Just ran across this great whiteboard video from an NPR post about low back pain. It’s a video by a Canadian primary care physician. It’s the best patient-friendly explanation I’ve seen of low back pain, what to know, and what to do about it.
While low back pain in the young athlete is not always the same as in adults and there are other kid- and teen-specific diagnoses AND PT treatments to consider, I still find this video very helpful for all ages. Though there are some very rare reasons they may have it, kids and teens almost never have problems like neurogenic claudication due to spinal column narrowing mentioned in the video. Discogenic pain is also more rare in kids and teens..
Given that low back pain is one of my favorite conditions to treat, particularly in the young athlete, I’d say this video hit the nail on the head for the most part. I love the physiotherapy, manual therapy, and Pilates shout-outs in the video. It’s important before beginning something like Pilates or yoga that you start slowly and ensure that your instructor is familiar with how to help people with injuries. In addition, if you are a kid or a teen, it’s important that the instructor is skilled in working with children and adolescents as there are special precautions that must be made in Pilates and yoga due to differences present in the growing spine vs. the adult spine. Typically what I do, as a Pilates instructor and PT, is teach kids the right movements they would need to know for Pilates, then find them the right Pilates instructor or class.
You can skip the ad at the beginning, but I also love the Neurac and WebPT advertisements at the start of the video. Between Pilates, Neurac, and WebPT, I use all of these things in my daily practice (in full disclosure: nobody paid me to say that).
The best 3 lines:
“Motion is lotion”
“A physiotherapist can probably help you with all of these things”
Last week I saw this Always ad defining #likeagirl. It went pretty viral among my facebook and twitter circles. If you didn’t get a chance to see it, see the link below. If you did, it’s worth another watch.
Upon watching this, I found myself wanting to cry, scream, smile, laugh, and fist pump. My personal and professional worlds were colliding. I love kids. I love psychological development (it was my major). I have studied peer relationships of children and teens. I love young athletes (it’s the title of this blog). I love a good youtube video and I love social media. I love advocacy for women’s health issues across the lifespan.
Like in the video, I wondered who is defining #likeagirl and why it is viewed by so many as an insult, especially when it comes to young athletes. Where did all of this come from–is this a thought women have of other women? Or a thought men have of women? How did girls’ own views of the phrase #likeagirl spin 180 degrees from positive to negative in a just few years across the young female lifespan?
Like any deep thinking blogger, I of course thought “this would make a great blog post.” I began to reflect on some striking #likeagirl challenges in my own upbringing as a female and how it affects my thoughts and views on this idea.
#Likeagirl defined during the “growing up” years
In 4th grade, I was one of only 3-4 girls in my class. I was teased, bullied, and outcasted for being the only member of the class in the gifted program. Anything anyone could try and take from me, they would. Lunch, pencils, erasers, paper, sanity, innocence…you name it. We tried to get the teacher and school to intervene but nothing really changed. So, fight #likeagirl I (well, my parents and I) did, and I moved on to a different school.
In 7th grade, the most “popular” girls sat next to me in science class. I specifically remember my “friend” asking me if she could cheat off of me during tests. I said no. There went that friendship. Apparently the way to popularity and being accepted #likeagirl was compromising morals.
As we walked down the staircase toward our 9th grade geometry class, my friend said “You know if you keep it up at this rate, none of the boys are going to like you.” It was me making straight A’s, swimming 5 hours a day, and setting nearly every school swimming record.
My friend then followed with “they’ll think you’re intimidating. Boys don’t like intimidating girls.”
At the time I remember thinking “wow, that sucks, boys won’t like me” for about 2.5 seconds. Then I was mad at her for thinking that saying that to me was going to change who I was and make me “give in” to the female norm (whatever that was) just so that boys would like me.
As if my friend were a fortune teller, I didn’t have a boyfriend for 3 years after that. That’s eons as far as high school goes. I had my moments of insecurity about it, but had plenty of other things going for me to distract me. I wasn’t worried about finding Mr. Right at 14, 15, 16, or 17. Ironically, I found him at 18. Mr. Right will tell you that he wasn’t intimidated by me, but looked up to and was inspired my successes. We started dating a month before high school ended. We’ve been together since then and now we’re married.
Daniel & I at our wedding in 2009. Duluth High School Class of 2002 representing!
Take that, Mean Girls.
Growing up, I was too busy swimming to get bogged down in the details and drama of teenage life. Being surrounded by a team that fostered friendship, acceptance, self discipline, self-confidence and the ability to rise from failure is an immeasurable benefit of youth sports teams. Unlike “throw #likeagirl” and “run #likeagirl,” there was no concept of “swim #likeagirl.” We trained in the same lanes as the boys, often pushing each other during practice to help each other improve.
That’s not to say I wasn’t an emotional, annoying teenager (sorry Mom and Dad) and that I didn’t have my moments of being challenged by the #likeagirl norm. I’m also not saying that every girl has to be a competitive athlete to have these values instilled in them. In fact, I believe just the opposite. There are countless other non-athletic outlets and avenues for girls to be successful and gain self confidence and self respect. We, as a society, need to embrace and encourage that.
Defining #likeagirl in the most educated circles
Along with sports, not every female needs academic success to define her, either. You may be surprised to know that even in the most educated circles of women, there are still struggles to define what #likeagirl means.
In college I was surrounded by new ways of defining female success. I’m not sure that I could have picked a better place to foster the #likeagirl mentality. But even Duke harbored its own challenges for women.
I remember walking around East Campus my freshman year thinking “why do these girls all carry purses with a big F or C’s on them? Who is Lilly Pulitzer? And who actually gets dressed in all of that stuff for an 8 AM Chem Lab when you have to wear a lab coat and goggles anyway?” I was completely flabbergasted with the materialistic side of all of the women around me. I had never been around so much privilege and entitlement. Feeling the “sink or swim” pressure, I accepted that I didn’t have to be just like them, even though I did gain an appreciation for things like Tory Burch shoes.
Let’s be honest, materialism is everywhere, not just at Duke. What I found more overwhelming than that was the fact that every female sitting in class with me was somehow like me. Everyone graduated in the top 1% of their class, made ridiculous SAT scores, was an incredible athlete, was devoted to community service and had already published books about it, was going to be the next Maya Angelou or rocket scientist…you get my drift. It was intimidating, impressive, and inspiring.
Here I was, surrounded by successful, accomplished women. I’d yearned for that given I’d run into problems with the definition of #likeagirl success in elementary, middle, and high school. I’m thinking “yes! finally people who are like me who will accept me!.” But something was still missing. I was a nerdy female athlete who liked to wear dresses and pearls one day, do crossword puzzles and hike the next day. This challenge to fitting in to the #likeagirl norm became abundantly obvious to me during sorority recruitment. Like in middle school, these women went to great lengths to be accepted into the most “popular” groups. Sometimes at the sacrifice of their own strengths and morals. That just wasn’t who I was. Also like in middle school, I did not sacrifice my standards to be popular. This was a blessing in disguise. I ended up being president of the sorority I joined, which was a phenomenal leadership and networking opportunity. In my group, women went on to become accomplished and successful lawyers, physicians, published authors, Teach for America leaders, CEOs, Miss America pageant contestants, Peace Corps and military officers, and stay-at-home moms. In our group, #Likeagirl took on many definitions of “awesome”, and that was ok.
In a men’s basketball-dominated school, the leaders of Duke Panhellenic sororities got together to support Duke Women’s Basketball. Our shirts said “Duke Women’s Basketball: the greatest thing since sliced bread.” We even got a notable men’s basketball player to join in our efforts.
#likeagirl challenged by Duke Women’s Initiative
While I was at Duke, these #likeagirl challenges played out before me on a daily basis like a great soap opera drama. It wasn’t just obvious to sorority women. Some smart Duke researchers caught wind of this, too.
The Duke Women’s Initiative was rolled out by woman President Nannerl Keohane in 2002-2003. It was a research initiative raising awareness to issues faced by women at Duke-women you’d think would have no problem defining or championing their successes. It highlighted the juxtaposition that the same women who were some of the most talented in the world in their fields would also find themselves downplaying their success by submitting to disillusioned social norms. They often gave into social pressures to build and mend their developing and broken female egos, respectively. In a sense, there was a real problem among Duke women to define what #likeagirl meant. Being around during this initiative is exactly why I chose to major in developmental psychology with a special focus on development of peer relations, particularly passive aggressiveness among females. I was so curious to know why we as girls act the funny ways we do.
The initiative coined the phrase “effortless perfection.” This describes the amount of effort many of these talented women put in to appear as if they’d put no effort into being successful. Why were they ashamed of people knowing they worked hard or were total nerds? Women confided that they didn’t want to make it look like they’d worked hard to achieve their successes, because hard work and determination connote “male”-like qualities they thought would be intimidating. And really–what it came down to–they wanted to appear this way because they were worried about acceptance and relationships with males and females on campus.
Whoa whoa whoa. That’s kind of like when my 9th grade friend told me boys wouldn’t like me for being successful, because that was intimidating. Or my 7th grade “friends” not liking me because I would not let them cheat. Or being bullied in 4th grade for being the smart girl.
