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Evidence-Based Practice in Action

This is an excerpt from Evidence-Based Practice in Exercise Science by William Amonette,Kirk English & William Kraemer.

On September 9, 2007, the second week of the 2007-2008 National Football League (NFL) season, the Buffalo Bills were at home for a game with the Denver Broncos. On a routine kickoff, third-year tight end Kevin Everett sprinted down the field and approached the kick returner, Domenik Hixon (Carchidi, 2008). Everett dropped his center of gravity and extended into Hixon for the tackle - a motor skill that he had presumably performed thousands of times previously. Everett led with the crown of his helmet, contacting the helmet of Hixon at a high velocity, inadvertently violating a common but too often disregarded fundamental of tackling. The consequences of the collision were devastating and nearly fatal for Everett.

Immediately upon impact, Everett fell to the ground and lay face down, motionless. The collision resulted in a fracture dislocation of his third and fourth cervical vertebrae, injuring the spinal cord and instantly paralyzing Everett (Cappuccino et al., 2010; Carchidi, 2008). The sports medicine staff reacted quickly to the injury, clearing the scene to ensure that Everett was not injured further. With an injury such as Everett's, the standard-of-care protocol provides that the helmet remain on, the player be placed on a board, the face mask removed, and the player carefully moved to a stretcher and then transported by ambulance directly to the hospital. The sports medicine staff appeared to perfectly execute the protocol, and Everett was carefully transported to Millard Fillmore Gates Hospital (Carchidi, 2008).

In the ambulance ride en route to the hospital, the neurosurgery team used an experimental therapy that they hoped would improve Everett's prognosis. Infusing a cold saline solution into Everett's veins, the medical team induced a mild hypothermic state (Cappuccino et al., 2010). The use of ice to treat an injury is not novel - ice is used acutely for virtually every orthopedic injury. The principle of inducing systemic hypothermia is similar. The cold saline solution acutely controls systemic inflammation, and the medical team apparently believed that the therapy would reduce inflammation surrounding the spinal cord injury, preventing further damage (Cappuccino et al., 2010; Mummaneni, 2010). After evaluation by the medical staff, the neurosurgeon performed an emergency surgery in an attempt to save Everett's life (Cappuccino et al., 2010). After the surgery, Everett was placed on a respirator; it was believed that if he lived, he was unlikely to ever walk again (Carchidi, 2008).

Two days after the injury, Everett was removed from the respirator; he was reported to have minimal voluntary movements in his lower extremities, suggesting a theoretical possibility that he could regain the ability to walk (Cappuccino et al., 2010). On the basis on previous cases, the medical team believed that Everett had a small chance of regaining full control of his extremities (Carchidi, 2008). In the weeks and months that followed, Everett made remarkable progress, recovering at a rate far greater than expected. He was transferred to a top rehabilitation center for neurologic injuries in Houston, Texas, that implemented a comprehensive rehabilitation program. On December 23, 2007, Kevin Everett walked onto the field of Ralph Wilson Stadium - a remarkable feat that a few short months earlier had seemed impossible.

Kevin Everett's recovery was remarkable and a testament to the professional competence and readiness of the integrated sports medicine team, who made numerous decisions improving the chances that he might walk. Everett's story is also a demonstration of personal determination and perseverance that has inspired hope. For patients suffering severe spinal cord injuries, the story validates that dramatic recovery is possible. Medical personnel are encouraged in that Everett's case shows that diligent medical and rehabilitative therapy facilitates recovery. However, there is one overriding question that surrounds Kevin Everett's case: Why did he recover and why so fast? There are a number of possible explanations:

• Everett's recovery was simply a statistical improbability - he was an outlier and his recovery a chance occurrence.
• It was the result of sheer human determination and will in an athlete who simply would not accept his prognosis and would give everything to ensure he had the best chance to walk.
• It was the result of the sports medicine team's careful execution of the standard-of-care practice to prevent further injury immediately post-accident.
• Everett's recovery was the result of the precise execution of the neurosurgery team.
• The recovery was a result of the rehabilitation protocol implemented by a leading neurorehabilitation center.
• The rapid recovery was the result of cryotherapy, an experimental method that dramatically improved his prognosis.

The case of Kevin Everett highlights an important concept, that knowledge is a dynamic phenomenon (Amonette et al., 2010). The team of doctors, physical therapists, athletic trainers, and exercise specialists involved in the acute and postacute treatment of Everett's injury made numerous decisions that positively or negatively affected his outcome. The athletic trainers and sports medicine staff identified a possible injury to the spine and ensured that the athlete was quickly transported to the hospital. A careful procedure was used to move him to avoid further injury. The physicians made a decision to use the hypothermic technique to reduce spinal swelling. The neurosurgeon decided to perform surgery, and at some point, a physician determined that it was safe to remove Everett from the ventilator. In the rehabilitative process, physical therapists along with the medical team decided which therapeutic interventions were best suited to the stage of injury and made daily decisions on when to increase, decrease, or hold parameters like the intensity, volume, and duration of the rehabilitation program.

How did the sports medicine team determine the appropriate treatment?

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