Neurology and Skiing

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We’re mostly talking about orthopedic, spinal cord and head injuries.

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Spinal Cord Injuries:

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The incidence of spinal cord injury (SCI) is around 1 per 100,000 visits (mostly thoracolumbar spine), usually caused  caused by a simple fall, followed by hitting a tree.

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The incidence of SCI for snow boarders is higher, around 4 per 100,000 visits (mostly cervical), and usually caused by a backward fall during a jump (>75%) or other tick.

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Most SCIs in skiers and snow boarders occur in 15-25 years olds.

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Head trauma:

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The incidence of head trauma is 3.8 per 100,000 ski visits, usually from direct collision with trees.  The incidence of head trauma is higher for snow boarding, around 6.5 per 100,000 visits, more often caused by falling backwards.  Most head traumas result in concussions, but 14% are severe head trauma, and 4% are fatal.

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Others

I came across this case report of another unusual neurologic skiing complication: 
A 45-year old woman first developed distorted vision in the left eye, like looking through a kaleidoscope while skiing.  Soon afterwards, her right leg started jerking, causing her to fall. 
It turned out that she had sustained a left carotid artery dissection causing high grade stenosis during skiing.
There are a few other reports of cervical artery dissection from skiing.

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Lawrence of Arabia and the Motorcycle Helmet

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Thomas Edward Lawrence,  (1888 – 1935) was a British army intelligence officer during the First World War.

His efforts in instigating the Arab Revolt against the Ottoman Turkish (allies of Germany) were featured in a documentary by American journalist Lowell Thomas, ultimately earning him international fame as Lawrence of Arabia.

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Lawrence had trouble adjusting back into civilian life after his retirement from military service, exacerbated by his fame and pursuit by the media.

He built a small hut in a then rural area of my home town, Chingford, where he completed his book “Seven Pillars of Wisdom”.  This is commemorated by a plaque fixed on the obelisk on Pole Hill.

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Lawrence was an avid motorcyclist and owned seven different Brough Superiors, dubbed the “Rolls-Royces of Motorcycles.”

On the morning of May 13, 1935, Lawrence was speeding down a narrow county road on his motorbike, when he suddenly swerved to avoid hitting two boys on bicycles and was thrown forward over the handlebars.

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At the time, helmets were only worn during races, and he sustained a skull fracture and massive head injuries.

He was taken to Bovington Camp Military Hospital in a coma, where the best specialists in the country were rushed to save him, one of them the young neurosurgeon Hugh Cairns.

Lawrence died 5 days later, without regaining consciousness.

Cairns was so profoundly moved by the tragedy of this famous First World War hero’s tragic death from severe head trauma, that he devoted his career to head trauma in motorcyclists.

During the Second World War, Cairns noted the high death rate amongst army dispatch riders, even before the actual start of hostilities, exacerbated by restricted radio communications and blackout regulations.

He observed that 2279 motorcyclists and pillion passengers were killed in road accidents during the first 21 months of the war.  However, there were only 7 cases of motorcyclists injured while wearing a crash helmet, none fatal.

His collected the monthly totals of motorcyclist fatalities in the United Kingdom from 1939 to 1945:

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And he noted that the decline in the number of fatalities took place after November 1941, when crash helmets became compulsory for army motorcyclists on duty.

Further work included an analysis of the pathophysiology and mechanisms of head injury, which led to the development of new more protective designs and materials for crash helmets:

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Click here to find out more about Lawrence, Cairns and crash helmets.

A Simple Device to Detect Concussions

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Preventing, evaluating and managing sports related concussions is a hot topic right now.

For example, Monmouth Neuroscience Institute, in association with the  Matthew J. Morahan III Health Assessment Program, offers baseline cognitive screening events and concussion evaluations for local school and college athletes.

Like most programs around the country, we use the ImPACT computerized testing to measure reaction times and assess concussions.  However, this type of computer testing requires specialized equipment and staff training.

Investigators are still looking for a more simple and cost effective assessment tool that can be used to asses athletes’ reaction times right on the side lines, to allow immediate return to play decisions during the actual game.

Sports medicine physicians from the University of Michigan have developed a homemade device that could be used in this way.

They stuck a hockey puck to then end of a long wooden dowel marked with centimeter spaced lines along its length.

The evaluator holds it in front of the athlete who is seated with one arm resting on a table. The evaluator lines up the puck with the bottom of the athlete’s hand and lets go.  Once the athlete has caught the falling stick, the evaluator marks where his hand lands, which gives a quantitative measure of reaction time.

A concussed athlete will have a slower reaction time and take longer to catch the stick (catching it further down) than a healthy athlete.