#Likeagirl challenges extended to body image and social success too. Duke women would go to great efforts to mask eating and psychological disorders behind guises of normal-appearing, almost reckless or “laid back” behavior. You’d have the summa cum laude chemistry major who partied every night with her friends, but never studied with her friends because she didn’t want people to know she spent 10 hours/day in the library to get a 4.0. She only wanted them to see that she was a “cool party girl.” She probably didn’t like to talk about her grades or successes.
Like her, many women didn’t want men or other women to be intimidated by their efforts at appearing perfect, so they often hid those efforts or behaved in polar opposite, sometimes reckless ways. They didn’t eat or exercise with others for fear people would see how hard they worked to remain thin. They didn’t want to appear aggressive and dominating or weak and vulnerable for fear that they would not find friendship or intimacy because of those things. So we didn’t want to appear aggressive or intimidating, but we didn’t want to appear vulnerable either. Whew. Make up your mind, ladies!
On the swim team, there was no hiding how hard we worked or how much we ate. We all trained together, ate together, and often studied together, supporting each other through all of our efforts to be successful. This is my friend Julia. Julia was a Rhodes scholar finalist who went on to Harvard law school. Now she’s a rock star lawyer in Chicago.
As much as we did not or do not want to admit it, all Duke women likely had a piece of this mentality in us. After all, I’ll bet several of those women were 9th graders who were told it was not “cool” to be smart or successful. Why else would we, as a cohort, mask our successes in “effortless perfection” to try and fit in?
It wasn’t as bad as it sounds, though. There were great things about being around so many smart, successful women. I was fortunate to live with a different woman each year. Each woman had her own unique background and definition of #likeagirl. One was a varsity athlete, another was a biomedical engineer. One was a former pageant contestant, Duke cheerleader, brilliant double major, international public servant and future rock star pediatric NICU specialist. One was a champion of all things liberal arts, challenging abstract and socially responsible thinking on a daily basis.
Duke psychology majors. The blonde at the far right of the photo is my freshman roommate, Katie. Katie is now a lawyer. The girl on the left side of the picture is my sorority sister, Claire. Claire did Teach for America and now works as a science teacher.
These girls all had one thing in common: like me, they all had their struggles with defining what #likeagirl means. But they also didn’t let their athletic, nerdy, or “intimidating” pursuits get in the way of their relationships with significant others or friends. They didn’t compromise their personal standards so that “boys or friends would like them.” And they didn’t hide their efforts in being successful. We didn’t compete, but challenged each other. We were ALL far from perfect and accepted each others’ effortful imperfections. We were proud of being successful women without feeling shame for it. Maybe that’s what #likeagirl meant to us and should mean to everyone else.
The girl in the boot is my junior roommate, Kaitlyn. My sorority sister and good friend Becca is at right. Dr. Kaitlyn just completed pediatric residency. Dr. Becca now has a PhD in clinical psychology.
Defining #likeagirl in the professional world
In physical therapy school, I continued to raise the bar for myself. I didn’t make straight A’s and get uber-involved because I cared about the 4.0 or what involvement would look like on my resume. I did these things because, after all, this is the profession I chose to do and was paying a lot of money for. People were going to be trusting me with their injuries and their lives…and paying money for that! I wanted to soak it all in, then continually grow and learn more.
That’s pretty much what I’ve done–and I’ve done so following in the footsteps of some other PTs who totally rock it #likeagirl. Read this keynote address for incoming PT students last year given by one of my PT mentors who also happens to have founded the practice where I currently work. She has a great message of fighting #likeagirl to overcome adversity, embrace change, challenge the “norms” and become successful. She mentions the idea of surrounding yourself with people who are better than you are, surrounding yourself with people who challenge you, and taking in as many professional development opportunities as you can. Never does she mention compromising your values because “it’s not cool to be successful.”
I love what I do and I love learning more. I keep finding new things to learn about and courses to take. And now-I love teaching about it too. I have the privilege to teach students in the clinic and teach in the same PT program from which I graduated. I’m surrounded by fascinating female (and yes, some awesome male!) colleagues to keep me driven.
Nerdy PTs, mentors, and mentees have fun together. Here is part of the #pelvicmafia, a grassroots group of rock star women PT leaders advocating for awareness of women’s health needs all over the globe.
Recently, along with some awesome PTs, I was invited to share my nerddom with other PTs by teaching at next year’s national convention. It’s completely intimidating, but in an inspiring way. But, to be honest, I don’t need a convention to share my excitement for what I do. In my own life, I’m retweeting, sharing, pinning, instagramming or posting every article or inspirational item I can find. To all of you who follow me—sorry I’m not sorry for bombing your newsfeeds and timelines with this stuff.
Nerdy PT posts dominate my twitter and facebook feeds often accompanied with #nerdclub
#Likeagirl, I’ve turned from the girl being bullied or shamed for being nerdy and successful to someone who is proud to own it. It helps that I have a few supporters who are proud to “own it” with me.
Nerds can be princesses or Wonder Women, too. Here I am with the #nerdclub president.
#likeagirl, Dr. Julie style
And now I find myself colliding all of my passions, specializing in and working with young athletes. Working with young girls from age 6 and up, I have the joy of seeing girls go from “cute” and running #likeagirl in elementary school turkey trots, “sassy” and competing #likeagirl to make the middle school cheerleading squad, to “sophisticated” and swimming #likeagirl in high school to set records. I’m just happy to help them explore and stay strong in their passions and dreams. Unfortunately, along the way I’ve seen my fair share of girls who have fallen prey to peer pressure and given up on the dreams they’d once devised for themselves at that cute, turkey-trotting age.
My favorite 6 year old: being a rock star cheerleader
The most common age for sports dropout is 13. It’s that “magic window” age when girls are in that 7th-8th grade world of “to give in or not to give in.” Unfortunately in our world, there aren’t other great activities that are always “acceptable” for girls to put their hearts and minds into. Though I imagine there are exceptions to this, girls who hang out with the geeky boys, are in engineering club, beta club, national honor society, robotics club, and the 4H club—but don’t play sports or do “girly” things– likely won’t get elected to be prom queen.
And that makes me sad. I’m not saying the traditional “girly” or “sporty” things are bad. Be a pageant queen! Be a princess! Be a star athlete! Go you! I’m also not saying that the 4H club president needs to be famous. But girls need credit and encouragement for more than the traditional #likeagirl roles they have been given. They shouldn’t have to become “effortlessly perfect” for fear that someone will think they’re intimidating, nerdy, or not feminine for being successful.
She may not know it yet, but my favorite 6 year old is also the president of the junior #nerdclub
See this fabulous video from GoldieBlox, a company and campaign devised to inspire girls AND our culture to balance, nuture, applaud, and respect girls’ interests, regardless of what they may be. When I saw that video, it took me back to more of my college observations about defining women’s success by more than just a gender role.
In my experience as a youth sports PT, I find in that “magic window” age of 10-14, too many girls show up on my caseload riddled with pressures placed on them for being too athletic or not athletic enough, too nerdy or not nerdy enough. Some have injuries that just won’t go away without a medical explanation for them. It’s no secret to many of the professionals with whom I work that the girls are often subconsciously using their injuries as an “out” from the pressure of sports. As long as they are injured, they don’t have to compete. Plus they get a lot of love and attention by way of parents, friends, and healthcare professionals worrying after them and making them feel special. It becomes an endless, often sad, cycle, that can end in being socially outcasted, or in medical complications including anxiety, depression, and general decreased conditioning because they are no longer exercising. I think we can all agree that overall these situations probably aren’t the most productive or positive ways to make the girl feel special and valued.
It’s my wish in working with young female athletes or non-athletes, that they never feel pressured to stay involved in a sport or activity that doesn’t make them happy. Likewise, she should be accepted for doing the things that do make her happy. If a girl does or doesn’t love an activity, she should live in a world where she feels ok saying so. She shouldn’t be shamed for being successful because “that’s intimidating.” That can backfire, too. She’ll give up on her dreams and eventually get herself into trouble in some way. Even the young athlete who loves her sport should be encouraged to find balance in her interests, to find success in more than just her sport, academics or her appearance.
It’s important we as a society (and medical profession) encourage success and self confidence in any interest a girl has. We need to encourage that #likeagirl means something awesome, not awful. Maybe that 8 year old princess-loving girl will become a beauty model or Hollywood actress. Awesome! Good for her! Or maybe she will be the CEO of a Fortune 500 company. Or perhaps she will design the next vehicle that takes humans into space. See this GoldieBlox video about women becoming engineers.
Developing girls are vulnerable. What we as adults say to them makes a lasting effect. What their peers say to them makes a lasting effect. Just notice how vividly I remember 16 years later when my friend (who is still a good friend) said to me how unpopular or undesirable I was going to be for being a successful female.
So please—no matter what inspires her—help your daughter, sister, niece, friend’s daughter, friend, student or patient have the confidence to be proud to be #likeagirl, no matter what she does to succeed. Help her be proud to humbly share with others how much effort she put into doing so.
Model positive behaviors. Service, encouragement of other women, making friends with boys without making them boyfriends.
Encourage healthy competition on things that should be competitive (which is almost nothing we do). Encourage teamwork, compassion and support on everything else (which is almost everything we do).
Help her learn the difference between “humility” and “weakness”.
Help her learn the difference between “aggressive/intimidating” and “assertive and motivated”
Define success and confidence in something other than trophies, first places, makeup, number of boyfriends or girlfriends, or the size of her bra or her pants.
