Concussion in Sport - The "Sprained Brain"

If you are happy to take 2-4 weeks off the field when you sprain your ankle, why then would you not do the same if you sprain your brain?

There has been increased awareness regarding concussion injuries in contact sports over the past few months with the start of the upcoming football season. Indeed head injuries are a weekly sight when watching professional NRL, AFL and Super Rugby matches. Management of these injuries are well scrutinised and we look to these professional codes to set a safe example for local sporting clubs to emulate on weekends. The advent of recent litigation cases resulting as a consequence of players prematurely retiring from professional football due to recurring head injuries and subsequent side effects has created much needed discussion about what is best practice when it comes to the management (short and long term) of such injuries.

The main issue causing concern is how to manage a concussion, or head injury, if and when they occur. It can happen at elite level as seen with the on-field assessment and management of the professional players that get 'knocked out' during a game. Rules and regulations have tightened over recent years with medical and coaching staff coming under close scrutiny for how and when they can let a player return to the field of play. But it can also happen at the weekend local under 8's game of rugby league where there is often no medically trained people available.

What is a concussion 

The meaning of the word concussion comes from the Latin word 'concutere' ('to shake violently') which fittingly describes how this most common form of traumatic brain injury occurs. The brain literally shakes inside the skull that can create a coup and contracoup style of injury. This can cause trauma to the cerebral brain tissue, the suspensory ligaments and the fibres that hold it in place resulting in an alteration in metabolic state that can last for up to 4 weeks. It can be associated with a variety if physical, cognitive and emotional symptoms that may or may not always be recognised, especially if they are subtle. 

Signs and symptoms to look out for 

• Headache
• Disorientation
• Dizziness
• Vomiting, and/or nausea
• Poor balance
• Possible loss of consciousness
• Post traumatic amnesia
• Confusion or irritation
• Altered or blurred vision
• Tinnitus or ringing in the ears

How to manage a concussion

As a general rule always following the first responder procedure learnt in basic first aid is the first priority. This being the DRSABC (Danger, Response, Send for help, Airway, Breathing, Circulation). Once this has been cleared then a safe assessment and management of the concussion can follow:

• Make sure there is no associated neck injury, if suspected call an ambulance and do not move the injured player
• Monitor signs and symptoms for at least 6 hours as these can be latent 
• If symptoms begin to worsen seek medical attention at hospital immediately
• Physical AND cognitive rest for 7-10 days (longer in children and adolescents) - such as time out from phone/TV/computer screens
• Medical assessment and be symptom free prior to returning to physical training with a graduated return to activity

As with as a sprained ankle, you are more susceptible to another concussion following initial injury, especially if you have returned to sport before the symptoms have fully settled. Repeated concussions can have long term detrimental effects and have been shown to increase the risk of dementia, Parkinson's disease and depression later in life.

If in doubt, and you suspect a concussion injury, consult your doctor or sports physiotherapist for a thorough assessment and advice with management. The athlete should be totally symptom free before returning to play and a rough guideline for a safe return to sport should follow:

• First Concussion - Review with doctor and minimum 2 weeks rest from contact sport 
• Second Concussion - Mandatory review with Sports Medicine Specialist for a thorough neuropsychological assessment followed by 4-6 weeks rest from contact sport
• Third Concussion - Repeat neuropsychological assessment, appropriate medical imaging of the head. Extended rest and/or no sport for the remainder of the season (3-6 months)

Post-Concussion Syndrome 

In recent years only has it become apparent in professional sport that a history of repeated and recurring concussive events can have a lasting and detrimental effect on the brain and its function. Post-concussion syndrome (PCS) has been described in the literature where features relating to concussion last for weeks, months or even years following the traumatic event. It is generally accepted that PCS can occur in up to 15% of those suffering from one concussion.

Symptoms of PCS can be similar to those experienced with an acute concussion but may also be less obvious such as behavioral, cognitive (such as memory loss and poor attention) and increased irritability and as such can often be misdiagnosed or overlooked. There is no treatment of PCS as such but instead treatment is symptom based and may require physiotherapy, behavioral therapy or medication.

