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CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

Case Report Presented to

The Faculty of the College of Health Professions and Social Work Florida Gulf Coast University

In Partial Fulfillment Of the Requirement for the Degree of Doctorate of Physical Therapy

By Jason L. Burns 2015

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

APPROVAL SHEET

This case report is submitted in partial fulfillment of the requirements for the degree of Doctorate of Physical Therapy

______________________________________ Jason L. Burns

Approved: May 2015

______________________________________ Dr. Stephen Black, DSc, PT, ATC, CSCS Committee Chair

______________________________________ Dr. Russell Hogg, PhD. Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline.

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES Acknowledgements I would like to express sincere gratitude to the following individuals who assisted in the completion of this independent study: Dr. Steven Black who served as my committee chair and provided guidance and support along the way; Dr. Russell Hogg who was my committee member, a mentor, and a consummate professional. This study would not have been completed without their wisdom, direction, and insight. I would also like to thank my fellow classmates and most of all my family for their endless support

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Table of Contents Abstract ..................................................................................................................................... 4 Introduction ........................................................................................................................... 6 Injuries .................................................................................................................................. 7 Wrestling ............................................................................................................................... 9 Traditional Martial Arts ...................................................................................................... 10 Informal Search of MMA Injuries ...................................................................................... 12 The Case Study ....................................................................................................................... 14 Introduction ......................................................................................................................... 14 Literature Review: Identification ........................................................................................ 20 Literature Review: Management......................................................................................... 25 Literature Review: Physical Activity Tolerance ................................................................. 27 Literature Review: Return to play....................................................................................... 29 Literature Review: Dual Task Activities ............................................................................ 30 Literature Review: Long-term Consequences .................................................................... 31 Future Research .................................................................................................................. 31 Case Description: ................................................................................................................ 32 The Examination: ............................................................................................................ 34 The Assessment: ............................................................................................................. 35 The Plan of Care ............................................................................................................. 36 Outcomes: ....................................................................................................................... 42 Future Recommendations: Team Approach to Management ............................................. 44

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References ............................................................................................................................... 45 Appendix: Tables .................................................................................................................... 49

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List of Tables

Table 1 .....................................................................................................................................46 Table 2 .................................................................................................................................... 48 Table 3 .................................................................................................................................... 49 Table 4 .................................................................................................................................... 50 Table 5 .................................................................................................................................... 51 Table 6 .................................................................................................................................... 52

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Abstract Mixed Martial Arts is in its relative infancy as an official sport, however, the various components of the MMA athletic competition have been in use throughout human history. Mixed Marital Arts is a conglomerate of virtually every form of unarmed combat sport utilizing: punches, kicks, knees, elbows, throws, takedowns, spinning, jumping, and other movements. The competitors will utilize a combination of strength, power, speed, and endurance throughout their matches. The early results of recorded injuries during these sporting events indicate that any physical therapist interested in working with mixed martial arts athletes or clients who prefer to exercise in a similar fashion will need to be well versed in several different areas such as; concussions, neck and back injuries, as well as upper and lower limb disorders. Therefore they will best serve their patients through an evidence-based “best practices” approach to treating these injuries

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Introduction On November 12, 1993 eight-men entered an arena in Denver, Colorado to participate in an event that would change the world of sports dramatically over the next two decades. This was the first Ultimate Fighting Championship. While hand-to hand combat has been around essentially since man’s beginnings here on earth, it first became a sport in 648 B.C. during the Greek Olympiad games. Fighters of that time participated in the Pankratian combat style which was essentially a mixture of boxing and wrestling. Over the centuries styles have branched out and evolved according to regional traditions and teachings. However, with the introduction of Mixed Martial Arts, those fighting styles have once again been brought back together and blended into a conglomeration of techniques which build a more rounded athlete. In a mixed martial arts competition, the contestants obtain victory by: concussing the opposing fighter until he or she is defenselessness through blunt head trauma; or disabling an opponent through joint subluxation, dislocation, or soft tissue trauma. The opponent at that point may choose to either forfeit the fight by “tapping out” or suffer injury (Buse, 2006). Over the years, numerous studies have shed light on the varying types of injuries common to each specific style of martial arts. These injuries are the result of a combination of techniques coming from styles such as; boxing, wrestling, Judo, Karate, and Jiu-jitsu. With Mixed Martial Arts (MMA) being so new to the scene, the science specifically targeting the discovery of MMA injuries is in the early stages. There are approximately 18 million people in the United States who practice some form of martial arts. While this is merely an estimate that is currently unverifiable, it does provide an idea of how wide spread the field of combat sports is.

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Additionally, professional mixed martial arts have become an industry that generates hundreds of millions of dollars of revenue each year. Owners, fighters, trainers, and even fans have a vested interest in the health of the athletes. With this in mind, it seems prudent to research the training for and injuries resulting from such a physical sport, and to determine where physical therapists will find their place in this emerging market. With a deeper grasp of the types of incidents of injuries and a full understanding of the training regimen of these athletes, physical therapists will be better equipped to implement preventative measures and best-practice therapy techniques for those athletes and solidify the importance of their practice in this field of sports rehabilitation. Injuries With Mixed Martial arts being a relatively new sport, there is a shortage of recorded data regarding the prevalence of injuries occurring during mixed martial arts bouts. More research needs to be conducted on the types of injuries and the long term repercussions that arise from them. In the few studies that did catalogue these injuries, the statistics showed a variety of injuries common to combat sports. For example, in one study done in 2010, 232 rounds of fighting were observed; during this time 55 injuries were recorded. They consisted of: 28 abrasions and lacerations, 11 concussions, 5 facial injuries, and 11 orthopedic injuries (3 metacarpal injuries, with 1 confirmed fracture; 1 acromioclavicular separation; 1 traumatic olecranon bursitis; 1 elbow subluxation; 1 midfoot sprain; 1 aggravation of elbow medial collateral ligament sprain; 1 elbow lateral collateral ligament strain; 1 trapezius strain; and 1 Achilles tendon contusion (Shadgan, Feldman & Jafari 2010). Elsewhere in Buse’s research on mixed martial arts, 642

