head injuries. The second would require a physician to give an OK before an injured player could get back on the field.
That second bill is similar to a proposal that the California Interscholastic Federation, which governs sports at about 1,500 schools, is considering.
Currently many California school districts mandate that injured student players must get a physician’s release before resuming play, according to the story. But not all schools have such a policy.
Zachery Lystedt was a high school football player in Washington who suffered a mild concussion early in a game but continued to play. Near the end of the game he suffered another concussion, which resulted in a severe brain injury. His injury became the impetus for a law in his home state of Washington prohibiting any return to play of a scholastic athlete after a concussion.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Evolution in the Understanding of Concussion – Length of Amnesia Correlates to Severity of Brain Damage
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is The Length of Amnesia is the Best Predictor of Severity of Injury. Today’s video is here:http://www.youtube.com/profile?user=braininjuryattorney#p/u/8/WB9ErwpKnXk
Brain injury is one of those things that everyone feels the need to classify, typically into categories of mild, moderate and severe. A severe brain injury is one that involves extended coma. I don’t have any trouble with that definition for severe brain injury.
The controversy in classifying brain injuries revolves primarily around whether there was a brain injury at all and where the break point is between mild and moderate brain injury. The problem with all classification battles in the mild to moderate category is too much is based upon the identification of symptoms in the first hour, where it is not how symptomatic a person is at two hours, but how long the symptoms last that is significant. This is especially true with the most predictive symptom, amnesia.
With respect to severe brain injury, the Glasgow Coma Scale is a reasonably accurate indicator of severity. It also has the benefit of nearly universal adoption, making outcome studies based upon it reliable because of the large number of patients studied. But when the brain injury is below the severity level that loss of consciousness or a change in mental state is witnessed by a medical professional, the GCS has little validity. Most concussed individuals will get the highest score of 15, regardless of how significant the concussion is and how symptomatic they are at the time given the score. The GCS score at the mild end is only a test for confusion, not amnesia. To get a “perfect” GCS score, a patient needs only have his eyes open, be able to carry on a conversation demonstrating orientation (he knows who he is and where he is) and that he can follow simple commands. Compare that to how oriented a quarterback must be to continue to play in the game.
In contrast, basing outcome on the length of amnesia not only correlates well with the GCS score in the severely brain injured population, it is sensitive enough to provide meaningful diagnostic guidance in the less severely injured. According to Lezak, Neuropsychological Assessment, citing Bigler 1990, the length of amnesia predicts as follows:
But the key to applying this score is first understanding what amnesia is and then assuring that the diagnostician, asks and records the right questions. Amnesia is not like the Hollywood head injury myth, where the main character does not remember who he is until he magically flashes on something, or gets that second blow to the head. According to Lezak as amnesia “does not end when the patient begins to register experience again, but only when registrations is continuous.” Lezak, 4th Edition, page 160.
The problem is that distinguishing between some imprinting of memory and “continuous” imprinting of memory does not lend itself to established tests which primarily focus on confusion. One standardized test for amnesia, the GOAT, (“Galveston Orientation and Amnesia Test”) has only one good question out of 10. The best question on the GOAT is “can you describe in detail the first event you remember after the accident.” But because this is the “subjective” question, it is the one researchers pay the least attention to. But even this best question, doesn’t account for the fact that amnesia may begin after the period for which this question is being asked. It is not what the person remembers about the first 10 minutes post-accident, it is what they continuously remember the next hours and days that is significant.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Brain injury is one of those things that everyone feels the need to classify, typically into categories of mild, moderate and severe. A severe brain injury is one that involves extended coma. I don’t have any trouble with that definition for severe brain injury.
The controversy in classifying brain injuries revolves primarily around whether there was a brain injury at all and where the break point is between mild and moderate brain injury. The problem with all classification battles in the mild to moderate category is too much is based upon the identification of symptoms in the first hour, where it is not how symptomatic a person is at two hours, but how long the symptoms last that is significant. This is especially true with the most predictive symptom, amnesia.
