Concussion Management For Massage Therapists

“The tricky part is that concussion signs and symptoms are not always straightforward and the effects and severity of injury and safe return-to-play can be difficult to determine”

– Mark Lovell

“That’s kind o the line I’ve got to walk now. I think the difference is the post-concussion is light-headedness, where I get that disconnect. Anything else is working and getting your heart rate up. I’m still a little nervous. It’s still a little scary”

– Keith Primeau

The sound from the hit echoed through the arena.

He laid there motionless on the ice.

The other players stared at us with a look of disbelief on their face.

As we opened the door to the bench to step on the ice, two players grabbed me and the AT to help get us to their team mate.

We crouched down beside him trying to get as good of an assessment as possible.

Thank god…he’s breathing.

Getting as close as I could to him to speak, to block out what was happening around us I simply asked “are you there?”.

He responded “yeah my head hurts, I just got my bell rung”.

“Can you move your legs?” Glancing down, they moved.

“Does it hurt if you try to move your neck?”

“No, it’s good, just my head”

As we stood him up and took him back to the bench, it was immediately noticeable, he wasn’t acting like himself.

Once in the treatment room, we could set up for a better more thorough assessment.

He was groggy and lathargic. He lost his usual jovial attitude.

Everything bothered him and his headache was getting worse.

Even the lights in the room were causing an issue.

So was it just a headache? Does he remember what happened? Is there something more going on?

The AT went to work with his assessment. He started asking the player a bunch of questions as I sat back and watched.

Some of the questions made sense.

Do you remember the hit?

Do you know what day it is?

Do you know approximately what time it is?

Then he gave the player a list of words and asked him to repeat it back.

Elbow, apple, carpet, baby, saddle, bubble.

I sat there with a dumb look on my face trying to remember the words too, couldn’t do it.

Afterwards the AT explained what he was doing and showed me this document called SCAT2. I had never seen it before.

First Aid Protocols For Acute Concussion

As research develops so does concussion protocols.

People of my generation probably remember as kids the only thing we were asked was: “how many fingers am I holding up” as if we were Billy Bob on Varsity Blues.

Back then there was talk about “degrees, grades or severity” of concussions, but that thinking is out the window now. There is no such thing as a “minor” concussion anymore.

When I started working in sport the SCAT2 document was the more commonly used method for concussion protocols. It has since evolved into the SCAT3.

Part of the SCAT3 is using the Glasgow Coma Scale (GCS) to assess level of consciousness before you decide to move an injured person. The GCS has been around as an assessment tool for years and if you take advanced levels of First Aid it is incorporated into those courses.

The GCS is used to decide if an injured person requires immediate transport to advanced medical care. It assesses the person on three different types of response (eye, verbal and motor) and gives them a numbered grade according to response.  It looks something like this:

Eye Opening

Open Spontaneously (4)

Open To Speech (3)

Open In Response To Pain (2)

Do Not Open (1)

Verbal Response

Communicates Normally (5)

Confused (4)

Inappropriate Words (swearing) (3)

Confused Sounds (groaning etc) (2)

No verbal response (1)

Motor Response

Obeys Commands (6)

Localizes Pain (swats your hand away) (5)

Flexion To Pain (elbow flexes in direction of pain) (4)

Abnormal Flexion To Pain  (3)

Extension To Pain (2)

No Response (1)

Once you designate a score for each level of response you add the scores together for a total. If it comes out to less than 15, the person should be transported to hospital for more advanced care due to the possibility of a brain injury. There is a great video you can watch here to see how it is done.

The player in the story above scored a 15, his eyes opened spontaneously, he obeyed movement commands and could communicate just fine so we were okay to take him to the dressing room.

SCAT3 A Valuable Tool For Massage Therapists

 Once the GCS is complete and determined it is okay to move someone, the rest of the SCAT3 can be used for assessment.

The document goes through several other assessment tools that include symptom evaluation, cognitive assessment, neck examination, balance and coordination examinations.

This is where those memory techniques of saying five words to the athlete and having them repeat the words back is completed to get an idea of their cognitive function.

Symptom evaluation is assessed by noting things like headaches, pressure in the head, sensitivities to light and noise along with feelings of anxiousness and sadness. Few things are tougher than watching a young athlete cry uncontrollably because of a head injury and being frustrated by not being able to understand what’s going on.

The SCAT3 also goes through return to play protocols for athletes. Most importantly is that once an athlete (or anyone for that matter) has been diagnosed with or assessed a concussion, they must be referred to a doctor (preferably a sport med doctor) to receive clearance to start physical activity again.