For further information see http://sportconcussion.com.au/ or download the "First Responder" App to your phone for use on game days.

Community Spirit

Jo is a long term patient of the clinic who's smiley face some of you may have seen on your way in or out the clinic. She uses a wheelchair due to a severe connective tissue disorder and deals with an array of medical issues and chronic pain everyday..

Although Jo is physically confined, she has not let this limit her participation in life and the communities she is a part of. Jo is a qualified social worker who works part-time for an organisation called Fighting Chance. This organisation works to find employment opportunities for disabled people. Jo runs an arm of the organisation called LifeX which is a social program that aims to combat endemic isolation and loneliness among people with disabilities. She does amazing work to build confidence and social networks for young disabled people. 

Her resilience and grace in the face of a very challenging body is always an inspiration. 

Recently Jo came in for an appointment after falling out of her wheelchair. She had been making a surprise birthday cake for her mom and was reaching into the back of the kitchen cupboard to get the cake sprinkles! 

That afternoon, I was in Howards Storage World in the Norton Plaza and I happened to notice some pull out kitchen cupboard drawers and immediately thought of Jo.

I wrote a letter to the Howards Storage World head office to explain Jo’s situation and relayed the ‘sprinkles story’ to them. Guess what - Janita from Howards Storage Leichhardt contacted me almost immediately and donated 4 drawers to Jo.

Janita and her friendly staff not only donated the drawers but also sent their on-road man to install them for her. We cannot thank Howards Storage World in Leichhardt enough for their generosity and kindness - they have given back to someone who gives so selflessly to her own community everyday.

Jo’s sprinkles now live within easy access and hopefully she will remain safely in her wheelchair.

Do you know how to activate your core?

So often we go to the gym or an exercise class and hear the words “turn on your core”. How many of us actually know what these words mean and how effective are we really being at using the muscles that stabilise our spine when we move? 

Unfortunately the term ‘core’ has become generic for anything abdominal. Just because we are doing regular abdominal strengthening exercises, does not mean we have an effective core. In fact, certain stomach strengthening exercises can do more harm than good, especially in people with lower back pain, neck pain and postpartum mums with a split in their abdominal wall.

The abdominal wall consists of four separate layers of muscles. Although all four layers have a role in spinal stability, the deepest layer is the most important when it comes to safety of the spine. This deep layer is a thin, endurance type muscle called the Transverse Abdominus. It is often the problematic muscle when we talk about the core. An effective contraction of this muscle co-ordinates with the pelvic floor muscles, diaphragm muscle and breathing to pre-tension the fascial system around the spine to keep the spinal segments safe when we move. 

Accurate activation and correct timing of this deep layer are very important. The core needs to be on before we load the spine. There are many reasons the timing of the deep layer is inhibited. Pain is the most common reason, but fear of movement and asymmetries in the abdominal wall that are caused by dysfunctional movement patterns in other parts of the body can also inhibit the core. All of our abdominal muscle attach to the thorax, so twists in this part of the body can have a huge effect on our abdominal function

We can see the layers of the abdominal wall with real-time ultrasound (RTUS) (click here for further information about RTUS). Being able to visualise them contracting on the screen, can help you learn and understand what you are really meant to be doing and how to co-ordinate this contraction with your breathing and your pelvic floor.

An effective core is important for spine health in every day function, but it is even more important during exercise and especially with heavy lifting in the gym. Men can also get an abdominal separation when they use an incorrect bracing strategy with heavy weight lifting. Heavy lifting in the female body with incorrect abdominal patterning is more likely to injure the pelvic floor.

You are welcome to make an appointment with us to have your core contraction assessed - you will be surprised how simple it is.

To Stand or Not to Stand?

Most progressive work places are beginning to recognise the perceived health benefits of standing and will offer their employees the option of a standing desk (or adjustable sit-to-stand desk that can be raised and lowered as desired) or at the very least be open to the option of investing in such changes in the office.

To Sit...

