3rd Matthew Gfeller Sport Related Neurotrauma Symposium

This past week, I traveled to the University of North Carolina (not for the "game", but for continuing education.  Continuing education can be many things to professionals; costly, convenient, enlightening, repetitive, etc.  In this case, it was superb.  Simply put, this was one of the best symposiums I have ever had the opportunity to attend.  I would strongly recommend this to any health care professional looking for the most recent and up to date information regarding concussion research and implementation.  The symposium offered a variety of presenters, including researchers, athletic trainers, engineers, lawyers, epidemiologists, optometrists, neuropsychologists, to name a few.  I will do my best to keep this concise, even though my notes alone were well over eleven pages, covering the 30 presentations we heard over the course of two days.

                               Panel discussion of clinical dilemmas in concussion management.

The Matthew Gfeller story is a powerful one.  His parents gave a very emotional speech, entitled "From Tragedy to Advocacy".  If you'd like to learn more about Matt, and the foundation which bears his name, I encourage you to visit: http://www.matthewgfellerfoundation.org  There is a short video as well which succinctly describes their difficult, yet valiant path.

Some highlights:

Former U.S. Women's Soccer Team member and Olympic Gold Medalist Cindy Parlow-Cone offered a very raw and honest take on her own personal experiences with concussion and symptom persistence afterwards.  She spoke of her difficulty since her career ended and gave a unique perspective that despite what current evidence states, you can be concussed when heading a ball.  She called for more in depth research in this area, specifically in youth soccer, where she currently serves as  a coach.

Dr. Dirk Keene had some interesting comments regarding CTE which certainly educated this clinician.  Chronic Traumatic Encephalopathy (CTE) is a clinical diagnosis (by definition), not a pathological one.  Simply stated, a pathologist cannot diagnose this condition.  To date, all cases of CTE neuropathology described in the literature are derived from a highly selected, non-random, non representative group of mostly former athletes who suffered untimely deaths.  What does this mean?  It means that it's application in an unbiased population base needs to be studied.  Effectively, if you only study one group, it is difficult to draw definitive comparisons and extrapolations.  That's not to say a link doesn't exist, but further research is needed.

Dr. Steven Rowson from Virginia Tech and it's Star Evaluation System (similar to NOCSAE, but definitely different) describing that as little as 5-7mm of movement cause brain injuries stood out to me.  You can find their recommendations for helmets here.  His slides describing the differences in helmet performance in testing were quite eye opening: not all helmets are created, nor perform equally.  If you are looking for a helmet to purchase, whether you are a parent, athlete or coach, you should really check out the link.

Concussion Vital Signs, a computer based neurocognitive assessment tool, made an announcement which will have a substantial effect:  As of April 15, they will offer their tools for free.  No charge.  They cited the desire to provide appropriate care to all, and more specifically "to do the right thing."  If you are interested, you can FMI at http://www.concussionvitalsigns.com

A mock trial was presented based on actual athletic training.  I thought this was very well done, and quite unique.  The level of detail was interesting, and too in depth to delve into here, but some main points were document everything, and make sound clinical decisions devoid of influence, or as Eugene Egdorf more distinctly put it "It will be very easy for me to make you look bad."  Of interesting note, he was also the lawyer who served on the EA Sports settlement case (regarding the unauthorized use of athlete likenesses/names by the NCAA)  as well as the wrongful death settlement against the NCAA, which resulted in all student athletes being required to test for sickle cell.

Dawn Comstock, an epidemiologist who tracks (thanks to the help of ATC's around the country) high school injury data to identify patterns of sports related injury had some interesting data.  You can actually view some of it here.  What a fantastic way to acclimate oneself with a particular sport with which they may have little familiarity.  Perhaps with this information, we can better predict and prevent!

