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Athletic Trainers: Who are we and What do we do?
So, you’re wondering what an athletic trainer is and what we do? You’re not alone. I get this question all the time. You know when you’re watching sports, and someone gets hurt? I’m the person in khakis with a fanny pack who runs onto the field to assess the situation. In this moment, I am evaluating the injury, making a determination if they can safely continue playing, or deciding if they need to be pulled from the game for their safety. In the case of suspected concussion, I first evaluate level of consciousness. How alert are they to person, place and time? Then I evaluate their symptoms. Are they immediately dizzy or off balance? Do they have a headache or nausea? Are there any red flags, like vomiting, that necessitate emergency medical care? If they need to be pulled from play, we implement the concussion protocol for their league. This involves evaluation by a medical doctor and appropriate therapies for safe return to participation in practices and games.
So, you’re wondering what an athletic trainer is and what we do? You’re not alone. I get this question all the time. You know when you’re watching sports, and someone gets hurt? I’m the person in khakis with a fanny pack who runs onto the field to assess the situation. In this moment, I am evaluating the injury, making a determination if they can safely continue playing, or deciding if they need to be pulled from the game for their safety. In the case of suspected concussion, I first evaluate level of consciousness. How alert are they to person, place and time? Then I evaluate their symptoms. Are they immediately dizzy or off balance? Do they have a headache or nausea? Are there any red flags, like vomiting, that necessitate emergency medical care? If they need to be pulled from play, we implement the concussion protocol for their league. This involves evaluation by a medical doctor and appropriate therapies for safe return to participation in practices and games.
At Colorado Concussion Clinic, I have a unique role as an athletic trainer where I use my screening skills and translate them into an appropriate plan of care for each patient. I am involved with the initial screening with the physician, performing an assessment of patient’s balance, vestibular, and oculomotor function. Based on the results of this screening, I facilitate referrals to the appropriate therapies. For patients who are referred to physical therapy, I am involved in the evaluation and treatment of their given symptoms. One of the most important tests I do is the Buffalo Concussion Treadmill Test. This helps to determine how much exercise is recommended for an individual based on their response to exercise. Frequently following a concussion, a patient’s heart rate and blood pressure regulation is impaired which can translate into poor tolerance of exercise. The results of the BCTT guide us in getting a patient safely back to exercise without symptom exacerbation. I also assist in the treatment of balance issues, vestibular symptoms such as dizziness, and visual dysfunction. I work closely with the physical therapists in carrying out the treatment plans for our patients.
My role as an athletic trainer in concussion management is unique given my work with athletes from practices, to their games, and throughout the continuum of concussion rehab. Given that I see patients in “real life” situations (ie practices and games), I may pick up on areas of breakdown where a patient may require further rehab prior to safe return to their sport. My sideline role is an integral part of the team, and is crucial in the management of a concussed athlete safely returning to their sport.
- Sara Altman, ATC, LAT
To Play, Or Not to Play, That is the Question.
As a cognitive therapist, I have worked directly with hundreds of people who have had multiple concussions. I am also a mother. One of the questions I am frequently asked is, “Would you ever let your kids play football?” With stories of suicides, severe depression, cognitive challenges, and persistent physical symptoms (e.g., headaches, ringing in the ears) associated with chronic traumatic encephalopathy (CTE) making headlines, a lot of people see this question as a no-brainer. Personally, I probably wouldn’t, but it just so happens my children have never expressed a desire to play football, and it likely will never come up. I think this issue is quite complex, and while I would choose not to let my children play, I don’t harshly judge parents who do. After all, I allow my children to participate in sports such as alpine skiing and soccer, which also have risks.
As a cognitive therapist, I have worked directly with hundreds of people who have had multiple concussions. I am also a mother. One of the questions I am frequently asked is, “Would you ever let your kids play football?” With stories of suicides, severe depression, cognitive challenges, and persistent physical symptoms (e.g., headaches, ringing in the ears) associated with chronic traumatic encephalopathy (CTE) making headlines, a lot of people see this question as a no-brainer. Personally, I probably wouldn’t, but it just so happens my children have never expressed a desire to play football, and it likely will never come up. I think this issue is quite complex, and while I would choose not to let my children play, I don’t harshly judge parents who do. After all, I allow my children to participate in sports such as alpine skiing and soccer, which also have risks.
You may have heard that a post-mortem research study on NFL players showed CTE in 99% of their brains. However, the research sample included only players who had concerns about CTE. Twenty-one percent of the people included in the study who played in high school were positive for CTE. Most high school players will not go on to play in college or beyond. For some parents, seeing their children display enthusiasm for anything is a relief. It keeps them out of trouble after school, and gives them something to care about. It allows children to understand what it means to be part of a team, to commit, and to be fit. It may motivate teenagers to get better grades. The one thing I know, is that if I were to let my children play football, I would stay involved. I would talk to the coach and learn about what education he or she was providing to the players. I would want to know whether the coach was up to date on the research around concussive injuries. I would talk to my own children about the risks and the importance of reporting symptoms. One of the scariest things, I think, is that many players will hide their symptoms for fear of being benched.