By now it is common knowledge that sitting all day at work is not only bad for your posture but sustaining such long periods of sitting can also adversely effect your health and lead to an increased risk of cardiovascular disease, obesity, poor blood sugar control, diabetes and even cancer. Not to mention the increased risk of eye strain and visual disturbances along with reductions in cognitive and neurological function. 

Then there are the postural and musculoskeletal problems relating to prolonged sitting. These are well known and will often see you and/or your staff members spending plenty of time and money visiting the local physiotherapist. Common problems will vary from person to person but can range from:

• Weak and/or poor activation of the gluteal and core muscles
• Tight hip flexor muscles
• Strained neck and shoulder muscles
• Damage and compression to spinal discs
• Headaches and neck pain

So the answer is to stand up at work instead, right?

To Stand...

Well not necessarily. There is still a lack of any concrete studies showing that standing all day at work has superior health benefits when compared to sitting. A systematic review by MacEwen et al (2015) revealed there is a lack of research in this area and that standing alone seems to show few physiological improvements when compared with sitting (treadmill desks on the other hand showed several benefits... but that is taking the topic a bit far here!). Often the use of a standing desk in a workplace will be short-lived. People try with little success, usually due to fatigue and soreness, which eventually leads them to return to the easier option of sitting. The benefits of standing have been documented but they are often anecdotal and nothing more than personal accounts and tributary blogs written about its benefits. They include:  

• Reduced lower back pain
• Increased productivity
• Improved leg strength and increased balance
• Increased calorie consumption
• Improved general body circulation (which is contrary to the increased risk of varicose veins)

But do the pro's out way the cons? There are several adverse side affects to having prolonged periods on your feet. Some research has shown that standing at work for longer that 6 hours a day can lead to:

• Increased circulatory stress resulting in varicose veins
• Increased risk of carpal tunnel syndrome with increased leaning while using a computer
• Fatigue
• Hip/knee/foot pain

The answer is, as with most things, about having the flexibility and the option to do both. There are many styles of desks now that can be adjusted to allow you the ability to both sit for a period and, with a slight adjustment, stand for a period. Standing at work is a new posture for many people, so it will take time for the body to build endurance for sustained standing.  Here are a few tips to reduce the chance of causing pain and to make the transition a bit easier: 

4 Tips for standing:

1. Stand differently - If you find yourself standing for longer periods where your body is stuck in extension (and often pain), try a few pelvic tilts using your anterior core and posterior gluteal muscles to set yourself in a slightly more neutral tilt. Here are some tips to correct poor pelvic position.
2. Breathe better - another way to get your pelvis to posterior tilt is to exhale fully, which lowers your rib cage and relaxes that increased lumbar lordosis. Try a table top stretch like this one but rest your hands higher than your hip height.
3. Rest postures - try to find time to sit, lie on your back on the floor or a half kneeling lunge position. While standing try to adopt a split stance position where is it harder to hang on one hip or arch your lower back into a fixed lordosis. Try some simple extension exercises like standing with your back to the wall and sliding your arms vertical up the wall.
4. Wear good footwear - obviously a no brainer if you are standing a lot. All feet are different so match the shoe you need with you foot you have. Feet with poor arch stability will need increased support and firmer feet might need more padding. Ladies, high heels + standing all day is never a good idea, so keep a change of shoes under your desk.

Whether you choose to sit or stand at work it is important that you do both well. Incorporating periods of standing into your nine to five working day is important to prevent extended periods of static, often poor postures and to help keep your body moving, healthy and hopefully injury free.

Headaches; A Pain in the Neck?

Most people will suffer from a headache at some point in their life. In fact, the WHO reports that up to 47% of people will have suffered from a headache within the past 12 months.

The cause of a headache is often multi-variate. It can be the result of a physical injury or illness, emotional or psychological stress, pharmacological overuse or genetics. They can have a huge impact on a persons quality of life and can often result in time off work. Neck pain and cervical muscle tenderness are commonly featured in primary headache disorders.

