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Understanding Concussions and How Chiropractors Can Help

In light of recent news from the Pittsburgh Penguins regarding Sidney Crosby sustaining another concussion during practice last Friday, the hockey community is a buzz. Crosby’s concussion history is well documented of recent, having sustained three in less than six years. Discussions and speculations of what this means for Crosby's season, and even career, are populating the Internet and sports talk shows.

Despite the advances in sports medicine as it relates to concussion diagnosis, management, and return to play guidelines, concussions remain a challenging condition for all involved.

The reality is concussions are truly challenging. Despite measures to "prevent concussions", concussions are not preventable. There is no such thing as concussion prevention. There is no single piece of equipment, be it a helmet or mouth guard, that is capable of preventing a concussion. Rather than prevention, the focus is on minimizing concussion rates through proper identification, management, and education.

Consider that within the United States, there are over 300,000 sport-related concussions per year and research suggests concussion rates are on the rise. If your child is in contact sports, there’s a risk of concussion. Thus making this is an extremely relevant conversation and one that shouldn't be taken lightly. That said, the goal of this article is to offer insights into what a concussion is, how they should be managed, and the chiropractors potential role in the process.

What is a concussion?
A concussion is a traumatic brain injury defined as a short-lived loss of brain function due to trauma that resolves spontaneously. With a concussion, there is no structural damage to the brain. Simply put, only brain function is altered.

Encased within the the skull, the brain floats in a pool of fluid, known as cerebrospinal fluid.  These protections allow the brain to withstand many of the minor injuries that occur in day-to-day life. However, if there is sufficient force to cause the brain to bounce against the bones of the skull, then there is potential for injury. It is the impact of the brain against the inside of the skull that cause the brain to be injured and interrupt its function. This impact is often due to rapid acceleration and deceleration movements of the head and neck. Rapid acceleration and deceleration of the head and neck can be created from a direct blow to the head or from impact that results in whiplash injury common in motor vehicle accidents and falls.

How are concussions diagnosed and treated?
First and foremost, anyone suspected of having a brain injury should seek evaluation by a neurologist trained in concussion evaluation.

The signs and symptoms of concussion may be obvious or very subtle. Most concussions are sustained without the individual losing consciousness or "blacking out". In several cases, the individual may not be aware they have sustained a concussion or may not connect their symptoms with a head injury. Complicating the picture is the fact that some individuals may have delayed onset of their symptoms, not presenting with concussion symptoms for several hours or days after the initial injury.

Typical symptoms of concussion include:

  • Headache
  • Difficulty concentrating or feeling “foggy”
  • Poor recall or memory of recent events
  • Changes in mood or personality
  • Slower reaction times
  • Dizziness, lightheadedness
  • Nausea or vomiting
  • Low tolerance of bright lights or loud sounds
  • Irritability
  • Changes in sleep patterns, such as being unable to sleep or sleeping more
 
In some cases, chiropractors can be the first point of access for individuals who recently sustained a head or neck injury, such as those occurring in sports, car accident or fall. Chiropractors, especially ones who are certified by the American Chiropractic Rehabilitation Board, regularly manage athletes who suffer sports injuries, such as concussions, and are trained in proper diagnosis and understand the importance of referral for additional medical evaluation. Gallagher Performance offers such quality in their chiropractic services and has been part of the co-managment team in a number of concussion cases.

An effective tool chiropractors may use to assess the severity of a concussion is called the Sport Concussion Assessment Tool 2 (SCAT2). The SCAT2 is used to evaluate, assess, and manage concussions in athletes 10 years and older with the end goal of safely returning the athlete back to the sport.

How are concussions treated and what is the Chiropractors role?
After evaluation, rest is the best treatment. Depending on severity, most symptoms resolve relatively quickly while treatment is directed at symptom control for headaches, nausea, dizziness, and sleep problems. Rest does not simply mean physical rest. Brain rest is equally important as physical rest. Exposure to television, computers, and smartphones and other devices can stimulate the brain and aggravate symptoms. Limiting use of those devices may be helpful in allowing the brain to recover more quickly. Brain rest may also involve student-athletes being held out of the classroom and encouraged not to read, study, or taking exams as this mental effort can aggravate symptoms and possibly delay healing.

When it comes to management and, for athletes, return to play guidelines, often a team of medical professionals are involved. Chiropractors may find themselves as part of this co-management team.

Chiropractors may not be the first medical professional you imagine when it comes to concussion management and treatment, but sport and rehabilitation chiropractors are trained to support the patient during the recovery process. Largely this is due to their focus on treating spinal joint dysfunction present in the head or neck, myofascial techniques to restore muscular and connective tissue function, and sensory-motor based exercise protocols to restore ideal neuromuscular function. For further consideration, two recent literature reviews outlined how chiropractors can effectively manage athletes with concussions (1,2).

