Concussions: The Immediate and Long-Term Effects

By Caleb Ludlow, SDPT

 

As a physical therapy graduate student at Upstate Medical University, I have had the opportunity to get involved with the world of research. I have chosen to spend my time and energies on an important topic in the lives of today’s youth. Lately there has been a significant rise in the amount of hospital emergency room visits due to concussive or mild traumatic brain injuries. This is due in part to the rise in awareness that concussions are not good for young athletes. In the “olden days” kids were told to “shake it off”, but now we are realizing that there are significant risks to returning to athletic competition too quickly.

 

When a child has a concussion or a mild traumatic brain injury, they have disrupted the way that some of their brain centers are functioning. Some concussion injuries may involve the cognitive centers of the brain; others may involve the motor performance centers involved with balance and movement. With any concussion injury, the motor domain of neurologic functioning should be assessed along with the cognitive domain before the injured person returns to sport. As the medical profession develops accurate and reliable tests for determining when a student is safe to return to sport, it is important that the student athlete is functioning at 100%, as well as feeling 100% better before returning to sport.

 

The literature is showing us that when a student athlete returns to playing their respective sport too soon, they increase their risk of injury by 10-15%. As physical therapists, we are noticing an increase of secondary concussions and an increase in orthopedic injuries when students return to playing sports too soon after a concussion. To decrease these risks, it is important to be tested for symptom changes, dual tasking ability, exertion ability, and balance. Being 100% before returning to sport is especially important because studies of high school and collegiate athletes indicate that cumulative effects may result from three or more concussive episodes.

 

Our goal at Sports PT is to make sure that every young athlete is able to have a safe and healthy childhood and enjoy the sports they love.

 

Resources:

  1. Centers for Disease, C., & Prevention. (2011). Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged </=19 years–United States, 2001-2009. MMWR Morb Mortal Wkly Rep, 60(39), 1337-1342.
  2. Gessel L, Fields S. Et. Al. Concussion Among United States High School and Collegiate Athletes. Journal of Athletic Training 2007;42(4):495-503.
  3. Guskiewicz K, Ross S, Marshall S. Postural Stability and Neuropsychological deficits after Concussion in collegiate Athletes. Journal of Athletic Training 2001;36(3):263-273.
  4. Langlois, J. A., Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil, 21(5), 375-378.
  5. Register-Mihalik, J. K., Littleton, A. C., & Guskiewicz, K. M. (2013). Are divided attention tasks useful in the assessment and management of sport-related concussion? Neuropsychol Rev, 23(4), 300-313. doi: 10.1007/s11065-013-9238-1.

 

The Causes of Hip Pain and Differential Diagnosis

By: Emily Rowles, SPT

 

Have you experienced difficulty in diagnosing the cause of your hip pain? Femoralacetabular Impingement (FAI) is increasingly being recognized as a cause of this pain, although it is oftentimes misdiagnosed early on and treated for a variety of conditions such as, lumbar spine pain, trochanteric bursitis, iliopsoas tendonitis, sports hernia, osteoarthritis and labral tear. This diagnostic dilemma may be attributed to the complexity of the hip joint, its overlapping and diverse referral pain patterns, and close relationship to the spine.1Also, both types of FAI (Cam and Pincer) have been shown to cause cartilage delamination, labral tears, and have been linked to early osteoarthritis of the hip.2

 

Common impairments of FAI include: sharp, anterior groin pain in a position of hip flexion, limiting the patients’ ability to tolerate activities like prolonged sitting, squatting, and stair climbing, resulting in both work limitations and decreased social participation.3

 

History: FAI usually occurs in young and middle-aged adults, typically men, with insidious onset groin pain that may be preceded by minor trauma, although many patients will report no history of any specific precipitating factor.3

 

Below is a chart that will help guide clinical decisions regarding hip differential diagnosis:

 

FAI

  • Impingement Provocation Test (passive abduction, extension and external rotation) – SN of 97% for posterior inferior labrum4,5
  • Impingement Test (passive adduction, flexion and internal rotation) – SN of 96% for anterior superior labrum3,4,5
  • Less squat depth and altered lumbo-pelvic kinematics4

Labral Tear

  • Thomas Test – SN of 89% and SP of 92%5
  • Corresponding trauma story
  • Severe pain with impingement tests3,5

Osteoarthritis

  • Hip Internal Rotation ROM <15 degrees
  • Hip flexion ROM <115 degrees
  • Age > 50 years
  • Morning hip stiffness < 60 minutes6

Sports Hernia

  • Bilateral adductor test with SP of 93% with a LR+ of 7.77
  • Squeeze test and single adductor test with SP of 91% and LR+ of 4.8 and 3.3 respectively7

Trochanteric Pain Syndrome

  • Single leg stance for 30 seconds – SN of 100% and SP of 97.3%8
  • Resisted External De-rotation Test – SN 88% and SP 97.3%9
  • Pain with palpation of greater trochanter.