Typically with a sports team each player is evaluated on the SCAT3 at the start of the season. This gives training staff a baseline to compare in case someone sustains a head injury. If the original is kept on file, it can then be used as a comparison during the acute injury and also as part of the return to play.

While this document was intended for athletes, it could be a valuable tool to be used in a clinical setting with anyone who comes in that has suffered a head injury whether in the workplace, MVI, or as the result of a fall.

Making the SCAT3 part of your intake, combined with regular communication with the patients doctor could give you a better idea how the patient is progressing.

https://flic.kr/p/fpZHhE

Photo by: University of the Fraser Valley

Massage Therapy Treatment For Concussions

Most people dealing with Post Concussion Syndrome will experience a variety of symptoms ranging from dizziness to headaches and balance issues as well as depression.

In order to help any patient that comes to you who has suffered a concussion, one of the biggest things we need to understand is the Mechanism of Injury that caused the concussion.

Was it a car accident?

Sports injury?

A fall?

Has the person suffered a concussion before?

Which direction did impact come from?

Most concussion treatment revolve around aerobic exercise (after periods of complete physical and mental rest) and then return to play protocols for athletes working up to full contact practices (depending on which sport).

When a patient suffers an injury significant enough to cause a concussion it is likely that they have also suffered an injury to the neck which can contribute to headaches as well as dizziness. It is important for us to try and differentiate where the patients dizziness is coming to discern if it is cervicogenic dizziness or a vestibular issue.

I asked a sportmed doctor why they always refer their concussion patients to a Massage Therapist and he said “it’s because there is usually a whiplash injury associated with the concussion, so getting treatment for anything associated with the neck helps in the concussion treatment”. One study showed that Massage Therapy helped a 23 year old athlete by having two 45minute treatments focused around the pelvic girdle, neck and atlanto-occipital and atlanto-axial joints one month after injury.

The SCAT3 (or any other acute concussion assessment tool) is important for Massage Therapists to understand because it will give the therapist better insight, not only on what was done to help a person immediately, but also as a tool to see how a patient is progressing. Above all when it comes to treatment, your clinical experience is going to be the best guide on how to treat someone with post concussion syndrome. While these tools were intended for athletes, it can also be a great tool in dealing with MVI and workplace injured people who are referred to you. Quite often these ones will be dealing with issues like depression, lack of focus, irritability and not understand why they feel this way. Using these tools can be a great method of tracking their progress and helping you refine or change your treatments according to their needs. There is always a concern around Second-Impact Syndrome where someone sustains a second head injury before the initial concussion symptoms are gone. There are companies starting to develop new protocols and services to help with concussion management like imPACT, King-Devick Test, Shift and axonsports but these all come with a cost. Using free resources like the SCAT3 and CATTonline are widely recognized and may be more suitable for sideline and clinical settings for you until the others are more affordable. Take it from someone who has suffered major head injuries in the past, this needs to be managed properly for successful outcomes, the delay in recovery can be frustrating and depressing. But hey, at least when it happened to me I thought I was in Hawaii, and my dad said it knocked some sense into me!

 

Massage Therapist Treatment For An Achilles Tendon Rupture

“I heard a loud pop and it felt like somebody hit me in the heel.”

I’ve had a few friends and patients over the years that ruptured their achilles tendon.

It just sounds terrible and I hope I never have to experience it.

The last time I heard a story about it, the guy was playing tennis and lunged after a ball. He just dropped to the ground.

He knew he shouldn’t move because the foot didn’t feel right and when you hear something like that, the last thing you want to do is move the injury.

Fortunately keeping still was the right thing to do.

First Aid For An Achilles Tear

I would treat this the same as I would for a fracture.

The person may still be able to limp or walk because the peroneals and other muscles deep in the leg compartment that remain in tact do not require push off with the superficial calf muscles.

Once that tendon is ruptured, immobilize as soon as possible, you want to do everything possible to prevent the calves from balling up.

Make sure to immobilize in the position found. Since the gastrocs cross the knee, do not straighten it because that motion would place more tension on the calf muscles and could further complicate the injury. However this is just my opinion from experience in dealing with things like this on an acute level (this study says that knee position does not affect the tendon gap at the injury site).

Once immobilized check the pulse distal to the injury to make sure circulation is okay.

If you’re not sure whether the injury is a rupture there is a few signs and symptoms to look for:

  • visible separation in the tendon
  • unable to stand or balance on the affected leg
  • swelling and bruising around the ankle
  • excessive dorsiflexion of the ankle
  • positive Thompson’s test.

