Category Archives: Injury Prevention

06.11.15
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Help! My kid is in pain! How do I talk about it with him or her? (Part 2)

 

It is not fun for anyone when kids, ‘tweens, or teens have pain. In an age group whose sole responsibility is learning, play, and exploration, pain can really get in the way of these things sometimes.

My favorite line is “My kid (or my friend’s) ’tween/teen hurts! What does this mean and what do we do about it?

In case you missed Part 1 of this blog series, I outlined what it means and why kids have pain. Since you’re probably proactive like me (otherwise, why would you be reading this?), let’s move on to “what to do about it.”

First and foremost-it is essential to give kids the opportunity to describe pain in based on their established communication skills. As mentioned in Part 1, many kids simply agree with what adults tell them to say about pain, while others learn metaphors of describing pain that don’t agree with their age or experience level. Example: the 11 year old who states her knee pain is “bone on bone” feeling. She’s too young to be using that metaphor appropriately. Most confusingly–some kids are too young to understand metaphors or communicate about their pain at all.

Keep it age-appropriate:

  • Very young kids (ages 0-3): Pay attention to body language, behavior, play activity, and body mechanics. It is less likely that kids in this age group will misinterpret pain or use it as “manipulation” to get something they want. They also will be less likely to discuss it in any detail with an adult. Use the FLACC pain scale to quantify your observations.
  • Preschool (3-5): if they are old enough to draw, have them draw how they feel. Use toys, dolls, or stuffed animals to have the child act out their feelings. Use the FLACC or FACES pain scale depending on their ability to communicate their feelings.
  • Elementary school age (6-10): Continue to use drawing and acting as needed. You can start to give suggestions of metaphors to describe the pain. Example: have the child stretch a non-painful body part & feel the sensation of “muscle stretch.” Ask them if the pain feels like that (stretch, pull sensation). Most children at this age know of bruises and cuts (dull, sharp), so you can ask them if it feels like that. Older elementary school kids have a better understanding of muscle soreness, so you can ask if the pain is reminiscent of how they feel after a hard day in PE when their legs may be tired (soreness, throbbing). It’s still important to let them use their own words. The FACES scale is most appropriate for this age group, even up to age 10.
  • Middle school (11-14): Believe it or not, ‘tweens and teens in this age group sometimes have the hardest time describing their pain. They are transitioning from “kid role” into more “teen & adult” roles, which often leads to confusion they don’t even know they’re experiencing. They are balancing the desire to please adults with the desire to gain independence, test limits and rules with adults. Anxiety normally increases with puberty, middle school social pressures, and a rapid developing brain and emotional regulation system. Plus kids are often rapidly growing while participating seriously in one or more sports. It’s a perfect storm—and all of these things often lead to increased pain, injuries, and problems in this age group. Be very gentle when communicating with ‘tweens and teens. The numeric pain rating scale is appropriate but it’s important to understand that kids in this age group may report pain differently depending on where they are emotionally, cognitively, hormonally, and socially.
  • High school & College (14-22): You thought young kids and middle school were challenging to understand pain? Welcome to adolescence and early adulthood! While teens and young twentysomethings are much more capable of complex thought processes and may have more experience with pain, they still may not be very adept at processing on how to communicate their symptoms with someone else. We also strike a dichotomy where many adolescents continue to aim to please adults, while others want nothing to do with adults. You know that teen—the one who thinks they know way more than you because they took high school anatomy and are chemistry whizzes. Or you have the teen (usually girl) who is unable or afraid to appear knowledgeable about her body. See my blog on this very subject here. She’s in 7 AP classes and aced the SAT, but has spent so much time becoming book smart that she has developed zero body awareness. She literally cannot tell you what is wrong with her, just that “it hurts, and I don’t know why.” You can talk calculus with her with ease, but getting info from her about her body is like pulling teeth. The numeric pain rating scale is appropriate for this age group, but bear in mind you’ll also have the teen/young adult who swears the pain is a 10/10 while maintaining a smile and seeming relatively at ease. See what I mean about not being able to communicate or understand pain?

Keep your game face on

Do not—-I repeat—-do NOT project your own fear and feelings about your child’s or your friend’s child’s pain onto him or her. This may be the hardest part, because I know this is not easy on you, either. Keep calm, maintain your game face, be objective and matter of fact, and help him or her exercise his or her own independence. This doesn’t mean you should avoid showing compassion or caring. Let him or her know that you’re concerned and will do whatever it takes to help him or her through it. This also doesn’t mean it’s not ok to be worried. This is normal and natural for you! Worry and cry about it in the comfort of your own private space.

Leave the doctoring to the doctors

Stop it with consulting Dr. Google or posting on facebook about it already. This only adds to overdramatizing something that may or may not be dramatic. Consult a medical professional!

Emergencies are emergencies and cannot wait

If it’s clearly deformed, the skin is open and bleeding/oozing, the child or teen cannot put weight on the body part, it appears infected, or your inner voice says “something just doesn’t seem right”-please consult urgent or emergency care! See more on this in Part 3 (coming soon!).

Sometimes there is just not a straightforward diagnosis

If it has been ongoing for a long time, the child or teen has had every test in the book, and there’s still no medical answer, consider the role of your child’s perception of the situation along with his or her emotional processing. It is exhausting and confusing for him or her to go through the rigmarole of myriad tests and physician visits. Cut your losses and consider consulting a functional/integrative medicine practitioner, pediatric pain psychologist, or physical therapist who specializes in chronic pain in kids and teens. Chances are, your child or teen is so burnt out on medical visits that he or she has now integrated a “sick” personality: seemingly more depressed, detached, disinterested in normal age activities, less successful at school and sports. He or she subconsciously realizes the attention they get from being “sick” or “broken” and this becomes part of who they are. Trust me on this one!

