A Day in the Life of a World Tour Cycling Team Doctor 4/2/13 Prentice Steffen, MD, FAAEM BIOGRAPHY: In July 2008 Dr. Prentice Steffen became the first American physician in the Tour de France's 100+ year history to care for a team competing in that prestigious race. He serves as Chief Medical Officer for Slipstream Sports which owns and operates the Garmin‐Sharp Professional Cycling Team. Dr. Steffen is board‐certified in Emergency Medicine with a Certificate of Added Qualification in Sports Medicine. He is a Fellow of the American Academy of Emergency Medicine. He graduated from the Vanderbilt School of Medicine in 1986 and completed his Emergency Medicine training at Highland General Hospital in Oakland, CA which was at the time the Emergency Medicine program affiliate of UC‐San Francisco. Dr. Steffen then spent 7 years on the faculty of UCSF working in the Emergency Department at Mount Zion Medical Center followed by three years on the faculty of Columbia University College of Physicians and Surgeons in NYC. Dr. Steffen is currently in private practice transitioning from the Emergency Department of Sonoma Valley Hospital in Sonoma to Dominican Hospital in Santa Cruz. Negotiating With Your Brain Concussion Identification, Response and Management Eric Freitag, Psy.D., FACPN BIOGRAPHY: Dr. Freitag is a licensed psychologist, a board certified clinical neuropsychologist, the founder and Executive Director of the Mt.Diablo Memory Center in Walnut Creek, and the co‐founder of the California Concussion Coalition. As a neuropsychologist, he works extensively with individuals with traumatic brain injury and other neurological illnesses. He started the Sport Concussion Program in 2006 and has provided baseline and post injury care to hundreds of athletes in the Bay Area. He currently serves or has served as the concussion program consultant for Marin Catholic High School, Marin Academy and Exergy Twenty12 Women’s Professional Cycling Team. In addition, he provides ongoing consultation services to the Cal Berkeley and Diablo Valley College athletic departments. Dr. Freitag’s athletic experience includes participation as a professional and collegiate soccer player, multisport high school athlete, state level soccer referee, USSF licensed soccer referee. BIBLIOGRAPHY: Webbe, FM. The Handbook of Sport Neuropsychology. New York, NY: Springer Publishing; 2011 McCrory, P., Meeuwisse, WH, et al. Consensus statement on concussion in sport: the 4 th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine 2013; 47:250‐258
Transcript
A Day in the Life of a World Tour Cycling Team Doctor 4/2/13
Prentice Steffen, MD, FAAEM
BIOGRAPHY: In July 2008 Dr. Prentice Steffen became the first American physician in the Tour de France's 100+ year history to care for a team competing in that prestigious race. He serves as Chief Medical Officer for Slipstream Sports which owns and operates the Garmin‐Sharp Professional Cycling Team. Dr. Steffen is board‐certified in Emergency Medicine with a Certificate of Added Qualification in Sports Medicine. He is a Fellow of the American Academy of Emergency Medicine. He graduated from the Vanderbilt School of Medicine in 1986 and completed his Emergency Medicine training at Highland General Hospital in Oakland, CA which was at the time the Emergency Medicine program affiliate of UC‐San Francisco. Dr. Steffen then spent 7 years on the faculty of UCSF working in the Emergency Department at Mount Zion Medical Center followed by three years on the faculty of Columbia University College of Physicians and Surgeons in NYC. Dr. Steffen is currently in private practice transitioning from the Emergency Department of Sonoma Valley Hospital in Sonoma to Dominican Hospital in Santa Cruz.
Negotiating With Your Brain Concussion Identification, Response and Management
Eric Freitag, Psy.D., FACPN
BIOGRAPHY: Dr. Freitag is a licensed psychologist, a board certified clinical neuropsychologist, the founder and Executive Director of the Mt.Diablo Memory Center in Walnut Creek, and the co‐founder of the California Concussion Coalition. As a neuropsychologist, he works extensively with individuals with traumatic brain injury and other neurological illnesses. He started the Sport Concussion Program in 2006 and has provided baseline and post injury care to hundreds of athletes in the Bay Area. He currently serves or has served as the concussion program consultant for Marin Catholic High School, Marin Academy and Exergy Twenty12 Women’s Professional Cycling Team. In addition, he provides ongoing consultation services to the Cal Berkeley and Diablo Valley College athletic departments. Dr. Freitag’s athletic experience includes participation as a professional and collegiate soccer player, multisport high school athlete, state level soccer referee, USSF licensed soccer referee.
