• Dr. Bob Cantu, one of the nation's leaders in concussion research and management, will recommend in a forthcoming book that no child under 14 should participate in collision sports like football, hockey or lacrosse.  Read an article about this announcement here.
• More than 500 athletes sign up to donate their brains for CTE research, in this ABC News article.
• CNN reports that the number of kids arriving at ERs with concussions has risen 160% between 2002 to 2009.  A likely reason is better recognition of the symptoms by parents and coaches. But that implies that possibly thousands of concussions were unrecognized for many years.
• Congress and CDC define concussion as "brain damage" and will enact legislation for its management in 2013.
• Can a helmet strap reduce concussions? Or is it manufacturers profiting from new fears?
• Another leader in concussion research won half of a million dollars for further research.  See if you agree with his policy regarding his own kids' participation in collision sports - or is he clinging to old thinking?

 COSTOCHONDRITIS: RADICULOPATHY IN DISGUISE?

 The synchronized swimmer wept from pain - and frustration.

It kept happening. Despite resting and an intense rehabilitation program - the pain always tore through her chest again when she got back in the water and tried to boost herself up on to the stage edge by leaning on hands and pushing down with upper spine arched, as the choreography required.

She was diagnosed as recalcitrant costochondritis.  Despite three injections into her sternocostal joint, hundreds of hours of rehab, and weeks of rest, the same pain persisted.

Why wouldn't it just get better? Why couldn't the medical staff help her?

As her athletic trainer, it haunted me for years.

Last week, a dancer asked me to assess chest pain that had onset during a yoga class months earlier, worsening and improving unpredictably. Her pain was over the lower right sternocostal joints, and occurred when she bore weight on her hands in certain yoga positions.

Sounded eerily familiar.

Pectoralis testing revealed good strength and mild pain - nothing that would indicate a tear. Palpation, deep inhalation and cardio exercise were negative for pain. She denied a MVA or any trauma.

She had full thoracic flexion and extension motion with no pain. Repeated flexion had no effect. Repeated cervical motion, in all directions, had no effect.

 However, repeated thoracic extension - just 8 repetitions -- flared up her chest pain. Thoracic flexion motion was just as suddenly lost, mechanically blocked and painful.

The problem was now apparent: an anteriorly-bulging disc in her thoracic spine that deranged (bulged) only during repeated extension, like repeated downward-facing dog and cobra in yoga class. It wasn't leaning on her hands that caused the pain; it was the repeated thoracic extension that bulged the disc.  And the bulging disc obstructed flexion motion and caused radiculopathy anteriorly -- chest wall pain.

For treatment, I guided her through gentle and repeated thoracic flexion in a partial range of motion, and this reduced the obstruction and restored her thoracic flexion motion. The rapid success of the treatment confirmed the initial diagnosis.  She left with almost the same flexion range of motion as when she arrived, although slightly sore. 

For home treatment, I taught her repeated thoracic flexion with self-overpressure.  I instructed her to self-treat by doing this maneuver every two hours.  I also advised her to avoid thoracic extension for one or two weeks.  Her symptoms will most likely be completely relieved by the program.  

Why did I check her thoracic spine? I've been hunting the radiculopathy beast for a few years. I know its tracks, its daily pattern, its methods of camouflage, its confusion tactics. I now recognize the symptom pattern. Unusual, temperamental or unremitting pain that has failed to respond to previous treatment now waves the red flag of disc derangement and radiculopathy to me.

In a sense, I've become a 'disc whisperer'. 

How? I studied mechanical diagnosis and treatment (MDT).

Learning MDT has advanced my clinical abilities more than any other clinical technique in my 20 years of practice.  MDT enables me to identify disc bulges that cause obstructions to movement and rare radiculopathies that cause pain. MDT helps me solve recalcitrant and idiopathic pain patterns nearly every day, relieving patients of excruciating and unrelenting pain.

Decades-old chronic back pain, freshly 'tweaked' backs or necks, stiff necks, sciatica, sacroiliac pain, headaches, peri-scapular pain -- all of these and many more can be addressed successfully using MDT. 

I wish I had had this knowledge when I worked with that synchronized swimmer. I might have been able to spare her the anguish of chronic pain, and possibly save her career.

[Note: Obtain your MDT training through the McKenzie Institute.  They teach the authentic approach, and include necessary information and thought processes that other programs neglect.  Without the complete, exhaustive Mckenzie training, you can harm your patient, rather than help.  Don't take a quicker or cheaper class.]

CONCUSSIONS CAN HAPPEN TO ANYONE

A new article can help describe symptoms and consequences of conceussions in many sports and activities, not just football.

Written by teen journalists, it gives a good initial view into what athletes feel, what are some long-term consequences and symptoms, and what tests can be used to clear an athlete for return-to-play (or, return-to-show).

