Álvaro Pereira Plays Defender Without Reciprocation

If you live under a rock or have been hanging out at Walter White's hide-a-way cabin then you probably haven't noticed anything strange. However, Twitter, Facebook, the global news, armchair quarterbacks, and the world player's union has been up in arms about Álvaro Pereira's head injury in the world cup match between Uruguary and England.

In case you didn't see it...Pereira suffered a blow to the head that rendered him unconscious. Nevertheless, he was allowed to continue to play despite that the team physician for Uruguay motioned for a substitution for Pereira. I won't delve too deeply into a play-by-play of the event but Pereira exhibited these obvious signs and symptoms of a concussion:

• loss of consciousness
• poor/altered balance and motor control
• Mood Swings
• Angrily signed to decline substitution
• repeated apologized for being "dizzy"
• Self-reported anterograde amnesia, couldn't remember much directly after being hit
• "It was like the lights went out a little bit."

Nevertheless, Pereira continued on and was allowed to play. FIFA has come under much scrutiny in the past couple of days because of this. My first reaction however is instant disapproval and disappointment with the medical staff and Pereira's own teammates. I shouldn't jump to conclusions because I do not know the true policies and procedures for the medical staff, team and the individual.

Regardless, knowing what I know and what the medical staff should know this decision was inexcusable. This stage...the WORLD CUP...sets a huge precedent for children, young athletes, parents and coaches alike of how concussions are/should/could be treated. It is disappointing and unacceptable. 

I honestly make the argument that if I was the team doctor or physio/AT and this event occurred in front of my eyes then I would interrupt the game until Pereira was substituted or I have to be dragged off the field forcefully without Pereira and be relieved of all responsibilities related to this event. I don't know how a teammate, comrade or brother-in-arms would comfortably feel OK with him continuing to play. This wasn't a possible head injury with shades of grey...it was an obvious one that was black and white and clear as day.

Some might argue that Pereira made his own choice, he is a professional, and that this is his life and he should be allowed to make this decision. To me that is akin to saying that a boxer should be able to continue after being knocked out if they want, to allow a race car driving to continue after racing after sustaining life threatening injuries or allow mentally impaired (drugs or alcohol) individuals/patients with brain damage to make their own decisions.

 There is a reason people have living wills, are not allowed to drink and drive or get tattoos under the influence of alcohol and etc. I have never met or evaluated an athlete that wanted me to remove them from competition after sustaining a head injury. They are all brave, courageous and have an incredible drive to compete but they can also make utterly ridiculous and stupid decisions at the same time.

I know that some of you may not agree with this whole-heartedly or may be vehemently against my opinion. However, I am trained to do no harm. Protect and prevent my patients from hurting themselves and others or potentially injuring themselves further. We wouldn't allow Pereira to continue to play with a fracture but one might be able to argue that the risk of permanent bodily harm or death is more likely with the injury that he did sustain that he was allowed to play with. Pereira is a defender on the field but where were the people that should have been defending him? I guess that is enough ranting for one weekend.

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Concussion, Cervical, TMJ/TMD or a Combination Thereof?

Myofascial Release of the Temporalis

Welcome readers! Today's post is about a very recent case of mine straight from the clinic! This is a mini case-study about a 22 year old male collegiate basketball player. This patient took direct blow via an elbow to the anterolateral aspect of the cranium during a basketball game on Saturday evening. After the game the athlete presented with several concussion symptoms as well as TMJ pain and a palpable and audible click with opening and closing of the mouth.

The patient presented with these findings during the assessment:

• Cranial Nerve Testing all WNL
• Dermatomes & Myotomes WNL
• Concentration, Immediate Recall, Delayed Recall, Balance, and Orientation via the SCAT3 were all WNL
• Patient Reported Concussion Symptoms
• Headache, "pressure in head", "Not feeling right", Difficulty Concentration, and eventually added the symptom of difficulty sleeping the next morning.
• Glasgow Coma Scale: 15/15 (WNL)
• 1 Previous Concussion in the symptom prior where the patient suffered much more severely on the SCAT2 and had post-concussive symptoms for 2-3 weeks following initial injury.