Dr. Erik Swartz also presented on his HuTT(R) helmetless tackling system, which is an interesting approach.  We tend to hear a lot about the need for helmet design advancement to reduce concussions, but, what if we had athletes perform more drills without helmets?  This obviously would reduce the number of "head to head" collisions in practice, while also simultaneously teach proper form.  More on that (along with a good short video) here.  Definitely an intriguing idea.
He also presented on the new EMS spine injury standards, and implications for athletic trainers.  Basically, the new guidelines will not require the use of a backboard.  Stated simply, there is no real data to support their continued use.   Why do we continue to put suspected injuries on a flat, rigid board when the body is neither of those two things? Once they are placed on a backboard (spine board), they then go on a gurney, which is a bit redundant. I blogged about this awhile back. In Europe, for instance, I have seen body vacuum splints being used, which, while certainly inhibitory, appear to be more comfortable.

Dr. Grant Iverson had a fascinating presentation describing the negative effects of rest...and how it's not really a great prescriptive tool for many maladies (back pain, etc.)  Maybe it's not a good idea for a concussion?  He even showed that not one study has shown that rest is beneficial; even going so far as to explain that abrupt cessation of exercise can actually cause headaches.  I really enjoyed his presentation style for sure, and it was SO REFRESHING to hear this presented (especially to AT's).  It's something I think many clinicians have navigated away from, but  many still adhere to, perhaps unnecessarily.  In addition, he stated that suicidality has not been clinically proven to be a symptom of CTE (no studies to support).  Perhaps more surprisingly, he referenced data which stated NFL players actually have a lower mortality rate than that of the general population.  This seems to be contradictory to mainstream media reports...absolutely fascinating stuff.

Honestly, there were many more fantastic topics, including the utilization of a Biopsychosocial model for the treatment of concussion, patient referrals, evaluating visual deficits following concussion and visual rehabilitation.  This post barely scratches the surface of the information presented, but I feel I need to keep it at an appropriate length.  As both an educator and a clinician, I need this information to not only practice at a high level, but to properly inform future health care providers of the latest evidence in clinical practice.  This symposium delivered.

All in all, a tremendous array of information and an absolute top tier, professional event put on by Dr. Jason Mihalik, Dr. Kevin Guskiewicz, and Dr. Johna Register-Mihalik.

Saved by the...suit?

I've been watching a lot of Winter Olympic sports on TV lately...can't get enough.  Maybe it's because  it's winter, but mostly I think it's simply because I love the sports.  One segment caught my eye because I couldn't quite believe it...but I found it fascinating.  A company named Dainese has engineered a skiing suit which inflates if/when a skier crashes.  Check out the article here. 
You can read the article itself...pretty cool stuff.  I'm sure engineers had a difficult time designing this, especially when they had to deal with forces exerted when a skier goes airborne.  I did a little digging, and found the company website, which posts a few mini-infographics (be sure to scroll down the page a bit) of a similar (but not exact?) design for motorsports.  Cool stuff.
Here is video of actual inflation:

Turns out, this company has worked with motorsports, but has been branching out.  

Upon further review, check it out this video...I know, it's not english, but body language is body language. 

At any rate, just some really interesting technology that might someday play a role in other sports...and increase safety.    Hope you enjoy!

EMS Evolution: Relaxation of Spine (Back) Boarding Rules Ahead?

Not sure if anyone has noticed or not, but the National Athletic Trainers' Association has a new blog directed to professionals and students in the field.  Content is generated via professionals from around the country, and a couple of days ago one was brought to my attention.
You can read it here.

While the post doesn't delve into specifics, it does state that several protocol changes are occurring in the area of spine boarding...most notably the prospective omission of the use of spine boards with suspected cervical injuries.  EMS appears poised to begin transporting certain cases (I am unsure at this point as to which ones) with a cervical collar only.   As Dr. Swartz points out, this should really spur ATC's to meet with their local EMS provider(s) to discuss their current protocols and how it might affect your overall management.    I'll certainly be looking forward to the upcoming position statement...