TYPES OF HEADACHE

According to the International Classification of Headache Disorders (ICHD) headaches can be classified into primary and secondary causes. Primary headache classification includes:

• Migraines
• Tension-Type headache 
• Cluster headache 
• Other primary headaches

Migraine headaches are uncommon and are generally attributed to a vascular inflammatory cause.  They can often begin early in life and be life long. Features of migraine are the sporadic 'attack' type nature, increasing intensity, short duration of a few hours, association with auras (such as light and sound) and nausea. Most effective management is medical with correct use of non-steroidal anti-inflammatory (NSAIDs) and analgesia (aspirin/panadol) medication. Acupuncture and relaxation techniques have also been shown to be effective in prevention of recurrence. New evidence with the work of Dean Watson however is showing that Migraine type headache can result from a sensitisation of the nerves of the upper 3 cervical vertebrae... more on that below.

Tension-Type headaches (TTH) are by far the most common type. They account for nearly 90% of headaches. The pressure-like pain from TTH is often felt from the base of the skull and can radiate to the forehead, eyes and neck. It usually effects both sides. Causes can include stress, sleep deprivation, posture, eyestrain and even hunger.

Cluster headaches are very rare and are identified by frequently recurring but brief, extremely severe headaches. These are usually felt one sided and with pain around the eye. There may be some associated autonomic symptoms such as tears, redness, nasal congestion, swelling and eyelid droop. There are limited effective treatments available. Most treatment options involve medication which are best discussed with your doctor.

In treating headaches, it is useful to understand the difference between a primary headache (such as TTH) and and secondary headache (such as cervicogenic). Management of these headache types vary though their symptoms may be similar. There is a vast list of secondary causes of headache, most needing further investigations and management with your medical doctor. Any severe headache that is new or different to your normal headache pattern should be investigated medically first.

Cervicogenic headache

Physiotherapy can successfully treat TTH, migraine and cervicogenic headaches that arise from the neck and surrounding soft tissue structures and help to prevent their recurrence. The symptoms experienced in relation to a headache that is referred from the upper 3 vertebra (C1/2/3) in the cervical spine (neck), can mimic a migraine, including the associated aura and nausea.

The upper 3 vertebra can refer pain to the face and head through the links between the nerves in the neck and the trigeminocervical complex (TCC) found in the upper cervical spinal cord. This linkage of nerve pathways allows pain from the neck to be referred to the face. Muscle spasm, joint stiffness, neural hypersensitisation and vascular changes can all be a source of pain in headaches referred from the neck. It is not uncommon for people who suffer from headaches to have identified certain triggers for their headaches. Certain foods, hormone cycles, dehydration and posture are all possible triggers which can sensitise the structures in the upper neck and result in a headache. 

Poor loading patterns of the neck and head can result in postural causes (relating to muscles and joints of the neck) that are associated with headaches, the term cervicogenic headache is often used. This term relates to headache symptoms that include:

• neck and/or jaw pain (such as following a whiplash injury)
• pain felt in the forehead or back of head
• feelings of dizziness or light-headedness

The symptoms often worsened with prolonged/sustained neck positions or repetitive neck movements (such as when using computers/phones/tablets). They are often eased by manual pressure to the base of the skull.

PHYSIOTHERAPY MANAGEMENT OF HEADACHE

Hands on treatment (manual therapy) of these types of headaches has been shown to be effective in reducing the severity of symptoms and frequency of occurrence. Your physiotherapist can use various manual techniques such as massage, joint mobilisations, dry needling and taping to correct any imbalances around the neck and to restore normal movement and mechanics to the joints in the upper cervical vertebrae. Your physiotherapist can help you recognise your triggers associated with the headaches and use these as a re-assessment tool to monitor the progress of your treatments.

Postural re-education is an important component of managing these headaches as stress on the lumbar and thoracic spines can create sub-optimal patterns of loading in the head and neck. Re-training of the deep stabiliser muscles around your neck and mid back (thorax) with a biofeedback tool and correcting the imbalances of the larger muscle groups has been shown to be effective in long term headache management. 