Keep it kid and teen specific, no matter what age they are

Remember that kids, ‘tweens, teens and young adults process pain very differently than you do, as do their developing bodies. Not all adult treatments that may work for you are appropriate for them, even when you swear by them. Let a medical professional, particularly a physical therapist who specializes in pediatric and adolescent injuries, pain, and psychology, make the decision for you on who or what to consult to help your child. Just because Johnny is 18 does not mean he is ready for an adult practitioner. Honor and consider that as you navigate his care.

Let someone else play quarterback

Let a medical professional skilled in dealing with acute pain and ongoing/chronic issues sort through this one and manage all the specialists and/or therapists you may need to see. It’s hard enough to be a rock star parent and it can really wear on you to try and be the manager of your child’s or teen’s health. Let the professionals play “quarterback” to manage the child or teen’s case. Most importantly and often not discussed-consider speaking with a family therapist or life coach to help you cope. It is completely natural, normal, and expected for it to hurt or stress you when you have to put on your smile/game face when your child or teen is suffering. Don’t be a hero—get help for yourself too. There is no shame in doing so and it’ll really pay off in the long run!

Have resources nearby to help them understand and cope with their bodies

Stay tuned for a future post on helpful books and websites for all youth injuries, conditions, and pains. See Part 1 for examples of 2 books that are appropriate for parents of kids of all ages and middle school age and up. Some other helpful titles are Look Inside Your Body (Louie Stowell/Usborne books) , Magic School Bus: Inside Your Body (Joanna Cole), Understanding Myself (Mary C Lamia, Ph.D.), Sammy’s Physical Therapy Adventure (Michael Fink, PT, DPT), and the Be the Boss of Your Body Series (Be the Boss of Your Pain, Be the Boss of Your Stress, Be Fit, Be Strong Be You (Rebecca Kajander CPNP, MPH and Timothy Culbert, MD)

Now that you know exactly how to communicate with your child or teen about his or her pain, you’re ready to take the steps to get him or her the right care depending on what is the problem. See Part 3 to understand the problem and determine where best to seek the appropriate care.

Disclaimer:

In an effort to conserve each person’s personal experience and beliefs about how to care for and deal with pain, I offer a bit of advice from the pediatric & adolescent healthcare provider’s perspective. It should be noted that I am not a parent nor do I fully understand all of the complexities and intricacies that go on in each family. Ultimately, how you discuss pain and teach your children and teens to deal with pain is a matter of choice and fully depends on each situation you encounter.

06.05.15
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Help! My kid is in pain! What does this mean? (Part 1)

I’d be willing to bet that you generally don’t like to be in pain. I’d be willing to bet more that you really don’t like it when kids and teens are in pain. Chances are, if you are the parent of a young athlete, your child or teen has been in pain at some point in their sports “career.” Maybe you knew what to do about it and your child got better without any problems. Maybe you had no clue and turned to your friends, Dr. Google, or relied on your own steadfast remedy system.

I’ve encountered a gazillion parents who fall all over the map of knowing how best to care for their children’s pain. Sometimes parents make decisions about how to care for a child’s pain that ultimately leads to worsening of the problem. These decisions may be based on an interest to keep a child playing a sport for a number of reasons. On the other hand, some parents fall more into the “hypervigilant” category. These are the parents who fast track their children to the urgent care center every time Johnny or Sarah complains of an ache or pain.

Despite a parent’s style in caring for pain, one thing all of these parents have in common is that they mean well, regardless of which way they handle each situation. Culture and experience lead people to act in different ways, but there are a few constants that hold true in caring for a child or teen’s pain regardless of one’s background.

Given that I happen to work with young athletes of all ages, I often get questions from patients, colleagues, friends, and family members about pain in their own or their friends’ children. Here is a sampling of the questions I am asked quite frequently:

  • “My 12 year old has been having ankle pain off and on for 3 weeks. She’s been wearing a brace and keeps doing her sport but she says it’s getting worse. When should I panic and do something about it?”
  • “My 8 year old just fell off the monkey bars, says his elbow hurts, and refuses to move his arm. I have 3 meetings I need to attend and he has a baseball game tonight. Can we wait and see how it feels tomorrow?”
  • “My 15 year old’s back has been hurting for 6 months and it’s getting worse. She has bad posture. I told her to stretch and do some yoga with me since that’s what helped me. We also put her on our home traction table, I let her use my TENS unit, and she’s been getting chiropractic adjustments from my chiropractor 3 times per week.”
  • “My friend’s 13 year old has mysterious abdominal pain and has been out of school for 6 months. Nobody can figure out what is wrong with her. Is there another specialist she should see or is this all in her head?”
  • “My 17 year old has hip and groin pain. I think it’s a hip flexor injury. She just needs to stretch her hip flexors and do some Pilates, right? Can you show me some stretches for her to do?”

<Spoiler alert: If any of these situations sound familiar, you’re not alone! We will revisit each of these situations—and what to do about them– in a future blog. Stay tuned!>

Parents, friends, coaches, and kids and teens themselves have lots of questions about how to deal with pain. This can be very confusing, and everyone has an opinion on it. Before we address the somewhat confusing question of how to deal with it or what to do about it, we must first address the possibly more confusing topics of what pain is and what this could mean in a kid or teen.

