Stair Training 101

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It's that time of year, again!  Time to stair train for the annual Climb to the Top for Multiple Sclerosis. I've previously written about this fundraiser here where I describe climbing New York's Rockefeller Center's 66 flights of stairs. This will be my fifth year participating with Team Kapniss - the Top Fundraising Team - in honor of my friend Leigh, who has MS.  Interested in donating? CLICK HERE.

Last year I completed the Climb in 23 minutes and 45 seconds and it is always my hope to do it faster than the previous year.  Over the past four years, I've cut seven minutes off my time, improving annually,  so now I've had four previous rounds of trying different training methods to see what has worked and what hasn't.  While everything has helped me improve - I think the biggest benefit has come from strength training - ie lifting weights - along with stair intervals and what helped the least was working on running endurance.  I had listed out in this blog post my 2018 training program - which was going really well until summer came and I just wanted to enjoy the sunshine and my kayak.  So now I'm back to developing my training program for this upcoming climb, mostly starting in a de-conditioned state, I'm definitely up in weight which will also be something that can slow me down.  I decided I'd use this opportunity to share more about the health benefits of stair training and discuss the ways I use stairs in patient care.

Livestrong.com has a nice article here that describes many of the health benefits of stair training.  It's cardiovascular exercise, so it helps build up your endurance and burns calories, but it also requires strength to propel yourself upwards against gravity!  Stair training is a difficult activity that can burn a lot of calories in a short time. Depending on how you're using the steps - you can target your aerobic or your anaerobic training systems using stairs.  If that's unfamiliar to you - a brief explanation is that your muscles make energy in different ways.  With long distance activities over a longer period of time, you will use oxygen to make the energy for your body to function - an aerobic activity.  For shorter bursts of energy, your body will make energy without using oxygen - an anaerobic training system.  (There are actually three systems the body uses for this, but for now - that's probably all we need to discuss).  Depending on your daily activity or the demands of a sport or activity you participate in, you may benefit from training aerobically or anaerobically or focusing on both of these systems.

In the clinic, I use step up and step down variations for numerous reasons.  We have steps of varying heights ranging from about 4 inches to metal boxes that are 18 inches high as well as a small stair case.  We use them to help with strengthening one leg at a time with optimal form. For example, someone who has knee pain or recently had surgery on their knee might not yet be strong enough to climb the stairs "normally."  But they may be able to go up and down a smaller height, so by practicing, they can improve their strength and form with the activity to progress up to higher steps until they are back to their usual level of function.

Stepping up onto one foot also challenges balance.  To stand on one foot on the ground requires control at the joints in your foot, ankle, knee, hip, pelvis, and core.  That's a lot of things to control!  Sometimes I work on balance from the ground-up... standing either on the floor on one foot or on various objects like a wobble board or bosu ball or airex pad. This makes you control all of those things at the same time, unless you're working on one of those activities sitting down and taking out the joints above the knee.  A step up exercise also works on balance from the ground up.  Sometimes I also train balance from the core/pelvis downwards - working in kneeling or quadruped (on hands and knees) positions so that you're taking the knee and foot out of the activity.  Either way, every time you go up a set of stairs, you're standing on one foot at a time and need to be able to balance and control all those joints - or you need to hold on to prevent yourself from falling over.

Recently I was working with someone who is recovering from an ACL reconstruction who is getting close to returning to soccer.  When thinking about soccer, it's easy to picture a lot of running and kicking, but people often forget about the amount of jumping that is involved.  You jump to head the ball or to kick the ball higher in the air or to change directions or to avoid an opponent. So we were working on some box jumps in the clinic.  With two feet, he could easily jump up onto the 12 inch box.  Piece of cake.  With his non-surgical leg, he could jump 12 inches on one foot.  But he couldn't get himself to jump up 12 inches on his surgical leg alone.  I've written about my own experience being unable to jump onto a 12 inch box before in that same post linked above - but watching a patient experience that block and then overcoming it was different than dealing with it myself.  We worked our way up to it two inches at a time, both jumping up and down, until he was able to jump that high.  Part of this is a confidence issue - where your brain doesn't think it can be successful, so it inhibits you from trying.  How cool is it that if your brain doesn't think you can land - it (usually) won't let you jump? By learning that he could land from a jump that high and from progressive heights below it, he was ultimately successful.  It was a big win for him and fun to see such a change in ten minutes in the clinic.   Even better was that he was still able to do it at his follow up visit - and right away!

