It's been an interesting and busy few months and I'll get into all that has been happening in due course. But let's start off with this.

The FIA (Federation International d'Automobile), like any organisation that sets itself up as the prime authority in a given field, cops a fair bit of criticism for many things. That said, within and around the organisation there are plenty of smart, progressive individuals. (I say "around" because not everyone who works with the FIA is necessarily an FIA employee or affiliate.)

For a while now, there have been a number of publications emanating from the FIA Institute (techically it's now the Global Institute for Motor Sport Safety), targeting specific interest groups. The first edition of a publication targeting the motorsport medical and rescue community, called AUTO+Medical, was released around mid 2014. You can check out the AUTO+Medical archive here.


My conflict of interest disclosure

It's about here that I should probably disclose a few major potential conflicts of interest.

I've been involved in a couple of projects in cooperation with the FIA and a little while ago, in the run up to the release of the fifth edition of AUTO+Medical, I was invited to join its editorial board alongside a number of others. I've met most of the rest of the editorial board members on an individual basis at various events and I've got a lot of time for people like Prof Rob Seal and Dr Kelvin Chew, as well as the editor-in-chief Dr Paul Trafford.

Now, I'm not trying to sell anything here, nor to to convince anyone that this is the pinnacle of medical literature, but perhaps there is a gain to be had here in terms of bulking up information and resources being made available to individuals who practice or have an interest in motorsport medicine, rescue and safety. I'll leave it to you all (yes, both of you) to make up your own minds regarding the content and quality. And here's a thing, if you have some input you can't resist, be it content, criticism or praise, please send it in, either to the publication itself (medical@fiainstitute.com) or to me (rollcagemedic@gmail.com).


AUTO+Medical Issue 5

The bulk of Issue 5 was already set by the time the editorial board was assembled, but we did get to influence a couple of items. The issue has a concussion focus, with a few different articles that address concussion in motorsport from several angles.


Concussion - clinical review



Primarily, at the back of the publication, there is a review article by Prof Peter Hutchinson and Dr Steve Olvey on concussion in motorsport. They go through the mechinisms of injury, the pathophysiology, features and assessment and the management of a concussed competitor. Here are a few highlights, with a few of my own comments thrown in:

  • Loss of consciousness is not required to diagnose concussion. Neither is retrograde nor anterograde amnesia (though the duration of anterograde amnesia correlates with severity and prognosis)
  • Rotational forces seem to be as important as direct impact in generating a concussive injury and a direct impact is not necessary to produce concussion
  • Symptoms resolve in 80% of individuals within 7 to 10 days
  • In patients with a mild head injury and a normal CT brain, 25% have an abnormal MRI. (No reference for this statement is provided, so I don't know where this estimate comes from. Also, it does not mean that everyone suspected of having a concussion must have an MRI of their brain; an approach which would be expensive, impractical and yield a large number of predictably normal scans along with a likely fair number of false positives. Instead, the decision to perform a CT should be based on decision guides such as the UK NICE Head Injury Guidelines or the Canadian Head CT Guidelines. MRIs are reserved for clinical need and those individuals with concussive symptoms persisting beyond 1 to 3 weeks.)
  • Interestingly, though a paper is not referenced, the authors mention a series over 6 months which found about a 12% incidence of anterior pituitary dysfunction, most often hypogonadic hypopituitarism, in symptomatic concussion patients attending a neurotrauma clinic.
  • There's a brief description of the three common concussion tests - ImPACT, SCAT-3 and King-Devick - though I'm a bit unsure where the assertions that the ImPACT is the gold standard and that normalisation to baseline is indicative of healing (Suggestive maybe, but I have seen no literature backing it as indicative. Happy to be shown that I'm wrong though) come from.
  • The authors rightly highlight the three important steps in management of first recognition, secondly removal and rest from sporting activity and finally a graded return to competition. They recommend that drivers "who are diagnosed with concussion should absolutely not return to driving the same day nor during the same race meeting." And sensibly, they also point out that drivers "should also not drive themselves home on the public roads after a concussion sustained during a race."
  • The article has a table that outlines a generic graded return to competition protocol. While it largely reflects the field and contact sports, it can be modified to suit a motorsport population by substituting in motorsport specific activities. For instance, while levels 1 and 2 might be unchanged, level 3 could make use of race simulator time, level 4 could consist of  speed limited, lap time-targeted non-competitive karting and level 5 might consist of category specific, speed limited, time-targeted laps. While there is little or no high grade evidence for the benefit of this strategy, it seems logical and practical and is the best we have for the moment.