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matches were studied; of those: 182 resulted in head-impact trauma, 106 showed musculoskeletal stresses to the participants resulting in a stoppage, and 91 fights were won by neck chokes. The degree to which orthopedic trauma was sustained was not determined in this study; however, joint-locks were noted as the primary cause for match stoppage when musculoskeletal stress was cited (Buse, 2006). For fighters of this genre, the risk of successive joint degeneration could be related to factors such as: intensity of the joint loading during the submission move, articular incongruence after healing, lack of or improper therapy post-injury leading to joint instability, and various other factors such as the fighter’s age, co-morbidities, lifestyle, etc. This is a prime reason for physical therapists to step in and introduce themselves into this up and coming sports platform. While the classification of injuries in MMA may be in its infancy, physical therapists may be able to have a solid understanding of the types of injuries they will likely treat by systematically breaking apart the components of the combat into researchable categories. Concurrently, the development of probable prevention strategies and exercises requires classification of injured patients as well as evaluations of the patterns of injuries sustained (McPhearson & Pickett, 2010). The mixed martial arts contest can be fragmented into several different modules; wrestling or “grappling” (which includes submissions), boxing and kickboxing, and traditional martial arts Each style has its own tactical strategies and therefore each lend more to the use of specific biomechanical movements which would, in turn, lead to varying injuries of the different styles. Wrestling Wrestling is the form of competition involving techniques such as clinch fighting,

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throws and takedowns, and joint locks. There are several well-documented injuries that are frequent to grappling and wrestling including; lacerations, strains, sprains, fractures, and dislocations. Head and neck injuries are also a major source of damage when involved in this segment of the fight-game and are commonly a result of an impact with the ground. Injuries seen from these movements could be; open wounds, pulled neck muscles, concussions, etc. (McPhearson & Pickett, 2010). To have some understanding about how these head and neck injuries occur, therapists can observe the more common maneuvers seen in a mixed martial arts contest. First, the hip throw, is a skill where one fighter positions the hip under the abdomen of the other and raises the opponent’s body off of the ground. The individual then rotates both bodies in the transverse plane while driving the opposition to the ground. One article identifies the first point of impact to be located at T2/T3 in the thoracic region of the spine (Kochhar, Back, Mann & Skinner, 2005). Another throw, the Suplex, is performed by having the fighter grab the opponent around the waist in order to lift him up over his shoulder. As their combined center of gravity moves, the fighter falls backwards on to the back, preserving the hold on the opponent, who falls forward, on to the face (Kochhar et al., 2005). This puts hyper-extensive strain on the neck/cervical region of the spine. Lastly, the Souplesse, is initiated when one fighter lifts his challenger from the waist, and swings him over his shoulder. At the last moment, the opponent is rotated over his upper chest and slammed down on to his back. The initial point of impact is, again, the T2/T3 region (Kochhar et al., 2005). Moves such as these often lead to debilitating injuries of the spine. While these methods are commonplace within the ring, there is not much statistical data ranking the resultant injuries amongst others. In terms of statistical

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rankings of injuries, there are some differing opinions as to which are the most frequently occurring in the sport of wrestling. In one study done by Shadgan et. al., the authors show that, recorded injuries resulted in; 19 skin lacerations (59.4%), 4 nose bleeds (12.5%), 8 sprains (25%), and 1 muscle strain (3.1%). The most common sites of injuries were the face and head (68.7%), followed by the upper limb (18.7%) and the lower limb (12.5%). They go on to say that their research shows similar results to some studies, but that the results differ from the findings of the International Olympic Committee Medical Commission and others who produced data aligned with the IOCMC (Shadgan et al., 2010). Traditional Martial Arts The term “Traditional Martial Arts can be considered a combination of several genres of combat including; Karate, Taekwondo, Akido, Kenpo, Kung Fu, and many others. Within this category we find that lower limb injuries were the most frequently occurring; and of the lower limb injuries McPherson and Pickett noted in their research that athletes were most likely to incur fracture injuries. The authors cite in their article that more injuries occurred in Karate than in the other forms of marital arts; in fact of the 189 fractures reported, approximately half occurred in Karate. (McPhearson & Pickett, 2010) They noted that falls, throws and jumps are the predominant cause of injury in most styles as opposed to karate kickboxing and taekwondo, in which kicks and foot strikes are the sources of the greatest morbidity, but where twisted ankles and lower limb fractures are still common (McPhearson & Pickett, 2010). Kickboxing Kickboxing also plays a crucial role in the world of MMA fighters and accounts

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for its fair share of injuries as well. Results of injury evaluations of this form of combat revealed a summation of 382 injuries from 3481 fighters, which yielded an injury rate of 109.7 for every 1000 fight participants; the most common region of the body was the head/neck/face which accounted for 52.6% (Zazryn, Finch, & McCrory. (2003). This can be explained by the fact that the head, neck, and face are the primary targets of striking. Lower extremity injuries were the second most common (39.8% of all injuries), which can be attributed to the focus of this discipline on the use of the legs as weapons and the lower limbs as a scoring zone in some competitions. Despite the prominence of punches that take place during a kickboxing match, fewer than 3% of injuries in the ring involved the upper extremities. Concurrently, there were a low number of injuries to the trunk area as well, only 2.1% were recorded (Zazryn et al., 2003). Informal Search of MMA Injuries While records are almost certainly being documented and scrutinized by the owners of major mixed martial arts organizations in order to protect their investments, these incidents often go unpublished. With no official source to pull from, it was necessary to conduct an informal search of professional mixed martial arts injuries in an attempt to categorize the variety of dysfunctions resulting from this sport. Interestingly, of the 101 injuries documented in professional Mixed Marital Arts in 2013, 66 of them were reported as “undisclosed injuries”. This means that 65% of the injuries that took place over the course of the year were not identified. The reason for this lack of reporting stems from the injured fighter not wanting a future opponent to be aware of a potential weakness. Fighters are very protective of their medical privacy in

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situations like these. Any information an opponent has is likely to be used for their benefit in the upcoming fight. For example, if “Fighter A” knows that “Fighter B” has recently recovered from an MCL injury of the knee, he is likely to target that knee with kicks. This can have negative effects both physically and psychologically for the previously injured individual. He or she may not fully trust in the recovery of their injury. If their opponent is specifically targeting that area, the fighter may end up changing his or her strategy in order to protect the effected body part. This could lead to them leaving openings in their defense that would not otherwise be available. Physical disadvantages may become prominent as well. Often athletes are faced with tough decisions to make about when to return to sport. Financial demands, opportunity for advancement, pride, and many other factors could lead a fighter to return to the ring before they are fully recovered. In recent years, medical professionals have put more emphasis on cataloging MMA injuries, and learning what are the best evidenced-based approaches to treating these injuries. However, these motives have created a culture of secrecy when it comes to injuries, making it difficult to track exactly how many mixed martial arts athletes are injured each year, and what types of injuries they experience. Below is a table (See Table 2) charting the 35 injuries that were reported in the year 2013, and the percentages of each category of injury. This summary is a snap-shot compiled to assist any medical professional interested in working with this subpopulation in understanding the types of injuries they are likely to encounter in their patients. The literature review of injuries occurring during combat sports leads to a

