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Traumatic brain injury (TBI) is a disruption in normal brain function caused by an impact of external forces on the head. TBI affects millions of individuals per year, many potentially experiencing chronic symptoms and long-term disability, creating a public health crisis and an economic burden on society. The public discourse around sport-related TBIs has increased in recent decades; however, recognition of a possible TBI remains a challenge. The fencing response is an immediate posturing of the limbs, which can occur in individuals who sustain a TBI and can be used as an overt indicator of TBI. Typically, an individual demonstrating the fencing response exhibits extension in 1 arm and flexion in the contralateral arm immediately upon impact to the head; variations of forearm posturing among each limb have been observed. The tonic posturing is retained for several seconds, sufficient for observation and recognition of a TBI. Since the publication of the original peer-reviewed article on the fencing response, there have been efforts to raise awareness of the fencing response as a visible sign of TBI through publicly available web-based platforms, such as Twitter and Wikipedia.
We aimed to quantify trends that demonstrate levels of public discussion and awareness of the fencing response over time using data from Twitter and Wikipedia.
Raw Twitter data from January 1, 2010, to December 31, 2019, were accessed using the RStudio package academictwitteR and queried for the text “fencing response.” Data for page views of the Fencing Response Wikipedia article from January 1, 2010, to December 31, 2019, were accessed using the RStudio packages wikipediatrend and pageviews. Data were clustered by weekday, month, half-year (to represent the American football season vs off-season), and year to identify trends over time. Seasonal regression analysis was used to analyze the relationship between the number of fencing response tweets and page views and month of the year.
Twitter mentions of the fencing response and Wikipedia page views increased overall from 2010 to 2019, with hundreds of tweets and hundreds of thousands of Wikipedia page views per year. Twitter mentions peaked during the American football season, especially on and following game days. Wikipedia page views did not demonstrate a clear weekday or seasonal pattern, but instead had multiple peaks across various months and years, with January having more page views than May.
Here, we demonstrated increased awareness of the fencing response over time using public data from Twitter and Wikipedia. Effective scientific communication through free public platforms can help spread awareness of clinical indicators of TBI, such as the fencing response. Greater awareness of the fencing response as a “red-flag” sign of TBI among coaches, athletic trainers, and sports organizations can help with medical care and return-to-play decisions.
Traumatic brain injury (TBI) is broadly defined as a disruption in normal brain function caused by an impact of external forces on the head or skull. TBI is both a public health crisis and an economic burden. In 2013, there were approximately 2.5 million TBI-related emergency department (ED) visits, approximately 282,000 TBI-related hospitalizations, and approximately 56,000 TBI-related deaths in the United States [
The most common types of TBI occur after rotational or acceleration/deceleration forces displace the brain within the skull without penetrating the skull (diffuse TBI) [
Perhaps due to the potential for long-term symptoms and disability, considerable public interest focuses on sport-related TBI among adolescents (<19 years) [
Recognition of a potential TBI and removing an athlete from play are the first steps to provide necessary medical care in the event of a TBI. However, mild to moderate diffuse TBI may not immediately present with overt clinical symptoms, putting individuals at risk for additional injuries if not removed from play. Current diagnostic tools for TBI vary in their accuracy, and recognition of a potential injury remains a challenge, prompting the need for additional screening criteria at or near the time of injury [
The fencing response is an immediate tonic posturing of the limbs, similar to the asymmetric tonic neck reflex in infants, where extension and flexion of opposite arms occur despite body position or gravity. Upon impact to the head, an individual demonstrating the fencing response immediately exhibits extension in 1 arm and flexion in the contralateral arm while falling to the ground; different manifestations have been observed between limbs. Tonic posturing is then retained for several seconds and readily observable by onlookers (eg, coaches, trainers, parents, and teammates). In 2009, Hosseini and Lifshitz [
The fencing response was additionally observed in adult male rats subjected to brain injury forces delivered by midline fluid percussion. However, the fencing response was observed only with brain injury forces of moderate magnitude and not mild magnitude or in uninjured sham animals [
The fencing response can thus be used as a visible indicator of TBI and may assist with screening and decisions regarding medical care [
First, we applied for academic research access for Twitter’s Academic Research Product Track v2 application programming interfaces (APIs) [
Raw data from Wikipedia were accessed using the RStudio packages
Prior to the start of the study, we submitted a project proposal to the University of Arizona’s institutional review board. The institutional review board determined that the study (STUDY 00000842) did not involve human subjects research as defined by Department of Health and Human Services and Food and Drug Administration regulations. Public Twitter data (ie, tweets from nonprivate Twitter accounts) posted over the last 7 days are available to any user with a Twitter account that registers on the Twitter Developer Platform. Further, a developer account can apply to access the academic research product track to gain access to the full archive of tweets dating back to March 2006. With academic approval from Twitter for the current research project, an authentication key provided unrestricted access to the full archive of tweets.
