Matt Schaub - Lisfranc fracture dislocation

I'm really behind on this post but I'd still like to write it up anyways given that it doesn't seem very common.

In Week 10 against the Tampa Bay Buccaneers, QB Matt Schaub of the Houston Texans sustained a Lisfranc fracture. It's not a very common injury, and is actually often missed.

Firstly, the loose term of "Lisfranc joint" can be applied to the connection between the metatarsals (most proximal long bones of the foot; analogous to the metacarpals that are the bones in the palm of the hand) and cuneiforms (analogous to the carpals, or wristbones, of the hand).
The Lisfranc ligament is what connects this joint and goes from the first (medial) cuneiform) to the second metatarsal. No other ligaments connect the cuneiforms and the metatarsals to each other.

Clear as mud?

How does it occur? Intuitively, since this ligament is all that connects the metatarsals and cuneiforms together, it is prone to injury. This usually occurs either by a direct blow to the joint itself or an increased load to the joint (think of when you're on your toes) accompanied by a rotational force. An example could be of a horseback rider falling while their foot is stuck in the stirrup.

What is the injury? There is a spectrum of injuries that can happen to the Lisfranc ligament.
- Grade I sprain: Pain at joint, no swelling
- Grade II sprain: Increased paint at joint, some swelling, slight laxity but no instability
- Grade III sprain: Complete disruption of ligament; could include a fracture dislocation (this is what Schaub sustained). Any injury of above Grade III doesn't affect prognosis.

How is it diagnosed? A good history of the mechanism of injury should raise suspicion of its possibility. It may present as simply as swelling and the inability to weight bear. The physician should palpate the joints within the foot and do his/her best to localize tenderness.
In terms of the fracture-dislocation, it can be diagnosed by X-ray which would show disruption of the normal alignment of the joint and possibly a bone chip caused by the ligament breaking off from one end.

CT scan can be used to better visualize the injury or if the X-ray is inconclusive.

How is it treated? Most sprains that are stable and not displaced can be treated medically with analgesia and rehabilitation. In athletes, there is a low threshold for treating it surgically given that no surgery can lead to instability, severe pain and damage in the future. The surgery performed is to fixate the joint with screws or wires. In terms of healing, the patient needs to wear a cast and cannot weight-bear for six weeks as the joint heals. Activity and rehabilitation can be increased as symptoms abate.


Sources:
eMedicine
American Association of Family Physicians

Derek Boogard - chronic traumatic encephalopathy

When news broke of Boogard's autopsy results of chronic traumatic encephalopathy, I thought of writing a post. Since then, I read an excellent article in the New York Times about this matter and more. It's exceptionally written and it details Boogard's last few years before he died. Really sobering.

It is a must-read. You'll never see fighting in hockey the same way again.

Peyton Manning update

Apologies, folks. It's been a while since I've posted here with any sort of substance. The last few rotations have been a lot busier, and we've been going through residency applications which is its own monster.

As news broke earlier this week, Peyton Manning is entering his next stage of rehab following his X-ray and CT scans that have revealed appropriate fusion of his vertebrae from surgery.

He has mentioned he will likely start throwing and lifting weights in the start of this next phase of what I'm sure will be intense physical therapy needed for a high performance athlete to return to optimal function. Considering he hasn't been able to do any practice for so long, his muscles likely have a lot of catching up to do.

As I mentioned in my previous post on this topic, the long-term prognosis after this surgery is not certain. However, like most sports injuries, how he does with his rehabilitation in these next few months will be an enormous factor in the success of this treatment.

He's back.

As per TSN.ca, Sidney Crosby will be in the lineup to face the New York Islanders on Monday.

I'm sure everyone is happy the best player in hockey is returning. Too often are careers (and lives) cut short by repeated concussions.

He's not out of the woods quite yet though. Everyone will be holding their collective breath when he gets hit for the first time tomorrow.

If ever he gets another concussion though...

James Reimer - "headaches"

Hey folks. Just thought I'd write a quick note on James Reimer, goaltender for the Toronto Maple Leafs (a.k.a. guy with one of the most badass nicknames in sports... with the exception of Calvin "Megatron" Johnson).

As you know, he was involved in a collision in a game against the Canadiens' last Saturday primarily involving his head. There has been no official statement released if he has had a concussion, post-concussion symptoms, etc.

Apparently today he developed headaches while at practice which worsened as it continued. Obviously with a combination of impact to the head + headache a few days later makes everyone jump to a concern of concussion but it's really only speculation at this point. When it comes to concussions, it involves a full clinical history (especially the day of injury at the time of the collision and hours after) and likely a number of symptoms rather than just relying on headaches alone.

