Archive for November, 2016

Exercise Intervention for Post-Traumatic Stress Disorder

Tuesday, November 29th, 2016

Posted November 29, 2016

Desi Rotenberg
MS, LAT, ATC

By Desi Rotenberg, MS, LAT, ATC

Since 2000, there is emerging evidence that exercise can and should be used in the therapeutic treatment plan of patients with Post-Traumatic Stress Disorder (PTSD). Before understanding how therapeutic exercise can be used as a modality for PTSD, we must identify a working definition of the disorder.

The National Center for PTSD defines trauma as “a shocking or anxiety-inducing event that a person witnesses or experiences.”1 It is reported that 6 out of every 10 men and 5 out of every 10 women will experience at least 1 traumatic incident in their life.1 While these traumatic experiences can cause acute forms of PTSD, the effects tend to be short lasting and asymptomatic. However, 8 out of every 100 individuals in the United States will suffer from PTSD at some point in their life.1

PTSD is described as an “anxiety disorder that is triggered by witnessing or experiencing a traumatic event.”2 PTSD is most commonly associated with veterans; however, it can also frequently affect survivors of “violent, personal assaults.” These include rape, mugging, domestic violence, childhood abuse, natural disasters, accidents and life threatening illnesses.

It is important to note the athletic population is not exempt from PTSD. Traumatic events that athletes have suffered either in their past or that are related to an athletic injury can cause substantial hindrances in their return to play. The consequences of traumatic stress can interfere with both an athlete’s rehabilitation as well as their return to play status. Furthermore, sport-related trauma can be a result of over-training or violence within sports.3

The main symptoms of PTSD are generalized anxiety, depression, insomnia, dysphoria and general fatigue. While depression is a common consequence of some of life’s most strenuous occurrences, there are physical and physiological benefits to utilizing exercise as a therapeutic intervention.

There have been several studies that have shown positive outcomes on patients with PTSD, and more data is emerging.  In 2009, Cohen and Shamus noted, “Low-to-moderate intensity exercise can elevate mood and reduce anxiety.”2 Additionally, Tsatsoulis and Fountoulakis determined in 2006 that exercise can “act as an overall stress buffer” which in effect can have a positive impact on the symptoms of depression and PTSD.2 Non-randomized controlled studies using physical activity and exercise as an intervention for patients with PTSD showed improvements in body image, prevention of eating disorders, alleviation of anxiety and depressive symptoms and decreased substance abuse.4 Cross-sectional studies have had high self-reports of a correlation between habitual exercise and better mental health.5

In the athletic population, habitual exercise is the activity that is done outside of organized team activities. Other longitudinal surveys have shown that exercise habits early on in an individual’s growth and development, between ages 18-28, can predict freedom from depression later on in their life.6

Farmer et al. surveyed 1,900 adults in 1988 with preexisting depression (causes were variable, some unknown). They determined that individuals who took part in physical exercise ranging from low intensity to rigorous training, successfully made it to the 8-year follow up, and confirmed the researchers’ ability to predict freedom from depression.7 Additionally, the Journal of Clinical Epidemiology published a study in 1994 looking at 1,758 adults with a variety of physical and chronic health problems and self-reported exercise time during a 2-year study period. The majority of these individual reported improvements in well-being, anxiety levels and reported low levels of depression and fatigue.8

There is extensive data on the efficacy of corrective exercise strategies for individuals who are suffering from PTSD as well as any residual behavioral symptoms that are associated with exposure to a traumatic event. While the occurrence of PTSD and injuries from blunt force trauma to the head are only growing in the United States, it will be up to behavioral specialists, occupational therapists, physical therapists and fitness professionals to facilitate an atmosphere that allows individuals to return to their normal activities of daily living.

Resources

1. National Center for PTSD. http://www.ptsd.va.gov. Date Accessed: October 20, 2016.

2. Kim, L. H., Kravitz, L., & Schneider, S. (2012). PTSD & Exercise: What every exercise professional should know. IDEA Fitness J, 9, 20-23.