Iliopsoas Tendonitis

  • Pain with palpation of iliopsoas and resisted hip flexion

Lumbar Spine

  • Concordant sign with active physiologic movements of lumbar spine4
  • Radicular symptoms9

*** All hip physical examination tests are considered positive if pain or discomfort is present.

 

Note: Few of the current studies are of substantial quality to dictate clinical decision-making. Currently, only the patellar-pubic percussion test is supported by the data as a stand-alone HPE test. Further studies involving high quality designs are needed to fully assess the value of HPE tests for patients with intra- and extra-articular hip dysfunction.7

 

References:

  1. Conservative management of femoroacetabular impingement (FAI) in the long distance runner Janice K. Loudon*,1, Michael P. Reiman Physical Therapy Division, DUMC 100402, Duke University, Durham, NC 27709, USA.
  2. McCarthy JC, Nobel PC, Schuck MR, et al. The Otto E. Aufranc Award: the role of labral lesions to development of early degenerative hip disease. ClinOrthop Relat Res 2001 (393): 21. Philippon MJ, Maxwell RB, Johnston TL, et al. Clinical presen-25-37.
  3. Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med 2008;38:863–78.
  4. Reiman et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 2012.
  5. Cook, CE & Hegedus, EJ. Orthopedic Physical Examination Tests: An Evidence Based Approach. Pearson Education; Upper Saddle River, NJ: 2013.
  6. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; (417): 112-20.
  7. Verrall GM, Slavotinek JP, Barnes PG, et al. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scand J Med Sci Sports 2005;15:36–42.
  8. Lequesne, M. et al. Gluteal Tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests. Arthritis Rheum. 2008;59:241-246.
  9. Cleland JA, Flynn TW, Whitman JM. “User’s Guide to the Musculoskeletal Examination Fundamentals for the Evidence-Based Clinician: Evidence in Motion”; 2008.

Are You a Runner With Knee Pain? It’s All In The Hips.

By: Sean Noonan, SDPT, CSCS

 

Imagine a long piece of strong plastic; together it is strong enough to withstand fair amounts of pressure. Now, anchor one end strongly and allow the opposite end to move freely back and forth without control of the forces placed on it. Over time where do you think this piece of plastic will deform or fail? Usually in the middle.  The portion that fails is your knee; the free flowing end is your hip. Without proper control of our proximal joint, the hip, other distal joints can fail without being the causation of the problem. The knee may be the painful area but it may not be the culprit. Joints that are distal and proximal to the painful joint can have a substantial effect on the area involved.

 

Current and emerging research has shown that various manifestations of knee pain may be a result of weak hip musculature, particularly the abductors and external rotators. Weakness of the hip abductor muscles was found in both male and female distance runners with illiotibial band syndrome when compared to their non-injured leg. Females with patellofemoral pain had lower strength measures in hip strength when compared to healthy uninjured females.

 

Hip strengthening exercises have been shown to assist in preventing knee pain, as well as decreasing current pain levels. Sample exercises that best activate these muscles include:

 

1. Single Limb Squat

 

 

 

 

 

 

 

 

2. Single Limb Deadlift

                                                                       

 

 

 

 

 

 

 

3. Single Limb Wall Squat

 

 

 

 

 

 

 

 

Visit a physical therapist; a trained movement specialist that can assist you in determining your cause of pain, proper exercise execution, and put you on a path to injury free training.

 

References:

1. Ayotte NW, Stetts DM, et al.  Electromyographical analysis of selected lower extremity muscles during 5 unilateral weight-bearing exercises.  Journal of Orthopedic and Sports Physical Therapy.  2007.  37: 48-55.