When training on stairs, you have to consider going both up and down.  So basically you're going to be using all the muscles in your legs and core - and if you use a hand rail or swing your arms - you're going to get the upper body and chest and back involved too!  All those joints I mentioned before that are involved in balancing - the muscles around those joints are needed to stabilize you and propel you up or control your descent.  The other thing to consider is that one leg is moving while the other is holding you up.  So it's a complicated activity that also requires coordination.

So, if you're looking for a new training activity to try out - stair climbing is an option you can consider.  Today I did a short training session of 450 stairs in 10 minutes on a stair climber machine and I'm convinced that the machine is considerably more difficult than being outside on the stairwell, but I didn't have to go back down when I ran out of stairs because on the machine, they just keep coming! 

Again - please consider a donation to the National MS Society in support of my Climb to the Top.  Link above.  And if you want to go climb some stairs around Seattle together, just let me know!

What Do Physical Therapists Do? Installment #5: Emergency Response

REI Seattle Outdoor Space

Welcome back to the recurring segment on the blog: "What do Physical Therapists Do?"  I've previously written four other posts on this topic, all tagged with #WhatDoPTsDo so you can search the blog for those previous posts if you're interested.  I spent the last two days getting my certificate in Wilderness Emergency Response and First Aid hosted by the REI flagship store in Seattle.  (Beautiful fall weather and somehow managed to get out of there without buying anything!)

Before you get too far into this, you should know that in general, many physical therapists are not trained for emergency response care.  As trained healthcare providers who usually have training in CPR and First Aid, I would think that a physical therapist would be better in an emergency than someone without any training - but in general we're not trained for emergency response.  But we can be!  This is a key difference between physical therapists and athletic trainers where, generally, physical therapists are not present when an injury occurs and help rehabilitate the injury days or weeks (or sometimes much more time) later.  Athletic trainers are specifically trained to respond at the time of an injury or to an onset of illness to the athletes they work with. There are many ways in which PTs and Athletic Trainers With regard to urgent response, athletic trainers and educated physical therapists also differ from EMTs in many ways.  In the case of an emergency, 911 is still your best bet, but since I just attended the course, I thought I'd share why I would learn about emergency response and some of the tips and tricks I learned.

The class was structured with didactic learning intertwined with case scenarios.  We'd learn how to assess a patient and then practice in groups. Then we'd learn about various signs and symptoms of different conditions and then assess patients again.  There were numerous repetitions and they even used makeup to make bleeding/bruising so that you were looking for injuries to treat.  Conditions we discussed included musculoskeletal injuries - like I'm used to treating - and special focus on injuries to the spine, plus wounds, burns, weather-related conditions, abdominal pain, chest pain, allergic reactions.  We learned basic treatment techniques to help determine needs for evacuation/emergency care as well as splinting and wound care.

Fake Makeup Hand Injury

Why would a physical therapist get trained in emergency response?  Many physical therapists are also athletic trainers and, as such, need to keep their education current to best treat urgent cases.  There are, however, PTs who are not athletic trainers who also provide sideline coverage for sporting events (like myself with the Seattle Storm) and who can take these advanced courses in order to work towards board certification as a Sports Certified Specialist Physical Therapist.  For me, personally, I was also an EMT in my previous life and have always loved learning about urgent response.  I like knowing that I can be a helpful resource in an emergency situation.  The courses are also great reviews of basic anatomy and common illness or injury situations.

Key tips and tricks I learned in this course:

1) If you ever come across a person or group of people who are in need of emergency response, you must first make sure that the area is safe.  Otherwise you risk becoming an additional victim!  A person who fell off their bike in the middle of the street or someone who experienced a snake bite are both scenarios in which you could be putting yourself in danger and need to consider the surroundings before you can really provide adequate care.

