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Physical Therapeutics for Fibromyalgia | Central Chiropractor

Physical therapy often takes a hands-on approach, which might make you cringe if you're experiencing pain from several hypersensitive tender points. However, in managing your fibromyalgia symptoms, gentle and effective are used by physical therapy, and will most likely play a part in the recovery process.

Can physical therapy help ease fibromyalgia?
There are a variety of physical therapy techniques. Passive treatments include hydrotherapy, heat therapy, deep tissue massage, electrical muscle stimulation, and ultrasound and relax the body. Your physical therapy program will often start with passive treatments. When you feel ready, you will begin active treatments that protect against fibromyalgia pain and strengthen your body. Your physical therapist may work with you to develop a suitable strategy.

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Evaluating Concussion in Athletes

Evaluating Concussion in Athletes - El Paso Chiropractor

A concussion is a syndrome characterized by an immediate and temporary alteration in the function of the brain, including an altered state of mental status and level of consciousness, due to a mechanical force or trauma from an injury or accident. In other words, a concussion is distinguished as an injury to the brain caused by a blow to the head, such as an uppercut in boxing, a clash of heads in football or a cyclist going over the handlebars onto the ground, which may often lead to temporary loss of normal brain function involving alterations in memory, judgment, reflexes, speech, balance and muscle coordination.
An uncommon cause of concussion involves an indirect blow where the force of the impact is spread up to the head from another area of the body, for instance, when a stationary rugby player is tackled from behind where the head is suddenly flicked back, some of the force of the tackle may pass through the brain, causing the player to suffer a concussion without receiving a direct blow to the head.
In a majority of cases, although cuts and bruises may be present on the affected individual’s head and/or face from the blow, many people whom experienced a concussion never lose consciousness. Because of this, coaches and sports physicians without the proper experience may not immediately suspect the presence of a concussion or they often assume these are not a cause for concern. Although the severity can vary, there is no such thing as a minor concussion. In fact, while a single concussion shouldn’t cause permanent damage, others could lead to permanent impairment or worse complications.
Prior studies support the concept best known as post-concussive vulnerability, which demonstrates how another blow to the head where the brain has already recovered from previous injury can cause worsening metabolic alterations within the cells. This indicates the importance of properly identifying a concussion as soon as possible to remove an injured athlete from the field of play and ensure another concussion doesn’t occur.

Concussion Diagram - El Paso Chiropractor

Initial Concussion Diagnosis

When an athlete suffers a blow to the head, the first priority should be to have a qualified healthcare professional evaluate whether concussion has occurred. While these type of assessments should always be performed by a physician specifically trained in this area, according to the American Medical Society for Sports Medicine, or AMSSM, the ability to perform this assessment should not purely be determined by specialty but it should also be dictated by the specialist’s training and experience. In other words, with proper training and experience, coaches, trainers and healthcare professionals are more than capable of performing a concussion assessment.
The American Medical Society for Sports Medicine also specifies that the diagnosis of concussion must be properly achieved by a healthcare professional who is both knowledgeable in the recognition and evaluation of concussion and familiar with the individual involved. Standardized sideline tests are a useful framework for making assessments, however, the validity and reliability of these evaluations can be tremendously reduced without some form of individual baseline test result with which to compare and any baseline score varies according to the involved individual athlete.  

Risks of Concussion

Concussions are common types of injuries in many sports and strenuous physical activities. It is estimated that as many as 3.8 concussions occur in the United States each year during competitive sports and recreational activities, although, as many as 50 percent of these often aren’t diagnosed. As a matter of fact, among individuals ranging from ages 15 to 24, sports are second only to automobile accidents as the leading cause of head injury. According to the Centers for Disease Control and Prevention, approximately 2 million Americans per year experience traumatic head injuries, with 14.3 percent caused by traffic collisions. This number may also be higher since concussions aren’t always immediately detected after an auto accident. Research indicates that even low-speed auto accidents can result in mild head trauma. Even those individuals involved in a fender bender type of accident where whiplash may have occurred, could result in head injury. Mild traumatic brain injuries or concussions are recognized as a source of long-term complications. In addition, traumatic head injuries occur in all sports with the highest number of incidents occurring in football, hockey, rugby, soccer and basketball.
During a study researching the epidemiology of concussions in high school athletes compared results between 20 different sports. Throughout the time of the study, 1,936 head injuries were recorded concurrently with 7,780,064 athlete exposures. The percentage of injury was reported to be greater in competition than in practice and the majority of head injuries resulted from participation in football, about 47.1 percent, followed by girls’ soccer, about 8.2 percent, boys’ wrestling, about 5.8 percent, and girls’ basketball, about 5.5 percent. When comparing the overall results, girls displayed higher incidents of head injury than boys while the most frequent mechanisms of injury included player-player contact, about 70.3 percent, and player-playing surface contact, about 17.2 percent. In more than 40 percent of the athletes evaluated, symptoms improved within 3 days where a majority of athletes returned to play in approximately 1 to 3 weeks.