While all of those signs and symptoms and the Thompson’s test are quality things to look for, I would be hesitant to have someone try to stand on the injured side or perform the test for fear of causing further damage. You are much better off to look at the mechanism of injury and let the doctors at the hospital perform any further testing that is required.

Achilles Tendon Rupture: Surgical Or Non-Surgical

I had no idea that there was a non-surgical procedure for this injury until just recently.

In doing research, there is quite the debate over which is better between surgical and non-surgical procedure and both have their advantages and disadvantages. It seemed like I could find just as many pro or against for either treatment.

In the non-surgical treatment the foot is braced in plantar flexion and three weeks later progresses to weight bearing exercise and manual therapy. Scar tissue fills the space between the ends of the torn tendon, which lengthens it and gives the patient less push off strength. It takes longer to recover, longer immobilization time and has a higher risk of a deep vein thrombosis.

There are a few different methods to the surgery but it comes with the risk of wound closure problems, infection and nerve damage.

One systematic review looked at seven articles from the last ten years and found:

  • there wasn’t a significant difference in re-ruptures of the tendon
  • more soft tissue injuries from the surgery (we could probably help out here)
  • better function after surgery
  • quicker rehab after surgery

The review also points out the difference between surgical and non-surgical treatments were minor so the importance lies in the rehab.

https://flic.kr/p/u8XA22

Photo by: Bob~Barely Time

 

How To Rehabilitate An Achilles Rupture In The Massage Clinic

Your approach to helping rehab this injury is going to vary depending on when the patient comes to see you and what type of repair was done to the tendon.

There are two approaches to rehab, the conventional approach and an early remobilization approach.

Getting a good history from your patient will be crucial to providing the appropriate care (as it always is).

When the conventional approach is used, somewhere around the 4 week point (after the operation) the person is usually put into a walking cast (ankle is placed in neutral) with some weight bearing exercises are started. Around the 8-10 week mark, the walking cast is taken away and range of motion exercises begin. After 12 weeks things are getting back to normal and full weight bearing activities are okay again.

When the early remobilization approach is used, weight bearing and range of motion exercise starts immediately (or within 2 weeks) after surgery while wearing a brace that holds the ankle in plantar flexion. Full weight bearing happens gradually at 3-6 weeks with orthotics in place that allow more dorsiflexion.

With either approach, weight bearing exercises are used around that 6 week mark. At this point it is also okay to start some Massage Therapy work around the tendon and the calf muscles. The biggest thing we want to do is help with increasing the ankle range of motion. Using some techniques like joint mobilizations, mild stretching, active and passive range of motion and manually stripping out the gastrocs will all help contribute to these goals.

The next goal should be strengthening the calf muscles. After being in a splint, brace or cast for that long there will be some wasting of the muscle. I had a knee surgery back in 2005 and had to wear a full length leg splint for 3 months after the surgery. My leg looked like it belonged to a 10 year old kid compared to the other one.

Because weight bearing is allowed in both approaches at the 6 week mark, strengthening should be tolerated as well. If you’re not comfortable setting up exercise programs, reach out to someone in your network that is and get some help with it. Chances are the patient will already have exercises in place, either prescribed by the surgeon or from a physio they have been referred to.

Whichever rehab approach is being used will be dictated by the doctor or surgeon. Reach out to them and find out which approach is being used and get some feedback on what they have seen success with. Sometimes with surgery structures are taken from flexor hallucis longus, plantaris, peroneus brevis or parts of the fascia from the gastrocs. Getting that kind of information from their doctor is valuable information and may alter your treatment. If you’re dealing with an acute achilles rupture, even though they may be able to limp on it, get them down on the ground and splint the ankle in place. Do whatever you can to prevent any further injury or complications. When a person is coming in to your clinic for rehab, do a little research on what works best for a successful outcome and have some open communication with the persons other practitioners. And hopefully the next time you’re out exercising it never feels like someone kicked you in the back of the heel.  

How Massage Therapists Can Deal With Acute Shoulder Injuries

 

I knew it was bad when I heard a “pop”.

I’ve given and taken several hits playing hockey over the years, but this one was different.

I got flipped over and landed directly on my shoulder and heard that “pop” on my right side.

I was slow getting up and immediately felt pain in that shoulder.

At first it didn’t seem that bad, the pain was manageable.

Skating back to the bench it started getting worse. Moving the shoulder got more difficult.

Once in the dressing room it became more painful to move. I slowly got my gear off and cracked a beer. I got up and looked in the mirror, it looked gross.

Having a shower was difficult, it got to the point I could barely move the arm and cradling it was the only way it felt comfortable. I packed up my equipment, slowly got dressed with one arm and made my way to the emergency room.

