Dr. Anthony Petraglia, MD on Management for Sports Concussions

On November 11th, the LSU Athletic Training Program, with the help of Dr. Burnham, MD, LSU Head Team Physician, welcomed Dr. Anthony Petraglia, MD to discuss the current research and science related to the proper management for sports concussions. Dr. Petraglia graduated from the University of Chicago in 2002 with a Bachelor of Arts degree in Neuroscience and earned his medical degree from the University of Rochester School of Medicine and Dentistry in 2007. Dr. Petraglia is the first neurosurgery resident to complete a Neurological Sports Medicine Fellowship and was the McNair Neurosurgical Sports Medicine Fellow in Houston, Texas. He is currently completing his Neurological Surgery training at the University of Rochester. Dr. Petraglia has worked under Dr. Julian Bailes, who has done extensive work on preventative treatment of concussions and the role of DHA/Omega 3. He has worked as a team physician for several collegiate and high school teams and has also helped establish a concussion clinic in the greater Rochester area.

Dr. Petraglia’s guest lecture not only defined concussions and the standard treatment, but it also featured prevention and up and coming research. His presentation included videos of athletes, from peewee football to high profile collegiate athletes and their concussion experiences. When asked about Dr. Petraglia and his presentation, clinical instructor, Melissa Thompson, PhD, Med, ATC, PES, said, “He provided a great summary of the most recent and relevant concussion research and its application to practitioners. There are still a lot of unanswered questions about concussions, but there is also a growing body of research evidence out there that EVERY medical professional who works with concussed individuals should know about AND USE IN CLINICAL PRACTICE.” The information Dr. Petraglia presented was very new and inventive and unique to any other concussion material the program has been presented with before. Second year athletic training student, Caitlin McKinley said, “He had such a new, fresh insight about concussions. Instead of the usual let's assess the concussion, he taught us what was physiologically going on inside the body and brain. His video's showed different levels of how a concussion can affect a person mentally. I think he did a fabulous job and really helped us learn more in depth information about concussions.” The LSU Athletic Training Staff and students feel fortunate to have had access to someone like Dr. Petraglia who is an expert and involved in cutting edge research that will help us all understand the intricacies of the brain and its response to concussions and traumatic brain injury. We thank him for his time and interest in our program at LSU.

Cutting Edge Advantage

Dr. Melissa Thompson Ph.D., ATC along with two other professors in the Kinesiology department, Dr. Hargroder and Dr. Landin, oversee a small branch of the Kinesiology department not common to undergraduate programs. In the LSU Veterinary School, there are two classes offered to undergraduate students to further their anatomy knowledge. Once a student has completed KIN 2500, human anatomy, they are offered the opportunity to take the 3519, cadaver prosection, or 4519, cadaver dissection. Each athletic training student is enrolled in the cadaver prosection class. Madeleine Scaramuzzo says, “the cadaver dissection course has helped expand my knowledge of human anatomy, and will greatly improve my ability to visualize structures and identify injuries in the future.” Dr. Hargroder said, “The experience gives undergraduate students an upper hand when they continue their education in graduate programs because they are able to identify parts of the body more quickly and easily than other students who weren't offered the advantage of participating in a cadaver lab.” Seeing the body first hand is a completely different experience than learning it in a textbook. Third year student, Raymond Champagne, who took the prosection course his second year in the program says, “The cadaver lab has been a very beneficial class and has contributed to my overall knowledge of the human body. Having an opportunity to be a part of this class has given me the upper hand over many other athletic training students in the state.“

For further information please visit: http://www.lsureveille.com/news/cadaver-lab-sets-university-apart-1.2647276#.TrlWfq7UrI

PES Certification

This summer, under the instruction of Dr. Melissa Thompson, numerous ATCs and ATSs took a course for the NASM Performance Enhancement Specialist certification. Melissa Sorrells, head athletic trainer at University Laboratory School, says “This course/certification has proven to be very valuable to me as an athletic trainer. Working at the high school level, my job duties entail more than just traditional athletic training. This course has allowed me to utilize my skills at a high level in many different areas while continuing to provide excellent quality of care to our student athletes.” An elite training program for fitness and enhanced athletic performance, the NASM Performance Enhancement Specialist is designed for athletic trainers, chiropractors, physical therapists, coaches and other sports professionals who want to work with players at all levels, from the secondary education and university tier, to professional and Olympic level athletes. The PES offers professionals the ability to learn cutting-edge performance assessment techniques, sport-specific program design, scientifically-valid, evidence-based applications which achieve remarkable results with top professionals and weekend warriors alike, human movement science, postural considerations, the elements of an integrated performance profile and assessment, integrated program design, and nutrition. Many of our graduate assistant ATCs also participated in the course including: Erin Greenwich, Scott Campbell, Dalis Boyette and Jessica Barton. Barton, Graduate Assistant assigned to Men’s Tennis says, “The process of acquiring my PES certification helped me mature as a Certified Athletic Trainer through exposure to aspects of athletic performance outside of the conventional healthcare field. It allowed us to look at athletic performance from a new perspective and study advanced concepts that have become invaluable as we strive to help athletes reach their full potential." Courtney Melanson, Camille Bordelon, Madeleine Scaramuzzo, Emily Mesa and John McLaughlin were among some of the students who participated in the course and are now certified. John McLaughlin, second year ATS assigned to Football, says, “The PES class was very helpful in regards to rehabilitation. I have used numerous exercises from the class in rehabs for athletes.”

Late Detection of Capitellar Osteochondritis Dissecans in a High School Football Player: A Case Report by Shari Benson, Former LSU Graduate Assistant

Shari Benson, former LSU Graduate Assistant, and currently in a fellowship with the Steadman Clinic, is presenting an Oral Case Study at this year's 62nd Annual NATA National Convention and Clinical Symposium in New Orleans, LA. Below is a brief overview of her case study. Be sure to attend the Convention to see Shari present the full Case Study. Yet another educational story and a reminder of how our LSU Alumni are contributing to the improvement of the health and well-being of athletes.