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realization that any physical therapist interested in working with mixed martial arts athletes or clients who prefer to exercise in a similar fashion will need to be well versed in several different areas such as; concussions, neck and back injuries, as well as lower limb disorders. Authors indicate that more than half of the injuries reported during tournaments affect the lower extremity (Shadgan et al., 2010). The physical therapist providing care for these fighters will need to be able to distinguish between strains, sprains, fractures, etc. in the knee and ankle, and determines the most fitting course of rehabilitation when treating the injury. With the increasing influence of jiu-jitsu and other grappling techniques in the sport of mixed martial arts, upper extremity submission locks are responsible for more musculoskeletal injuries such as shoulder subluxations and dislocations. The physical therapist choosing to go into this field will no doubt treat numerous rotator cuff injuries, and so he or she will need to have an evidence-based “best practices” approach to treating the shoulder as well as numerous other musculoskeletal disorders. The Case Study When investigating the various injuries associated with the sport of mixed martial arts, there is no doubt that as stated above researchers will discover an array of dysfunctions. While lower extremity injuries seem to be at the top of the list as far as sheer numbers of incidents go, in terms of greatest potential for fatalities concussions are the foremost concerning to fighters and medical personnel. Concussions, which are referred to as commotio cerebri in European and most other countries, make up 6 – 10% of all sports-related injuries, and can be considered a brain injury which is a complex pathophysiological process brought on by biomechanical

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forces (McCrory et. al., 2012). They are defined as, “A traumatically induced alteration in mental status” (American Academy of Neurology 1997). Concussions generally present with rapid onset of short-lived interruptions in neurologic function that resolve spontaneously. In some instances, symptoms could develop over a number of minutes to hours. These incidents may or may not involve a loss of consciousness which is particularly concerning to fighters because most Knock Out stoppages occur when the fighter becomes unconscious due to blows to the head, however, as stated fighters may experience head injuries without realizing it and continue to participate in their matches. In fact, loss of consciousness was recorded in less than 10% of athletes diagnosed with concussions (Broglio et. al., 2014). It is important for athletes, coaches, parents, and medical professionals alike to realize that it is not always the big hits that lead to trauma; concussions have been recorded even on “light contact” days! Rationale It is no secret that discussions regarding concussions have now come to the forefront of full-contact sports. The National Football League’s Player’s Union recently settled a class action lawsuit on behalf of retired players for $765 million (Curry, 2013). High school and collegiate coaches are under more scrutiny than ever to make sure they do not send players who’ve received a head injury back into the game. However, the problem is that not everyone has been fully educated on what to look for in suspected concussion cases. Players themselves have reported that 61% of high school athletes could not correctly identify concussion symptoms and 25% believed that loss of consciousness was required in order for a concussion to take place (Broglio et al., 2014). Additionally, 70% of collegiate athletes and 50% of high school athletes did not report

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the concussions they suffered that took place during football games. These statistics are important for pointing out shortfalls in the reporting of concussions. It is imperative that occurrences of concussion symptoms be conveyed immediately by athletes, coaches, physicians, and family members to avoid underdiagnoses and the potential for more serious damage. Statistics show 75% of repeat concussions happen within seven days of the first concussion, and 92% of repeat concussions happen within 10 days of the first concussion (Guskiewicz, 2007). Additionally, players with 1 previous concussion are 1.5 times more likely to receive another, and those players suffering 2 previous concussions are 2.8 times more likely to incur a third (Guskiewicz, 2007). Furthermore, it is not just enough to have a report of symptoms, rather a trained medical professional is paramount in the diagnosis of suspected concussions as 33% of players with concussions who were permitted to return to play on the same day were allowed to continue because of a delay in the onset of their symptoms as long as three hours post-incident. Cases have also been recorded where individuals who initially appeared symptom free for the first 15 minutes post-injury, still faced memory deficits as long as 36 hours later (Guskiewicz, 2007). The latter situations are examples of the types of dangerous situations that could potentially lead to the development of Second Concussion Syndrome (SCS). This occurs when the athlete receives a second concussion before the symptoms of the first concussion have resolved, and can have major implications in terms of injury severity. The damage incurred from Second Concussion Syndrome likely stems from the body’s inability to auto-regulate blood flow within the brain. When this happens, venous flow gets backed up allowing blood to pool in the brain and can lead to a hemorrhage. With

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recent attention shedding light on the seriousness of these brain injuries, cases of SCS are now being studied and have shown; 100% morbidity (meaning long-term permanent damage), and worse 50% mortality rates (Guskiewicz, 2007). Literature Review: Etiology Concussions are categorized as mild Traumatic Brain Injuries (TBIs) which are brought on by biomechanical insults to the brain. Sheering forces to the vascular supply can cause damage to the vessels, and Cerebrospinal fluid (CSF) volume increases may be the result of blockage of outflow pathways or interference with reabsorption (Goodman, 2009). The implications of the vascular changes that take place include a decreased ability of the cerebral vessels to maintain a level of homeostatic blood pressure and blood gas composition. Within the first few hours the injury, a decreased level of cerebral blood flow can cause ischemia. Normally neurotransmitters in the brain such as acetylcholine will cause a dilation of the vessels when they release and endotheliumderived releasing factor. This will allow relaxation of the smooth muscle in the vessel wall. In contrast, this reaction is interrupted in the concussed brain, resulting in abnormal vasoconstriction (Goodman, Boissonnault, & Fuller 2009). The rise in neurotransmitters, and an increase in potassium, leads to unregulated depolarization in the injured brain along with disturbances in postsynaptic functions resulting from imbalances in the interactions between neurotransmitters and amino acids (Goodman et al., 2009). Glutamate, a neurotransmitter with excitatory properties, rises to abnormal amounts during TBI’s, and when levels are increased the glutamate becomes neurotoxic (Goodman et al., 2009). The depolarization brought on by the injury creates nonselective openings of the voltage-sensitive calcium channels and an abnormal