In the meantime, consider my curiosity piqued.  Two questions linger for me:
Are backboards even effective?
Are cervical collars even effective?
So, I did a bit of searching and this is what I found.

This article challenges conventional wisdom (perhaps a better term is conventional practice) regarding the blanket use of cervical collars.  In fact, validation for challenging the efficacy of cervical collars was studied a decade ago.  Which ultimately lead me to this article, which was a real eye opener.  There are a number of valid points the article raises, and one of them is the topic of patient comfort.  Having seen a full body vacuum splint used when I was in France a few years ago, I can honestly say it makes a lot of sense to potentially use one of those as compared to a traditional spine board.  It seemed far more comfortable compared to it's stiff counterpart.

So after becoming  more convinced evidence is lacking, I stumbled upon  Neurosurgery PreHospital Cervical Spinal Immobilization After Trauma, which states virtually the exact opposite of what other studies are saying. 

Needless to say, it will be very interesting to see how this situation develops, both regionally and nationally.  While I fully realize I'm not answering any definitive questions here, I am trying to illustrate the difficulty clinicians face when attempting to best care for their patient.  That headache, neck and/or back pain may be exacerbated by the very tools we use to "safely" care for them.   

PowerPlay Cold & Compression Product Review

Earlier this month, I was contacted to complete a product review for PowerPlay Portable Cold & Compression systems.  I replied that I would be more than happy to do so.  Before we begin, I offer  that I am not receiving reimbursement of any kind, and offer my objective and unbiased view of the product. 

I was shipped the PowerPlay Standard Kit, which included the Cold and Compression Ankle Wrap and the  Knee Wrap.  The entire contents of the system, which was shipped in a convenient and small bag (14" x 10.5"), weighed less than 10 pounds.  My initial thoughts were that this is a fantastic, lightweight, portable system which would travel easily.  As an ATC who travels, this would certainly be very easy to toss into my checked baggage.  The product was clearly designed with efficiency and portability in mind.  That said, it would work very easily in a standard sports medicine clinic as well.
 

The directions for each "unit" came with easy to read instructions, which included both written and diagram instructions.  The instructions were quite simple and straightforward, covering everything from contraindications to battery life, true to electrical modality form.  Set up only took 3 minutes, but I was fiddling around with it.  By the third time I used it, I could set it up in under a minute and a half.  Ease of use is a tremendous bonus with this product. 

For the compression unit itself, these items were included:
1. PowerPlay Pump

2. Cloth Sleeve (this serves as a protective area for exposed skin)
3. Gel Pack (one each for ankle and knee)
4. Compression Wrap (one each for ankle and knee)

Prior to applying,  the gel packs must be frozen for a minimum of one hour, remove from the freezer and then attach them to the inside of the Compression Wraps.  This is done via velcro attachments, which fit quite snugly inside.   You simply had to fit the patient, then attach the hose to one of the three ports on the PowerPlay Pump, which you then turned on.  I love the fact that there were three different ports, as you can treat multiple regions/body parts at once. The pump is small, but very efficient and easy to use.  It only has four buttons, a Power On/Off, and one each for the port of choice. 

Once attached, you press the port of attachment, and choose a level of compression both appropriate and comfortable for the athlete.  I did notice a discrepancy here, as the instructions indicate you can choose between 30 mmHg and 70 mmHg of pressure, however the pump only displays 50-70 mmhg, in 5 mm increments.  Not a huge deal, but a discrepancy nonetheless.  Once you set the pressure, the unit will automatically turn on and provide intermittent compression for a 20 minute time period, automatically shutting off at the conclusion.  Again, the design is so convenient and easy to use, I could see myself utilizing this product on a very regular basis. 

During it's first trial run, I kept getting a "HI" message on the LED screen, which upon further inspection revealed cord compression (the athlete's leg was compressing the cord, impeding airflow).  Simply moving the chord was not difficult, as each compression wrap has a 5 foot long air hose, which I thought was well thought out.  Not everyone likes to have a compression unit buzzing on their chest during treatment! If you needed a longer one, an additional 5 foot extension was located in the bag as well.