Your physiotherapist can show you how to alleviate your symptoms through self-massage and specific self-mobilising techniques to maintain the mobility of the upper cervical joints. It is important to identify the patterns of movement and the structures in the body that are responsible for your symptoms. Your physio will identify which static postures or dysfunctional movement patterns that you have adopted in your daily movement tasks or sports are contributing to your headache. Restoring normal movement patterns in your thorax and neck can help prevent further occurrences. 

An ergonomic assessment of your work station will often be recommended by your physiotherapist. Correct setup of your computer at work (or home) can help manage symptoms. This may require changes to chair/desk height, monitor position and height, foot placement and sitting postures. Using a standing desk may be an appropriate alternative, read more here to learn about this. Your physio will help you understand how your posture at the computer is related to your headache.

Finally, management of a headache is multifaceted and will often require attention to other factors such as:

• Diet  
• Sleep patterns
• Medication (prevent overuse)
• Lifestyle choices and stress management strategies

Discuss these and other treatment options with your physiotherapist.

Patellofemoral Pain

Patellofemoral pain (PFP) represents about 25-40% of all knee injuries. It presents as anterior knee pain that is worse with stairs, squatting, jumping, running and after long periods of sitting. It is an injury that is often poorly rehabilitated and it is not uncommon for symptoms to persist for years after the initial onset. 

Unfortunately, persistent symptoms often result in reduced levels of activity and in some cases  physical activity is stopped all together, which has long term consequences for our general health.

The key to managing PFP pain is to address it early (anterior knee pain is common in adolescents) and rehabilitate it thoroughly. Most rehabilitation programs fail because they are not specific enough and are not continued for long enough to build the strength and endurance necessary for the knee to cope with the loading demands of everyday life.

So what causes PFP?

There is ongoing debate as to the cause of PFP, but a widely recognised theory is that mal-alignment or mal-tracking of the knee-cap (patella) alters the stress on the tissues of the joint between the patella and the femur. 

Symptoms most commonly start with an overload situation. Too much, too fast, too hard is a common story in PFP.

Some of the risk factors for PFP are:

• Weak quadriceps muscles especially when there is an imbalance between the medial and lateral quadriceps muscles
• Weak gluteal muscles which effects the alignment of the thigh bone under the patella
• Weak core and trunk muscles
• Weak calf muscles
• Foot pronation and poor dynamic function of the foot
• Tight hamstrings and calves

Pain is a big factor in perpetuating the patterns of weakness seen in PFP. Once the knee is symptomatic, the body alters its movement patterns and reduces the loading demands on the knee to avoid and reduce pain. This results in further de-conditioning of the relevant muscles and perpetuates a vicious cycle of chronic pain and weakness.

An accurate diagnosis is important as there are many causes of anterior knee pain and the rehabilitation of these other injuries differ slightly from PFP rehabilitation. Taping of the patella during the initial phases of rehabilitation is important to manage pain and allow the rehabilitation program to progress. Exercises that target all the relevant muscles in the lower limb and pelvic area need to be progressed as the symptoms improve and need to be continued until the strength of these muscles match the demands of your lifestyle.

Once again, rehabilitation of PFP often fails because the program is not specific enough and it is often stopped before the necessary strength gains are achieved.

A good physiotherapy rehab program for PFP should:

• Educate you as to what factors are contributing to your problem
• Advise you about appropriate activity modification during rehabilitation
• Set realistic expectations for how long the rehabilitation process will take - regaining the necessary strength in the appropriate muscles takes time!
• Motivate you to stay on board with the rehabilitation 
• Manage your pain with hands on treatment and strapping
• Use foot orthotics where appropriate
• Address any biomechanics issues or technique issues in sport that are contributing to the problem
• Especially in Adolescents - manage pain early and rehab well! Remember studies have shown that symptoms can persist for years after initial onset and can predispose the joint to arthritic change in later years

In summary, a good physiotherapy program will:

• Unload
• Settle
• Improve movement patterns
• Reload. 

This process takes time and patience and often requires an element of continued self-management to prevent re-occurrence of the symptoms.

Take home message for PFP:

Manage early, diagnose thoroughly, rehabilitate well and to full function.