Recovery from concussion – a guest blog by Kate Moores

Following our last blog on concussion, I started talking to Kate Moores via twitter (@KLM390) who had some very intersting experiences and ways of managing concussion. So, I am very pleased to introduce Kate as a guest blogger on the topic of Concussion assessment & management – we have decided to split Kates blog into 2 more manageable parts rather than one super-blog (My contribution may have been to add the occassional picture to the blog).

The original blog (here) discussed generalized pitchside assessment of a concussion, irrelevant of age. However Kate has drawn on her knowledge and experience with young rugby players to highlight in particular, the ongoing assessment of young athletes as well as adults and how it differs. Kate raises some very good points throughout but the point that really made me reflect was the consideration over “return to learn.” Looking back at concussions I’ve managed in academy football, I didn’t properly respect the impact that a day at school may have had on symptom severity or neurocognitive recovery. I was mostly interested in “have you been resting from activity?” I think this blog is an excellent resource for medical professionals, but also for teachers, coaches and parents to consider the impact of this hidden injury.

This is part 2 of Kates guest blog (part 1 here).

 

Recovery

Any player regardless of age should never return to play or training on the same day that they sustain a concussion. So when should they return? The general consensus is that players should be symptom free prior to starting their graded return to play and that youth players should have a 2 week rest period and that youth athletes should have returned to their normal cognitive activities symptom free prior to considering a return to play. It is therefore recommended that cognitive rest is adhered to for 24-48 hours post injury. This means no texting, computer games, loud music and cognitive stress. This can be difficult to get players to adhere to however research has shown that a period of cognitive rest helps to reduce the duration of symptoms.

“They said something about no computer games”

The concern with any concussion, but increased concern with children returning to play too quickly is the risk of second impact syndrome, with well publicised cases including the tragic death of Ben Robinson a 14 year old rugby player and more recently Rowan Stringer a Canadian rugby player aged 17. Children are at a higher risk of second impact syndrome (McCory et al 2001) and this risk continues for anything up to 2/3 weeks post initial injury. This is part of the reason why an u19 rugby player can not return to play earlier than 23 days post injury unless they are being managed by a medical doctor who is experienced in managing concussions. Below is the concussion management pathway from the WRU.

Under this protocol adult athletes would be able to return within a minimum of 19 days after a concussion whereas u19s would not return before 23 days. Both groups need to be symptom free and have had a 2 week rest period prior to return. For the younger age group it does state that they must have returned to learning however there is no guidance as to how this should be staged. The graded return to play protocol consists of 6 stages which gradually increase the level of activity. Stage 2 starts with light aerobic exercise, stage 3 includes light sport specific drills, stage 4 includes more complex drills and resistance training, stage 5 is return to contact with stage 6 being return to normal activity. With children there must be 48 hours in-between stages as opposed to 24 hours with adults.

As mentioned, return to learning protocols are less well documented, there has been some proposed protocols from Oregan and Halted et al (2014) who state that a youth athlete should be able to tolerate 30-40 minutes of light cognitive activity prior to a return to school and that players should be gradually return to normal school activities prior to their graded return to play.

At present youth athletes are part managed as students and part managed as athletes, however there is an emerging theme that return to activity is potentially a far more appropriate method of managing a childs recovery from concussion. We need to do more work to align both protocols. A player may well be “fit” to return to school and therefore deemed “fit” to return to light activity and subsequently drills, however very little research has been done to look at the impact of skill acquisition in a physically challenging environment. Learning your french verbs might be fine (in isolation), gentle jogging may well be fine (in isolation) but there is no denying that trying to do the two in consecutive lessons may well be far more challenging, yet that may well be what we are expecting some of our youth athletes to do. We already know that a concussion can impact players non related injury risk for a year following a single concussion, could it is be impacting on the skill level of players we produce?

Howell et al (2014) (here) explain that traditional concussion severity scales are being abandoned in favour of individualized concussion management with multifaceted evaluation of function. For example, the SCAT3 assesses static balance as part of motor control, however Howell’s study found that up to 2 months post concussion, adolescent athletes display increased centre of mass displacement medial-lateral compared to a matched control group. Could it be that we are clearing people for activity based on a static assessment when in fact dynamic balance may take longer to recover? (a potential study for anyone interested).

Whats up doc?

