Friday, October 1, 2010
How can injuries be minimized in youth sports?
Concord-Carlisle High School Athletics Director and President of the Massachusetts Interscholastic Athletic Association (MIAA) Barry Haley organized a symposium last week with speakers who discussed youth sports injuries: concussions, ACL injuries and sudden cardiac death syndrome. Exercises we can all do to increase balance and core strength were also discussed.
Dr. Robert Cantu described a new concussion education law, passed by the state legislature in July, and spoke about its implications for athletes. Cantu is Chairman of the Department of Surgery, Chief of Neurosurgery and Director of Sports Medicine at Emerson Hospital. Cantu has a clinical interest in sports medicine, specifically in the area of concussions and head/spine injuries.
“Massachusetts is the seventh state to pass concussion legislation,” Cantu said. The law states that all coaches, trainers, parent volunteers helping with athletic activity, doctors and nurses that are employed at the school and student athletes in all public schools and any school subject to MIAA rules will go through an athletic head-injury safety-training program annually. Training will include recognizing the symptoms of potentially catastrophic head injuries, concussions and injuries related to second impact syndrome.
The law will also prevent athletes from going back into a game if they have any symptoms of a concussion. In addition, they will need permission from a medical professional to go back to the game. All athletes have to provide information on any previous head injury history at the start of each season.
Cantu defined concussion as a violent shaking of the brain. He said that athletes cannot safely practice or play if they have spinal cord or brain injuries. He explained that part of the new law entails arming athletes with information so they will understand the symptoms of concussions and they can pull themselves or their friends out of play.
“Proper concussion management is complicated,” Cantu said. He said there was not sufficient data to know when it is safe for an athlete to go back into the game or practice. The hallmark of treatment includes physical and cognitive rest. Cantu explained this meant walking, not lying in a dark room. Also, to reduce the cognitive load on the brain, do not watch TV or movies, avoid texting and lighten the academic load. If studying causes symptoms, then lighten the academic load further.
There is a check-list of 25 symptoms that may be associated with concussions. Some of these are: headaches or “pressure” in head, nausea, vomiting, balance problems, dizziness, blurred vision, sensitivity to light, feeling sluggish, hazy or groggy, concentration or memory problems and confusion. Signs observed by parents and coaches include: appears dazed or stunned, moves clumsily, unsure of game, score or opponent, answers questions slowly, shows personality or behavior changes, cannot recall events before the hit or fall or can’t recall events after the hit or fall. [See www.sportslegacy.org for more information.]
Cantu stressed that if athletes show any of these symptoms, they can’t go back into play. They must be immediately removed from the game or practice. “If in doubt, sit them out.” The legislation also states that any athlete who has suffered a concussion, or is suspected to have suffered a concussion, must submit written authorization to return to play from a licensed physician, licensed neuropsychologist or certified athletic trainer.
Many more hits are sustained during football practices than during games. Cantu recommends changing how collision sports are practiced. He said more practices should be done without helmets, doing drills with less hitting.
“There is a collaborative effort to bring concussion management plans, recognition and treatment to all 42 national governing bodies that represent sports, said Cantu. Coaches need to know that plan. Athletes need to report any concussion-like symptoms so they can be put in a record. Also “The NFL is also trying to do the right thing.” Cantu noted that the NFL has changed their rules and three- and four-man wedges are no longer allowed. Also, no hits above the neck are allowed on unseeing opponents.
The Centers for Disease Control and Prevention (CDC) also have information and videos for parents on concussions. Cantu recommends looking at the Sports Legacy Institute (SLI) website (www.sportslegacy.org), of which he is a co-founder. The mission of SLI is to advance the study, treatment and prevention of the effects of brain trauma in athletes and other at-risk groups.
Q & A
Cantu took questions from the audience. “Why are no helmets used in Girls Lacrosse?” Haley answered that Girls Lacrosse had helmets eight to ten years ago, but expert opinion felt that play was more dangerous with helmets. Cantu added that ice hockey got more violent when they added helmets and face masks. Haley reminded the crowd that anyone can propose rule changes to the MIAA.
Cantu said, “There’s a fair amount of research that suggests youngsters and young ladies in particular are more susceptible to concussions and recover a bit more slowly.” He thought this may be because their brains and/or necks are not as well developed. “We are more concerned and more conservative about that age group.”
Another question was about what sports result in the most concussions. Cantu said football, ice hockey and soccer. Ice hockey has many fewer hits to the head than football, but the hits are bigger when they happen. One of the most dangerous activities in soccer is heading the ball, but not because of hitting the ball, but rather hitting another head or body part. He added that there was no published data to suggest that heading soccer balls through the college level causes evidence of brain damage.
In addition to Cantu’s other distinctions, he is a clinical professor of neurosurgery at Boston University Medical School and a co-director of the BU Center for the Study of Traumatic Encephalopathy. He was thrilled with the legislation, but repeated throughout his talk that it is only a beginning and lacks teeth.