Long before this case presented to myself I often wondered about possible connections between concussion symptoms, and temporomandibular joint(TMJ)/temporomandibular dysfunction(TMD)/ and cervicogenic headaches. I questioned whether a person could present with concussion symptoms due to potential muscle guarding/spasm and possible involvement of TMD/TMJ issues.

Obviously I still treated this patient as having a concussion and his symptoms had slightly increased the following morning(Sunday) as well. Nevertheless, despite the fact that I was treating him for a concussion and ordering complete neurocognitive rest (despite having perfectly acceptable objective test scores on the SCAT3) I decided to treat his TMJ and neck musculature using manual therapy. NOTE: Current policy with our team neurologist is to assume its a concussion and wait to imPACT test the patient with cessation of symptoms.

I only did a few minutes worth of manual therapy for this patient and they were done with very light pressure. I started with 1-2 minutes of light IASTM to the Masseter, and myofascial release of the Temporalis using my hands. (Both pictured in the above photos.) I followed these up with some light lateral mandibular glides bilaterally for about 30 seconds each.

Finally, I applied lateral-medial/posterior-anterior pressure with the pads of my second digit on both sides of the first palpable spinous process while the patient simultaneously performed an active cervical retraction or chin tuck, if you will. This was done in an alternating fashion with pressure on again/off again in 2-3 second cycles for about 30 seconds total.

The patient reported rapid improvement in their symptoms but not complete cessation and they started to slowly return about 40-50 minutes later...Which one might expect with a concussion...or with a rapid responding patient that wasn't given a HEP to perform after manual therapy. Which one is it? I can't be sure but I play on the safe side and assume the worst. Additionally, the click/pop of the TMJ was no longer present after treatment

The following day (Monday) the patient reported complete cessation of his symptoms and the TMJ issue had not returned. The patient underwent imPACT testing which came back normal and began the first step of a graduated return to play progression.

In conclusion, what does this all mean? I don't know. What if I wouldn't have chosen to treat the patient with manual therapy. Perhaps he would have awoken still with total cessation of symptoms and would have passed his imPACT as well. (This still doesn't even prove he didn't suffer a mild concussion!) Another potential alternative is that the patient could have continued to suffer from "concussion" symptoms for days at a time and perhaps this would have delayed his imPACT testing and subsequent return to play/activity/sport. 

This is not necessarily a bad thing because it is always best to play it safe. However, it also means that my patient/athlete would have had to suffer undue pain/discomfort related to his TMD/"concussion" symptoms. He also would potentially have to miss out on class/social activities/and experience a lot of undue psychological stress if I hadn't treated these findings. I am just curious if others if had these similar thoughts/case/experiences or what you all think of this? 

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Stay A-Head of the Game: Concussion Literature

Concussions are still a hot topic and will continue to be for the foreseeable future. The media loves to discuss them, coaches loathe them, parents fear them, and the research is still within its infancy. It isn't time for anyone to jump to conclusions or panic but it is definitely a good time to stay informed and properly educated on the topic.

This blog post came as a result of the latest edition of the Journal of Athletic Training, which had several concussion related articles. To begin the issue there was a special editorial written by concussion research expert, Kevin Guskiewicz, PhD, ATC, FNATA, FACSM. He is also the chair of the Department of Exercise and Sport Science at the University of North Carolina at Chapel Hill.
Dr. Guskiewicz recommends that sports medicine professionals stay informed on upcoming concussion research to be published within the next 6 months. 

This includes the ‘‘Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012’’ that was published in this edition of the Journal of Athletic Training and originally published in the British Journal of Sports Medicine in March, 2013. He advises that these documents "will define the standard of care for athletic trainers and team physicians for at least the next 4 to 5 years. These documents are very well prepared and will make significant contributions to the sports medicine community." 

He also had these three major closing points:

1. Read these documents,
2. Develop and implement a sound concussion-management program and policy
3. Check the boxes each time you manage a patient with a concussion. 

Dr. Guskiewicz had one last closing piece of advice that is very important for concussion management but is applicable to everything we do as clinicians and arguable important for any person to learn. I know football season for me is fast approaching so I know I need to make sure I get caught up on my concussion literature.  I will leave you with his advice in quotes and a link to the latest journal issue!

"But just as important, be sure you go the extra mile to educate yourself and your athletes and to ensure that both you and your athletes are protected. "

Latest Journal of Athletic Training 

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