Fencing response
 | This article has multiple issues. Please help improve it or discuss these issues on the talk page. (Learn how and when to remove these messages)
|
The fencing response is an unnatural position of the arms following a concussion. Immediately after moderate forces have been applied to the brainstem, the forearms are held flexed or extended (typically into the air) for a period lasting up to several seconds after the impact. The fencing response is often observed during athletic competition involving contact, such as combat sports, American football, Ice hockey, rugby union, rugby league and Australian rules football. It is used as an overt indicator of injury force magnitude and midbrain localization to aid in injury identification and classification for events including on-field and/or bystander observations of sports-related head injuries.[1]
Relationship to fencing reflex and posturing
The fencing response is similar to the asymmetrical tonic neck reflex in infants. Like the reflex, a positive fencing response resembles the en garde position that initiates a fencing bout, with the extension of one arm and the flexion of the other.
Tonic posturing preceding convulsion has been observed in sports injuries at the moment of impact[2][3] where extension and flexion of opposite arms occur despite body position or gravity. The fencing response emerges from the separation of tonic posturing from convulsion and refines the tonic posturing phase as an immediate forearm motor response to indicate injury force magnitude and location.
Pathophysiology
The neuromotor manifestation of the fencing response resembles reflexes initiated by vestibular stimuli. Vestibular stimuli activate primitive reflexes in human infants, such as the asymmetric tonic neck reflex, Moro reflex, and parachute reflex, which are likely mediated by vestibular nuclei in the brainstem. The lateral vestibular nucleus (LVN; Deiter’s nucleus) has descending efferent fibers in the vestibulocochlear nerve distributed to the motor nuclei of the anterior column and exerts an excitatory influence on ipsilateral limb extensor motor neurons while suppressing flexor motor neurons. The anatomical location of the LVN, adjacent to the cerebellar peduncles (see cerebellum), suggests that mechanical forces to the head may stretch the cerebellar peduncles and activate the LVN. LVN activity would manifest as limb extensor activation and flexor inhibition, defined as a fencing response, while flexion of the contralateral limb is likely mediated by crossed inhibition necessary for pattern generation.[citation needed]
In simpler terms, the shock of the trauma manually activates the nerves that control the muscle groups responsible for raising the arm. These muscle groups are activated by stimuli in infants for instincts such as grabbing for their mothers or breaking their falls. The LVN has neurons that connect it to motor neurons inside grey matter in the spinal cord, and sends signals to one side of the body that activate motor neurons that cause extension, while suppressing motor neurons that cause flexing. The LVN is located near the connection between the brain and the brain stem, which suggests that excessive force to the head may stretch this connection and thus activate the LVN. The neurons that are stimulated suppress neighboring neurons, which prevents neurons on the other side of the body from being stimulated.
Injury severity and sports applications
In a survey of documented head injuries followed by unconsciousness, most of which involved sporting activities, two thirds of head impacts demonstrated a fencing response,[4] indicating a high incidence of fencing in head injuries leading to unconsciousness, and those pertaining to athletic behavior. Likewise, animal models of diffuse brain injury have illustrated a fencing response upon injury at moderate but not mild levels of severity as well as a correlation between fencing, blood–brain barrier disruption, and nuclear shrinkage within the LVN,[4] all of which indicate diagnostic utility of the response.