Defining Pain

The first thing we need to do is define pain. Get ready for a blast back through science class. A person can perceive and experience pain for any number of reasons. According to the International Association for the Study of Pain, Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” What that means is there is not always damage somewhere in the body when pain is present. If that’s the first time you’ve heard that, you’re not alone. What we know about pain barely scratches the surface of what lies beneath the understanding of why it occurs.

Pain is an output from the brain

 One thing we do know is that pain is absolutely, positively, 100 percent produced as an output from your brain. See this great youtube video to explain this. While the video is about chronic pain, the same concept applies to just about any type of pain.

Think of the body like an email communication system. You bump your knee, and your ultra-fast email system sends a message through your nervous system to a part of your brain that acts as a switchboard. The switchboard decides if the message is relevant and if it merits being sent on to any other part of the brain. What you need to know about the switchboard is it is not in the conscious part of your brain. If the switchboard deems the message relevant, it sends the message along to your cerebral cortex. This is the part of your brain where you make thoughts, perceptions, and do all the cool, complex processing that makes us human. It’s not until the email message gets to your cortex that your body then decides “oh wow! Bumping my knee hurts!” Thus, it is an output, or a decision, just like any other decision you make.

Now you may be thinking here “Ok Julie, I didn’t decide that I wanted to be in pain.” That’s right. You didn’t. But your conscious brain did. Due to wiring in your brain that you’ve been formulating since before birth-your brain decided whether or not that knee bump was going to be painful. The combination of your life history, culture, environment, previous experience, previous pain and injury, overall health status, emotional status, and many more factors – things that you sense and direct every day—was responsible for deciding if that bumped knee was going to hurt or, well, just feel like you bumped your knee.

painbucket

You can think of pain in a kid like a wheel–it’s totally dependent on so many factors. These factors include intrinsic ones (stuff within the kid that can’t change, regardless of what is going on around the kid), and extrinsic factors (stuff that can change–IE the environmental factors going on around the kid).

 Notice that I said perception of pain is based on factors like life experience, previous pain and injury, and emotional status. Those are just a few factors that might make pain perception a little different in kids. Why is that? Kids have less life experience, likely fewer pains and injuries, and emotional and cognitive/thinking statuses that are not fully developed. This makes pain perception very different for them.

If things are going well, most kids experience the occasional bump, bruise, scrape, splinter, or “owie” as my 21-month-old niece likes to call it. Most “kid pain” gets better with a kiss from mom and dad, maybe a band-aid, and encouragement to “shake it off.” Healthy kids without serious problems are often seen to be running, jumping, and playing through pain. It’s not until pain slows them down or changes their behavior that it usually registers on parents’ or coaches’ radars.

What this means is that as kids develop, they may not know exactly what is going on with their pain. They often don’t have the experience or previous pain and injury to be able to describe it. This can make it hard for parents, coaches, and healthcare providers to understand how to help them.

Oftentimes kids learn how to describe pain based on what an adult tells them it should feel like. Case in point: I’ve had an 11-year-old tell me that her knee feels like “bone on bone.” In actuality, this is how physicians or patients may describe an extremely arthritic joint in someone who is a middle-aged adult and has lost all cartilage cushioning in the joint. While not impossible, it’s not something that we would typically expect a ‘tween to say. Ask a 7 year old to describe the pain and they will give you a blank stare. They just don’t have the experience, the complex thinking processes, or the knowledge to know how to describe it. Typically they will just agree with whatever an adult says.

Not only do we have the challenge of getting kids to describe what’s going on, but kids’ behavior around pain is also all over the map. Depending on influence from adults, siblings, and friends who may have pain or have loved ones in pain, kids learn how to behave and perceive pain from those around them. Some kids learn from a very young age that pain is scary. They may panic or complain constantly about every ache and pain. They may also learn that being in pain is a way to get support, attention, or avoid an unwanted activity. This would mean the real underlying problem may not actually be related to the pain at all (more on that later).

Other kids may learn that “being tough” while in pain is admirable and brave. These kids may not complain at all when they probably should be. This means you may have one kid who has a total meltdown over a splinter, and another kid who seems calm and collected over a broken leg. As you may imagine, there’s clearly a fine line to walk here in teaching kids and teens how to cope with pain. We don’t want to panic them, and we don’t want them to be heroic at the expense of hurting themselves more. And even if you think you’re toeing that line just right as a parent or coach, chances are they’re learning about pain coping (and everything else kids, ‘tweens and teens learn) from other outside influences, too.

Needless to say—pain is complex in any person, regardless of age. Add a developing brain, body, and lots of family and sports influence in the young athlete—and we have the potential of launching those complexities to exponential levels.

Now that you’re armed with more knowledge than you ever wanted to have about what pain is and what it means in a child, teen, or young adult, you’re probably asking–So what do we do about it?

Stay tuned for Part 2 to learn how to address and cope with a child, ‘tween’s, teen’s, or young adult’s pain situation.

03.07.15
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6 Reasons Why the Diaphragm may be the Coolest Muscle in the Body

What if I told you that there is a muscle in your body that is key to giving you good posture and participates in weight lifting between 17,000 and 25,000 times per day? What if I told you it does this without you even knowing it? What muscle do you think that is? Hint: it’s not a heart muscle.
Stumped yet? Check out this great blog by my colleague Jessica Reale to find out the answer. Young athletes of all ages and backgrounds need to learn from a young age the importance of this muscle.