Football Concussion Demonstration - El Paso Chiropractor

A history of concussion can be associated with an increased chance of suffering another injury to the head in which a greater number, severity and duration of symptoms can express the outcome of an extended recovery. Younger athletes are believed to experience prolonged recoveries as they can also be more susceptible to head injuries accompanied by more serious complications. Physicians and healthcare professionals have also stated that pre-injury mood disorders, learning disorders, attention-deficit disorders and migraines could make an initial diagnosis for head injury difficult.
Early prevention may be achieved through an appropriate modification and enforcement of the rules and fair play. Helmets should also be enforced as these can help prevent impact injuries, although further research is necessary to determine their effectiveness to reduce the incidence and severity of head injuries. There is no current evidence that mouth guards could reduce the severity of or prevent concussions. Further prevention strategies may be achieved through appropriate return-to-play management techniques and procedures.

Concussions Explained



AMSSM Guidelines

In 2013, the AMSSM, or the American Medical Society for Sports Medicine, announced a position statement regarding the most appropriate practice on the initial evaluation and subsequent management of concussion in the sporting field. The main recommendations were organized by reviewing the evidence over several years, summarizing them as follows:
Any athlete suspected of having a concussion should be impeded from playing in order to receive a proper assessment by a qualified healthcare professional specializing in the evaluation and management of head injuries, preferably, someone who is familiar with the athlete as stated above. The initial evaluation guideline must include a symptoms checklist, a cognitive analysis including orientation, past and immediate memory, new learning and concentration tests and balance examinations as well as neurological and physical assessments.
Those evaluating an athlete with a traumatic head injury should be aware that while issues maintaining proper balance is a specific indicator of a concussion, these aren’t necessarily true. Performing balance examinations may yield considerably different results than baseline tests simply because of variations in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injuries which might have also occurred during the incident involving the head injury.
Furthermore, any athlete suspected of or diagnosed with a concussion should be closely monitored to make sure they don’t experience deterioration of their physical or mental condition. Most importantly, the athlete should not return to play on the same day they are diagnosed with a traumatic head injury. In the meantime, imaging should be reserved for athletes where intracerebral bleeding is suspected.
Even though most concussions can be properly managed without utilizing neuropsychological, or NP, testing, the purpose of these are to measure the condition of the brain and detect subtle cognitive impairment, as compared to simple clinical examinations. Additionally, comprehensive NP evaluations are useful when managing the condition of athletes after suffering a concussion with persistent symptoms or complicated progressions. Nonetheless, neuropsychological testing should be used only as part of a comprehensive concussion management strategy and should not be used alone otherwise. Also, the ideal timing, frequency and type of NP testing required for each individual athlete’s case have not been fully determined through sufficient research and studies.
Computerized NP tests should be analyzed by healthcare professionals who are trained and familiar with the type of assessment and the individual test limitations. Paper and pencil NP tests are equally as valuable and are able to test different areas of expertise as well as assess for other conditions, which may disguise or complicate concussion evaluations.
Before returning to play, the athlete must have improved symptoms and they must have medical clearance from a qualified healthcare professional trained in the evaluation and management of concussions. The proper return-to-play progression involves a gradual, step-by-step increase in the athlete’s physical requirements, sports specific activities and the risk of contact. If any symptoms persist with activity, the progression should be stopped and restarted at the previous symptom-free step. The primary concern with early return-to-play involves the decreased reaction time leading to an increased risk of experiencing another concussion or other type of injury which may prolong the symptoms. Furthermore, there is an increasing concern that exposure to impacts on the head and frequent concussions can contribute to long-term neurological complications. Some studies have suggested concussions may be associated with chronic cognitive dysfunction.
Healthcare professionals should be prepared to provide counseling regarding potential long-term consequences of head injury and recurrent concussions. However, there are currently no evidence-based guidelines suggesting an athlete should no longer participate in their specific sport after a concussion. More generally, further efforts are required to educate athletes, parents, coaches, officials, school administrators and healthcare professionals alike to improve the recognition, management and prevention of concussions.

