Posted on 3/16/2018 by Stephanie Wilkins, MSEd, ATC, and Leah Friedland, M.S., ATC
Concussions are a great concern throughout the world of sport and especially in the high school setting. They can impact the student-athlete not only on the field, but also in the classroom and their daily lives. As athletic trainers in the high school setting, when a concussion has occurred, we are involved in the entire process, including:
We help with education, implementation of proper concussion protocols and serve as an advocate for the student-athlete in their sport, classroom and life.
Education – Despite the growing awareness and concern that is present in the media over concussions, we find that coaches, parents and athletes are often still uninformed about the seriousness of concussions and the proper way to handle them. A concussion is a traumatic brain injury that is caused by either a direct force/blow to the head or a force transmitted through the body to the head. As high school athletic trainers, we find ourselves explaining to coaches that “getting your bell rung” is the same as sustaining a concussion, and that it is not something that can be ignored. “This wasn’t a big deal back when I played sports, and I turned out fine,” is not an acceptable way of viewing this issue.
We are seeing now that, decades later, people are experiencing abnormal brain function and lasting damage as a result of previous head trauma that might not have been managed properly. Concussion education is not intended to scare people, but rather to inform and stress that concussions should be handled appropriately and taken seriously.
We must also work to change the team attitude around concussions and urge athletes and coaches to take responsibility for their well-being and the well-being of their teammates. The culture of not reporting concussions for fear of sitting out or being made fun of must not continue. High school athletic trainers are in the unique position of helping create this cultural change within sports programs and we strive to do this by forming relationships with our coaches, parents and student-athletes that are based on trust and compassion.
Baseline Testing – Every concussion is different; even in one person, different concussive episodes can present in different ways. Symptoms of a concussion include:
Appearing dazed or confused
Nausea and vomiting
Imbalance… and more
There are few objective measures available to diagnose concussions, so it’s important to have a baseline evaluation for each athlete to help determine return-to-play.
We perform this evaluation at the beginning of the season to obtain a baseline score, i.e. an athlete’s “normal” level of functionality. If the student-athlete sustains a concussion during that season, a second test will be administered. This second test occurs when they are symptom-free and have completed the return-to-play progression.
In our high school, we implement two different tools for baseline testing. With more than 800 student-athletes, we prioritize the high risk contact sport athletes (like those participating in football or soccer) and administer baseline tests to those sports. The first test is ImPACT®, a computer neurocognitive exam that tests word and image recall, reaction time, motor speed and symptom report. The alternate test we use is C3 Logix. In addition to a neurocognitive exam, C3 Logix includes a balance and vision component. It is more comprehensive and time intensive, whereas the ImPACT® Test is more easily administered to a large team all at once.
We don’t use ImPACT® or C3 Logix to diagnose concussions, but rather as a tool to monitor their healing process and identify any potential problem areas.
Evaluation and Diagnosis – The most important aspect of concussion management in the high school setting is communication. We’ll discuss concussion management with both the student-athlete and parents/guardians to discuss next steps and answer any questions they may have
Next, we communicate with our Concussion Oversight Team (COT). The COT is a multidisciplinary group of individuals who help manage the student-athlete’s post-concussion care. It includes the athletic trainers, team physician, school nurses, athletic director and school counselors. We also email the coach and physical education teacher. This is our opportunity to provide athletic and/or academic accommodations as needed. The counselors and nurses are vital for helping communicate with the student-athlete’s teachers.
Occasionally, a student-athlete will require academic accommodations. These are specific to each individual and can include wearing sunglasses to help with sensitivity to light, postponing quizzes or tests, limiting use of computer work or leaving class early. Most students don’t require academic accommodations, but all are excused from gym class and athletics until their symptoms have resolved and they have completed the return-to-play progression.
Follow-Up – Oftentimes, parents will ask, “Does my son/daughter need to go to the doctor or the emergency room?” The emergency room is rarely indicated unless there are signs and symptoms of a brain bleed. This will be evaluated at the time of the injury and, if there is concern, a referral to the emergency room will be made.
Research shows that most concussions resolve within 7-14 days. Our protocol recommends following up with a physician if the symptoms have not resolved within 7-10 days. And, referral to an appropriate health care provider is essential. When possible, we will refer to a concussion specialist who works with these cases on a normal basis. The average primary care physician will not have expertise in concussion management. We will sometimes recommend following up with an ophthalmologist if the student-athlete is having difficulty with vision or physical therapy due to vestibular problems.
As athletic trainers, we take care to be as best prepared to diagnose and treat concussions as possible. We put a strong emphasis on communication with the athlete, parents, coaches and school in order to return the student-athlete safely to school and sport. Concussion research will continue to evolve over the years to come, just as we will continue to adapt and update our management protocols to keep student-athletes safe and active.
By: Stephanie Wilkins, MSEd, ATC, and Leah Friedland, M.S., ATC. Stephanie and Leah serve certified athletic trainers for NovaCare Rehabilitation in Chicago, Illinois, and currently work at York Community High School. Stephanie also serves as the sports medicine program director and helps manage other sports medicine contracts around the Chicago-land area.
