Are you an athlete? Is your kid an athlete? Are you more of a weekend warrior just trying to stay healthy? Whatever your situation, it’s likely you’ve thought about injuries. Whether you’ve had an injury, know someone who’s had an injury, or just don’t want to ever get an injury, the thought of “injury” has certainly crossed your mind. With that, hopefully this comes to mind: Injury Prevention. This blog post will cover just that. You will learn about the perfect injury prevention program, and it may not be what you think it is.
Before we delve too much into the ‘ins-and-outs’ of injury prevention, it is important to understand who the injury prevention is for. How old is the person, and how old is the person? (That’s not a type-o).
Chronological Age vs. Biological Age vs. Training Age
Typically, these age definitions are more applicable to children/adolescents/teenagers (which will make sense shortly), but can apply somewhat to adults (which I will touch on later). For now, a clarification on each definition.
Chronological age: how many years and months old is Person A (let’s call him Mike). Mike was born in January 2006. Today is June 2018. Therefore, Mike is 12 years old. More specifically, Mike is 12 years and 5 months. Therefore, he will play Under-13 hockey. As many of us have seen, not all Under-13 hockey players are physically the same. Read on.
Biological age: this is far more complicated, and probably warrants its own blog post. In short, you need to calculate the maturity offset of the individual (i.e. predicted years from their peak height velocity). (Peak height velocity is the period of time in which a child experiences their fastest upward growth in their height – i.e. the time when they grow the fastest during their adolescent growth spurt). On average, this happens in females at age 11, and in males at age 13.
In adolescents, you can calculate this with anthropometric measurements (i.e. age, height, etc.). Calculating this in adults is much more complicated. If you are interested in reading more about this, check out Klemera & Doubal's article here, Mirwald and Baxter-Jones here, and Ford et al here.
Why does this matter? In very short, our chronological-aged Mike from earlier who hit his peak height velocity at age 10, may therefore require a different training regime than his buddy Maverick, who is still 2.3 years away from hitting his peak height velocity. This would apply even though Maverick was also born in January 2006 (12 years, 5 months old). If you want additional clarification, check this out.
Training age: refers to the total training time (experience) the person has in their sport (or in that aspect of training - i.e. weight lifting or agility training). Fairly straightforward definition; often overlooked in practice.
Why did I tell you this?
The primary reason I chose to outline these differences is because training age and biological age (even a prediction of whether or not the adolescent has hit their peak height velocity or not), can help determine a more appropriate training focus (more so than chronological age, especially in those aged 8-18 years). Consider 2 new made up children who are both 13 years old:
Of course, Charlie and Kenny are the extremes, but it hopefully illustrates my point that the training (read: Injury Prevention) programmes for these two individuals will probably be quite different, even though they both play Under-14 soccer (they could even be on the same team!)
In children/adolescents: evidence suggests that preadolescents (i.e. Kenny from above) benefit most from sprint training and plyometrics (high levels of neural activation). While adolescents (i.e. Charlie from above) benefit more from training types which target both neural and structural development (strength training and plyometrics).
In adults: it is important to consider training age when formulating an exercise program. If you are you going to target strength changes via weight lifting, how much experience does the person have with weight lifting? 15 years of good weight lifting form, practice, and consistency? Great, you can probably try most things. Never lifted a weight in their 35 year lifespan? Maybe start a little more basic and progress slowly.
Here’s a tough pill to swallow: injury prevention might not be entirely possible (based on current evidence, anyways). To my knowledge, the only true risk of injury is a previous injury (and maybe gender for a few types of injuries). The risk of reinjury is usually higher when you first return to the sport and it weans with time. That’s right, with time. Often, we don’t give ourselves enough time to heal, and that could be a big part of re-injury.
Additionally, many injuries may be considered ‘unavoidable’, or have nothing to do with the athlete/person’s inner strengths, (im)balances, and (in)abilities. For example, you could step in a pothole while running, another player could collide with you (accidentally or on purpose), or the puck/ball could hit you in the arm/foot/head.