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accumulation of calcium within neurons and glia. The neurometabolic chain of changes within the brain including the release of excitatory neurotransmitters results in changes to cellular membranes and ionic imbalances as well (Mjersek et. al., 2008). Changes at the level of the endothelium result in a disturbed blood-brain barrier in the injured brain. There is an initial increase in glucose metabolism and then a period of decreased abilities of the cells to “uptake” the glucose for use as energy. This reduced uptake stage may last anywhere from one to nine months (Majersek et. al., 2008). Additionally, researchers have noted an increase in the quantities of adenosine triphosphate (ATP) within the brain. It is thought that the ATP increases are the body’s attempt to counteract the ionic imbalances caused by free radical formation. The increased glucose metabolism, and initial decrease in cerebral blood flow due to acute swelling, results in an incongruity between the energy required by the cells of the brain and the amount of energy available (Majersek et. al., 2008). Concussions occur in one of three ways. A Rotational Concussion stems from pivoting around the axis of the neck left to right or right to left such as those incurred from a roundhouse kick to the head. Compression Concussions are those that take place in a top to bottom fashion as might be experienced if a fighter landed on their head from an opponent’s throw. Finally, Tensile Concussions, the most common form, are those caused by a sudden movement from back to front or front to back, and can be caused by straight punches, kicks, elbows, etc. to the head (Guskiewicz, 2010). Symptoms of concussions are considered to be functional and not necessarily structural (McCrory 2012). They can be classified into three categories; somatic, neurobehavioral, and cognitive. The somatic concussion symptoms will present in ways

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such as; headaches, nausea, vomiting, paresthesia, disturbances in balance, sensitivity to sound and/or light. The neurobehavioral symptoms often include; fatigue, drowsiness, increased sleep, nervousness and trouble sleeping. The cognitive symptoms of concussions are; feeling slowed down or “foggy”, difficulty concentrating, and lapses in memory. Medical personnel attending MMA practices and matches should be alert for these symptoms, but research shows that symptoms may not always be observable. In fact, as many as 38% of athletes who experienced a concussion reported no symptoms however, they may still have neurological deficits (Guskiewicz, 2010). Often times athletes individuals suffering from concussions will experience dizziness. This symptom can be the result of many pathological conditions (e.g., benign paroxysmal positional vertigo, labyrinthine concussion, and/or perilymphatic fistula), central nervous system disorders such as post-traumatic migraine, brainstem concussion, autonomic dysregulation/postural hypotension, and oculomotor dysfunctions as well as other causes including psychological and/or musculoskeletal disorders (Stewart, McQueen-Borden, Bell, Barr, & Juengling 2012). It is important to correctly identify the underlying source so that appropriate interventions may be prescribed. Headaches are listed as the most common post-concussive symptom of sportrelated concussions. There are numerous reasons that people experience headaches including; cervical spine injury, sensitivity to light and loud noises, impaired sleep, increased intracranial pressure, and others. If headaches are severe enough, they may have an impact on other normal body functions including energy levels, motivation, sleep, focus and attention, control of emotions, higher level cognition, exercise tolerance, and appetite (Stewart et. al., 2012). Physical therapists should take care to complete a

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comprehensive assessment of the neuromusculoskeletal system to determine if these dysfunctions are the reason for the athlete’s headache. If so, interventions can be properly administered to the individual. While sleep and rest are traditionally recommended it has been discovered that too much inactivity can be counterproductive. Stewart et. al., 2012)., found that three to six days of bed rest can result in an athlete’s complaint of headache, restlessness, and difficulty sleeping, which may complicate the treatment of the patient with persistent post-concussion symptoms. (See Table 3 for list of post-concussion symptoms): There are numerous aspects to consider in the prognosis of concussion recovery potential for athletes. See Table 4 for implicating factors that may have a bearing on; the risks of injury, symptom severity, and length of recovery. Literature Review: Identification When time is of the essence to an athlete and their coaching staff, a rapid assessment tool that is reliable and valid should be used. The Standardized Assessment of Concussions (SAC), the Sports Concussion Assessment Tool (SCAT3), or even the King-Devic test have all been researched and found to be effective. These tests should not be done alone however; concussion evaluations need to incorporate many facets of examination which will be discussed hereafter. Furthermore, it is important to point out that the traditional line of identification questioning such as orientation to; time, place, and person have been shown to be unreliable when compared with the current use of more thorough assessments (McCrory et. al., 2012). For this reason, there is a vital need for trained medical personnel to administer on-site assessments and become involved in follow up care. The attending medical staff will be able to more accurately diagnose the

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concussion and progression or resolution through the use of; a comprehensive history a detailed neurological exam that focuses on evaluation of the patient’s mental status, cranial nerve testing, cognitive functioning, gait, and balance tests as well as the determination of the clinical status of the patient. This clinical status will include observations as whether or not there has been progress or deterioration in the individual’s condition since the time of injury. Often this will involve seeking additional information from parents and/or coaches (McCrory et. al., 2012). Medical professionals responsible for monitoring the safety of athletes participating in mixed martial arts competitions or training will need to be extremely well acquainted with the red flag signs that may indicate a detrimental decline in a fighter’s condition. The signs include; extensive loss of consciousness greater than one minute or a decreasing level of consciousness, amnesia, deterioration over time instead of progress, increasing confusion or irritability, numbness in the arms or legs, pupils that are uneven in size, repeated vomiting, seizures, slurred speech or inability to articulate, inability to recognize people or places, and a headache that becomes progressively worse over time (Harmon, Drezner & Gammons 2013). These are signs that are grounds for an immediate trip to the Emergency Room for further testing and observation (see Table 5). In addition to the Red Flag signs indicated here, the on-site medical professional should be trained to observe and/or administer several other evaluations to ensure the safety of the participants. These include items like; nystagmus which could indicate a cerebellar problem, changes in breathing: which may be the result of autonomic instability, check pulse and blood pressure, palpate the head and neck to feel for painful or tender areas, swelling, or crepitus, administer range of motion tests of the neck (only

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on athletes who are able to stand up and move around), and grip, strength (Guskiewicz, 2010). To determine if the intracranial pressure is building athletes should be given special tests for cognition, coordination, and cranial nerves. The Cognitive tests may include drawing a clock with numbers, a 3 word recall, verbalizing the days of the week in reverse order. For coordination testing, the athlete may be asked to perform tests like; fingers-to-nose touches, heel-to-shin rubs, heel/toe balancing, or alternating pronation/supination hand flips. Furthermore, cranial nerves tests including: eye tracking, blinking, hearing, sticking out the tongue, smiling/frowning, etc. should be performed during the evaluation as well. With the recent incorporation of computerized diagnostic testing in the field of concussions, identification of cognitive and reaction time testing is becoming fairly standardized. However, these types of diagnostic tools fail to utilize a balance component. Recent research shows the increased accuracy of concussion diagnosis when integrating a balance and gait test such as the Berg, DGI, BESS, etc. The inclusion of these tests has been shown to add up to 37% more sensitivity to the detection of these problems even when athletes are reporting they experience no symptoms (Guskiewicz, 2010). Additional research into the co-occurrence of concussions with balance deficits has revealed that; individuals with headaches and/or migraines report more balance problems and that athletes who have experienced two or more concussions are more likely to have balance problems (Guskiewicz, 2010). This may be helpful in ascertaining the repeat concussions in competitors have not been forthcoming with their prior history, which could lead to the prevention of long term consequences. Finally, balance tends to be more effected in instances where amnesia is present; however, this is not exclusive to

