Archive for the ‘Athletic Trainers in the News’ Category

A Look into Concussion Protocols

Wednesday, March 15th, 2017

Posted March 15, 2017

Nicole T. Wasylyk
MSEd, LAT, ATC

By Nicole T. Wasylyk, MSEd, LAT, ATC

Preventing, identifying and managing sport-related concussions (SRC) continues to be a challenge for both healthcare professionals and for patients. The complexity in management of SRC may be mitigated by adopting solid policies and procedures to follow for those involved with concussion care. Best practice for concussion management encourages all high schools, colleges, club and professional sports to have policies in place regarding SRCs.

Both the National Hockey League (NHL) and National Football League (NFL) have accepted policies1,2 with the NHL adopting a new mandatory protocol this season. The purpose of the protocols is to educate players and provide guidelines for identifying and managing sports-related concussions. It has been well publicized that both the NHL and NFL face litigation from former players accusing the leagues of failing to protect them from concussions and head injuries. They also allege the withholding of information about long-term effects of concussions.3,4 These new protocols may achieve improved player education, prevention and recognition of concussion.

At their core the protocols are very similar; the NHL and NFL reference the Zurich II Consensus Statement from 2012 to define concussion as a “brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.”5 The NHL’s protocol specifically states that all players must watch an educational video and received a brochure of the information prior to the first day of training camp. All players are also required to complete baseline concussion testing, a well-adopted best practice for all contact sport athletes. Players complete both the SCAT3 and ImPACT® Test, core components of baseline testing.

The protocols both take into account thoughtful details regarding baseline and follow-up concussion testing. For example, they recognize the importance of an appropriate baseline testing setting.  Baseline testing environment and timing of the test (not immediately after physical exertion) should be considered carefully.  It is crucial for these tests to be completed in an environment where a player has minimal distractions to ensure validity of these tests.

As both protocols describe baseline testing, they also describe recognition of sports-related concussion during game play and on-field management. Signs and symptoms of concussion are mentioned in detail along with the way each league monitors for concussions. During gameplay, the NHL utilizes 2 types of spotters or individuals who monitor game play for potential athletes who may have sustained a head injury.

The first type is a Central League Spotter described as an Athletic Trainer (AT) or athletic therapist who observes the games via multiple live game feeds in the NHL offices. The second is an In-Arena League Spotter described as an Off-Ice Official who observes the game live in the arena. If either spotter suspects a player has sustained a concussion the player is then taken off ice and assessed by the club’s medical personal as described in the protocol. In contrast, the NFL only describes a Booth Athletic Trainer; this individual serves as the spotter similar to the Central League Spotter for the NHL.

If an NFL player is suspected of having a concussion during a game, they are removed from play and assessed as described by the “Madden Rule.” This rule states that the player must be removed from the field and evaluated in the locker room area by medical personal. If medical staff concludes a concussion was sustained that player is not permitted to return to play the same day. If no concussion is suspected, then video of the game play must be reviewed to remove any doubt of head injury prior to allowing the player to return to participation. The NHL describes assessment similar to the NFL’s “Madden Rule.” Return to play progression is also outlined in both protocols and both leagues encourage a multidisciplinary team approach to treatment. The medical teams are comprised of either a neurotrauma consultant or neuropsychologist along with the team medical doctors and ATs.

These concussion protocols serve as a comprehensive approach to education, diagnosis and management of sports related concussions. It is important that a transparent policy is adopted as a part of best practice so players, coaches, medical staff and officials understand not only the actions to take to protect athletes but expectations surrounding concussion recognition, management and return to sport.

References

1.https://images.nflplayers.com/mediaResources/lyris/pdfs/NFL_Diagnosis_Mgmt_Concussion.pdf

2.https://nhl.bamcontent.com/images/assets/binary/282574512/binary-file/file.pdf

3.http://www.cbsnews.com/news/supreme-court-rejects-former-players-challenge-1-billion-nfl-concussion-settlement/

4.https://www.boston.com/sports/boston-bruins/2016/02/06/105-former-nhl-players-are-plaintiffs-in-class-action-concussion-lawsuit-against-league

5.http://bjsm.bmj.com/content/47/5/250.full

 

Resources

https://www.nata.org/sites/default/files/Concussion_Management_Position_Statement.pdf

http://www.bocatc.org/blog/athletic-trainers-in-the-news/concussion-baseline-assessments-what-should-clinicians-capture/

About the Author

Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection. 

