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concussion

HEAD & NECK INJURIES

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Recently, the topic of head injuries, including concussions, has rapidly come to the forefront of sports medicine. The prevalence of head and neck injuries in all sports has led to an increased awareness and education on concussions; what they are, how they occur, and how they’re diagnosed. However, risk factors related to demographics and optimal treatment approach to a diagnosed concussion is still evolving. The “boom” of the concussion topic begs the question: why are there so many concussions? Are our bodies prone to head injury? Is there something we can do to decrease risk for a head injury? Recent studies have shown that women take longer to recover from a TBI (traumatic brain injury), report more symptoms and receive more concussions than men in similar sports, possibly due to neuroanatomical differences, weaker neck muscles and hormonal changes. Hormones and the physiology of women’s necks and upper bodies are two possible reasons why women experience concussions differently than men.1 Specifically in the sport of soccer, concussions are recorded to occur just as frequently as they occur in football and ice hockey, with the risk being higher in goalkeepers, females, and youth.2 Head-to-head contact is the most common mechanism for concussion diagnosis in soccer, while heading the ball is not a common cause. Many head-to-head contact injuries occur accidentally, or unintentionally, but there is less understanding of how intentional head impacts (i.e. heading in soccer) can also cause brain injury and affect cognitive function. Although concussions have been the “hot topic” in recent years, all head injuries are not diagnosed as concussions. In soccer, intentional head impacts (i.e. heading the ball) have been shown to worsen cognitive function, specifically associated with frequent ball heading, rather than unintentional head impacts due to collisions.3 Furthermore, another study revealed that kids between the ages of 9 and 11 who experienced at least one “subconcussive” impact associated with heading the soccer ball showed decreased cognitive test scores. These changes in cognition showed variation in gender, suggesting girls had memory changes, whereas boys had processing changes.4 Another study has shown that heading soccer balls is more damaging to the female brain than the male brain. These findings suggest that gender-specific guidelines for soccer heading may be required. Researchers suggest that females are more at risk for brain injury associated with heading a soccer ball due to differences in neck strength, sex hormones or genetics.5 Not only does heading in soccer cause head injury, but it can also lead to neck injuries associated with the cervical spine. These potential injuries include muscle strains, ligamentous sprains, compressive disc injuries and joint injuries. With all this risk for injury associated with heading the soccer ball, what should be done about it? Some researchers, after analyzing the data of their respective studies, have considered the question of whether or not heading should be allowed, but realized that that would be unrealistic. They have also posed rules and heading restrictions that are gender-based and age-based. Research is providing evidence that neck muscle development and protective headgear may play a role in the prevention of head injuries, specifically concussions.2 Additional research has found that cervical spine biomechanics is a modifiable risk factor in reducing sports-related concussions. This being said, preventative treatment of head injuries can be geared towards improving cervical spine biomechanics and postural education.6 Furthermore, a combination of cervical and vestibular physiotherapy has decreased the medical clearance time to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion.7 Therefore, the employment of both cervical and vestibular exercises to accelerate recovery and return to sport is important. Historically, treating a concussion has been quite passive, physicians and sports medicine staff relying heavily on pure rest to allow for the brain to heal and recover from the traumatic and potentially damaging event. Progressive research and evidence are now suggesting that an active approach to all types of head injury recovery is the most appropriate for returning an athlete to normal activities of daily living and his/her sport. This includes a multi-modal approach of collaboration among health care professionals who are able to apply their respective areas of expertise to a patient-centered recovery.8 Please contact us at Elevate to set up an appointment for an active approach to your PT treatment plan following a head or neck injury.   References:   Covassin, T., Swanik, C.B., & Sachs, M.L. (2003). Sex differences and the incidence of concussions among collegiate athletes. J Athl Training, 38(3), 238-244. Al-Kashmiri, A., & Delaney, J. S. (2006). Head and neck injuries in football (soccer). Trauma, 8(3), 189–195. https://doi.org/10.1177/1460408606071144. Stewart, W.F., Kim, N, Ifrah, C, Sliwinski, M, Zimmerman, M.E., Kim, M, Lipton, R.B., Lipton, M.L. Heading frequency is more strongly related to cognitive performance than unintentional head impacts in amateur soccer players. Frontiers in Neurology, 2018; 9 DOI: 10.3389/fneur.2018.00240 Lopez-Roman, LR, Diaz-Rodriguez, YI. Are subconcussive impacts harmless in youth soccer players?: 1965 Board #226 May 31 3. Medicine & Science in Sports & Exercise. 50. 475. 10.1249/01.mss.0000536644.03929.cd. Rubin, TG, Catenaccio, E, Fleysher, R, Hunter, LE, Lubin, N, Stewart, WF, Kim, M, Lipton, RB, Lipton, ML. MRI-defined white matter microstructural alteration associated with soccer heading is more extensive in women than men. Radiology 2018 289:2, 478-486. Streifer, M, Brown, AM, Porfido, T, Anderson, EZ, Buckman, J, Esopenko, C. The potential role of the cervical spine in sports-related concussion: clinical perspectives and considerations for risk reduction. J Orthop Sports Phys Ther. 2019 Jan 15:1-22. doi: 10.2519/jospt.2019.8582. Schneider, KJ, Meeuwisse, WH, Nettel-Aguirre, A, Barlow, K, Boyd, L, Kang, J, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. (2014) 48:1294–8. 10.1136/bjsports-2013-093267. Ries E. (2017 March). Beyond rest: physical therapists and concussion management. PT in Motion, 18-27.