Help her learn that she does not have to strive for perfection in anyone’s eyes, not even her own. Flaws and differences are good, too. If she is that successful girl (which she will be if you follow all this blogworthy advice), let her know it’s ok to show and be proud of how much effort she put in to that success.
It’s ok to be different. Help her embrace the things that inspire her and make her unique, even if you don’t necessarily find yourself inspired by those things.
Encourage her to fight #likeagirl in whatever area inspires her and not let her gender define her in any way.
Step it up ladies! You don’t have to be a muscle bound, Rosie the Riveter type to be #likeagirl. It’s ok to be a pageant superstar, a cheerleader, or a princess. But it’s also ok to be an aerospace engineer, high powered CEO, blacksmith, NFL football coach, farmer, or construction worker. Be proud of who you are and model a positive female outlook for all those girls who are looking up to you. If you think someone looks “weak” just say so. If they look strong or successful, just say so. It doesn’t have to be tied to gender roles. Let’s make #likeagirl mean #likeawesome and not #likeawful.
Physical therapists have a vast toolbox of skills to help improve someone’s ability to move. Within that toolbox may be exercise techniques, Pilates, Redcord Neurac, dry needling, other manual therapy techniques, taping, tapping, yelling, cheerleading, lecturing, parenting, inspiring, and mentoring. The truth is, despite what any studies say or any expert will tell you, there is probably not ONE best treatment for any young athlete. I will say no more because Adam (@thesportsphysio) who I follow on twitter really just summed it up best. I’ll let him do the rest of the talking…
Young athletes deserve the highest quality of care. They may be young, active, and often have fewer complicated impairments as their adult counterparts. However, this does not mean that they deserve to be seen at the same time as more than one patient or by any provider other than a PT. Kids and teens have special needs that differentiate them from adults–their cognitive processing and ability to understand movement and exercise concepts often requires more attention than the average adult. Read this great post from my colleague, friend and boss about the ever changing waters and defnitions of what is “quality” physical therapy.
As a physical therapist practicing in Georgia, I have the privilege of being able to use the skill of trigger point dry needling to help patients with myofascial pain and dysfunction, joint stiffness issues, acute and chronic injuries, tendon problems…the list goes on.
Working with a majority of younger patients, I often get questions like “Do you dry needle kids? What’s the youngest patient you have needled? Will my 10 year old benefit from needling like I have?” Those are all good questions. Before I answer them, I think we should cover a little background on this whole needling thing.
What is trigger point dry needling?
In a nutshell, dry needling is a form of manual therapy where the physical therapist or other trained practitioner inserts a solid filament needle into a trigger point in a muscle. This may stimulate a local twitch response in the area, creating a cascade response that ultimately results in a release of the trigger point…or at least that is what we believe happens.
While there is growing evidence for the effectiveness of trigger point dry needling and several studies on what is happening during the technique, the reality is that nobody knows exactly what happens during each treatment in each person. We just know it works and have seen it work time and time again. We believe that the response may be chemical, neurological, mechanical, all of the above, or some of the above. This may vary from place to place between patients or even in various locations within the same patient. Or perhaps it’s a higher order sensorimotor experience change in the brain’s cortex–which I suppose would technically be all of the above depending on who you ask. Either way, there can be great changes that when used in adjunct with other physical therapy tools, pave the way for the patient to see outstanding functional changes.
If you’re still not sure what dry needling is, I recommend you visit these websites for some information:
Is dry needling the hot new thing in physical therapy? Why have I never heard of it?
In some places and in some schools of thought—yes or no. In the grand scheme of the constantly-evolving practice of physical therapy, dry needling is the new kid on the block in many states and in many areas of PT practice. You may not have heard of it because while most physical therapists possess the skills to do it, not all 50 states allow them to do it yet.
What physical therapists can perform trigger point dry needling?
Currently, dry needling requires advanced training beyond the realm of entry-level doctorate level physical therapy education. It is recommended that new graduates wait a year or so to begin training in this practice as good performance of dry needling requires more advanced skills. While new graduates have many excellent skills, the decision-making and safety behind dry needling takes extra time to develop the “finesse” of performance.
Is dry needling the best physical therapy treatment out there?
That is all a matter of opinion. But generally-the answer is probably that there is not one BEST physical therapy treatment out there. Don’t get me wrong-dry needling is one very helpful tool for many patients, but it is not THE tool. In states where dry needling is not legal for PTs to perform, patients see great results with a plethora of other treatment options. Not being able to perform dry needling does not make a clinician any less skilled; likewise, being able to perform dry needling does not necessarily make someone more skilled. It’s just an additional skill to add to the “PT skill toolbox.”
What’s most important are the “above the neck” skills of decision making, assessment, clinical reasoning, and finding the BEST treatment option for EACH patient that allows him or her to optimize the ability to move. See great recent blog about this here. This ability requires a good balance between manual therapy/dry needling, functional movement assessment and re-education, strengthening, stretching, and the good old fashioned teaching and learning interventions my patients lovingly call “Julie’s Sermons.”
So now that we’ve established what it is, where it is, who can do it, and how it fits into PT practice, I can move on to the question I know you’ve all been asking…
But Julie…do you needle KIDS?
My answer is usually something along the lines of “Well, it depends on your definition of kid.” See my first post in this blog to understand my definition of kid. Some “kids” are 44 year old elite athletes who cry like babies when I so much as mention the word “needle.” Some kids are 11 year old elite gymnasts who come in begging for needling and swear it is the one thing that keeps them competing at Level 9.
In general, I tend to look not at chronological age, but a plethora of other contributing factors. This requires the need to use all of my senses to determine just who is the right candidate. One could argue that this rule applies to any patient of any age. Chronological age is one factor. Other factors include emotional stability, emotional and cognitive maturity, education level, personal pain experience, activity level, overall/general health, and tendency to faint or scream at the topic of needles.
So, it’s complicated. If you’re looking for an age “limit” recommendation on dry needling, you’re reading the wrong blog. What I can definitively tell you is maybe you want to steer clear of the super young children. Maybe under 6. Then again, I’ve heard from colleagues that it’s been done on younger kids before, as have trigger point injections performed by some of my physician colleagues. It’s just not black and white.
What I can also tell you is that as of this blog posting date, the oldest patient I have needled is 82 and the youngest is 11.
See this resource from a few pediatric and adolescent sports medicine experts on the practice of dry needling in this population.
Let’s dissect a few of these factors to determine which kid is the right needling candidate.
Emotional stability and maturity
I am not going to lie to anyone. Dry needling can be a little uncomfortable. In general I find that anyone who is not in an emotional place where some discomfort can be tolerated may not be the best candidate. On the other hand-some patients can be fearful of movement/exercise and prefer the security and relief that needling brings after treatment, despite discomfort. Sometimes it’s just emotionally easier when passive treatment is performed on them. They can get a little emotionally attached to the technique. This can be a problem too.
Kids and teenagers—and even adults–can be afraid when it comes to medical interventions. Fear and anxiety can sometimes improve with some coaching and the patient will eventually agree to try dry needling. Others are totally emotionally on board, and then it maybe didn’t live up to their expectations—so they jump ship and ask to not have it performed again. See what I mean? It’s complicated.
Cognitive Maturity
“Wait so, you’re telling me this may be uncomfortable. Remind me again how doing something that’s uncomfortable is going to make me feel better?” To some kids, particularly younger kids—this concept is not even an approachable topic of conversation for me. From a cognitive maturity standpoint, some kids just haven’t developed the ability to discern the “later” benefit of doing an uncomfortable “now” treatment. I general I see that in many kids this improves from age 9-11. But then again-it really just depends on the kid.
I also find—and this is my TOTAL anecdotal experience—that sometimes the more the parent is on board with the kid having the technique done, the less the kid is willing to try it. There are many exceptions to this. Some kids and teens do exactly the opposite of what the parents recommend. Most parents would probably agree this concept isn’t exclusive to physical therapy sessions! In other cases, the parent says “poke him” and the kid says “let’s do it!”
But—I use some definite discretion here. Bottom line: I have a strict rule that I must get a resounding YES from the kid or teen before I glove up and pull out the needles. An “I guess” or “Whatever my mom says” just won’t cut it. Sometimes it takes kids a few sessions to warm up to it. Sometimes we try it and it doesn’t really seem to help—largely because I don’t believe they truly understand what I’m doing. The good news is we have so many other interventions we can use that sometimes we don’t even need to go through with needling.
Education level
It’s important any patient be at an education level that they can understand the basic concepts of benefits, risks, alternatives, and outcomes required of an informed consent. Generally, most kids at about 8th or 9th grade can handle a mature discussion on the pros and cons needling without a lot of parental intervention.
What I find often is that the patient who is not WELL educated on medical procedures, but ALMOST well educated is the biggest threat to dry needling candidacy. These are kids who are super smart and have done a little research on their own. Perhaps they have consulted Google, their high school anatomy class, or just talked to friends. Needless to say—they thought that because they knew the name of one muscle in the vicinity of their injury or pain, that it MUST be the muscle that needed to be dry needled.
And kids can be very black and white about it—believing dry needling is the only thing that will fix it. Kids can be very smart, but let me remind you about cognitive and emotional maturity. They generally don’t develop their higher level processing and abstract thinking skills until late high school, college, or even mid adulthood. Some people never develop it. So they firmly believe that putting a needle in the muscle will immediately fix their problem that has been going on for months.