Dr. Paul Re, an orthopedic surgeon from Emerson Hospital, spoke about ACL injuries. He explained, “The knee is a complex joint. It is not a simple hinge. There is a rotational component to it . . . The anterior cruciate ligament, ACL, doesn’t have a very good blood supply so when it tears, it doesn’t heal.” Because of the lack of good blood supply, it is common that the ACL gets reconstructed. “The most common injuries are from contact hyper-extension and the non-contact pivotal shift and they rarely heal.”
“We are seeing an increase in non-contact loading injuries, more so in women and more so in soccer,” said Re. He said there were many reasons for the injuries. One reason is that men have more developed hamstrings than women so women should try to strengthen their hamstrings. He also suggested that women are more knock-kneed. “They tend to roll their knee inwards and this puts on more stress.”
To prevent such injury, Re recommended core strengthening, training for good posture and playing on a grass surface. “Bracing doesn’t help.” He highly recommended taking a look online at the Santa Monica ACL Injury Prevention Program. [See website: www.orthopedicdocnet/ACL%20Injury%20Prevention%20Program.htm.] The website defines a set of exercises to increase flexibility, strengthen muscles, teach correct technique and define a regimen to follow.
When reconstructing an ACL, Re recommended using your own tendon from another part of your body rather than using a tendon from a cadaver. There is a higher risk of more injuries in the future if you don’t use your own tendon. Also, save as much of your ligament as possible.
Another tip was not to rush back into sports after an ACL injury. Re said the earliest someone could get back into sports was six months after the injury. But you should expect six months to a year.
When asked about the artificial turf fields at CCHS, Re responded, “The field here is pretty darn good.”
When asked whether Dr. Re saw any chronic injuries in kids that play the same sport year around, Re answered, “Yes.” He said that young children who do not get balanced exercise are more prone to injury.
Sudden Cardiac Death Syndrome
Dr. Benjamin Tillinger, an Emerson Hospital Cardiologist, explained that Sudden Cardiac Death Syndrome, (SCDS) although tragic, was extremely rare. He advocated for routine screening of students with medical history and a physical exam for all athletes. Automated external defibrillators (AEDs) should be at every sports venue. More people should have CPR training.
Tillinger explained that the number one cause for teen death in the U.S. is car accidents, stressing again that SCDS is very rare. He said that there are roughly six million student athletes in high school and college. Of those, 7.5 men in a million and 1.3 women in a million die of SCDS. That is, 0.0009% of student athletes die of SCDS. Hypertrophic Cardiomyopathy, HCM, is the most common cause of SCDS. He defined this as a thickening of the heart muscle causing the cavity to be reduced in size. The heart can no longer be flexible enough to adapt to change.
Tillinger said athletes should be screened. He noted, “It is difficult to screen for something so rare, like finding a needle in a haystack.” In Italy, all athletes have an EKG. If abnormalities are found, the athlete has further testing done. Those tests may eliminate that player from being eligible to play, even though he seems healthy and has no symptoms. “It’s a very big decision. It’s very controversial,” said Tillinger. He explained that if all six million student athletes are tested here in the U.S., about 15% will have some abnormality. After further testing, 1-2% will be told to limit their activity. That’s a much higher percentage than the nine in a million that statistically die from SCDS. [See websites: www.cardiosmart.org and www.suddendeathathletes.org for more information.]
Tillinger pointed out a few things to look for in young people. They shouldn’t have chest pain or chest discomfort. If a student has passed out, there should be significant concern. High blood pressure, heart murmurs and abnormal fatigue or being overly out of breath are other warning signs. Another concern is if there is a family history of heart-related death before the age of 50.
In noting that Sudden Cardiac Death Syndrome is so rare, Tillinger asked that teens avoid the common causes of teen injury and death: the use of alcohol, tobacco, drugs and guns.
Crystal Fontas, Doctor of Physical Therapy, senior therapist at Emerson Center for Sports Rehabilitation and Specialty Services, spoke about core stability and core strengthening to prevent injury. Core stability is the ability of the trunk to control movements of arms and legs. Control is achieved by abdomen, back, pelvic and hip muscles and the diaphragm.
Fontas talked about two effective exercises for core strengthening. The bird-dog exercise is done with your knees and hands on the floor. You lift one leg and the opposite arm out straight, hold it, then repeat with the other hand and leg.
The side-plank exercise is done by lying on your side on the floor. With legs one on top of the other and your elbow propping your torso up, lift your body to form a straight line from toes to shoulder. Repeat.
Fontas said, “Core stability training should not be overlooked in pre- and off-season training. An increase in trunk control may decrease the likelihood of sustaining low-back and extremity injuries during athletic participation.”
Barry Haley thanked the speakers. He also praised CCHS’s athletic trainer Clayton Abrams. “We are very lucky to have the resources we have here.” ∆
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