2. Distefano LJ, Blackburn JT, et al.  Gluteal muscle activation during common therapeutic exercises.  Journal of Orthopedic and Sports Physical Therapy.  2009. 39: 532-540.

3. Dolak KL, Silman C, et al.  Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial.  Journal of Orthopedic and Sports Physical Therapy.  2011.  41: 560-570. 

4. Fredericson M, Cookingham CL, et al.  Hip abductor weakness in distance runners with iliotibial band syndrome.  Clinical Journal of Sports Medicine. 2000; 10: 169-175.

5. Ireland, ML, Wilson JD, et al.  Hip strength in females with and without patellofemoral pain.  Journal of Orthopedic and Sports Physical Therapy.  2003; 33: 671-676.

6. Krause DA, Jacobs RS, et al.  Electromyographic analysis of the gluteus medius in five weight-bearing exercises.  Journal of Strength and Conditioning Research.  2009.  23: 2689-2694.

 

Are You Getting Enough Vitamin D?

By: Brian Hehr, SPT

 

Ever wonder why your doctor or physical therapist might tell you that 20 minutes of sunlight is good? Or why so many individuals are placed on a vitamin D supplement during the winter in upstate NY?

 

Well, the body uses sunlight to produce this (not technically a vitamin) vitamin.  I say “not technically” a vitamin because to be classified as a vitamin, the human body must not produce it. The only natural food sources of vitamin D are fish and egg yolks, which is why many other common foods are fortified with this vitamin. Despite this, many people may be at risk for deficiency.

 

Some reasons for this deficiency include diet, obesity, low consumption levels of vitamin D over time, lack of sun exposure, dark skin, and GI tract diseases preventing absorption. Also, the kidneys’ ability to convert vitamin D to its active form decreases over time.

 

It works like this: Sunlight (or ultraviolet B, UVB) turns a chemical in your skin into vitamin D3, which is then carried to your liver and your kidneys, where it is transformed into active vitamin D. Vitamin D’s best-known role is to keep bones healthy by increasing the intestinal absorption of calcium. Without enough vitamin D, the body can only absorb 10 to 15 percent of dietary calcium, but 30 to 40 percent absorption is the rule when vitamin reserves are normal. This is why getting enough vitamin D is especially important for women, because they have a much higher incidence of osteoporosis in later adulthood.

 

But men, don’t think you are safe! Vitamin D deficiencies were rare when most men rolled up their sleeves to work in sunny fields. But as work shifted from farms to offices, this reality changed. Because pigmentation can reduce vitamin D production in the skin by over 90 percent, nonwhite populations are at particular risk. Deficiencies are also common in patients with intestinal disorders that limit absorption of fat and those with kidney or liver diseases that reduce the conversion of vitamin D to its active form, calcitriol.

 

In addition, for both men and women, this popular vitamin has receptors that are present in many other organs — from the prostate to the heart, blood vessels, muscles, and endocrine glands. And current research suggests that good things happen when vitamin D binds to these receptors. The main requirement is to have enough vitamin D — but many Americans don’t.

 

As summer winds down and you begin to have less opportunity to get your daily dose of sunlight, it may be beneficial to have your vitamin D levels tested to ensure you aren’t at risk for vitamin D deficiency.

 

For more information, including tips for getting adequate vitamin D, please contact us at info@sptny.com.

 

Sources:

http://www.health.harvard.edu/newsweek/vitamin-d-and-your-health.htm

http://www.webmd.com/food-recipes/vitamin-d-deficiency

 

Meet Alyssa Tallo, DPT, at Our Webster Clinic

What made you want to enter the healthcare field?

 

I wanted to work in a field that was active, fun, and one where I could really get to know people and change their lives while they changed mine.

 

What do you enjoy most about working with Sports PT?

 

Making memories with patients, and getting to know them while they get to know me. Having patients that will stop in and say hi even though they haven’t been treated in years makes it so special!

 

What is your favorite advice to give to patients?

 

Don’t be afraid to have fun. We know that you are in pain and taking time out of your day to be here, so I will do whatever I can do to make you smile so that you are not only getting better, but having fun doing it!

 

What is the most rewarding part of your job?

 

Seeing people return to whatever they love and knowing that we worked hard to get there!

 

If you’re in the Webster, NY area and need to visit a physical therapist, you can contact Alyssa here.

