by evergreenpt, February 5, 2018
Happy New Year!
With all the excitement and anticipation for the big game, it’s a great time to bring a little PT perspective on one of the most controversial topics of the sport: concussions. In 2015, the movie Concussion starring Will Smith hit the big screens highlighting Dr. Bennet Omalu’s daring research and ensuing struggle against the National Football League to make the public aware of the brain degeneration suffered by professional football players. Despite a main stream movie and the many decades that have passed since Dr. Omalu’s findings were revealed, the NFL is still being criticized by the likes of Richard Sherman, 4 time pro-bowl cornerback for the Seattle Seahawks, who recently gestured with air quotes around the NFL’s concern for “player safety” which he called a public-relations attempt and an “absolute joke”. In fact, one of the most recent changes occurred just this past December after Houston Texans Quarterback Tom Savage re-entered a game with an obvious concussion. The NFL is mandating the presence of an unaffiliated neurotrauma consultant to be onsite during every game of the season. You can read more about it here in this article from the New York Times.
So how does this affect us, some of us fans, sitting safely on our living room couches with a bowl of chips in one hand and a soda in the other? Most often there are not cameras to catch events on permanent record of trauma to the head. Usually we do not have “neuro-trauma” consultants on the sidelines on the harshest of sports, let alone the low risk sports. Do we really need to be concerned if we or our loved ones aren’t football, hockey, or soccer players? The answer is yes! Because even if you or someone you know doesn’t play a collision sport, participating in any sport, physical activity, driving a car, walking near slippery floors, or stepping off a curb in the dark, can carry the risk of concussions!
With Dr. Elisabeth Ashoff, PT, DPT
Concussions can cause cognitive, emotional, and physical impairments. It is old school and wrong news to down play the event as just “knocked in the noggin”, “getting your bell rung”, or suffering a “stinger” (the last of which has more to do with the neck and exiting nerves). The common thought that these are simply remedied by rest, every 2 hour pupil checks, and staying in dark spaces while shutting down computer time is already outdated. Concussion can affect sleep patterns, memory and concentration, multi-tasking, and moods. Concussions can throw a curve ball at resiliency to the multi-facets of one’s day, demands, and concerns. Concussions can make one more emotional even with routine life events. Read the testimonial from Cheryl Simmons below to get insight on how we can underestimate the effect. Concussions can also disturb equilibrium and balance or the ability to focus on moving objects, especially while moving our head. In some cases, a patient’s physical impairments seem to be the primary deficit but they can only make progress if other areas of impairment have been dealt with as well. All that to say, it can be complex, and the last thing the person suffering the concussion needs to do, nor can they do alone, is to process what to do or how to interpret symptoms.
That’s why it’s so important to have a multi-disciplinary approach to managing concussions. Finding a good primary care physician (PCP) who specializes in concussions is just the first step. A PCP who is well versed in identifying the multiple dimensions of concussion symptoms will be able to help you narrow down the areas in which you are most affected. Evergreen collaborates with many nearby PCPs who have helped us in the management and direction of healthy recovery from these traumatic events. We are happy to provide contact information to people searching for a PCP or specialist MD knowledgeable in this area. After they’ve narrowed it down, your PCP can refer you to the appropriate combination of providers which may include a vestibular physical therapist, neuro-psychologist, neuro-opthamologist, upper cervical chiropractor (NUCCA), nutritionist, athletic trainer, or for students, an educational support therapists. If you add any level of prior learning disability to the situation you can see how it can all be complicated to sort out. It is important that one with a concussion follows an intentional path with professionals who will be able to help sort out the details, refer to the needed areas (not all are needed in every case) and thus speed up recovery.
What About Return to Sports and What is Sports Specific Exertional Training?
Sports specific exertional training is a graded intensity program designed by a physical therapist or athletic trainer to monitor and train an athlete who has concussion symptoms back to their original level of performance during sports.
It is a critical step to be taken prior to returning to a sport. While some athletes may no longer experience symptoms during their routine day to day activities, like driving, attending classes, or using a computer, the demands on an athlete’s body and brain are very different when you put them into high stress situations of physical exertion, multitasking, and competition during sports. If they return to play before they are ready, athletes will have an increased chance of re-injury, or worse, second impact syndrome (SIS), which is a more rapid and dangerous brain swelling that occurs when a second concussion happens while the first concussion is still healing. The point is, no matter how minor a concussion is interpreted to be, a health care professional with expertise in evaluating the sometimes subtle signs of concussion must be involved in the decision for that person to return to the sport. Exertion training is just one of the tools necessary to best determine that readiness and reduce risk of permanent or subsequent injury.
You can read more of Dr. Ashoff’s insights on concussion injuries in the athletic youth population here in an earlier blog post “Help is Just A-Head!”.
She has treated both adults and children with concussion injuries and is passionate about keeping athletes of all ages healthy and active!
My Concussion Story
Cheryl Simmons, PhD Sport and Exercise Psychology
Professor / Lecturer CSULA
Pasadena Rose Bowl Master’s Swimmer
Sport and Exercise Psychology Consultant, Kinnections,
Rose Bowl Aquatics Center
I have over 30 years of experience in competitive swimming and had not imagined I would ever get a concussion in this sport. I was swimming backstroke in a pool that did not have backstroke flags. I made a conscious attempt to use a different marker to let me know where the wall was, but I misjudged the distance. As I reached for the wall with my hand, I tipped my head backwards and surprisingly crashed my forehead into the wall. I was moving with enough speed that my head slipped back and my nose crashed into the wall. I then felt the vertebrae compressing down my neck and spine. At first I thought I might have broken my nose, but a concussion did not cross my mind. I kept swimming for another 10 minutes, but finally stopped because my nose and face were hurting so much. After applying ice, I thought I was fine, so I actually got back in for my workout, still not suspecting a concussion. About 30 minutes after the accident I started feeling nauseous as I was swimming and then knew a concussion was a possibility.