If there was no evidence of a concussion last Saturday AND if he only had an isolated bout of headaches today, it makes it very difficult to claim that a concussion is the most likely diagnosis. With that said, if he had a concussion on Saturday and he's developing symptoms with activity today, there obviously has to be concern they're related. Confused yet?

So either the Maple Leafs are trying to keep a concussion out of the spotlight, or Reimer just got some unrelated headaches today. Either way, they're playing it safe which is a very very good idea.

I'll write more if/when more details become available.

Jerome Harrison UPDATE: Brain tumor was an ependymoma

These were the details I was looking for!

An update by ESPN shed more light on the nature of Jerome Harrison's brain tumor. To summarize (and elaborate):

• Harrison had surgery and the neurosurgeons believed they were able to remove all of the tumor. The tumor was located in the fourth ventricle of the brain (see diagram to the right for the anatomic location). It's actually located lower down in the brain just in front of the cerebellum and is one of the spaces (i.e. ventricles) that contain cerebrospinal fluid (CSF). The function of the CSF is to act as a buffer between the brain and the skull. The brain literally "floats" in the fluid.
• The tumor was identified, presumably via histology, as an ependymoma. I'll talk about ependymomas below.
• Apparently Harrison also had an arteriovenous malformation which may have contributed to the tumor. I posted about arteriovenous malformations earlier when Eagles DT Mike Patterson had a seizure in training camp presumably as a result of one. I didn't actually know AVMs were a risk factor for tumors. You learn something new every day I guess.

Now, about ependymomas...

Ependymomas are a rather rare form of neurological tumor. They can actually occur almost anywhere in the spinal cord, not just the brain, although most commonly in the fourth ventricle like in this case. They only account for about 10% of all central nervous system tumors and 25% of all spinal cord tumors. These tumors arise from tissue called ependyma which are cells that normall produce CSF. 

They are definitively diagnosed through histology and with molecular genetics although when they are seen on MRI or CT there are certain visual characteristics that may make an ependymoma vs. other type of brain tumors more likely. 

Treatment, as stated before, involves surgery to remove as much of the tumor as possible. With ependymomas, some patients receive radiation therapy after surgery.

Prognosis: A number of factors affect chances of recurrent disease. These factors include... 

1. how much of the original mass was resected in surgery (the more removed, the better obviously), 

2. Grade (cell appearance) - patients with high histological grade tumors (i.e. cells that do not resemble the original tissue) tend to have higher tumor recurrence rates

One study cited disease-free rates at 5 and 10 years at 84.8 and 76.5%, respectively.

Jerome Harrison - brain tumor

Click here to see my UPDATE (10/23) on this story

As you may have heard, Lions running back Jerome Harrison was diagnosed with a brain tumor.

The way the malignancy was discovered is probably the most fascinating detail of the story. Harrison was supposed to be traded to the Eagles for RB Ronnie Brown this week. While undergoing a physical, an MRI of his head was performed, which is how they found the tumor. What puzzled me the most is that when performing a "routine physical" on someone, you don't usually just randomly MRI their brain. It turns out that Harrison had been suffering recurrent headaches and that's why he got the MRI.

The term "brain tumor" is vague to say the least. First off, a cancer in the brain can either be a primary malignancy or metastasis. A primary malignancy means that this was the site where the cancer originated. Metastasis refers to the cancer showing up in the brain as a result of spreading from another site. The origins of brain metastases are most commonly from melanoma (WEAR SUNSCREEN), lung cancer, genitourinary cancers (e.g. testes, kidney), osteosarcoma (bone) and breast cancer.

Now even presuming that this is a primary brain malignancy, it's still a super vague term. There is a multitude of tumors that can grow in the "brain" region. Sorry, multitude is the wrong word. How about THE LONGEST SHOPPING LIST EVER.

How is it found? Sometimes masses in the brain can cause generalized symptoms as a result of its size and growth alone. Think about it - your brain doesn't like getting pushed on and moved around. General symptoms include headache, seizures, nausea/vomiting, altered level of consciousness and decrease in cognitive function. And these symptoms tend to occur slowly or sporadically over time; they're unlikely just to pop up all of a sudden. Sometimes, the tumor can cause some specific symptoms based on its location - seizures (again), weakness or sensory loss into certain areas of the body, difficulty speaking, or vision problems. Now I know about half of you that are reading this now think you have a brain tumor. Stop it. Far more common things cause all of the above symptoms.

Treatment: neurosurgery. I won't even dare go further into explaining how, when or why some get treated or some don't because ... it's neurosurgery. I do know that size, rate of growth and location all play a role in whether all, some or none of it is operable but that's really all I know.

Mario Williams - pectoralis major rupture

Quick post tonight.