The annual number of tweets mentioning the fencing response increased overall from 2010 to 2019, with notable peaks in 2013 and 2017 (
In examining each year from 2010 to 2019 separately, a seasonal pattern was again observed, with most tweets occurring between September and February (
Trends in Twitter mentions of the fencing response. (A) The annual number of tweets that mention the fencing response increased overall from 2010 to 2019. (B) The highest number of tweets occurred on Sunday, followed by Monday. (C) The total number of tweets varied by month, with most occurring between September and January. (D) The years were divided into two 6-month periods roughly representing the American football season (September-February) and its offseason (March-August). There were more than 3 times as many tweets that mentioned the fencing response during the months of September-February compared to March-August.
Tweets per month by year, 2010-2019. This is a topographical map of months by year, with the total number of tweets represented by elevation. In addition to the seasonal peak of tweets that mention the fencing response between September and February, there was an increase in the number of tweets over the years 2010-2019, with notable peaks in January 2013 and December 2017.
Tweets per day of the week by month. This topographical map shows that tweets that mention the fencing response were most common on Sunday and Monday during the months of September-February, which corresponds to the American football season.
Notable events contributing to Twitter mentions and Wikipedia page views of the “fencing response”a.
Date | Event | Description | Number of tweets day prior to event | Number of tweets day of event and 3 days after | Number of Wikipedia page views day prior to event | Number of Wikipedia page views day of event and 3 days after |
September 27, 2012 | NFLb game between Cleveland Browns and Baltimore Ravens | Browns wide receiver Josh Cribbs sustained a TBIc on a punt return | 0 | 25 | 83 | 1034 |
January 20, 2013 | NFL game between New England Patriots and Baltimore Ravens | Patriots running back Stevan Ridley had a TBI with loss of consciousness. An article was subsequently published on the website |
0 | 284 | 3527 | 19,485 |
November 10, 2013 | English Premier League soccer match between Manchester United and Arsenal | Manchester United defender Nemanja Vidic sustained a TBI in a collision with goalkeeper David de Gea and was taken to the hospital | 2 | 27 | 91 | 400 |
November 28, 2013 | NFL game between Pittsburgh Steelers and Baltimore Ravens | Steelers running back Le’Veon Bell sustained a TBI during a collision with an opposing player | 0 | 26 | 99 | 1881 |
April 26, 2015 | English Premier League soccer match between Chelsea and Arsenal | Chelsea midfielder Oscar dos Santos Emboaba Júnior was taken to the hospital after sustaining a TBI in a collision with opposing goalkeeper David Ospina | 0 | 65 | 101 | 17,806 |
January 9, 2016 | NFL game between Pittsburgh Steelers and Cincinnati Bengals | Steelers wide receiver Antonio Brown sustained a TBI after being hit by an opposing player | 0 | 40 | 166 | 20,363 |
January 16, 2016 | NFL game between Kansas City Chiefs and New England Patriots | Chiefs defensive back Jamell Fleming sustained a TBI on a punt return after a hit by an opposing player | 16d | 27 | 414 | 8128 |
December 3, 2016 | National Collegiate Athletic Association football game between the University of Oklahoma and Oklahoma State University | Over the course of the game, 3 University of Oklahoma players—Dede Westbrook, Jordan Parker, and Samaje Perine—were removed from play due to apparent TBIs | 1 | 60 | 177 | 1275 |
October 15, 2017 | NFL game between Washington Commanders and San Francisco 49ers | Commanders safety Montae Nicholson made helmet-to-helmet contact with 49ers receiver Pierre Garcon. The hit knocked Nicholson’s helmet off. He was evaluated for TBI and returned to play after about 20 minutes, despite displaying apparently involuntary arm extension and leg twitching immediately following the hit | 0 | 54 | 239 | 3534 |
December 10, 2017 | NFL game between Houston Texans and San Francisco 49ers | Texans quarterback Tom Savage sustained an apparent TBI after being tackled by an opposing player. He returned to play following a brief evaluation by medical staff. However, he was later removed from the game after a second evaluation revealed signs of a head injury | 1 | 392 | 206 | 21,886 |
January 7, 2018 | NFL game between Buffalo Bills and Jacksonville Jaguars | Bills quarterback Tyrod Taylor sustained a TBI when his head struck the ground as he was tackled by an opposing player. Taylor laid on the field for several minutes while being evaluated and was ultimately removed from the game | 2 | 36 | 351 | 7742 |
June 15, 2018 | Soccer World Cup match between Morocco and Iran | Morocco’s Noureddine Amrabat was removed from play and taken to the hospital after sustaining a TBI in a collision with an opposing player | 0 | 47 | 341 | 6337 |
October 6, 2018 | NFL game between Pittsburgh Steelers and Baltimore Ravense | Steelers quarterback Mason Rudolph sustained a TBI after being hit by multiple Ravens defenders. He was removed from play and taken to the hospital | 0 | 94 | 133 | 4905 |
October 7, 2018 | NFL game between Los Angeles Rams and Seattle Seahawkse | Rams wide receiver Brandin Cooks sustained a TBI after a helmet-to-helmet collision with an opposing player | 0 | 94 | 148 | 4934 |
aThe table lists several notable examples of injury events that prompted discussion of the fencing response on Twitter and Wikipedia page views. The list is not meant to be exhaustive but serves to explain several of the spikes in Twitter mentions over the years 2010-2019.