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in amnesia patients. The deficits listed above could be due in part to the impaired postural control commonly seen in athletes experiencing with post-concussion symptoms. Postural stability testing therefore should be used when objectively assessing the motor domain of neurologic functioning. A likely source of postural dysfunction is an interruption in the body’s capacity to process vestibular information (Stewart et. al., 2012). The human body utilizes the vestibular system, proprioception, mobility and strength in the joints and muscles respectively to control postural stability and balance. Any disruption in; afferent or efferent coordination of these components would potentially have adverse effects on an athlete’s posture which could then lead to a change in the center of gravity disrupting their stability. The resultant cognitive symptoms associated with a concussive blow to the head typically include; difficulty concentrating, lack of extended focus, memory problems, decrease in executive functions such as organization, planning and problem solving as well as slowed mental processing. The application of neuropsychological (NP) testing has shown clinical value by adding significant information to the results of the concussion evaluation (Stewart et. al., 2012). Athletes presenting with these symptoms are more likely to fall into the category of a positive identification of a concussion. Most acute concussion measurement evaluations will contain a cognitive portion in their exam. For example, the SCAT3 contains a section for an immediate word recall, a delayed word recall, and a concentration task where the athlete will list a set of numbers in reverse order. Medical professionals charged with the determination of the presence of concussions should include a structured interview with the athlete to uncover any

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cognitive deficits they may be experiencing in the days following the incident. The athlete may report findings such as; difficulty with completing regular daily activities, difficulty driving, forgetfulness, trouble recalling conversations, decreased tolerance to distractions, slowness or “fogginess”, and errors in academics or the workplace as well as mental fatigue (Stewart et. al., 2012). Along with cognitive symptoms, psychological conditions and behavioral changes may be noted in post-concussion patients. Medical staff should address this with the athlete to make them aware that they may experience abnormal feelings such as depression and anxiety. These symptoms are common in almost all types of traumatic brain injuries, and armed with this information, the athlete may feel more comfortable discussing such a sensitive topic (McCrory et. al., 2012). The use of imaging as a whole for the identification of persons with concussions is generally not recommended. Computerized Tomography (CT) and magnetic resonance imaging [MRI]) adds very little to concussion evaluations. However, it may be helpful to incorporate these techniques if suspicion of an intracerebral hemorrhage or structural lesion such as a fracture exists (McCrory 2012). In these situations, indicators such as; prolonged unconsciousness, focal neurological deficits, or symptoms which are worsening rather than regressing are likely to be experienced by the athlete. In summation of the diagnostic process, it is important to note a few items in regards to working specifically with athletes that have not yet been mentioned. First, it is critical to ensure the competitors are well hydrated at the time of evaluation, as moderate to severe dehydration may present with similar symptoms which could negatively influence the outcome of the clinical measures (Berkoff, Cairns, Sanchez & Moorman.

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2007). Next, the significance of baseline testing cannot be overstated. The intent of baseline testing is to give the medical professional data for an accurate comparison to the athlete’s pre-injury functional levels. For example, if an individual had deficiencies in an area such as poor tandem balance or a learning disability that were not previously recorded; they may inadvertently be scored as a false positive in those specific categories of the concussion diagnostic evaluation. Finally, having a timeline of when to conduct follow-up evaluations is fundamentally important. At the APTA’s annual meeting on traumatic brain injury, Dr. Kevin Guiskewitz proposes that athletes should be tested; at the time of injury, then between one and three hours after the initial incident the symptoms checklist should be re-administered, and 24 hours post-injury a full reevaluation should be completed. Once athlete is asymptomatic screeners should allow 24 more hours of rest before final testing is completed, or if symptoms do not resolve after 7 days, a full functional test including; balance, cognition, coordination, and symptoms checklist should be performed and the athlete referred to a neurological specialist (Guiskewitz, 2012). Literature Review: Management The traditional theory of thinking dictated that patients suffering from concussions should be prescribed bed rest. However, prolonged inactivity has been shown to lead to several co-morbidities associated with concussion; vestibular disorders, depression, posttraumatic stress disorder, chronic fatigue, and pain disorders are among the list (Stewart et. al., 2012). Patients who underwent between three and six days of bed rest reported complaints of headache, restlessness, and difficulty sleeping, which may

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complicate the treatments. For this reason, bed rest for longer than three days is counterindicated (Stewart et. al., 2012). During the acute phase of post-concussion healing, the athlete should avoid all sports-related physical activities and only engage in actions that require mild to moderate physical effort. Initially, cognitive tasks such as; school, work, video games or other cognitively demanding events should be avoided. The current theory of pathological implications of a mild TBI’s are that the sympathetic nervous system activity is increased which raises heart-rate. This along with the interruption in cerebral blood flow can give rise to a re-surfacing or exacerbation of post-concussion symptoms with physical exertion and a potential increase in blood pressure (Goodman, 2009). This knowledge lends to the thought that sub-symptom threshold exercise can be applied to target disrupted blood flow and alleviate the dysfunctional sympathetic nervous activity. Once concussion symptoms have resolved, the complete assessment should be administered again and the results compared to the previous test and to the baseline numbers. Approximately 80% to 90% of concussions resolve in 7–10 days, in some instances persistent symptoms of more than 10 days are reported (McCrory, 2012). In this latter group; patients often experience prolonged, physical, behavioral, neuropsychological, and personality changes which have been termed post-concussive syndrome (PCS) (Stewart et. al., 2012). Even when patients are asymptomatic, up to 40% percent have shown cognitive deficits, suggesting that a cognitive component be included in the therapy process and the Return-to-Play protocols. After the initial prescribed rest period, the therapeutic program should include; motor, vestibular, cognitive, and if necessary psychological therapies. Then, according to