The Perfect Injury Prevention Program
After reading the last two paragraphs, you’re probably wondering how there could be a ‘perfect’ injury prevention program. Well, that’s just it, because there is no scientifically agreed upon, completely proven, 100% successful injury prevention program, the one I’m going to outline is as perfect as it gets :) .
Before we get into the next part of this blog post, it is important to note that everything in this blog post is for information purposes only. This blog post is not intended to be strict medical or exercise advice. Everyone is an individual, and therefore, individual variances do occur. It is important to consult your physiotherapist, doctor, or exercise scientist for the most applicable advice for you.
Injury Prevention Program - General Steps to Success:
Step 0: Make Sure You’re Not Already Injured
Step 1: Ensure Appropriate Mobility
Step 2: Build Basic Strength
Step 3: Start to Gain Power (Learn Plyometrics)
Step 4: Gain Real Power and Train Perturbations
Caveat: Where you start with the above Injury Prevention Program, how much you focus at each level, and how fast you progress will depend entirely on your previous experience, ability to safely perform exercises, and your individual variances. Hopefully some of the introductory discussion of this blog post will help you decide where approximately you sit (remember biological and training age). When in doubt, progress slowly, monitor your body’s responses, and enlist the help of a professional.
Why This is the Perfect Injury Prevention Program
The perfect injury prevention program is individualized. It’s based on an individual’s strengths/weaknesses, goals/ambitions, and sport/activity. Therefore, the injury prevention program outlined above is perfect because:
Further, it is highly likely that as you work on building a resilient body, you will be blending the steps together. In general, they are a progression. However, once you make good progress, it’s important to remember the value each step has on your overall abilities. Just because you can complete high-level plyometric training, it certainly doesn’t mean that you should stop trying to improve mobility/control, and strength.
When we’re talking about progress, you may be thinking how quickly can I move through these steps? When do I know how to take the next step? Can I get injured by progressing too quickly? Recently, researchers have come up with a great way to track your progress, and to help guide your training, thus reducing injury risk. The calculation they’ve used is called the acute to chronic workload ratio. In a nutshell, it’s used to measure the amount of exercise you’ve done over the past week compared to the past four weeks. If there’s a large difference, you’re at a potentially higher risk of injury. A lot of this research has been based on adults. There’s more that needs to be done for adolescents. This also warrants it’s own blog, so for further information about this ratio, check this out.
The Additional Steps to Make This Program More Perfect-er
Unfortunately, many injuries are unavoidable. That being said, building a resilient body helps prepare you for the variety of forces that could be placed upon it with sports/exercise. Slowly, and progressively work on your athleticism. Work hard. Rest hard. Get help when you need it.
At Strive Physiotherapy and Performance, we are committed to providing an in-depth assessment to ensure we can work together to find the best plan of action for each individual client. Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists.
Tyler Allen and Mike Major
Physiotherapists at Strive Physiotherapy & Performance
When you have an injury, decreasing the amount of pain you are experiencing is often at the forefront of your mind!
For physiotherapists, we are considering MANY factors in your recovery: your range of motion, the strength of your muscles, getting you back to work/your sport, and preventing future injuries. However, we recognize that uncontrolled pain can be a barrier to achieving these goals. Physiotherapists (and other health care practitioners you may have seen) can do many different techniques in order to reduce the pain that you experience with movement. Two different health care practitioners may do completely different treatment techniques, and both may have the same effectiveness in reducing pain with movement.
It is important to keep in mind that these techniques help you move more easily, which helps your injury heal. Your physiotherapist will walk you through exactly what type of movement will be the best to help your specific injury recover.
Before we get started, let’s review the basics.
What is pain?
In your body, you have receptors that tell your brain information about what is going on. There are receptors that collect information about temperature, stretch, and chemicals (among other things!), and send that information via nerves up to the brain to decide what all that information means.
Do you know where your pain receptors are?