3. Wenzel, T., & Zhu, L. J. (2013). Posttraumatic Stress in Athletes. Clinical Sports Psychiatry: An International Perspective, 102-114.Lawrence, S., De Silva, M., & Henley, R. (2010). Sports and games for post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev, 9.

4.  Lawrence, S., De Silva, M., & Henley, R. (2010). Sports and games for post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev, 9.

5. Salmon, P. (2001). Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory. Clinical psychology review, 21(1), 33-61.

6. Krause, N., Goldenhar, L., Liang, J., Jay, G., & Maeda, D. (1993). Stress and exercise among the Japanese elderly. Social science & medicine, 36(11), 1429-1441.

7. Farmer, M. E., Locke, B. Z., Moscicki, E. K., Dannenberg, A. L., Larson, D. B., & Radloff, L. S. (1988). Physical activity and depressive symptoms: the NHANES I Epidemiologic Follow-up Study. American Journal of Epidemiology, 128(6), 1340-1351.

8.  Stewart, A. L., Hays, R. D., Wells, K. B., Rogers, W. H., Spritzer, K. L., & Greenfield, S. (1994). Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. Journal of Clinical Epidemiology, 47, 719–730.

About the Author

Desi Rotenberg, originally from Denver, Colorado, graduated with his bachelor's degree in 2012 from the University of Northern Colorado. He has been a BOC Certified Athletic Trainer since 2012 and earned his master's degree in Exercise Physiology from the University of Central Florida in 2014. He currently is a high school teacher, teaching anatomy/physiology and leadership development. Along with being a teacher, he wears many hats, such as basketball coach, curriculum developer and mentor. He has been a contributor to the BOC Blog since the summer of 2015. 


In-Depth Look: Athletic Trainer for the United States Soccer Federation

Monday, November 21st, 2016

Posted November 21, 2016

Steven Bagus, ATC, NASM-PES is an Athletic Trainer for the United States Soccer Federation.

Describe your setting:

I work with the United States Soccer Federation (USSF). In this setting, I work with a variety of national soccer teams at a variety of locations. This setting allows for a great deal of travel and the opportunity to work with athletes of different ages.

The diversity of coaches, athletes and staff members provides a constantly changing atmosphere. This setting forces me to use all of the tools in my athletic training box. Learning the health history of the players, their needs during training camps or tournaments and the expectations of the coaching staff in a short time frame and an unfamiliar environment helps me to be a more dynamic Athletic Trainer (AT).

How long have you worked in this setting?

My first experience working with the USSF was in 2009, but I entered my current role in January 2016.

Describe your typical day:

A typical trip working for the USSF involves meeting the team at an airport to travel together for international trips or traveling to the location of a domestic camp.

The camp begins with setting up your athletic training facility, typically an empty hotel room. A typical camp has an average of 12 boxes of athletic training supplies. Once your functional athletic training facility is set up, it is important to review the physicals for each athlete. Each day of camp can be different depending on the needs of the team.

As the AT, I am expected to join the team for all team meals, prepare the athletes for practice and games and evaluate and treat the athlete’s post-activity. Each day is exciting, challenging and demanding but can be a very rewarding experience as an AT.

What do you like about your position?

I love that this position allows me to travel all over the world with the highest level of athletes.

What do you dislike about your position?

The biggest challenge of this job is learning the needs and expectations of different athletes and coaches on a regular basis.

What advice do you have about your practice setting for a young AT looking at this setting?

My advice to young professionals looking for this setting is to be very flexible and excited to help the team accomplish their goals. If you are interested in working for a national program, seek out the medical administrator and see where you can help.

 

Adopting Injury Prevention Programs in High School

Wednesday, November 16th, 2016

Posted November 16, 2016

Tim Koba, MS, ATC
Twitter: @timkoba
Blog: www.timkoba.blogspot.com

By Tim Koba, MS, ATC

Participation in high school athletics carries an intrinsic risk of injury, but that doesn’t mean certain types of injuries can’t be decreased. There has been a proliferation of injury prevention programs. These programs have the ability to improve performance and decrease risk of sustaining certain injuries, especially ACL injuries and ankle sprains. While this information is readily available, there has been some hesitancy to adopt these and similar programs.

