Who is responsible?

Part 2 of my interview with Yelverton Tegnér.
 
 
 
The sport related concussions are increasing. But who is responsible? The trainers? The Athletes? Doctors? Parents?
 
Yelverton told me a fearsome story:
"I have always been aware of how serious the sport related concussions really are, but this haven´t always been positively met. Many years after it has happend I´ve been told by athletes that they, after they had sustained a concussion, been told by their trainer not to tell the doctor (me) what had happened. They had been told to shut their mouth and keep quiet or else they wouldn´t be allowed to keep playing due to their brain injury."
 
WHAT HAPPENS ON THE INSIDE OF THE SKULL?
Not many people actually know what goes on in inside the skull when a concussion accure. Yelverton explained that aswell:
"It all depends on how much force that finds its way into the skull. Some hits aren´t hard enough to injure the brain. But what happens during a concussion is that nerv cells in the brain breaks. When they break they secretes a poisonous substans that kills nearby nerv cells."
 
"The scary part is that you are not good to go after a concussion even when you don´t have any symptoms anymore. When you lose brain activity in one part of the brain due to a concussion other parts of your brain takes responsibilty for the lost parts. In this way it can appear as if the person is good to go and that there are no further damage to the brain. But in reality the brain injury is still there, you just can´t see it." 
 
 
IS MORE BETTER?
Before this interview I had written many emails to Dr Tegnér regarding the increasing concussion statistics at the same time as most players in most sports are wearing more and more protection gear. Yelverton are seeing a clear pattern between the increasing number of brain injuries and players wearing more protection gear:
 
"When you are putting on as much gear as a knight you start doing things that you otherwise would never do. If there is no risk of feeling any pain, players will try to use their bodies in situations that would seriously hurt them if they were not wearing their gear. Earlier in ice-hockey we saw a lot of injuries on elbows and shoulders. But when the new elbow and shoulder protection came, those kinds of injuries almost disappeard, but the players started using their shoulders and elbows for other purposes and that could possibly be one of the factors that have increased the number of concussions in sport.
 
WHEN ARE YOU FULLY RECOVERED AFTER A CONCUSSION?
"Well...now you have to ask yourself what fully recovered means. I say that a single concussion is probably not very dangerous. But the danger is in the repeated hits to the head, that is what kills the brain. I was the doctor for the famous ice-hockey player Cam Abbott that after he had sustained a concussion was taken out of play for 450 days and he had been free from symptoms for months before he started playing again but I had all this time told him that I wanted him to completely stop playing. After playing two more seasons Cam Abbott sustained a new concussion and his sport career was over. Sadly enough doctors can´t forbid players to keep playing or training. As far as I know it is only possible, as a doctor, to prevent athletes from keep going in sports like boxing, MMA and such. 
 
Dr. Yelverton finished our interview with a very sad message
"I am very worried about the future of some sports due to the increasing number of concussions in many of them. Do we really want our sons and daughters to keep playing a sport that eventually will result in a broken brain? If some sports don´t make some serious rule changes I have a hard time to imagine that the sport eventually will survive."
 
Big thank you Dr. Yelverton Tegnér for this interview!

Mr Concussion

A few months ago I had the privilege to interview Dr. Yelverton Tegner.
 
 
MR CONCUSSION
Dr. Yelverton Tegner aka Mr Concussion, born 1946, is a doctor and professor in sport medicine who has been working most of all in the Swedish town Luleå as a team doctor with Luleå ice hockey team. Yelverton has also been working with different national teams within football, basketball, ice hockey among other sports. His main focus has been on sport related concussions and brain injuries. 
 
Early years as a doctor
After he graduated from Med-school in Lund in south of Sweden he moved to Luleå, working with their adult hockey team, where he among his colleagues noticed how common it was that the players sustained concussions while playing. From there, they worked on a program to prevent these injuries as best as they could.

"In the 1980s you could only find 12-15 articles on concussions. Today there are thousands." - Yelverton said. 
 
 
When asked what the greatest problem is today regarding concussions Yelverton said:
- People don´t think it´s dangerous. They don´t know how dangerous it can be and how bad it can get.
Instead of using the term "concussion" (in swedish "hjärnskakning") I use the term "brain damage", because it is a brain damage, no matter how small people might think it is. 
 
Yelverton continued:
- The most dangerous part about concussions are the sub-concussive blows that the players are recieving. Those hits to the head that dosen´t feel dangerous but are hard enough to shake the brain inside. Even a person who says that he or she have never sustained a concussion can might aswell have injuried their brain through repetitive blows to their head during games and practices. After studying ice hockey players before and after their game season we have noticed that they have a worse brain activity afterwards
 
INCREASE or DECREASE?
I wanted to know if the amount of concussions have decreased or increased during the last 10-30 years per player and game time. Yelverton answered:
- There is no question about it. The answer is yes! 
Players today are faster, stronger and more fit. This makes it more likely for them to produce more force in there tackles, punches and kicks. People do not respect the injury either.
 
Yelverton says he has overheard a lot of players telling their team mates to go for the head and harm the other players.
 
 
 
HISTORICAL ASPECTS
I wanted to know what Yelverton thought about the growing sport culture of MMA and boxing. I got a very historical and well thought answer:
- Boxers and MMA-fighters are our times gladiators. There has been a red line between when the gladiators fought in the arenas in Rome, the tournaments in 14th century Europe to the underground fighting clubs in England during the 18th and 19th century. This continues today in the form of boxing and MMA. 

