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Athletes Who Suffer Concussions Are Returned to Games

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Medical researchers say sideline concussion tests are often ineffective—sometimes leading to false positives and more detrimentally—missing concussions.

One way to remove an opposing player from a football game is to initiate helmet-to-helmet contact and hope he fails his sideline concussion test.

If the player fails his test, he will be removed from the game, and will not return.

However, a recently released study suggests that the standard method of concussion testing is faulty, resulting in false positives for some athletes, while others who have suffered concussions have been ruled as healthy.

“If you don’t do well on the cognitive exam, it suggests you have a concussion. But many concussed people do fine on the exam,” Dr. Kimberly Harmon, the study’s lead author, said in a press release. “Some people weren’t concussed and they didn’t do well. So I thought we should study it.”

Dr. Harmon, sports medicine professor at the University of Washington (UW) School of Medicine, has been responsible for testing athletes on the sideline of UW football games. She and a team of researchers set out to determine whether the Sport Concussion Assessment Tool (SCAT)—which requires athletes to repeat a list of 10 words—can provide an accurate finding.

This test, which has been used by the NCAA (National Collegiate Athletic Association) since 2004—with five updates—requires the athlete to listen to a list of 10 words as they are read aloud. Then he or she is required to recite the list, to test immediate memory. The sidelined athlete has three chances to listen to the list and repeat it. The athlete’s ability to concentrate is also tested by listening to short sequences of numbers and then repeating them in reverse order.

The first step in the SCAT test requires athletes to report whether they are suffering any of 22 symptoms, including headaches, blurred vision, and nausea. They are also tested on basic questions of mental orientation, such as the month and day.

A concussion is defined as a traumatic brain injury, caused by a jarring blow to the head, neck, or upper body, or sudden head acceleration or deceleration. The most common cause of concussions is a fall, according to the Mayo Clinic. Symptoms include headache, dizziness, ringing in the ears, and amnesia of the event causing the injury. Although the symptoms can last for several days to a lengthy period most people recover fully.

The Study

The concussion test study focused on 92 athletes at Division 1 universities who had a concussion evaluation within 48 hours, between July 13, 2020, and Dec. 31, 2022. The researchers also tested 92 teammates of the concussed players as control subjects. The concussed subjects included 37 football players, 14 women’s volleyball players, 7 women’s softball players, 7 women’s track and field, 5 baseball players, and 22 athletes from other sports. The subjects were 48 male and 44 female athletes.

The NCAA requires all athletes to complete baseline concussion tests, for comparison to post-injury tests. The researchers discovered that the tests of recalling 10 words were not valuable in diagnosing concussions.  Nearly half the athletes who were diagnosed with concussions—41 of 92—tested at or above the word tests they took before their injuries.

The researchers acknowledged that their study was limited because it only included Division 1 college athletes, the highest category of educational athletics. The study “may not represent other populations such as high school or professional athletes,” they reported. Another limitation of this study was that it did not take into consideration prior concussions of the subjects, except for the exclusion of athletes who were concussed during the prior year.

A Controversial Subject

The subject of brain injuries in sports is highly controversial. Universities rake in millions of dollars from their athletic programs, while the NFL (National Football League), NHL (National Hockey League), and other sports leagues report revenues rivaling those of major corporations.

Many athletes are also well-paid and depend on good health to reap the rewards of participation. Assessments that depend on an athlete’s self-reporting of their condition or cognitive abilities are subject to the athlete’s will to return to the field of play. Another important element affecting the athlete could be pressure from other people who are invested in winning.

The decision on whether an athlete should return to play that day or when they should return to their sport, should be led by the team physician, said a consensus statement of team physicians, published in May in the journal of the American College of Sports Medicine.

“The team physician has the central role in not only protecting the athlete’s health but also protecting the athlete from coercion to participate,” said the statement, approved by 16 physicians.

“For the team physician, an athlete plays a central role in SDM [shared decision-making], providing input and direction for the RTS [return to sport] decision.”

Dr. Margot Putukian, chief medical officer for Major League Soccer, said “The sideline assessment of concussion is challenging,” in a review of literature on the subject, published in 2017 in the Journal of Athletic Training. She said it is important to be familiar with the athlete and have sound clinical judgment.

The Challenge of Sideline Assessments

An accurate sideline assessment of a concussion is challenging, because of “the elusiveness and variability of presentation, reliance on athlete-reported symptoms, and the varying specificity and sensitivity values of sideline assessment tools,” Dr. Putukian said. “The recognition of injury and assessment often occur in a time-pressured environment, requiring rapid disposition and decision making.”

An athlete might not report specific symptoms, even after an incident on the field that tends to indicate a head injury. During the preseason, many athletes practice in the heat, multiple times per day.

“It is not unusual for athletes to be fatigued and have headaches and other symptoms that may or may not be related to concussion. The challenge is to try and decipher whether the symptoms are new and related to a blow to the head or body versus those that might be related to another process (eg medical or emotional),” Dr. Putukian wrote in the conclusion to her literature review.

“In the sideline setting, it is again preferable to err on the side of caution and treat symptoms as concussion related until determined otherwise, removing the athlete from play for a more comprehensive evaluation.”

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