2) Once the surroundings are determined to be safe, start with the key life threatening findings which are remembered by ABC.  Airway.  Breathing.  Circulation.  If a person is sitting up and talking to you after an injury - their airway is open and they are breathing and have a pulse - but you should still look for major bleeding that can impact circulation.  Nothing else matters if the person does not have an adequate airway, respiration, or circulatory system because those are life threatening situations.

3)  Medicine happens at the skin level.  This is something that was discussed a lot in PT school and I appreciated this reminder.  If someone says their shoulder hurts - LOOK AT THEIR SHOULDER! I remember a case we discussed in school where a patient came to PT complaining of back pain.  He went to the doctor first, was given pain medications (that weren't helping) and was sent to PT.  The physical therapist started their examination by lifting up the shirt to look at the back and see if there was any bruising - only to find a large rash.  PT wasn't going to help that condition.  Once life threatening conditions are ruled out, an injured person should be assessed from head to toe and any pain region should be exposed.

4) Failing to prepare is preparing to fail.  Take a first aid kit with you when you go hiking or backpacking in the woods.  At the very least, have the ability to splint an injury, protect injured skin, and stay hydrated and energized with enough water and food.  And always tell someone where you're going and when you should be back.  If you don't return by a certain time, they should send for help because if you're stuck in the wilderness with a major injury, you're going to need help.

5) Injuries may be easy to see, but illness may not be.  Things like heat exhaustion, altitude sickness, hypothermia, allergic reaction, diabetic emergency, or a heart attack are hard to identify if you don't know what to look for.  If you're concerned about someone feeling poorly but you can't see anything - you're better off calling for help!

I hope this is helpful if you ever find yourself in a situation where someone needs emergency care - but know that this was a 5 minute overview of a 2 day course, and that my EMT training was weeks long with ambulance calls and real life response training.  Again, you should always call 911 in an emergency situation, and only help a person in ways that you have been trained to do so.  If you're an adventurer, you should probably take a course in emergency response and/or first aid, whether or not it's specific to the wilderness, because many of the principles are similar.  I hope you go learn all this information and never need to use it!

Chronic Pain Clinic

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This morning I visited the pain clinic to observe patient examinations at the Seattle Children's Hospital- Bellevue location.  If you've read my blog in the past, you've probably noticed that I've taken a particular interest in chronic pain over the past two years having seen more and more children experiencing pain for an extended period of time.  I've written about chronic pain on several occasions - particularly referencing the books I've read - to better understand the science behind pain.  Some of those posts can be found here, here, and here.

Today's post isn't about the science of pain... I've done a fair amount of that in the posts linked above.  Instead, this looks at how a patient experiencing chronic pain can be evaluated from a multidisciplinary perspective.  Each patient was started off with a whole group of healthcare providers interviewing the patient (and their accompanying parent). The providers included a physician, a pain psychologist, and a physical therapist. This was done so that the patient's story didn't have to be repeated numerous times when each provider evaluated them individually.   Since all of these patients had already seen a handful of healthcare providers to examine their symptoms, their stories have been told countless times.

When evaluating a patient experiencing chronic pain, it's important to discuss their medical history fairly extensively.  They started with the symptoms being experienced currently, and then worked backwards through pain experiences and previous conditions.  Things like how did your pain start?  When did it start? What has been done to try to make it feel better?  What makes it worse?  Describe your pain in words. Describe your pain in numbers on the pain scale.  What do you think is the reason for your pain?  It was very thorough - and sometimes the pain has been going on for so long that details have been lost along the way.   If I had stubbed my toe three years ago and ultimately developed chronic pain from that experience, I'm not sure I would be able to remember the details of my toe injury.  So the recall of the history is challenging enough - and then you go into so many other areas of life.

