Concussions: post concussive rehabilitation options

Concussions differ so widely that it takes skilled health care providers and trainers to properly assess, treat and make decisions on return to play (RTP) with a variety of assessment tools. Remember that nerve cells in the brain are extremely fragile and vulnerable to re-injury at this time and there are good systems in place to minimize the individual’s risk of further damage.  Premature mental tasks, physical tasks and stress delays healing and therefore direct communication amongst school staff, coaches, trainers, physical therapists and providers offers maximum success for a full recovery.

Once the person’s symptoms have subsided at rest and with mental challenges (headaches, dizziness, visual disturbances, increased sensitivity to light and sound, agitation, loss of memory, uncoordinated movements and loss of balance are examples), they are likely ready for conditioning. According to the American College of Sports Medicine and other published literature on the safety and efficacy of  the rehabilitation process, the following 5 day progression can be implemented.

Day 1: Light aerobic exercise for 5-20 minutes which can include a stationary bike, stair climbing, rowing, a brisk walk, or elliptical machine, to name a few options.

Day 2: Aerobic exercise at moderate intensity and to continue up to 20 minutes, as tolerated

Day 3: Interval training, sprinting or otherwise high intensity aerobic exercise

Day 4: Contact exercises begin but in controlled, supervised setting

Day 5: Return to sports without limitations/restrictions

It is so important it bears repeating that this is not “one size fits all.” Individuals must be assessed all along to observe for any changes in coordination, balance and ability to concentrate and follow directions, as well as be symptom free.

Concussions: a few facts to keep in mind

Concussions are a common topic as regulations are in place amongst team sports in the United States. Information floods the internet for parents, coaches and caregivers, and for the lay person, this can be overwhelming. My goal here is to highlight a few facts and offer suggestions to help avoid unnecessary dangers to kids having had suffered a concussion.

Concussions can happen by any blow to the body which results in a disruption to a normally functioning brain and causes neuronal shearing. This may not include a hit to the head (less than 10%) and often does not include unconsciousness. Most incidents include a resolution of symptoms in 2-3 days. Also, whiplash associated disorders (WAD) are common in conjunction with concussions due to the rapid deceleration of the neck on the head. Symptoms from WAD can take longer to subside.

Typical complaints after concussion include, but are not limited to, headaches, nausea, dizziness, balance issues, difficulty with memory, depression, double or blurred vision, light/noise sensitivities, confusion, and sluggishness. Furthermore, what a coach, parent or friend might see are clumsy movements, mood changes, personality changes and/or difficulty answering simple questions.

Here is what everyone needs to know and follow. Any person who is suspected of suffering a concussion needs to be systematically evaluated by a trained health care provider and at that point determined if imaging of the brain and/or neck is warranted. The good news is that the examination is thorough, objective and offers a lot of information very useful for rehabilitation purposes, should that need arise. Only after this evaluation will it be determined if the person is safe to return to play (RTP). Because the nerves in the brain are injured, they are very susceptible to re-injury and the likelihood of long term damage rises. Multiple concussions are dealt with much more conservatively as the health risks rise.  Almost half of athletes do not report symptoms after suffering a concussion. Be aware and on the lookout for symptoms and complaints to show up a few days after the incident. This warrants a visit to a trained health care provider for guidance on activity restrictions, rehabilitation strategies for optimal healing, and a safe plan for RTP.

My next week’s blog will discuss successful rehabilitation strategies to minimize long term adverse effects, provide education and use a systematic approach to evaluating safety in returning to activities.

 

Have you been told your balance issues are “just your age?”

Yes, balance does decline with age, in general. It is also true that there is quite a bit one can do (and easily incorporate into every day activities) to slow this down and actually improve balance. For most people, this translates to a better quality of life, more confidence to remain active, and reduced risk for falls. The important piece of information you must know is that a proper assessment of your balance issues allows you to have a targeted home program that is meant just for you. It is not “one size fits all.”  Some people can practice standing on one leg all day long but their true issue may not be addressed. Just a short list of things that disrupt balance are back and orthopedic injuries, prior ear infections, viruses, medications, peripheral neuropathy, and vestibular issues. When a thorough exam is completed by a skilled health care provider, often there is successful, efficient intervention that helps dramatically.