Anyone who knows me knows that this is not quite how I operate, nor how I believe humans operate. I am not a one-and-done type of physical therapist. I get down to the source of WHY that muscle is affected due to how the patient moves or how the patient believes he or she should move. Address that first and see if the trigger point is still there later. Then we’ll talk about putting needles in the serratus posterior inferior. Yes, someone asked me to specifically do that and no, I’m not trained to put a needle there.
(End rant)
Personal pain experience
Someone call Lorimer and David. They can explain this part way better than me, but I’ll take a stab at it (pun intended). I could probably go on for days about how a person’s experience with pain is highly individualized. Some people get a hangnail and it is the most painful thing they’ll ever describe. My good friend just gave birth to a nearly 9 pound kiddo without the use of drugs or any intervention. She didn’t say it wasn’t painful, but she certainly lived to tell about it with a smile on her face. I’ve seen 15 year olds burst into tears when I told them I was not going to needle the tiny knot in their back muscle because I did not believe it would be beneficial.
Pain is emotional.
Pain is an output from the brain. See this post to explain that further or the video below to understand pain better.
For some, dry needling is a valuable tool to help people navigate through nociception, central sensitivity, blurred sensorimotor maps, freaked out “protectometers,” or any other great descriptions for that thing we call “pain.” Some people look at you like you have 10 heads when you recommend dry needling. Some are completely convinced it will not help them, while others call themselves “dry needling evangelists.”
For kids, a large part of why I haven’t gone younger than 11 years old is that GENERALLY (not the bold and italics there please) speaking, most kids are healthy and do not have a lot of experience with pain. Generally, pain at this age is highly driven by emotion, fear, and a lot of internalizing of parents’ experiences with pain. Simply put-most kids learn how to cope with pain based on how other family members and their culture breeds them to cope with pain.
Having said all of that—in any person who has very little experience with pain, an injury is often treatable without a lot of passive or manual intervention. I’m not knocking the value of these therapies, but most of these people have not yet learned that “someone else can fix this for me.” They’re open to doing exercises and not afraid of moving. For a few fearful patients, a lot of times we may do manual therapy and/or needling to coax them back into movement. They’ve had pain for so long or on so many instances that they no longer know “which way is up” so to speak. They don’t know what helps or what hurts them, so they just assume avoid all movement and opt for passive treatment.
Needless to say, pain can be very individualized. Even in kids. We have to determine who is the right candidate based on our interpretation of his or her individual pain experience.
What other factors might a PT consider?
Generally, I encourage all patients to start or maintain a level of physical activity. I try and minimize the amount of time that I perform treatments on the patient. The patient is with me maybe 2 hours a week and with themselves (7 X 24)-2 hours. That’s a lot of hours out in the world by themselves. I tell all patients that “movement is medicine.” I’m not expecting my patients to go run a marathon, but everyone has to do something. Kids included. Most kids are pretty active, but some aren’t. I find that age is not a factor here. If a kid is not active, he or she will probably not respond well in the long run to dry needling or to any other interventions. They must learn to take an active approach to caring for themselves.
As for fear of needles: if someone is legitimately terrified of needles-we don’t even go there. This is a screening question I ask all patients when approaching the topic. This can be an issue in kids, though I often find that adults are more afraid of needles than kids. Kids have to get shots all the time for school and have yearly well checks, so they aren’t strangers to needles. Some people just need a little coaching to be ok with needling, while others will tell me the second they find out that we do dry needling that we will NOT be trying this.
Lastly…what caused the trigger point in the first place? Are trigger points really all that bad?
NO! Trigger points happen in everyone. They can be angry little creatures, but they don’t always have to be the problem. Oftentimes they are the result of poor movement strategy. I know several physicians who have learned that dry needling can help patients and refer patients to PT “Just for dry needling.” They are shortchanging the patient when they tell them this. The patient comes in with the understanding that dry needling will fix their problem. What most physicians aren’t trained to do is analyze and retrain movement. And that’s not anything against their exceptional skills. That’s just not a huge part of medical school, residency, and fellowship. That’s part of PT school and advanced PT training.
So, does my kid need dry needling or not?
While there may be exceptions, typically the younger patients (7-13) do not necessarily need dry needling as the first line of defense. Typically, even with the elite young athlete, we do all sorts of kid-friendly and sports-friendly therapy and the kids get better quickly. Sometimes it’s just a matter of quelling their fears and showing them that a little heel or knee pain can get better with some education, strengthening, and proper retraining.’
Now that we’ve established cheerleading as a sport, why does it matter to sports medicine?
My point in painting this picture in Part 1 of cheerleading-as-a-sport is not because I want to see cheerleading in the Olympics. It has nothing to do with my former 6th grade dreams to become a cheerleader. There is the bigger issue. At the end of the day, as with all other sports, cheerleaders get injured. The more participants and complex skills that are required for participation, the more kids will get hurt.
Just as with any other athlete, we are all faced with having to understand cheerleading so that we can rehabilitate them back to their sport. Or better yet—prevent the injuries in the first place. Part of understanding a sport you’ve never done is taking the time to learn about it. So I’ve been to cheer practice, a competition, got the team t-shirt, and have been doing some bedtime reading. I’ve been completely out-tumbled by a 6 year old, too.
According to Shields & Smith (2009 and 2010), some of the most common injuries in cheerleaders (of any variety) are ankle injuries, knee injuries, and low back injuries. When humans have to lift other humans overhead, there is going to be a risk of falling. Either the lifter (known as the “base”) or liftee (known as the “flyer”) could be injured as a result of a flying human failure (that’s a technical term, by the way). Shields & Smith showed that up to 52% of all injuries in competitive cheerleading happen during stunts, up to 24% occur specifically to the base/spotter, 15% from tumbling and 14% from traumatic falls of the flyer. That’s a lot of flying human failure.
In addition to stunting and tumbling skills, the surface on which these athletes cheer may vary from grass to spring floor, resilite (foam) to hardwood floor. The same 2009 study mentioned above showed that 34% of competitive cheerleading injuries occurred on foam floor and 30% on spring floor. The diversity in competition/performance surface literally impacts an athlete’s ability to perform certain skills and has the potential to place undue strain on certain areas—putting them at greater risk for injury. A different study by the same researchers showed marked differences in risk for head injury in cheerleading stunts performed on various surfaces, with higher height of stunt and lower impact-absorbing surfaces leading to greater risk for injury.
Patients of mine have ranged from the competitive cheerleader with a traumatic ACL tear or ankle sprain, to the sideline cheerleader with a stress fracture in the back from improper base and tumbling mechanics. I’ve seen flyers who have fallen from a stunt with severe concussions. I wrote about concussion in cheerleading last month, and the CDC has some great educational information and athlete stories out to spread the word, too.
Last month I began working with a 15 year old high school cheerleader/tumbler who very eloquently told me the reason for her injury was “because I don’t tumble or base with the right form.” Not only was I impressed that a 15 year old identified the root of her problem, but she identified a risk factor that Shields & Smith (2009 and 2010) have shown to be the biggest predictor for injuries in bases. Remember how I mentioned in Part 1 how impressed I was with the University of Kentucky base body mechanics? I take notes for my patients. This is part of what we make sure our bases can do before they can return to cheerleading after injuries. Check out this photo of great base mechanics being taught in 4-6 year olds. Great coaching from an early age instills great injury prevention for the future.
Great body mechanics, coaching & spotting at Stingray All Stars (4-6 year olds) in Marietta, GA
So what do we do in PT? I find that generally for all cheerleaders, no matter what their position or role, the treatment plan mirrors the same plans that I use for gymnasts, divers, or even pole vaulters with similar injuries. The only difference is that for several sideline and all star cheerleaders, we also have to train the skill of avoiding flying human failures.
It is unfortunate to be injured, but fortunate when a young cheerleader ends up in physical therapy. I see it as a great educational, rehabilitative and prevention opportunity to keep a young athlete active and engaged in the sport he or she loves so that he or she can move into a healthy and active adulthood. I love a good challenge and love being creative with my PT skills to develop cheerleading-specific programs to help these young athletes get back to their sports.
I use some cool tools like Pilates apparatus and Redcord Neurac to design kid-friendly and cheer-specific exercises while educating on alignment, spinal mechanics, central stability, breathing mechanics, and all other “typical” concepts I teach to other tumbling and flying patients. If you want to read more about other “core” ideas I incorporate into my young tumbling and stunting athletes, visit this blog or check out this video from my PT colleague Julie Wiebe in Los Angeles.
Unfortunately, many young and even collegiate level cheerleaders do not often make it to a medical provider. In fact, the same 15 year old I mentioned above was injured then immobilized for 6 weeks. That’s a long time to not move a body part, folks. Had her mother not brought it up in conversation with me one day, she would have returned to cheerleading without correcting the imbalances and poor mechanics that likely led to the injury in the first place. As I mentioned, even she knew her mechanics were an issue. They had to ask to be referred to physical therapy. It shouldn’t happen that way.
The disconnect in sports medicine: why cheerleaders don’t get the right care
Why is it that cheerleaders do not regularly receive medical attention? Due to the fact that several sport governing bodies like the NCAA, AAU and sports medicine governing bodies like the ACSM and NATA do not always recognize cheerleading as a sport, cheerleading does not receive money nor sanctions to create a standard set of rules and standards of medical care. It is not heavily researched, though several small groups of researchers have begun to explore this concept. The American Academy of Pediatrics released a position statement on cheerleading. The STOP Sports Injuries campaign also has begun with cheerleading advocacy & safety campaigns.