Late Detection of Capitellar Osteochondritis Dissecans in a High School Football Player: A Case Report

Abstract: Case report on a 17 YO football player at a rural high school who went misdiagnosed of R elbow OCD for 4 years. He had no MOI, but reported catching and locking with activity and was treated for lateral epicondylitis. A CT Scan revealed multiple loose bodies and moderate to severe damage to the articular surface of his capitellum. He underwent a R elbow synovectomy, loose body excision, and chondroplasty of his capitellum. He has now returned to sport without issues. The significance of this report is that OCD is commonly misdiagnosed in high school athletes, but is a common injury in adolescent football players and gymnasts. Due to the length of time this athlete went untreated, his lesion worsened to the point where he had 4 large loose bodies and significant damage to his articular cartilage, which makes him 50% more susceptible to having arthritis later in life. Most physicians are hesitant to operate on young athletes due to growth plate factors and their ability to heal non-operatively, however, untreated OCD is the leading cause of permanent elbow disability. Therefore, it is important to have the knowledge and clinical skill set to detect OCD early in adolescent athletes in order to avoid elbow arthritis and disability long-term.

"Phantom Pain in a Collegiate Football Player" by Madeleine Scaramuzzo

The LSU Athletic Training Department would like to share another case study which was submitted by one of our Athletic Training Students to the SEATA Student Symposium for presentation. Madeleine Scaramuzzo is a 2nd year Athletic Training Student in the LSU Athletic Training Department, having worked at University High and currently assigned to assist with the Football Program. She authored a case study on "Phantom Pain in a Collegiate Football Player". Below is the abstract including: Personal Data, Past and Current Personal Medical History, Signs and Symptoms, Differintial Diagnosis, Imaging and Lab Results, Final Diagnosis, Treatment and Outcome, and Deviation From the Expected.

AUTHORS AND AFFILIATION

Madeleine Scaramuzzo, Athletic Training Student, Louisiana State University, Baton Rouge, Louisiana Andy Barker, MS, ATC, LAT, Senior Associate Athletic Trainer, Louisiana State University, Baton Rouge, Louisiana

Personal Data

The patient is a nineteen year old Caucasian male collegiate football placekicker.

Past Personal Medical History

The patient was born without a left upper extremity. The shoulder joint, including a portion of the humerus and the musculature of the shoulder, was present at birth. The musculature of the upper arm and below, including the biceps brachii muscles, triceps brachii muscles, coracobrachialis muscle, and others were absent at birth. During the patient’s childhood the humerus experienced some growth, and therefore the patient was required to undergo multiple surgeries in which the end of the humerus was shaved down. The patient has no family history of congenital limb abnormalities or missing limbs.

Current Medical History

The patient reports neuropathic pain occurring in the absent limb from time to time. Hitting the tip of the arm can sometimes elicit these symptoms; however, the symptoms can also occur without provocation. The patient is otherwise healthy and the missing limb has no effect on his overall health.

Physical Signs and Symptoms

The patient experiences several abnormal sensations occurring in the absent limb on a monthly basis. These abnormal sensations include feelings of pain that originate in the shoulder and upper arm and seem to run down the length of the arm to the absent hand. The patient describes the pain as “a nail running down through the entire arm.” In addition to pain, the patient experiences an abnormal sensation of water running down the “entire” arm after getting out of the shower. The patient also occasionally experiences what seems to be an itching sensation in the absent hand. Other sensations described by the patient include a thumping pain located at the tip of the limb, and a constant shocking pain occurring during cold weather which can be relieved by applying pressure to the limb. Because of the lack of blood vessels and overall abnormal vasculature in the left limb the patient experiences random periods of burning and heat which resolve on their own. During these periods of burning and heat the left limb is visibly red and warm to the touch.

Differential Diagnosis

Neuropathy, spinal cord injury, Phantom Limb

Results of Diagnostic Imaging/Laboratory Tests

N/A

Final Diagnosis

Phantom arm pains

Treatment & Outcome

The patient has never sought medical treatment for the condition because the signs and symptoms have never been severe enough to warrant it. The patient does admit, however, to taking over the counter NSAIDs occasionally to relieve symptoms. Other possible treatments include narcotics, anticonvulsant medication, and antidepressants. A form of treatment that could be beneficial to this patient and other patients with phantom limb pain is mirror box therapy. The mirror box is a box with two compartments separated by a mirror. The patient places both limbs in the box on either side of the mirror and watches the mirror on the side of the intact limb. This will create the appearance of the missing limb and can help to cure phantom pains.

Deviation from the Expected

What makes this case unique is that Phantom Limb is a condition that usually occurs in an amputated limb, however this case is seen in a congenitally absent limb. With Phantom Limb the brain still believes that the amputated limb is present because the brain was equipped with the necessary neurologic anatomy of the limb at birth. Therefore, the brain continues to send information to it, resulting in pain and abnormal sensations. With phantom arm pains the abnormal sensations experienced by the patient with a congenital missing limb occur because the neurological wiring in the brain may not be consistent with the actual anatomy of the limb, causing inappropriate sensations.

"Traumatic Brain Injury in a Collegiate Football Player: A Case Report" by Camille Bordelon

For the 26th Annual SEATA Student Symposium on February 3-5, 2011, nine 2nd year Athletic Training Students submitted Case Study Abstracts. All nine students were chosen to present either orally or a poster presentation at the Symposium. Camille Bordelon, a 2nd year Athletic Training Student with Football wrote her Case Study Abstract on "Traumatic Brain Injury in a Collegiate Football Player". This case study is of significant relevance to Sports Medicine today, with the increasing concern over head injuries and long-term complications in professional football. Below is Camille's abstract that covers Personal Data, Past and Present Medical History, Signs and Symptoms, Differential Diagnosis, Diagnostic Testing, Final Diagnosis, Treatment and Outcome, and Deviation from the Expected in a severe head injury of a collegiate football player.