Posted on 3/8/2018 by Joshua Cramer, DAT, LAT, ATC, CES, CSCS
Injuries can happen at any time to anyone. Whether playing your favorite sport, working on the job or living your daily life, it’s important to get the proper treatment when an injury occurs, and that starts with the evaluation process.
During an evaluation, a clinician will discuss a patient’s medical history, discuss goals and specific needs, inspect for abnormalities, tenderness or deformities and test musculoskeletal health. All of these components are essential to making a proper diagnosis, but they rarely provide the whole picture. These evaluative techniques focus on the area of the patient’s chief complaint, but what if the issue is in a different region or system in the body?
To design more effective treatments, it is important to look at the body as a whole – the upper and lower body, the front and back of the body and the limbs. This is where postural and functional assessments come into play.
Functional movements are essentials movements found in activities of daily living. They usually involve multi-joint movements in numerous directions, which place demand on the body's core muscles. Our clinical team frequently include functional movement screens in the evaluation process, which are designed to examine these daily essential movements and help identify limitations and dysfunction, reduce the risk of injury and improve efficiency and performance. Functional movement screens also include a detailed report and customized corrective exercise program.
There are a handful of functional movement tools available to clinicians. Some of the more popular are through the Functional Movement System, which is divided into two main parts: the Functional Movement Screen (FMS) and the Selective Functional Movement Assessment (SFMA). Another popular functional movement tool is Fusionetics.
The FMS is a screening tool which takes the patient through a series of basic movements with the intention of determining if the patient is at risk for injury. Its role is to impose minimum standards on movement patterns. The movements include:
Stepping over a hurdle
Reaching behind the back
Core test – the patient starts on his/her hands and knees and touches the elbow to the knee
The SFMA is a full-body assessment broken down into two parts, the top-tier and the breakouts. The top tier helps determine if movements are functional versus dysfunctional and painful versus non-painful. The breakouts determine the type of dysfunction a patient may suffer from. The movements consist of:
Various neck movements
Reaching behind the back
Hip flexion (bending forward)
Hip extension (arching backward)
Hip rotation (twisting)
Single leg stance
The SFMA will help define what type of dysfunction exists, whether that’s stability and motor control dysfunction, joint mobility dysfunction or tissue extensor dysfunction. Once the clinician determines which dysfunctions exist, he/she will set up an individualized treatment protocol to correct the faulty movement pattern and treat the injury and prevent future occurrences.
Fusionetics is designed in the same manner, but is web-based. It is a series of 10 exercises that determine whether someone is susceptible to certain injuries due to form and body mechanics. At the end of the Fusionetics assessment, the system will provide patients with corrective exercises. Each patient can create a free account with Fusionetics and access the results and corrective exercises from any computer, tablet or smartphone.
These screenings and assessments can be done on both injured and healthy individuals to identify movement and stability deficits. As you continue to play your respective sport or go through your daily routines, keep in mind that proper functional movement is a necessity. It is just as important to treat your body properly when you’re healthy as it is when you’re injured.
By: Joshua Cramer, DAT, LAT, ATC, CES, CSCS. Josh has been with NovaCare Rehabilitation for five years and serves as the head athletic trainer for Germantown Academy and the Philadelphia Freedoms. He is certified in various manual therapy techniques and has treatment expertise in shoulder injuries and concussion.
Posted on 1/24/2018 by Jeff Lambert-Shemo, ATC
Throughout the 2017 NFL regular season, a plethora of superstars saw their seasons cut short due to serious and season-ending injuries. Carson Wentz, Odell Beckham and J.J. Watt were just a few of the headliners bit by the injury bug. Overall, 35 players who had previously been elected to the Pro Bowl or could be considered major contributors to a team sustained a serious or season-ending injury. Many fans were left wondering whether there were key factors that contributed to this increase in sidelined players.
One possibility lies within an increase in physical abilities of the athletes participating in pro football. While an influx of bigger, stronger and faster players may make for a more exciting product, it also increases the opportunity for injuries to occur. Advances in the field of strength and conditioning along with nutrition have allowed these gladiators of the gridiron to reach new peak performance levels in regards to power and speed. With the difference in speed and strength among players becoming negligible, athletes are now relying on different skills to make an impact for their team.
One of the most important skills for the player is the ability to transfer speed and strength into movements, allowing a receiver to get separation, a defensive lineman to get a step on his adversary and a running back to evade a would-be-tackler. This skill allows an athlete to use their other talents to make a big play. So if athletes are more skilled at movement, why are these injuries still occurring?
As the speed of movement increases, control of that movement will naturally decrease, also affecting an athlete’s ability to maintain control. Athletes who are relied upon to change the course of a play, game or season must continuously perform at a level that is tiptoeing between success and failure and that can put their physical safety at risk. Changing direction, stopping, turning and jumping all become less controlled as speed increases. For a player in the NFL, an opportunity to make a great play also increases the opportunity for injury.
