Author Response: Medical retirement from sport after concussions: A practical guide for a difficult discussion
James M.Noble, Assistant Professor of Neurology, Columbia University Medical Center
Published April 04, 2018
On behalf of my co-authors, we appreciate the very thoughtful and supportive letter from my colleague Dr. Sethi. In the course of developing our algorithm and manuscript,[1] we were careful to be inclusive of the various terms, both current and historic, describing sudden neurologic phenomena following concussion aside from simply loss of consciousness. In our experience, some of these phenomena, particularly “concussive convulsions” (fencing postures and other tonic postures) are not uniformly known by neurologists to be a part of concussions unless the neurologists are involved with sports medicine programs supervising high risk sports, or very frequently encounter patients with mild traumatic brain injury. The neurologic localization of “concussive convulsions,” either as cortical or subcortical phenomena, has been a matter of some debate, but these events are inarguably obvious signs of sudden neurologic dysfunction following concussion.
We agree that the terms “immediate epilepsy” and “impact seizures” are potentially confusing and warrant further clarification. The term “impact seizure” is best used to describe an obvious seizure (focal or generalized) at the time of concussion, instantaneous to or within seconds of the time of injury. We included the term “immediate epilepsy” in our review, as some of the older literature interchangeably used the terms “impact seizure” and “immediate epilepsy,” to represent seizures at the time of concussion. The term “immediate epilepsy” would be used differently now (if at all) and reflects changing definitions of the term “epilepsy”over time.[2] Epilepsy in its current use reflects a chronic or recurrent condition involving unprovoked seizures, including those with a recent or remote history of head trauma. For the sake of inclusiveness, we cited the term “immediate epilepsy,” as defined by Jennett in his article 1974, “as a fit occurring within seconds of injury, this uncommon phenomenon consists of a generalized seizure following a mild injury in an adult.” [3] Further, we agree that in current clinical practice, “early post-traumatic epilepsy” describes an epilepsy syndrome following the concussion (and not at the time of injury), and consider such a distinction in an early step of our retirement algorithm.[1]
References
1. Davis-Hayes C, Baker DR, Bottiglieri TS, et al. Medical retirement from sport after concussions: A practical guide for a difficult discussion. Neurology Clinical practice 2018;8:40-47.
2.Wolf P. History of epilepsy: nosological concepts and classification. Epileptic disorders : international epilepsy journal with videotape 2014;16:261-269.
3.Jennett B. Early traumatic epilepsy. Incidence and significance after nonmissile injuries. Archives of neurology 1974;30:394-398.
On behalf of my co-authors, we appreciate the very thoughtful and supportive letter from my colleague Dr. Sethi. In the course of developing our algorithm and manuscript,[1] we were careful to be inclusive of the various terms, both current and historic, describing sudden neurologic phenomena following concussion aside from simply loss of consciousness. In our experience, some of these phenomena, particularly “concussive convulsions” (fencing postures and other tonic postures) are not uniformly known by neurologists to be a part of concussions unless the neurologists are involved with sports medicine programs supervising high risk sports, or very frequently encounter patients with mild traumatic brain injury. The neurologic localization of “concussive convulsions,” either as cortical or subcortical phenomena, has been a matter of some debate, but these events are inarguably obvious signs of sudden neurologic dysfunction following concussion.
We agree that the terms “immediate epilepsy” and “impact seizures” are potentially confusing and warrant further clarification. The term “impact seizure” is best used to describe an obvious seizure (focal or generalized) at the time of concussion, instantaneous to or within seconds of the time of injury. We included the term “immediate epilepsy” in our review, as some of the older literature interchangeably used the terms “impact seizure” and “immediate epilepsy,” to represent seizures at the time of concussion. The term “immediate epilepsy” would be used differently now (if at all) and reflects changing definitions of the term “epilepsy” over time.[2] Epilepsy in its current use reflects a chronic or recurrent condition involving unprovoked seizures, including those with a recent or remote history of head trauma. For the sake of inclusiveness, we cited the term “immediate epilepsy,” as defined by Jennett in his article 1974, “as a fit occurring within seconds of injury, this uncommon phenomenon consists of a generalized seizure following a mild injury in an adult.” [3] Further, we agree that in current clinical practice, “early post-traumatic epilepsy” describes an epilepsy syndrome following the concussion (and not at the time of injury), and consider such a distinction in an early step of our retirement algorithm.[1]
References
1. Davis-Hayes C, Baker DR, Bottiglieri TS, et al. Medical retirement from sport after concussions: A practical guide for a difficult discussion. Neurology Clinical practice 2018;8:40-47.
2.Wolf P. History of epilepsy: nosological concepts and classification. Epileptic disorders : international epilepsy journal with videotape 2014;16:261-269.
3.Jennett B. Early traumatic epilepsy. Incidence and significance after nonmissile injuries. Archives of neurology 1974;30:394-398.