Mario Williams of the Houston Texans ruptured his pectoralis major (i.e. torn pectoral) against the Oakland Raiders in Week 5. He had surgery on it a few days ago to repair the injury. He will be out for the rest of the season rehabilitating.

We actually have two pectoral muscles - the pectoralis major and pectoralis minor. The pectoralis major is the one most people know about, with each one spanning half of the chest starting at the clavicle and along the sternum and inserting into humerus. Since it spans such a large area and has multiple attachments, it can perform a number of actions:

1. flexing the humerus (lifting your arm at the shoulder joint)
2. extending the humerus (lowering your arm at the shoulder joint)
3. adducting the humerus (bringing your arm closer to the midline - e.g. think of the lifting action of the bench press when you draw your elbows inward)
4. medial rotation of the humerus (turning your entire arm inwards)
5. aiding with deep inspiration

Needless to say, it can be pretty important. The pectoralis minor, on the other hand, is relatively small in comparison and actually hides underneath the pec major. It starts on the third, fourth and fifth ribs and goes to attach to the scapula (shoulder blade). It mainly acts as a stabilizer for the scapula, bringing it down and forward.

Obviously, of the two the pectoralis major is used far more often. Strangely enough, pectoralis major ruptures are relatively uncommon, possibly due to its size and strength. One source mentioned there were fewer than 100 documented cases in the past 25 years. It requires a very large load to overcome this large sheath which is why it makes sense that most of the time this type of injury occurs when weight-lifting (i.e. bench pressing) large weights. 

Williams wasn't weight lifting that Sunday but you can imagine the forces involved in football are pretty comparable.

Patients suffering from this injury usually present with marked weakness in the arm where the corresponding pec major inserts as well as extensive bruising (or ecchymycosis). 

In many non-athletic people, they can get by without surgery since they usually don't require the pec to function at 100%. Understandably, athletes usually elect to receive surgery so they can hopefully return to perform at high levels. As usual though, rehab is key. With proper physiotherapy, the athlete can usually return to pre-injury performance of the pectoralis major. 

Taylor Fedun - complex femoral fracture

I feel awful for Taylor Fedun. This player was a guy is 23, an undrafted free agent, and was not supposed to come close to making the Edmonton Oilers starting line-up. This preseason, he was giving management something to really chew on given his strong play.

... then this happened. The view isn't great but you don't want to a clear view of someone fracturing their femur. Trust me, it's not pretty. Now, Fedun's entire playing career is in jeopardy not just because he will have to fight hard to make a team again, but also because of how catastrophic a femur fracture can be and the loooong (but very important) road through rehab. Unfortunately, it's not an unheard of injury. People in the hockey community know what happened to Kurtis Foster almost three years ago and how long it took for him to recover. Those who watch football may remember Vikings' E.J. Henderson's injury in 2009 and his slow but eventual return.

Photo source: myhealth.alberta.ca

Picture source: Wikipedia

The femur is the longest and strongest long bone in the body. It is the only bone that runs through your thigh and forms joints at the hip and the knee. In healthy people, it is very difficult to break and these fractures are usually seen either in high velocity motor vehicle accidents or falls from a height.


Surrounding the femur are three muscle compartments - anterior (to extend the knee and flex the hip), medial (to adduct the hip), and posterior (to flex the knee and extend the hip). The strong pull of all these muscles can actually lead to a greater angle of the fracture and separation of the fragments. Also, it has a very rich blood supply which can be disrupted from the fracture and cause a lot of bleeding. Fortunately, there is often enough supply from the blood vessels in the bone itself that can provide nutrients to help with healing.

Definitive treatment involves orthopaedic surgery where a nail is inserted to help the union of the two fragments and enable strong fixation. It is associated with 98-99% union rate.

The Oilers have already revealed these following details via twitter:

Fractures can be classified (via the Orthopedic Trauma Association) as simple, wedge, or complex. Complex fractures occur when there is no contact between the main fragments, and there is usually (not always) more than two fragments broken off. A fracture is usually classified in many other ways including the angle of the proximal and distal fragments, if the bone broken through the skin (which would require immediate IV antibiotic therapy), etc. These details were not disclosed though, and understandably so because it is not useful public information.

Also, it's good to hear he went through surgery successfully. Early surgery in this case is usually associated with better outcome.

Below are reasons why this injury is concerning:

1. It can be life-threatening if not addressed promptly. The rich blood supply of the femur means that a fracture can result in a lot of bleeding. You can lose up to 3 L of blood, although the average is closer to 1 L. FYI, we generally have a total of 5 L of blood in our bodies at any given time. Maintaining adequate volume early (via IV fluids) in the injury is a very high priority. The femoral artery (largest artery in the lower body) and the sciatic nerve (largest nerve in the entire body) run nearby, but because they are surrounded by muscles, they are usually protected from injury.