In an Oregon survey of high school soccer and basketball coaches, many of the coaches were aware that injury prevention programs existed, but they were not adopting those programs for their own teams.1 Some of their reasons included the belief that what they currently did was similar to the program; their program was superior to the researched program; or they were not aware of how much actual sport performance gains occurred as a result of these programs. Those concerns have validity and merit further discussion.

Many injury programs have similar features that are easy to adopt and implement such as squatting, jumping, cutting and using a balance apparatus. The key with any of these exercises is to focus on form and ensure the athletes are appropriately performing the required task and not going through the motions. Some of the programs are definitely more involved and time consuming and may cut into the limited time available for training. However, before changing or eliminating exercises, it is important to understand the mechanics and rationale behind those exercises and why they were included in the first place. Arbitrarily eliminating exercises can invalidate the program resulting in a failure to achieve the intended prevention outcomes.

A relatively new option for reducing injury risk, improving fitness and performance is to adopt a training program in physical education (PE) classes.2 This exercise vehicle may be a great way to teach fundamental movement skills to adolescents who carry on to their chosen sport. In a study out of Canada, researchers compared a typical PE class with a specific training PE class. The specific training PE class was geared toward the improvement in movement, reduction in injury and had significantly fewer injuries than the control group. The exercises regimen they chose was similar to the FIFA 11+ and included squats, jumps, lunges, planks and running drills. The inclusion of this, or a similar program, in middle and high school may help to decrease on field injury rates during athletic participation.

The potential for injury will always be a part of athletics, but accepting that there is nothing to help prevent injury is not accurate. At this point there are many options to keep players healthy and participating safely. Knowing the common injuries in your chosen sport and available resources are essential for successful participation in athletic endeavors.

Conclusion

- Injury prevention programs can decrease risk for certain injuries and improve performance

- There is hesitancy to adopt these programs despite their proven effectiveness for a variety of reasons

- Implementing a school wide program can help to bridge the gap between player safety in athletics, exercise, fitness and movement

References

1. Norcross, M.F., et. al. (2016). Factors influencing high school coaches’ adoption of injury prevention programs. Journal of Science and Medicine in Sport, 19: 299-304.

2. Richmond, S.A., et. al. (2016). A school based injury prevention program to reduce sport injury risk and improve healthy outcomes in youth: A pilot cluster randomized controlled trial. Clinical Journal of Sports Medicine, 26(4): 291-298.

About the Author

Tim Koba is an Athletic Trainer, strength coach and sport business professional based in Ithaca, New York. He is passionate about helping others reach their personal and professional potential by researching topics of interest and sharing it with others. He contributes articles on injury prevention, management, rehabilitation, athletic development and leadership.

 

 

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Medical Therapeutic Yoga Series: Yoga as a Therapeutic Intervention

Tuesday, November 8th, 2016

Posted November 8, 2016

Tim Koba, MS, ATC
Twitter: @timkoba
Blog: www.timkoba.blogspot.com

By Tim Koba, MS, ATC

As research continues to improve and advance, it is important to stay abreast of current trends. One of those trends is the development of yoga as a therapeutic intervention. While yoga has been practiced for thousands of years, its popularity for fitness has increased worldwide. In conjunction with this increase in practice comes an increase of research evaluating the therapeutic effectiveness of yoga on different diseases and populations.

There have been some recent literature reviews that evaluate the state of the current research and can help practitioners gain an understanding of alternative and complementary forms of treatments. Yoga has been routinely associated with breathing, movement and mindfulness that can improve stress levels. Indeed, one of the benefits of yoga is the ability to decrease stress. This reduction in stress has additional health benefits including the regulation of breathing; decreasing hypertension; and potentially modulating post-traumatic stress disorder (PTSD), anxiety and depression. It has also been shown to be an adjunctive therapy for asthma.