BIBLIOGRAPHY: Webbe, FM. The Handbook of Sport Neuropsychology. New York, NY: Springer Publishing; 2011 McCrory, P., Meeuwisse, WH, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal of Sports Medicine 2013; 47:250‐258
4/1/2013
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A Day in the Life of a WorldTourCycling Team Doctor…
Prentice Steffen, MD, FAAEM
Chief Medical Officer, Slipstream Sports LLC
Team Physician, Garmin‐Sharp Pro Cycling Team
First Questions…
• How did I get here ?
• History of Slipstream Sports LLC ?
• Why are YOU here ?
The Players
• Riders• Administration• Medical• Soigneurs• Mechanics• Etc.
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Alphabet Soup of Pro Bike Racing
• NGB, IGB
• ADO
• WADA
• etc.
The Office
• Team Car
• Bus
• Hotel
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When Exactly Does the Day Begin?
• 2008 Tour de France… aka, “Groundhog’s Day”
• Morning ?
• Night ?
• After the stage ends ?
Paris-Nice 2013 Day 3
• Breakfast
• Pre-race rounds
• Car 1
• MPCC testing
Paris-Nice Day 3 (cont.)
• Saddle sore, URI, asthma, etc.
• Race
• Anti-doping
• Hand fracture… trip to local hospital
Paris-Nice Day 3 (cont.)
• Evening rounds
• A quick run?
• Dinner
• Late night knocks on door …
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Advanced Concussion Training
Eric Freitag, Psy.D.
California Concussion Coalition, Northern Chapter Co‐Chair
Diplomate, American Board of Professional NeuropsychologyThe Mt. Diablo Memory Center ‐Sport Concussion Program
President Elect Northern California Neuropsychology Forum
)
CALIFORNIA CONCUSSION COALITION
Case Presentation• Elite Professional Cyclist
1. (2010) Crash during descent with fractured pelvis and dented helmet
– LOC, Post traumatic Seizures
– Airlifted to hospital
– Discharged same evening
– Friend stayed in hotel room, woke up next morning had another seizure
– No medical care sought, flew home that day
– No further follow up regarding head injury
2. (2010, Six weeks later)• Training ride• Crashed. No recall of hitting
head but was foggy and out of it for several days
• No Medical follow up• Competed season with post
concussion symptoms• Neurological symptoms with
extreme exertion or exhaustion
• Chronic fatigue
3. 2011 –Approx. 1 year later• Elite International Event• Crashed during warm up• Facial bruising and abrasion• Teammate had to carry in to
medical tent• Slurring words, sluggish, balance
problems• Still wanted to race• Cleared to race later that day
Evaluated 4 Months Later
• Fatigue
• Poor sleep
• Slow thinking
• Overall close to “100%”
• Off season training 25‐30 hours per week
Evaluated 4 Months Later
• Assessment Results
– Impaired complex attention, speed of processing, memory, language fluency, visual spatial processing
• Treatment
– Continue but reduce training demands
– Treat emotional symptoms
– Address sleep difficulties with Rx and behavior strategies
– No Competition until full recovery
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What is a Concussion?
• A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works
• The head does not have to be directly hit for the brain to injured
• Some athletes will not display any signs or symptoms initially, but symptoms may appear within minutes or hours
• Don’t underestimate adrenaline or an athlete’s ability to rationalize symptoms as something else, like a cold
• Females tend to suffer more reported concussions than males that play the same sport.– High school basketball – Females are diagnosed with 3x more concussions– High school soccer - Females are diagnosed with 68% more concussions
• Females tend to have longer recoveries than males in the same sport.
Honesty – females are more likely to report concussion symptoms than males.
Physiologic – hormone differences between males and females may account for a differing concussion experience.
Biomechanical – males tend to have stronger necks, which may absorb some of the force of a blow.
McCrea M et al. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004 Jan;14(1):13-7
• Historically, the general consensus had been that athletes didn’t report symptoms because they didn’t want to be held out of the game. Research shows that is not true
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Why Players Don’t Report Concussions
Total Concussions in the US
• CDC estimates that between 1.6 to 3.8 million concussions occur in sports and recreational activities each year
• Key Takeaway – Only a small percentage of concussions are diagnosed
• If signs and symptoms of a concussion disappear within 15 minutes, player may return– Only universal agreement was never allow return to play after LOC
• 2. Ensure that the athlete is evaluated by a health care professional experienced in evaluating for concussion. – Do not try to judge the severity of the injury yourself.