2. It is a long road through rehabilitation. Early physical therapy is important, like for many orthopaedic injuries. Of course, each case is different, and activity depends largely on how well the fragments are fixated. Actual healing of the fracture itself takes anywhere from 3-6 months, and then muscle rehabilitation begins. Baseline function and strength can return anywhere from six months (esp in young patients with aggressive physical therapy) to two years (older patients). Athletes usually take a solid year to return to sports.

Fortunately, prognosis is usually excellent. Complication rates are relatively low. These complications include infection (~1%), malunion (healing at the wrong angle) and/or nonunion (no sign of healing at 3 months) of the bone (3-5%) and neurovascular injury.

It's a long road.

I remember thinking when I was younger that I loved touch-icing because of the odd time the offense beat the icing call and generated an exciting scoring change. Now, I agree with the NHLPA and I can see the likelihood for these serious injuries outweigh the potential for 'entertainment'.



Sources: UpToDate

Recent articles on injuries/health and sport

Decided I'll sneak this in every once in a while once I find a couple good reads on some deeper talk on injuries and health related to sports today.

ESPN: "NFL - No more pain-tolerance talk"
Battling the age-old, and likely outdated, philosophy that athletes should battle through pain.

Football365: "Ignorance to mental illness not bliss" tweeted from @alimsomji
Talks about a few cases of depression of soccer players in Europe.

OilersNation: "More important than Stanley: Parenthood"
Great article by Jason Gregor on an NHL player's struggle in trying to become a parent

Tony Romo - fractured rib AND pneumothorax

People may call Tony Romo a pretty-boy, but he sure takes the physical punishment. He recently fractured one rib AND was diagnosed with a pneumothorax in last week's game against the 49ers. Oh, and he came back to lead his team to victory before being diagnosed with these two conditions. No big deal. Also, this is the same guy who fractured his left clavicle last year.

I'll discuss both of these diagnoses below.

Fractured rib
You may want to scoff at the fact that I'm making a big deal of Romo coming back to play with a fractured rib, but hold your judgment. Sure, it's a small bone, and it's not involved in running or throwing, and you don't really cast it... but it #%$*ing hurts. Think about it: with a fracture of any of the long bones, you can rest, immobilize it, or plain just stop using it. Now guess what bones move every time you inhale or exhale. Yeah, those ribs... and you can't stop it.

Pain is such an issue with rib fractures that analgesia is the cornerstone of management of rib fractures on an inpatient basis. The reason for this is not only to make sure the patient isn't in excruciating pain every time they breathe, but if pain management isn't under control it can lead to irregular chest movements and breathing which can lead to a pneumonia (complication of 11-17% of patients under 65 with rib fractures). In fact, patients with 3 or more rib fractures are usually admitted to hospital for observation.

Fortunately for Romo, he only fractured one rib which can sometimes be controlled with just non-steroidal anti-inflammatories plus or minus opioids. With that said, most people with rib fractures aren't playing football right away. It's probably an interesting balancing act the training staff have to make with him. Not only is he going to be aggravating the injury (heavy breathing, fast twisting, moving arms/shoulders, more trauma from hits, ie. DeAngelo Hall) but they have to balance how they control his pain. Opioids usually work well for analgesia, but they will inevitably cause sedation, decreased reaction time, or drowsiness, which isn't usually the best side effect profile for a guy who has to make split-second decisions.

We'll see what happens tomorrow night...


Pneumothorax (aka "punctured lung")

Figure 1: NOT Tony Romo's CT scan,
but it does show a pneumothorax
(photo credit: Wikipedia)

Punctured lung is kind of a strange way of putting it (I guess unless his lung was actually physically damaged). Usually a pneumothorax refers to a "collapsed lung" which occurs when air gets in between the lung and the rest of the cavity, preventing the lung from inflating completely. Bigger ones can actually become medical emergencies, like what happened to Drew Bledsoe ten years ago.

To the right is a CT scan of a pneumothorax (i.e. NOT Tony Rom's CT). It's a pretty big one but it also makes it easy to see what happened. When reading CTs, the left lung is on the right and vice versa. You can see in this case the right lung (on the left) is a lot smaller and there's some black (air) surrounding it. That air in the pleural cavity is preventing the lung from inflating fully.

Fortunately for Romo (again), the pneumothorax was quoted as being "very small" (see ESPN article above). I assume that since no invasive treatment was mentioned, it was likely smaller than 3 cm and didn't require anything drastic to re-inflate the lung. A pneumothorax that is <3 cm can just be treated with supplemental oxygen and monitored. Supplemental oxygen can actually help the lung tissue resorb the free air in the cavity spontaneously. Usually if it's larger than that and/or it is causing the patient pain or to be short of breath  it may need to be drained via a needle or inserting a chest tube to relieve the pressurized air. Doesn't sound fun, does it?