The most challenging aspect to managing sport-related concussion (mild traumatic brain injury, TBI) is recognizing the injury.[5] Consensus conferences have worked toward objective criteria to identify mild TBI in the context of severe TBI.[5][6][7][8][9] However, few tools are available for distinguishing mild TBI from moderate TBI. As a result, greater emphasis has regularly been placed on the management of concussions in athletes than on the immediate identification and treatment of such an injury.[5][6]
On-field predictors of injury severity can define return-to-play guidelines and urgency of care, but past criteria have either lacked sufficient incidence for effective utility,[10][11] did not directly address the severity of the injury,[12] or have become cumbersome and fraught with inter-rater reliability issues.[13]
Fencing displays in a televised game
- Tank Abbot vs John Matua at UFC 6. John Matua is knocked out, his body stiffens, his arms stretch out front in the air, his legs are also in the air, and he is shaking involuntarily. Clearly showing a strong fencing response and seizure. John Matua goes on to have a full recovery with no reports of permanent brain damage after this fight. [14]
- Stevan Ridley playing in the NFL for the New England Patriots against Baltimore Ravens clashed with Bernard Pollard. Ridley was knocked unconscious, with medical professionals declaring it fencing response. Steven went on to have a full recovery, a long career, and became a Super Bowl champion (XLIX). He has not reported any signs of permanent brain damage since.[15]
- Kenny Shaw, NCAA football wide receiver for Florida State, September 17, 2011[16]
- James May, a television presenter, after being thrown to the ground by a taut line[17]
- Oscar, professional footballer, after a collision with Arsenal F.C. goalkeeper David Ospina in a Premier League fixture on April 26, 2015[18]
- Xiong Fei, professional footballer, after being kicked in the head by Shanghai Shenhua FC teammate Li Jianbin, October 17, 2015[19]
- Hector Bellerin, professional footballer, after receiving an elbow to the temple by Chelsea F.C. player Marcos Alonso, February 4, 2017[20]
- Joe Flacco, professional American football quarterback for the Baltimore Ravens, October 26, 2017[21]
- Tom Savage, professional American football quarterback for the Houston Texans, December 10, 2017[22]
- Donald Parham, professional American football tight end for the Los Angeles Chargers, December 16, 2021[23]
- Tua Tagovailoa, professional American football quarterback for the Miami Dolphins, Sept. 29, 2022[24]
- Garry Ringrose, profession Rugby player: following a collision with Blair Kinghorn's hip after attempting a tackle in 73rd minute of the 2023 Six Nations Championship's Scotland vs. Ireland game on March 12, 2023.[25]
- Terry Etim, mixed martial artist was knocked out by Edson Barboza following a wheel kick at UFC 142.[26] Etim is stiff with his left arm outstretched and feet rotated inward.
References
- ^ Newton, Phil (August 28, 2009). "Youtube helps identify a new tool in the evaluation of brain injury". Psychology Today. Retrieved April 4, 2015.
- ^ McCrory, P. R.; Berkovic, S. F. (11 April 2000). "Video analysis of acute motor and convulsive manifestations in sport-related concussion". Neurology. 54 (7): 1488–1491. doi:10.1212/wnl.54.7.1488. PMID 10751264. S2CID 43197411.
- ^ McCrory, P. R; Bladin, P. F; Berkovic, S. F (18 January 1997). "Retrospective study of concussive convulsions in elite Australian rules and rugby league footballers: phenomenology, aetiology, and outcome". BMJ. 314 (7075): 171–174. doi:10.1136/bmj.314.7075.171. PMC 2125700. PMID 9022428.
- ^ a b Hosseini, Ario H.; Lifshitz, Jonathan (September 2009). "Brain Injury Forces of Moderate Magnitude Elicit the Fencing Response". Medicine & Science in Sports & Exercise. 41 (9): 1687–1697. doi:10.1249/MSS.0b013e31819fcd1b. PMID 19657303.
- ^ a b c Guskiewicz, Kevin M.; Bruce, Scott L.; Cantu, Robert C.; Ferrara, Michael S.; Kelly, James P.; McCrea, Michael; Putukian, Margot; Valovich McLeod, Tamara C. (2004). "National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion". Journal of Athletic Training. 39 (3): 280–297. PMC 522153. PMID 15514697.
- ^ a b "Concussion (Mild Traumatic Brain Injury) and the Team Physician". Medicine & Science in Sports & Exercise. 38 (2): 395–399. February 2006. doi:10.1249/01.mss.0000202025.48774.31. PMID 16531912.
- ^ Aubry, Mark; Cantu, Robert; Dvorak, Jiri; Graf-Baumann, Toni; Johnston, Karen; Kelly, James; Lovell, Mark; McCrory, Paul; Meeuwisse, Willem; Schamasch, Patrick; Concussion in Sport (CIS) Group (2002). "Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport, Vienna 2001". Clinical Journal of Sport Medicine. 12 (1): 6–11. doi:10.1097/00042752-200201000-00005. PMID 11854582.