Most cheerleading competitions are not held in traditional athletic venues; rather they may be held in large convention centers which may not be designed to support emergency medical needs. It is rare to hear of athletic trainers covering cheerleading events and competitions, or for a cheerleading squad to have their own team physician. Without recognition by national and/or international sports and sports medicine governing bodies, there is no requirement for standardization of safety and care.
Enter several of the national cheerleading safety organizations which have formed over the years. Some have been formed by parents who see the need for awareness and advocacy for their young athletes. It’s not perfect, but it’s definitely a start. See links to some major cheerleading safety organizations below:
These organizations are not necessarily unified. Each has different rules and standards for competition and performance and they have different governing “roles” for each type of cheerleading. The spread of leadership and rules contributes to confusion of “who’s in charge” and requires a very diverse skill set in coaches and in athletes.
As we move along the chain from national organizations into the various forms of more “local” cheerleading, including high school, middle school and recreational leagues-there is even less organization. Some school systems include cheerleading as a varsity sport, while others call it a “club.” In college, some schools offer varsity scholarships for competitive cheerleading, while at others it is not recognized as a varsity sport. The NCAA Injury Surveillance survey, an ongoing project chronicling incidence and risk factors for injuries in 16 collegiate sports does not include cheerleading in its study of collegiate sports. This means that these athletes may not be covered nor managed by the school’s athletic training and medical team. They may not be required to undergo preseason physicals or baseline concussion testing, two key injury prevention checkreins. At the end of the day—there is no standardization of rules and care. This leads to an overall problem of funding for research, prevention programs, and management.
In summary, without all of this information, people just don’t know the right way to handle cheerleaders. It’s a safety issue.
What do we do about this?
So what do we do about this? We have to change our language and understanding. There is no use in denying it as a sport. What does one gain from doing this? Does it make one feel like more of an athlete to say that someone else isn’t an athlete? A 2004 study showed that the Vo2 max, body composition, strength & endurance of collegiate cheerleaders rivals that of other collegiate athletes. They’re in shape, they are performing feats that require a high level of athletic skill, and they deserve the same wellness and prevention attention of other athletes. With the number of cheer-related concussions and injuries on the rise, it’s just not worth the risk of ignoring it at this point.
The AACCA is one of several organizations offering a credentialing process for cheerleading coaches. While there are likely many non-credentialed skilled and talented coaches out there, it is generally accepted credentialing protects the consumer—in this case the athlete and family. It improves safety awareness, injury prevention/management, and standardization of coaching and level progression protocols. While there has been conflicting evidence to show the relationship between coaching credential and injuries, a 2004 study in North Carolina high school competitive cheerleaders showed a 40% decrease in cheerleading injuries when credentialed coaches were present. I am a firm believer that a credential does not guarantee skill. However, it does show a commitment to the betterment of a profession and a sport. Find a credentialed coach near you.
In the case of the young cheerleader, this is something that runs rampant on my caseload—and I blogged earlier this year about how am seeing injuries and early specialization in sports from increasingly younger ages. Some of that is parent-driven, as described in this post, but some of it is culture-driven. Early specialization leads to injuries. It’s a problem. But on the flip side-there has to be a balance. Our kids need to stay healthy and active, and sometimes early participation and specialization in a sport is a way to do that.
Ride the cheerleading safety and prevention wave with me! You just might get to wear a cool shirt like the one below and support one of the fastest-growing athletic activities for young athletes.
Disclaimer:
Out of respect for all sports, the comparisons made in this post were not meant to downplay or discount the hard work or dedication of athletes in any other sport or activity. In addition, this was not meant to be an exhaustive post about all factors which contribute to sports injuries in cheerleaders. Be on the lookout for future posts that highlight additional issues in these and other athletes. I welcome your feedback and thoughts for future ideas.
Wave your pom poms, do a few jumps and leaps, and get excited for this marvelous awareness campaign!
For anyone who knows me, you may wonder why in the world I’ve decided to blog about cheerleading safety. I’ve never been a cheerleader. In 6th grade when every single one of my female friends was signing up for recreational cheerleading—the penultimate way to become popular and gain friends in middle school—I was qualifying for travel swim meets to California and Orlando. I went to Disney on both coasts in one summer. Let me tell you, I really suffered at making friends. Regardless of that, I still felt a little left out at the time from this seeming rite-of-passage activity for many young ‘tweens. Nowadays we call this a #firstworldproblem.
So why do I care? Perhaps it’s because a friend of mine has a high-flying-tumbling-and-stunting fanatic 6 year old who can pull off some pretty fancy skills. Or maybe it’s the plethora of cheerleaders I have treated over the past few years for a plethora of injuries and problems. While I’ve learned there are many types of cheerleading, there always seems to be a common denominator among their injuries: no one definition for the sport, leading to no unified standards for safety, and subsequently increased risks for injury.
So let’s just start with one fact: Cheerleading is a Sport.
There. I said it. Did you agree with me? Roll your eyes or shudder at the thought of considering it a sport? Vehemently disagree? Still on the fence? If you answered yes to any of those, then please humor me and proceed.
By calling cheerleading a sport, it would imply that I’m lumping all types of cheerleading into the same category. Yes, I do realize there are differences. Keep reading.
The cheerleading “purists” out there might argue that sideline cheerleading is not the same as all star or competitive cheerleading. You may be thinking “well MY KID does the athletic type of cheerleading. Those other kids who stand on the sideline: that’s not a sport.” Some types of cheerleading require higher levels of athletic skill and teamwork than others. But for the sake of argument and keeping me from writing 4 separate blog posts, let’s just put them all together.
On the contrary, some cheer “haters” would throw out every excuse and argument in the book to support the “cheerleading is NOT a sport” campaign. Some have even blogged about it, asking “how dare cheerleaders compare themselves to LeBron James?” I’m not sure anyone is actually comparing cheerleading to LeBron, except perhaps the author of that post. That’s like apples and oranges. Both are fruit, yes, but there really is no comparison. Both cheerleaders and basketball players are athletes, yes, but comparing is futile. If I could figure out the reason anyone would spend his or her time arguing against cheerleading as a sport, I think it would solve the meaning to life. Did cheerleading wrong you in some way? Did it trip you in middle school or steal your lunch?
I’ve heard that girls (and guys!) who jump and clap for another sport are not, in fact, participating in their own sport. Who cares if the sport is in support of another sport? Take cheerleaders who cheer on football players, for example. They jump for 2-3 hours, dance, lift each other up overhead, tumble, and perhaps perform a well-choreographed routine for several minutes at halftime. A casual observation would see that some cheerleaders—even the sideline ones—do more on their feet than the 4th string benchwarmer. I’m not knocking the freshman who is anxiously waiting for play time, but I’m just sayin’…the cheerleader is burning more calories than you dude.
Let’s look at it another way. How great it is that two sports are put together for an overall end result of everyone-gets-a-workout and everyone-works-as-a-team? What a marvelous concept! You go to a football game and also get to watch cheerleading. That’s two-for-the-price-of-one, folks. And who doesn’t like a good BOGO deal? Perhaps we should rephrase and say you’re watching cheerleading and as an added bonus, there are guys in funny padded costumes knocking each other over in the background. Depending on how your favorite football team’s season is going (or not going), you may prefer to spend your season ticket money watching those tumblers and stunters.
Then there’s the “costume” argument. I’m going to just call it like it is. If you’re going to argue anything about the appearance of a cheerleader having anything to do with it being a sport or not, I’d urge you to reconsider. I’ve heard the phrase “Girls who wear barely any clothes, wear makeup and glitter are not athletes.” So how do you explain gymnastics? Have you SEEN the hair spray, makeup, glitter, and lack of clothing in gymnastics? If you haven’t, take a look at the photos below.
Have you been to a swim meet lately? We all used to joke about girls who curled their hair and put on make up just to dive in the pool and mess it all up. Then they’d go re-do their makeup in between events. And last time I checked—swimmers don’t wear ANY clothing. Don’t even get me started on the “acceptable” amount of swimsuit wedgie. Let’s just say that we all knew who THAT girl was who crossed the line (literally) in her Arena suit. She always swore that’s how they’re worn in Europe. And we won’t even discuss guys in racing Speedos.
Skilled runners all over the world wear spandex shorts that barely cover their bums and sometimes up top they wear only a sports bra. Last time I watched the Olympics even the male runners had on jewelry and the female runners had beautiful hairstyles and wore makeup. Don’t believe me? Check out this blog on “What Professional Runners and Prom Queens Have in Common”.
Makeup, glitter, and barely any clothes are just part of the pedagogy in most of these activities. It’s what helps them function in their roles. Visualize an Olympic sprinter in full football gear, or a gymnast in a helmet or elbow pads. Gotten a good mental image down? Just wouldn’t have the same effect, now would it?
Next argument. If an activity has organized practice, requires conditioning, stretching, strengthening, coaching, hydration in between exercises, stresses someone’s cardiovascular reserve—is that not an athletic activity by any other name? Then you add the judging and scoring associated with all star cheerleading—and now you have an athletic competition.