In the end, the fractured rib to me is more of a fascinating storyline to follow tomorrow night than the pneumothorax given that after another CT scan Thursday it seems to have resolved. Once again, we don't know Romo's medical information and all of what I discussed above is speculation and a lot of what-ifs, but still interesting nonetheless.

Peyton Manning - cervical disc herniation and disc fusion surgery

Likely the biggest story in the NFL right now is the Indianapolis Colts without their future all-star quarterback Peyton Manning. Last week was the first time he missed a start for the first time in 227 games. The last time Colts fans saw someone else start a game behind center was in 1997.

The reason he isn't starting (or projected to play for at least another couple months) is that he has a herniated disc in his neck (cervical spine). 

Fig. 1

Let's start with the basics. The first seven vertebrae that make up our backbone are known as the cervical vertebrae, or "C-spine". In between each of these vertebra (in our entire "backbone") are intervertebral discs that act as buffers between the vertebrae, shock absorbers, and like mini-joints to provide flexibility/mobility. These discs are made primarily of two parts: the annulus fibrosus and the nucleus pulposus. The annulus fibrosus is made of cartilage and forms the outside of the disc, containing the nucleus pulposus. The nucleus pulposus is made of proteins but has a gel-like consistency. 

Fig. 2
Photo credit: myhealth.alberta.ca

With normal wear and tear or injury, the annulus fibrosus can become damaged or rupture, allowing the jelly-like nucleus pulposus to herniate or prolapse out of the disc. As you can see in Fig. 1, the discs and vertebrae sit neatly on top of each other. When one of these discs is herniated or prolapsed (Fig. 2), it can put physical pressure on the nearby spinal cord and cause the patient a wide range of  symptoms, depending on which nerve roots are affected.

In the case of a cervical herniated disc, it can start with some non-specific neck pain and can progress to pain shooting into the arms or shoulders as well as muscle weakness, numbness, and/or tingling. 

As for treatment, usually conservative measures are tried first. These treatments include rest, anti-inflammatories, glucocorticoids (oral or injections), and physical therapy with increasing mobilization. Out of the above, epidural steroid injections currently have the best evidence for relief of symptoms. 

Surgery is usually considered as an option if 6-8 weeks of conservative therapy provide no improvement in symptoms. Other guidelines propose requiring all of the following: (1) symptoms/signs of nerve root impingement, (2) evidence of nerve root compression on CT or MRI, and (3) persistence of pain despite 6-12 weeks of conservative therapy.

In Peyton Manning's case, he received anterior cervical discectomy and fusion surgery. The ESPN article also states Manning had surgery on two other occasions earlier, but I don't think the procedures were ever specified, so it would be difficult to speculate why he's having his third surgery this year. From the article: 

"An anterior fusion procedure usually involves... removing soft disk tissue between the vertebrae and fusing the bones together with a graft... Recovery from the procedure typically takes at least eight to ten weeks."

So taking what we've learned so far, this make sense that the entire disc is being removed because its physical presence was causing compression of the nerve roots.

In terms of prognosis, from what I've read, previous evidence has produced a mixed bag of results. In many cases, patients improve spontaneously over time. For cervical radiculopathy, it seems that the line between conservative management and surgery is still relatively blurry. A relatively small randomized control trial (n = 81) revealed that patients that received surgery had, at 4 months, less pain and sensory loss and better muscle strength than non-surgical patients. At 1 year, the only difference between the two groups was that the surgical patients reported better muscle strength.

In the end, I guess it's tough to say how Manning's long-term prognosis will be with this issue. It's reassuring to see that many people tend to do well with a cervical herniated disc, but as always, we don't know the full medical story. What were the two previous surgeries for? How long has he dealt with this problem? Only time will tell...

Sources: UpToDate and DynaMed

Sidney Crosby and postconcussion syndrome

One of the biggest stories heading into the start of the NHL season: When will Sydney Crosby play again? Unfortunately, it seems that not even Crosby knows at this point. A growing number of people are starting to wonder if that day will ever happen...

The topic that I'll look at here will revolve around postconcussion syndrome (PCS) and general information about the prognosis of it.

• Symptoms and disability are usually greatest between 7-10 days after the concussion.
• Most recover from PCS by three months, with 10-15% still experiencing symptoms after one year (the article quotes possible biased reporting in the study which means the prevalence may actually be lower).
• In a small study of 79 patients who presented with concussions to the Emergency Department, 28% had one or more complaints after 6 months.
  

In the quick review I did of some studies, the risk factors for a prolonged recovery time usually included...