The group did a really great job at explaining to each family that pain can be really complex and that sometimes it takes a team working together to help guide patients through it.  While the conversation began with pain, it certainly didn't end there. Further questioning regarding previous treatments trialed up to this point were recorded.  All of today's patients had seen multiple doctors of different specialties - cardiologists, rheumatologists, surgeons, orthopedic physicians, and physical therapists - and they had also received multiple potential diagnoses for what may have been causing their pain.  This has to be super confusing for children and frustrating for parents.  It's also difficult to recall all the treatments that have been attempted over extended periods of time.  Painting a complete picture of the past is challenging.

And then the discussion transitioned into activities that pain impacts in their lives.  Are they going to school?  Are they regularly bathing?  Do they exercise despite the pain or can they not tolerate that? What activities do they like to do? Does it impact their time with their family and friends?  Is it at the same time of the day or does it come and go?  How is sleep?  It was a lengthy discussion, for all the right reasons.  It was interesting to see what came up from asking some questions that seem rather simple - but then exposed patterns in these kids lives.

After completing the medical history, the providers individually worked with each patient to further examine their areas of specialty.  The physician discussed past medical history of more extended family members, medications, hospitalizations, surgeries, things documented in the medical record, bowel and bladder function.  He did many components of a typical physical exam looking in the mouth, palpating areas of the body that are known "pain points," assessing flexibility, mobility, and strength and checking reflexes as well as using tools to assess response to temperature, sharp pressure, and light touch.

The psychologist also had an opportunity to have a one on one conversation with the child and parent as well as with the child alone to try to rule out any concerns with abuse or neglect and to further examine mental health.  These conversations further explored relationships with family members and friends, participation in school and recreational activities, any interactions with a therapist or counselor in the past, self assessment of mood, emotions, sadness, anxiety, depression, and suicidal ideation.  She asked questions about dating and relationships and about friendships.  It was interesting to see moments when the patient would feel as though their pain is worst when stressors int heir personal life were also increased - which doesn't always occur but did in one case today.

And the physical therapist also did an examination.  This is what I was most interested in observing, because I'm hoping to have the chance to use this knowledge more in my evaluation and treatment of this patient population.  The number of tests available to a physical therapist is extensive - so I kept wondering if we would have the patient do certain movement patterns or choose other components instead to prioritize the use of time.  The patients were observed walking and running, balancing, a cardiovascular test was done, squat pattern and plank form were screened, strength and mobility were assessed.  It was a more global assessment than is frequently used in the clinic for a more localized patient in an acute or shorter term pain pattern.

Then the providers sat down and compared notes on each patient and discussed what should be included in the patient care plan.  Were medications indicated?  Should they participate in PT and are there any particular recommendations for the patient to follow as a component of that treatment?  Should acupuncture be trialed?  Follow up with the pain psychologist for some counseling?  It was very interesting hearing the different providers discuss each patient with their pertinent findings and then each patient was provided with a plan and appropriate referrals for follow up.

My key takeaways of the morning were:
1) Pain presents very differently from person to person and oftentimes requires a collaborative effort to help move patients forward.
2) A child's perspective of their pain or what's going on in a child's mind is generally not the same experience their parent is having.  Even when kids discuss their pain or their mood or troubles at school with their parents - it may not be the complete picture.  Sometimes opening up to a complete stranger is more comfortable than potential embarrassment in front of a parent.
3) As a healthcare provider, the language we use with patients is a BIG DEAL. To treat this patient population means working to change their beliefs about pain, how their bodies work, what they're able to do, and their perspective of themselves relative to the world.  I wrote down quotations from each patient session that were negative images that had to come from somewhere.  We have to do better with the words we use with our patients so they don't think their backs are "out."  They're not so fragile!
4) Learning about how long it took for these patients to be seen demonstrates a likely high demand for this type of patient care.  Physical therapists are a vital contributor to this team as we're likely to be the ones seeing the patients for follow up visits most frequently to get them moving in new ways and to regularly reinforce pain science education.  This is optimized by a collaborative effort - but also - physical therapists with interest in working with this patient population need to have a better understanding of how pain works than we get in PT School.
5) Don't give up hope.  If you've experienced pain for a long time - or your child has experienced pain for a long time - it may be frustrating that you haven't found the answers to improve your quality of life yet.  But the key is - YET.