There are the artistic and skill components of choreography and tumbling in cheerleading. Wait! Gymnastics has choreography and tumbling in the floor routine! Interesting! Some may argue that a “subjective” activity like gymnastics or diving with a scoring system is not really a sport or game. I’d like to see you practice gymnastics for 20+ hours per week and tell me you’re not doing a sport. Tell Gabby Douglas she’s not an athlete. Let me know how that goes for you.
In addition, there’s synchronized swimming and one of my favorites- the new Olympic sport of synchronized diving (shout out to Duke Women’s Diving Olympic Silver Medalist Abby Johnston, by the way!). Both have choreographed tumbling-esque components. Oh, and check out the makeup and costumes in synchronized swimmers. Minus the whole don’t-drown-while-dancing-upside-down-underwater part, how is synchronized tumbling in cheerleading any different?
Let’s layer on teamwork. The amount of teamwork required for cheerleading stunts is impressive if you have ever seen a competitive cheerleading routine. This level of teamwork and coordination is present in other activities we call “sports” including rowing, soccer, basketball, and football. And no, if you think I’m being the pot calling the kettle black– I’m not comparing University of Kentucky Cheerleading to the Miami Heat. I’m just making a point on teamwork. So, if sports require teamwork, then I would presume that cheerleading should fall into the sports category, correct?
But wait! Some of those sports I mentioned are games. Cheerleading is NOT a game, right? So what is a game? According to the University of Google, a game is a “form of play or sport, esp. a competitive one played according to rules and decided by skill, strength, or luck.” By that definition, I think we can call cheerleading a sport, athletic activity, and I would go so far as to call it a (gasp!) game.
Unlike the similar activities of gymnastics and diving that I already mentioned, there is one element of cheerleading that makes it unique. Weight lifting. Let me clarify. This is not CrossFit Cheerleading. By “weights” I mean humans. Now that’s some high-risk weight lifting. While I completely respect (and love!) diving and gymnastics, neither of those sports requires humans to lift other humans in a completely well-timed choreographed routine. Then there is the comparison we could draw with weight lifting and throwing. Do you see Olympic weight lifters dead lifting another weight lifter? No. Do you see the javelin thrower launching another human into the air? No. Come to think of it, the entertainment behind both of those ideas might actually get me to watch them on TV.
So in summary—if cheerleading is not an athletic pursuit, sport, game, or whatever term you’d like to use, then I feel I’ve been misinformed for 30 years about what IS a sport.
Still not convinced? Check out this video. These collegiate cheerleaders (arguably the best in the nation) have earned the title of “sport” in my book. I might also add that I’m ridiculously impressed with the body mechanics of the bases. They make it look easy. Read on to Part 2 to find out why basing body mechanics are important and why cheerleaders, like all athletes, need good safety awareness, sports medicine care, and research.
If you’re just picking up this post, you may have missed the story from Part 1 about my recent patient (Patient 1) who presented with a concussion. I discussed how without my recognition of his symptoms, he may have been misdiagnosed and/or mismanaged.
Mirror this case with another case of a high school athlete (Patient 2) I was treating at the exact same time of Patient 1. Patient 2 sustained a head injury when falling backward onto her head during a home plate collision during a softball game. Her father, a pediatric physician assistant, was on the scene and immediately recognized signs of a concussion. She was monitored and taken to a local emergency department. She followed up within a day or so with a pediatric primary care sports medicine physician, who recommended cognitive rest, a modified school schedule and program, and prompt referral to physical therapy.
Within 3 days she was in my office with similar signs and symptoms of the other athlete mentioned before. We performed several specialized manual therapy techniques to her spine, neck, and head to address the physical ailments from whiplash associated with a head injury. She performed gaze retraining and stabilization exercises to assist with convergence and visual tracking. These are skills necessary for reading, viewing the environment, and sports participation. We also utilized Redcord Neurac, a suspension-based neuromuscular re-education system to help restore her balance and stability. She followed a personalized stepwise progression back to school and softball.
And yes, like every good overachieving and motivated athlete out there, she overdid it. I warned her on her first visit that her symptoms would clear long before she was ready to return to sports. True to form, she felt better and decided to exercise—something like simple jogging and softball throwing. She reported a severe headache the next day and she was unable to fully participate in school.
This is common in concussion recovery, and it is paramount that athletes be monitored as they gradually return to their sports. It’s also important they be encouraged not to overdo it. The good news is that she learned her lesson and followed the rules. Soon enough, she was back in the classroom and the field.
In her case, she was in the right place at the right time when she was injured. Her dad knew what to do. She got to the right physician, who just-so-happened to be a pediatric sports specialist and affiliated with her school. Her physician had previously set up a concussion monitoring and management program with the school and athletic program for all students, not just athletes. Importantly, he referred her to physical therapy within a week of her injury. It was the ideal situation.
Ironically, one week before encountering these two patients, I had just had an interesting conversation with my PT colleague who posted this informative blog post about her 8-year-old son’s concussion. She was less aware of the role that sports medicine and neurologically-trained physical therapists play in concussion assessment and rehabilitation.
As with any other injury that keeps a person from participating in their activities of daily living and sports, specialized physical therapists are trained to rehabilitate and safely monitor patients as they return to activities following concussion. According to a 2012 position statement released by the American Physical Therapy Association House of Delegates, physical therapists trained specifically in sports medicine, vestibular rehabilitation, and/or neurologic rehabilitation can play a key role in evaluating and treating the movement impairments, functional limitations, and participation restrictions associated with concussion and mild traumatic brain injury.
Concussion is not only a hot topic on my recent caseload, but it is also running rampant everywhere else. Recently another PT colleague told me of a conversation she overheard at her daughter’s competitive cheerleading gym. Evidently on one girl’s high school cheerleading squad, 4 girls were recently out of commission due to concussions.
Just as participation of females in sports has increased, concussions in female athletes are also a growing issue. Many people may think of male-dominated contact sports such as football, baseball and lacrosse as the most common denominators for head injury and concussion. You may be surprised to know that some statistics show that cheerleading and women’s soccer are resulting in more concussions than other male contact sports. A 2012 position statement by the American Medical Society for Sports Medicine found that in sports with similar rules, female athletes sustain more injuries than their male counterparts.
Females experiencing concussion also report higher number and severity of concussion symptoms as well as longer duration of recovery from concussion. Read here about concussions in competitive cheerleading and here about a 9-year-old softball player who made a full recovery. Visit pinkconcussions.com, the first-ever dedicated online site to education and information on concussions specific to female athletes.
Concussions are not just happening in youth sports, but they’re also becoming famous, too. Much controversy surrounds Major League Baseball’s new rules to ban home plate collisions for several reasons, some of which were due to repercussions of injuries sustained by players. The current news is filled with the story the landmark settlement between the National Football League and 4500 former players claiming the NFL’s responsibility in the long-term health deficits of the players who sustained concussions while playing. There’s also the story of the college football player whose coaches ignored his symptom complaints and pushed him to continue to play. Sadly, that player eventually died.
On the youth level, it may not be on the front page of ESPN, but it’s just as much of a big deal. As of January 11, 2014, all 50 states have enacted legislation mandating some form of concussion “reform” in school and recreational sports leagues. In Georgia State Law, the Return to Play Act was passed in April 2013 and enacted on January 1, 2014. This mandates that all teams and leagues must provide concussion education to parents and coaches, recommend baseline concussion testing, hold athletes from play until cleared by a healthcare professional. In 2008, the state of Washington passed the Zackary Lystedt Law, named for a second impact syndrome survivor who was permanently disabled after returning to sports too prematurely following concussion.
Unfortunately, the sad thing is that these injuries have required state and federal action to bring everyone onto the same page on this important issue. Let’s be honest, even with the laws, “Everyone” and “on the same page” are probably generous phrases. But, it’s a start. We have a long way to go, but judging by how much my twitter feed has blown up with this topic in the last few months, I’d say that we are really getting the word out there.
It’s not just a problem for kids. It’s a problem for everyone.
So—even for you grown-ups out there, the next time you get your “bell rung” (by the way, please don’t use that term) or you just feel a little “fuzzy” after you bang your head on the open cabinet in the kitchen for the 80th time (don’t you just hate it when you do that?)…please put down your computer, your phone, cancel that workout or meeting tomorrow, and consider the long term effects such an injury may have on you.
If you’re an athlete-please tell someone you feel bad. It’s common, but not normal, to feel the way you do after your injury. You’ll get back to your sport faster if you do. No game, school exam, or competition is worth the risk of pushing it too far.
Whoops, looks like I missed out on #throwbackthursday. Maybe it’s because I have #chemobrain. Or maybe it’s because I have had several concussions in the past and there’s a likelihood that my memory has been affected-even for some minor tasks like publishing a blog post. Or in this case, re-posting a blog post. In honor of the 2-year anniversary of this blog, I’ve decided to wake up from my 6-month long radio silence and re-publish one of my first posts with a little updated commentary. Nobody likes to reinvent the wheel after all.
Many of us have hit our heads, whether during sports or otherwise, and don’t even realize we have had a concussion. We’re pretty resilient-and smart. And a lot of times we don’t know what we don’t know–even when we are medical professionals who actually treat concussions–and we end up with symptoms we think are characteristic of something else or are “completely normal”:
Oh, I’m just tired. Maybe it’s because I’ve been so busy lately.