bNFL: National Football League.
cTBI: Traumatic brain injury.
dTweets that mentioned the fencing response prior to the event on January 16, 2016 were all referencing the prior notable event from January 9, 2016.
eTweets and the number of Wikipedia page views prior to and on October 7, 2018 include references to both the notable event on October 6, 2018, and the notable event on October 7, 2018.
The annual number of page views of the
Trends in page views of the “Fencing Response” Wikipedia article. (A) The annual number of page views increased overall from 2010 to 2019. (B) Page views by day of the week varied with no clear pattern (eg, weekend vs weekday). (C) Monthly page views varied with January representing the peak month. (D) Dividing the years in half revealed only slight seasonal variation, with more page views occurring in September-February.
Page views of the “Fencing Response” Wikipedia article per month by year, 2010-2019. Article page views increased overall from 2010 to 2019. The topographical map does not appear to demonstrate a clear seasonal pattern; rather, it identifies multiple peaks across various months and years.
Research published in peer-reviewed journals serves as the foundation of society’s scientific knowledge, and still the content remains out of reach to the public. Publicly available platforms, like Twitter and Wikipedia, vary in quality and have the ability to reach a broad audience. The 2009 peer-reviewed article on the fencing response published in the journal
Twitter mentions of the fencing response and page views of the
Specific peaks in Twitter mentions were identified in January 2013 and December 2017. These and other minor peaks were associated with notable events that generated discussion on social media and also led to increased page views on the Wikipedia article (
The December 2017 peak was associated with an NFL game between the Houston Texans and San Francisco 49ers on December 10, 2017, in which Texans quarterback Tom Savage sustained an apparent TBI after being tackled by a 49ers defender. Savage returned to play following a brief evaluation by medical staff. However, he was later removed from the game after a second evaluation revealed signs of a TBI. The day prior to the injury, there was 1 tweet that mentioned the fencing response. Whereas, on the day of the injury and 3 days following the injury, there were 392 tweets that mentioned the fencing response (
Of note, the NFL added the fencing response (tonic posturing) as a sign of potential concussion to their Concussion Diagnosis and Management Protocol in 2017 [
One limitation of the Twitter data in this report is the restriction to primary tweets and retweets, without analysis of “likes.” Further analyses, including visualization of a Twitter conversation with Treeverse, may more completely characterize the Twitter conversation by hierarchical indexing of primary tweets, retweets, and “liked” tweets. However, some of these analyses require an index tweet to drive the conversation, whereas most discourse on the fencing response originates from observed experience, not a single tweet. It should also be noted that Twitter and Wikipedia are available worldwide to anyone with internet access. Thus, the patterns reported here may be explained by differing usage rates of these platforms in countries across the globe and by the popularity of American football. The United States has, by far, more Twitter users than any other country at approximately 77 million. Following are Japan and India with approximately 59 million and 24 million users, respectively [
In this study, data from Twitter and Wikipedia were used to demonstrate an overall increase in public discussion and awareness of the fencing response as an indicator of TBI over time. The results show weekly and seasonal patterns of increased discussion that align roughly with the American football season. Peaks in Twitter mentions and Wikipedia page views represented national-level events that created public discourse about the fencing response. Public platforms such as Twitter and Wikipedia can play an effective role in science communication and greater awareness of the fencing response among coaches, athletic trainers, and sports organizations has the potential to help with “return-to-play” and other medical care decisions after a potential TBI.
application programming interfaces
Emergency department
National Football League
traumatic brain injury
Data analyzed during the current study are available from the corresponding author upon request.
KLR was responsible for data collection, analysis, and writing the manuscript. KRG was responsible for data collection, analysis, and editing of the manuscript. GAE was responsible for conceptualization, data collection, analysis, and reviewing and editing the manuscript. JL was responsible for conceptualization, interpretation, and reviewing and editing of the manuscript.
None declared.