Posted on 3/8/2018 by Joshua Cramer, DAT, LAT, ATC, CES, CSCS
Injuries can happen at any time to anyone. Whether playing your favorite sport, working on the job or living your daily life, it’s important to get the proper treatment when an injury occurs, and that starts with the evaluation process.
During an evaluation, a clinician will discuss a patient’s medical history, discuss goals and specific needs, inspect for abnormalities, tenderness or deformities and test musculoskeletal health. All of these components are essential to making a proper diagnosis, but they rarely provide the whole picture. These evaluative techniques focus on the area of the patient’s chief complaint, but what if the issue is in a different region or system in the body?
To design more effective treatments, it is important to look at the body as a whole – the upper and lower body, the front and back of the body and the limbs. This is where postural and functional assessments come into play.
Functional movements are essentials movements found in activities of daily living. They usually involve multi-joint movements in numerous directions, which place demand on the body's core muscles. Our clinical team frequently include functional movement screens in the evaluation process, which are designed to examine these daily essential movements and help identify limitations and dysfunction, reduce the risk of injury and improve efficiency and performance. Functional movement screens also include a detailed report and customized corrective exercise program.
There are a handful of functional movement tools available to clinicians. Some of the more popular are through the Functional Movement System, which is divided into two main parts: the Functional Movement Screen (FMS) and the Selective Functional Movement Assessment (SFMA). Another popular functional movement tool is Fusionetics.
The FMS is a screening tool which takes the patient through a series of basic movements with the intention of determining if the patient is at risk for injury. Its role is to impose minimum standards on movement patterns. The movements include:
Stepping over a hurdle
Reaching behind the back
Core test – the patient starts on his/her hands and knees and touches the elbow to the knee
The SFMA is a full-body assessment broken down into two parts, the top-tier and the breakouts. The top tier helps determine if movements are functional versus dysfunctional and painful versus non-painful. The breakouts determine the type of dysfunction a patient may suffer from. The movements consist of:
Various neck movements
Reaching behind the back
Hip flexion (bending forward)
Hip extension (arching backward)
Hip rotation (twisting)
Single leg stance
The SFMA will help define what type of dysfunction exists, whether that’s stability and motor control dysfunction, joint mobility dysfunction or tissue extensor dysfunction. Once the clinician determines which dysfunctions exist, he/she will set up an individualized treatment protocol to correct the faulty movement pattern and treat the injury and prevent future occurrences.
Fusionetics is designed in the same manner, but is web-based. It is a series of 10 exercises that determine whether someone is susceptible to certain injuries due to form and body mechanics. At the end of the Fusionetics assessment, the system will provide patients with corrective exercises. Each patient can create a free account with Fusionetics and access the results and corrective exercises from any computer, tablet or smartphone.
These screenings and assessments can be done on both injured and healthy individuals to identify movement and stability deficits. As you continue to play your respective sport or go through your daily routines, keep in mind that proper functional movement is a necessity. It is just as important to treat your body properly when you’re healthy as it is when you’re injured.
By: Joshua Cramer, DAT, LAT, ATC, CES, CSCS. Josh has been with NovaCare Rehabilitation for five years and serves as the head athletic trainer for Germantown Academy and the Philadelphia Freedoms. He is certified in various manual therapy techniques and has treatment expertise in shoulder injuries and concussion.
Posted on 3/16/2018 by Stephanie Wilkins, MSEd, ATC, and Leah Friedland, M.S., ATC
Concussions are a great concern throughout the world of sport and especially in the high school setting. They can impact the student-athlete not only on the field, but also in the classroom and their daily lives. As athletic trainers in the high school setting, when a concussion has occurred, we are involved in the entire process, including:
We help with education, implementation of proper concussion protocols and serve as an advocate for the student-athlete in their sport, classroom and life.
Education – Despite the growing awareness and concern that is present in the media over concussions, we find that coaches, parents and athletes are often still uninformed about the seriousness of concussions and the proper way to handle them. A concussion is a traumatic brain injury that is caused by either a direct force/blow to the head or a force transmitted through the body to the head. As high school athletic trainers, we find ourselves explaining to coaches that “getting your bell rung” is the same as sustaining a concussion, and that it is not something that can be ignored. “This wasn’t a big deal back when I played sports, and I turned out fine,” is not an acceptable way of viewing this issue.
We are seeing now that, decades later, people are experiencing abnormal brain function and lasting damage as a result of previous head trauma that might not have been managed properly. Concussion education is not intended to scare people, but rather to inform and stress that concussions should be handled appropriately and taken seriously.
We must also work to change the team attitude around concussions and urge athletes and coaches to take responsibility for their well-being and the well-being of their teammates. The culture of not reporting concussions for fear of sitting out or being made fun of must not continue. High school athletic trainers are in the unique position of helping create this cultural change within sports programs and we strive to do this by forming relationships with our coaches, parents and student-athletes that are based on trust and compassion.