I can’t focus. I’ll take a break later. I have to push through and finish this.
My clients seem so unreasonable lately. They just don’t get it.
I have a killer headache. Let me take some medicine.
I keep having trouble with sleep. Maybe I should cut back on caffeine.
I feel like I have too much on my plate and can’t remember all the things on my list. Maybe I need to re-prioritize.
My husband/kids is/are driving me CRAZY lately. I just can’t take them these days.
Driving seems a lot harder. Same with going to the grocery store. There’s just too much going on all at once.
I’m dizzy. Maybe it’s because I’m getting older. I hear a lot of my friends have vertigo.
The thing is–none of these things are normal whether you’ve had a concussion or not. Regarding whether they’re normal if you haven’t had a concussion-that’s another blog post for another day. But if you have recently (say, in the last 1-2 months) had a car accident, whiplash, a fall, sports injury, or even something where you haven’t actually hit your head but your body has incurred trauma–CONGRATULATIONS! You may qualify for the concussion club.
No wait, that’s not something to be proud of. But it is something to be aware of and to tell someone.
Why?
A recent study at the University of Illinois at Urbana-Champaign published in November 2015 showed that two years after incurring a concussion, children ages 8-10 showed lasting deficits in brain function and cognitive performance compared to other children who did not incur a concussion. This means that they are falling behind in school, sports, and likely social function.
No bueno! I don’t want that for MY KID!
Yeah, I don’t want that for your kid, either.
So wait Julie, you’re talking about a study on kids. So why did you begin this post talking about adults? Stay focused, woman!
Maybe it’s my history of concussion talking that has made me move from talking about adults to kids in a matter of sentences. Or maybe, just maybe, I care just as much about kids as I do about adults.
We’ve heard countless studies about the long term effects of concussion in adults. Don’t believe me? See the blog post below that I wrote 2 years ago, Cracking Concussions Part 1 and its sister post, Cracking Concussions Part 2.
Now it’s finally starting to be studied in kids. Just like everything else in the sports medicine world-we tend to study adults before we study kids.
But the punchline here is that concussions can have long term effects on ANYONE who has one. You don’t have to be an athlete to have a concussion. You can be an everyday average Joe, age 2-122 and have it still affect you.
Quick examples:
A friend of mine hit her head almost 2 years ago and didn’t realize she had a concussion. She was in her early 30’s. I recognized her symptoms before she did. Initially within a few days of hitting her head, she didn’t have symptoms. By the time I saw her-several days later, I encouraged her to go home from work. She obliged and was out of work for nearly a week as her symptoms gradually worsened. She saw a sports concussion specialist and had to really ease her way into working and exercising-quickly learning the hard way that it was very easy to “overdo” it without even realizing-until later-that she was doing that. But now–2 years later–she still notes deficits for which she must seek very specialized medical care. The Take Home: You may not be aware you’ve had a concussion. But even when you follow all the rules once you realize you have had one, you may see deficits later. A concussion is the real deal. You can’t see it and it doesn’t show up on a scan or blood test (yet!), but it is an injury and illness with dramatic lasting effects. You can lessen the effects on yourself by following specialized protocols.
Another friend of mine was in 2 traumatic motor vehicle accidents within 2 months of each other-also in her early 30’s. She saw deficits in her athletic performance, ability to do her corporate leadership job, and a smattering of emotional and social deficits. She was surprised when I told her she had symptoms of concussion. She ended up seeing a battery of specialists including neuropsychology, vestibular PT, sports medicine PT, neurology, acupuncture and integrative medicine–along with many others. She had some pre-existing issues which made her concussion injuries and illness more difficult to overcome, but 1 year later she still notes deficits in concentration, memory, energy, and other health-related factors. But she has made drastic, leaps-and-bounds progress from where she was 1 year ago. Take home: you can REALLY do all the right things, and it will REALLY help you, but it just takes time to let your body heal and recover.
So, if you or your child have a fall, have whiplash, have an accident where you hit your head or some other body part–chances are, you may have had a concussion. And remember–your chin, your nose, your eye, and your jaw are all part of your head too. Injuries to these areas-no matter how minor you think they are–are officially a head injury.
Concussion symptoms are so sneaky and can rear their ugly heads weeks, months, or even years after your injury. While I never advocate over-treating or over-assessing yourself or your child, it’s always better to be safe than sorry. Seek help from a medical professional who specializes in concussion assessment and treatment. Taking the right steps to care for yourself and your family will lessen the sneaky effects of concussion on you in the long run!
“So, I fell and hit my head while playing basketball 3 days ago and blacked out, but the doctor told me it’s not a concussion.”
A month ago, a high school athlete–let’s call him Patient 1–I was already seeing for another injury came in and told me that. Having experience in concussion assessment and rehabilitation, my internal alarm started to sound. This conversation ensued:
“What type of doctor did you see?” -Me
“The emergency room doctor.” -Patient 1
“How did they decide you did not have a concussion” -Me
“They took a CT scan and it didn’t show anything.” –Patient 1
“Played on the computer, did schoolwork, and played video games.” –Patient 1
Hmmm…Exactly what you shouldn’t do…
“So, how’s your headache today?” -Me.
“Pretty bad. Wait, how do you know I have a headache?” –Patient 1
High five to the mentor who taught me to ask that!
“Did you go to school today?” I asked.
“Oh yes!” said Patient 1
Wonderful. Because going to school is a fabulous way to recover from a traumatic brain injury.
“Tell me about how you felt all day. Everything normal?” I asked.
“Well, I had trouble focusing on the board and reading my handouts, so my teacher said I could just listen. I felt nauseous around lunch and didn’t eat much. I really wanted to take a nap after that and could barely keep my eyes open. Later in the afternoon my friends were making fun of me because I was off-balance and walking into lockers.” he said.
My eyebrows raised. It doesn’t get much more “textbook” than that, folks.
I asked Patient 1, who plays multiple contact sports both for school and recreational leagues, if the school administered a computerized or non-computerized baseline concussion assessment. He said no.
Great.
I asked him several questions about his symptoms. He answered “yes” to almost every concussion symptom on this list:
Confusion
Clumsy movement or dizziness
Nausea or vomiting
Memory loss
Tiredness
Upset stomach
Vision problems
Sensitivity to noise and light
Numbness or tingling anywhere on the body
Loss of balance or trouble walking
Mentally foggy, cannot think clearly or remember things
Slurred speech or other changes in speech
Irritable or more fussy than usual
Acts differently than normal (does not play, acts fussy or seems confused)
More emotional, perhaps very sad or nervous
Different sleeping patterns
Then I asked him to perform some simple cognitive tasks like saying a list of 3 numbers backward, remembering a list of random words, and reciting the months of the year backward. He left out October, August, and May, and put January before March.
Yowza.
Then I did some balance tests. Physical therapists are trained to evaluate and treat balance problems caused by vestibular disorders. The vestibular system is the behind-the-scenes system that detects head movement and helps maintain a sense of balance. This system is often impaired with a head injury. He lost balance immediately when asked to “stand like a statue” with his feet together and his hands on his hips. When asked to perform this with eyes closed, he reported feeling very dizzy. Just a week before this, he had been doing fine on these tests.
These tests were part of a quick concussion assessment I used to determine if the patient had any cognitive or motor deficits. Though best performed at the time of injury, this test is just one of several research-validated options for kids over age 10. A 2011 study published in the British Journal of Sports Medicine, showed that if the young athlete has not had a pre-injury or baseline assessment, it’s hard to know how “abnormal” his or her results may be. Even if the validity of my test was limited, I knew I needed something to back up what I was suspecting.
After this test, I checked his ability to track an object with his eyes. He could not track a pencil approaching his nose. This is a skill called convergence which is necessary for reading. No wonder schoolwork made him worse! He reported a worsening headache during this test. Meanwhile he asked me to turn off the lights because his head hurt worse.
I’d seen enough. I contacted my colleague, a local pediatric sports medicine specialist. He asked me what the patient’s signs and symptoms were, to which I replied “about as textbook as they come.” He agreed that Patient 1 more than likely had a concussion and would need medical management.
I spoke with the patient’s parents and recommended a prompt referral to the child’s pediatrician. They told me that the patient had a concussion 3 years ago as well. I thought of a scary condition called second impact syndrome. Sometimes occurring in players experiencing a second concussion within the same season or year of the first concussion before the first one heals, Patient 1 did not exhibit signs of this condition. Fortunately, Patient 1 also reported his symptoms before he could potentially re-injure himself.
A lot of players are at risk for this or other serious conditions when they don’t tell someone they feel bad after an injury. Players feel the pressure when they’re injured and often don’t tell anyone. To them, being “benched” from injury may cost them play time, scholarship opportunities, pride, or their first-string spot on a team. A 2013 study from Cincinnati Children’s Hospital found that half of high school football players would continue to play if they had a headache stemming from an injury sustained on the field.
Not speaking up about any injury can really cost you, as evidenced by this story of a player who not only experienced life-threatening issues, but nearly missed out on a year of her young life trying to recover from them.