TRAUMATIC BRAIN INJURY IN A COLLEGIATE FOOTBALL PLAYER:

AUTHORS AND AFFILIATION:
Camille Bordelon, ATS, Louisiana State University, Baton Rouge, Louisiana
Jack Marucci, MS, ATC, LAT, Louisiana State University, Baton Rouge, Louisiana

Personal Data
The patient is a 20 year old African American male collegiate football wide receiver.

Past Personal Medical History
The patient has no past medical history of a traumatic brain injury.

Current Medical History
After jumping to receive a pass on the turf, the patient's legs were undercut, causing him to land directly on the back of his head. There was no loss of consciousness, but the patient was extremely disoriented and could not keep his balance without assistance.

Physical Signs and Symptoms
The patient had no loss of consciousness, but his mental status deteriorated quickly. He exhibited symptoms of profound confusion, headache, dizziness, and slurred speech. He was extremely groggy, falling asleep every few seconds and had to be held upright while seated to keep him from falling. In addition to showing symptoms of brain injury, he also reported facial pain and was noted to have constant blood-tinged clear drainage from his right nostril. In the ER, he was noted to show focal findings of a right pronator drift and right-sided finger-to-nose abnormalities.

Differential Diagnosis
Grade One Concussion, Grade Two Concussion, Grade Three Concussion, Intracerebral hemorrhage facial contusion, facial fracture

Results of Diagnostic Imaging/Laboratory Tests
A CT of the head done in the ER was WNL. A CT of the C-spine was also ordered and was WNL. Additionally, an MRI of the brain and a CT scan of the facial bones were ordered. The MRI of the brain was WNL. The CT Scan of the facial bones showed non-displaced right infraorbital and nasal fractures. Follow-up MRI of the brain on Day 4 was also WNL. The symptom score for his Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was a 44 whereas his baseline score was a 3.

Final Diagnosis
The patient was diagnosed with a Grade Three Concussion by the Cantu Scale, as well as nasal and infraorbital fractures.

Treatment and Outcome
The patient was hospitalized for 4 days due to the severity of his concussion and balance problems and was discharged when he was able to walk without assistance. His facial fractures were treated non-operatively. Soon after discharge, the symptom score for his Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was a 44 whereas his baseline score was a 3. After a consultation with a neurologist, the patient was instructed to rest for 4 weeks before participating in full activity. After this rest period, patient's ImPACT test was back to baseline. His symptoms resolved and he then participated in light contact and running drills for ten days before his symptoms returned. Prior to a game, he reported dizziness with contact warm-up drills. He then reported the dizziness had been occuring since the plane ride the day before. He also reported a mild presistant neck ache, blurred vision, and difficulty focusing in the classroom. He was held from the game and reevaluated. At that time, his ImPACT test symptom score was higher than his baseline at a score of 22. He underwent another MRI and CT Scan with unchanged results from the previous tests. The neurologist felt most of his signs and symptoms were post-concussive. However, he also thought there was a possibility of vestibular signs and symptoms as well, which would explain the patient's focal findings on exam in the hispital despite normal imaging studies. The patient began vestibular rehabilitation with a specialized physical therapist. The rehabilitation program was initially based off of the University of Pittsburgh Medical Center Concussion Rehabilitation Protocol. The initial focus was remedial therapy of the Posterior Cervical Spine muscles. Prior to onset of therapy, the patient was still reporting blurred vision, stiff neck, discomfort with head rotation, balance difficulty with eyes open and closed, and tenderness on C4-C5 with increasing pain and decreased ROM with rotation. The treatment also included cold laser therapy to help reduce pain and inflammation, manipulation of the cervical spine joints, and stretching. The next step was vestibular ocular reflex therapy and cervical ocular reflex therapy. With vestibular ocular reflex therapy, the patient looks at a target and shakes his head in a yes and no movement while walking forwards and backwards. With the cervical ocular reflex therapy, the patient keeps his head fixed on a target while walking forwards and backwards with torso twisting. After two to three weeks of vestibular therapy, the patient's symptoms had resolved and he began participating in individual drills and was slowly worked back into the rotation. He is now playing without limitations and reports his movement and hand-eye coordination to be better then before.

Deviation from the Expected
This patient's case had several unique features. First, his post-concussive symptoms were two-fold. He showed symptoms of the typical diffuse injury seen in a concussion but he also had symptoms of a focal vestibular injury. The impact of the fall caused brain trauma, but it also harmed the vestibular system, causing the patient's eye movement, proprioception, and inner ear to not function properly. This in turn affected his vision, balance, and concentration ability even after the concussion was resolved. Another unique feature is that the patient sustained facial fractures even though the blow to the head was on the posterior aspect. This is a true "contra-coup" injury, which is defined as an injury that occurs when the maximal area of injury is on the opposite side of the skill where the impact occurred due to the transmission of forces. Additionally, the nasal drainage, which was initially concerning for a spinal fluid leak from a basilar skull fracture, was in retrospect a mix of blood from the trauma of the nasal fracture as well as mucous that was jarred loose from his sinuses as a result of the impact. Due to the unique aspects of this patient's case, his treatment was tailored specifically to his needs, which ultimately provided him with a good outcome and a full recovery.

A College Coach's Perspective by Brian Tompkins

"Who Knows the Scoop? Reflections On My Open Door Policy"
Why Athletic Trainers know more than coaches.
Published on May 30, 2010
If you want to get the scoop, spend some time with your athletic trainer. For coaches and support personnel, the wealth of knowledge that an athletic trainer may be able to offer could be invaluable to the success of the program. In this article written by Head Soccer Coach Brain Tompkins, he uncovers the truth that many athletic trainers know to be true .. we do more than just tape ankles! - Shelly Mullenix, MS, ATC

“I have always maintained an open door policy in my office and, except for the occasional confab that requires privacy, it literally stands open to the world all day every day. The grandiose intention of this policy is to be welcoming to my student athletes and to be available if they need advice, support, counsel or just want to sit down and chat. In essence it is my way of symbolically saying: "Bring me your troubles and concerns; I care about you and I'm here to help." So why, given this type of laudable magnanimity, do so few players, of their own volition, ever come through the door?

