All posts by TheTraumaPro

Cognitive Rest??

One of the more commonplace recommendations for recovery from mild traumatic brain injury (TBI) is “cognitive rest.” Sports medicine professionals recommend it, physiatrists recommend it, and trauma professionals talk about it.

First, what is it, exactly? I’ve seen a number of descriptions, and they vary quite a bit. The main concept is to avoid all activities that involve mental exertion. This includes using a computer, watching TV, talking on a cell phone, reading, playing video games, and listening to loud music. Huh?

What good does this allegedly do? Most articles that I’ve read theorize that cognitive activity somehow increases the metabolic activity of the brain and that this is bad. One of the more interesting papers I read (from 2010!) says it best: “It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed.”

Read carefully. Well-accepted. The paper cites unpublished data on children by one of the authors, 2 meta-analyses and 2 consensus opinions. In other words, no data at all. Yet somehow the concept has caught on.

First of all, I don’t think it’s possible for most people to realistically practice cognitive rest. Who knows if there is really any difference in metabolism and energy use by the brain if you are engaging in any of the banned activities above? And let’s go to the other extreme: if one lies quietly in bed meditating, shouldn’t this be the ultimate cognitive rest? Yet fMRI and PET studies suggest (also limited data) that cerebral flow in specific areas of the brain increases during this state.

Maybe a modest increase in activity is good. Physical activity (within limits) has been shown to be very beneficial to physical and psychological well being time and time again. And the only paper I could find on the topic with respect to TBI showed that randomization to bedrest vs normal physical activity had no difference in post-concussive syndrome incidence or severity. However, the active group recovered with significantly less dizziness.

Bottom line: There is no data to support the concept of cognitive rest. Any type of activity, either mental or physical, can cause fatigue in a variable amount of time in people with mild TBI. It is probably best to interpret this as a signal to take it easy and recover for a while before exerting oneself again. But so far there is no objective data to show that cognitive activity either helps or hinders recovery.

References:

  • Cognitive rest: the often neglected aspect of concussion management. Athletic Therapy Today, March 2010, pg 1-3.
  • Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry 73:167-172, 2002.

The Future of the Medical Journal – Part 2

After posting yesterday, I was informed that LWW was not the first to enter the small screen arena. The British Medical Journal (BMJ) released content for the iPad platform beginning in December 2011. This journal uses the built-in Newsstand app on the iPad or iPhone.

On first look, it appears to be more robust than the LWW app for Neurosurgery. The BMJ allows access to other related content streams, such as their news, blogs, podcasts and video. It is a bit more interactive and does allow searching and bookmarking.

Bottom line: I’m sure someone will step forward with yet another earlier entry into the smartphone/tablet arena. Regardless, it’s all good. Either Newsstand or independent app works, although the Newsstand offers some pre-built functionality for developers that might make it a bit easier to create. However, the Newsstand is also Apple-specific, and won’t work for all the people with Android or Windows based phones and tablets who will be screaming for this content.

Reference: search for “BMJ” in the Apple App Store

The Future of the Medical Journal

Journals have been printed on trees since forever. Within the past 10 years, there has been a shift toward also making this content available on the publishers’ web sites. Now, Lippincott Williams & Wilkins (LWW), publisher of the journal Neurosurgery (and many others) has taken an important step forward.

Beginning with the current issue (March 2012), this journal is now available within an iPad app. One of the problems with the traditional journal was that you had to go to the library to read it. And medical libraries can’t carry every journal, so if the one of interest was not in the collection, you had to wait a few days for the librarian to get a copy.

With the onset of the internet age, journals began to appear online. Most major publishers had a web presence and made their journals available online. However, most provided full text content for free only to their subscribers. At best, a non-subscriber would get the abstract, or an occasional free article. Biomedical libraries typically subscribed to services where hundreds of journals were available as full text to medical staff members, residents and students. The downside was, and still is, that you need access to a desktop to comfortably consume the articles. The web sites were just not that friendly for the small screen.

Finally, LWW has made a concerted effort to provide this content in tablet format. More and more trauma professionals are carrying these devices and using them in their practices. This brings the content closer to the patient and provides it in a very consumable format. It also allows the publisher to add dynamic digital content (audio and video) to the material.

I’ve been using this app for about a day and am impressed. Here are some key features:

  • Portability is excellent. A continuous internet connection is not needed. The entire journal issue is downloaded and added to your library, and you are only limited by the amount of storage on your iPad.
  • Extra digital content is routine. And since it is already downloaded with the issue, there is no waiting for it to load.
  • Articles have the same look and feel as the journal and can be panned or zoomed for readability.
  • Content sharing is possible (somewhat). Each article allows the user to share on Twitter or Facebook. The article can also be emailed to others. However, only a link to the article is provided, and if you are not a journal subscriber you’ll either have to pay up or use your medical library account to get full text when the link is opened.

What doesn’t it do? There is currently no ability to search through an article or issue. And it would be nice to interact with one of the authors via an email link to ask questions or make suggestions. Finally, Apple is not the only tablet maker out there. Publishers will need to make sure apps are available on the Android platform as well.

Bottom line: This is a great first-try at moving journals onto a mobile platform. I expect that LWW will begin to roll out this format for all their journals since they’ve now figured out how to do it. And expect all the other publishers to jump on the bandwagon as well. Journals are eventually going to go the way of DVD movies, and we’ll end up streaming our professional content from some company with a big red logo.

Reference: Search for “Neurosurgery” in the Apple App Store.

New Technology: Fracture Putty

Fracture healing takes a long time, as many of our patients can attest to. Six or eight weeks, and even more may be required for full healing. Researchers at the University of Georgia and in Houston have completed an animal study on rats using a type of “fracture putty” that dramatically speeds up this process. 

The researchers used adult mesenchymal stem cells that produce a protein which is involved in bone healing and regeneration. They created a gel using these cells, and injected them into the fracture sites which were stabilized externally (imagine a rat external fixator!). The fractures healed rapidly, and within 2 weeks the rats could run and stand on their legs normally.

Bottom line: The next step is to translate this work to larger animals. Strength and durability are major concerns. The amount of stress placed on rat legs and human legs is considerably different. If this pans out, it could revolutionize fracture healing, especially in cases where there may be highly disabling segmental bone loss (read: military). It will be several years before this can move to human studies.

Reference: University of Georgia Regenerative Bioscience Center

Why Did The Trauma Team Cut Off My Clothes?

The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting. 

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.