...They don’t exist.
That is because pain is actually an OUTPUT. Your brain collects a massive amount of information and uses all the information at its disposal to create an output of a painful sensation if it decides there is a threat to your body. This is a good thing in a lot of cases - this sensation tells you something is wrong and to do something about it! It will help prevent the situation below:
If you get an ankle injury while you’re playing soccer, the pain the you get at the time of injury will prompt you to sit out of your soccer game, therefore preventing any further injury to your ankle.
As you progress through your recovery process, your brain also will use lots of seemingly unrelated information to create that output of pain. Have you had a super stressful day and are pulling your hair out? You may find that your pain is a little worse. Are you having a zen, calming, sunshine and rainbows day? You may find that your symptoms aren’t so bad. Check out the chart below for more things that can impact your pain level! The effect of each part of the pie is different for everybody.
Does pain sound really complex? It is! Because of the complicated nature of pain, there are lots of factors that could make your pain worse, but also lots of ways to improve your pain!
Here are 5 “tricks” that physiotherapists can use to help decrease the pain you have with movement - and I’m going to explain each one!
IASTM stands for Instrument Assisted Soft Tissue Mobilization. You may have seen the physiotherapists at Strive Physiotherapy & Performance using this crazy looking tool:
This is a stainless steel tool which physiotherapists can use to GENTLY scrape the skin over areas that are painful. At Strive Physiotherapy & Performance, we use this treatment in a way that does not cause bruising or skin irritation. This provides a novel input into your nervous system that is not a danger to your body. It’s going to fire off more receptors in the area to send feedback to your brain. This helps to decrease the level of threat in your nervous system. More specifically, effects can include improving your brain’s awareness of where your body is in space, and reducing muscle tone. This is a very gentle treatment that can be used on many areas of the body (whether it’s a small or large area!).
There is a type of cupping that uses fire underneath the cups - but don’t worry, we don’t do this type of cupping!
The type of cupping done at Strive Physiotherapy & Performance is with a soft silicone cup. Check out the video below!
The cup is squeezed gently and then applied to the skin with a little bit of cream to create a gentle suction force. Then the cup is slid along the skin in the areas we are looking to reduce pain in - typically over muscles. By keeping the cup moving, it is less likely to create a bruise mark underneath the cup. While there are different sizes of cups for different areas of the body, this treatment will be more effective on more flat surfaces so that it doesn’t lose suction (ie. probably not your finger or over very bony areas!). Instead of a force being applied into the tissues (like in massage), this treatment provides a “suction” force. This can increase blood flow and stimulate your nervous system to decrease the pain of movement.
Moist heat is a treatment that can be helpful to warm muscles up, and help decrease the amount of pain in the area. It also helps to increase blood flow! This has a number of great effects including bring more oxygenated blood to muscles. Just like any of our other treatments, it also has an effect on your nervous system. It’s an input into your nervous system that is safe and comforting, which can reduce the output of pain. 10-15 minutes can do the job. The heat should always feel comfortable, and never so hot that it’s painful! Our hot packs at the clinic sit in a hot water tank - that’s how they stay toasty warm!
4) Compression bands
One way to help movement feel better for your joints is to wear a compression sleeve. While this works really well for some areas of your body, other areas may benefit from some compression too! We can use a compression band in order to provide a “hug” to your limb, and then move your limb. Again, this gives more information for your receptors to collect and send to your brain, therefore reducing the output of pain or the sensation of stretching/pulling you feel. Take a look at the video below!