Daphne is a certified athletic trainer. She has worked here for more than thirty years and is one of a team of trainers and interns that function in a loud and crowded room surrounded by athletes of all shapes and sizes. In direct contrast to me, when it comes to knowing the troubles and concerns of my athletes, she knows all. Daphne knows who is struggling in school and why; she knows who was out late on any given night of the week; she knows who hooked-up with somebody else's girlfriend at a party; she knows who's mad, who's sad and who's unhappy. In reality, although I generally have an inkling of what is going on, I know about half the juicy or sometimes gory details that she knows about my athletes.

Why is it that coaches like me are not in the loop with more information? After all, when we recruit kids out of high school we develop a palpable bond and they always arrive on campus so gung-ho and excited to have the opportunity to get a great education and play high-level soccer under my stewardship. There is typically a reasonable degree of closeness that brings with it optimism for a strong personal relationship.

Once they arrive at school however, most athletes' perception of that connection with the coach becomes altered as the relationship morphs from personal to pragmatic. The coach that spent so much time traveling across the country to watch them play, getting to know them and their family, calling and writing them to come to the school, is now on the other side of some sort of moat of undergrad coolness; a divide that often lacks hostility but is nonetheless an unspoken prerequisite of many an athlete. It is no longer quite so acceptable to be close with the coach because, in spite of the fact that they may be a good person with whom they have close ties, they still bear the title of Head Coach and, in the world of college athletes and adolescent culture, that necessitates maintaining, or at least creating the perception of, some distance.

For many students, particularly upperclassmen (who then in turn influence the newcomers), the coach comes to be viewed by their title or position rather than by the content or affect their personality and although the pre-college relationship is rarely completely lost with a student, it begins to revolve around an altered axis.

Over the years I have seen that my reality is similar to that of almost every other college coach and I have come to accept that I will always be looked at in a "coach-first, person-second" manner by my athletes and consequently, in spite of my best efforts, the threshold of my open door will likely remain infrequently crossed, except in the case of dire need or emergency.

Thank goodness then for Daphne and the training room! She has told me that once within the secure confines of that room and while getting ankles taped or muscles heated, athletes will, with minimal prompting, talk openly and candidly about anything and everything from school to sports to their personal lives. She and the other trainers become almost invisible to them and the students have little compunction about the bawdy or self-incriminating content or form of their discussions with her or with each other. It is by turns a place of confession, explanation, and revelation and it clearly serves as an opportunity for the sort of therapeutic purging and release that does not come quite so easily in the office of the coach.

It is an environment that proves that young student athletes value the chance to talk and share with adults but not necessarily with those they view as having iconic authority roles. Trainers are exempt because of their "invisibility" and because they are not typically viewed as figures of authority (although Daphne can certainly lay down the law when it's required!); similarly, assistant coaches may also have more freedom of access because they tend to be younger and usually seen, rightly or wrongly, as less authoritative than head coaches.

While the potential exists for this to be an undermining or counter-productive situation wherein information is hidden and damaging secrets kept, I view it as anything but. Experience has taught me to keep my door open but to not be offended or surprised if the flow of students walking through it is minimal and infrequent; consequently if and when I need to meet with somebody I simply schedule a time for them to come in and they are invariably happy to oblige.

However, it has also taught me that what a trainer knows about your players and their lives is invaluable and that the quality of my relationship with the trainer will determine how much or how little useful information I come to find out. Daphne and I have worked together for many years and she has a highly trustworthy filter regarding what I need to know and what I don't. I respect her privileged position and try to never abuse it because she has the hard-earned smarts to know what is important and what is trivial and ultimately has the best interests of all concerned at heart.

It is undeniably challenging for a Head Coach, especially when young and idealistic, to come to terms with being viewed first and foremost as an iconic role or job title rather than be seen as the open and supportive person that you might wish they would see. Some go to great lengths to "pal up" to their athletes which can have the effect of eroding propriety and respect on both sides. The privilege of leadership brings unwanted distance, even for the most beloved manager, director, chief, teacher, superintendent or even coach; it goes, as they say, with the territory and you can't force people to love you.

Somebody once told me that it takes a college athlete ten years to appreciate their college coach and to finally "get it." After twenty-plus years I still somewhat ruefully await the enlightenment of some of my former charges while being pleased to note that many others have required far less than a decade to understand and appreciate that their experiences were not just about having fun with their teammates, wins and losses and playing time but also about connectedness and mentored life lessons from coaches and other adults, often forged through struggle, sacrifice and adversity.

So, as I look forward to a new school year in the fall, my open door policy and my good intentions will remain. However, Daphne will not; she is heading into a well-deserved retirement. Hopefully she will leave her cloak of invisibility and her legacy of great wisdom in the training room for whomever takes her place”.

Written by: Brain Tompkins, Head Male Soccer Coach at Yale University in New Haven, CT
Article found at: http://www.psychologytoday.com/blog/view-the-dugout/201005/who-knows-the-scoop-reflections-my-open-door-policy

New Technology in the Athletic Training Setting: Digital X-Ray Processors

Recently, at the start of this school year, the LSU Athletic Training Program installed a brand new Fuji FCR Prima, a Digital X-Ray Processor to replace the outdated X-Ray films. According to Andy Barker, MS, ATC, Senior Associate Athletic Trainer for Football, the digital X-Ray processor was installed for several reasons:

• Do not have to purchase x-ray film
• Do not have to purchase chemicals needed to process the film
• No need for excess storage of films
• Can burn x-rays to a CD, allowing student-athlete to have a copy
• Can e-mail x-ray to an iPad for Team Physicians to have easier and more efficient access to the x-ray
• Compact and light features

Only one disadvantage was noted in the digital x-ray processor, and that was the inability to pull up past x-rays taken on the old, traditional x-ray machine. This means that past x-ray films will still be stored in the Athletic Training Room.
The Fuji FCR (Computed Radiography) Prima is a digital x-ray processor designed specifically for use by small, low-volume private practices that only perform about 5-15 studies per day.

So what are some other advantages of Digital X-Ray Processors versus the traditional radiographic techniques?