Here is another article that describes a blood test that may one day help us chemically confirm the presence of a concussion. 

 Nevada just passed legislation to allow MDs, PTs and ATs to clear athletes to return-to-play after concussions.  Has your state?  If so, it's time for you to get very familiar with concussion recognition and management.  

The brain is the most important organ in the body, so it's beholden on us to be VERY good at concussion recognition and mangement.  

Be thorough, be conservative, be serious about concussions.  

You may be the only thing standing between a concussed performer and a lifetime of debilitating symptoms. 

PRIORITIES IN BACKSTAGE INJURY EVALUATION

Backstage injury evaluation is much like on-field injury management - time is of the essence, and a backstage PT needs to learn to assess an injury in seconds.  We don't have the luxury of doing a 1/2 hour evaluation, as do our counterparts in outpatient clinics.

What are the priorities in assessing a new injury during a show?   Think A - P - T - A.

1. ABCs: As always, assess for ABCs (airway, breathing, circulation).  If the injured person lacks any of these, or is not oriented, or is in severe pain, activate your emergency action plan (call 911).
2. PERFORM?  Here's where we veer away from normal assessment patterns: if the person is awake, oriented, and not in severe pain, ask the person if s/he can keep performing.  Stage management will need to know if they have to prepare a swing to cover or if they need to change show cues ASAP, and the PT must understand that this is a priority information need for the rest of the show to continue.  Yes, before you assess the injury, you determine if the person will stay in the show, and notify stage management if s/he will not.
3. TIME?  If the injured person is staying in the show, ask him/her how much time s/he has for assessment and treatment.  The PT needs to know if there are 2 minutes or 15 minutes until the injured person's next show cue, as this will dictate what can be assessed and treated in that time.
4. ASSESS  Only now should you ask what is hurting and how it happened. Be prepared to assess/treat very quickly.  Practice honing your skills to the bare essentials that will allow you to do a rapid, effective treatment to help the performer get back on stage ASAP.  

GLOVES FOR MANUAL THERAPY

Here's a quick tip.

When using your hands to hold a patient's body part for PROM or manual therapy, a good grip is priceless.

¤ A good grip results in less finger-digging into patients to hang onto slippery skin. Less finger-digging = less guarding. So the patient can be more relaxed.

¤ A good grip also helps avoid grip fatigue and wrist tendinitis in the therapist's hands.

I use these, football receiver gloves.    

The sticky material on the volar side palm and fingers is perfect. Available at any sporting goods store.  Cost is about $20-40.

Use for PROM, joint mobs, trigger point release, manual traction, PNF, or anything else that might otherwise tire out your fingers or hands.

If your patient has flaky skin, you can wipe down the gloves easily with soap and water. Or, use exam gloves. If you prefer not to use your football gloves on compromised skin or certain skin conditions, then use regular clinic single-use latex or vinyl exam gloves. They also have greater friction than the skin on your hands, so they increase "grippability" while saving your hands AND preventing infectious contamination of the next patient, your football gloves, or you.

CONCUSSIONS DON'T HAPPEN JUST TO FOOTBALL PLAYERS.

Post-concussion syndrome, Second Impact Syndrome and Chronic Traumatic Encephalopathy (CTE) can be caused by untreated or repetitive concussions.

As backstage PTs, we cover musicals and shows that have increasing acrobatics and risky tricks required of the actors and dancers. Concussions can become more likely.

Quick points:

• "Concussion" does not mean a person has to black-out or get hit on the head. Concussions can be caused by any quick stop of the head during motion.
• Learn the signs and symptoms of concussions. Have a high degree of suspicion for them.
• Do not ignore any symptoms of concussion, even if they are mild or it's weeks post-injury. Any degree of concussion is brain trauma; you must treat it as such.
• Be sure not to return performers to activity too early after a concussion.
• Keep in mind that any additional trauma to an unhealed brain (including spinning or jumping) can cause Second Impact Syndrome, which results in 50% mortality and 100% disability . This means that if an unhealed concussion is traumatized a second time, even mildly, there will be some form of permanent brain damage (learning disability, chronic headaches, emotional problems, etc).
• Take responsibility to prevent post-concussion syndrome and CTE in your patients.
• Listen to the entire 38 minute story about concussions and CTE from National Public Radio (since the transcribed text does not contain all the info): 

• Your performers could come into work not realizing that their headache from the fender-bender on their day off is a concussion. If they then proceed to jump, spin or fly, they can induce Second Impact Syndrome.
• Keep your ears open for rumors of car accidents amongst the cast, and go interview the involved person for signs/symptoms of concussion. Be thorough and persistent. Often, doctors miss those symptoms or dismiss them.
• Hint: If the person you interview reacts irritably and out of character to your questions, strongly suspect concussion. Irritability is one of the common symptoms.

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