With respect to severe brain injury, the Glasgow Coma Scale is a reasonably accurate indicator of severity. It also has the benefit of nearly universal adoption, making outcome studies based upon it reliable because of the large number of patients studied. But when the brain injury is below the severity level that loss of consciousness or a change in mental state is witnessed by a medical professional, the GCS has little validity. Most concussed individuals will get the highest score of 15, regardless of how significant the concussion is and how symptomatic they are at the time given the score. The GCS score at the mild end is only a test for confusion, not amnesia. To get a “perfect” GCS score, a patient needs only have his eyes open, be able to carry on a conversation demonstrating orientation (he knows who he is and where he is) and that he can follow simple commands. Compare that to how oriented a quarterback must be to continue to play in the game.
In contrast, basing outcome on the length of amnesia not only correlates well with the GCS score in the severely brain injured population, it is sensitive enough to provide meaningful diagnostic guidance in the less severely injured. According to Lezak, Neuropsychological Assessment, citing Bigler 1990, the length of amnesia predicts as follows:
- Less that five minutes, very mild.
- 5 minutes to 60 minutes, mild.
- 1 to 24 hours, moderate.
- 1- 7 days, severe.
- 1-4 weeks, very severe.
- More than 4 weeks, extremely severe.
But the key to applying this score is first understanding what amnesia is and then assuring that the diagnostician, asks and records the right questions. Amnesia is not like the Hollywood head injury myth, where the main character does not remember who he is until he magically flashes on something, or gets that second blow to the head. According to Lezak as amnesia “does not end when the patient begins to register experience again, but only when registrations is continuous.” Lezak, 4th Edition, page 160.
The problem is that distinguishing between some imprinting of memory and “continuous” imprinting of memory does not lend itself to established tests which primarily focus on confusion. One standardized test for amnesia, the GOAT, (“Galveston Orientation and Amnesia Test”) has only one good question out of 10. The best question on the GOAT is “can you describe in detail the first event you remember after the accident.” But because this is the “subjective” question, it is the one researchers pay the least attention to. But even this best question, doesn’t account for the fact that amnesia may begin after the period for which this question is being asked. It is not what the person remembers about the first 10 minutes post-accident, it is what they continuously remember the next hours and days that is significant.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Evolution in the Understanding of Concussion – Non-Athletes are At Much Higher Risk of Disability
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is Non-Athletes are at Far Greater Risk of Disability. Today’s video is here: http://www.youtube.com/profile?user=braininjuryattorney#p/u/5/Z3QvSHrWykI
Sport is an ideal laboratory to study concussion. First, almost all sport concussions get witnessed and in today’s world, most get videotaped. Second, a very significant percentage of them happen on university campuses where scientists and medical researchers are looking around for things to study. Three, they are predictable, happen in a confined space and to a subset of people who we can control. The predictability and control means we can actually study and test their cognitive abilities before they have the concussion. And then because we know they will have repeated concussions, we can study that as well.
The problem with sports as the laboratory is that we are studying those people who tell us the least about what might happen to average people who suffer accidental concussions. In the sport laboratory we are studying those people who are most likely to get better, to have an “apparent full recovery”. Thus, the sport and concussion literature has done an excellent job of dealing with the primary issue which they care about, determining when it is safe to expose our football players to another concussion. But the truly important issue, of what disability is likely to come from a concussion and how can we best diagnose and treat that disability, the sport laboratory tells us very little.
In fact, the dark side of neuropsychology is trying to use sports concussion research as evidence that concussion does not cause permanent damage. Anyone who has worked with Post Concussion Syndrome survivors knows that concussion or mild traumatic brain injury, can disable. The young male athlete’s apparent full recovery does not tell us very much about how someone older, someone not in extraordinary shape, someone who was not expecting to get hit, will recover.
Here is the reality of the real world of concussions: If you are significant at 24 hours, and you are female and you are over 40, you need to go see the doctor every couple of days until you get better. You need to see a doctor who is going to test your memory. You need a doctor who is not just to test your memory for things you know about your life, but what you have been doing in the 24 hours before that examination. And you need a doctor who is not going to just ask you those questions, but also ask the people you live with.