National Physical Therapy Month

October is National Physical Therapy Month!  Wahoo!!!  A whole month to celebrate physical therapists - which means celebrating so many of my friends, my coworkers, the providers who keep me moving when I need some physical help, and my old pals from UConn Physical Therapy!  If you're currently seeing a physical therapist for care, wish them a Happy PT Month!

I frequently get asked about what PTs do. The cool thing is that we can do so many things!  PT school is a little bit like medical school in that when you finish, you're a generalist and basically know enough to not hurt people (hopefully)... while you then continue your education to specialize.  The big difference is that PTs don't (yet) have to complete residencies and fellowships for our specialties - we learn them in our choices of clinical affiliations towards the end of school and then we further learn our practice on the job.  Physicians go into many years of residency to specifically learn the specialty they will practice.  

The current specialties for physical therapists - in which you can become board certified - are: cardiovascular/pulmonary, clinical electrophysiology, oncology, women's health, geriatrics, neurology, orthopedics, pediatrics, and sports.  But this is just areas we can choose to further our knowledge in, take a test, and then get some fancy letters after our names.  (Don't get me wrong, I'm working towards this and think this is great - I'm just pointing out that this is only the start of things PTs can do).  

Physical therapists are considered to be the musculoskeletal experts.  We help people optimize their functional mobility - whether that be rehabilitative (trying to gain a function they used to have but somehow lost) or habilitative (acquiring a new function they haven't previously had). This could include treatment for patients with burns and wounds, care for children born with developmental or congenital conditions, adults who have had a heart attack and are regaining their endurance, children who need help at school... so many things!  We can work in clinics, hospitals, sports venues, athletic training rooms, large corporations, nursing homes, schools, in people's homes, at a horse barn!, in a gym or fitness center, in a doctor's office, in the emergency department.  We can work with old or young people, males and females and those who do not identify with either of those, people who just had surgery or who are trying to prevent it, people with all different sorts of pain, and more!

The best part is - we don't really have to choose just one patient population or one location to work, either!  Personally, I only work as a Sports/Orthopedic Physical Therapist.  My full time job is at Seattle Children's Hospital's North Outpatient Clinic and I treat children between ages 5-21 with sports or musculoskeletal injuries.  The most common conditions I treat there are people with knee pain or who had a knee surgery, ankle sprains, broken arms, and back pain - though I also work with children who have been experiencing chronic pain, concussion symptoms, neck pain, and many other conditions.  The ways these kids get hurt varies considerably, too!  On the side of treating patients, I also participate in research projects around the conditions I'm working with, which helps me learn.  When I'm not at Children's, I also treat athletes in the athletic training room or at the basketball arena as well as at a dance studio.  I get to work in three different settings and find that to be cool  In the past I have treated people in nursing homes - and that setting wasn't for me, but some physical therapists love doing that!  And, if I woke up tomorrow and decided I wanted to start working in a different setting, I could change my continuing education and learn more so that I could transition to a different area of work.

Why am I discussing this?  Well... first of all, because so many people just don't know what we do... and that's partially because we do so many different things based on the environment we're working in.  But also because I've previously written about "What Physical Therapists Do" and those were more from my perspective as a Sports Physical Therapist.  This is one of the recurring themes on my blog - and you can check out "What Do Physical Therapists Do? Installment #1: We Look at Mechanics, here.  Or #2: We Listen. here.  And the third installment: "We Strength Train" here.  But truthfully - we do so much more!

One of the big initiatives the American Physical Therapy Association has been working on is fighting the opioid epidemic in the United States.  This is a target because physical therapists help patients who are experiencing pain to get back to a more functional life. Often times, people experiencing pain use medication to try to get rid of the pain... but pain is a symptom!  Medication can sometimes attack the cause of the underlying problem, but oftentimes - it will only mask the symptom, perpetuating the problem.  I've previously written about chronic pain several times: here, here, here, and here.  PTs are learning more and more about the science of how pain works and can help patients better understand pain so that they can move forward and back to their optimal level of function.