If you want (yet) another perspective on concussion in sport, here's an article I read recently that may be of interest. :

It takes a look at the current difficulties with defining concussion and the implications for diagnosis and management. The authors then propose an evolved way of thinking about concussion and how it might influence our approach to managing it. I suspect that many of us are already thinking about concussion along similar lines to Column B displayed in Figure 2 of the article.

There appears to be a strong push for neuroimaging and an emphasis on the pharmaceutical options for managing concussion in this article, particularly when the symptoms are prolonged. The authors declare no competing interests and receive funding from the National Institute for Health Research and the Brain Clinical Fellowship.


The concussion survey

What is particularly interesting is that following Hutchinson and Olvey's article is a short invitation to participate in a survey on concussion. It is open to all, competitors, teams and medics. This is a part where the editorial board had some influence on the shape and content and I think it could be really useful if as many motorsport people would complete the survey as we can capture. It's not a perfect survey, but it might give us some pointers on where to head next (Pun absolutely intended).



You can start the Concussion in Motorsport Survey here. It only takes a few minutes.


The other stuff related to the concussion theme

There's an interesting interview with WRC driver Andreas Mikkelsen regarding his experience with concussion towards the end of the 2012 IRC Circuit of Ireland Rally (I started a bit of a discussion on this incident on the Rollcage Medic site shortly after it happened which you can read here - Continuing after concussion).

Mikkelsen recalls that he "didn’t feel 100 per cent but I felt well enough just to finish the rally", though he describes fairly typical concussive features, including that he "felt my eardrums weren’t right, my hearing was really strange," and later while being interviewed by rally radio "they could clearly see I was out of it because I was strange in that interview, I didn’t really know what was going on."

It's a bit disturbing that despite admitting that he couldn't work out which country he in was following the impact and that he should probably not have been allowed to continue on, he still feels that he would not change his approach if faced with the same situation again.

He says all of the classic things that downplay the occurence and consequences of a concussion, such as:
  • "I was knocked out for a little bit, but I felt fine and just suffered the memory loss"
  • "nothing was really wrong, just a normal concussion"
  • "Luckily in my case there was nothing really wrong, except for the loss of memory and the fact that there is concussion,"

Some other bits of interest

While you should of course go and read the whole issue, the other pieces of note for me were:
  • An introduction to the new FIA closed cockpit training model. It looks like it will not be as pricey as the open cockpit tub that was sold to a number of ASNs for use at Formula 1 and other events.

  • A pictorial overview of the Formula E medical car, the crewing of which includes a dedicated battery specialist from Williams whose sole task is to disconnect the high tension cables and prevent the medical team from being fried on the circuit.
  • A brief overview of a vision project that aims to assess a visually impaired competitor's ability to race safely. You can form your own opinions and no doubt its outcomes will be greatly anticipated be certain groups.
  • A seemingly upbeat piece about the FIA Motorsport Accident Database. I really hope that this leads to good things, however there is a fair bit of concern about the practicalities of the database, including data protection and who will get to use the information therein, that isn't really addressed in this short article.
  • Finally, I noted a clever article that described a day put on by NASCAR where drivers were invited to see what goes in to a medical response to a track incident. They got to hear about the medical planning for an event and the resources that are made available to them should the need arise. It seems that the drivers went away with a new-found appreciation for the medical teams and the work that goes in to providing the best medical response possible at a motorsport event. Perhaps days like this could be replicated around the world through the various motorsport bodies.
Anyway, go and read Issue 5 for yourself and, whether you love it or hate it, perhaps send in some comments and maybe we can serve the needs of the intended audience.

Take care


References and resources