 

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Sports Dentistry: Why is it Critical to have Dentists Part of the Pre-participation Examination?

Monday, March 13th, 2017

Posted March 13, 2017

Kurt Andrews
MS, ATC, PES, CES
kandrews@lagalaxy.com

By Kurt Andrews M.S., ATC, PES, CES

It’s not even day 1 of the new season yet. It’s the first time the lights have been turned on in the athletic training facility since an early exit in playoffs gave rise to a dramatic ending and unexpected offseason. Memories of the holidays remain fresh but need to be stored in the long-term memory bank as it is now time to get things prepared for the upcoming season.

The offseason has brought many changes within the organization as old faces have gone on to new challenges where new and old faces have assumed new positions. In preparation for the upcoming physicals, it’s encouraging to know that the medical staff has remained the same, thus ensuring continuity and efficiency at the doctor’s office.

All stations are set, the orthopedic doctors are set to do their exams, the podiatrist is confirmed to come down and scan everyone and the primary care providers are all set for electrocardiogram (EKG) testing. The doctor’s office has hired nurses to run all the tests for general health, the ophthalmologist is ready to do the annual eye exam and the chiropractors are coming by to do spinal evaluations. The dietician is ready to sit down and do one on one evaluations with all the athletes, the neuropsychologist is ready to impact test everyone and the performance staff is ready to put the team through physical test to get an understanding of the performance perspective. Amongst the organized chaos in the doctor’s office is a familiar face, one that doesn’t get much sideline attention during games.  But, one who is a crucial component of the sports medicine staff, the team dentist.

Sports dentistry is a new area of sports medicine specialization, not so much in terms of utilization amongst the athletes and athletic departments, but more so in its utilization in prevention principles of potential oral and facial injuries involved in the related sports. Sports dentistry also focuses on the prevention of any oral diseases and manifestations that may occur along with the maintenance and treatment of oral and facial injuries.

Dental trauma in sports is the major link between sports and dentistry, thus making dentists a necessity at pre-participation examination (PPE). During the team physicals the team dentist conducts oral health screenings and is involved with the fabrication of custom made mouth guards for certain sports such as  football, hockey, lacrosse, basketball or wrestling. They also make themselves available for any sort of emergency care or dental procedures that need to take place before the season starts preventing athletes from missing time during the season. Dentists should also be playing an active role in educating the public and athletes on the use of protective equipment for sporting activities not only to prevent injuries but also to reduce healthcare costs (Ramagoni et al., 2014).

Many sports related traumatic dental injuries are preventable with the use of appropriate, properly fitted and protective athletic equipment. These include but are not limited to helmets, facemasks and custom mouth guards. The National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. estimates that during the season of play athletes have a 10 percent chance of sustaining an injury to the face or mouth (Ramagoni et al., 2014). The most common orofacial sports related injuries include soft tissue injury and hard tissue injury including those to the teeth and facial bones such as tooth intrusions, luxations, crown/root fractures, complete avulsions and dental facial fractures (Saini, 2011).

The front teeth are the most affected by dental trauma with the maxillary central and lateral incisors being the most commonly injured teeth. The most common tooth injury is an uncomplicated crown fracture (Soares et al., 2014). Most of the time these injuries occur from a direct hit by a ball or from player to player contact. On the rare occurrence, while on the road for a game, it can be critical for an Athletic Trainer to have the team dentist available via phone or text to assist in the trouble shooting of a problem and come up with a short-term solution until the team comes back home.