In a study published last year these investigators first used their homemade device to measure pre-season reaction times of football, soccer and hockey players.  Then they waited for these same athletes to get injured with concussions, and had them to re-take the test within at least 48 hours of the head injury.  They found that the concussed athletes took significantly longer (sometimes as much as a full second) to catch the rod than before the head trauma.

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The catch?  You still need a baseline measure for each athlete – but it might be easier to get high school and college kids to do this simple 5min test before the first game of the season than have them go to specialized testing center for a computer based test.  Then, with those baseline test results recorded, any coach can repeat the test on the side-lines after an injury and decide if they should be worried.

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I am sure the use of a hockey puck was no accident!

Read more about the study here.

Read more about concussion and concussion screening.

Find out more about the Matthew J. Morahan III Health Assessment Program at Barnabas Health.

The advantages of a truly comprehensive concussion program

Newly published research questions the use of the computerized tool ImPACT in isolation for assessing concussion.

While ImPACT is useful for evaluating concussion overall, some parts of the rest can mistake normal controls as impaired almost half of the time.

This underscores the importance of using multiple assessments when evaluating concussion patients.

Another recent study shows that professional athletes are more likely to seek medical evaluation after sports concussion that university athletes.  Research published earlier this year already showed that high school athletes are least likely to be aware of the danger of concussions, and most likely to return to play too quickly.

All athletes referred to the Monmouth Neuroscience Concussion Center will get a truly comprehensive evaluation, including an evaluation by a neurologist, balance testing and the ImPACT test.

Prosopagnosia

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Memo to Hollywood: Don’t take it personally if Brad Pitt has no memory of meeting you. The World War Z actor, 49, apparently has a difficult time recognizing people’s faces. In fact, he thinks he may suffer from prosopagnosia, or face blindness.

Speaking about the problem in his much-talked-about interview for Esquire magazine’s June/July issue, Pitt says that even if he’s had a “real conversation” with someone, he’ll forget what the person looks like almost as soon as he or she walks away. “So many people hate me because they think I’m disrespecting them,” the actor confesses to the mag.

Prosopagnosia is a rare brain disorder that impairs the ability to recognize faces without affecting other aspects of visual processing.  It is usually caused by a lesion affecting the fusiform gyrus such as stroke or head trauma, although there are even rarer congenital cases.

Perhaps the best known case is “Dr. P.” in Oliver Sacks‘ 1985 book The Man Who Mistook His Wife for a Hat:

Dr P. was a musician of distinction, well-known for many years as a singer, and then, at the local School of Music, as a teacher. It was here, in relation to his students, that certain strange problems were first observed. Sometimes a student would present himself, and Dr P. would not recognize him; or, specifically, would not recognize his face. The moment the student spoke, he would be recognized by his voice …….. At first these odd mistakes were laughed off as jokes, not least by Dr P. himself …….. His musical powers were as dazzling as ever; he did not feel ill—he had never felt better ……. The notion of there being ‘something the matter’ did not emerge until some three years later, when diabetes developed. Well aware that diabetes could affect his eyes, Dr P. consulted an ophthalmologist, who took a careful history and examined his eyes closely. ‘There’s nothing the matter with your eyes,’ the doctor concluded. ‘But there is trouble with the visual parts of your brain ……… ‘What seems to be the matter?’ I asked him at length. ‘Nothing that I know of,’ he replied with a smile, ‘but people seem to think there’s something wrong with my eyes.’ ‘But you don’t recognize any visual problems?’ ‘No, not directly, but I occasionally make mistakes.’

Dr P. illustrates another important symptom in cognitive neurology, anosagnosia. Dr P. is himself completely unaware that he has a problem, he compensates without even knowing it.  It is his wife and students that encouraged him to seek medical attention.

Concussion Assessments at Monmouth

The Matthew J. Morahan, III Memorial Health Assessment Center for Athletes is now available at Monmouth Medical Center.

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What does this mean?

1. Monmouth will be offering baseline IMPACT screening and cardiac screening to high school and college athletes, either at a free screening event or by appointment.

2. Athletes who sustain a sports related concussion and require immediate medical attention will be evaluated in the Monmouth Medical Center Emergency Room.  If they are felt to be suffering from ongoing symptoms of concussion, they can be referred to the Monmouth Concussion Center for same or next day evaluation by a neurologist and return to play determination.

3. Evaluation in the Monmouth Concussion Center will typically include a physician assessment, simple balance testing and IMPACT (R) cognitive testing.

4. The results of these evaluations with be forwarded to the athlete’s primary physician and athletic trainer, and arrangements will be made for appropriate follow-up.

Click here for more information about concussion.

Click here for directions to the Monmouth Neuroscience Out-Patient Area.