Boxing for Patients with Neurological Conditions

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An Elevate PT is shown here working with a patient with Parkinson’s Disease utilizing boxing as sensorimotor agility therapy. Movement is one of the most important things you can do if you are living with a neurologic condition. One of the most common neurologic condition today is Parkinson’s Disease which can affect one’s functional mobility including flexibility, speed, agility, and balance to navigate in a variety of environments.   New research suggests that intense exercise can improve brain function in patients with neurological disorders. Boxing is a fun and novel way to address speed, agility, dual tasking coordination, quick changes in direction, and balance to navigate tight spaces in patients with neurological conditions.  It does this by requiring patients to make postural adjustments and balance corrections, perform fast arm and foot motions, and coordinate timing and sequencing in different directions and planes of movement. Elevate PT Dr. Jasmine Burton, PT, DPT is shown here working with a patient with Parkinson’s Disease utilizing boxing as sensorimotor agility therapy. Laurie A King, Fay B Horak; Delaying Mobility Disability in People With Parkinson Disease Using a Sensorimotor Agility Exercise Program, Physical Therapy, Volume 89, Issue 4, 1 April 2009, Pages 384–393, https://doi.org/10.2522/ptj.20080214

Concussions Part 4: Concussion Treatment

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Following the diagnosis of concussion, patient and symptom-specific treatment is utilized to address the presenting impairments of each patient. It is a typical recommendation to implement activity modifications or restrictions during early management following a concussion. This period, which may last between 0-3 days, commonly involves recommendations for rest; altering school, work, and daily activities; limiting reading, television, video games, and computer use; and avoiding exertion, but decisions regarding these recommendations are based on symptom response. After this period of activity modification, presentation-specific treatment is typically implemented based on the patient’s symptoms and examination findings. Although treatments related to neck pain, vestibular-ocular dysfunction, and physiologic conditioning are commonly implemented in physical therapy, patient education, such as sleep and stress management strategies, and physician referrals are common in the management of patients with concussion. The video demonstrates various management strategies for several types of concussion seen in the physical therapy setting. Each treatment is specifically tailored to each patient to maximize their outcomes!

Concussions Part 3: Concussion Examination

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Patient and symptom-specific testing is crucial for identifying the subtypes of concussion presentations that may be present and determining the best treatment strategies. Here are some tests that are commonly used to categorize concussion. Symptom Assessment Examination begins with patient-reported symptoms utilizing a standardized, self-report symptom scale (pictured), which is vital for understanding and tracking symptoms following a concussion!   Neuro-cognitive testing Neuro-cognitive testing using tests, such as the King Devick Test (pictured), are vital for assessing visual performance, concentration, and memory. Physiologic testing Physiologic testing using the Buffalo Treadmill Test protocol, which is a standardized and progressive treadmill walking test is implemented for concussions to determine the impact of physical exertion on symptoms. Cervical spine testing Cervical spine testing that assesses posture, range of motion, muscle flexibility, joint mobility, and palpation for tenderness is used to determine if the neck is contributing to concussion symptoms that may include neck pain, dizziness, visual disturbances, and headache. Vestibular-ocular testing Vestibular and visual testing assess the status of the vestibular (inner ear) and the visual systems that are vital for visual tracking and focus and maintaining balance, which are often impacted after a concussion, resulting in difficulty reading, blurry vision, dizziness, and loss of balance.