According to Ward, et al., traditional radiographic techniques, although easy to perform and widely available, lack precision in skeletal assessment. The main source of imprecision was the difficulty to measure the width of cortical bone and estimate the exact points of major regions of the bone (Ward, et al., 2003). However, Digital X-Ray Radiogammetry (DXR) uses the principles of traditional radiography in addition to added techniques which increase the precision needed to identify skeletal abnormalities. DXR uses image processing to reduce errors from estimation of bone landmarks by automating exact location of regions needed for analysis. "Automated computer vision techniques will always be more reproducible than those dependent on human decisions and actions, explaining why DXR has improved precision in comparison with previous methods of radiogammetry" (Ward, et al., 2003). The biggest advantage of DXR in Athletic Training settings is the ability to take the radiograph in one location, and almost immediately access the same radiograph from remote settings connected to the network. This portability and easy access to X-Rays is particularly important in the collegiate setting, where on-site access to physicians is not always possible.

"The practice of digital radiographic imaging if poised to undergo dramatic change in the very near future owing to a rapid proliferation of electronically readable x-ray detectors" (Chotas, et al., 1999). In conclusion, there are two main reasons why digital radiogammetry is becoming more popular in health care settings: promise of very rapid access to digital images wherever radiography with stationary X-Ray equipment is performed and the anticipation of image quality that exceeds that of traditional radiographic systems because of improvements in X-Ray detector technology (Chotas, et al., 1999).

References
Ward, KA, Cotton, J, & Adams, JE. (2003). A technical and clinical evaluation of digital x-ray radiogammetry, Osteoporos Int, 14. Retrieved from: http://www.springerlink.com/content/x83hxk4lfu2wfepu
Chotas, HG, Dobbins, JT, & Ravin, CE. (1999). Principles of digital radiography with large-area electronically readable detectors: a review of the basics: Radiology, 210. Retrieved from: http://radiology.rsna.com/content/210/3/595.full

New Found Studies Linking Amyotrophic Lateral Sclerosis (ALS) to Athletic-Related Head Injuries

Throughout the recent media surrounding professional and collegiate football, there have been numerous controversies concerning the potential for athletically-related head injuries to cause serious brain damage and other medical problems later in life. These reported occurrences headline sports media and spark interest in Sports Medicine professionals, including Athletic Trainers to be more educated and aware of the potential for long-term brain damage in athletes suffering concussions during collegiate and professional play.

The article, "TDP-43 Proteinopathy and Motor Neuron Disease in Chronic Traumatic Encephalopathy" in the Journal of Neuropathology and Experimental Neurology provides evidence for a new link between repetitive athletic head injuries and the formation of Amyotrophic Lateral Sclerosis, or ALS. ALS is a chronic, progressive disease characterized by degeneration of motor neurons in the brain and spinal cord. The article lists some environmental risk factors thought to be the cause of ALS, and athletic-related risk factors including history of trauma to the brain and spinal cord, history of participation in varsity athletics, and a slim physique, and strenuous physical activity (McKee, et al 2010). Various studies cited in the article state that there is an increased risk of ALS when the latest head injury suffered occurred at an older age, or there were a small number of years between the last head injury and diagnosis of ALS. Sports included in the study were sports of most contact including football, soccer, and boxing. Although the diagnosis of ALS occurs in the later years of life, there is still a greater risk for athletes with repetitive head injuries to be diagnosed with ALS and therefore severe damage to the brain and spinal cord, resulting in death.

To read the entire article on the relationship between athletic head injuries and ALS, click here.

Clinical Instructors Making an Impact on Athletic Training Curriculum

Certified Athletic Trainer and LSU Athletic Training Education Program Instructor, Melissa Thompson, presented one of her recent publications at the 2010 NATA Convention this summer. Melissa Thompson, MEd, ATC, along with Dennis Landon, published the article entitled "Scapular Upward Rotation and Acromiohumeral Interval Changes in Collegiate Baseball Players During a Weighted and Un-Weighted Scaption Exercise" in the Supplement to the Journal of Athletic Training, Volume 45, Number 3.
For a link to the poster presentation, click here.
For more on the abstract article, view page 103-105 in the Supplement to the Journal of Athletic Training, 45(3).


Also this year at the 2010 NATA Convention in Philadelphia, Ray Castle, PhD, ATC, LAT, Director of Athletic Training Education Program, was elected as the new District IX Chair on the NATA Research and Education Foundation Board of Directors. He was featured in the August edition of the Southeast Athletic Trainers' Association Newsletter. For more information on his position, visit the NATA Foundation website.

LSU Athletic Trainers Educate the Community on Sickle Cell at the Annual LSU Health and Wellness Fair

Each year the LSU community joins together to host a Health and Wellness Fair. The fair provides an opportunity for the LSU population to interact with many different organizations on campus which support and promote wellness, including student organizations, LSU departments, and community agents. Over 100 various booths are set up in the Student Union which allow participants to gather information on many different wellness topics and also provide the opportunity to receive free health screenings including: cholesterol levels, glucose levels, blood pressure, hearing, and vision.

In the past the LSU Athletic Training Department, particularly Shelly Mullenix, Senior Associate Athletic Trainer/Director of Wellness, has made it a point to have the Athletic Trainers at LSU be involved in the Wellness Fair. Mullenix states, "As a health care provider, I feel it is important for Athletic Trainers to utilize opportunities such as these to educate not only the athletic teams we provide care for, but the general population as well." Along with Mullenix, one of the LSU Graduate Assistant Certified Athletic Trainers, Ben Stollberg, created informational pamphlets as well as coordinated attendance of our Certified Athletic Trainers at the Wellness Fair. The Athletic Training Department chose the topic of Sickle Cell to provide information on at the Health and Wellness Fair this year.

Sickle cell anemia is a chronic hereditary blood disorder in which red blood cells (RBC) are sickle or crescent shaped instead of round. It is caused by an abnormal type of hemoglobin in the blood. A person may either have sickle cell disease, sickle cell trait, or neither. It is an inherited disease and thus is present from birth and cannot be acquired later in life. Sickle cell is most prevalent in African American, Native American, and Mediterranean populations.