By having a team or university dentist involved during the entrance physical, this professional can help facilitate the custom fabrication of mouth guards for the athletes involved in contact sports. These custom made mouth guards are superior to the stock or “boil and bite” mouth guards because of their adaptability and retention but are also believed to interfere the least with breathing and speech. Mouth guards should be worn when there is a possibility of any sort of physical contact with an opponent because they can help to prevent injuries to the teeth, lips, gingiva, tongue and mucosa. They cushion the blows that could cause jaw fractures, dislocations and trauma to the temporomandibular joint (Saini, 2011). According to the American Dental Association, the use of faceguards and mouth protectors prevent more than 200,000 orofacial injuries in football annually (Saini, 2011).

During the Athens Olympics in 2004, dental services were the second most utilized service in the Olympic village behind physiotherapy. The most common procedures were dental fillings (313 permanent and 31 temporary), root canals, pericoronitis treatment and mouthguard fabrications. The entrance physical is a perfect place for the dentist to be involved so every athlete can have a dental assessment. This will ensure that their oral health status is verified and cleared and any issues that may come up can be handled in the preseason.

In a study from 2003 to 2006, professional soccer players from the Spanish team Barcelona were compared with students of Dentistry and Medicine from the University of Barcelona. The researchers found that the average active dental cavity was significantly higher among professional soccer players compared to the dental student (Soares et al., 2014). What this shows is that the students practiced what they preached and were more willing to participate in dental hygiene practices, but that’s because they are familiar with them. The take home message from a study like this is that these dental issues are more widely spread amongst  athletes and the team dentist needs to establish a program encouraging oral health to the athletes of a university, college, professional or amateur teams.

A different study looking at 400 medical records of 353 amateur and 47 professional soccer players, found the results of poor oral health far worse for amateurs than the pros. In the amateur athletes, they found 283 cavity lesions (71 percent), 109 root canals (27 percent), 33 abscesses (9 percent) and 78 tooth extractions (22 percent). When compared to the professional athletes, they found 32 cavity lesions (68 percent), 11 root canals (23 percent), no cases of abscesses (0 percent) and 24 tooth extractions (51 percent) (Soares et al., 2014).

Swimmers have also been found to have a higher than normal tooth enamel decay. Researchers have found that swimming athletes are affected with biocorrosion of enamel because of the chlorine used to keep the pools clean; the acidic water in contact with the teeth causes irreversible tooth structure wear especially to the anterior teeth (Soares et al., 2014).

It is easy to understand now how important it is to have a dentist involved within the sports medicine team, and why they could and should be involved during the PPE or entrance physical exam. The duty of the sports dentist is to work alongside the athletic training staff to ensure the oral healthcare of the athletes, identify any individual risks, and develop prevention plans so that the athletes can avoid any major dental issues. The inclusion of a dentist to your sports medicine program can be a major component of your injury prevention model.

Dr. Padilla’s (Team Dentist for LA Galaxy) Top Tips for Dental Health

1. Regular scheduled dental exams and professional cleanings.

2. Be proactive rather than reactive. Complete any necessary treatment in a timely manner. Don’t put off treatment because it doesn’t hurt yet. This will insure minimal treatment performed.

3. Have good home dental hygiene care. Brush and floss at least twice a day.

4. Diet can contribute to dental problems. Limit excessive acidic drinks like sodas, fruit juices and sports drinks. These acidic drinks may dissolve tooth enamel which may contribute to tooth erosion and cavities. Rinse and hydrate with water after taking these acidic drinks.

5. Avoid smokeless tobacco, which can cause periodontal and oral cancer complications.

6. Wear custom made athletic mouth guards in competing in trauma related sports.

Resources

Ramagoni, N. K., Singamaneni, V. K., Rao, S. R., & Karthikeyan, J. (2014). Sports dentistry: A review. Journal of International Society of Preventive & Community Dentistry4(Suppl 3), S139.

Saini, R. (2011). Sports dentistry. National journal of maxillofacial surgery2(2), 129.

Soares, P. V., Tolentino, A. B., Machado, A. C., Dias, R. B., & Coto, N. P. (2014). Sports dentistry: a perspective for the future. Revista Brasileira de Educação Física e Esporte28(2), 351-358.