• older age
• increased number of symptoms immediately after the concussion (i.e. headache, dizziness, nausea, decreased level of consciousness) - one study these symptoms doubled the risk of PCS
• longer post-traumatic amnesia
• abnormalities seen on MRI or CT immediately after the concussion
• more disability when admitted to rehabilitation
  
• preinjury unemployment, substance abuse (you'd like to think that these last two aren't relevant to Crosby's case)

In a nutshell, it looks like the majority of factors that are correlated with long-term disability lie more in the acute injury itself rather than the length of recovery time itself. (Does that make sense?)

One stat that made me think of Marc Savard: In a prospective cohort (I know, not the best evidence) of 2995 people, disability 1 year after a traumatic head injury was also often associated with disability 5-7 years after the injury. However, this was also highly dependent on the severity (i.e. initial level of consciousness) of the injury.

Interestingly, some of what I was reading started to go into complications of repeated traumatic head injuries. Lo and behold, common complications of the repeated injuries include increased risk for depression and chronic pain. Ring a bell?

Here's hoping the NHL takes these head injuries as seriously as trying to keep the Coyotes in Phoenix...


Sources: UpToDate and DynaMed

Depression

Trying to talk about depression in sports, or just depression for that matter is like saying I want to discuss "apples". Where would I begin?

Given the news of Rick Rypien's passing, and arguably that of Derek Boogard, mental illness has been in the NHL newswire a lot more recently than I can remember.

And rightfully so.

I think the most important conclusion I want to draw in this post is that depression is a medical disease. It may seem like a simple and obvious statement to some, but maybe a bit harder to accept for others. I'm not going to get into how it's diagnosed, treatment, etc. Today's post is just focusing on my argument that for most people it's not something trivial or an excuse.

First off, let's clarify - sadness is part of life. Duh. We get our sad days, mad days and happy days and everything in between -- those are just emotions. We're supposed to feel them. However, a major depressive disorder is not just being sad. It comes down to a chemical imbalance in the brain that causes someone to feel hopelessness, despair, or even numbness for extended periods of time. You wouldn't say to someone with diabetes, "Hey! Stop being so tired and just correct your sugars already!". Nor would you tell someone with half a foot to try to walk properly. That would be stupid.

Pathogenesis

If you grouped all the patients in the world with depression, you'd actually have a large group of people with similar symptoms but a wide variety of different reasons for being depressed. Let's list a few key causes:

• Genetics - Single gene causes haven't been identified yet, but there is a strong pattern of heritability of depression - 42% heritability in women, and 29% in men.
• Early life adversity - exposure to severe stress and trauma as a child can cause major changes in a child's brain to stress and negative stimuli. If you want to get technical, studies have shown overactivity of corticotropin-releasing cells in the hypothalamus - that basically means the cells in the brain that stimulate stress response in the brain become overly sensitive.
• Social factors - Strangely, proximity to someone who is depressed can make you more prone to get it too. Chew on this: you're 93% more likely to become depressed if you are directly connected to someone who is depressed. Other factors include poor sibling relationships, and persistent negative and critical comments.
• Psychological factors - pessimism, neuroticism, and certain personality types are more likely to lead to depression than others.
• Secondary depression - this can arise from a number of medical conditions like heart attacks, neurologic diseases, and metabolic problems.

On top of all these causes, research has shown physical changes in the brain in patients who are depressed. I'll admit that it's tough to determine whether or not these changes are present in people who will become depressed, or occur after people are depressed (i.e. cause/effect vs correlation).

Certain neurotransmitters, or chemicals that cause signal conduction in the nerves of the brain, have shown to be imbalanced or functioning abnormally. As mentioned above, overstimulation of the corticotropin-releasing cells in the hypothalamus, resulting in abnormally increased stress responses can play a role as well. Other physical changes seen are an abnormal density of glial cells in the frontal or occipital cortex of the brain, a smaller hippocampus, or altered brain activity.

Now don't go to your family physician tomorrow and ask for an MRI of your brain to assess the size of your hippocampus, or ask for certain hormone levels to see if you're depressed. That's not the point. What I'm trying to get at here is that many people who suffer from depression should not be dismissed.

A common but often misplaced argument is: "this person has no reason to be depressed. He/she is hot/has money/lives the life." (Exhibit A: list of famous people with depression, from Wikipedia) Such a scenario is actually common with people with depression. They could have a great spouse, supportive children, a stable job, and still find sadness and disparity... that's how their brain has been wired.

Sources: UpToDate

Dolphins Brandon Marshall - borderline personality disorder

This story came through the news a couple weeks ago but I feel it's worth addressing giving the relative lack of public knowledge regarding borderline personality disorder, or many psychiatric disorders for that matter. Many people view psychiatric diagnoses as scapegoats for people to act out, behave inappropriately, etc. so I think it's warranted to clear the air.