Complications of sickle cell may include, but are not limited to:

• Decreased oxygen transport.
• Shorter RBC lifespan, leading to a deficiency of RBCs.
• Increased risk of thrombi or "clogged" blood vessels.
• Increased risk of rhabdomyolysis (rapid breakdown of muscle tissue due to lack of blood supply). The risk is 200 times greater for people with sickle cell trait and is also the leading cause of death in athletes that have "sickle cell crisis".

Due to the complications of sickle cell it is easy to see that it is important for Athletic Trainers (and athletes) be educated on this blood disease. As Shawn Eddy, Senior Associate Athletic Trainer, stated in our previous newsletter, "Here at LSU we do a simple blood test on each of our student-athletes during their pre-participation physical exams to screen for both sickle cell trait and sickle cell disease." Knowing this can help Athletic Trainers better monitor student-athletes during workouts and respond if that student-athlete ever experiences a sickle cell crisis. Student-athletes with sickle cell trait or disease have increased risk of complications due to the exhaustive nature of practice and competitions. Extensive exhaustive exercise can induce sickling of the RBCs. Heat, dehydration, altitude, and asthma also contribute to increased risk or sickling. Sickle cell collapse is often mistaken for a cardiac problem or heat related problem.

How to Tell the Difference Between Heat Cramping and Sickle Cell Crisis:

• Heat cramping is often preceded by muscle twitches; sickling is not.
• The pain is "different"; heat cramping pain is more excruciating.
• Heat crampers hobble to a halt with "locked up" muscles, while sickling players slump to the ground with weak muscle.
• Heat crampers have visibly contracted, rock hard muscles. Sickling players have muscles that look and feel normal.
• Sickling players caught early and treated right recover faster than players with major heat cramping.

The fact that many people, not just athletes, are active and potentially vulnerable to the complications of sickle cell means education can become important for everyone. All people are screened for sickle cell at birth. However, many do not know the results of these screens. Since sickle cell is an inherited disease, blood screening only needs to be done once and is very easy to do. Just as many health care providers do, Athletic Trainers often encourage screenings such as sickle cell for everyone.

Pre-Participation Exams

Written by:
Shawn Eddy
Senior Associate Athletic Trainer
Louisiana State University

It's the middle of March, our Spring sports are in full swing; winter sports are wrapping up and much of the country is caught up in March Madness. It's also at this time that I start looking at Semester schedules, getting in touch with coaches as well as compliance and academic offices as to when their teams are reporting and when orientation meetings are being held for the sole purpose of coming up with a Pre-Participation Exam (PPE) schedule.

Over the years, we have seen changes to our PPEs. Some of these changes have been necessitated by NCAA rule changes, others by the tragic occurrences that have been taking place in sports at all levels, sudden deaths. Currently at LSU, we are doing PPEs 6-7 times a year depending on when the sports teams report. However, we have two primary dates: the Sunday prior to start Summer semester and the Sunday prior to start of Fall semester. Not only do Freshman and Transfers receive PPEs, but our returning athletes do as well. All Freshman and Transfers undergo a complete physical while returnees go thru a "recheck" process. These rechecks are done within the first week of classes in the Fall. At that time we are able to follow-up on any injuries or illnesses that are unresolved from the prior season or summer vacation. The recheck exam provides us the opportunity to re-assess vital signs, heart and lung function, height/weight and follow-up on any orthopedic injuries. In the end, every student-athlete (S-A) will complete a physical each year prior to sport competition.

The most recent addition (since around 2001) to our PPE has been the implementation of Echocardiograms (ECHO). While we continue to do the standard ECG, our team of physicians felt this would be a helpful addition to our standard protocol. Every S-A receives an ECHO at the beginning of their eligibility at LSU; the decision is not based on one's history. Our Team Cardiologist, along with a Radiological Technician, is on-site to administer, observe, and read the ECHO during physicals to rule out any pathology that may predispose an athlete to heart ailments. There is controversy both within our Conference as well as nationally as to the real benefit to doing an ECHO. The three primary arguments are: (1) the cost of performing an ECHO, (2) the liability and potential cost to the Department is something is found, and (3) the reliability of the ECHO to actually uncover pathology. For LSU, the cost has been offset by the fact that the echocardiogram equipment has been donated; so has the time of both the Team Cardiologist and Radiological Technician. As for concerns over liability, our Administration agrees that accepting a scholarship athlete to LSU will sometimes bring the potential fro medical problems. Our medical personnel would rather accept responsibility versus not knowing what potential problems may exist. Finally, uncovering pathology, even if the chances are slim, would be well worth it if it meant the difference between life and a catastrophic cardiac event. The most critical pathology that could be uncovered is Hypertrophic Cardiomyopathy (a thickening of the left ventricular wall). This can be clearly evaluated by an Echocardiogram. As of 2010, several more universities have added the ECHO to the PPE regimen.

Height, weight, pulse rate, blood pressure, orthopedic evaluation, and general health evaluation are still a major part of each PPE. Each S-A also has blood drawn. With the blood evaluation, our physicians are assessing the S-A's general health as well as identifying those athletes with sickle cell trait, and potentially sickle cell disease. LSU includes a psychological screening tool that is evaluated by our contracted sports psychologist. This is used to pre-screen new student-athletes for a multitude of psychological, social, academic, and substance abuse issues. Additional areas of medical concern that are evaluated during the PPE are oral evaluations and eye examinations. The oral exams, performed by one of our Team Dentists, are done to rule out early stage oral cancers. In addition to oral exams, mouth molds are taken so that custom mouthpieces and be made for those sports that require mouth guards. Our eye exams check for any changes in vision since their last evaluation. Any functional testing that an ATC would like to do for an individual or team is done around the time of the PPE but is not generally a part of the scheduled exams.

Once a S-A completes his or her athletic eligibility, they receive an exit physical. The exit exam has allowed us to follow-up of any unresolved issues that an athlete may have or had in their athletic career that needs additional follow-up.