About the Author

Kurt Andrews, originally from the metro Detroit area, graduated with his bachelor’s degree in Exercise Science in 2008 from Oakland University. He has been a BOC Certified Athletic Trainer since 2011 where he earned his master’s in Athletic Training from the entry level master’s program at the University of Arkansas. He currently is in his fifth year as an assistant Athletic Trainer for the Major League Soccer (MLS) club LA Galaxy. He currently holds memberships with NATA, CATA and PSATS where he serves on the sponsorship, continuing education and research committees and was presently serving as the Western Conference senator.

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Make a Life-Saving Decision: Become an Organ and Tissue Donor

Thursday, February 23rd, 2017

Posted February 23, 2017

By Mackenzie Simmons, ATC

National Donor Day was February 14th, and the main purpose is to raise awareness for organ, eye, tissue, marrow, platelet and blood donation. In addition, the day aims to recognize those who have donated organs, have received a donation or are currently waiting for an organ transplant. It is important to know that all people, regardless of age or medical history, are eligible to become a potential donor. It is also essential to encourage all members of the community to become organ donors because transplant success tends to be better when organs are matched between persons of the same ethnic or racial background.

Here are some important statistics about organ donation:

1. There are currently 119,000 people who are awaiting lifesaving organ transplants

2. In the United States, 8,000 deaths occur every year due to organs not being donated in time

3. By becoming a donor, you can:

- Save up to 8 lives if you donate your organs

- Restore eyesight in 2 people if you donate your cornea

- Heal up to 75 people if you donate your tissue

4. 683,000 transplants have occurred since 1988

5. In 2016, 33,600 transplants took place; this is an 8.5% increase from 2015

There are several ways for you to donate. First and foremost, you can register to be a donor, which can be done online or at your local DMV. Another way to support organ donation is to offer financial support to Donate Life America to help save lives in future.

One of the best ways to raise money for Donate Life America is to create a fundraising page, in memory of a loved one or in honor of a life event. Educating others on the importance of organ donation can help bring awareness to the issue; educational resources are available on www.donatelife.net. Lastly, as an individual, you can take steps to avoid the need for an organ transplant or donation. By visiting your doctor once a year, exercising regularly and eating a healthy diet, you are taking steps to reduce the chances of being on the organ donation list.

Resources

https://www.donatelife.net/

 

2017 NFL Pro Bowl Concussion Symposium and Health Screening

Tuesday, February 21st, 2017

Desi Rotenberg
MS, ATC

Posted February 21, 2017

By Desi Rotenberg, MS, ATC

The 2017 NFL Pro Bowl is a tradition that stems back to its inception in 1938. While the teams have changed drastically since then, the NFL Pro Bowl has become a tradition of competitive fun and entertainment for players, NFL front offices and fans. 2017 was the first year since 1980 (minus 2009) that the game was held within the continental United States. This venue change hoped to bring more fans, more attention and enhanced exposure of the game itself.

One of the attention grabbers for me during the Pro Bowl weekend occurred off the field. This year, The University of Central Florida (UCF) hosted the 2017 Pro Bowl Concussion Symposium and Health Screening. The purpose of this symposium was two-fold. First, retired NFL players were invited to partake in health screenings for free to help identify any neurological, cardiovascular or other issues plaguing them due to their playing time in the league. Second, the NFL Players Association partnered with the UCF Psychology Department to present all of the latest research and treatment options related to concussions in the world of sports, and more specifically, the game of football.

Here are a few of the highlights:

Following the U.S. Supreme Court settlement regarding previous NFL players and head injuries, the science has gained a significant amount of traction. As new empirical data emerges and technology continues to develop, more funding is becoming available to allow athletes to have increased access to neurological assessment and professional evaluation following head trauma. Interestingly, the Supreme Court settlement included a 65-year plan that will give retired NFL players and their families financial support if they experience symptoms of amyotrophic lateral sclerosis (ALS), dementia or any other life-altering behaviors or symptoms that may arise secondary to traumatic brain injury.