Obviously, disability happens to those who are not 40, not female, but the more vulnerable your brain is because of age, because of prior concussions, because of emotional challengers you have had in your life, the more likely you will have a bad result. If you are at risk for a bad result, you must be followed and diagnosed in that first week. If you don’t get that type of evaluation we will have no way of predicting whether this concussion will give you a few bad days, a few bad weeks or keep you disabled the rest of your life.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Sport is an ideal laboratory to study concussion. First, almost all sport concussions get witnessed and in today’s world, most get videotaped. Second, a very significant percentage of them happen on university campuses where scientists and medical researchers are looking around for things to study. Three, they are predictable, happen in a confined space and to a subset of people who we can control. The predictability and control means we can actually study and test their cognitive abilities before they have the concussion. And then because we know they will have repeated concussions, we can study that as well.
The problem with sports as the laboratory is that we are studying those people who tell us the least about what might happen to average people who suffer accidental concussions. In the sport laboratory we are studying those people who are most likely to get better, to have an “apparent full recovery”. Thus, the sport and concussion literature has done an excellent job of dealing with the primary issue which they care about, determining when it is safe to expose our football players to another concussion. But the truly important issue, of what disability is likely to come from a concussion and how can we best diagnose and treat that disability, the sport laboratory tells us very little.
In fact, the dark side of neuropsychology is trying to use sports concussion research as evidence that concussion does not cause permanent damage. Anyone who has worked with Post Concussion Syndrome survivors knows that concussion or mild traumatic brain injury, can disable. The young male athlete’s apparent full recovery does not tell us very much about how someone older, someone not in extraordinary shape, someone who was not expecting to get hit, will recover.
Here is the reality of the real world of concussions: If you are significant at 24 hours, and you are female and you are over 40, you need to go see the doctor every couple of days until you get better. You need to see a doctor who is going to test your memory. You need a doctor who is not just to test your memory for things you know about your life, but what you have been doing in the 24 hours before that examination. And you need a doctor who is not going to just ask you those questions, but also ask the people you live with.
Obviously, disability happens to those who are not 40, not female, but the more vulnerable your brain is because of age, because of prior concussions, because of emotional challengers you have had in your life, the more likely you will have a bad result. If you are at risk for a bad result, you must be followed and diagnosed in that first week. If you don’t get that type of evaluation we will have no way of predicting whether this concussion will give you a few bad days, a few bad weeks or keep you disabled the rest of your life.
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Evolution in the Understanding of Concussion: The Need for Periodic Followups
Continuing on with the discussion of my Concussion Clinic videos, today’s topic is the Need for Periodic Follow-ups. Today’s video is here: http://www.youtube.com/profile?user=braininjuryattorney#p/u/11/dEWHgwRywtY
When the sport and concussion guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.
While the 15 minute rule is not quite good enough, it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a process not an event that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. Yet I realize that 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious. But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.
The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. (What happens in amateur sports may be entirely different but is a topic for a different blog.)
If we could take that model of periodic follow-ups and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Add two more levels of inquiry to that process and we could have an excellent concussion diagnosis system.
Distinguish between Confusion and Amnesia. I have discussed this issue in depth earlier in this series, but absence of confusion does not mean absence of amnesia. Amnesia is the real litmus test for concussion. Remember that amnesia is not a black curtain of memory, but the inability to remember the amount of information we would normally remember. What does “normal memory” mean? Take this an example.
At a real world hospital, if you aren’t bleeding when you get to the Emergency Room, you start your time there with a 20 minute conversation with the billing department. Then you sit in the ER waiting room for a while, normally too long. A normal person’s memory might not include the name of the person who was taking their insurance information. But a normal person would remember the process. They would remember filling out a form, even if they didn’t remember what the form said. A normal person would remember fishing the insurance card out of their wallet. Likewise, a normal person would very clearly remember how long they waited in the ER. A normal person would remember the most seriously hurt person who was waiting with them. People tend to remember blood, etc. If the doctor or other ER person would ask these kind of questions, evidence of amnesia would likely be clear.