It should be said that not all physical therapists practice the same way.  This has made the general perception of what we do cloudy for many people.  At the end of the day, what should matter most is that you're feeling better and doing more of your favorite activities.  Here are a few things you should consider if you are currently going to physical therapy:

1) Your physical therapist should not be hurting you!  Now - if you just had surgery last week, and we're guiding you with some gentle movement, you may feel some discomfort... but you should only be working within your tolerance and if it's really painful, the PT should stop.  If you don't exercise often and you're starting PT and moving in new ways - your muscles may feel some soreness.  But again, this should remain within your comfort level.  Think about the last time you were having pain.  You tighten up and definitely can't relax. What good is it doing to fight through that?  I can't say this enough... treatment should not be painful.  Nobody should feel like they're receiving torture when they come to PT.  Physical therapy is not the place for cliches like "No pain, No gain." Period.  

2) Your physical therapy treatments should be specifically made to address your issues and goals.  If your goal is to walk without pain - and you're not doing any exercises that look like they're going to get you to your goal, you have the right to ask why you're doing the things you're doing.   Sometimes it's hard to tell how the path you're on may get you to the target destination.  But - in order to run, you must first be able to walk, and to walk, you must first be able to stand up.  When I'm working with patients, I'm breaking down the goal activities into components, and I can explain why I have chosen every single activity.  Healthcare providers should be encouraging their patients to ask questions and understand their own care.  They should also be educating patients/  

3) Physical therapy only works if a) the patient buys into the things the physical therapist is saying and b) the patient commits to doing the program.  You may only spend 1 hour per week with your PT.  That leaves you with a whole lot of time where you're not working with them - but should be working on things to improve yourself.  Take charge of your recovery.  Take charge of your own body! As a patient, it can be hard to understand medical conditions - and that's scary!  Your back hurts and someone you don't know is touching you and then telling you to move in weird ways... you have to feel comfortable and there needs to be a little bit of trust to be successful.  This is really difficult when patients have previously seen a different physical therapist and didn't get better.  Maybe it wasn't the right fit for you... give another PT a try and make sure they treat you differently than the last one.  

4) You have the right to "fire" your physical therapist.  At Seattle Children's, I often share the patients I'm treating with one other physical therapist.  There are pros and cons to sharing a patient - but my favorite pro is this: if you don't like me - see the other therapist!  My feelings won't be hurt... I just want you to get better!  I can promise you we won't do things exactly the same way.  The best way is the one you like most as the patient.  Sometimes I even recommend patients see one of my coworkers because I think they'll be a better fit.  I'm a female... sometimes young male patients just do better with a male physical therapist.  I'm very direct and tend to be pretty loud... sometimes the more shy kids need one of my more gentle or softer spoken coworkers.  Any PT who gets upset that you would prefer to see someone else isn't looking out for your best interests.   

5) If you feel like you've been going to PT for months and not making gains - you should see if you have a better outcome with another PT.  Don't give up hope!  I think - because health insurance often pays the bulk of the costs - and because people are having pain - they forget that their healthcare providers are PROVIDING SERVICES.  We only have jobs because patients find us to be helpful.  You wouldn't use a carpenter to fix your toilet instead of a plumber just because they both know how to use a wrench... don't settle for a physical therapist who isn't fitting your needs.  

Now that you know more about Physical Therapists, make sure you reach out to your favorite PT and let them know that you're celebrating them this October.  If you're experiencing pain or having trouble with one of your favorite activities - sports or otherwise - find a PT near you to get treatment.  Having trouble finding the right fit? I'm happy to help you find someone near you.  Reach out with questions.  And know that the biggest compliment you can ever give to a physical therapist is to send your friends or family members to see them.

Concussion and the Brain

Happy October 1st! Fall is upon us and schools here in the Pacific Northwest has been up and running for about a month.  With the return of school comes the start of the local fall sports teams.  This year I've noticed several patients in the clinic coming in with a recent concussion.  For my caseload, they've all been girls and most of these have occurred with playing soccer.  This is of course not a rule - in the past I have worked with males who have experienced concussions and they've come from all sorts of mechanisms of injuries.  What comes to mind are falling off a bike, getting hit in the head playing softball, inner tubing, and trampoline parks.  Though football players statistically tend to have more concussions, I don't think I've treated any of those.