Ultimately, the brain will recover at it’s own pace. For athletes, return to play guidelines are established to ensure they are safe to return to sport competition. This involves the close observation of the athlete to ensure no symptoms are present during gradual exposure to increased cardiovascular demands all the way to more intensive and sport-specific measures.

Dear Patient, Be Patient
While 80 - 90% of individuals who suffer a concussion will recover within 7 - 10 days, some will experience symptoms for weeks or months. The length of recovery is not necessarily related to the extent of the initial injury.

Employers or school officials should be informed of the concussion diagnosis and aware of potential issues of poor performance due to difficulty with concentration and comprehension. Return to sport is fully dependent upon complete resolution of concussion symptoms and this decision should come from the neurologist overseeing care. Remember to be patient. The brain is a delicate structure and will heal with time. Don’t rush your recovery process. Returning too quickly can put you at increased risk for worsening your previous condition. Let the brain recover and reboot.

Gallagher Performance has extensive training and experience in evaluation and co-management of patients and athletes who have sustained a concussion. Our experience allows us to assist in providing gold standard care when it comes to concussions.

This blog post was written by Sean Gallagher, DC, DACRB, PES
To schedule your appointment, call (724) 875-2657.

References
Johnson, C.D., et al. Chiropractic and concussion in sport: a narrative review of the literature. Journal of Chiropractic Medicine 2013 (12):216-229.
Shane, E.R., et al. Sports Chiropractic management of concussions using the Sports Concussion Assessment Tool 2 symptom scoring, serial examinations, and graded return to play protocol: a retrospective case series. Journal of  Chiropractic Medicine 2013 (12): 252-9.
 
 

Advanced Training for Elite Athletes

The concept of sport-specific training has continually gained popularity over the years. It’s a growing market and business-minded individuals are taking notice. Similar to trends in functional exercise, you have a growing number of trainers stating they offer the “latest in sports training”. Frankly, anybody online can say their method or approach is the best. In a competitive market, people enjoy using words to attract your business. There are plenty of gimmicks that exist, namely in the world of speed training. Often times, athletes acknowledge such methods did little or nothing to improve on-field performance. If these gimmicks worked, it's simply because the athlete was a novice or of low qualification. Novices have the unique ability to respond to almost any form of training. But does this mean what was done is most appropriate? Does it mean training was efficient or effective? Not necessarily. When it comes to the training of higher level athletes, previously used methods and/or exercises will eventually fail to produce continual improvements in sport performance. There is a point of diminishing returns and training must adapt accordingly.

For any athlete, sport-specific training must ensure maximal transfer of the training program to on-field results. If exercise selection or organization has little carry over to making athletes better, you are wasting valuable time and money. Transfer of training can be summed up with the SAID Principle (Specific-Adaptations to Imposed-Demands). The SAID Principle has been proven time and time again in both research and training. This principle implies that training is most effective when resistance exercises prescribed are similar to the target activity or primary sport form/movement. Furthermore, every training method will elicit a specific (and different) adaptation response in the body. There must be compatibility between training and sport. This becomes of increasing importance as an athlete reaches higher and higher levels of athletic competition.

As mentioned before, research has demonstrated how exercises that once worked to improve sport performance for an athlete at a lower qualification level, will eventually lose training effect as the athlete gains mastery. For instance, indicators of maximal strength (squat 1RM) often have a direct correlation in low-level athletes, but lose significant correlation with enhancing sport performance in higher-level athletes. Similarly, movement abilities such as sprinting and change-of-direction (agility) are each separate motor tasks, characterized by specific motor abilities. Improvements in linear sprint speed and change-of-direction ability have limited transfer to each other and the degree of transfer decreases as an athlete progresses.

Thus, in order to enhance the sporting ability of high-level athletes, there comes a time when we must get more detailed than simply chasing increased strength and 'quick feet'. It’s inevitable. There is no way to avoid it. The world’s greatest Sport Scientists understood this and proved the need to go beyond traditional training approaches to see continual improvements in performance as athletes reached higher levels of competition. This is where the concept of Special Strength Training (SST) becomes of importance in the training plan.

Introduction to Special Strength Training
Pioneered by Dr. Anatoli Bondarchuk, SST has been incorporated for decades by coaches in other countries, mostly in the Olympic sports. Dr. Bondarchuk is most noted for his involvement in the throwing sports, particularly the hammer, and his results speak for themselves. It was Bondarchuk’s identification and implementation of special exercises with the highest degree of dynamic correspondence to the sporting movement that became the focus of his athletes' training plan. His organization of training allowed athletes to set world records and win numerous international and Olympic medals despite the fact that they did not possess the greatest strength in movements such as the clean, squat, or bench press.