Next Day Follow-up. Even more important than asking better questions on the day of the accident, is to have a medical professional ask them something about their memory the next day. Amnesia at 24 hours is far easier to spot. How much they remember of the pervious 24 hours events will show how severe this particular concussion is. With all of the momentum for better diagnosis for NFL and amateur football players, we must also clearly recognize that the care they are getting is infinitely better than the million plus other people a year who suffer a concussion, most who are at much higher risk of a bad outcome. See http://www.tbilaw.com/blog/2010/01/nfl-football-concussions-versus-real.html
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
When the sport and concussion guidelines are applied properly there is a 15 minute post-injury evaluation to determine whether this concussion or “ding” was serious enough to require further follow-ups. An injured player is not supposed to return for at least 15 minutes. At 15 minutes, if they continue to be symptomatic, they are not to return to play in that game and not until the expiration of 7 days from the date they cease to be symptomatic.
While the 15 minute rule is not quite good enough, it is important that an athlete is at least required to wait that long before he or she returns. As brain injury is a process not an event that can take 72 hours to manifest itself, the 15 minute rule isn’t perfect. Yet I realize that 15 minutes is a compromise, that generally protects the player. While there are exceptions, the concussion that is completely asymptomatic at 15 minutes is probably not going to be serious. But keep in mind, that Natasha Richardson could likely have passed a superficial orientation test at 15 minutes and she died before they could get her to a hospital. Also with non-professional sports, there is a strong movement to not allow any return to play.
The truly important part of guidelines is the “no play for seven days” if the concussion continues to be symptomatic at 15 minutes. Thus if there is symptomotology of brain injury at 15 minutes, the professional team’s medical staff will do follow-up testing each day to determine whether the athlete continues to be symptomatic. (What happens in amateur sports may be entirely different but is a topic for a different blog.)
If we could take that model of periodic follow-ups and apply that to the brain injuries that happen in accidents, we would then likely identify almost all concussions that are likely to be disabling. Add two more levels of inquiry to that process and we could have an excellent concussion diagnosis system.
Distinguish between Confusion and Amnesia. I have discussed this issue in depth earlier in this series, but absence of confusion does not mean absence of amnesia. Amnesia is the real litmus test for concussion. Remember that amnesia is not a black curtain of memory, but the inability to remember the amount of information we would normally remember. What does “normal memory” mean? Take this an example.
At a real world hospital, if you aren’t bleeding when you get to the Emergency Room, you start your time there with a 20 minute conversation with the billing department. Then you sit in the ER waiting room for a while, normally too long. A normal person’s memory might not include the name of the person who was taking their insurance information. But a normal person would remember the process. They would remember filling out a form, even if they didn’t remember what the form said. A normal person would remember fishing the insurance card out of their wallet. Likewise, a normal person would very clearly remember how long they waited in the ER. A normal person would remember the most seriously hurt person who was waiting with them. People tend to remember blood, etc. If the doctor or other ER person would ask these kind of questions, evidence of amnesia would likely be clear.
Next Day Follow-up. Even more important than asking better questions on the day of the accident, is to have a medical professional ask them something about their memory the next day. Amnesia at 24 hours is far easier to spot. How much they remember of the pervious 24 hours events will show how severe this particular concussion is. With all of the momentum for better diagnosis for NFL and amateur football players, we must also clearly recognize that the care they are getting is infinitely better than the million plus other people a year who suffer a concussion, most who are at much higher risk of a bad outcome. See http://www.tbilaw.com/blog/2010/01/nfl-football-concussions-versus-real.html
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
Evolution in the Understanding of Concussion: Distinguish Between Confusion and Amnesia in Diagnosing Concussion
Continuing on with the topic “The Evolution of Our Understanding of Concussion, Otherwise Called Mild Traumatic Brain Injury,” our next point of emphasis is the importance of distinguishing between confusion and amnesia after a brain injury. The video on this topic is at: http://www.youtube.com/profile?user=braininjuryattorney#p/u/6/xuO69e9Vv_c
You can have significant amnesia and not be confused. How do we know that? On this specific issue, the sports arena is the ideal laboratory – NFL quarterbacks the perfect test subject. We know from hundreds of reported cases that a football player can finish the game, a quarterback can finish the game, and have no memory for the game when asked about it later. Thus, we know they were amnestic.