The PPE gives us an opportunity to uncover pathologies and orthopedic injuries. The simple introduction of rehabilitation could potentially strengthen joints that would be more vulnerable to injury. It is not unusual to find elevated blood pressure during physicals. This can be effectively treated prior to the start of one's season. Most important is the blood work that could uncover the life threatening condition, sickle cell. With conditions such as sickle cell, knowledge is power. Adjustments can be made to practices and conditioning workouts that would accommodate the special needs of these individuals. While we recognize that PPEs are time consuming for all of the individuals involved, we all agree that they are one of the most critical parts of our pre-season preparation.

Pilates

Pilates is an exercise program designed to both stretch and strengthen the body. A German man by the name of Joseph Pilates developed this program which was originally named “Contrology” in the early 1900’s. He developed this program during World War One as a method of helping rehabilitate injured soldiers who were bedridden. Joseph Pilates would take springs from the bed and connect them to the bed posts to allow the immobile patients some form of movement. This was the origin of the “Trap Table”. His theory was that lifestyle, bad posture, and inefficient breathing patterns were the root of poor health. His exercise regimen was directed towards improving overall flexibility and strength, correcting muscular imbalances, as well as incorporating proper breathing patterns. Joseph Pilates moved to the United States at the age of forty years old. He worked on perfecting his craft until his death in 1967 at the age of eighty three years old. It was said that Pilates would boast that he was ahead of the times. This statement was very true due to the 1980’s “Pilates” craze that swept the nation.

There is more than meets the eye to the art of Pilates. It is more that the commercialized series of exercise videos that we see across the nation. The true art of Pilates incorporates both mat and machine exercises to engage the body. The reformer table (pictured above) has been developed to aid the body in this regimen and is used in Pilates studios across the country. This table has been modified from the original sick beds that Pilates used and has a sliding carriage for a person to move back and forth on. The series of cables attached to the carriage allow for both assistive and resistive training. This allows for both healthy individuals as well as people with restrictions to safely engage in these exercises. Another machine used in the Pilates studios, the Cadillac (left), allows for more difficult movements by having bars and levers attached to the sides of the table to allow for other degrees of freedom.

The focus of Pilates is body positioning, alignment, posture, and proper breathing techniques, said Jude Chatelain, certified Pilates instructor and Program Director of Balanced Body in Baton Rouge. Jude has spent a number of years perfecting his craft and helping tons of people in the Baton Rouge community. He works both with fit people who just want to get into better shape, as well as patients coming in to the studio for a rehabilitative component.

The many benefits that result from Pilates can include:

• An increase in overall flexibility and range of motion
• An increase in strength and overall endurance
• Indentify and address muscular imbalances
• A decrease in overall stress levels

Why Pilates works so well is that it can be adjusted to meet each individuals needs and address their weaknesses. It can be used on all ages and genders. This program is actually very safe for older individuals with restrictions due to the assistive components that the tables offer. This regimen of exercise is outstanding for the athletic population as well. Many pro athletes use Pilates in combination with their other training routines to help with their overall flexibility and wellness.

Jude Chatelain recently came over to LSU to work with the Athletic Trainers in the instruction of the Pilates reformer table. LSU is fortunate to have a reformer table located in the Broussard Center for Athletic Training. Jude comes to LSU every few years to re-familiarize the new Athletic Trainers with the art of Pilates and the specific use of the Pilates Reformer Table. The in-service was specific to the treatment of lumbar spine and core muscular imbalances. He will be coming next semester to instruct on both an upper and lower extremity flexibility and strengthening routine.

Below are a few of both the stretching and stabilization exercises that can be incorporated into a Pilates routine, click the exercise to view a video:

• Kneeling Runner Stretch
• Elephant Stretch
• Monkey Stretch
• Bridges with Side Shift
• Figure 8’s
• Knees in Straps

For a video on breathing techniques, click here.

Much thanks to Jude Chatelain and Balanced Body. If anyone is interested in the Baton Rouge area in taking a class, please contact Jude at (225) 927- 2134.

For more information on the history of Pilates, click here.

Ana Gross, MS, ATC
Associate Athletic Trainer
Louisiana State University

Concussions: Q & A with Dr. Jeff Burnham

A concussion, or mild traumatic brain injury, can be defined as a transient disturbance of neurological function caused by head trauma. Common signs and symptoms include headache, nausea, dizziness, difficulty concentrating, visual disturbances, confusion, tinnitus, slurred speech, loss of balance, post-traumatic amnesia, and loss of consciousness. These symptoms are not generic, and vary between individuals. This variation in symptoms is due to the type of sport, position played, impact of the trauma, and other factors unique to the individual. Concussions are commonly graded on a scale of I, II, or III, depending on the pre-established guidelines used. The three most common guidelines used by Certified Athletic Trainers are the Cantu, AAN (American Academy of Neurology), and the CMS (Colorado Medical Society).

The majority of concussions in high school and collegiate sports occur in Football, however other sports here at LSU where concussions are common are Gymnastics, Men’s and Women’s Basketball, and Women’s Soccer.

Here at LSU, our primary Sports Medicine physician, Dr. Jeff Burnham, M.D. has a specific protocol that he uses to diagnose concussions and determine when the athlete can return to play. His protocol is based on the athlete’s signs and symptoms, and their progress of recovery.

Question and Answer with Dr. Jeff Burnham:

1. When evaluating an athlete that you suspect has a concussion, what are the first steps you take?
“The very first step is to evaluate the athlete’s general demeanor. It is important to note any abnormal behavior that is not common to the athlete’s normal everyday demeanor. To recognize these differences, it is important for the Athletic Trainer to know their athletes’ normal behaviors. Examples of this abnormal behavior include a vacant stare like a “deer in head lights”, talking unintelligibly, mumbling, lack of coordination, unusual quietness, confusion, and so on.”

• See The Fencing Response to view a recent news report from ABC news on one sign that can occur from concussions.