With an increase in the number of exceptionally strong and fast athletes in the NFL, the number of players who have the skill to separate themselves from other athletes within a particular position is dwindling. With fewer players who have the skill to make a difference, teams are relying more heavily than ever on a few key individuals to adjust the course of a game, which is also putting those players at a higher risk of injury.
As a point of emphasis, training and practicing athletics at full competition speed is the best way to create appropriate muscle patterns to increase skill in movement while decreasing the risk of injury.
At NovaCare Rehabilitation and Select Physical Therapy, we offer sport-specific programs to help athletes of all performance levels restore function, decrease pain, increase strength and flexibility, optimize performance and gain education on injury prevention. Contact a center near you to speak with a member of our sports medicine team today!
Jeff Lambert-ShemoBy: Jeff Lambert-Shemo, ATC. Jeff is a certified athletic trainer and the director of sports medicine for NovaCare Rehabilitation in Northern Ohio. He has been a NovaCare team member for six years and brings more than 20 years of experience in youth, high school, collegiate and professional athletics, including soccer, lacrosse and football. Most recently, Jeff served as the head athletic trainer for the Cleveland Gladiators of the Arena Football League.
Posted on 1/12/2018 by Laila Hasham, P.T., DPT
Parkinson’s disease is a chronic, progressive movement disorder that affects one in 100 people over the age of 60. While the average age at onset is 60, people have been diagnosed as young as 18. It is the second most common degenerative brain disorder affecting adults (Alzheimer’s disease is the most common). Recent research indicates that at least one million people in the United States and more than five million worldwide have Parkinson’s, and there are around 50,000 new cases diagnosed each year.
Parkinson’s involves the malfunction and death of vital nerve cells in the brain, called neurons. Some of these dying neurons produce dopamine, a chemical that sends signals to the brain to control movement and coordination. As Parkinson’s progresses, the amount of dopamine produced in the brain decreases, leaving a person unable to control movement normally. People with Parkinson’s disease are at risk of falling and sustaining injuries due to their movement and balance impairment.
Treatment includes a combination of medication and physical therapy, and in some cases surgery. A physical therapist who has experience treating Parkinson’s can help a person improve mobility, strength and balance.
The universal benefits of exercise in helping everyone feel better and improving overall health are well documented. There is evidence that exercise has specific benefits for people with Parkinson's in staying active and improving balance and coordination. Exercise approaches have long played a role in the management of Parkinson’s disease, to maximize function and minimize secondary complications and inactivity.
For decades, the Lee Silverman Voice Technique (LSVT) has been an effective way to treat the symptoms of impaired voice and swallowing from Parkinson’s called LSVT LOUD®. In 2005, a new approach to therapy called LSVT BIG® was developed. LSVT BIG is a research-based exercise program specifically designed for people with Parkinson’s. It has been shown to improve function with significant improvements noted in trunk rotation, balance and faster walking with larger steps1. LSVT BIG is provided by physical and occupational therapists who have received specific training in this technique.
LSVT programs include the combination of:
An exclusive target on increasing amplitude, or loudness in the speech motor system, and bigger movements in the limb motor system.
A focus on sensory recalibration to help patients recognize that movements with increased amplitude are within normal limits, even if they feel ‘too loud’ or ‘too big.’
Training self-cueing and attention to action to facilitate long-term maintenance of treatment outcomes. In addition, the intensive mode of delivery is consistent with principles that drive activity-dependent neuroplasticity and motor learning2.
The LSVT BIG program includes 16 sessions of therapy over four weeks, at a frequency of four days each week. These sessions are provided in a one-to-one manner and include high intensity, whole body movements. Depending on the nature and severity of the condition, treatment sessions may focus on activities that are important to the patient and education to help transfers, bed mobility and hand movement. While other exercise interventions may focus on external cues and breaking down task components, LSVT BIG focuses on movement amplitude to achieve bigger and faster movements in the attempt to restore normal movement patterns and improve gait speed.
The program is both intensive and fun, and the hard work and dedication of the patient is integral to the success of the program. Find a local Select Physical Therapy center to see if the LSVT BIG program is offered near you.
For more information on Parkinson’s disease and the LSVT BIG program, please visit the LSVT Global website at www.LSVTGlobal.com.
Farley et al (2008) Intensity amplitude-specific therapy for Parkinson’s disease. Topics in Geriatric Rehabilitation 24(2) 99-114.
Cynthia Fox, Georg Ebersbach, Lorraine Ramig, Shimn Sapir. LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinson’s disease. 2012;2012.
By: Laila Hasham, P.T., DPT. Laila is a physical therapist with Select Physical Therapy in Austin, TX. Her primary expertise is in orthopaedics, but she is passionate about treating people with Parkinson’s and similar movement disorders in order to improve quality of life and overall function. Laila is pictured above treating a patient.