One of the MOST IMPORTANT techniques that physiotherapists use to help movement feel better is just that : more movement! While you may find that “everything hurts”, usually we can find a movement that either doesn’t hurt, or hurts less the more you do it! Our bodies are very responsive to movement throughout our day. If we move too much, our brain may respond as if a threat is posed to our body. This level of threat can already be really high if you already have an injury, and therefore movements which normally feel good may be painful. However, if we don’t move at all, our body gets used to not moving, and you may be able to move even less! You often hear people say “just rest up and you’ll get better” - this usually isn’t true for most musculoskeletal injuries. “Relative rest” is the better way to rest. This means that you are perhaps taking a break from higher activity levels that are aggravating your symptoms, but keeping all the movement that doesn’t aggravate your symptoms, and also adding in some extra movements that are going to facilitate your recovery the best. Does this sound complicated? Don’t worry, this is what physiotherapists love to do! Physiotherapists will tell you what to do, what not to do (for now!), and what movements you will be working towards getting back to. And this can change over time! The movements you are working on this week may be super easy next week. Then you’re ready to progress to the next stage of exercise. A progressive exercise program over time will ensure you continue challenging your body to be able to do more.
While it can seem like some of the treatments physiotherapists or other health care practitioners use are “magic”, there should be scientific research or a biological mechanism through which the treatment works. It’s “magic” or “it just works” is not a good enough answer! Not clear on what a treatment you’re getting is doing? Just ask! The more you know, the better you can understand your recovery process.
These are just some of the many treatment options there are to reduce pain with movement. Your therapist may choose different treatments depending on the person, the injury, and the stage of your recovery. These treatments are also often TEMPORARY. They can create a “window of opportunity” to get you moving more easily, but if you don’t take advantage of that window, you may find that you’re back where you started. The most important lesson here is to get moving.
Do you have painful movement that won’t go away? Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists, and they will perform an assessment and create a treatment plan for you.
Physiotherapist at Strive Physiotherapy & Performance
I am not a doctor. I did not study neurology past my first-year psychology classes in university, nor do my six years of studying sociology help me to better understand the science behind concussion recovery. What I do have, is first hand experience of the lack of answers out there for treatment and recovery expectations. If there is someone in your life who has suffered a brain injury, or if you have yourself, I invite you down my rabbit hole. We’re taking recent research of Traumatic Brain Injuries (TBIs) and Post Concussion Syndrome (PCS) and breaking down the facts, to offer a better understanding of what is going on after a serious blow to the head.
Point of Impact: The Concussion
Concussions are not restricted to athletes, although the sports industry may be the most common place to hear of the injuries. Car accidents, falls, work incidents, and physical violence can all lead to a concussion. A concussion is the forced impact of your brain against your skull. Considering the plethora of mysteries we have yet to solve surrounding brain function, we sometimes forget how much the brain is affected after a concussion. All of your senses, thoughts, personality, memories, and basic functioning happen because of your brain. When such a vital organ gets injured and jostled around, there can be devastating effects.
A brain injury can also occur as a result of whiplash. Just because your head did not make direct contact with another object, does not mean you are in the clear. Whiplash causes hyperextension and hyperflexion in your neck within milliseconds. This rapid bending to your neck’s extremes not only causes neck injuries, but as the head is thrown backwards, your brain collides with the front of your skull, resulting in injury to the frontal and temporal lobes. When your head is thrown forwards, the opposite occurs, and your brain collides with the rear of your skull which can injure the occipital lobe and cerebellum. It is important to note here that every incidence of whiplash does not bring a concussion, and this should in no way be used as a tool for diagnosis. Now for those of us who no longer remember high school biology, the frontal lobe controls writing, speaking, personality, behaviour, concentration, problem solving, and motor control (so only minor importance, right?). Your temporal lobe is responsible for comprehension of languages, memory, sequencing, and hearing. Meanwhile, your occipital lobe interprets your vision for movement, light, and colours, and your cerebellum controls balance and coordination.