The National Football Leauge
Mostly through the 2015 movie Concussion with Will Smith in the lead role where Will Smith playes Dr. Omalu who discovers a never seen brain disease in dead NFL-players, the questions about concussions in sport has rised rapidly in the United States. 
I asked Yelverton about the situation in NFL and if they knew long before the players did that there was a lot of sport related brain injuries in the NFL
- We never discussed it before the question erected with the new discovered disease in American football players. Those articles from the NFL that you could find before that proposed that concussions was not dangerous or that they didn´t occure at all in the NFL. 
 
Future doctors in Sweden
Yelverton also thinks that concussions aren´t discussed enough in Med-school:
- The only ones who seem to have knowledge about it are the experts, fx neurologists, but they are usually working with more difficult brain traumas than sport related concussions. When I was lecturing AT-doctors their jaws almost hit the floor when I told them how serious the situation really was. 
 
This was Part 1 of our interview. 
To be continued. 

Consensus statement on concussion in sport

This time we´re looking at: Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016

You can find the link to the article HERE

http://bjsm.bmj.com/content/early/2017/04/26/bjsports-2017-097699

 

Every year there is an international conference on SRC (Sports Related Concussions) where some of the best within this field tries to improve their and other peoples’ knowledge on SRC. The problems are many and sometimes there are more questions created than there are answers. But is this a bad thing?

Of course not! The simple fact that people are starting to ask more and more questions is proof of improvement. People are scared and confused. Parents don´t want to make the wrong choices for their kids, trainers don´t want to spoil anything for their athletes and the athletes themselves want to keep chasing their dreams. Knowledge is power, but what do we know? Do we know exactly how to define and diagnose a concussion? Do we have enough routines to make sure we don´t take more risks than is necessary?

Sadly...no! 

 In the consensus statement on Sports Related Concussions, they wrote:

"SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The majority of SRCs occur without loss of consciousness or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC in the sporting environment."

Did you guys see that? It says that the majority of Sports Related Concussion occur without loss of consciousness or frank neurological signs. With this in consideration, please keep reading.

 
 

At any sports event, there is (or at least should be) a doctor or some other healthcare provider or physician that should be able to properly examine and treat a SRC. 

But here we run into trouble. Because far from all sports events have doctors or physicians with knowledge of SRC. This is a big problem because some of the decisions that are made to keep players in the game are mostly made by doctors. They are the ones who are supposed to be able to decide if players or athletes are fit to keep playing. How is it that the injury which is the most difficult to diagnose, is also the one that is most overlooked?

This is sometimes the biggest problem of them all. Not the injury itself, but the trainers and physicians who don´t know their limits. They think it´s tough for athletes to "take a punch, like a man" and keep going. And of course, the athletes listen to their coach, they don´t know any better. 

 

 MMA-fighter at the hospital after a fight
 

Me myself have had discussions with doctors on competitions while they were examining my athletes saying to me that "No, it can´t be a concussion. She is still conscious..."


WOW!! So, I was told by the doctor at the ----------- championship, that my athlete didn´t have a concussion, because she was NOT knocked out?? Is that the standard? Is that really where they draw the line? The person may be a good doctor but in that scenario, the knowledge of SRC was limiting the safety of my athlete.

 

But even if you have doctors and physicians with enough knowledge, is that still enough? Just think of your own sport, the chaos, the speed of the game, the audience, the coaches, the parents and friends who are screaming and shouting. It´s not an easy environment to make a calm decision and diagnose an athlete in. Some of the athletes only have minutes and seconds between rounds. How are you supposed to make the diagnosis of SRCs flawlessly? It´s a difficult task, but consider this statement from the SRC-meeting:

"We acknowledge that many contact sports are played at a fast pace in a disorganised environment, where the view of on-field incidents is often obscured and the symptoms of SRC are diverse, all of which adds to the challenge of the medical assessment of suspected SRC."

 

 


Depending on which sport or sport event we´re looking at the problems are quite different. In future articles I´m going to write about standardised tests for SRC such as SCAT5 and King Dewicks, but for now we´re only looking at the surroundings. Imagine your sport or any other sport event and take this next statement in consideration:

 "When a concussion is suspected, the athlete should be removed from the sporting environment and a multimodal assessment should be conducted in a standardised fashion (eg, the SCAT5). Sporting bodies should allow adequate time to conduct this evaluation. For example, completing the SCAT alone typically takes 10 min. Adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule changes to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalising the injured player’s team"


Can you imagine what this would mean for sports where they are depending on a tight time schedule, where things are supposed to happen smoothly and effectively? This would mean some major rule changes in all of sports. Are we ready for that? Is that a sacrifice we are willing to make just to make sure that our children and athletes won´t go the rest of their life with life changing symptoms from their sport related brain injury? Is it worth the time, money and education to make sure that our athletes world-wide won´t die younger than necessary from Alzheimer’s, Parkinson’s and CTE due to that their coaches didn´t know enough or that the sport they were playing didn´t give them that support because it was too much of a sacrifice of money and time to keep their players healthy?


I sincerely hope not. I hope that we in a few years will look at SRC in the same way we look at knee injuries. We all can in some way recognise a knee injury, and maybe in the future, we will be able, as a crowd, trainer, athlete and doctor to recognise Sports Related Concussions and take them seriously.

 
 

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"I write this, not to prevent people from practicing a sport or martial art, but to teach how to practice it safely" - Victor Bull

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