Of course, we don't know anything about Marshall's condition so I will write in generalities for borderline personality disorder (BPD).

Borderline personality disorder - From UpToDate: "[it is] characterized by instability of interpersonal relationships, self-image, and emotions and by impulsivity. The name of the disorder was originally based upon a concept that this syndrome constituted the boundary or borderline between neurosis (a pattern of maladaptive traits and coping mechanisms) and psychosis (a condition of grossly impaired reality testing)."

What causes it? The exact suspect isn't exactly known, but likely due to a combination of factors including genetic susceptibility (i.e. family history of mental health issues), previous traumatic life experiences including those in interpersonal relationships. A number of clinical trials cite high rates of childhood sexual and physical abuse in patients with BPD. Neglect has also been correlated. (**Note: Keep in mind that there is a difference between "correlation" and "cause-and-effect").

In terms of how it manifests itself in the brain, it is still difficult to understand, but some neurotransmitter dysfunction has been seen. Again, whether this is a correlation or cause/effect pattern is uncertain.

OK, but I still don't get how these people act? The disease usually manifests itself in a number of ways:

• Interpersonal difficulties - Patients with BPD tend to have unstable relationships with close friends or romantic partners. They often alternate between idealizing somebody to seeing them as betraying or cruel. These two extremes tend to happen when the person is present (i.e. seen as perfect), or absent (i.e. seen as awful). In essence, the partner or friend is viewed as completely good or bad; this phenomenon is called "splitting". During times of strong negative emotions, the patient often thinks this person is going to leave or abandon them, leading to anger, depression, hopelessness or suicide. They also tend to see minor or neutral facial expressions, words or events as overly negative - i.e. an imagined desire that the other party wants to leave or terminate a relationship.
• Affective instability - We all have mood swings or fluctuations throughout a day but people with BPD have these to an extreme. These changes can occur within minutes, usually from environmental factors. They can alternate from explosive outbursts to someone close (from dissatisfaction) to extreme bouts of shame, guilt and worthlessness.
• Impulsivity - Patients with BPD have trouble controlling impulses. These can include binge eating, irresponsible spending of money, unsafe sex, or ending a job or relationship.

How is it diagnosed? All psychiatric illnesses are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, and can only be made by a qualified health professional. A diagnosis of BPD requires five of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense relationships
3. Unstable sense of self
4. Impulsivity in two potentially harmful ways (drugs, sex, money)
5. Recurrent suicidal behaviour/self-harm
6. Unstable mood/affect
7. General feelings of emptiness
8. Difficulty controlling anger
9. Transient dissociative symptoms (i.e. temporary hiding of a memory, feeling or sensation) or paranoid ideation associated with stress

Treatment

In short, psychotherapy. Now, this isn't just your run-of-the-mill counselling or talking to somebody. It involves very deliberate direction and focus in order to be effective. UpToDate mentions a few goals or objectives that need to be reached:

• Teaching or helping with emotional regulation
• Targeting impulsivity - getting patients to observe emotions rather than feel them
• Targeting relationship difficulties - helping patients become cognizant of other people's emotions

Yeah, I know it looks pretty elementary like stuff you would see or learn about in primary school; I could try to go into details but that would require writing paragraphs of text. Basically, it's a lot more complicated than it sounds.

Drug therapy can be used in conjunction with psychotherapy - many patients receive mood stabilizers or antipsychotics. The use of drugs with BPD is a bit hazy though because patients often have other psychiatric issues like major depressive disorder, or post-traumatic stress disorder that also need treating.

So people with BPD have a rough time, I get it. But does all this diagnosing, treating, etc. really make a difference?

Yes. With proper treatment, remission of the disease was found to be anywhere from 45-54% within 2-4 years of follow-up. In one study, 93% of patients were in remission by 10 years. 86% of patients achieved remission that lasted for at least four years.

The proportion of patients with "good psychosocial functioning" (i.e. at least one close, emotionally sustaining relationship AND good work or school performance for at least 50% of the study period) increased throughout the years to up to 56% in year six.

Unfortunately, recurrence is relatively common. Loss of recovery has been in seen in 34% of people.

Sources:

Toronto Notes, 2010 edition

UpToDate

Philadelphia Eagles DT Mike Patterson - seizure from AV malformation

This week during training camp, defensive tackle Mike Patterson of the Philadelphia Eagles collapsed on the practice field, had a seizure and was taken to hospital. Given that the Minnesota Vikings recently remembered the 10 year anniversary of Korey Stringer dying from a heat stroke in training camp, needless to say it was a scary sight.