Hip pain and bursitis

Lateral (outer side) hip pain is all too common and leaves many people with questions about how it happened, how to avoid it, and what to do about it. One of the many diagnoses of lateral hip pain is bursitis. There are 3 distinct bursa in the hip region but the greater trochanter bursa causes pain in this specific region. How does this occur and what to do? Less common causes are a direct fall onto the outside of the hip which results in swelling and tissue damage.  Early intervention of anti-inflammatory modalities, gentle stretching and gentle exercise can help minimize long term issues. Back issues can lead to bursitis because of nerve impingement and/or abnormal range of motion. However, most often this pain comes from a chronic disuse of muscles supporting the hip, sacroiliac joint, low back and knee. Abnormal friction over the bursa by tendon attachments causes swelling inside the bursa and in the tendons. It is not uncommon for Magnetic Resonance Imaging (MRI) to show “gluteal tendonopathy” as well. This means that the gluteal tendon does not appear to be strong and healthy. Treatments such as cortisone injections into the bursa are commonly performed by physicians but the actual cause of the bursitis must be addressed. Your Physical Therapist should perform a thorough gait assessment which tells so much about muscle compensation and functional mobility of the whole lower quarter. A detailed evaluation of the back, and lower quarter (even the foot/ankle!) often guides us to the primary problem so it can be addressed appropriately the first time. Your Physical Therapist will help rule out some other structures that can result in outer hip pain-a nerve from the back, certain muscles in the hip and back, the hip labrum, sacroiliac joint, and even viscera (ie. kidney).

 

Ankle sprains and avoiding long term issues

Have you ever sprained, or rolled, your ankle which resulted in pain, swelling and possible bruising? You then rested, iced and compressed it as you were told?  After an ankle sprain, the use of an ankle support for every day weight bearing activities is important for protection and to avoid re-injuring the ankle. Ice with elevation and compression are also important things to do early on. Ligaments take a minimum of 6 weeks to be somewhat stable (and only if they are nurtured correctly) and most often there are injured tendons and/or muscles involved that also take time to heal.  However, studies support the importance of moving the ankle, foot and knee (yes, knee) in very specific directions beginning in the acute stage of recovery to prevent excessive scarring and joint stiffness, atrophied muscles and to prevent much proprioceptive loss (our ability to make micro adjustments in ankle positioning to stay balanced).  Class IV laser kickstarts tissue regeneration and reduces swelling and can be done immediately. In addition, soft tissue manipulation, neuromuscular re-education, taping and balance are just a few things that should be implemented right away. These things will so often get you back to “normal”, with good strength, range of motion, and without pain on stairs, walking uneven surfaces and/or getting back to impact sports. Be sure you are not guessing as to what you need to be doing on your own as further injury can result. To be safe, have a Physical Therapy evaluation who will do a whole lower quarter assessment and guide you through what to do at home and to instruct you on contraindicated movements, as well.

Effects of Class IV Laser on Fibromyalgia Impact and Function on Women with Fibromyalgia

Abstract

OBJECTIVES:

This study evaluated the effects of Class IV laser therapy on pain, Fibromyalgia (FM) impact, and physical function in women diagnosed with FM.

DESIGN:

The study was a double-blind, randomized control trial.

SETTING:

Testing was completed at the university and Rheumatologist office and treatment was completed at a chiropractic clinic.

PARTICIPANTS:

Thirty-eight (38) women (52±11 years; mean±standard deviation) with FM were randomly assigned to one of two treatment groups, laser heat therapy (LHT; n=20) or sham heat therapy (SHT; n=18).

INTERVENTION:

Both groups received treatment twice a week for 4 weeks. Treatment consisted of application of LHT or SHT over seven tender points located across the neck, shoulders, and back. Treatment was blinded to women and was administered by a chiropractic physician for 7 minutes.

OUTCOME MEASURES:

Participants were evaluated before and after treatment for number and sensitivity of tender points, completed the FM Impact Questionnaire (FIQ) and the pain question of the FIQ, and were measured for function using the continuous scale physical functional performance (CS-PFP) test. Data were evaluated using repeated-measures analysis of variance with significance accepted at p≤0.05.

RESULTS:

There were significant interactions for pain measured by the FIQ (LHT: 7.1±2.3 to 6.2±2.1 units; SHT: 5.8±1.3 to 6.1±1.4 units) and for upper body flexibility measured by the CS-PFP (LHT: 71±17 to 78±12 units; SHT: 77±12 to 77±11 units) with the LHT improving significantly compared to SHT. There was a time effect for the measure of FM impact measured by the FIQ, indicating that FM impact significantly improved from pre- to post-treatment in LHT (63±20 to 57±18 units), while no change was observed in the SHT (57±11 to 55±12 units).