Baseline Testing – Every concussion is different; even in one person, different concussive episodes can present in different ways. Symptoms of a concussion include:
Appearing dazed or confused
Nausea and vomiting
Imbalance… and more
There are few objective measures available to diagnose concussions, so it’s important to have a baseline evaluation for each athlete to help determine return-to-play.
We perform this evaluation at the beginning of the season to obtain a baseline score, i.e. an athlete’s “normal” level of functionality. If the student-athlete sustains a concussion during that season, a second test will be administered. This second test occurs when they are symptom-free and have completed the return-to-play progression.
In our high school, we implement two different tools for baseline testing. With more than 800 student-athletes, we prioritize the high risk contact sport athletes (like those participating in football or soccer) and administer baseline tests to those sports. The first test is ImPACT®, a computer neurocognitive exam that tests word and image recall, reaction time, motor speed and symptom report. The alternate test we use is C3 Logix. In addition to a neurocognitive exam, C3 Logix includes a balance and vision component. It is more comprehensive and time intensive, whereas the ImPACT® Test is more easily administered to a large team all at once.
We don’t use ImPACT® or C3 Logix to diagnose concussions, but rather as a tool to monitor their healing process and identify any potential problem areas.
Evaluation and Diagnosis – The most important aspect of concussion management in the high school setting is communication. We’ll discuss concussion management with both the student-athlete and parents/guardians to discuss next steps and answer any questions they may have
Next, we communicate with our Concussion Oversight Team (COT). The COT is a multidisciplinary group of individuals who help manage the student-athlete’s post-concussion care. It includes the athletic trainers, team physician, school nurses, athletic director and school counselors. We also email the coach and physical education teacher. This is our opportunity to provide athletic and/or academic accommodations as needed. The counselors and nurses are vital for helping communicate with the student-athlete’s teachers.
Occasionally, a student-athlete will require academic accommodations. These are specific to each individual and can include wearing sunglasses to help with sensitivity to light, postponing quizzes or tests, limiting use of computer work or leaving class early. Most students don’t require academic accommodations, but all are excused from gym class and athletics until their symptoms have resolved and they have completed the return-to-play progression.
Follow-Up – Oftentimes, parents will ask, “Does my son/daughter need to go to the doctor or the emergency room?” The emergency room is rarely indicated unless there are signs and symptoms of a brain bleed. This will be evaluated at the time of the injury and, if there is concern, a referral to the emergency room will be made.
Research shows that most concussions resolve within 7-14 days. Our protocol recommends following up with a physician if the symptoms have not resolved within 7-10 days. And, referral to an appropriate health care provider is essential. When possible, we will refer to a concussion specialist who works with these cases on a normal basis. The average primary care physician will not have expertise in concussion management. We will sometimes recommend following up with an ophthalmologist if the student-athlete is having difficulty with vision or physical therapy due to vestibular problems.
As athletic trainers, we take care to be as best prepared to diagnose and treat concussions as possible. We put a strong emphasis on communication with the athlete, parents, coaches and school in order to return the student-athlete safely to school and sport. Concussion research will continue to evolve over the years to come, just as we will continue to adapt and update our management protocols to keep student-athletes safe and active.
By: Stephanie Wilkins, MSEd, ATC, and Leah Friedland, M.S., ATC. Stephanie and Leah serve certified athletic trainers for NovaCare Rehabilitation in Chicago, Illinois, and currently work at York Community High School. Stephanie also serves as the sports medicine program director and helps manage other sports medicine contracts around the Chicago-land area.
Posted on 1/2/2019 by Grant Shanks, P.T., OCS
For many patients recovering from injuries and surgeries, a period of immobilization in a cast or sling and/or restrictions on weight-bearing and activity is necessary to ensure proper recovery and tissue healing. Immobilization and lack of use comes with a significant cost, though: decreased muscle strength and size, known medically as atrophy.
Even after the restrictions are lifted, it takes months to recover to pre-injury levels of strength and ability. However, recent research has led to exciting advancements in what is possible when it comes to regaining muscle strength, size and ability following injury and/or surgery. The development of Blood Flow Restriction training has opened up new doors for patients and the therapists who treat them.
What is Blood Flow Restriction (BFR) training?
Blood Flow Restriction (BFR) training uses external pressure – via a tourniquet – to reduce (restrict) arterial blood flow to working muscles and completely occlude (block) venous blood flow return to the heart. By doing so, one can achieve substantial hypertrophy (muscle growth), strength and endurance changes while using significantly decreased loads/weight. The gains in these areas of performance are consistent with what is typically observed with heavy load lifting.