Pelvic Floor Physical Therapy Specialists in Metro Atlanta

I have a small confession to make– I love the study of human anatomy. Always have. It was studying human anatomy and physiology that made me shift my undergraduate degree at Gordon College away from “Biology” and into “Movement Science” (which has now become “Kinesiology”… Who would have known that years later, “Movement Science” would have been the coolest name for a major ever? Am I right fellow PTs?). The human body is fascinating and incredible. So, it should come as no shock to you that I have favorite muscles. In PT school, my favorite muscles were the ones with the most fun names… like the Gemelli brothers (who are small hip external rotators) or Sartorius (a thigh muscle…best, if sung to the tune of “Notorious“). Of course, you know that now the pelvic floor muscle group ranks pretty high on that list…but the diaphragm, well… it just takes…

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03.04.15
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Are you the parent of a young female athlete? 10 things to know right now

Female athletes have a million awesome attributes that make us way cooler than boys. Girls rule and boys drool, right?

Even though we are sugarier (word invention), spicier, and everything nicer than our male counterparts, we have some unique considerations to worry over that sometimes make being a female athlete a challenge.

Maybe you were a female athlete from a young age. Think back to your first competition, meet, match, or game. For me, it was at age 6 in a summer league swim meet. I fell in love with the sport and the rest was history.

Dedicated to my sport, I raced through the rankings and ended up training 8-9 practices per week by 8th grade. Little did I know that the 2 fractures I had as a teenager were warning signs of a potentially bigger problem. Yikes. And little did I know that the “mental slump” I was in during high school and the depression that set in when I could not swim after shoulder surgery in college might catch up to me later.

How annoying is it that I can look back and see so many of these warning signs for things that became bigger issues later? How much more annoying is it that there’s nothing I can do with my current knowledge and skills to go back and help young athlete Julie? I guess that’s why I dedicate my career to doing that for everyone else.

If only it were that easy.

Parents and athletes often resist or fight against the education I so eagerly want to provide them and—perhaps most notably—that they are paying me to give them. I regularly hear or encounter phrases like these. Maybe you’ve heard them too, or said them yourself:

“Oh, that couldn’t possibly apply to my daughter”

“Injuries and burnout are ‘normal’ and expected for this particular sport”

“Of course she loves the sport! Look at how well she is doing!”

“She couldn’t possibly take time off or give up the sport. It’s the only thing we have getting her into college!”

I had a meeting with an awesome pediatric/adolescent sports medicine physician this morning and we commiserated over these phrases we so often hear, in addition to several other topics that young female athletes and parents just don’t love to discuss or address—but so desperately need to.

Yeah ok, I get it. Your daughter is flawless and invincible. She is actually an exception to the rules, statistics, and science behind health and wellness in young female athletes. And this is because of her natural talent and passion and of all the money and time you put into allowing her to succeed, right?

I will never fault a parent or loved one for doing what they think is the right thing to do. Most or all of these phrases and thought processes are 100 percent uttered out of caring, good intention, and well meaning. But sometimes—just sometimes—it’s possible people just don’t know any better. That’s what those of us who have personally been there as the athlete, and who now work in this field, are here to help you understand.

Regardless of what you believe or support, what we can all agree upon is that no parent or athlete has a crystal ball. None of us in the medical and sports medicine world can predict the future, either. BUT-we do have a little bit more gypsy skill than meets the eye. We can look back and use our clinical judgment to determine what types of behaviors and movements might lead to a problem in the future. And great news!!! We’re actually on your side! We want to help you and your daughter succeed! So just read and listen for a few minutes. Here are some key points you should know about how you can help her too.

  1. It’s not about you

This should go without saying, but unfortunately, I’m finding I still have to say it. This means it’s a real issue out there, folks. Susie’s gymnastics competition may, in fact, be a fashion competition for moms. You are convinced the only way for your 5 year old all star cheerleader will win a national championship is with her belly hanging out, 5 pounds of makeup and bling, and hair extensions. Maybe there’s an unwritten competition for which family provides the best, most organic, gluten free, Pinterest-worthy snacks after the baseball game. Or maybe you’re sure your 6th grader is going to be the next basketball star, just like you were in college. This means you have to be at every practice, on the edge of your seat, letting your blood pressure go through the roof and finding all the flaws in the referee calls because some other kid just outscored your kid. I get it. You mean well. And these are real things that actually happen. It’s likely that as parents, you get caught up in them. That’s fine. But do your daughter a favor: keep the attitudes and the behaviors to yourself. You may not realize it but she is watching you. Chances are, she is internalizing how YOU feel about her sport, and this could eventually backfire. Make her sport all about her.

  1. Milk: it does a body good

Disclaimer: Dairy allergies and sensitivities are real. I respect that. This is not actually about milk, but I needed something catchy to get your attention. Did you know that almost all of a young female’s bone health is built and stored before she reaches her 20’s? Flash back to teen Julie and her stress fractures. Did you know that the biggest risk for a stress fracture is a prior history of fracture? Bummer for me and my 30-something bones now. That’s what my allergist meant when she told me that being on inhaled steroids as a teen with asthma and participating in non-weight bearing exercise could adversely affect my bones. How are you ensuring that your daughter is getting the right amount of calcium, and the essential vitamin D to help her body absorb the calcium and build strong bones? Maybe let her play outside in the sun a little—with adequate sun protection but not so much that she doesn’t get the natural healthy effects of sun exposure. And maybe let her have that fro yo she’s been begging you for.