 

Swollen Arms or Legs? You could be suffering from Lymphedema

By: Mary Emminger, SPTA

 

Lymphedema is a condition where protein-rich fluid builds up and causes swelling in the arms or legs. Most commonly, this occurs after damage or removal of your lymph nodes during cancer treatment. The disease is not completely treatable; however, like most other medical conditions, early detection and treatment of lymphedema is critical for successful outcomes. Do you and your family members know the signs, symptoms, and risk factors for lymphedema?

 

Four risk factors for lymphedema:

  1. Genetics: Your genetic background can predispose you to developing lymphedema. You may develop lymphedema throughout any phase of life, and based on your age of development, you will be classified into three subgroups: congenital (birth to 1 year old), praecox (1-35 years old), and tarda (onset of symptoms after 35 years old).
  2. Lymph node removal: In women who have undergone axillary lymph node dissection due to breast cancer, the risk of developing lymphedema ranges from 20-53%. For women who have had sentinel lymph node dissection due to breast cancer, the risk of developing lymphedema ranges from 5-17%.
  3. Radiation therapy: Radiation therapy, especially direct exposure to an area of lymph node location, may increase your risk for developing lymphedema.
  4. Obesity: Excessive fat tissue may increase the amount of fluid in the extremities and place stress on the lymphatic system, which may result in the faulty removal of fluid and lymphedema.

 

Signs and symptoms of lymphedema:

  1. Increase of 2 cm (just under 1 in.) in circumference of upper extremity (for upper-extremity lymphedema)
  2. Redness and swelling
  3. Decreased range of motion
  4. Difficulty wearing bracelets, watches, and rings
  5. Pins-and-needles sensation in the affected arm
  6. Difficulty swallowing after neck surgery

 

Physical therapists have the ability to treat lymphedema with specific hands-on techniques. For more information or to inquire about lymphedema treatment, please contact us at info@sptny.com

 

 

Sources

  1. http://www.breastcancer.org/treatment/lymphedema/risk_factors
  2. Shon W, Ida C, Boland-Froemming J, Rose P, Folpe A. Cutaneous angiosarcoma arising in massive localized lymphedema of the morbidly obese: a report of five cases and review of the literature. Journal Of Cutaneous Pathology [serial online]. July 2011;38(7):560-564. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 24, 2014.
  3. Connell F, Brice G, Jeffery S, Keeley V, Mortimer P, Mansour S. A new classification system for primary lymphatic dysplasias based on phenotype. Clinical Genetics [serial online]. May 2010;77(5):438-452. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 20, 2014.
  4. Shinawi M. Lymphedema of the lower extremity: is it genetic or nongenetic?. Clinical Pediatrics [serial online]. November 2007;46(9):835-841. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 20, 2014.
  5. Deng J, Murphy B, Ridner S, et al. Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life. Head & Neck [serial online]. July 2013;35(7):1026-1035. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed July 24, 2014.
  6. http://www.breastcancer.org/treatment/lymphedema/signs

Quick Tips to Stay Fit on Vacation

By: Alanna Pokorski, PT

 

It’s the summer season and many of us take some time off for a family vacation to relax, unwind, and enjoy the nice weather. What can we do to incorporate some easy healthy tips so we don’t feel the post-vacation guilt?

 

Whether it’s camping, beach, or amusement parks, here are some quick things to keep in mind when vacationing:

 

 

1.)    Pack healthy food options. Alternatively, take a visit to the grocery store on Day 1 of vacation so that you have healthy snacks and light meals at your disposal. You can certainly enjoy some meals out… just not every meal!

2.)    Take a long walk! You aren’t in any rush on vacation. Instead of taking the car places, take a long walk to your destination. You will feel better and likely take more time to see the beautiful surroundings.

3.)    Shake it up! Try something new. If you’ve always wanted to try canoeing, kayaking, waterskiing, or hiking, it’s time! Vacation is the perfect time to try something new. Your muscles will appreciate the new challenge and you will feel accomplished.

4.)    Hydrate. Your schedule will be off (aka- you wont have one), so it’s important to remember to hydrate. Drinking 8-10 glasses of water per day is a healthy guideline. With the hot weather, activity, and restaurant food, your body needs more water to feel healthy on vacation. Plan ahead and have bottled water available to you in your hotel room or house.