If parents do decide to let their children play, they should encourage the coach to hold a meeting at the beginning of the season for both players and parents. Topics covered should include concussion protocols, signs and symptoms of concussive injury, risks, and treatment options. These meetings should not be limited to football teams. Another option for parents is to look into and support a shift to flag football. The Aspen Institute’s Sports and Society Program has recommended that youth leagues shift to flag football for children under 14 years old. It is important to remember that children are counting on adults to be informed and make choices that are in their best interest. The brain is a precious organ, and protecting it, especially in young people, should be a priority.
- Ramya Shyam, MS CCC-SLP
What is Cognitive Rehabilitation?
Cognitive rehabilitation is a specialized type of therapy designed to help people who have cognitive impairments. These impairments might be due to a concussion or traumatic brain injury, stroke, illness, or learning disability. Oftentimes after a concussion, people feel overwhelmed by their job responsibilities, school, or household chores. They may feel as though tasks that were previously simple are much more challenging because they are having difficulty remembering, focusing, communicating, solving problems, setting and meeting goals, and organizing. Cognitive rehabilitation is one of the most important therapies following concussion, as patients are offered both compensatory strategies and restorative exercises to improve these areas, and consequently, their ability to perform activities of daily living.
Cognitive rehabilitation is a specialized type of therapy designed to help people who have cognitive impairments. These impairments might be due to a concussion or traumatic brain injury, stroke, illness, or learning disability. Oftentimes after a concussion, people feel overwhelmed by their job responsibilities, school, or household chores. They may feel as though tasks that were previously simple are much more challenging because they are having difficulty remembering, focusing, communicating, solving problems, setting and meeting goals, and organizing. Cognitive rehabilitation is one of the most important therapies following concussion, as patients are offered both compensatory strategies and restorative exercises to improve these areas, and consequently, their ability to perform activities of daily living. The cognitive therapists at CCC are highly qualified speech-language pathologists who have expertise in assessment and treatment. During the first session, they will have an in-depth conversation with the client about his or her struggles and strengths, and formulate a comprehensive treatment plan tailored to their needs. The goal is for the patient to feel supported and empowered!
Four Ways Physical Therapy Can Help With Post-Concussive Symptoms
Concussions are rehabilitative injuries. Gone are the days of resting until symptoms subside! As we have discussed previously, rest beyond the first couple of days following a concussion can be detrimental to long term recovery. There can be many symptoms following a concussion that affect different systems. These symptoms can include: dizziness, lightheadedness, balance impairments, headache, neck pain, fatigue, blurry vision, nausea, and eye fatigue. A physical therapist with specialized training in concussion can evaluate these symptoms and develop a treatment plan to assist patients with a more timely recovery.
Concussions are rehabilitative injuries. Gone are the days of resting until symptoms subside! As we have discussed previously, rest beyond the first couple of days following a concussion can be detrimental to long term recovery. There can be many symptoms following a concussion that affect different systems. These symptoms can include: dizziness, lightheadedness, balance impairments, headache, neck pain, fatigue, blurry vision, nausea, and eye fatigue. A physical therapist with specialized training in concussion can evaluate these symptoms and develop a treatment plan to assist patients with a more timely recovery.
It’s important to note that following a concussion, a multi-disciplinary team approach is best for providing comprehensive care. This team may include medical doctors, neurologists, physical therapists, neuro-optometrists, speech therapists, psychologists, athletic trainers, and others. For the purposes of this blog post, we will focus on the role of PT in concussion rehab.
There are multiple systems in our bodies which can contribute to physical post-concussive symptoms: the cervical spine, vestibular and oculomotor systems, and the physiological system. Since one or more systems can drive symptoms, a thorough PT evaluation should include an assessment of each of these areas to identify all possible sources of dysfunction. For example, dizziness can be caused by impairment in any of these four areas, and treatment of just one area may not alleviate the dizziness.
Cervical spine: Dysfunction of the neck often goes hand in hand with concussion. If a person sustains a force great enough to cause a concussion, they likely have also sustained a cervical injury. This may or may not present as neck pain. Impairment of the cervical spine can contribute to headaches, dizziness, and visual impairment. Even if a person does not have neck pain, the cervical spine may still be driving their overall symptom presentation.