Since then, Patterson has being diagnosed with an arteriovenous malformation, or AVM, of the brain which likely caused his seizure. ESPN has an excellent article (and consequently does most of my work for me) here. I'll try not to repeat too much of what they say.

What is an AV malformation? Basically, it's a tangling of the arteries and veins in your head. Normally, your body's arteries carry oxygen-rich blood to tissue and organs to provide sustenance to your cells. The oxygen is delivered via tiny blood vessel beds, or capillaries. The blood vessels that carry blood with little oxygen left are the veins. So the sequence is artery --> capillary --> vein. With areas of AVM, you have some arteries feeding into veins, veins feeding into arteries, often no capillaries in between... it's just a giant mess. As a result, tissue that have these malformations don't get enough oxygen.

So then what happens? Smaller AVMs can cause hemorrhages (40-60%) because of the large pressure difference between arteries and veins (which should not be connected directly). Seizures, like in Patterson's case, are more common in larger AVMs (50%). Patients can also get localized headaches due to increased pressure in the brain, or other neurological symptoms like trouble with speech, eye movements, muscle weakness, etc.

Do I have it??? It's quite rare. 0.14% prevalence, more common in males than females, and it can only be inherited. The average age of diagnosis is ~33. People don't usually know they have it until they have some sort of event (i.e. seizure or intracranial bleed) that results in an MRI that picks it up.

Can it be fixed? The only definitive treatment is surgery, but this is only if the site of the AV malformation is accessible, if there has been a bleed, and if the benefits of the surgery outweigh the risks (think: a young strapping man like Patterson vs. a 95-year old man with severe heart and kidney failure). Many people who only experience seizures do well on anti-convulsant medication.

Surgery normally involves excision of the AVM. An alternative (which is what Patterson received) involves blocking the fistula (i.e. the direct pathway from artery-to-vein) which should normalize blood flow. There are other treatment options like endovascular embolization and stereotactic radiosurgery which kind of go above the scope of this blog and my interest level in the topic (haha).

Prognosis? Provided the doctors gave him a clean bill of health, Mike Patterson is a lucky guy. 10% of people die from each one of these bleeds, and 30-50% have some sort of neurological deficit as a result. Patients with AVM have a 2-4% chance of a major bleed each year.

Sources:

ESPN.com

Toronto Notes, 2010 edition

CURRENT Medical Diagnosis & Treatment, 2011

Ryan Kesler - "labrum repair" surgery

For my first post with actual content, let's go with some fresh hockey news despite the fact that I abhor the Canucks. Never liked Ryan Kesler's antics but he carried the Canucks on his back for portions of the playoffs when others didn't show up *cough* SedinsLuongo *cough* and I can admire that.

Anyways.

As per TSN.ca, Canucks forward Ryan Kesler just underwent "hip surgery" to repair his labrum.

The labrum of the hip, or the acetabular labrum, is a ring of cartilage that surrounds the hip joint and helps with stabilization. It deepens the "socket" portion of the joint making it more difficult for the femur to slip out (coincidentally this is pretty much Wikipedia says in its article). The hip, like the shoulder, is a joint with lots of flexibility and range of motion. With these types of joints, what you gain in flexibility you often lose in stability. The labrum helps counteract this instability. (the shoulder also has a labrum)

I am GUESSING that Kesler tore his labrum at some point in the playoffs (was it the end of the Nashville series where he pulled up lame after chasing the puck?).

Many fans are probably asking why he didn't go for surgery immediately after the playoffs. With labral tears, conservative treatment (i.e. physical therapy/rehab + rest) is used first to see if symptoms of the tear abate. Only if symptoms continue despite rehab is surgery offered. Surgery involves either the repair (sewing up of the labrum) or a resection, where the torn piece is removed.

Sources:

http://orthopedics.about.com/od/hipinjuries/qt/labrum.htm

UpToDate

Wikipedia (sketch of hip)

Inaugural post

I honestly have no idea how successful this blog will turn out to be, but it's something that's been on my mind for a while.

I'll admit, I'm an avid sports fan, sometimes moreso than I should be. If there's a big game on, odds are I'll choose that over reading about... hypothyroidism.

About me: I'm a medical student in my last year of training in one of Canada's fine medical schools (no, not the University of Phoenix or something) with hopes of becoming more of a "generalist" and some additional training in Sports Medicine.

Disclaimer: None of what I mention or say here should be taken as medical advice - I am merely writing about medicine in professional sports more for educational purposes so people can have a better idea when TSN or ESPN says somebody has a "labrum tear" or a "high ankle sprain". Although, if someone is listed as having a lower body injury or a bruised ego, I probably won't have much to say.

Anyways, let's see how this goes.