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patient tolerance a graded exercise program can be introduced along with an assessment of any lingering, prolonged symptoms that need to be addressed. The patient will need to be closely monitored to avoid exacerbation of symptoms. The program will need to be individually tailored to the athlete’s level of fitness as athletes engaging in high levels of activity after experiencing mild TBI’s have shown worse neurocognitive performance. However, those who participated in a more moderate level of activity demonstrated the better performance on these tasks (Majerske et. al., 2008). Finally, additional therapy techniques may include components such as; treatment for those patients who present with cervical spine or vestibular dysfunction, interventions to improve postural stability, sensory integration exercises, balance training, oculomotor training, eye-head coordination training, visual motion sensitivity training, neuromuscular control, and patient education on proper body mechanics. Pharmacologic therapy in the management of concussion-related dysfunctions could include the management of specific or prolonged symptoms like headaches, depression, anxiety, and sleep disturbances through appropriate medications (Stewart et. al., 2012). Literature Review: Physical Activity Tolerance At the latter end of rehabilitative therapy, prior to administering return-to-play activities, an athlete will need to be assessed to determine their readiness to partake in an exercise program of more moderate intensity than that which addresses the initial symptoms and recovery. This is referred to as physical activity tolerance. One recommended protocol for the activity tolerance assessment includes the use of the Balke treadmill test. The Balke test uses a graded application of treadmill running and ratings of perceived exertion (RPE) to monitor the individual’s response (Stewart et. al., 2012).

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The Balke protocol is varied for males and females. Male participants will begin with the treadmill set at 3.3 MPH at a grade of 0%. After one minute the grade is raised to 2%. Each minute following the grade is increased by 1%. When the participant is no longer able to carry on, either from symptoms or from fatigue, the test is concluded. Females athletes start at a setting of 3.0 MPH and a grade of 0%. The grade is increased 2.5% every 3 minutes, and again the test will be terminated when the participant can no longer continue (Stewart et. al., 2012). The medical professional conducting the test should keep a log of the speed, grade, and heart rate associated with symptom exacerbation and/or fatigue. By keeping a detailed record the heart rate at which symptoms or fatigue were experienced can be noted and used as a guide to create an individualized exercise program for that athlete. The heart rate at which symptom exacerbation or fatigue is associated is considered the athlete’s heart rate threshold (HRT). In the article by Stewart and colleagues, the authors suggest that exercise intensity should begin at a level less than 70% of the HRT for no longer than 15 minutes. Progression of the exercise will be in 5 minute increments each session until the participant reaches a 30 minutes. After the goal of 30 minutes has been accomplished, the intensity of the treadmill activity can be increased by adjusting the speed or grade so that the athlete has about a 5% increase in their heart rate (Stewart et. al., 2012). This protocol represents one method for monitoring and prescribing exercise tolerance, and these are general guidelines. It is important to mention that if symptoms are experienced during the testing, it should be halted for that day. It may begin again the following day at the same intensity. Progression should not be made while symptoms are present and the author believes that

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a regression in the protocol should be incorporated if symptoms are greater than those experienced during baseline testing. It is also is interesting to note that alternative exercise protocols other than continuous cardiovascular exercise can be utilized as well. Some athletes may tolerate other forms of training such as interval training better than a strictly cardiovascular approach. Although, in this author’s opinion clinician’s should utilize resistance training with caution initially as it has the potential to impact blood pressure which may be problematic especially within the injured brain, and there is limited evidence to support the use of resistance training in obtaining beneficial outcomes with post-concussion rehabilitation (Stewart et. al., 2012). As with each stage of concussion therapy, the patient will need to be monitored closely, but even more so during the incorporation of exercise due to the fact that glucose uptake in the brain is interrupted, and cortisol levels are increased both of which have the ability to negatively affect the neuronal energy mismatch that occurs post-concussion (Majerske et. al., 2008). Literature Review: Return to play For athletes to participate in a Return-to-Play program, evidence suggests that they be symptom free for 24 to 48 hours, perform at levels consistent with baseline testing for all aspects of diagnosis, and pass a clinical medical examination (Stewart et. al., 2012). Each individual will respond in an independent fashion to symptom recovery and tolerance to rehabilitation, but the typical athlete is withheld from sport for approximately one week. This time frame can be adjusted by the medical professional, but athletes experiencing concussion-like symptoms should never return the same day. Athletes whose symptoms last longer than the 7 to 10 day period are considered to have

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Post-concussion Syndrome; these individuals can expect a longer recovery process with an extended Return-to-Play protocol that takes into account their decline in physical conditioning (Stewart et. al., 2012). Return-to-Play protocols developed by the National Athletic Trainer’s Association in conjunction with the American Academy of Neurology show a progression of activities, or stages, the athlete should participate in during the recovery process. Each stage will be separated by a 24 hour period after successful completion that includes no reports of concussion-related symptoms (Stewart et.al., 2012). If at any stage during therapy, the participant experiences symptoms; the activity should be stopped immediately and a 24 hour rest period should be implemented before resuming the graduated protocol. (See Table 4 for a suggested Return-to-Play program) Literature Review: Dual Task Activities One area showing promising results in concussion management is the use of dualtask activities. This method for addressing problematic symptoms is particularly pertinent to the field of physical therapy because of the association between concussions and gait abnormalities as well as various other functional limitations. Dual-task activities are those that require the athlete to perform multiple activities across varying categories at the same time (Stewart et. al., 2012). For example, a patient may be asked to perform balance and cognitive activities simultaneously such as standing on a wobble board while counting to 100 by 3’s. Simultaneously conducting attention-oriented activities and balance training has been found to be especially effective in treating post-concussion athletes with dizziness, balance and visual disturbances. The deficiencies seen when performing dual-task activities are hypothesized to be a result of the impaired ability of the executive functions of the brain to share attention between the demands of the two

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tasks (Stewart et. al., 2012). In the article written by Stewart and colleagues, it is suggested that therapists appropriately level the types of dual-task activities they are asking patients to perform whether it is for motor, visual, cognitive deficits, etc. so that the tasks are feasible for patients to perform as a single-task intervention. Outcomes such as balance errors, correct number of counting sequences, words read per minute, etc. can be used to monitor progress. Literature Review: Long-term Consequences As of yet, the impact of concussions on a patient’s long-term physical and cognitive health have not been clearly defined. Early reports show changes to motor control, neuroelectical activity, and neurocognitive abilities (Harmon 2013). Professional athletes participating in high-impact sports have indicated via self-report survey methods an increase in late-life cognitive impairments, depression, anxiety, lack of impulse control, and chronic traumatic encephalopathy. While current studies may lead to the likely conclusion that repetitive concussive and sub-concussive impacts have a direct correlation with the symptoms listed above, variables such as genetic predisposition, comorbidities, lifestyle risk factors, and normal decline through the aging process have not been extracted so the reliability of such studies remains uncertain. Future Research Research in many areas of identification and management are growing and evolving as science delves deeper into understanding these brain injuries. One new experimental advancement that may have some future merit is that of gene marker identification. New studies are looking into the significance of apolipoprotein (Apo) E4, ApoE promotor gene, tau polymerase, and other genetic markers in the identification,