I personally have experienced two concussions myself!  My first one was in high school when a friend of mine and I were walking away from each other and she threw a basketball and it bounced off the back of my head.  I initially thought I was fine and later woke up on the bathroom floor.  I had a headache for a few days and saw a doctor for it but was ultimately fine.  My second concussion was getting hit in the face with a softball that broke my nose and I had a loss of consciousness for about 3 seconds.  Apparently that's what the glove is for... catching the ball.  I didn't see a doctor that time, which was not the smartest on my part.  With that one I also had headaches for a few days, dizziness, some nausea, and a lot of sensitivity to light.  My sleep was disrupted and I had trouble looking at my computer screen at work.  My glasses broke during the injury so I was wearing my prescription sunglasses at work which helped some.  I'm so fortunate that both of mine were years apart and that I recovered so quickly, and it helps me to relate to these patients since I've gone through it a little bit.  Plus this gives me a great opportunity to share the photos of my black eyes from when I had my last one!  Notice the softball stitches visibly imprinted into my face.

Concussions are a really interesting diagnosis because each person presents very differently.  I've previously written about the WNBA Concussion Protocol here following one of the Seattle Storm players experiencing a concussion this past season, but since I've been treating more of these patients in the clinic, I've been reviewing my previous Medbridge courses on concussion and refreshing my knowledge to better treat this patient population.  Here are some interesting things about concussions you should know.

1) Concussions are brain injuries.  Concussions get a reputation for being less significant than they are because people have used terms like "getting their bell rung" to describe what happened on the playing field when the injury occurred.  This is a problem because concussions are brain injuries.  Many of the kids who come in for concussion treatment have a variety of symptoms - headaches, dizziness, trouble with school from a variety of causes, difficulty sleeping... and they almost brush these off as normal because of a concussion.  But these are all symptoms of the brain going through a healing process!  You wouldn't act the same way if you had a fractured skull or a stroke - both also serious head injuries.  Let's start acknowledging how serious a concussion is so that kids who experience them take their recovery a little more seriously!

2) Concussions are not anatomical problems- they are physiological.  I'll simplify that.  Anatomy defined: the structure of something.  So with a concussion - we're not looking at the structure of the brain.  With an anatomical (structural) problem, when a doctor is trying to diagnose what is wrong, imaging is generally done.  Typically, a person who has experienced a concussion will not have anything wrong on XRAYS, CT Scan, or MRI.  These imaging studies are used to look at anatomy - again - like the skull fracture - to see if any structures have been damaged.  Imaging is helpful to rule out these other anatomical problems, but they don't tell us much about the concussion or the person experiencing it.  So - if the structure of the body isn't the problem - what is?  The function of these structures are what is affected in a concussion.  Physiology is how things work... so how the anatomical structure operates.  Example - your lungs are a structure which can be injured.  They also function to breathe.  Anatomy: lungs.  Physiology: breathing.  Concussion structure involved is the brain - but there is no anatomical problem.  The physiology of the brain is what has been injured.

This concept is important because it can impact expectations of recovery.  It's pretty easy for people to understand the idea of an anatomical injury and how that recovers.  A broken bone takes approximately 8 weeks to heal and can be seen on an XRAY broken and then healed later on.  Concussion recovery is much more complicated and you can't see a starting point or a finish line.  So what's actually happening?  Well.. that's what I'm working hard on learning to better understand. 

The brain is composed of about 100 billion neurons.  Neurons are the types of cells that make up nerves.  Neurons look a bit like this:

https://biology.stackexchange.com/questions/25967/nerves-neurons-axons-and-dendrites-by-example

These nerves interact with each other to send electrical signals throughout the brain and the body so you can do whatever task you want to do in life - and even the tasks you don't choose to do but that the body does for your survival, like breathe.  When a concussion occurs, these nerve structures can be stretched or twisted just enough that the way that the electrical signals are passed along is impacted and all different types of messages can be influenced.