Furthermore, baseline testing is being made available to all retired NFL players and will be done immediately upon retirement. This will allow the players’ medical teams to identify any behavioral, cognitive or neurological changes that may arise over the remainder of the individual’s life.

The overarching goal is to have every college, high school and middle school offer some form of baseline testing in at least one sport for all student athletes. We are slowly, but surely, making our way towards that goal. However, there still remains room for improvement when it comes to baseline testing.

The areas of deficiency that were identified was a lack of baseline testing within recreational sports and ease of administration within middle schools and high schools. If we want to ensure the safety of all athletes, we must do what we can to have concussion education, a concussion protocol and return to play protocol in place.

At the academic levels, we must also ensure that we have a return to learn protocol in place. The question that acts as a defense for medical professionals responsible for the return to play decision is, “If you cannot learn new information, should you be returning to play?”

Emerging Technology

To this point, there are 2 questions that remain: 1) How do we diagnose Chronic Traumatic Encephalopathy prior to death, and 2) How do we avoid the high cost of imaging when it comes to concussion diagnostics?

There is by no means an answer to the first question as of yet, but I am hopeful due to the emergence of Diffuse Tensor Imaging (DTI). DTI has been around for roughly 20 years and has been mainly used in the diagnosis of strokes and other ischemic disorders of the brain.1 Within the past 10 years, research has shown that DTI can also be used to assess the integrity of the white matter in the brain.2 The goal of physicians at the symposium was to make DTI more streamlined and allow patients access to this form of diagnostic following head trauma.

In the image below, the varying colors represent the orientation of various white matter within the brain. In the second image, neurological specialists have the ability to zoom in on a specific location and can visualize a physical abnormality or disruption in neuronal activation due to a disturbance in neuronal integrity.

Images Obtained from Journal of Neuroradiology

So how do we lower the cost of imaging?

We start by locating private medical companies that offer this type of imaging. There were several speakers at the symposium who owned businesses that focused on the neurological diagnosis and treatment of individuals who suffered traumatic head injuries. The businesses offer consultations and diagnostics at a fraction of the cost of normal imagining techniques.

Cognitive and Behavioral Effects of Head Trauma 

Neuropsychologists want to make one thing very clear to all health practitioners: There is no such thing as the average TBI patient. While there are several concussion treatment protocols, it is paramount that each case be treated on an individual basis according to the needs of the patient and the underlying symptoms present. Cognitive changes following head trauma occur on a varying spectrum, and can include, but are not limited to: changes in vigilance, reaction time, mental tracking, verbal retrieval, mood and information processing.

Common symptoms that can be seen are the emergence of anxiety, depression, inability to focus and difficulty sleeping. Each symptom can lead to frustration, impatience and social disconnect. There is one congruity with all of these cognitive and behavioral changes: a concussion is a physiologic injury of the brain, where normal cerebral flow has been altered and the normal “algorithm” of information input and output has been compromised.

Unfortunately, head injuries cannot be cured; however, there is hope for individuals seeking refuge from this life-alerting injury. There are many clinics that exist, such as the UCF Psychology Clinic that can help patients learn to cope with the inhibiting effects of head trauma. Treatments include consultations with neuropsychologists, who walk patients through cognitive rehabilitative exercises and various forms of talk therapy. These treatments can help an individual compensate for the mental, emotional or physical deficiency that has arisen. The goal of treatment is to help the individual learn how to live within this new reality, and how to improve their overall quality of life.

The central message of the symposium is concussion research and concussion management are constantly changing. Unfortunately, policy change happens at an even slower rate. Due to this constant evolution, this is a topic All medical, fitness and cognitive specialists need to stay up to date on this topic due emerging information and the constant evolution of the topic. This can be accomplished by staying up to date on the latest research and emerging trends, in order to be able to follow “best practices” and avoid liability.

Resources

1. Hagmann, P., Jonasson, L., Maeder, P., Thiran, J. P., Wedeen, V. J., & Meuli, R. (2006). Understanding diffusion MR imaging techniques: from scalar diffusion-weighted imaging to diffusion tensor imaging and beyond 1. Radiographics, 26(suppl_1), S205-S223.