They sent me in for x-rays immediately.

I could see the guys taking the x-ray and the look on their face was terrible. I actually heard them say “oh man, that’s bad”, umm I’m right here.

Recognizing The Degree Of Shoulder Injuries

After the x-ray I sat and waited impatiently for the on-call doctor to come in and give me the bad news.

“You’ve got a third degree separation of your A/C joint”.

He called the local Orthopedic shoulder specialist, who got mad at the doc for waking him up and was informed they don’t do surgery, just put the shoulder in a sling.

With an Acromioclavicular separation they are classed from Type I – III with more severe cases being Types IV – VI.

According to the Foundations of Athletic Training, a Type I separation the ligaments are still intact and there is minimal deformity. Type II starts to show some deformity, the A/C ligaments are damaged but the coracoclavicular one is still fine. Type III shows obvious deformity and all the ligaments are damaged.

There is also more pain and restricted range of motion with a Type III compared to Type I or II.

When it comes to a Type IV – VI there is total disruption of the supporting ligaments and where surgery is necessary.

If you’ve never seen a separated shoulder injury when it happens, it can be difficult to figure out if it’s a separation or a dislocation. Magee gives some good information on how to tell the difference. There’s a few indicators that would point to a dislocation:

While it’s important to know the difference between the two, it’s not going to change how you deal with it.

First Aid For A Separated Shoulder

Whether it’s a dislocation or separation, we just want to stabilize the shoulder until we can get more advanced medical attention.

Chances are the person will be holding their arm/shoulder in the position that is most comfortable for them, you just need to work around it.

As it is with a fracture, dislocation or separation there are a few principles to keep in mind.

  • Immobilize in the position found.
  • Always check distal to the injured area for circulation.
  • Put ice on the injury to help with pain and inflammation.
  • Stabilize the injured joint or area as much as possible.
  • Keep the injured area above the heart as much as possible (but only if it can be done pain free)

The easiest way to remember is with the mnemonic RICE

 

R – Rest, stop whatever activity the person was doing.

I  – Immobilize

C – Cold, cool the area for 20 minutes

E – Elevate

When it comes to applying a sling to immobilize and stabilize a shoulder, the most common thing used is a triangular bandage. Some people hate these things, but I think they’re great because they may be the most versatile tool in a First Responder kit.

Not only can you make a sling, you can turn them into broad bandages, donut rings, stabilizing ties and various other things. One of the other reason they’re in most First Responder kits is because they’re cheap.

You can buy premade shoulder slings and braces but they cost ten to thirty dollars and when you send someone to the hospital with one, its doubtful you’re getting it back. A triangular costs anywhere from twenty five cents to a dollar.

No big deal if you never get it back.

If you ever have to deal with it, here’s some instructions on how to put the shoulder in a sling:

Anatomy Knowledge

An article published in 2012 used 24 articles to draw information from on the best practice for treating A/C separations.

For a Grade I – III range of motion and strengthening exercises within pain tolerances were recommended. Exercises were mainly to provide stability to the shoulder blade and rotator cuff. Grade IV – VI are typically dealt with by surgery.

There wasn’t much information as far as any treatment protocols. The advice was to use your  knowledge of anatomy, movement and healing process to develop the best plan for you patient.

What I can tell you from personal experience is that for that first week, having one of my buddies that is an Athletic Therapist tape the joint helped with pain management and providing stability.

Getting regular Massage Therapy to treat the muscles connected around the AC joint also helped with pain management and function. Even a year and a half later it feels like there is constant tension from the joint all the way through the shoulder.

If ever dealing with something like this, it’s important to remember that patient comfort is key. Applying a sling, icing the injured area and stabilizing the joint not only provides more comfort but also prevents further injury. Your anatomy and movement knowledge is critical not only in the acute treatment but also in the rehab of this injury. If the separation is severe enough, the person will be left with a step deformity at the joint. But because you helped take care of them properly when it happened, they should be able to get full function back. If nothing else came from this, at least I get to show students what a step deformity looks like.

How Massage Therapists Can Deal With Compartment Syndrome

The cracking sound echoed through the arena.

He went down to block a shot and when the puck hit him, we knew it was bad.

He couldn’t put any weight on one leg. Once he started to get up a teammate helped him to the bench.

We carried him to the treatment room and started stripping and cutting gear off.

He had severe pain around his shin, where he had blocked the shot. We carefully cut away his shin pads and compression socks.

The area was getting swollen and red throughout his shin. We couldn’t feel a pulse in his foot.