When seeking diagnosis of a concussion, not every doctor will have the same protocol, so I will be discussing only what has been most common in my geographical area. If there has been a loss of consciousness, it is advised to seek immediate medical attention. However, the official ‘concussion’ diagnosis may not be given unless symptoms persist beyond 48 hours. Again, this is not medical advice nor is it official protocol, so if you experience something different, don’t be alarmed. The severity of a concussion has changed in name several times over the years, and so you may find two different doctors use different scales. A scale commonly referred to in the past was mild, moderate, and severe concussions. This was also translated into ‘grades’:
Grade 1: no loss of consciousness, and either no memory loss or memory loss that subsides after 30 minutes
Grade 2: loss of consciousness for under five minutes; memory loss anywhere between 30 minutes and 24 hours
Grade 3: loss of consciousness for more than five minutes and/or memory loss lasting longer than 24 hours
This grading system has changed since its conception in 1998, and some medical professionals choose to disregard the scale entirely, and instead choose to simply diagnose brain injuries as either a concussion or a TBI. Now, is there a real difference between the two? No. A mild Traumatic Brain Injury (mTBI) is just a fancy way of saying concussion. Since there is no official grading scale for brain injuries, and what new research determines is in constant flux, there is not going to be a consistent measurement or diagnosis.
Surprising to some, 90% of diagnosed concussions do not involve a loss of consciousness. This means that just because you didn’t pass out doesn’t mean you should not take your hit to the head seriously.
Some TLC: The Recovery
If you thought defining a concussion was difficult, now is a great time to grab a snack and get comfy. With all the uncertainty that still surrounds the brain and its three-pound grey and white mysteries, it isn’t surprising that treating brain injuries is like playing leapfrog with a unicorn.
There are some myths surrounding the do’s and don’ts of concussion recovery. The key to remember is to treat your brain injury like a really bad muscle injury. If you can’t put weight on your ankle at all, you aren’t going to play in your soccer game tonight. If you do, you’ll find out rather quickly just how bad of a decision that was, and your injury will feel worse. The same thing happens with your brain; the problem is that we use our brain for e-v-e-r-y-t-h-i-n-g. Dimming any screens, wearing sunglasses indoors, earplugs, and taking a lot of naps are all common in the days after your concussion. It used to be taught that sleeping immediately after a concussion was the worst possible course of action, however recent studies have shown that the more you let your brain rest, the better! Yes, that does mean daytime naps - yes, it is glorious.
In the past, it was also thought that exercise was detrimental to concussion recovery. Recent studies have actually found that exercise does not lengthen recovery time in athletes with concussions, and researchers from Ohio University Heritage College of Osteopathic Medicine found that those who exercised during their recovery had a shorter time span between seeking medical attention and recovery (you can read more about their research here). This, and other similar research, was used in the new guidelines from Concussion in Sport Group, saying that “patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds.” Start slow, and don’t continue to exercise once your symptoms begin to increase. If you are cutting grass or shovelling snow and you have an onset or worsening of symptoms, do not continue to exert yourself. Rest, to allow your symptoms to subside.
Vestibular physiotherapy is a great plan of treatment for post-concussion rehabilitation. It deals with eye movements, eye tracking, balance, and motion sensitivity. Your vestibular system senses linear and angular speed, head movements, as well as sensing your head’s actual position in relation to the space around it. The most common symptoms for post-concussion clients seeking vestibular physiotherapy include dizziness, nausea, problems with balance, headaches, blurred vision, and sensitivity to visual motion (eg. motion sickness). Vestibular treatments can include head eye coordination exercises, eye tracking exercises, ocular-motor exercises (which help your ability to look quickly from different targets and your ability to turn your eyes inwards to look at an object), and balance exercises. Below I have added some pictures of a few of the more common exercises for vestibular physiotherapy.
Here we have two objects or targets where you first practice moving your eyes from target to target without moving your head. The second part to the exercise is to look at the first target, close your eyes and turn your head, then open your eyes to look at the second target. As is true with all of your concussion rehabilitation exercises, once your symptoms increase, stop. Time how long it takes your symptoms to return to ‘normal’ or your ‘base’. Ideally, in time, it will take less and less time for your symptoms to go away.