- ^ Cantu, Robert C. (October 2006). "An overview of concussion consensus statements since 2000". Neurosurgical Focus. 21 (4): E3. doi:10.3171/foc.2006.21.4.4. PMID 17112193.
- ^ McCrory, P; Johnston, K.; Meeuwisse, W.; Aubry, M.; Cantu, R.; Dvorak, J.; Graf-Baumann, T.; Kelly, J.; Lovell, M.; Schamasch, P. (1 August 2005). "Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004". British Journal of Sports Medicine. 39 (Supplement 1): i78–i86. doi:10.1136/bjsm.2005.018614. PMC 1725173. PMID 15793085.
- ^ de Kruijk, J R; Leffers, P.; Menheere, P. P. C. A.; Meerhoff, S.; Rutten, J.; Twijnstra, A. (1 December 2002). "Prediction of post-traumatic complaints after mild traumatic brain injury: early symptoms and biochemical markers". Journal of Neurology, Neurosurgery & Psychiatry. 73 (6): 727–732. doi:10.1136/jnnp.73.6.727. PMC 1757354. PMID 12438478.
- ^ McCrory, Paul R.; Berkovic, Samuel F. (1998). "Concussive Convulsions". Sports Medicine. 25 (2): 131–136. doi:10.2165/00007256-199825020-00005. PMID 9519401. S2CID 22738069.
- ^ Collins, Michael; Iverson, Grant; Lovell, Mark; McKeag, Douglas; Norwig, John; Maroon, Joseph (2003). "On-Field Predictors of Neuropsychological and Symptom Deficit Following Sports-related Concussion". Clinical Journal of Sport Medicine. 13 (4): 222–229. doi:10.1097/00042752-200307000-00005. PMID 12855924. S2CID 18035638.
- ^ Gill, Michelle; Windemuth, Ryan; Steele, Robert; Green, Steven M. (January 2005). "A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes". Annals of Emergency Medicine. 45 (1): 37–42. doi:10.1016/j.annemergmed.2004.07.429. PMID 15635308.
- ^ "UFC 6 Tank Abbott vs John Matua" on YouTube
- ^ "Stevan Ridley's Concussion: Biomechanics of His Injury, 'Fencing Response'".
- ^ "FSU's Kenny Shaw OK after being knocked unconscious". Orlandosentinel.com. Archived from the original on June 8, 2014. Retrieved 2015-04-04.
- ^ "James May hurt during Top Gear stunt". Telegraph.co.uk. 2010-12-23. Retrieved 2015-04-04.
- ^ Bonn, Kyle (26 April 2015). "Oscar headed to hospital after thunderous clash with Ospina". ProSoccerTalk.
- ^ Newell, Sean (19 October 2015). "Chinese Player Knocks Out Teammate with Bicycle Kicks to the Face". Vice.
- ^ Davis, Callum (2017-02-04). "Marcos Alonso challenge on Hector Bellerin was '100% a foul', says Arsene Wenger". The Telegraph.
- ^ "Joe Flacco suffers concussion on hit from Kiko Alonso". NFL.com. 2017-10-26. Retrieved 2017-10-27.
- ^ Schad, Tom. "NFLPA will review Tom Savage concussion protocol". USA Today. Retrieved December 11, 2017.
- ^ Lyons, Dan (December 17, 2021). "NBC Sports Medicine Analyst: Donald Parham Experienced the 'Fencing Response'". Sports Illustrated. Retrieved 19 October 2022.
- ^ Maadi, Rob. "Dolphins' Tua Tagavailoa Injury, Fencing Response and NFL Protocol". Retrieved 3 October 2022.
- ^ Sunderland, Tom. "Ireland's Garry Ringrose given oxygen on pitch after horror incident in Six Nations match". Retrieved 2023-03-14.
- ^ "UFC 142 Results: Edson Barboza Knocks Out Terry Etim With A Wheel Kick". www.bloodyelbow.com. Retrieved 2023-03-29.
- ^ 40. Donald Parham injury brings plenty of concern on Twitter from NFL players. https://arrowheadaddict.com/2021/12/16/donald-parham-injury-brings-plenty-concern-twitter-nfl-players/ Retrieved December 16, 2021