The focus on the breath with yoga helps to regulate breathing and improve lung capacity. Recently, a study looked to see if this improvement in breathing ability transferred to actual physical performance. A small sample of matched female participants were measured for cycling performance before, during and after being in a yoga group or a control. The practice group showed improvements in lung regulation and capacity at rest, but no improvement in cycling performance or VO2max. So, while yoga may help with regulating breathing, it is still important to undergo training modalities to achieve physiological adaptation.

Another common reason to perform yoga is to improve balance and flexibility and both of these outcomes are achieved with routine practice of yoga. Athletes have even seen improvements in these areas compared to those who did not practice yoga. Unfortunately, no study has evaluated the on-field transfer, prevention or rehabilitation potential of yoga on injury risk and performance measures. It still remains to be seen if yoga is a viable standalone prevention or rehab strategy.

An area of rehabilitation that does show promise is chronic low back pain. One of the main reasons for participants to choose yoga relates to low back pain (20 percent). Yoga practice has demonstrated effectiveness in decreasing the pain and dysfunction associated with chronic low back pain. Yoga also improves the symptoms and function of those suffering from knee arthritis. Yoga can help to decrease the pain, swelling and stiffness associated with osteoarthritis (OA).

While the use of yoga is showing promise as a therapy, there are definite opportunities to learn more. It is important to note a few things regarding its effectiveness as a therapeutic modality. The range of yoga styles and instructors makes it very difficult to standardize yoga therapies, and thus, hard to compare outcomes to traditional therapies. The differences of the styles, instructor, location, class level and overall vigor of practice all have an effect on how a client will respond to the intervention. As studies regarding yoga become more robust, we can make better recommendations to athletes and clients regarding its use, but currently our knowledge is limited.

Conclusion

- Yoga can improve pain and stiffness of OA and improve chronic low back pain

- Yoga can improve balance, flexibility and strength

- Yoga can decrease stress, including the regulation of breathing and decreasing hypertension

- Yoga may have a positive benefit on PTSD, anxiety and depression

- Yoga may be useful as a complementary practice for treatments, but more standardization and research is required to make specific recommendations

Resources

Beutler, E., et al. (2016). Effect of regular yoga practice on respiratory regulation and exercise performance. Plos One, 11(4).

Chang, D., et al. (2016). Yoga as a treatment for chronic low back pain: A systematic review of the literature. Journal of Orthopedic Rheumatology, 3(1), 1-8.

Field, T. (2016). Yoga research review. Complementary Therapies in Clinical Practice, 24, 145-161.

Jeter, P., et al. (2015). Yoga as a therapeutic intervention: A bibliometric analysis of published research studies from 1967-2013. The Journal of Alternative and Complementary Medicine, 21(10): 586-592.

Park, C., Braun, T., & Siegel, T. (2015). Who practices yoga? A systematic review of demographic, health related and psychosocial factors related to yoga practice. Journal of Behavioral Medicine, 38, 460-471.

Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2), 49-54.

About the Author

Tim Koba is an Athletic Trainer, strength coach and sport business professional based in Ithaca, New York. He is passionate about helping others reach their personal and professional potential by researching topics of interest and sharing it with others. He contributes articles on injury prevention, management, rehabilitation, athletic development and leadership.

 

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Would ECHO testing during the PPE prevent sudden cardiac death?

Wednesday, November 2nd, 2016

Mike McKenney, MS, ATC

Posted November 2, 2016

By Mike McKenney, MS, ATC

During the pre-participation examination (PPE), many healthcare practitioners employ a traditional cardiac questionnaire and physical examination to detect potential abnormalities and other serious medical conditions that may impact safe participation in sport. However, a physical examination and history are not always sufficient to detect abnormalities of the heart that can result in sudden cardiac death (SCD). More recently, there has been increasing support for broader implementation of electrocardiograph (ECG) testing at all levels of sport. This includes attempts to mandate ECG testing for all high school athletes. Barriers to mandatory ECG testing typically revolve around cost, but there are other factors to consider before requiring this form of screening in an athletic population.