– As a coach, recording the following information can help health care professionals in assessing the athlete after the injury: ▫ Cause of the injury and force of the hit or blow to the head or body
▫ Any loss of consciousness (passed out/knocked out) and if so, for how long
▫ Any memory loss immediately following the injury
• Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says they are symptom‐free and it’s OK to return to play.• A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long‐term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death.
• The following symptoms REQUIRE a trip to the emergency room:– Medical Changes in alertness and consciousness– Convulsions (seizures)– Muscle weakness on one or both sides– Persistent confusion– Persistent unconsciousness (coma)– Repeated vomiting– Unequal pupils– Unusual eye movements– Walking problems
**The relationship between “Official Educational Partners” and SLI is strictly an educational and awareness raising relationship and is not intended to be a product endorsement by either party.
Upregulation and Recovery of Function. Journal of Neuroscience, 125, 129‐139
Conclusions
• Rats exercise day 0‐6
– No enhanced upregulationof BDNF
– Showed decreased cognitive performance
– Disruption of molecular response
Griesbach, Hovda, Molteni, Wu, Gomez‐Pinella, Journal of Neuroscience, 2004
Conclusions
• Rats exercise 7+ days PI
– Increased upregulation of BDNF
– Improved performance on cognitive activity
Griesbach, Hovda, Molteni, Wu, Gomez‐Pinella, Journal of Neuroscience, 2004
• Objective: To evaluate the safety and effectiveness of subsymptom threshold exercise training in tx of PCS
• 12 refractory PCS patients <6 weeks or >52 weeks PI
• No control group
Leddy, et. al. (2010). A Preliminary Study of Subsymptom Threshold Exercise Training for Refractory Post‐Concussion Syndrome. Clinical Journal of Sports Medicine. 20, 1, 21‐27
• 5‐6 days/week of treadmill training at 80% max. HR
• Significant reduction in overall symptom reporting
• All participants returned to pre‐injury levels of activity
Leddy, et. al., Clinical Journal of Sports Medicine, 2010
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Importance of Medical Clearance
• A concussion typically results in short‐lived neurological impairment that resolves spontaneously within one to two weeks
• Return‐to‐play too soon after a concussion can result in:– Prolonged post‐concussion symptoms [>3 weeks]
– Post‐concussion syndrome [>6 weeks]
– Increased risk of second concussion
– Sudden death or severe brain injury due to Second Impact Syndrome
• Second Impact Syndrome occurs when an athlete, who has already sustained a head injury, sustains a second head injury before symptoms have cleared from the first injury
• This second blow to the head, sometimes minor, can result in a loss of auto-regulation of the brain's blood supply, leading to rapid brain swelling.
• 50% of SIS sufferers die, and the survivors rarely recover fully. It usually occurs to athletes <21 years old, although it can happen to older athletes
Source: NY Times, Cantu, R. C. (1996). Head injuries in sport. British Journal of Sports Medicine, 30, 289-296.
Adapted from McCrory, W., Meeuwisse, W., Dvorak, J., Aubry, M., Molloy, M. & Cantu, R. (2009). Consensus statement on concussion in sport‐ The 3rd International Conference on concussion in sport. Journal of Clinical Neuroscience, 16, 755‐763.
• Look for students that show increased problems paying attention, problems remembering or learning new information, inappropriate or impulsive behavior, greater irritability, less ability to cope with stress, or difficulty organizing tasks
• THINK ABOUT how difficult and stressful it is for a student with a malfunctioning brain to be in the classroom with normal expectations for performance
McCrea M et al. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004 Jan;14(1):13-7
Historically, the general consensus had been that athletes didn’t report symptoms because they didn’t want to be held out of the game. Research shows that is not true.
The top reason high school athletes don’t report concussions is that they do not believe a concussion is a serious injury!
This groundbreaking study revealed that athletes are poorly educated on concussions.– Another recent study found that fewer than half of college athletes
were aware that concussions can have negative consequences.
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• Concussion education for athletes has focused only on individual health benefits
– “It’s better to miss a game than the season.”
• Are all youth athletes good at delaying gratification?
“In case any man in any game gets hurt by a hit on the head so that he does not realize what he is doing, his teammate should at once insist that time be called and that a doctor come onto the field to see what is the trouble.”