This doesn’t even make sense

Concussion management is further complicated by contradictory advice, youth concussion is not only a sporting issue, but a public health one. If GP’s or A&E do not feel able to confidently manage concussions, how can we expect them to make decisions regarding return to play? I’ve attended numerous times to A&E with players who have been told once you feel better, get back to training. With Scotlands new concussion guides they are starting to address the associated public health concerns around child concussion. It can no longer be deemed as just a sport issue or just a medical issue as the potential long term consequences go beyond these two areas.  With the Scottish guidelines being aimed across sports at a grass roots level it begins to address the disparity between the quality of concussion management across sports and levels. Whether you’re an elite athlete, a weekend warrior or a 15 year old school child you still only have one brain!

 

Prevention

Prevention is better than cure right? Non contact rugby until the age 20? I don’t think so. Considering the reaction to suggesting removing the header from football in youth sport due to concerns around sub concussive events, the suggestion we remove contact from rugby is a no go. However there are lots of benefits to playing a contact sport, from social development, self confidence and the physical benefits from contact so maybe managing the amount of contact sustained in training is one way of combating the risks of concussion and sub concussive events.

How about a helmet, monitors or head guards? Considering the issues within the NFL and concussion with players recently retiring due to concerns around concussion, it would suggest that protective headgear does little for prevention of concussion (think back to blog 1 about mechanisms within the skull). It’s widely accepted that protective headgear has a role to play in prevention of catastrophic head injuries (ie your cycle helmet) however scum caps may well give players a false sense of security which in turn increases the risk of a concussion. RFU guidelines indicate that a scrum cap must be able to compress to a certain thickness and must be made of soft, thin materials – their main purpose is to protect against lacerations and cauliflower ear, they have little to no impact on concussions.

Following a severe head injury (skull fractures), Peter Cech has become synonomous with this head gear. It provides him with the confidence to play – but what does it do?

Every concussion needs attention. Every team has a coach or a parent watching. But not every child has access to a health care professional pitch side.

Cournoyer & Tripp (2014) (here) interviewed 334 American football players 11 high schools and found that 25% of players had no formal education on concussion. 54% were educated by their parents (but who is educating the parents?!). The following percentages represent who knew about symptoms associated with concussion:

Symptoms	Consequences
Headache (97%)	Persistent headache (93%)
Dizzyness (93%)	Catastrophic (haemorrhage, coma, death) (60%)
Confusion (90%)	Early onset dementia (64%)
Loss of Consciousness (80%) – how this is lower than headache is worrying.	Early onset Alzheimers (47%)
Nausea / Vomitting (53%)	Early onset parkinsons (27%)
Personality change (40%)
Trouble falling asleep (36%)
Becoming more emotional (30%)
Increased anxiety (27%)

Table 1: Frequency of concussion symptoms and consequences identified by American Football playing high school students (Cournoyer & Tripp 2014)

Education is key! Players, parents, coaches, friends, family. Everyone! The IRB has some great online learning for general public, coaches and medical professionals (here). Only by symptoms being reported, assessed and managed can we make an impact on concussion.

 

Kate is a band 6 MSK physiotherapist, having graduated in 2011 from Cardiff Univeristy. Beyond her NHS work, Kate has worked for semi-pro Rugby League teams in Wales, the Wales Rugby League age grade teams and is now in her 3rd season as lead physio for the Newport Gwent Dragons u16 squad.

Concussion Assessment – a guest blog by Kate Moores

Following our last blog on concussion, I started talking to Kate Moores via twitter (@KLM390) who had some very intersting experiences and ways of managing concussion. So, I am very pleased to introduce Kate as a guest blogger on the topic of Concussion assessment & management – we have decided to split Kates blog into 2 more manageable parts rather than one super-blog (My contribution may have been to add the occassional picture to the blog).

The previous blog discussed generalized pitchside assessment of a concussion, irrelevant of age. However Kate has drawn on her knowledge and experience with young rugby players to highlight in particular, the ongoing assessment of young athletes as well as adults and how it differs. Kate raises some very good points throughout but the point that really made me reflect was the consideration over “return to learn.” Looking back at concussions I’ve managed in academy football, I didn’t properly respect the impact that a day at school may have had on symptom severity or neurocognitive recovery. I was mostly interested in “have you been resting from activity?” I think this blog is an excellent resource for medical professionals, but also for teachers, coaches and parents to consider the impact of this hidden injury.