  1. Don’t be afraid to discuss menstruation. Period.

You wouldn’t believe how many people I freak out when I ask them about menstrual history. What’s the deal here people? You are female. You are over age 9 or 10. It’s part of your life, or soon to be part of it. So much a part of your life—that if it is NOT happening—we have some reasons to be majorly concerned. So let’s talk about it! While the age of menarche-the onset of menstruation-varies widely from girl to girl, it’s important as parents and medical providers to be having conversations about it BEFORE it’s time for her to begin menstruating. Why? Did you know that being an active female affects estrogen and progesterone levels and exercise in excess can lead to irregular menstrual cycles? Add on stress, rigors of school, and possibly inadequate nutrition: and those young girls’ periods are at risk of being jeopardized. Problems with hormone fluctuation are often seen by young girls in certain sports as “cool”–as in–you’re not cool unless you’re skipping periods. Why are they learning this and from whom did they learn it? Sure, not having to deal with the hassle each month sounds awfully appealing from time to time. However, knowing the lasting effects this phenomenon has on reproductive, bone, endocrine, mental, and physical health is important. We need to teach each girl that menstrual irregularity is just as concerning as discovering a bad zit on her chin the morning of school pictures.

  1. She CAN be a Disney Princess: preferably Sleeping Beauty

Why are girls skipping periods? There are lots of reasons. One of them is too much energy spent for the amount of rest provided. This is called a RED-S, or relative energy deficiency in sport. You may have heard of this concept referred to as the Female Athlete Triad before. It’s all about energy. Energy is a math problem (sorry if you hate math). It is the sum of rest (physical, mental, and emotional) and nutrition minus the energy lost during exercise and daily life. See the equation:

Energy = (Rest (physical, mental, emotional) + Nutrition/Calorie Intake) – Caloric Expenditure (energy lost during exercise/daily activity/metabolic activity)

The body is smart. If energy is lacking, it will steal it from the energy used to do other things, notably that which is used to produce hormones and run the reproductive system. You may think “Susie is not going to reproduce for another 15-25 years, what’s the big deal? Hello! This is NO BUENO people! Lack of estrogen has a strong correlation to later infertility, poor bone health (read: osteoporosis), in addition to problems with the adrenals (stress hormone producers). She needs those stress hormones to build adrenaline, stay awake in school, take an exam, and participate in her sport! This can have a dramatic effect on her later in life. So for that young female who is practicing 40 hours per week, she needs to get just as much energy input through nutrition (see point below), but also through sleep. To add insult to injury—she probably isn’t sleeping as much for education and social reasons. Isn’t it every kid’s dream to stay up late? That’s a normal part of childhood/teen rebellion. Not to mention she may be up all night doing homework for her 37 AP classes and SAT/ACT/MCAT prep classes (MCAT? Isn’t that an exam for college students? Of course it is! But Susie will start studying at 14 for it!) If she truly loves her sport, she needs to learn that sleep will help her jump higher, run faster, and shoot better. And help her make her 4.5 GPA and ace the MCAT. Sleep hygiene is a habit to address when she is 6, not when she is 26 and running ragged in medical residency.

  1. The drama llama: Kid problems are REAL problems

For the next paragraph, we’ll completely flip the situation and blame little Susie for all of her problems. This means you’re off the hook mom & dad, right? Wrong. Susie’s brain is NOT like yours, mine, or her older college age brother’s. This means that it is completely normal for her to be a dramatic, rollercoaster riding, irrational and emotional kid/teen. Why? Because she is a growing kid/ teen and we can’t stop that! The female brain processes and responds to information very differently than the male brain. In addition, she’s growing. Just because she is good at her sport and makes good grades, that does not mean her developing brain is equipped to handle the real problems of childhood, ‘tween-hood, and teenage life. You know what I’m talking about here: how that swimsuit looks on spring break, who she will dance with at the 7th grade dance, if she will try beer at the 9th grade birthday party (or if she will get invited), how many instagram “likes” and emoji tag-backs she got yesterday, and how to talk to YOU (her parents) about the fears and anxieties she faces as a young woman, including her opinion on how you parent her. Those are the real problems that often preoccupy her mind and affect her performance in her sport and her schoolwork. Plenty of scientific evidence supports the fact that a young female’s brain does not fully develop emotionally and cognitively (IE, the ability to feel, think and process) until her mid-20’s. She cannot process, communicate, and understand things the same way you and I do. And even then, some brains never develop those skills. Every girl needs a valuable mentor to help her navigate through all of her perceived life-or-death problems. Make sure she has that.

  1. The apple does not fall far from the tree

Speaking of role models, it’s important to remember the old adage I wrote above. Girls learn how to act from their parents. If you’re a 2 times-a-day gym rat, she will think that is normal and the right thing to do. If you eat the whole box of Samoas while stressing over the girl drama you face at work, what do you think she will do when she is faced with drama among her peers? What happens if you are the overachieving parent who fills his or her plate with 300 (Well-meaning) activities with little down time? What do you think she will do with her spare time? Fill it! Some of the biggest predictors of problems in young girls are the problems faced by their parents. These could be medical, social, emotional, or financial problems. That is not anything to be afraid of. It’s important to be aware of your own vulnerabilities, acknowledge them and most importantly-model that you are taking a stand to take care of them yourself. If you take care of yourself, she will be taken care of too.