The intended purpose of an ECG is to assess electrical activity of the heart and assist clinicians in determining if a cardiac abnormality is present, whether it be genetic, structural or conductive in nature. However, only 3 percent of cases that result in SCD are of conduction-related causes.1, 2 In young, competitive athletes, structural abnormalities represent the largest percentage of SCD, 84 percent of reported cases,1 which includes conditions such as hypertrophic cardiomyopathy (HCM). Simply put, mandating ECG testing in sport may not be the best step forward due to the test’s limitations in screening for the primary causes of SCD.

The difficulty in utilizing ECG to detect structural abnormalities is reflected in a high false-positive rate due to detection of cardiac adaptations regularly found in trained athletes,1, 3 and other variations that are common with normal cardiac rhythm.3Furthermore, ECG lacks the specificity to reliably detect HCM,3 which is a condition that is largely asymptomatic until an SCD event occurs.2 Additionally, results can be interpreted differently between physicians if consistent standards are not being applied.4 Due to the aforementioned factors, athletes are often subject to unnecessary referrals for further screening that often turn out to be of no concern,4 and add further cost to the evaluation process.2

Echocardiograms (ECHO) are the gold standard for visualizing the heart and are what athletes typically receive when referred to a cardiologist for advanced evaluation. Traditionally, the ECHO is performed in a cardiologist’s office. However, with advances in portable ultrasound technology, there is an emerging application for ECHO testing to be conducted by a front-line physician at a school’s sports medicine facility.2 At Northeastern University, a study5 was conducted utilizing this procedure and found that referral to a cardiologist was reduced by 33 percent. There were no differences between measurements obtained by the school’s physician and an outside cardiologist. In addition, research currently in review found the portable ECHO procedure to be significantly quicker than a traditional history and physical or ECG.2 This finding could potentially lead the way to a more thorough and efficient PPE process.

The costs associated with cardiac screening will always be a point of contention, but results of the previously discussed research are going to shift the discussion in a new way. It is not yet known if on-site portable ECHO testing will be a cost saving measure.  However, in theory, a reduction in unnecessary referrals should reduce the overall cost of screening. Moreover, clinicians will have the added benefit of being able to visualize conditions that can result in SCD, instead of trying to infer their presence from electrical activity alone. If we are to continue advocating for access to advanced cardiac screening, future efforts should be focused on methods and services that provide a more efficient and accurate assessment.

Resources

1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115(12):1643-1455.

2. Kerkhof D, Gleason C, Basilico F, Corrado G. Is there a role for limited echocardiography during the preparticipation physical examination?. PM & R: The Journal of Injury, Function, And Rehabilitation. March 2016;8(3 Suppl):S36-S44.

3. Maron B, Friedman R, Thompson P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation.2014;130(15):1303-1334.

4. Hainline B, Drezner J, Thompson P, et al. Interassociation consensus statement on cardiovascular care of college student-athletes. Journal Of The American College Of Cardiology. 2016;67(25):2981-2995.

5. Yim E, Basilico F, Corrado G. Early screening for cardiovascular abnormalities with preparticipation echocardiography: utility of focused physician-operated echocardiography in preparticipation screening of athletes. Journal Of Ultrasound In Medicine: Official Journal Of The American Institute Of Ultrasound In Medicine.2014;33(2):307-313.

About the Author

Mike McKenney is an Athletic Trainer (AT) at Northeastern University in Boston, Massachusetts, where he is the Medical Coordinator for their Division I men’s ice hockey program.  Prior to Northeastern University, he served as an AT in multiple settings including secondary schools, Division I athletics and professional cycling; additionally, he worked as an AT who extends the services of a physician for a large orthopedic group.  He has also provided services for many organizations to include the Boston Marathon, USA Cycling and USA Volleyball.

McKenney is a hydration and electrolyte replacement consultant for the Atlanta Hawks of the NBA.  His professional interests include hydration, electrolyte replacement, thermoregulation in sport and postural restoration.  McKenney completed his athletic training education at Gustavus Adolphus College in Saint Peter, Minnesota and master’s degree at North Dakota State University in Fargo, North Dakota.  His graduate research was published in the February 2015 edition of the Journal of Athletic Training.

 

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