Concussions 101: Part 2 – Types of Concussions

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Concussion Types Not all concussions are alike! If someone sustains a concussion, what symptoms might we expect? Headaches, difficulty concentrating, fatigue, drowsiness, and dizziness are among the most common symptoms that may occur. However, not everyone will experience these symptoms at the same intensity, for the same amount of time, or even at all! The more we learn about concussions, the more we have identified that each person (and presentation!) is different and should be treated as such. Even though each case may have similar signs and symptoms, each person may respond differently to a concussion and the cause of those symptoms can vary between people. For instance, a headache is the most common symptom experienced after a concussion, but a headache can be caused by altered metabolic activity within the brain, impaired visual function, injury to the muscles and joints of the neck, fatigue, anxiety, etc. Luckily, due to increased research investigating concussions, we are more versed in concussions now than we have ever been before.   It is now clear that concussions are not a “one size fits all” diagnosis. Clinical research has identified multiple subtypes of concussions with different causes, presentations, and treatment options.   Concussion Subtypes The most common concussion subtypes managed in an outpatient physical therapy clinic include physiologic, vestibular, ocular, and cervical concussions. Physiologic concussion symptoms are the result of altered metabolic activity and energy demands on the brain and worsen with physical exertion Vestibular concussion symptoms originate from vestibular (inner ear) dysfunction and can cause dizziness and impaired balance Ocular concussion symptoms result in visual dysfunction that can cause blurry vision, double vision, and difficulty tracking objects Cervical concussion symptoms originate from structures of the neck including the muscles, joints, and ligaments and can cause neck pain and headaches Other concussion subtypes include post-traumatic migraine, cognitive/fatigue, and anxiety/mood, each of which is best managed with the help of other medical professionals. Post-traumatic migraine concussion symptoms include headaches, nausea, and sensitivity to light and sound Cognitive/fatigue concussion symptoms include fatigue, headache with cognitive demands, and difficulty sleeping Anxiety/mood concussion symptoms include anxiety, difficulty sleeping, and depressed feelings However, it is common that multiple subtypes present at the same time for a given individual, which is called a mixed concussion presentation. Therefore, it is recommended that a thorough clinical examination is performed to develop an individualized treatment program for the specific presenting conditions. Remember, every person is different, and every concussion is different!

Concussions 101: What You Should Know – A Four-Part Series

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Concussions have become a highly discussed and debated topic. Because of our increased awareness, the diagnosis of concussion has increased dramatically at all levels of athletics and in the general population. However, many athletes, parents, and even clinicians lack a good understanding of the underlying condition, the several types of concussion, and the appropriate ways to properly evaluate and manage the condition. WHAT IS A CONCUSSION? A concussion is a functional injury of the brain that results in altered metabolic activity within the brain. This alteration involves changes in chemical activity, increased energy demand, and decreased blood flow within the brain. Simply put, the combination of increased energy demand and decreased blood flow results in an “energy crisis” that impairs optimal function and leads to the symptoms of a concussion. Many of these changes occur within the first 24 hours of the injury, but some of these changes can persist for multiple weeks! Contrary to widespread belief, a concussion does not involve any structural damage to the brain or surrounding structures of the head and neck. Other injuries to the head and neck may occur in conjunction with a concussion but are not required to be diagnosed with a concussion, which is diagnosed based on the individual’s signs and symptoms. Therefore, if a concussion is suspected it is imperative to be evaluated by a medical professional that can guide appropriate care and rule out the possibility of a structural injury that may require diagnostic imaging. However, if a head or neck injury is not suspected, then diagnostic imaging is not indicated, and diagnosis is based on a thorough clinical examination. WHAT CAUSES A CONCUSSION? Concussions can occur through a variety of mechanisms. Although most common in impact sports, they can also occur in non-impact sports and in incidents such as motor vehicle accidents. Typically, a concussion occurs when an impact is made with the head, or the head and neck undergo a violent acceleration or deceleration motion. These motions can place stresses on the structures within the brain that result in injury and responds with altered metabolic activity. It is important to remember that a concussion does not always require a violent motion or loss of consciousness. Even seemingly innocent injuries can lead to a concussion! Furthermore, signs and symptoms do not always present immediately, so it is important to be aware of and monitor for the signs and symptoms and seek medical care if suspected. WHAT ARE THE SIGNS AND SYMPTOMS OF A CONCUSSION? Typical signs and symptoms of a concussion can vary between individuals. The most common symptom of a concussion is a headache, but other common symptoms may include: Additionally, symptom presentation and recovery can vary drastically between individuals and may be based on age, gender, activity level, and history of prior injury, among other factors. For instance, symptoms may be exaggerated in younger individuals due to an immature neurologic system. On average, professional athletes become asymptomatic in 1-2 days, collegiate athletes in 2-7 days, and high school athletes in 1-2 weeks! And, while most people recover in less than 2 weeks, approximately 20% of individuals take more than 3 weeks to recover! This is referred to as post-concussion syndrome and can lead to persistent symptoms that not only impact return to athletic activities but can impair mental performance and cause persistent pain. In these scenarios it is especially important to seek medical advice from a qualified medical provider that can accurately identify the type of concussion, contributing factors, and appropriate management options. WHAT TO DO… Now that you are more informed about the potential causative factors and signs and symptoms related to concussion, it is important to recognize when a concussion might be present and be evaluated by a medical professional if it is suspected. If sustained at a school-related sporting event this may be performed by the Athletic Trainer, but, if one is not present, a physician that specializes in concussion is a great option. They can decide if further testing is warranted and refer to Physical Therapy! As we will soon see in the next segment in this four-part series, a concussion is not as simple as we once thought, and Physical Therapy can be a fantastic treatment option to promote return to function.