Part 1 (of Blog 2)

Conor McGoldricks first day at school

Children are not just little adults… a phrase commonly heard within healthcare. It’s particularly true when it comes to concussion. Children’s brains are structurally immature due to their rapid development of synapses and decreased levels of myelination, which can leave them more susceptible to the long term consequences of concussion in relation to their education and sporting activities. With adults the focus is usually on return to play, with similar protocols being used in managing youth concussions, albeit in a more protracted time frame.

However a child is physically, cognitively and emotionally different to adults, therefore is it appropriate for these return to play protocols to be used with youth athletes? Youth athletes are still children – still students as well as athletes. It is during these years that children develop & learn knowledge & skills (academic and social), in a similar way these youth athletes need to be learning the tactical knowledge and motor skills they will need for their sport. Shouldn’t “return to learning” be as much the focus in youth athletes as a “return to play” protocol?

“Youth Athletes are still children balancing studies with sports”

Assessment

So, the pitchside decision on management has been made (blog 1) and now the assessment continues in the treatment room

The use of the SCAT3 (here) and Child SCAT3 (age 5-12) (here) have been validated as a baseline test, a sideline assessment and to guide return to play decisions. O’Neil et al 2015 compared the then SCAT2 test against neuropsychological testing. They found that SCAT2 standardised assessment of concussion scores were correlated to poorer neuropsychological testing for memory, attention and impulsivity. However symptom severity scores had poor correlation with those same components. Therefore simply being symptom free may not be a good enough indicator that youth athletes are ready to return to learning or sport.

There has been recent research into the King Devick (K-D) test as another option for the assessment on concussion in children with research being done comparing SCAT scores with K-D testing (Tjarks et al 2013)

One of the benefits of using the KD test is that it has stronger links with the neurocognitive processing which may mean that it has a greater role to play with regard to return to learning as well as return to play. Another benefit is that unlike the SCAT3 tests the KD test does not require a health care professional to administer the test.

We educate people about how robust their body is, but should we be more cautious with brain injuries?

At a club with full time staff and consistent exposure to players, the SCAT3 can be useful to compare to pre-injury tests conducted as part of an injury screening protocol. It also helps if you know that person, for some the memory tests are challenging without a concussion so post injury assessment with the SCAT3 may score badly, but is that the person or the injury? It is also important that this assessment is done in their native language. These reasons throw up some complexities if you are working part time for a club, or covering ad hoc fixtures as part of physio-pool system. Its advisable in this instance to get a chaperone in with the athlete to help your assessment – this may be a partner for an adult player or a parent / teacher for a child. A quick conversation with them to say “please just look out for anything odd in what they say or how they say it.”

Beyond the assessment tool, there is evidence now to suggest we should be asking about pre-injury sleep patterns. Sufrinko et al (2015) (here) look prospectively at 348 athletes in middle school, high school and colligate athletes across three different states in America (aged 14-23). At the start of the season the researchers grouped the athletes as those with “sleep difficulties” (trouble falling asleep, sleeping less than normal” and a control group of “no sleeping difficulties”. Following a concussion, assessment was conducted at day 2, day 5-7 and day 10-14 using the Post Concussion Symptom Scale (PCSS) and found that those with pre-injury sleep difficulties had significantly increased symptom severity and decreased neurocognitive function for longer than the control group.

Looking in the other direction, Kostyun et al (2014) (here) assessed the quality of sleep after a concussion and its subsequent impact on recovery. Looking at 545 adolescent athletes, the results indicated that sleeping less than 7 hours post-concussion significantly correlated with increased PCSS scores, where as sleeping over 9 hours post injury significantly correlated with worse visual memory, visual motor speed and reaction times. A word of caution with this study, the authors assumed that “normal” sleep was between 7-9 hours – but anyone who has adolescent children, or hasn’t blocked the memory of being an adolescent themselves, knows that sleep duration does increase when you are growing. Saying that, the impact of both of these studies suggests that we should be:

1) Asking about normal sleep patterns prior to injury to help us gauge recovery times (disrupted sleepers may take longer than we originally predict) and;

2) We need to keep monitoring sleep quality along with regular re-assessment as sleeping more than normal may indicate ongoing recovery from concussion.

 

In Part two (here), Kate continues to discuss ongoing assessment and the recovery process.

Kate is a band 6 MSK physiotherapist, having graduated in 2011 from Cardiff Univeristy. Beyond her NHS work, Kate has worked for semi-pro Rugby League teams in Wales, the Wales Rugby League age grade teams and is now in her 3rd season as lead physio for the Newport Gwent Dragons u16 squad.