  1. You are what you eat

I’ve already touched on this several times throughout this post. An athlete is only as good as the fuel she provides for her body. My colleague Mandy says “You wouldn’t try and drive across the country without putting gas in your tank and checking your oil, would you?” The same goes for the body. Most athletes and their families underestimate how many calories they burn throughout the day in addition to during a sport. This means they also underestimate just how many calories they need to be taking in. It’s all about energy availability for a healthy athlete. Consult a pediatrician and sports dietician for the best advice.

  1. Variety is the spice of life

Believe it or not, Susie likely has interests outside of horseback riding. She may have her room decorated with posters of horses, ribbons, and ask for a horseshoe-shaped birthday cake. Problem is, she may not know what those interests actually are. Why? Let’s pretend she began to specialize in equestrian at age 8. She was so good at it that it’s all she wanted to do. You’re thinking “I just want her to be happy and do what she loves” and maybe “sweet! College scholarship in the making,” so naturally, you reinforce this behavior. Why wouldn’t or shouldn’t you, after all, that is good parenting. I agree. There is more to it, though. What happens when Susie gets hurt at age 13 and can’t ride for a few months? Maybe she has school to fall back on. But maybe not. Equestrian has been so rooted in her identity that she may begin to experience symptoms of anxiety and depression when she cannot participate. She has no idea who she is or how to define her successes and failures. Everything feels like a failure if it’s not equestrian. Compound that with the fact that she may have been so dedicated to her sport that she cannot identify several other interests to keep her busy, and you now have a snowball effect. As adults, we know that this does not make logical sense. However, to a teen-this can be world ending for them. We have to protect them and give them skills and mentoring to honor themselves and their passions-whatever those may be. Girls don’t have to be the all star at 50 different activities, but it’s important to have other activities on which to fall back. After all, remember that when she is an adult, she may not have the time or money to ride horses anymore. Make sure she has other things to keep her engaged and enthusiastic about life. It will pay off in the long run.

  1. No pain no gain

Ah, finally. A moment to write about the “PT” part of this post. Playing through pain and injury is not, I repeat, is NOT admirable! With the exception of Kerri Strug in the 1996 Olympics, nobody is going to look back on their life as a young athlete and say “wow! I am so glad I played on that sprained ankle! Look at all the fame and admiration it brought me.” Pain in a young athlete is most often not anything majorly serious, but it is a sign that something is going awry in how they are moving, that they are not getting enough rest, or that their tissues are not able to heal. This means those same tissues will not help them perform as well. Their performance will suffer.  Pain is not just “growing pains” that they will “grow out of.” A brace and some KT tape will not fix the problem. At a very minimum, get them checked by a pediatric/adolescent sports medicine physical therapist or physician and make sure you’re not ignoring an issue that could rear its ugly head months or years down the line. The small investment in time and money doing that for your young female athlete will make a world of difference in the repercussions it may cost her later.

  1. Have a Plan B, C, and D

Lastly—college scholarships, professional sports, or whatever end game result you’re looking for may not ultimately happen. There are thousands of reasons that it could all work out, and thousands more that it may not. It’s important for every young athlete to have an adult facilitate for them a plan B, C, and/or D. It’s important to be active and healthy (the repercussions of not being active are far worse), but it’s important to balance that with being a kid, being healthy, and going about it the right way. Nobody is perfect. Even if you followed all of this advice (which, admittedly, is far from comprehensive), something still may go wrong. Be there for her when it does and help her unleash her plan B.

In summary:

You may have noticed a habit or behavior you’ve done at some point along the way–either to yourself or your young athlete. We’ve all done them! That’s ok! Nobody is perfect, and nobody has all of the answers. But now that you’re armed with some information and tools, you can start to pave the way to a healthy, successful, athletic life for your young female athlete. These things are arguably more important than any practice, costume, Pinterest snack, hair extensions, or $400 swimsuit you could possibly provide. That’s what we call “sponsoring” your athlete. Nike is a sponsor to sports teams and provides all of those things-but you better believe they don’t consider themselves parents of the same athletes. Girls need your awesome sponsorship, but also your awesome parenting skills. This means support, guidance, and unconditional love regardless of how well they perform or how much they truly love their sports. It’s our job as grown-ups to give that to them–and most importantly, ensure that the number one priority for all athletes is that they are having fun.

01.14.15
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Swimmer’s Shoulder: Best Friends and Mortal Enemies

Athletes of all ages and backgrounds thrive on efficient movement, maximizing results with as little energy as possible. In swimming, inefficiency can lead to many injuries, especially shoulder pain. Meet a swimmer’s best friends and mortal enemies. It’s often the enemies—those that pretend they’re friends—who cause the most trouble. ­­

BEST FRIENDS

KISS Principle and the 3 Bs

When it comes to swimming efficiency, we need to establish two simple truths for keeping it simple, swimmer (KISS):

Truth 1: Swimming is not all about the arms. You may have lats (“swimmer muscles”) of steel, but they do more than propel the body in water. They interconnect with the core and are sewn into your glutes. The arm bone is connected to the leg bone after all! But that doesn’t mean it has to do all of the work. Truth 2: Swimming is all about the 3 Bs: balance, buoyancy and breathing. But how do you make those your best friends? Read on to find out how to use them to help your arms and swimming efficiency, specifically in the freestyle (front crawl) stroke.

