Posts tagged concussion
The Neck's Impact On Recovery From Concussion
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Concussions have received significant media and medical research attention over the last decade due to in part to the incidence of chronic traumatic encephalopathy (CTE) among former football athletes. This increase in attention to brain injuries has led to improved medical training and early recognition of concussion symptoms leading to improved care of athletes and patients suffering from post concussion symptoms. Authors estimate an incidence of 750 cases of mild traumatic brain injury per 100,000 person years and close to half of all of these individuals will experience post concussion symptoms including headaches, neck pain, dizziness, balance impairments, and fatigue. Experts in concussion report a large percentage of these symptoms may not be due to the brain but instead concurrent injury to the neck, specifically the upper neck bones.

Kennedy and colleagues examined a cohort of patients with persistent post concussion symptoms (median 5 weeks post concussion) to determine the coexistence of associated neck impairments (JOSPT. 2019). Authors examined patients both before and after treatment of their necks. Consistent with prior research impairments of the upper joints and musculature were found among this cohort including neck pain, limited range of motion, muscle and joint tenderness. These impairments are consistent with findings from patients with cervicogenic headaches and likely help explain the positive benefits of treating the neck in patients with concussion.

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Reducing Your Risk Of Alpine Skiing Injuries
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Alpine skiing remains one of the most popular outdoor winter sports in Colorado. It is estimated over 6.8 million skiers participated in the sport over the 2016/2017 winter season. There are inherent risks of death and injury in both skiing and snowboarding, but thankfully due to technological updates and innovations overall injuries have fallen by half over the last 30-40 years. Although injuries on the whole have decreased some traumatic cases, such as ACL tears, remain common today. A recent article summarized the available evidence on the most common ACL tears, as well as, offered an update on injury prevention strategies in alpine or downhill skiing.

Davey and colleagues published the review article recently in the journal Sports Health (2018). Authors reviewed the available evidence on ski injury prevalence including injury location, known risk factors, and ski injury prevention. Data was available from a total of 64,667 ski injuries over a 25 year period. They reported the average age of skiers injured was 30 years old with a range of 24 to 35 years. Those found at highest risk included both the young, adolescents and children, as well as, older adults (>55 years). While males were more likely to experience lower extremity fracture, consistent with other sports females are more prone to ACL tears.

As expected, the lower extremity remains the most commonly injured area of the body accounting for up to 77% of all injuries. Further, 14% of injuries involve the thumb and shoulder and 13% involve the head and neck. The knee ligaments (ACL and MCL) remain the most common injury followed by thumb and head and facial injuries. Trend data showed a drop in tibial fracture, but an increase in ACL tears. Most common mechanisms included deep knee flexion with rotation or knee hyper extension and forward movement of the thigh over the stationary leg in the boot. In addition, despite advances in helmet use and technology, the number of traumatic skiing fatalities remained constant.

Ski technological advances, including helmets, bindings, and ski poles, deserve the most credit for the 50% reduction of ski injuries. Helmet use has increased to 80% of all skiers and has been a significant advancement in the safety of participants and reduction of head and face injuries. As expected, helmets have consistently been shown to reduce both the prevalence and severity of head injuries without a subsequent increase in “risky skiing”. The risk of death with head injury has stayed relatively constant either because the forces of impact exceed the protective capacity of the helmet or the skier sustained other bodily injury causing death despite sparing their head and face.

Ski boot binding systems have contributed to the large decrease in leg fractures and contusions due to improved release mechanisms. In addition, skiers who routinely have their bindings checked by certified ski shops sustain fewer injuries than those who ski without inspected bindings. These bindings are designed to prevent fracture and leg injuries, not knee ligaments, and bindings often do not release with common ACL injury mechanisms in skiing.

Established programs such as “lids on kids” and “heads up” remain effective at improving the awareness and utilization of helmets. ACL prevention programs (Vermont Ski Safety Equipment) have focused on educating skiers to avoid situations most associated with knee sprain, as well as, instructions in how to fall with decreased risk to your knee. These programs have been shown to reduce a skier’s risk of knee injury by 60%. Interestingly, ski lessons have not been shown to reduce the risk of knee injury among skiers. In our practice, strength also remains a key component of injury prevention programs. Skiers are recommended to work with a local Physical Therapist to design an effective ski injury prevention exercise program.

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Concussion Rates at Altitude

Winter sports are in full spring in Colorado with many people taking their athletic pursuits outside.  Skiing and snowboarding continue to grow in popularity throughout our state among both children and adults.  Thankfully, ski helmets have become the norm at our state's ski areas.  These helmets are an essential piece of equipment to reduce the forces placed on the brain and skull during a fall.  Concussion is one of the most commonly diagnosed injuries to the head among athletes.  New research is examining the impact of altitude on concussion incidence and symptoms.   

Authors have previously reported fewer concussions are diagnosed in high school and professional athletes competing at higher altitudes (Myer et al. 2014, Smith et al. 2013).  This has led clinicians and researchers to believe high altitudes may have a protective effect on brain injuries like concussion.  These first two articles were only preliminary reports and the definition of injury and high altitudes was not clear.  A recent article in the Journal of Orthopedic and Sports Physical Therapy examined concussion rates at 21 NCAA division I football programs across the country (Lynall et al. 2016).  The article stated 169 concussions were reported by these programs medical staffs over 63 seasons (1-5 seasons for each team).  Surprisingly, these authors found higher altitudes may be associated with higher rates of concussions.  

Differences between this study and previously studies may be due to differences in research methodology including injury tracking and athlete selection.  For example, the college athletes in this study may not have enough time prior to competition for beneficial physiological adaptations to occur compared to their pro counterparts.  Usually adaptations are observed 48-72 hours after traveling to altitude.  Further research is needed to determine the impact of these physiological changes on brain health in athletes, but this research adds to existing research questioning the protective benefits of altitude competition on concussion rates. 

Concussion and Risk of Future Injury

Concussion recognition and management has improved dramatically over the last decade.  Coaches and Physical Therapists are able to both recognize the signs and symptoms of concussion and direct the athlete to the appropriate health care treatment.  Without proper management concussions can have serious and deadly consequences for the nervous system and musculoskeletal system.  Lynall et al. reported concussed collegiate athletes were twice as likely to suffer an acute lower extremity injury compared to non concussed athletes (Med Sci Sp Ex. 2015).  This increased risk is due to changes in our nervous system's ability to communicate with the muscles and joints in our body.  In particular, we have identified lasting balance, coordination, and control changes after a concussion injury.  

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Authors estimate 1 player in the NFL sustains a concussion every 2 or 3 games (Casson et al. 2010).  These numbers are likely higher given the under reporting of concussions in collision sports.  Building off Lynall et al. report a recent article examined the impact of concussions on future injury in NFL players (Pietrosimone et al. Med Sci Sp Ex. 2015).  The authors mailed a survey to 3600 retired players and received 2,429 surveys in return.  60% of these athletes reported having at least 1 concussion during their NFL career.  When the authors compared injury rates among the concussed and non concussed athletes they found higher rates of injury in the players who sustained a concussion.  With each concussion athletes had a higher rate of musculoskeletal injury.  Players with >3 concussions had 165% greater odds of reporting injuries to their arms, legs, or spine during their careers.  This article provides further support on the link between concussion and injury.  Athletes should be both symptom free and use Physical Therapy to reduce the risk of future injury on the field.