On-Field and Same Day Assessment

The initial evaluation of concussion in adult athletes can be challenging if the symptoms indicating a head injury are not recognized, primarily due to the evolving nature of concussive injuries. A review paper examined the evidence related to on-field concussion assessments and studied several questions relating to same day return-to-play including: what to do when no physician is available on-site as well as the benefit of remote notification of potential concussive events. It concluded that the on-field assessment of concussions relating to sports can be difficult to diagnose, given the elusiveness and variability of presentation, the pressure to make an immediate diagnosis, the specificity and sensitivity of the on-field assessment tools and the reliance on symptoms presentation.
The authors of the research concluded that on-field assessments were based upon recognizing the presence of an injury, evaluating the symptoms, cognitive and cranial nerve function in which balance has value. They warned, however, that a number of assessments over a short period of time is often required where the symptoms may have been delayed. Therefore, keeping an athlete out of participation when there’s the suspicion of an injury is essential. In addition, the researchers determined that although a standardized assessment of concussion can be useful when evaluating an athlete for injury, it should not be replaced with the judgement of a healthcare professional or another qualified specialist.  
In another study, researchers concluded that several valid assessments can be appropriately utilized to determine the presence of an acute concussion in competitive sporting environments, providing essential data on the symptoms and functional disability which could be included into a clinician’s diagnostic formulation. They also warned that such tests should not be used alone to diagnose a concussion.

Sport Concussion Assessment Tool Variations

As previously mentioned above, the initial assessment of an athlete with a concussion is still primarily mandatory to determine the following action a healthcare professional must take to help treat an individual’s head injuries. There are various diagnostic tools available, the most notable being the Sport Concussion Assessment Tool, or SCAT. The SCAT3 is a standardized tool utilized for evaluating concussion in athletes and it was designed for use by medical specialists. SCAT3 took the place of the original SCAT and SCAT2. Most importantly, baseline testing with the SCAT3 can help interpret post-injury test scores at a later date. In the case there is no one present with medical training to tend to an injured athlete, it is recommended to utilize the Sport Concussion Recognition Tool instead.
Utilizing the Sport Concussion Recognition Tool, concussion should be suspected if one or more of the following visible clues, signs and symptoms, or errors in memory questions are present. Visible clues include: loss of consciousness or responsiveness; lying motionless on the ground; slow when standing; unsteady stance; balance issues or falling over actions; poor coordination; grabbing/clutching of the head; dazed, blank or vacant look; and confusion or unawareness of players or events. The signs and symptoms include: loss of consciousness; headache; seizure or convulsion; dizziness; balance issues; confusion; nausea or vomiting; slowed down sensation; drowsiness; head pressure; feeling more emotional; blurred vision; irritability; sensitivity to light; sadness; amnesia; fatigue or low energy; foggy feeling; nervous or anxious; neck pain; sensitivity to noise; difficulty remembering things, difficulty concentrating; and an overall not feeling right sensation. Furthermore, alterations to the athlete’s original memory function by failing to answer the following questions correctly may suggest a concussion: what venue are we at today; which half is it now; who scored last in this game; what team did you play last week/game; and did your team win the last game.
If an athlete is suspected to have suffered a head injury, they should be removed from play immediately and should be assessed by a healthcare professional as soon as possible. Red flags signaling a traumatic head injury requiring immediate medical action includes: neck pain; deteriorating conscious state; increasing confusion or irritability; severe or increasing headache; repeated vomiting; unusual behavior change; seizure or confusion; double vision; and/or weakness along with tingling, burning sensations in the arms or legs.
The SCAT3 is a detailed tool that assesses the following fields: background, symptom evaluation, cognitive and physical function, neck injury, balance and coordination. According to the SCAT guidelines, the first results of an assessment are essential and any of the following authorize the utilization of emergency procedures and urgent transportation to the nearest hospital: a Glasgow Coma score of less than 15; deteriorating mental status; potential spinal injury; and progressive, worsening symptoms; or new neurological signs.
It’s important to give first concern to the fact that scoring using the SCAT3 should not be utilized as the sole method to diagnose a concussion, measure recovery or make decisions about an athlete’s capacity to return to competition after experiencing an injury. Furthermore, because the symptoms may change over time, it’s essential to consider multiple assessments when evaluating for head injuries. Finally, when diagnosing a concussion it needs to be priority for it to be ideally identified by a healthcare professional through clinical judgement. The SCAT3 should therefore not be used only to make or exclude the diagnosis of a traumatic head injury or concussion without seeking the appropriate evaluation of a qualified specialist. An athlete may have experienced a concussion even if the SCAT3 score appeared normal.

By Dr. Alex Jimenez

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