 

 

 

 

 

 

Case Study: working through the pain with Nick Atkins

Nicks 30/30 challenge

A bit of an unusual blog from us, but I hope its as popular as our previous ones due to the message it contains. A very good friend of mine is undergoing a year-long series challenges to help raise money for a cause very close to his heart.

Below is a summary of the 30 challenges that Nick Atkins is doing, having turned 30 this year.

Nick Atkins 30 / 30 challenges

I’m sure a lot of people will question the management of some of his injuries I’m detailing here because I’ll admit its not how I would typically manage these problems, so let me explain quickly why rest is not an option here:

Nick, along with his sister Jen & brother Jon, very sadly lost their mum, Judith Atkins, to pancreatic cancer in 2013. Pancreatic cancer has the lowest survival rate of any cancer. Doctors believe there is a period of remission around 5 years that if reached, the risk of the cancer returning is negligible. Judith was a few months short of this milestone before the pancreatic cancer aggressively returned. While we are generally winning the fight against cancer, pancreatic cancer remains the outlier and part of Nicks aim is to not only raise money for research, but also awareness. (Nicks justgiving page here). For this reason, he is displaying an incredible amount of grit and determination to complete these challenges, despite his body saying otherwise.

Nick, certified drinking athlete. Pre-challenge training

A quick background into Nick, he is what his friendship circle would describe as a “drinking athlete” and certainly not a runner. So while some endurance junkies out there may do physical challenges like these regularly, Nicks starting position was certainly not one built on endurance.

Nicks injuries to date:

 

Disclaimer – I have permission from Nick to share these details regarding his injuries.

 

The nature of Nicks challenges meant the timeframes were dictated by inflexible dates, making it very hard to periodize any training. So load management became critical, forecasting time periods where we could off-load but maintain a crucial level of fitness.

The first problematic injury(ies) was the bilateral plantafascia pain with right sided calcaneal fat pad irritation. This was the first time we had to make decisions about the program. Previous aches and pains in the lower limbs and back were manageable and its not in Nicks nature to complain. But this pain in his foot was affecting ADL’s as well as training. Typically inflammatory in nature and progressively increasing pain, it took him to the point where he couldn’t weight bear through his heel – but was still completing physical challenges.

Controlling the controllables:

Dropping or moving a challenge was not an option, so we had to sacrifice road running training and hockey for a period of two weeks. Nick maintained fitness via swimming and cycling (a lot) in the mean time we addressed some biomechanical issues in the foot. I say this very tentatively, because in fact it was a lack of biomechanical issues that we had to address. Nick was prescribed some permanent orthotics when he was about 16 for “collapsed arches” – in fact these orthotics were probably causing more problems than solving. Nick had good active control of the medial and longitudinal arches in both feet, so no evidence of a collapsed arch. These orthotics were encouraging him to laterally weight bear via some high density medial posting of the calcaneus & preventing any medial rocking after heel-strike. We removed these, added some gel heel cushions to his work shoes to help offload the fat pad and temporarily reduced running training, which seemed to resolve the pain after two weeks. Instead, nick ramped up the swimming and cycling as part of his triathlon training.

 

Nature of the beast:

There have been times recently however where we can’t modify load. Nick is currently running with right sided Achilles pain and in the last week has developed sharp pain in his left groin which is present following a rest at the end of a long run. This presented us with a problem; a month of 10k’s, with half marathons immanent and full marathons on the near horizon. Nick can’t afford to rest.

Typical management of tendon problems would be modifying load along with addressing strength. There was a dramatic difference with single leg heel raise between left & right. Temptation would be to add some exercises here to address this, but we need to acknowledge the accumulative load and consider if there would be any benefit. We decided that the back to back events could in themselves serve to maintain fitness, so we could drop a training session during the week.

The other consideration is where & when Nick is getting the pain. The Achilles pain is only present with compression, so with full plantaflexion – recreated both actively and passively, which makes me suspect a retrocalcaneal bursa involvement. We know that tendons don’t like compression but the absence of any Haglunds deformity and with adequate, well fitting running shoes there is reason to think the tendon may not be a source of symptoms. (See my previous tendon blog here with references).