The compression was uniform and quite comfortable, as opposed to say, plastic wrap around an ice bag on a joint, which can be effective but also uncomfortable.  It was also surprisingly cold (in a good way), which surprised me.  Sometimes feedback from athletes is that it's not cold enough when compared to ice, but with this product, it was definitely not an issue. The gel packs themselves were designed well, and I was particularly fond of the knee wrap, which left a horizontal opening in back, allowing for a comfortable treatment of the knee not only in extension, but stages of flexion as well.

The unit is powered by an internal NiMH battery, which according to the manufacturer will run the system for 4-6 hours prior to needing a charge.  A wall charger is included in the package.  Of interesting note, it is recommended that the battery be charged every 60 days while NOT in use, and will last for roughly 500 recharges in between replacements.   Translation:  this should last you a long time.

In terms of price, it is very comparable to similar systems.  It is more expensive than traditional CryoCuff systems, but much less expensive than a Game Ready, both of which require water and ice. While cold therapy has had it's knocks over the past few years, I do still believe that it has a place in treatment, and can plainly see the advantages to using this.  In my opinion, this is a sound product and investment in the care of your patients and athletes. 

Two Months on the Road...A Sochi Recap

As I type, it has been two months since I've set foot in the United States.  I had the pleasure of working with the United States Bobsled and Skeleton Team both prior to and through the Winter Olympics.  The experience was awesome... but it's always good to be home. Our travels took us through Germany, Switzerland, Austria, and onto Russia.  The following are some musings I've had both during and after this experience. While difficult to capture concisely, I'll do my best to keep a bullet item style entry list.   The list is random and in no particular order of importance.

The US Bobsled and Skeleton Federation was very successful at the Olympics, garnering at least one medal in each event.  Congrats to the following medalists whom I had the humble honor of working with:
Matt Antoine:  Bronze Men's Skeleton
Noelle Pikus-Pace:  Silver Women's Skeleton
Steve Holcomb & Steve Langton: Bronze Men's Two Man Bobsled
Steve Holcomb, Chris Fogt, Curt Tomasevicz & Steve Langton: Bronze Men's Four Man Bobsled
Elana Meyers & Lauryn Williams: Silver Women's Two Man Bobsled
Jamie Greubel & Aja Evans: Bronze Women's Two Man Bobsled

I would be remiss if I did not mention the rest of the athletes who competed at the highest level; there are many that were on the World Cup team who didn't make it to the Olympics, just as there were Olympic athletes who didn't garner a medal. Simply getting to that point is a feat in and of itself; they are all shining examples of devotion to their sport and truly embodied the Olympic ideals...my heart ached for them when they didn't achieve what they desired to.  Just because an athlete doesn't medal, doesn't mean that they aren't giving their all, and I think that can be easily dismissed.

Apologies to the Dos Equis Guy, but fellow ATC Byron Craighead (pictured above) may truly be the most interesting man in the world.

The Olympics were an emotional roller coaster.  I teared up more times in the past two months than in the past two years.  OK, that's not true. I tear up a lot.  But the moments were raw, real, emotional, and to be a part of that, even a bit part, will leave an indelible mark on this athletic trainer.

Regarding those who complained  the facilities/hospitality were subpar, my advice is simple.  Gain some perspective, or come travel with me to some parts of the world where everything isn't tailored exactly to one's lofty expectations.  In many ways the region reminded me of my travels in the Dominican Republic.  Applying "first world" logic to all parts of the world simply doesn't work.  I took the experience for what is was; brand new infrastructure that went up in the blink of an eye.  Was it perfect?  No...but I've yet to find perfect anywhere.  The lodging was fine; the volunteers were amazing!  Their spirit was palpable on all levels.  I'm not sure I could ask for much more considering the region we were in.  Of course, to be fair, this was my first Olympics, so if I were only comparing to other Olympics, my perspective or expectations may have been different.  The people were great, and they did their job...plain and simple.  They deserve our gratitude, not our complaints.