5.)    Breathe. Part of vacation is taking time to quietly reflect and invest in you. One way to relax and help your core is through diaphragmatic breathing. Diaphragmatic breathing has many core strength benefits as well as general relaxation benefits. Follow these steps for the proper way to breathe. Inhalation: Breathe in through your nose so that your belly pushes out. Exhale: Air will come out through your mouth as your belly comes in. Be sure not to use your upper chest when performing this. It should all come from your lower abdominal area.

 

Happy vacation!

 

 

Why do Non-Baseball Fans Know the Name Tommy John Now?

 

By: Drew Jenk, PT, DPT

 

A recent USA Today article highlights the surge in Ulnar Collateral Ligament (UCL) surgery among youth baseball players.

 

Years ago, when most of us reading this blog were playing sports, we never talked about rotator cuff surgery, Tommy John (UCL of the elbow) surgery, or pitch counts. However, these are all household terms now. So why are we blowing out our elbows at alarming rates? Perhaps the answer lies in a few different areas.

 

The first is the fact that professional pitchers need rest. Greg Maddux, who was just inducted into the National Baseball Hall of Fame, never needed major arm surgery. He thanked his doctor and trainer in his acceptance speech. He pitched on four days’ rest throughout his career. So why do we ask our kids to pitch all summer long on multiple teams, multiple times a week, and with a skeletally immature body? Furthermore, why do we have them doing indoor pitching clinics in the off-season when the pros don’t do that? If we want our kids to be pros, then maybe we should start acting like pros ourselves. Another aspect is not appreciating the benefits of cross-training. According to the USA Today article,“Sillanpaa gave up football and basketball and devoted himself to travel baseball.” Another Baseball Hall of Fame inductee, Tom Glavine, is a pro in two sports, having been drafted by the National Hockey League as well as the MLB.  Maybe giving up multiple sports and the cross-training effect they have on our muscles is not in the best interest of our young athletes.

 

The final consideration is the need for pitch counts. To quote the USA Today article again: “In 2007, the Little League International Board of Directors unanimously approved pitch count limits based on research conducted by Andrews and Fleisig. Andrews said that injuries at that level have dropped by 30%. His next project is to get similar rules adopted by each high school athletic association.” This is awesome! This is objective research that proves the reduction of repetitive stress to the skeletally immature arm results in a reduction of injuries.

 

Further evidence that less pitching results in greater success was highlighted in a Sports Illustrated article.

 

This article clearly shows that MLB pitchers with 200+ career wins were born primarily north of the Mason Dixon line, where they were limited in their pitching presumably due to weather.

 

Medicine is not an exact science, but we are getting better. In the end, we know that pitching is a high stress to the arm. A little common sense and a lot of current research show us that moderation is the safest way to preserve longevity in our youth athletes. My son is 8, and the worst thing I could imagine would be that he hates baseball. I encourage his interest, but I don’t overload him. What I know now is that less is more at an early age to preserve the love of the game and the health of the arm.

 

 

 

 

Five Tips for a Health and Wellness Plan

By: Jason Wambold, MSPT

 

We are all aware of the negative effects of stress and of making poor choices. But most of us never put together a plan to improve our overall wellness. Consider these simple things you can do that can have a dramatic impact on your overall health and life balance.

 

Portion Control:

When dining out, ask your server to box half of your meal before bringing it to the table. Most portions are oversized anyway, and you will likely not notice the difference!

 

Stress Management:

Think of your life capacity as a pond. If water flows in but never out, the pond will eventually overflow, become stagnant, or both. But if the in flow and out flow are equal, your pond will be very healthy! What specific things are you doing daily to allow water to flow out of your pond?

 

Eliminating Time Bandits:

The average person spends 18 minutes each day checking their phone. For each activity that you do during the day, ask yourself: “Does this help me to be a better version of myself?” If it doesn’t, consider eliminating it.

 

Overloaded Schedules:

We must control our schedules and commitments, or they will control us!  Take 10 minutes to write a mission statement for your life. Then ask yourself, “Does this activity help me to fulfill my mission statement?”

 

Prioritizing:

Pretend that you have $100 to spend each day. Are you overpaying certain areas of your life, and underpaying others? How can you change that?

 

Although following these five tips won’t make you immune to health issues, they can help you achieve a more balanced life.