2. Le Bihan, D., Urayama, S. I., Aso, T., Hanakawa, T., & Fukuyama, H. (2006). Direct and fast detection of neuronal activation in the human brain with diffusion MRI. Proceedings of the National Academy of Sciences, 103(21), 8263-8268.

3. Rutgers, D. R., Toulgoat, F., Cazejust, J., Fillard, P., Lasjaunias, P., & Ducreux, D. (2008). White matter abnormalities in mild traumatic brain injury: a diffusion tensor imaging study. American Journal of Neuroradiology, 29(3), 514-519.

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. 

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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. 


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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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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Is Cupping the New “Fad” Therapy?

Friday, October 14th, 2016

Posted October 14, 2016

By Mackenzie Simmons, ATC

If you watched the Olympics this summer, you likely saw many Olympic athletes covered in perfectly circular red spots. These red spots are left by a therapeutic tool, known as cupping. Cupping is an ancient therapy, most prominently used in Middle Eastern and Asian countries.  Cupping has recently started to become popular in the United States over the past few years.

The process of cupping involves heating glass suction cups and placing them on the treatment area. The suction cups are usually left on the skin for around 5 minutes before they are removed. As the suction cups cool down, a partial vacuum is formed with the skin. The number of cups that are used is dependent upon the size of the treatment area; the bigger the area, the more cups that are used.

Cupping is believed to relieve pain by stimulating the muscles while increasing blood flow. It has also been shown as a form of deep-tissue massage that helps with the relaxation of sore muscles. Unfortunately, there has not been much research conducted that shows the positive effects of cupping.

Cupping might be the new “fad” therapy for Olympic, professional and collegiate athletes. Over the past 10 years, Kinesiotape, cryotherapy chambers and power bands have all become well-known and are used by professional athletes. With the limited research on cupping, time will tell  if this therapy will be around in 4 years for the next Summer Olympics.

Reference

http://www.cnn.com/2016/08/08/health/cupping-olympics-red-circles/

 

 

Medical Therapeutic Yoga Series: A New Movement in Healthcare

Monday, October 10th, 2016

Posted October 10, 2016

Desi Rotenberg
MS, LAT, ATC

By Desi Rotenberg, MS, LAT, ATC

Medical therapeutic yoga is a new movement within the rehabilitative realm that is quickly becoming more widely accepted as a pragmatic route to improving physical, emotional and mental well-being. There has been a paradigm shift within the medical field, as yoga therapy becomes more and more integrated into healthcare. Furthermore, yoga therapy is becoming more popular in the treatment of musculoskeletal injuries.

The core premise and philosophy behind medical therapeutic yoga is to understand your own limitations to be able to deliver the safest and best care possible. This includes a comprehensive understanding of the human anatomy and the treatment of specific diseases, disabilities or disorders. Additionally, in order to become a yoga therapist, a medical professional must have knowledge of indications and contraindications for safe breathing practices, as well as a strong knowledge base in various yogic practices to ensure patient safety.1

In 2012, the International Association of Yoga Therapists (IAYT) advisory board approved the educational standards for the training of yoga. This approval opened the door for medical therapeutic yoga to be held to competency-based educational standards. Although, Yoga Therapy is not governed nor regulated by the IAYT. The focus is on entry-level requirements for the training of yoga therapists and includes a definition of yoga therapy and training requirements. The goal for any organization when developing competency-based standards “is to define the foundational knowledge and skills required for the safe and effective practice of yoga therapy.”2

The Scope of Practice for yoga therapy can be found here: http://www.iayt.org/news/308692/IAYT-Updates-Scope-of-Practice.htm.3

The Professional Yoga Therapy Certification can be a post-certification option for Athletic Trainers who are interested in furthering their knowledge base. The Professional Yoga Therapy Institute (PYTI) is one of several institutes who offer both continuing education courses and a full professional certification.