I believed that it was only a “mild concussion” and rested that day and the next thinking that I was fine. Luckily, I saw David Johnson, PT, MPT and Nick Tavoukjian, MS, ATC at Evergreen Physical Therapy Specialists in Pasadena and over the next few days they strongly recommended that I see a physician. The neurologist confirmed a concussion. The first few weeks I was having trouble with dizziness, headaches, multitasking and speech. I kept swimming, but I had to reduce the frequency, intensity and duration. I began physical therapy for concussion management, which I didn’t even realize existed. The exercises that Elisabeth Ashoff PT, DPT used (neck stretching, inner ear, and eye tracking exercises) helped with the headaches and dizziness. Probably more importantly, Liz would ask about my symptoms and reassure me that it was normal as I progressively recovered.
After 8 weeks, I attempted to return to my normal activities (lecturing at CSULA, as well as teaching exercise classes) at full-time. I wasn’t ready and within a couple of weeks I experienced a substantial setback with the dizziness and my ability to focus. At this time, I even attempted to swim in our regional competition. I got lightheaded and very emotional after my events and realized that I needed to start over again with the resting. Together with Liz, we designed a plan for rest, gradually introducing everyday tasks as tolerated and incorporating swim strokes that didn’t bring on symptoms. I had not understood how challenging it would be to rapidly turn my head to breathe while swimming freestyle. We created a new way to train my eye tracking, which has greatly reduced my dizziness while swimming.
Now, four months after my accident, I can honestly say that I am feeling better, but I’m not competing yet. This has been a much slower process than I had anticipated. As a mother of teenage boys, a full-time teacher, and an athlete I really had to cut back in every area of my life. It is hard to understand how athletes get back on the playing field with only 1-2 weeks of rest. I start back to teaching next week and I’m hoping that I’m ready for it. I am also hoping to compete at USMS Nationals in May.
Cheryl Simmons, Ph.D. is a professor in Kinesiology, exercise psychology, psychomotor development, therapeutic water therapy and water aerobics, and water exercise with older adults at CSULA; and if that wasn’t enough, she’s also a Rose Bowl Masters competitive swimmer and swim coach.
The Importance of Baseline Testing and a Multi-disciplinary Approach
an interview with Brian Roberts, MS, ATC, ITAT
Concussion continues to be very puzzling to many clinicians and can be difficult to treat. While Traumatic Brain Injury has gleaned much attention clinically over the years, concussion has continued to present challenges for the clinician as it is an ever evolving science. One of the biggest deficits in treatment is lack of proper diagnosis, and the lack of timely Physical Therapy care.
We know that concussion patients do well when they have access to multi-disciplinary care, but key to early diagnosis and recovery is the Physician that is specialty trained in concussion management, and a team of Physical Therapists that are skilled at both musculoskeletal and vestibular rehabilitation. Many concussion patients present with a multiplicity of symptoms (we call these co-morbidities) that require a highly skilled and experienced doctor and Physical Therapist to recognize and treat
One of the biggest advances in concussion care is the implementation of Baseline testing. The NFL, NCAA, Olympic Committee and MLB all use Baseline Concussion testing as part of the “Best Practices” needed to determine injury severity and key components of recovery like “Return to Play” and “Return to Learn”. Without the necessary baseline testing, concussion care can be very difficult. This is the reason that Evergreen Physical Therapy is providing Baseline testing as part of their overall Concussion services to the community
While there are similarities to treatment for youth and adults suffering from concussion, the youth population have underdeveloped brains and as such predisposes them to greater risk of injury and protracted recovery. There are a number of areas where prevention is needed to protect at risk youth, these include schools and clubs being compliant with all state guidelines pertaining to participation (AB 2007). This California law was signed January 1, 2016 and among its key components it (1) mandates that all athletes 17 years of age or younger will be immediately removed from competition if they present with symptoms of concussion. (2) In addition, AB 2007 mandates a 7 day period before the athlete can be returned to competition. And (3) requires clearance by a Physician (MD/DO) specialty trained in Concussion management before they may return to practice or competition.
Similar legislation exists within the bylaws of the California Interscholastic Federation (CIF) the entity responsible for oversight in all athletic events in California with rule 313 which also calls for mandatory coaching and student athlete education on a yearly basis. In addition to compliance with these guidelines the single greatest factor needed in injury prevention and concussion management in particular at the high school and club sports level is a Certified Athletic Trainer (ATC) at every high school and club sports program. California is currently the only state in the union that does not require licensure for athletic trainers at secondary school sites, which presents a tremendous risk to our youth athletes.
Brian Roberts, MS, ATC, ITAT has been a certified Athletic trainer for over 30 years. He has served as a consult to major sports leagues such as the NFL and MLB. Most recently, he has helped create two innovative sports concussion programs: one at Casa Colima Rehabilitation Center, and the other with Sports Concussion Associates, Inc.
To reach out to San Gabriel Valley teams of all sports, ages and levels, Evergreen is proud to have Nick Tavoukjian MS, ATC, Athletic Trainer who serves as our resident first-responder, tactical strength and conditioning specialist and community team liaison.
Both he and Liz were recently invited panelists at the concussion discussions of the Interprofessional Community of Pasadena, which is a multidisciplinary group who regularly meet to share knowledge and insight to better serve the people and needs of Pasadena. It is spearheaded by our colleague and friend Giancarlo Licatta DC of Vital Head and Spine. Giancarlo is one of only 220 NUCCA Chiropractors in the United States.