The pain has stayed at the same level for over 4 weeks now, so we have identified an upcoming gap in events as a window to unload and reassess. In the mean time we can achieve short term relief with soft tissue massage to the gastrocs and some tib-fib, talocrural and subtalar mobilisations.

The groin on the other hand presents like a classic tendinopathy and we were able to exclude any pubic synthesis involvement via a series of tests. This injury was a lot more acute in nature compared to the Achilles. We tried some isometric adduction through different ranges of hip flexion and achieved some short term reductions in pain. Once again, we had to sacrifice some hockey training to try and reduce load and cutting actions in the groin, but in place of this we added isometric groin squeezes into Nicks program.

What’s next?

Nick & his wife Cat, who has done every challenge with him so far & ironically is conducting her PhD in tendon pathology.

At the time of writing, I have my fingers crossed as Nick is running a “True Grit” obstacle course with his dedicated wife, Cat, who has done every challenge with him so far! (Except the 100 different beers in a year).

With some half marathons and marathons coming up, along with long distance treks I’m anticipating an update to this blog in the summer. Like I said, the plan now is to highlight a window of relative rest where we’ll do some detailed analysis of the right leg in particular. Overall though, I’m incredibly impressed that someone with no endurance running experience has had so little problems. It wont be typical management that’s for sure – while there are long term goals to be met, performance is not the main driver. I’m used to managing similar problems with a view of being pain free, able to perform at high level and minimising the risk of re-injury. So some of this management may not appease the purists, I understand.

For Nick, however,  there are no specific performance targets to be met, it is just essential that he finishes. He’ll do that without my help because of the level of determination he has, but my job is to try and keep a lid on the severity of injury (he insists 90 days without a hot drink is harder than any marathon or combination of marathons).

But the description of Nicks injuries & management are secondary to the fact that hopefully I’ve helped promote Nicks challenges and ultimately an awareness of Pancreatic Cancer. For that reason, if you’ve read this far please help share Nicks challenge.

Nick & his mum, Judith.

https://www.justgiving.com/nicks3030challenge/

On behalf of Nick, yours in sport

Sam

ps – the 30th challenge is yet to be decided, Nick wants to make it something special so please send us your suggestions!!

 

Massage: A case for the defence

Just because we can’t prove what something does, doesn’t mean it doesn’t do anything.

The older I get, the more I read, the less I know. I know that for a fact. But recently I’ve started re-reading around the topic of massage and its place in sport and recovery. And with my critical head on, the one thing that I can consistently critique is the literature. The methodology, the participant population, but not necessarily “Massage” itself.

A good starting point for this defence would be to read the antithesis for this blog, a great blog by @AdamMeakins (There is no skill in manual therapy). Adam makes a valid point that there is not a strong background of evidence to support massage. Agreed. And its worth pointing out that a large, very large, part of my practice is exercise based rehab – I’m a strong believer of “move well, move often”. However, massage is a very well used tool in my pocket of possible treatments, so I’m going to fight for the underdog.

Below is a summary of terms / applications commonly used with recognised massage techniques (not an exclusive list).

Table 1: A summary of western massage techniques (Weerapong et al)

Technique	Definition	Suggested Application	Proposed clinical effects
Effleurage	Gliding movement over the skin in a continuous movement	Beginning & end of a session	Stimulates the parasympathetic nervous system, promotes relaxation and enhances venous return.
Pretissage	Lifting, wringing, squeezing and kneading of soft tissue.	Following effleurage	Mobilise deep muscle and subcutaneous tissue. Increases local circulation and enhances venous return
Friction	An accurate penetration of pressure applied with the fingertips	Used for specific purposes, such as reducing muscle spasm or breaking down adhesions.	Break down adhesions from old injuries
Tapotement	Various parts of the hand striking the tissues in a rhythmical but rapid rate	Before and during competition	Stimulation of tissues either by direct mechanical force or by the reflex action

 

The problem with Evidence Based Practice:

I think that all medical professions are dependent on research to ensure our practice evolves for the better. But I think sometimes we overlook the importance of anecdotal evidence. It must be considered that not all aspects of sporting competition depend on physical attributes, the mind and perceived benefits of treatment play an important role. The majority of people that go back for massages are because it made them feel better. Maybe not during, but after. A prime example, my wife never says “Can you give me an exercise program for my neck & shoulders please?” But I know that anecdotal evidence on its own doesn’t wash.

