Source: American College of Sports Medicine
With the Summer Olympics in Paris in full swing, I couldn't think of a better time to talk about fencing... ok not the combat sport that features sword fighting, but yet the fencing response. This unnatural and involuntary response is a cascade of events that resembles an athletic fencing position when one arm is bent or flexed towards the body while the other is extended or outstretched as the person is supine on the ground after a blow to the head. The image above is the classic presentation seen most, but not all of the time. As you can see, the above individual gets struck in the head and is rendered unconscious. You'll then notice the extension of one arm and contralateral flexion of the other. This is sustained over several seconds before arm flaccidity returns.
The response got widespread coverage after Miami Dolphins NFL quarterback Tua Tagovailoa took a nasty hit early in the 2022 season. You may have noticed though that Tua had some decorticate rigidity where the hands turned in and the arms moved up towards the neck and not towards the sky. My point here is that the presentations can differ depending on where in the brainstem and/or cerebral cortex the focused trauma occurs. Convulsions may or may not following this reflexive display. They can occur separately or together. Regardless the response is arguably hard to watch for some.
This response helps indicate that a serious insult to the brain has occurred. Patterns of abnormal electrical activity (neurochemical storm) are one of the driving forces behind such an immediate response. In not so fancy terms, the brain within the skull is much like Jello in the fridge that hasn't quite "set up" completely. Abnormal brain movements as little as 5-7 mm can cause big time consequences. The head and brain are not fans of being stretched. Additionally, while transient, the blood brain barrier is also disrupted especially within the very vulnerable midbrain. The exact cause still puzzles many experts, but it seems to resemble reflexes caused by vestibular stimuli (the vestibule being the part of the ear). These activate very primitive motor reflexes – such as when we ‘jump’ when startled by a noise – particularly in infants. One such reflex is that of the asymmetric tonic neck reflex and parachute reflexes (named after how they look).
The fencing response is without a doubt a form of traumatic brain injury (TBI) and should be treated as such. This blog's purpose is to bring more awareness about the severity of the response as it should be a huge red flag sign for parents, coaches, athletic trainers, and sports organizations who may witness this on the sidelines. The athlete should have a thorough evaluation from a physician and should not be allowed to return to the playing field until cleared to do so by a medical professional. If an athlete or victim of violence takes a blow to the head and starts posturing in any fashion, it should not be deemed a simple stinger or a benign concussion.
We must also recognize that some long-term negative effects could be associated with this injury. Recovery can take months or longer and requires patience. Sometimes improvement is slow or appears to plateau before recovery resumes.
Safety and prevention of another insult are essential during the recovery process. Sometimes extensive rehab is needed. This could include a combination of physical therapy, occupational therapy, cognitive therapy, psychological counseling, and getting enough rest. Not everyone who has a fencing response will need all of these types of therapies. The determination will be based on the effects of the brain damage.
In closing, enjoy your contact sports and continue rooting on your favorite athletic superstars, but realize they are not superhuman. They are simply human, no different than you or I. Everyone wants championships and dynasties, but at what cost?? TBI and CTE are no joke.
August 5, 2024
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC
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