I felt euphoria marching during opening ceremonies.  Not sure I deserved to be there as much as others, but it's certainly how I felt walking into that stadium.  I heard many thought the sweaters were ugly, but I have to tell you, walking in wearing the letters USA on your back, amidst a sea of your fellow teammates instills a sense of pride that transcends fashion.

I may be a teacher, but this experience was a strong reminder that I am still a student; I learned a multitude of information on this journey.  I need to be better at maintaining this mindset on a more permanent basis.  Speaking of which, I have yet to find the book that explicitly guides me on how to remain a confident, assertive practitioner while also remaining open to new ideas, proven or not.  If you find one, let me know.  Better yet, maybe I should start writing it.  I should be ready by the time I'm 90.

Dry needling is not acupuncture.  But it kind of is?  I need to learn more about it, but it does fascinate me.

Athletic Training does not have to be reactionary practice (post-injury); it can be performance enhancing.

Athlete's often know their body better than coaches/therapists.  LISTEN to them.
Coaches/Therapists often know an athlete's body better than the athlete.  DISCUSS with them.  The problem that can arise is a LACK of, or complete omission of communication and open mindedness which can impede athletic performance.  We can all learn from each other if all parties knock down traditional walls of professions.  It's a complicated dance at times, but quite lovely when all parties collaborate equally on the finished product. 

Message to ATC's:  If you haven't already, learn Kinesio Taping.  Learn manual therapy skills.  Practice them often.  Be open to new ideas, but don't be afraid to voice your own thoughts...through careful collaboration, the most positive outcome for the athlete can be attained.

Contrary to some colleagues, I would argue that classic taping with 1.5 inch white tape is not a dying breed...in fact I utilized it quite regularly throughout.

My thanks to the USOC, USBSF and USM for a wonderful experience!

New Ligament Discovered in Human Knee...No Biggie

Fascinating news out of Belgium...researchers have located and identified the existence of a new ligament within the knee.  The ALL or Anterolateral Ligament (seen here).  So why is this so interesting?  A phenomenon that many of us have experienced are those athletes who have trouble with stability AFTER successful ACL reconstruction.  The ligament is repaired, strength is full and equal bilaterally, and yet,  some athletes still experience occasions when their knee will "give way", or as we know it in our field,  the Pivot Shift. 


                                                                      Classic example of Pivot Shift Test

This issue of chronic, unpredictable knee instability presents numerous problems for those injured, and those responsible for rehabilitating them.  The identification of this ligament could potentially pave the way in terms of surgical techniques, rehabilitation, etc.  Very interesting stuff...I'm both baffled and impressed that a ligament has been "discovered" in 2013.    Kudos. 

Urinalysis via Smartphone?

Wow.  No other way to describe it.  While reading BBC online via my app this a.m., I came across this little treat:
http://www.bbc.co.uk/news/technology-21586082

A couple of items which struck a chord with me:
1.  The term "consumer based health care".  I love this, and have been using it for years in my classes.  Be a savvy consumer; shop around, and collect information.  Never a bad thing at all.
2.  While the app won't be available until the end of March, and they discuss using it in developing countries, I think this could be incredibly useful in our country

Random Sidebar:  I love TED conferences.  Great info, and possibly the second most used app I use, behind Netflix of course.  If you haven't explored TED Talks yet, check them out here.  A good buddy of mine turned me onto them. 
While it's early yet, and nothing is completely substantiated, this could have a huge impact on urinalysis in the AT setting. Essentially, this has the potential to take our urinalysis test strips to the next level.   I surmise that most ATC's now own a smartphone (I could be wrong here, but it seems that way to me).  How easy would it be to download this app (at a marginal cost, mind you), and run the test strips!  This could make the referral and management process much smoother and more efficient.