So here is where I think the literature lets massage down. The effectiveness of massage will vary depending on duration, method and depth of pressure (Drust et al) however none of these variables have been standardized making comparisons between studies very difficult (Mancinelli et al).

Jönhagen et al investigated the effects of sports massage on recovery following eccentric exercise. 16 “recreational athletes” (I have issues with this terminology for a start) were asked to complete 300 maximal eccentric contractions of their quadriceps using a Kin-Com dynamometer. Subjects received a pretissage massage once a day for 3 days before re-testing single leg long jumps to analyse “functional recovery”. SHOCK – The study found no improvement in function following massage.

@ConorMcGoldrick has been quiet on blog front, but promises he is still working hard in the gym. Trying a new technique of 300 eccentric max contractions

 

• Firstly, it may not be possible for one to truly maximally contract for such a high number of repetitions, therefore cannot be considered functional for an athlete; professional or recreational.
• Secondly, name a sport that requires 300 maximal eccentric contractions in succession. Even an eccentric dominant sport like basketball would be interspersed with periods of rest and I don’t imagine basketball players would define those eccentric actions as maximal.
• Thirdly, pretissage is a deep and firm technique, the use of which immediately following 300 eccentric contractions and continued for 3 days is more than likely going to cause mild muscle trauma. Not exactly a therapeutic choice for a tissue with acutely induced micro-trauma.

In another study investigating fatigue, Zainuddin et al studied the effects of massage on the upper limb following 60 maximal eccentric contractions of the elbow flexors of a single arm in 10 healthy subjects (5:5 M:F). The results indicated no significant change between the two arms in isometric & isokinetic strength and torque, but it did find reductions in muscle soreness and swelling. The lack of significance in the results may be due to measurements, including maximal strength, being taken before, immediately and 30 minutes after, and at 1, 2, 3, 4, 7, 10 & 14 days after, which may have been too many re-assessments of maximal strength following eccentric activity. Also, the 10 minute massage protocol consisted of 3 minutes frictions to the major muscles in the upper limb. As explained earlier, frictions are designed to promote inflammation, not to promote recovery!

The point of these studies was to investigate the use of massage in recovery from sport. Eliciting DOMs in untrained subjects and concluding that they still hadn’t returned to baseline in 3 days is not representative of the demands you will be faced with in sport. For the most part, the athletes are familiar with the exercise, so apart from pre-season or the introduction of a new exercise technique, DOMS is relatively rare throughout a season.

No blog on massage would be complete without mentioning Lactic Acid

Fatigue is believed to be determined by the accumulation of lactate in exercising muscle (Monedero & Donne). However, the notion that lactic acid (consisting of lactate ions and H⁺) is detrimental to muscle function is derived from early findings on amphibian muscles, in which acidosis is more pronounced than mammalian musculature. These early studies were conducted at 10-20°C, when they were repeated at 25-30°C the effects of acidosis were abolished (Cairns). Studies on human skeletal muscles have shown a positive correlation between increased lactic acid and muscle fatigue, but what is usually overlooked is that there is also a relationship between fatigue and a decrease in ATP, increases in inorganic phosphate and increased ADP, as well as decreased nitrous oxide and reactive oxidative species (Franklin et al) – so why do we bang on about lactate clearance all the time?!

There is now a belief that lactic acid may have ergogenic effects on performance. It is well known that acidosis stimulates the Bohr effect, whereby H⁺ causes the release of oxygen from haemoglobin, which stimulates increased ventilation, enhanced blood flow, and an increased cardiovascular drive. (Cairns). Despite this recent shift in opinion, many studies still believe lactate to be detrimental to performance, and investigations continue into the most efficient method of lactate removal.

Monedero & Donne investigated different recovery strategies after maximal exercise using 18 trained cyclists. It was concluded that a combined treatment of massage and active recovery was significant in aiding future performance compared to passive recovery, active recovery or massage alone. Despite quoting in the introduction that “the role of lactate in fatigue is questionable”, the removal of lactate forms the bulk of the conclusion as to why massage alone was not a viable treatment for recovery.

 

Judging a fish by its ability to climb trees:

I mentioned earlier that I have reservations over the term “recreational athletes” – its unclear if this is an accepted scholarly word for “weekend warrior” or if its 3-times-a-week gym goers at the local spa and health club. Even so, the use of these participant populations to make assumptions on elite sport should be taken with caution. So should the use of athletes asked to perform unfamiliar tasks. Robertson et al used cycling to exhaust 9 male subjects and found no significant effect with blood lactate clearance following 20 minutes massage. However participants were from field based backgrounds such as football, rugby and hockey.