2. What protocols do you use here at LSU to grade a concussion?
“I use a protocol called a Graded Symptom Checklist (GSC) with patients at Burnham Family & Sports Medicine Clinic, as well as with the athletic teams here at LSU. The GSC is a list of symptoms such as: blurred vision, concentration problems, confusion, dizziness, drowsiness, excessive fatigue, feeling foggy, headache, inappropriate emotions, irritability/nervousness, loss of consciousness, memory problems, nausea/vomiting, personality change, poor balance/coordination, seizures, sensitivity to light, sleep disturbances, and any others the patient may be experiencing. The athlete is instructed to grade the severity of the symptom they are experiencing at the following intervals: the time of the injury, 2-3 hours, 24 hours, 48 hours, and 72 hours post-injury. Grading of the severity of the symptoms is as follows: 0=not present, 1=mild, 2=moderate, and 3=most severe.”

“Following the GSC, I will perform a neurological exam, assessing cognitive function and cranial nerve assessment. If neurological exam is within normal limits, I will then perform balance/coordination tests, and lastly check the ability of the athlete to perform sport specific skills.”

• For more information on Neurological, Cognitive, and Coordination Tests and a sample of the Graded Symptom Checklist, visit the NATA Position Statement for Management of Sport-Related Concussion

3. Is there a pre-established Grading Scale that you prefer to use?
“A combination of CANTU and American Academy of Neurology, but it is important to note that no general scale applies to every athlete because of variation in symptoms.”

• Click here to view a table that compares the three guidelines. It is important to remember that if you suspect an athlete has a concussion, referral to a physician is necessary for further evaluation.

4. Since every athlete is different, and there are no generic signs and symptoms, how do you account for these differences when diagnosing and grading concussions?
“The most common SYMPTOMS are headache, dizziness, blurred vision, sensitivity to noise and light, fogginess, and excessive fatigue. The most common SIGNS are photophobia when performing visual tests with a light, blank stare, unusual speech, balance, and mood or personality change. Some people get less or more talkative than usual; anything out of the ordinary behavior for that individual should be noted.”

5. Can you explain the ImPACTTM and any advantages and disadvantages that you find associated with the test?
“The ImPACTTM test is used to determine the athlete’s brain function AFTER symptoms have concluded. It also helps determine if the patient is experiencing Post-Concussion Syndrome. An initial baseline test must be performed to asses normal cognitive function for that individual athlete.”

“There are many advantages for this particular test because it assesses reaction time and concentration. It is OBJECTIVE. Other than the physical exam, we rely on the athlete to be truthful about signs and symptoms, but the ImPACTTM provides us with a more objective evaluation of the patient’s brain function. A disadvantage is that sometimes the concussed athletes do better on the repeat test than they do on the baseline test, because they take it more seriously, and really try hard to concentrate and pass the test. Also, there can be a learning curve associated with taking the ImPACTTM test multiple times for individuals having multiple concussions.”

• For more information on the ImPACTTM, click here.

6. What is Post-Concussion Syndrome?
“Post-Concussion Syndrome is when the athlete’s symptoms last for weeks, months, and even years after the initial concussion.”

• To read a recent article on Post-Concussion Syndrome from the New York Times, see Ex-N.F.L. Executive Sounds Alarm on Head Injury

7. Briefly describe your Return to Play (RTP) criteria.
“Most important, there should be absolutely no return to activity as long as symptoms are still present. If the athlete had a Grade I concussion and signs and symptoms resolve within 20 minutes and stay resolved, the athlete may be able to RTP the same day if symptoms do not return with sideline exertion tests. A Grade II concussion, with or without Loss of Consciousness (LOC), will result in being held from activity that day. They need to be re-checked every few hours the first day and then periodically until symptoms resolve. Symptoms could last 48 hours to months. A Grade III concussion would include LOC, immobilization, and transportation. The same progression below would be used, but the time to start the progression would be substantially longer than with a Grade II concussion.”

“To assess ability to return to activity we follow this general guideline: once symptoms completely resolve, this graded activity progression can begin. At any time, if ANY symptoms return, activity is stopped and possibly resumed the next day with possible modifications.

• Day 1, post symptoms: Ride bike (Level 1 or 2)
• Day 2, if no symptoms return: Light jog for 5-10 minutes
• Day 3, if no symptoms return: Non- Contact Sport-Specific Drills
• Day 4, if no symptoms return: Return to sport with modifications and limited contact
• Day 5, if no symptoms return: Full contact

Exceptions to this would include high school athletes (because of their still developing brain and high risk for further damage) and athletes with previous history of concussions. They will go through a slower progression plan in order to prevent further damage. In some situations cognitive as well as physical rest may be prescribed (e.g. no studying, video games, excessive texting, etc.).”

8. What are some ways to prevent concussions in contact sports like football?
“Remember, once an athlete experiences a concussion, the chances of sustaining another one increases 3-9x. As far as equipment, a good helmet fit is important. However, no specific helmet willtotally prevent a concussion. Your Equipment or Athletic Training Staff must be trained in the proper fit and use of helmets. It is important that the coaches and athletes are educated on good hitting techniques and rules such as no helmet-to-helmet contact or spearing.”

• For more information on proper helmet fit, visit the National Operating Committee on Standards for Athletic Equipment (NOCSAE).

9. Is there any other important evaluation information to know?
- “Most importantly, evaluate thoroughly, no return to play until symptoms cleared, and gradual progression checklist is performed after symptoms have resolved.”
- “While recovering from concussion, do not give strong pain medications or NSAIDs (such as Advil), because these will thin the athlete’s blood, and cause further bleeding and damage to the brain or mask severity of the concussion. Tylenol in small doses is the medication of choice.”
- “Athletes often think that no competition means they cannot participate in games or practices, and they think it is okay to lift weights. However, this is NOT okay. Lifting weights puts increased pressure on the brain, putting the brain at risk for further damage.”
- “There is new research being conducted on the effects of a concussion and a student-athlete’s ability to attend class regularly while recovering. This research indicates that, in certain instances, the athlete may need to be removed from classes and all concentration activities that engage the brain.”

A special thanks to Dr. Burnham for taking the time and allowing us to interview him for this month’s Tiger Talk!