Vestibular system: Located in the inner ear, this system gives us information about where we are in space, our relation to gravity, if we are still or moving, and it plays a large role in our balance and stability. It also impacts movements of our eyes. Dysfunction of the vestibular system can present as dizziness, vertigo, lightheadedness, visual issues, headache, imbalance, nausea, and motion sensitivity.
Oculomotor system: Visual changes following concussion are common and can include difficulty focusing the eyes, blurry vision, double vision, difficulty reading, sensitivity to screens (computer, phone, TV), and eye fatigue. Visual issues can contribute to dizziness, headache, and neck pain. A trained physical therapist can screen for visual issues, provide exercises as appropriate, and refer patients to specialty providers as needed.
Physiological system: A concussion causes metabolic and physiologic changes which can impact the function of the autonomic nervous system. This can lead to impaired blood flow and exercise intolerance, and it may drive or contribute to headache, nausea, and dizziness, among other symptoms. A trained PT or athletic trainer can administer a treadmill test to identify physiological dysfunction and design an individualized, sub-maximal exercise program to treat the symptoms.
A solid evaluation of all of these areas is essential to determining the priorities in a treatment approach. A concussion is not a “wait and see” injury! If you are not feeling right following a concussion, there is a lot that can be done from a rehabilitation perspective to speed the recovery process. Physical therapists with specialized training in concussion are often a good entry point into the medical care system as they may be more accessible than other medical professionals, and early treatment is key to long term recovery.
- Kate Smulligan
Concussion and Sleep
I can’t fall asleep. I can’t stay asleep. I’m so tired all the time. I feel like a zombie.
Do any of these sound familiar? If so, you are not alone! Sleep disturbances are among the most common issues reported by patients following a concussion. Issues with sleep can include sleeping less than normal, sleeping more than normal, difficulty falling asleep, difficulty staying asleep, and of course, excessive fatigue. Research shows that sleep impairments following brain injury are associated with poorer overall recovery, cognitive impairment, and overall lower productivity (1,2).
I can’t fall asleep. I can’t stay asleep. I’m so tired all the time. I feel like a zombie.
Do any of these sound familiar? If so, you are not alone! Sleep disturbances are among the most common issues reported by patients following a concussion. Issues with sleep can include sleeping less than normal, sleeping more than normal, difficulty falling asleep, difficulty staying asleep, and of course, excessive fatigue. Research shows that sleep impairments following brain injury are associated with poorer overall recovery, cognitive impairment, and overall lower productivity (1,2).
One factor that has a big influence over our sleep cycle is the production of a hormone called melatonin. This is a hormone made by our brain, and is normally released in the evening and overnight. Appropriate melatonin levels are important for falling asleep more easily and getting more REM sleep. Melatonin production is inhibited by light, which is why it is released at night. Something important to know, is that melatonin levels are not just impacted by natural light - artificial light also inhibits the production of melatonin. This includes light bulbs as well as blue light from electronics. Research has found that following traumatic brain injury, patients have significantly lower levels of evening melatonin production compared to people of the same age without an injury. This also correlated to people with brain injury having lower time spent in REM sleep (3).
Given that sleep disturbances are so prevalent following concussions, and lack of sleep is detrimental to overall function, it’s important to set yourself up for success when it comes to your sleep! Here are some sleep hygiene tips for naturally improving your sleep cycle and decreasing restless tossing and turning:
Ensure you are allowing your body to sleep for an adequate amount of time.
Establish a routine for relaxation 1 hour prior to going to bed.
Limit naps during the day to 30 minutes.
Limit caffeine consumption to morning only.
Avoid alcohol. It will interfere with your ability to stay asleep.
Avoid large meals close to bedtime.
Expose yourself to natural daylight for at least 1 hour daily, this helps your body recognize when it’s time to be awake and asleep.
Try to get 30 -60 minutes of exercise daily.
Limit screen time (phone, TV, computer) starting 1 hour before bedtime.
Stay well hydrated.
Keep your sleep environment cool and as dark as possible.
Use “white noise” to help block out other noise and assist sleep.
If you are unable to sleep, get up, do a quiet relaxing activity then return. Do not expose yourself to lights or computers during this time.
References:
Grima NA, Rajaratnam SM, Mansfield D, et al. Efficacy of melatonin for sleep disturbance following traumatic brain injury: a randomized controlled trial. BMC Med. 2018;16:8.
Kostyun RO, Milewski MD, Hafeez I. Sleep Disturbance and Neurocognitive Function During the Recovery From a Sport-Related Concussion in Adolescents. The American Journal of Sports Medicine. 2014;43(3):633-640.
Shekleton JA, Parcell DL, Redman JR, et al. Sleep disturbance and melatonin levels following traumatic brain injury. Neurology. 2010;74:1732-1738.
- Kate Smulligan