Patient 1’s parents wondered why they were told he had not had a concussion when at the hospital. There were plenty of reasons for this discrepancy. Sometimes symptoms of a concussion may be delayed, showing up a day or so later. I also discussed with them that a concussion is a functional, chemical process, not a physical one. It was good they sought emergency care for a head injury, as other serious or life-threatening injuries could have occurred. It’s important for a trained physician to determine how to rule those injuries out and make the proper diagnosis and referral. But, because concussion is a chemical and physiological process, it means that the concussion itself would generally not show up on a CT scan. They understood that’s why they were told “the CT scan did not show a concussion.”
I recommended that the patient begin cognitive rest. This included no “screens,” including cell phones, TVs, video games, and computers—IE, everything he had done the day before. A recent study indicated that lack of cognitive rest following concussion in individuals age 8-23 can impede recovery time. Cognitive rest also includes avoiding school, something that most parents and kids typically do not like to hear. I forwarded them this information about rest from school and activity recommended by an international consortium on concussion management. I again reiterated that they follow-up with their pediatrician for further guidance.
I received a call the next day stating the patient was diagnosed by the pediatrician with a concussion. I eventually saw the patient 3 weeks later upon being cleared by the physician to return to activity. Later he would tell me he missed several days of school and had to make up his exams.
For this athlete, everything was managed perfectly except for a few things. His cognitive rest was delayed. He got worse after spending a day playing video games and going to school. He did not participate in formal concussion rehabilitation PT. In fact, even though I was already treating him for something else, he was instructed to cancel his PT appointments and avoid all activity, then cleared to return to activity without formal testing or monitoring.
Read on to Part 2 to find out what else should have happened, and why we need to improve awareness and management of this problem everywhere.
We’ve now established that I love working with kids and teenagers, I love working with “big kids” or grown-ups, and I have a nice PT-filled history of my own to fuel that inspiration. But we haven’t yet answered the million-dollar, highly-debated question that I’m sure you’re all asking by this point: “But whywould kids need PT? Isn’t it a bad thing that all these kids are getting hurt?” Just last week I overhead one of my grown-ups say to one of my kids “But whyare you here? Oh what a shame. You’re too young to have an injury and need to come to physical therapy!”
No! Don’t say that! He just might believe you, and then I’ll be out of a job!
Just as the number of kids participating in organized sports is estimated to grow to between 30 and 40 million in the next decade in the United States, so will the number of injuries.[i] Kids are specializing early in sports, leading to more injuries and problems as they board the bullet train toward adulthood. While on this train, they need specialized, age-appropriate training to ensure safety as they move along the normal cognitive, motor, and emotional developmental train tracks into adulthood.[ii] The problem is that sports participation at earlier ages is skyrocketing, and subsequently, so are injuries.
That’s me at age 9. I remember making my first regional championship qualifying time at this meet and a coach saying to my mom and me “Good news! She can travel to championship meets now!” It was at this age that I decided to quit all other sports and activities and focus on swimming.
Many people blame the media for these problems. They believe that it has influenced parents to believe their kid will be the next Tim Tebow or Kobe Bryant. They believe their kid will undoubtedly be in that top 1% to receive a college scholarship to a Division 1 school of their choice or join a professional sports league. There is the idea that this belief drives parents to push their kids, or kids to push themselves, beyond their physical and mental limits, inevitably leading to injury or burnout.
I’m not going to say that these cases aren’t out there, nor that I haven’t seen them. I have. Every day. Usually I want to give some of these parents a good all-star teenage eye roll when they swear to me that their 7th grader will definitely get a full ride to play basketball with the best basketball program. These kids don’t get the right age-appropriate training and often begin advanced skills before their bodies are physiologically capable of doing them correctly.
Without proper integrated training, the body takes the path of least resistance to perform a skill. I call this “cheating without knowing you’re cheating.” This eventually leads to breakdown and injury. Too much breakdown and injury without adequate rest can cause kids to burn out early. They may develop chronic physical or mental impairments that just won’t seem to get better. This gives them an “out” from their sports that is easier to swallow than feeling as if they’ve failed a parent or grown-up’s dreams for them. These patients are becoming an epidemic those of us who dare to work in this precipitous youth sports environment. See this reference about how to judge when play is too much.
That’s not to say that I haven’t encountered some elite pre-collegiate or pre-professional athletes who do, indeed, make it into the next level. Surprisingly, those patients and parents are often the most realistic in their expectations. Having been there myself, I don’t ever recall my parents or any of my swim friends’ parents having the “my-kid-is-the-next-Michael-Phelps” attitude, even though we were all undoubtedly going to swim in college. In fact, until NBC and Chico’s jumped into her life, I’m fairly certain that single mom Debbie Phelps was not outspoken during Michael’s whirlwind and very impressive teenage upbringing through the swimming world.
If a kid was truly on the fast track to college or professional sports greatness, we all just knew. I still see this today, now in the young athletes and families I treat. In these cases, it is often the self-driven inspiration of the child or teen himself, perhaps the influence of a fascinating coach, or possibly a natural, innate talent that drives a kid to excel at a sport at an early age.
Despite whichever belief or reason for sports participation or specialization at any age, statistics and genetics do not work in any athlete’s favor. My college statistics professor, not at all a medical specialist, would easily tell you that injuries will always increase with increased participation in sport. Statistics would also tell us that some people are just going to be more genetically predisposed to injury than others. This will happen regardless of whether a kid is pushed by a parent to be the next Missy Franklin, or if the kid simply just loves the sport like I did.
That’s me again, dressing up as Missy Franklin at age 28. I still love the sport even though I am “retired.” I can promise you my parents did not pressure me to wear this outfit.
Sometimes, though, most of us cannot see the simple reality that increased sport participation inevitably leads to increased injuries. It can be devastating when any person gets hurt, whether he or she is an athlete or not. Parents become enraged and kids become depressed. Kids often drop out of their sports or become more injured because at that point, their hearts just aren’t in it anymore. Recent studies have shown that even uninjured collegiate athletes suffer from depression. [iii][iv][v][vi] We need professionals to help them all along the way.
Enter the specialty field of pediatric and adolescent orthopaedics and sports medicine. This is a growing niche that includes specialists in all different fields, including physicians, physical therapists, occupational therapists, speech therapists, mental health professionals, nurse practitioners and nurses, physician assistants, athletic trainers, strength and conditioning coaches, and dieticians. Each has advanced training not only in sports medicine and orthopaedics, but also in pediatrics. We treat young athletes from elementary school age through young adulthood.
Most importantly, access to these specialists is becoming easier all over the country and the world. In addition to private practice clinicians like me, there are numerous specialty programs all over the country in places like Atlanta, Boston, Cincinnati, Los Angeles, Miami, Philadelphia, and Seattle, to name a few. Some programs are even offering telemedicine options to reach kids in rural areas who may not have access to a specialist.
I love this field. Being yelled at in a corner by a stressed out family member typically does not make me flinch. Sure, it can be frustrating to me in the moment when I have to deliver the news of “No football for 6 weeks” and the parent or child fails to see that this news is for the betterment of the child’s health. But it’s so rewarding when I can help that same child get back to their sport safely, better than they were before, and bring comfort to a worried parent. These rewards have come in the form of hand-drawn thank you cards, art projects, homemade cookies, and the satisfaction of knowing that perhaps, that kid just might not turn into a physically or mentally injured adult. That last part is what makes all the late night tweeting worth it.
I believe that with the right passion and training, we can play our cards right and be an integral part in paving the way for a young athlete’s success story—whatever that successful outcome is.
With the Dynamo National Team winning Speedo Junior Nationals at age 14 in Auburn, Alabama.
This is pediatric & adolescent sports medicine. All of us in this field are in it together, advocating all for same mission: to give kids a better experience in becoming more active and competitive. To get kids back in the game. To help them become healthy adults. The list of inspirational mission statements goes on and on.
One of my favorite resources in this field is this consortium formed by several key sports medicine organizations and professions, advocating together to achieve our individual and team mission statements. We recognize that despite the reason for kids’ sports participation, the reality is that we all must push kids to be active and healthy. It’s much better than the alternative, and we all have heard about the consequences of unhealthy lifestyles in kids. With this push for activity comes the responsibility of keeping kids healthy, and we must work together as a team to educate all of you on just how to do that.
The purpose of this blog is to raise public and professional awareness to this specialty field, and serve as a resource for management, prevention, and referral for youth orthopaedic & sport-related injuries. I will cover key issues related to this field, welcome guest writers, and hopefully help spread the love on this issue for which I am so passionate.
[i] Myer GD, Kushner AM, Faigenbaum AD, Kiefer AK et al. Training the developing brain, part I: cognitive developmental considerations for training youth. Current Sports Medicine Reports. 2013; 12 (5): 304-310.
[ii] Myer GD, Lloyd RS, Brent JL, Faigenbaum AD. How young is “too young” to start training? ACSM’s Health and Fitness Journal. 2013; 17(5): 14-23.
[iii] Wojtys E. Sports specialization vs. diversification. Sports Health: A Multidisciplinary Approach. 2013; 5: 212-213.
[iv] Jayanthi N, Pinkham C, Dugas L, Patrick B, LaBella C. Sports specialization in young athletes: evidence-based recommendations. Sports Health. 2013;5(3):251-257.
[v] Weigand S, Cohen J, Merenstein D. Susceptibility for depression in current and retired student athletes. Sports Health. 2013;5(3):263-266.
[vi] Yang J, Peek-Asa C, Corlette J, Cheng G, Foster D, Albright J. Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clin J Sport Med. 2007;17(6):481-487.
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