A study by Mancinelli et al investigated the effects of massage on DOMS using female athletes. 24 volleyball and basketball players underwent a vigorous strength and conditioning training session to elicit DOMS. The study found that the massage group (n=12) had significant increases in vertical jump scores (P=0.003) and decreased levels of perceived soreness (P=0.001), while the control group significantly increased their shuttle run times (P=0.004). The study that used functional tests appropriate to the subjects sport found favourable results for massage.

More recently, in a series of studies Delextrat et al (and again here) compared the benefits of massage alone and in combination with other recovery modalities (stretching; cold water immersion) using basketball players. Again using measure specific to the sport. While I question the conclusions about different reactions between sexes (9:8 M:F), there was significant improvements in interventions compared to control groups, supporting the use of massage as a recovery modality.

So what do we think massage might do but we can’t prove?

“Massage therapy modulates the autonomic nervous system” – Franklin et al

The good thing about the Franklin paper is that it looks at potential systemic effects of massage, in particular the vascular endothelial function of the upper limb following lower limb massage – and they found a single treatment of massage had an immediate (90mins) parasympathetic nervous system response, characterised by reduced heart rate and reduced systolic blood pressure.

We think that massage, administered appropriately with appropriate techniques to suit the situation, may:

• Decrease pain (Mancinelli et al; Delextrat et al)
• Reduce swelling (Weerapong et al)
• Improve mood state (Hemmings et al; Robertson et al)
• Increase range of movement (Rushton et al)

I would question the last point – for how long does this influence last? Do we actually increase length? Or do we restore it following a loss of range (injury / pain / change in tone following exercise)? I don’t think even regular massage is enough to encourage creep deformation on tissues, but I’m more open to a change in tone to achieve an optimal length / range.

 

Conclusion:

Therapists working within a sports setting often have to adapt the duration of a massage depending on the number of athletes that require treatment, the number of clinicians available, the seniority of players (!) Clinical based MSK therapists may also be restricted by time constraints. There is also a dearth of techniques and combinations with other modalities to chose from. Two therapists performing the same technique will apply different pressures for different durations in slightly different directions possibly over different tissues. I can see this being an argument against, but its for this reason that its very difficult to measure and quantify effectiveness. To create a sturdy study design, you end up being far removed from how clinical practice actually operates. My point is, although it is important I don’t think you can base an opinion of an intervention soley on published literature.

A lot of the literature with non-significant findings will question the use of massage in clinical application, but I can’t think of any occasions where the intervention has caused a detrimental effect! This leads me back to my first sentence.

“Just because we can’t prove what something does, doesn’t mean it doesn’t do anything.“

Remember that the field I practice in means I’m exposed to athletes for long periods of time through the day and through the week. As a proportion of that day, massage does not make up a large percentage of treatment time. Gym based, movement optimisation does. So I’m not saying we should all go and massage every athlete and patient that requests it. Like everything I think there are certain individuals that benefit from certain techniques and methods. Given time restraints in an outpatients clinic, it may not feature at all as part of my treatment. But regardless of the size this cog plays in the treatment machine, I believe its a valuable one.

 Yours in sport

Sam

Cryotherapy: Therapeutic but is it clinically relevant?

ACPSEM members can access PRICE guidelines here

Try thinking of a title about Ice and avoid the temptation to put “Baby” in it!

 

The thing that I love about physiotherapy is that nothing is ever black & white. Things will come in and out of fashion and our understanding about interventions and treatment modalities will continuously evolve. One of the great debates is about the use of ice following injury. How long should we apply it? In what form should we apply it? Should we use it all?

I recently skimmed through the Physical Therapy in Sport journal under “Articles In Press” and saw two papers within that category alone that discussed the use of cryotherapy. (For anyone that is a geek like me and hasn’t got the Health Advance App by Elsevier, get it! ACPSEM members can access all the content for free here http://bit.ly/PTISaccess).

The first paper was a systematic review (Martimbianco et al 2014), which instantly lost my attention, from my point of view they combine the conclusions of a multitude of papers and varying methodologies (all with their own unique methodological flaws) to create a super-conclusion that most of the time isn’t clinically relevant or is very noncommittal. Essentially, systematic reviews are literature stereotyping. In this case, said paper based a lot of its findings on papers from in the early 1990’s. It concluded that there was not enough evidence to draw a definitive conclusion on the use of cryotherapy following ACL reconstruction.