We also know that they were not confused while they were playing the game because football, especially quarterbacking, is not something someone can do while confused. Think of all the sequential, memory and processing intensive things an NFL quarterback must do on every single play. If he were confused, he wouldn’t survive a single play. While one can argue that a boxer can fight on auto-pilot, a quarterback cannot. A quarterback must remember the plays and make differential decisions under high stress, with instant processing.
The reason I make this point over and over is that in the vast majority of cases, the inquiry at the scene, in the Emergency Room is an inquiry only to determine whether a person is confused. If a person is not confused, they are presumed not to have suffered a brain injury. If the inquiry does not include a test for amnesia as well as confusion, then the diagnosis of brain injury will likely be missed.
The diagnostician, be it an EMT, an ER doctor or primary care doctor must put on the sports writer hat and ask about the events since the injury, not just about what happened before the injury or what is happening now. What we want to know about is what happened “during the game” – the period of time between the concussion and now. Tell me about the ambulance ride. Tell me about who else was in the Emergency Room.
And doctors, don’t be in such a hurry to decide there was no concussion. Amnesia often materializes in the hours after an accident – not the minutes – because brain injury is a process, not an event. For more on that topic, see the general treatment of that topic found on my website http://subtlebraininjury.com/ and the specific treatment at http://subtlebraininjury.com/tbiprocess1.html
At times the world of sport is a useful laboratory for us to learn about concussion, such as with this issue, but we must remember that the average person with an accidental concussion, is not an extraordinary physical specimen, who expected to get hit. More on the distinction between real world brain injury and sport concussions on my Brain Damage Blog, http://tbilaw.com/blog
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney
You can have significant amnesia and not be confused. How do we know that? On this specific issue, the sports arena is the ideal laboratory – NFL quarterbacks the perfect test subject. We know from hundreds of reported cases that a football player can finish the game, a quarterback can finish the game, and have no memory for the game when asked about it later. Thus, we know they were amnestic.
We also know that they were not confused while they were playing the game because football, especially quarterbacking, is not something someone can do while confused. Think of all the sequential, memory and processing intensive things an NFL quarterback must do on every single play. If he were confused, he wouldn’t survive a single play. While one can argue that a boxer can fight on auto-pilot, a quarterback cannot. A quarterback must remember the plays and make differential decisions under high stress, with instant processing.
The reason I make this point over and over is that in the vast majority of cases, the inquiry at the scene, in the Emergency Room is an inquiry only to determine whether a person is confused. If a person is not confused, they are presumed not to have suffered a brain injury. If the inquiry does not include a test for amnesia as well as confusion, then the diagnosis of brain injury will likely be missed.
The diagnostician, be it an EMT, an ER doctor or primary care doctor must put on the sports writer hat and ask about the events since the injury, not just about what happened before the injury or what is happening now. What we want to know about is what happened “during the game” – the period of time between the concussion and now. Tell me about the ambulance ride. Tell me about who else was in the Emergency Room.
And doctors, don’t be in such a hurry to decide there was no concussion. Amnesia often materializes in the hours after an accident – not the minutes – because brain injury is a process, not an event. For more on that topic, see the general treatment of that topic found on my website http://subtlebraininjury.com/ and the specific treatment at http://subtlebraininjury.com/tbiprocess1.html
At times the world of sport is a useful laboratory for us to learn about concussion, such as with this issue, but we must remember that the average person with an accidental concussion, is not an extraordinary physical specimen, who expected to get hit. More on the distinction between real world brain injury and sport concussions on my Brain Damage Blog, http://tbilaw.com/blog
Attorney Gordon Johnson
Chair Traumatic Brain Injury Litigation Group, American Association of Justice
g@gordonjohnson.com :: 800-992-9447 :: Attorney Gordon S. Johnson, Jr.
http://subtlebraininjury.com :: http://brainanatomyguide.com :: http://car-accident-rain.com :: http://tbilaw.com
http://waiting.com :: http://vestibulardisorder.com :: http://youtube.com/profile?user=braininjuryattorney