CONCLUSIONS:

This study provides evidence that LHT may be a beneficial modality for women with FM in order to improve pain and upper body range of motion, ultimately reducing the impact of FM.

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http://www.ncbi.nlm.nih.gov/pubmed/23176373

Efficacy of 780-nm laser phototherapy on peripheral nerve regeneration after neurotube reconstruction procedure (double-blind randomized study).

Efficacy of 780-nm laser phototherapy on peripheral nerve regeneration after neurotube reconstruction procedure (double-blind randomized study).

Author information

  • 1Division of Peripheral Nerve Reconstruction, Tel-Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. rochkind@zahav.net.il

Abstract

OBJECTIVE:

This pilot double-blind randomized study evaluated the efficacy of 780-nm laser phototherapy on the acceleration of axonal growth and regeneration after peripheral nerve reconstruction by polyglycolic acid (PGA) neurotube.

BACKGROUND DATA:

The use of a guiding tube for the reconstruction of segmental loss of injured peripheral nerve has some advantages over the regular nerve grafting procedure. Experimental studies have shown that laser phototherapy is effective in influencing nerve regeneration.

METHODS:

The right sciatic nerve was transected, and a 0.5-cm nerve segment was removed in 20 rats. A neurotube was placed between the proximal and the distal parts of the nerve for reconnection of nerve defect. Ten of 20 rats received post-operative, transcutaneous, 200-mW, 780-nm laser irradiation for 14 consecutive days to the corresponding segments of the spinal cord (15 min) and to the reconstructed nerve (15 min).

RESULTS:

At 3 months after surgery, positive somato-sensory evoked responses were found in 70% of the irradiated rats (p = 0.015), compared to 30% of the non-irradiated rats. The Sciatic Functional Index in the irradiated group was higher than in the non-irradiated group (p < 0.05). Morphologically, the nerves were completely reconnected in both groups, but the laser-treated group showed an increased total number of myelinated axons.

CONCLUSION:

The results of this study suggest that postoperative 780-nm laser phototherapy enhances the regenerative process of the peripheral nerve after reconnection of the nerve defect using a PGA neurotube.

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http://www.ncbi.nlm.nih.gov/pubmed/17603852

 

Phototherapy in peripheral nerve regeneration: From basic science to clinical study.

Abstract

OBJECT:

This review summarizes the continuous study of low-power laser radiation treatment of a severely injured peripheral nerve. Laser phototherapy was applied as a supportive factor for accelerating and enhancing axonal growth and regeneration after injury or a reconstructive peripheral nerve procedure. In nerve cell cultures, laser phototherapy was used to stimulate activation of nerve cells.

METHODS:

Low-power laser radiation was used for treatment of peripheral nerve injury using a rat sciatic nerve model after crush injury, neurorrhaphy, or neurotube reconstruction. Nerve cell growth and axonal sprouting were investigated using laser phototherapy on embryonic rat brain cultures. The outcome in animal studies facilitated a clinical double-blind, placebo-controlled, randomized study that measured the effectiveness of 780-nm laser phototherapy on patients suffering from incomplete peripheral nerve injuries for 6 months to several years.

RESULTS:

Animal studies showed that laser phototherapy has an immediate protective effect, maintains functional activity of the injured nerve, decreases scar tissue formation at the injury site, decreases degeneration in corresponding motor neurons of the spinal cord, and significantly increases axonal growth and myelinization. In cell cultures, laser irradiation accelerates migration, nerve cell growth, and fiber sprouting. A pilot clinical double-blind, placebocontrolled, randomized study showed that in patients with incomplete long-term peripheral nerve injury, 780-nm laser radiation can progressively improve peripheral nerve function, which leads to significant functional recovery.

CONCLUSIONS:

Using 780-nm laser phototherapy accelerates and enhances axonal growth and regeneration after injury or a reconstructive peripheral nerve procedure. Laser activation of nerve cells, their growth, and axonal sprouting can be considered as potential treatment of neuronal injury. Animal and clinical studies show the promoting action of phototherapy on peripheral nerve regeneration, making it possible to suggest that the time for broader clinical trials has arrived.

 

http://www.ncbi.nlm.nih.gov/pubmed/19199510

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