Be strong and carry a big kick

“I am not a strong kicker” and “I hate kick sets“ are common quotes from swimmers with shoulder pain. We may love-to-hate kicking, so let’s make it more digestible with a metaphor. Imagine you have a beautiful boat that you use each week. You’re thrilled until one day—BAM! The boat starts to slow down and feel sluggish each time you take it out. You take impeccable care of your boat, so you’re baffled. You take the boat to a mechanic, who asks how you drive it. You proudly present two paddles that you hand-carved. He smiles and points at the boat’s motor. “This is a motor boat,” he says. “Have you been paddling it all along?” You answer, “Yes! I don’t want to pay for gas and put in the time to service the engine!”

Friends don’t let friends overlook the importance of having a strong motor in the water. Using your “paddles” to do all of the work is not only inefficient, but it will slow you down and worse—potentially injure you. Dragging your motor along is added weight for your arms to pull. Use that weight to your advantage! Find a precisely balanced use of that motor coupled with good body rotation (twist), balance, and buoyancy so that you won’t have sore “paddles.” Want to know more? See this article about efficient freestyle kick in swimmers and triathletes.

Do the twist

There is no one-size-fits-all answer to swim posture and balance, but here are a few guiding principles:

  • Head position: Head position and shoulder pain are related. Poor head posture begets a sluggish hip position and vice versa, leading to a sluggish motor. Gaze through the top of your goggles instead of tilting your head up. Keep the water line at mid-forehead or cap line.
  • Pelvis and hip motion and rotation: drives the kick, which in turn drives the body, then the arms. This requires glute and hamstring strength and flexible hips.
  • Upper back: follows the pelvic and motor motion. You need flexibility and strength into twisting motions in the upper/mid back, shoulder blades, abs, and low back.
  • Knees and ankles: neither held too rigid nor floppy. Kick from the hip, not the knees or ankles.

Utilize your own personal floatation devices

If you don’t breathe well, your motor and 3 Bs will suffer. Swim lessons begin with bubble blowing and floating for a reason: to teach use of the most buoyant part of the body—the lungs—to stay afloat. Diaphragmatic breathing keeps your core engaged with your arms and delivers oxygen to your muscles. And be an equal opportunity breather! Breathe bilaterally to keep the work balanced on each arm/leg.

Swim toys: the good guys

  • Swimmer’s snorkel: Ditch the nose plug. The swimmer’s snorkel may help you with the 3 Bs. It keeps your head and body in line while working on your body rotation and kick. Sure, you won’t breathe to both sides or compete with it, but it does help you sync your inhales and exhales with your strokes. That’s a step toward 3 B success and a best friend for swimming life!
  • Swim fins: Not only will they help you practice your Little Mermaid impression, but swim fins will also help you run over everyone at practice. While they are no replacement for establishing an efficient motor and 3 Bs on your own, they do boost kicking and, in exchange, take a load off of your arms. Word of caution: if your ankles are stiff, they can cause shin pain.

Hand entry

It’s easy to get caught up on hand entry (pun intended). It’s important, but not everything. Hand entry is akin to a runner’s foot strike: both are dependent on body position. This has less to do with your arms and more to do with—you guessed it—kicking and the 3 Bs. With these in check, the hand should enter fingertips first, just wider than the shoulder. Too wide or too narrow likely means there’s under- or over-rotation in the hips and torso, respectively. This can lead to technique issues and stress the shoulder.

Training terrain

This is mainly applicable for triathletes and open water swimmers, though pool swimmers can benefit from this part, too. Just as trail runners need to train off road and road cyclists need to train on the road, swimmers need to train in their competition “terrain.” Accessibility, weather and water temperature pose a challenge here. For open water races, train where you can’t see in front of you. Vision affects the 3 Bs, so practice lifting your head too look for race buoys, support crew, and other competitors. Just remember keeping your head up too long will affect your 3 Bs and motor. If a current or waves are involved, train in choppy water. Wear your wetsuit before race day to ensure fit, comfort, and no change in your 3 Bs.

MORTAL ENEMIES

Improper FITT

That’s not a spelling error, and I’m not referring to swimsuit fit. That’s training Frequency, Intensity, Type, and Time. Too much or too little of each can be problematic. Periodic muscle soreness is normal, but should taper with experience and improved technique. Increase training distance or duration by no more than 10-20 percent per week and vary your strokes to allow for this gradual change. Having stroke variety (e.g. breastroke or backstroke) in the back of your Speedo can be handy if you need to change your position or speed in a race.

Swim toys: the bad guys

  • Kick boards: Kicking is essential to healthy shoulders, but kicking with that 12-inch piece of foam is not. It puts the shoulder in the “impingement” position, pinching your rotator cuff and other structures against your scapula. That’s PT-speak for “ouch.” Kicking with no board helps master the 3 Bs. Kick on your side with one arm up or on your back or stomach with both arms down.
  • Hand Paddles: These are a privilege, not a right. Added resistance is great for building shoulder strength and to the swimmer who paddles the motorboat. Remember what I said about the arms? It’s not about them! Unless you have no pain, a good kick and the 3 Bs, just don’t even go there.
  • Pull buoys: Why would you take away your motor especially when your shoulder hurts?

Poor ergonomics in other activities

What you do out of the pool is just as important as in the pool. Poor cycling and running posture can beat up a shoulder. That goes for workplace, school, and car ergonomics, too. Habits accumulate quickly and can catch up to you when you least expect them.

IN SUMMARY:


Now that you’re armed with a checklist, you’re ready to dive in and make lots of new best friends. But if you find you’re having trouble with them, don’t wait until you’re in pain to ask for help. Sports physical therapy is not just for when you’re broken. We can identify factors that may put you at risk for injury not only in swimming, but in other activities too. Video stroke analysis can be key to help identify and correct errors that may strain a shoulder.