I thought it looked bad, but didn’t realize just how bad. Fortunately I was surrounded by people with more experience who are much smarter than me (yes I know, that’s not difficult to find!). They immediately realized that the player had to go to the hospital.

What I thought was a contusion, could actually have been a life threatening emergency if not handled properly. After things calmed down and we got him sent to the hospital, I asked why this was such a big deal. In unison the team Doctor and head Therapist looked at me and said:

“Compartment Syndrome”

Recognizing Increased Compartment Pressure

When this happened I was still a student and honestly a pretty fresh student Massage Therapist.

I was fortunate enough to be able to start volunteering with a hockey team to get some sports experience. I had never heard the term “Compartment Syndrome” (aka: Volkmann’s Ischemia) at that point, or if I had, I didn’t remember it.

Later in Massage school we briefly talked about it, but more from the standpoint of how to treat it post surgery.

When we learned about it in school, we only talked about Compartment Syndrome happening around the shin. Turns out that it can happen in other compartments as well.

I learned that the forearm is another common place for it to happen because the Athletic Therapist used to quiz me on things like that.

Also, did you know that part of Scaphoid doesn’t have vascular supply, so if it gets broken the bone can die? More things he used to quiz me on.

Anyway, in researching for this article, I came to find out that any osteofascial compartment can have a Compartment Syndrome. Areas with deep fascia that is very strong that enclose compartments can be subject to a Compartment Syndrome.

The most common areas are the flexor compartment of the forearm and anterior tibial compartment of the leg. The hand, abdomen, glutes, thigh and upper arm can also be affected.

Acute Compartment Syndrome is a buildup of pressure in one of these compartments due to an injury. It can be both limb threatening and life threatening if not treated properly and in a timely fashion.

As swelling increases in a compartment, blood flow creates more pressure on the structures inside, causing capillaries to collapse and begins to starve the area of oxygen and nutrients.  The nerves can hold up for two to four hours and the muscles can only survive for six hours before becoming permanently damaged.  

Photo by: Hernan Pinera

Photo by: Hernan Pinera

What Causes Compartment Syndrome

There are a number of things that can cause Compartment Syndrome to take place. So having a good knowledge of the mechanism of injury is our biggest help in recognizing what’s going on:

If any of these things have happened and you’re not quite sure if this is a medical emergency, better safe than sorry, have the person sent to the hospital.

But there are some tell tale signs to look for that will help make your decision.

Pain is going to be your first indication that something is wrong. But the pain may not seem to be normal compared to the injury.

Now that you’ve established that this is a medical emergency, it can’t be treated the same way you would typically think to do it.

If there is a long bone fracture in place you can’t put a splint in place as you normally would for a fracture. Anything restricting the area must be cut away to allow the area to swell. Putting on a splint or bandage is only going to make the Compartment Syndrome worse.

However any movement is going to aggravate the pain, so you will have to manually support the injured limb/area as best you can with the help of others around you.

If there is no fracture to the area then it can be treated as you would other soft tissue injuries.

Immobilize the limb as best you can (without bandaging it) and apply ice to the area. If possible, elevate the limb above the heart to help decrease circulation to the area.

But the most important thing you can do is call 9-1-1 and get the person to more advanced medical care as soon as possible.

Once in the care of the hospital, surgical interventions will take place in order to relieve the pressure. A “fasciotomy” is performed, where surgeons cut the muscle and fascia in order to back off the pressure and hopefully save the surrounding tissues.

Massage Therapy And Compartment Syndrome

I actually wrote this article with some encouragement from a former student (thanks, Chelsea).

I wasn’t sure what topic to write on and she told me Compartment Syndrome would be a good topic because we didn’t learn a lot about it in college.

Holy was she right!

Just in doing research on this one I came to learn more about the different compartments that can be affected. I had no idea that the glutes, thigh and upper arm were also at risk. Nor did I know much about Chronic Compartment Syndrome and how it is an overuse injury from excessive vigorous exercise.

The biggest takeaways are just to remember the mechanisms of injury that can create a Compartment Syndrome. Much like the player in the story at the beginning, blocking that shot caused a bad bruise that led to Compartment Syndrome of the anterior lower leg. Always be careful and check (especially with traumatic injuries) if there is a long bone fracture or circulation impingement.

As you assess the injured area, look for pain that doesn’t seem suitable to the injury, increases with muscle stretching and burning/tingling sensations around the area. If you follow your First Aid protocols and take things step by step, you should have no problem figuring out exactly what is wrong. 

Recognizing all of the above could possibly save a limb or a life, the next time you have to treat a Compartment Syndrome.

Now if I could just get that Athletic Therapist to keep quizzing me on things, I might get a little smarter!