To this point, the American College of Sports Medicine has shown that optimal muscle strength and hypertrophy can be achieved by lifting at high intensities, defined by their research as: eight-to-10 upper and lower body exercises, performed two-to-three times per week for six-to-eight weeks at intensities greater than 65 percent of the individual’s one repetition maximum (RM). Certainly, this is not possible for the immobilized/injured/post-surgical patient. Utilizing BFR, these same gains in strength and hypertrophy have been observed using only 20 percent of an individual’s one RM and in just two-to-three weeks.
How does BFR work?
While the exact mechanisms are not completely understood, it appears to be a combination of factors related to muscle physiology:
Decreased oxygen to the muscle causes a build-up muscle-building metabolic products.
A preferential recruitment of larger, fast-twitch muscle fibers.
An increase in growth hormone and stem cells following exercise with BFR.
Increased muscle protein synthesis via the extreme “muscle pump” following BFR.
BFR Leg What kind of device/equipment is used for delivering BFR?
By definition, anything that restricts blood flow is a tourniquet, which is considered a medical device and falls under FDA Class I regulations. In order to determine how much blood flow restriction to create in a limb (upper or lower extremity), an individual’s limb occlusion pressure (LOP) must be determined. In order to do this, a Doppler is used to assess for the presence or absence of a pulse.
Once enough pressure has been created by the tourniquet, the pulse will be absent. This amount of pressure is the LOP and then the working pressure is a percentage of this amount – either 80 percent for the lower extremity or 50 percent for the upper extremity. Machines that have a built-in Doppler are considered the gold standard. A hand-held Doppler could also be used.
Who would benefit from BFR?
Patients who are recovering from surgery to the upper or lower extremity and cannot bear weight, move their extremity and/or have been weakened by conditions may be good candidates to receive BFR. Some conditions include:
Total joint replacements
Rotator cuff repair/injury
Upper extremity fracture
Lower extremity fracture
Knee arthroscopy (knee scope)
Achilles tendon repair/injury
Shoulder labral repair/injury
Hip labral repair/injury
How do I know if BFR is right for me?
Your physical therapist will be able to go through the indications (reasons to perform) and any possible contraindications (reasons not to perform) BFR with you.
BFR is a new and growing area of rehabilitation, strength and conditioning and not all physical therapists have been trained and educated on the matter. Contact your local NovaCare or NovaCare Rehabilitation center to see if BFR is available.
By: Grant Shanks, P.T., OCS, area sports medicine coordinator for NovaCare in Tennessee. Grant also serves as center manager of our Mt. Juliet location.
NovaCare and NovaCare Rehabilitation are part of the Select Medical Outpatient Division family of brands.
Posted on 3/25/2019 by Mike Montez, M.S., ATC, CSCS
With an aging workforce, increasing health care costs and a continued demand for physically demanding jobs to be completed by humans, more and more companies are looking into providing their employees with access to an onsite injury prevention specialist.
The injury prevention specialist role is often filled by a National Athletic Trainers’ Association Board of Certification certified athletic trainer whose unique training, skills and abilities make a great fit for the job. Athletic trainers perform skills including immediate injury triage and care, biomechanics assessment, health and wellness education and strengthening/conditioning of active individuals.
Onsite athletic trainers work with industrial athletes who might be delivering online purchases, assisting with luggage at the airport or even cleaning a hotel room. The main goal of the industrial athletic trainer is injury prevention. Just like in sports, industrial athletic trainers “keep the worker in the game.”
Many individuals don’t know when to use ice or heat, how to stretch a tight muscle, basic nutrition needs for a physical job or even how lack of sleep can affect the body’s ability to heal, decrease motor coordination and increase blood pressure. That is where the role of the industrial athletic trainer comes into play.
Employees suffering a wide array of pain or discomfort from work-related and non-work related activities can seek out care from the onsite injury prevention specialist. Care may include assessing the individual, developing a plan of care and attempting to conservatively manage the issue through a combination of ice, heat, soft tissue massage, prophylactic, non-rigid taping and the application of a topical analgesic.
More often than not, an employee’s symptoms resolve within a few visits. If not, the industrial athletic trainer will discuss potential next steps in the process which could include following up with a doctor for further treatment. The industrial athletic trainer also serves as a referral source for other available services which may include dentistry, registered dietitians, follow-up with the employee’s primary care physician/specialist or even psychological consults.
Think of the industrial athletic trainer as a one-stop shop for all your health and wellness needs while on the job. The service is free (paid for by the employer) and is designed to keep the workforce healthy, happy and safe!
For more information regarding services for the industrial athlete through the Select Medical Outpatient Division’s WorkStrategies Program, please call 866.554.2624 or email [email protected] today.
By: Mike Montez, M.S., ATC, CSCS, WorkStrategies coordinator for NovaCare’s Southern California community. He serves as the site supervisor with our OnSite Program at Delta LAX and offers more than 15 years of experience. He is a graduate of Cal State University Long Beach.