07.28.14
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Pilates: Not Just for Grown-Ups

“Hey, do you know of any places where my daughter can do Pilates after she is finished with PT?”

“Should my 6 year old do Pilates classes?”

“She has a stress fracture in her back and the doctor said she needs to strengthen her core. I heard Pilates is good for that so I bought her a DVD. Is that ok?”

“I need to do Pilates as conditioning for dance. What should I do?”

I get these questions all the time from parents and young patients. My answer to them has often been “Well it depends.” That is, until recently!

One month ago I had the absolute joy of attending the Pilates Method Alliance® Pilates 4 Youth teacher training in Berkeley, California. What a fabulous 2-day course in the most beautiful setting with the most interesting and brilliantly creative minds!!! It was perhaps one of the most inspiring courses I have taken in my entire PT and Pilates career thus far. It helped that we had a nice view of the San Francisco Bay, San Francisco, the fog, and the Golden Gate Bridge the whole time. I called it my #nerdcation.

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Claremont Hotel & Spa in Berkeley.

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I’m not sure if I spent more time learning or more time gazing out the window from my seat

The course was full of 60 or so instructors from all over the USA and the world who work with children and adolescents in all different settings: schools, clubs and camps, inner city wellness initiatives, health care/PT clinics and private practices, girl scout troops, and private Pilates studios.

The course was led by Celeste Zopich, Brett Howard, and Dawn-Marie Ickes, who co-authored the course manual and textbook Pilates for Children and Adolescents. These three brilliantly creative master teachers spearheaded the Pilates in the Schools movement, an initiative begun in the early 2000’s in the wake of decreased physical education time in public and private schools. You can read more about Pilates in the Schools and the research project they did with the kids here.

Watch a video about Pilates 4 Youth & Pilates in the Schools here:

I can’t say enough good things about the instructors. Celeste has a wealth of experience teaching in a parochial school. Brett teaches classes for children of all ages and brought a wealth of research and creative cueing and activity design perspective to the group. Dawn-Marie, the PT & Pilates teacher of the book, seems to be leading a life rather parallel to mine on the west coast. She works not only with young clients and incorporates Pilates into PT with them, but also has a special interest in women’s health and is a Redcord Neurac teacher trainer. I can’t wait to continue following these three as the Pilates 4 Youth initiative continues to take off.

See interviews from the book’s authors & course instructors here:

Too often children (especially girls) drop out of sports by age 13 due to burn out from early specialization, self esteem and body image issues, lack of success and fear of failure, or lack of funding from parents or other guardians. Or—on the other hand, children do not become active in the first place for so many cultural and societal reasons (that I don’t have time to discuss in this blog post) and we have even bigger problems of childhood obesity, low self esteem and body awareness, and low exercise interest or confidence.

Perhaps most interestingly, the course taught us about the “magic window” age of 9-13. This is when kids and teens are at the most vulnerable for both physical and psychological injury. The mind-body approach of Pilates targets these problems in a very kid & teen-friendly way. This is the best stage to intervene from an injury prevention standpoint in PT, too.

Favorite video quote from videos above (from a 13ish year old):

“Well I’m a swimmer and doing regular Pilates has helped me a lot with having regular breathing and opening up my shoulders and using my back muscles to move my arms.”

If that quote doesn’t sum up my personal and professional vision for helping my most beloved target clientele, I don’t know what does.

In the course, we learned how to design classes or private sessions for children of all ages and ability levels, from 5-6 year old girl scouts to 18 year old elite Olympians,. We had a great segment taught by Dawn-Marie on program design for children with special needs, or “special opportunities” as she liked to call it. She reminded us that all children and teens have challenges that vary on a long, diverse scale, regardless of the diagnosis or “category” in which they are placed. For youth of all ages and ability levels, it is our duty to determine how best to tap into each of their movement systems, regardless of the challenges and opportunities they face each day.

superhero pilates

Superhero themed Pilates! It’s not hard work when you’re having fun while learning! I bet I know a few adults who would probably want to come to a class like this one…

 

 

 

 

 

 

 

 

 

 

The Pilates 4 Youth initiative is in a pretty grassroots stage now. So far the course has been put on twice to a total of about 150 people thanks to a grant from a generous donor. Hopefully it will continue to grow in popularity so that we can improve access for children of all ages to Pilates in a non-competitive environment. But we’re not exclusive to Pilates. And we are all over social media!

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#hashtags are everywhere Follow the PMA on twitter at @PMATWEETER

Stay tuned! I’ve already been incorporating Pilates into my clinical practice for several years, but I’m anxious to start incorporating many of the new concepts I learned into practice and hopefully into group classes in the community soon. I’m excited to exercise my creative juices and have already invested in some fun tools to help me do so:

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That’s a scooter board

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Fabulous imagery and kid-friendly Pilates terms

To learn more about the Pilates 4 Youth initiative, check out the information on facebook.

“First, educate the child.”

Joseph Pilates

07.20.14
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Movement is medicine for low back pain

 

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” 

“Movement is medicine.”

Enjoy!

03.26.14
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National Cheerleading Safety Month: Why it Matters (Part 2)

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

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:

American Association of Cheerleading Coaches and Administrators (AACCA)

National Cheer Safety Foundation (NCSF)

United States All Star Federation (USASF)

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.

 

03.26.14
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Rah! Rah! It’s National Cheerleading Safety Month! (Part 1)

Welcome to National Cheerleading Safety Month!

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.

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Cracking Concussions: Part 2

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.