This is the infamous Brock String. Holding one end of the string against your nose, and the other either tied to a stable object or attached to a wall, the beads are spread along the string at various intervals. The goal is to be able to shift your focus to each bead without feeling like you are going to vomit or have your head implode. Feeling like you just stepped off of a roller coaster or wanting to hit your physiotherapist may also be experienced with this exercise.
In this exercise, you hold the paper a fair distance from your face and start looking at the letter A. You want your eyes to track A,1,B,2,C,3, and so on. I find it helpful to say it out loud as I go, that way I know I am doing it in the right order (we hope).
The Happily Ever After: Maybe
For roughly 80% of people, your concussion will be fine after 7-10 days. The remaining 20% often recover within 3 months or less. What happens after that three months is often determined by how many concussions you have suffered previously. In short, if you’re going to hit your head, don’t. If a life-changing experience is what you’re looking for, go do some serious volunteering. We are talking about leapfrog over a freaking unicorn people.
When you have at least 3 symptoms persisting past the 3 month threshold or your Doctor’s expected time of recovery for you, we welcome you into the PCS family (again, this is more of an observed guideline not a rule, and can change depending on the doctor). Post Concussion Syndrome (PCS) is like permanently housing the Dursleys. The symptoms go far beyond physical difficulties like vomiting, balance, dizziness, light/noise sensitivity, and headaches. There are cognitive symptoms such as difficulty concentrating, memory, or feeling slowed down. My personal favourite cognitive symptom is ‘feeling in a fog’ which is something that makes zero sense until you experience it for yourself. A friend once shared a video that explained it as ‘staying awake for three straight days then trying to calculate advanced quadratic equations’ - I had always just described it as feeling drunk when you’re completely sober. Beyond physical and cognitive, there are sleep problems and emotional symptoms. Feeling more emotional or irritable are symptoms of PCS, as are anxiety and depression. If you suffered from mental illness prior to your concussion(s), do not be alarmed if your mental health declines. Speak with your support systems and doctors, and make sure you stay on top of it. Just know that you are absolutely not alone, your PCS family has been (or is still) there, and you WILL be ok.
If you need someone to talk to or having trouble coping with your mental illness call 1-844-437-3247 (Waterloo-Wellington Region) or visit http://www.yourlifecounts.org/need-help/crisis-lines for the list of international support lines.
I was diagnosed with PCS in 2013, and have used way more sticky notes since then than I had ever thought possible. However, just because I have been dealing with this for the past five years does not mean I have not shown significant progress. Below I have added a snapshot of where I was at in 2015 after I was hit in the head again, versus where I am today.
This progress was not miraculous, nor did it come easy. Physiotherapy takes a lot of hard work, and you have to commit to your exercises. Since 2013, here are the tricks and treatments I found worked best for me (again, not a doctor, this is not medical advice):
The emotional side effects of PCS are by far the most difficult to deal with. Accepting that the person you used to be is no longer the person you are, is incredibly difficult. (You can read more on that here). Once you have overcome this incredibly difficult challenge, you then have to re-introduce yourself to your friends and family. No part of PCS is easy or simple, nor should we expect it to be. Our brains are still an area where we have only scratched the surface of understanding. Recovery from a head injury is complex, and no singular solution is going to work the same for each person. It is incredibly frustrating to not have a solution to a problem, especially when it concerns your health. Unfortunately, this is a reality we face with PCS. The best thing you can do is be aware of your limitations, track how your symptoms are doing day-to-day, and work with your trusted health professionals. If you plateau, or stop showing signs of improvement, don’t give up! The brain can do a lot of incredible things, and it may take its sweet time to recover.
My main advice: take preventative measures, be cautious. Do not hit your head again. (Coming from the girl with double digit concussions...)
Still not sure what your findings mean, or what to expect with your injury? Call us at 519-895-2020, or use our online booking tool on www.strivept.ca to book an appointment with one of our knowledgeable physiotherapists, and they will be sure to help you understand your injury.
Best of luck on your road to recovery,
Administration and Social Media Coordinator at Strive Physiotherapy & Performance
Strive Physiotherapy & Performance
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