If you fall on the ground and scrape your knee on the ground, your skin may experience an abrasion and bleed a little bit.  The skin cells near the surface will, over the next several days, heal.  Fortunately, with the type of injury that occurs to neurons (nerve cells) during a concussion, they can also generally heal.  Most concussions will heal spontaneously very quickly, but some take much longer to recover.  These patients with slower recovery concussions are the ones I generally work with in the clinic.  People whose neurons may have recovered from the initial concussion processes, but who are still experiencing symptoms.

3. Treatment varies for each person with a concussion. This is because every person who experiences a concussion will present differently.  Even better... a single person experiencing concussion symptoms can vary hour by hour or day by day with their own symptoms, particularly in the first few days after a concussion.  So I track symptoms (using a graded symptom checklist like this one) over time with these patients to see if they're trending towards improvement and I can't compare one person's recovery to any other.  Every time I have taken a course learning about symptoms with concussion, it has been important to recognize that the goal is not to be a 0 on all of these items.  Teenagers get headaches occasionally.  They also get emotional sometimes.  But the goal is to reduce the overall symptom total and get them to stay at a relatively consistent level that does not fluctuate in response to physical or mental stressors.

I will say that there are some common themes with treating these patients.  Just like I don't treat every patient who experiences an ankle sprain the same way - the components of treatment for those patients is usually similar.  With a person who has experienced a concussion, there is often a headache and neck pain which tends to come from the upper cervical spine more than the lower cervical spine.  Some have vision and vestibular symptoms that require completely different treatments.  Symptoms for concussion have been grouped together into four categories of concussions: 1) vestibular symptoms, 2) visual symptoms, 3) cognitive symptoms, and 4) migrainous/headache symptoms.  These can overlap, but the treatments tend to fall into the categories that match the symptoms.  If the person is experiencing headache symptoms alone, the treatment likely shouldn't target vestibular or vision problems.  This is important because a person experiencing vestibular symptoms likely won't recover from those without specific vestibular treatments and those should be addressed prior to the other considerations.

4. It is the law that you must be cleared by a medical provider to return to sport activities following a concussion.  Laws vary by state and Washington State was the first one to pass such a law in 2009.  However, if you are a coach, and you have an athlete who experiences a concussion, there are many states which require 1) That the athlete stop playing immediately and cannot return for a minimum of 24 hours and 2) that the athlete must be cleared by a healthcare provider to play.  Some states allow physical therapists to be the person who clears these athletes for return to activities - but at Seattle Children's Hospital, we leave that decision up to the diagnosing physician.  So any of these kids who I'm working with to get back to sports - they're not playing in a sport competition until the doctor says so.  And it's not just word of mouth.  Schools are supposed to require that the clearance comes in writing!  Here's why these rules are important.

First - let's say you hit your head in a game and show some mild signs of a concussion but then a few minutes later you think you're feeling ok and try to play again.  Concussion symptoms are not immediate to show up, but reaction time and coordination can be impacted by a concussion.  So now, you've just experienced a concussion and are re-entering your game at considerably higher risk for another injury.  This is dangerous.  No sporting event - championship or scrimmage - is ever important enough to risk a brain injury.  Second - there is actually a name for someone who experiences a concussion, and then experiences a second one before the first one has resolved.  It is called Second Impact Syndrome.  It has a name because it increases the risk of mortality by 50% and it increases morbidity by 100%.  That means that if you experience two concussions in close succession, you increase your risk of death by 50% and 100% of these people have significant delay in recovery.  Doesn't it just make more sense to recover fully from the first one to reduce the risk of these much more severe outcomes?

I'm really enjoying learning about this patient population because it is fairly complicated in comparison to some of the other things you treat, and once these patients start to feel better, their quality of life is significantly impacted for the better.  Concussions can affect tolerance to sitting through classes in school with reading or looking at the whiteboard, they can influence tolerance to lights and noises and participation in sports - which is huge for some of these kids.  They can make you dizzy which makes all activity terrible.  These are serious and I hope that writing this helps people better appreciate the need for them to be treated appropriately. 

Happy Fall Sports Season, everyone!  Let's try to play smart and safe!