The PYTI defines medical therapeutic yoga as “the practice of yoga in medicine, rehabilitation, and wellness settings by a licensed health care professional who is completing or has graduated from the Professional Yoga Therapy Institute program and has been credentialed as a Professional Yoga Therapist-Candidate or Professional Yoga Therapist.”4

Becoming a medical yoga therapist is not for everyone. While knowledge is essential to a medical professional’s success as a practitioner, the journey of accruing wisdom holds an even greater weight. The uniqueness of this new field focuses on the well-being of the patient, while also ensuring the individual who practices medical therapeutic yoga is able to achieve a balance within every aspect of their life, both professionally and personally.

More information on medical yoga therapy and becoming a professional yoga therapist, can be found at the following websites:

International Association for Yoga Therapy- http://www.iayt.org/

Professional Yoga Therapy- http://proyogatherapy.org/

Medical Therapeutic Yoga- http://www.gingergarner.com/therapies/medical-yoga/

Resources

1. Garner, G. (2007). The Future of Yoga Therapy and the Role of Standardization. International Journal of Yoga Therapy, 17(1), 15-18.

2. Educational Standards for the Training of Yoga Therapists. (2016). http://www.iayt.org/?page=AccredStds. Accessed September 27, 2016.

3. Scope of Practice for Yoga Therapy, (2016). INTERNATIONAL ASSOCIATION OF YOGA THERAPISTS. http://c.ymcdn.com/sites/www.iayt.org/resource/resmgr/docs_certification/scopeofpractice/2016-09-01_IAYT_Scope_of_Pra.pdf. Revised: September 1, 2016.

4. Professional Yoga Therapy Institute, (2016). http://proyogatherapy.org/about-pyts/. Accessed September 27, 2016.

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. 

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Return to Sport Post ACL Reconstruction

Wednesday, September 21st, 2016

Posted September 21, 2016

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

By Tim Koba, MS, ATC

ACL injuries continue to be a hot topic in the sport world. A big reason is that even though they are still not very common, percentage wise, they have a large impact on long term joint health, recovery, cost and ability to return. As reconstruction techniques continue to evolve, athletes are able to return to play, but how successfully?

After surgery, the treatment consists of rehabilitation to regain motion, function, proprioception strength and control. Once athletes have completed about 6-9 months of rehab, they return to sport. Here’s the sobering news: Of those who suffer an ACL reconstruction, only 65% return to their pre-injury level of sport, with only 55% returning to competitive play. Even more discouraging is the fact that of those who return to sport, up to 1 in 5 will suffer a tear to their reconstructed knee, or the ACL on the non-reconstructed side.

In order to determine what risk factors existed, and ways to modify them, researchers looked at elite soccer players who had their ACL reconstructed and then followed them. They looked at the type of surgery they had, their rehabilitation process and their return to sport. What they discovered was that athletes who did not meet certain bench marks in rehab were 4 times more likely to have another ACL injury. The following table shows the exercises and the discharge criteria that were deemed successful.

Discharge tests and criteria used during the study period

6 part return to sport tests Discharge permitted when criteria was met
Isokinetic test at 60, 180 and 300 degrees/sec Quadriceps deficit <10% at 60 degrees/sec
Single leg hop Limb symmetry index >90%
Triple hop Limb symmetry index >90%
Triple crossover hop Limb symmetry index >90%
On field sport specific rehab Fully completed
T test <11 sec

In addition to the tests above, athletes who had lower hamstring-to-quadriceps strength ratios were also more likely to injure their ACL. Since strong hamstrings act as an assistant to the ACL, weakness there can mean more stress on the ligament.

Conclusion

This study highlights a couple of key points when rehabilitating ACL injuries.

- Prior to return to play, athletes should be fully recovered with equal strength bilaterally

- They should be able to seamlessly perform multidirectional drills

- Athletes should have adequate hamstring strength. Most of us do not have access to isokinetic testing, but spending time having athletes perform hamstring strengthening during their rehabilitation is essential.

Reference

Kyritsis, P. et. al. (2016). Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British Journal of Sports Medicine, 50. http://bjsm.bmj.com/content/early/2016/05/23/bjsports-2015-095908.abstract

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.