Exercise Classification System
Bondarchuk classifies exercises into 4 categories:

  1. GENERAL PREPARATORY EXERCISES are exercises that do not imitate the competitive event and do not train the specific systems.
  2. SPECIAL PREPARATORY EXERCISES are exercises that do not imitate the competitive event, but train the major muscle groups and same physiological energy systems as your sport. However, movement patterns are different.
  3. SPECIAL DEVELOPMENTAL EXERCISES are exercise that replicate the competitive event in training but in its separate parts. These exercises are similar to the competitive event, not identical.
  4. COMPETITIVE EXERCISES are exercises that are identical or almost identical to the competition event.
It’s important to note that as an athlete rises from general preparatory exercises to the competitive event, each category on the list becomes more specific and will have greater dynamic correspondence to the athlete’s sport. Thus, as specificity increases, exercise selection decreases. There are hundreds of exercises that potentially could be considered Preparatory exercises. Preparatory exercises prepare the body for more specific sport training, while Developmental exercises aim to develop strength and technique. Special Developmental and Competitive exercises have the highest degree of transfer. The greatest focus from a planning and organization standpoint is placed on these exercises in order to yield improvements in sport performance. At this point, exercise selection has narrowed greatly. Often, the competitive exercise is simply the competitive event. In the case of a track athlete, the competitive exercise is considered the event (hammer, shot put, long jump, 100m, etc). This can also include subtle variations to the event. For team-sport athletes, the competitive event  is the game. The classification of exercises as they relate to specific athletes is not the scope of this article. That discussion is far too detailed and is always dependent upon the athlete, their level of qualification, and the competitive event.

In explaining SST, Bondarchuk said,
“General exercises have little relevance to the sporting action. Specialized preparatory exercises use the same muscles that are involved in a particular sporting action. Specialized developmental exercises include single joint actions that duplicate one portion of the sporting action. They also mirror the velocity and range of motion seen in the competitive movement. Competitive exercises are those that fully mimic the competitive movement in more difficult conditions and easier ones.”
Advantages of Special Strength
There are a number of advantages to programming SST within an athlete’s training program. Among many reasons, arguably the most important application of SST is the development of strength as it relates to specific movement and skill execution in an athlete’s sport. This advantage cannot be overlooked since very few approaches train physical qualities (strength, power, work capacity, etc) and technical skill development simultaneously. Programming should provide the avenue for athletes to achieve higher levels of sport mastery. Rather than applying appropriate programming, many trainers get caught chasing quantitative numbers (squat or bench 1RM, 40 yard dash time). While focus on general motor abilities is important for the novice athlete and provides performance-enhancing benefits, they lose their carryover for the more advanced athlete. SST ensures that strength gains will have a direct transfer into sport technique and skill development.

Special Strength is Task-Specific 

The effectiveness and accuracy of exercise selection within special strength training is dependent on a thorough understanding of what a given athlete is being asked to perform in competition. Selecting an exercise is great, but you have to put it into a program and a plan. You need to know your athlete and what exercise(s) works well for them. For team sports, task-specificity also takes into account that you understand the athlete’s position and the physiological/energy demands relative to their sport. Care must be taken to stay within certain parameters, above or below, the sporting movements to avoid yielding negative adaptations on the expression of sport skill. For example, applying loads that are too heavy will negatively influence technique by causing breakdown in mechanics that are important for developing speed strength. Speed strength is essential for throwing, jumping, and sprinting. Conversely, loads that are too light will also have a negative influence on mechanics since the lack of resistance with fail to promote the building of specific strength.

Summing It All Up
This article attempted to offer insight into the concept of special strength training and how it correlates with higher levels of sport mastery. Due to the nature of SST, it’s important to keep in mind that early specialization in training, similar to early specialization in sport, can occur too soon. Athletes like NHL stars Sidney Crosby, Jonathan Toews, and Henrik Zetterberg (pictured above) don't train like novice, youth hockey players and young hockey players should not be training like them. Research has proven that athletes at low levels of training and physical ability need to focus on increasing general physical qualities such as strength, as strength will carry over greatly to movement speed. In fact, novice trainees have the ability to attain simultaneous increases in strength, power, coordination, speed, core stabilization, proprioception, and reduced injury risk. However, as an athlete reaches higher levels of mastery, effectiveness of basic training methods become limited quickly due to the specificity of movement and skill related to sport.

If you are unclear on how to properly utilize the training methods of SST, you should not blindly implement SST into your training. The incorrect application of exercise and program variables would likely have a negative affect on the neuromuscular actions involved in sport movement. Athletes looking to ensure the best results from SST would be wise to have their training overseen by a coach/trainer who is knowledgeable and competent in its application.

Sources

Bondarchuk. Transfer of Training in Sports. Ultimate Athlete Concepts, 2007.
Siff & Verkhoshansky. Supertraining. Ultimate Athlete Concepts, 2009.
Verkhoshansky. Fundamentals of Special Strength-Training in Sport. Sportivny Press, 1986.