The second paper however, provoked a bit more thought. This study was by Phil Glasgow, Roisin Ferris and Chris Bleakley – with Glasgow and Bleakley from the recent POLICE guidelines fame – who better to critique the use of ice?
Glasgows paper was a randomised trial looking at the effects of cold water immersion (CWI) comparing different temperatures and durations of immersion on Delayed Onset Muscle Soreness (DOMS). It was this paper that inspired the forthcoming discussion…

 

What do we think we know about cryotherapy?

 

The first thing to distinguish is the method of cryotherapy; in what form should ice / cold be applied? Cryotherapy comes in forms of crushed ice to blocks of ice, buckets of cold water to cold water baths, compression devices to good old-fashioned ice spray on the side of the pitch. In any form, the proposed clinical benefits encourage a pumping effect on vascular system to encourage blood flow, nutrient and waste transportation (Wilcock, Cronin & Hing 2006). Then there are psychological benefits of feeling more “awake” and less fatigued (Wilcock et al 2006). A recent Cochran review (Bleakely et al 2012) found that CWI is superior to passive intervention at reducing muscle soreness. (I know, I slate systematic reviews then use them to my advantage). The point I’m getting at is that of all the proposed benefits of cryotherapy, the most weight is behind the subjective benefits. Take Glasgows recent paper; The control groups scores of VAS pain following eccentric hamstring exercises were 20% higher than one of the intervention groups that underwent 10 minutes immersion at 6ºC (see image below source). The results were not statistically significant but they do look clinically relevant. These percentage differences do not have to be statistically significant for them to have a major benefit in elite sport, where marginal gains has now become a specialised role in itself thanks to Dave Brailsford and the British Cycling team. Everyone is looking for that extra percent to enhance performance & results.

 

Where does ice fit in the treatment room?

 

If we return to the basic scientific theory underpinning cryotherapy, we think that it decreases metabolic activity and therefore limiting secondary hypoxic damage – essentially reducing risk of secondary injury. The injury has happened, there is nothing we can do about that, but we can prevent it worsening. Secondary hypoxic damage not only weakens affected tissues, but the associated swelling can effect surrounding tissues. In steps the counter argument…

It has been found that tissue temperatures below the subcutaneous layers are very difficult to influence due to the highly sophisticated homeostatic systems in place. Bleakley, Glasgow & Webb (2012) found the changes in tissue temperature are not enough to influence metabolic activity. However we do know that CWI will reduce skin temperature, even if it doesn’t affect tissues below (Algafly & George 2007). We also know how important the skin is in feeding information back to the CNS. It plays a huge role in proprioception and nociception.

 

In our treatment room, we still advocate the use of ice despite the emergence of this new understanding. What has changed in recent years is our thought process behind what is happening as a result of the ice. Instead of using cryotherapy in isolation to limit swelling, we now combine it with compression (which is proven to assist with swelling and decreasing CK levels etc) to reduce pain. For more proximal soft tissues injuries, we have the luxury of a Game Ready machine to compress and cool affected areas. However for more distal injuries, e.g. Following an ankle sprain, we will encourage the player to submerge their foot in a bucket of 1/3 ice and 2/3 water. As soon as the foot goes numb, we begin some appropriate movements (cryokinetics) depending on injury location, structures involved etc. By doing this, we believe the hydrostatic pressure of the water will act as local compression while the ice provides appropriate analgesia. The analgesia then allows us to begin some loading of damaged structures – thinking back to the POLICE guidelines that advocate Optimal Load. Every stage of this treatment is clinically reasoned. The movements undertaken should not exceed normal ranges of movement and must be pain-free.

 

Lets wrap it up…

At the moment, cold water immersion is commonly used as a recovery modality from exercise, especially exercises that elicit DOMS, but with very little empirical evidence to support this. Despite this, we have subjective improvements in pain following any ice interventions. If we can accept that and build that into our clinical reasoning, then we have a way of removing pain from our limiting factors and enabling us to introduce movement to an injured structure. So, although we can’t clinically justify the use of cryotherapy as a recovery modality, I would advocate it as part of a treatment & rehabilitation program.

 

Yours in Sport,

 

Sam

 

Game ready professionally photographed in my kitchen