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management, and benefits to outcomes of rehabilitation. At the present time, no solid evidence has been uncovered. However, evidence from human and animal studies in more severe traumatic brain injuries are showing variant levels of genetic and cytokine factors, such as insulin-like growth factor-1 (IGF-1), IGF binding protein-2, fibroblast growth factor, Cu-Zn superoxide dismutase, superoxide dismutase-1 (SOD-1), nerve growth factor, glial fibrillary acidic protein (GFAP), and S-100 associated with concussion injuries (McCrory 2012). Additionally, electrophysiological recording techniques such as; evoked response potential, cortical magnetic stimulation, and electroencephalography are, at least in the early stages of research displaying reproducible abnormalities for subjects in the post-concussive state. Unfortunately, results are mixed with some studies revealing no significant difference between concussed players and control groups. These methods are in the developmental stages and continued research is being done to determine the validity of their use as identification tools (McCrory 2012). Case Description: The following is a fictitious case study based on the author’s experience with working with an actual client, but one who did not fit the criteria of being a mixed martial arts fighter. The patient is a 27 year old male who reports he received an insult to the left temporo-parietal area of the cranium during a mixed martial arts fight on 8/30/15. Headaches started shortly after on the right forehead region. Symptoms of vertigo began in September. The patient was under the care of a D.O. and was receiving stretching and soft tissue treatments from the cranium down to the sacrum, but no thrust maneuvers were performed.

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There are no reports of tingling, numbness, cracking or popping. He currently presents with pain; in the right temporal region, the right cervical region, and the right trapezius however, occasionally the pain will be located on the left side as well. He describes his discomfort as a pressure and heaviness at those points. The patient reports his pain level is currently 5/10, at its best it has been 3/10, and at its worst an 8/10. Symptoms of dizziness and spinning wake him at night when turning onto his right side; they generally subside within a minute or two. Cervical extension and forward bending initiate the vertigo which is associated with nausea. He reports fatigue that comes on rapidly and exacerbates the symptoms. He states that he is even fatigued by taking a shower, and is having difficulties remembering “normal things”. Sensitivities to sound and light also provoke headache symptoms. He reports barriers to his activities of daily living (ADL’s) such as; the inability to drive, not being able to read due to headache and neck pain, and an intolerance for activities that require a lot of movement. He also described feeling “not so steady” on his feet and claims he has been very irritable and emotional since the incident. The patient states that he had neurological tests and imaging; he was told that there were no fractures and that he had a concussion. He felt that he was not progressing in his treatment; his primary physician referred him to physical therapy. He does not have any scheduled follow-up appointments at this time. His past medical history is significant for a right knee arthroscopy on 9/12/11 and a kidney stone on 12/18/13. He denies taking any prescription medication, illegal drugs and drinks 6-8 alcoholic beverages per week. His goals for physical therapy were to be

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independent with driving and to return to working out and mixed martial arts. The Examination: •

Postural Examination: - Mild subcranial side-bend to the left - Slight forward head, with protracted shoulders - Right should slightly elevated - ASIS, PSIS indicate nothing remarkable

• Range of motion: - Cervical flexion within normal limits but brings onset of headache symptoms - Cervical extension is limited due to dizziness - Cervical lateral bending within normal limit - Cervical rotation within normal limit •

Dermatomes: - C1 – C8 all within normal limits

•

Reflexes: C5-6, C6-7 bilateral 2+

•

Myotomes: - Bilateral upper extremities and lower extremities 5/5

•

Special tests: - Static Stabilization (-) - Gaze Stabilization (-) - VOR (-) - Bilateral Head Thrust (-) - Smooth pursuit (-)

33

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- Hallpike-Dix (+):

34

patient presents with tortional upbeat nastagmus with a right Hallpike-Dix test. A right Eply’s maneuver was performed and the patient experienced extreme sense of dizziness, spinning and nausea that subsided after 3 minutes and 30 seconds. The patient was sat back up and experienced a mild relapse of dizziness during which he had a mild counterclockwise sway when seating unsupported. This quickly went away. The maneuver was repeated, patient reported feeling 60-70% less dizzy; no nystagmus was present.

- Alar Ligament and Transverse Ligament Tests: (-) •

Neck Flexor Muscle Endurance Test: 11 seconds with associated neck and headache pain and dizziness

•

Neck Disability Index (NDI): 68/100

•

Berg Balance Test: 32/56

The Assessment: Findings are indicative of BBPV in the right, posterior semi-circular canal with co-occurring post-concussion syndrome as confirmed by the torsional, up-beating nystagmus, the presentation of severe dizziness with specific directional movements, as well as memory loss, exaggerated emotional responses, increased susceptibility to fatigue, decreased tolerance to fatigue, sensitivity to light and sound, a high risk Berg Balance test. Additionally, he may be encountering cervicogenic headaches as a result of soft tissue cervical and subcranial reactivity in relation to Wiplash Associated Disorder

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(WAD). These results are evidenced by tenderness to palpation in the upper cervical and subcranial regions, the unilateral headaches, postural imbalances including forward head posture and protracted shoulders, as well as a below average Neck Flexor Muscle Endurance Test time. The Plan of Care: The patient is expected to attend physical therapy sessions 3x’s per week for 4 weeks with an application for an extension if it is deemed medically necessary. Treatments are to include additional canolith repositioning maneuvers, AROM, PROM, and soft tissue manual therapy to the subcranial, upper and lower cervical regions, vestibular habituation exercises, postural education and strength exercises, dual-task activities that include cognitive interventions in conjunction with balance, coordination, or motor control activities, and cardiovascular endurance activities. The following is the 4 week intervention plan initiated with the post-concussion client: Week 1 – 2 Day 1-3 (Acute Phase): - Mild to moderate activities of daily living. - No activities that require stressful cognitive demands like school or work. Day 4-7: - Recumbent bike (5 mins.) - Cervical spine AROM/PROM, stretching, and manual therapy techniques - Vestibular Habituation exercises:

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1. Brandt-Daroff Vestibular Habituation Exercise: Side-lying w/ 45 degree opposite rotation (dizziness +30 seconds) 5x’s 2. Corrective Saccades: 2 fingers – 12 in. apart, Eyes look right. Head turns right. Eyes look left. Head turns left. (10x) 3. VOR X1: One sticker in the middle of card. Head moves L/R card stays stable. 4. VOR X2: One sticker in middle of card. Head moves L/R, eyes stable, card moves horizontally opposite of head while eyes track. Then repeat vertically. (1 minute each). - Postural Education and maintaining posture during static balance 1. Tandem stance: (3x’s 30 seconds ea.) 2. Feet together: EO/EC (3x’s 30 seconds ea.) 3. Standing on foam pad: EO/EC, turn head R/L (2x’s 30 seconds) - Coordination exercises: 1. Alternating pronation–supination hands: (2 sets 20x’s) 2. Sobriety test: Finger to nose R/L (2 sets 10x’s) 3. Bounce ball: one hand, opposite hand, floor to wall, dribble (10x’s ea.) Day 8-14: - Airdyne bike (5 mins.) - Cervical spine AROM/PROM, stretching, and manual therapy techniques - Review postural education and begin dynamic balance activities:

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1. Toe taps on steps: (2x’s 10 ea.) 2. Turn 90 degrees: R/C/L/C (3sets of 3 ea.) 3. DGI activities: walk turn head R/L, U/D 4. Side-stepping: over half-bolsters - Vestibular Intervention: Laser pointer tracking: patient in dark room, seated in chair that rotates, approximately 4.5 feet from the wall. Track laser on wall w/ fixed head position (Clockwise/Counter-clockwise Circles, figure 8’s, “H’s”, Diagonals). Progress to turning chair R/L as patient tracks - Coordination and Cognition activities: 1. Star-stepping: 8 Post-its placed in semi-circle around patient approximately 24 inches from center. Post-its are labeled 1-8. Patient stands feet together in center. Therapist calls out foot R/L and number. Patient responds by stepping to the number and back with the correct foot. (2 sets of 8 each leg) 2. Tandem Cities: Patient stands arm’s length from wall. 4 rows of 3 post-its are placed on wall each labeled with a different letter of the alphabet. Therapist calls out a letter, patient reaches out and touches the post-it with that letter on it and then names a city that begins with that letter. (activity can be progressed by beginning each turn by verbally recalling the

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cities that have been recited so far before picking a new letter). (1 complete round of 12) 3. Stack and Add Dice: Patient is given 3 dice. Patient rolls dice, calls out the numbers represented on each dice, then adds those three numbers. Next the patient stacks the 3 dice on top of each other. Repeat using non-dominant hand as well. (10x’s each hand) Week 3: Day 15-21 - Airdyne bike (8 minutes) - Cervical spine AROM/PROM, stretching, and manual therapy techniques. - Vestibular Habituation exercises: 1. Laser pointer tracking: patient in dark room, seated in chair that rotates, approximately 4.5 feet from the wall. Track laser on wall w/ fixed head position (Clockwise/Counter-clockwise Circles, figure 8’s, “H’s”, Diagonals). Progress to turning chair R/L as patient tracks - Motor control and dynamic balance exercises: 2. Balance a ball on clipboard: Patient balances a ball on a clipboard, tennis racket, etc. Then, patient walks down the hall

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trying not to let the ball drop. Repeat with other hand. (3 sets down and back with each hand) 3. Rolling ball under 1 foot: Patient stands with 1 foot on top of a ball, the other foot flat on the floor. Patient makes 10 clockwise and 10 counter-clockwise circles with the ball. Repeat with other foot (2x’s each foot. 4. Weave between cones and step over: 5 cones are placed approximately 24 inches apart in a straight line. Patient weaves in between the cones, then on the return trip he/she steps over the cones. Repeat with side-stepping each side as well. (3x’s each direction). 5. BOSU marches and bounces: Patient sits with good posture on BOSU ball and flexes one hip at a time, raising the knee and lifting the foot off of the ground. (3 sets of 15x’s with each leg). Next, patient engages the core and completes 20 seconds of bouncing (3 sets of 20 seconds) - Coordination and cognitive activities: 1. Catch and reverse: Patient stands approximately 10 feet from therapist. Therapist will throw the ball and say a sequence of 3 numbers. Patient catches the ball, repeats the numbers in reverse order, and then throws the ball back. (2 sets of 10) 2. Comprehension questions “and”: Patient is given a newspaper or magazine article and asked to read it. At the same time, they

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are also asked to count the number of times the word “and” appears in the story. When they are finished reading, they will tell how many “ands” they counted, and answer 3 comprehension questions based on the article. - Cardiovascular endurance activity: 5 minute walk on treadmill at < 70% HR max Week 4: Day (22-30) - Posture and core stability exercises: 1. TA Contractions and bridges: 2 sets of 15 2. Standing rows: with shoulder blade pinching 2 sets of 15 3. Elbows on table Donkey Kicks: 2 sets of 15 each 4. Standing shoulder horizontal abduction and extensions: 2 sets of 15 each w/ theraband 5. Side-stepping with weighted resistance: 2 sets of 3 repetitions 10 steps down and 10 steps back on each side. - Cardiovascular endurance activity: 10-15 minute walk on treadmill at < 70% HR max

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Outcomes: The patient progresses slowly over the course of the 4 week treatment plan. He initially displayed a decreased tolerance to cervical end range activities due to an increase in symptoms of headache and dizziness. Balance was moderately affected and was quite problematic for him initially; memory deficits were troubling to the patient also. Initially, the Eply test was repeated on the second visit and did not result in nystagmus, although he continued to experience a moderate level of dizziness of 3/10. The patient was given Eply exercises to complete as his HEP, and on the third visit symptoms of dizziness were no longer existent. The Berg Balance Score increased from 27% to 44% putting the participant back into the independent category. Through 12 physical therapy sessions, the patient improved cervical flexion and extension to within normal limits without provocation of symptoms, and was able to complete full flexion as well. Cervical headaches persisted until the 8th physical therapy session when the patient reported a 0/10 on the pain scale for headaches and neck pain. His 30 day NDI score was 32% which is considered a statistically significant difference. The patient has shown independence in his awareness of proper posture and body mechanics. His forward head posture is reduced but still present; shoulder blades appeared mildly more retracted with no signs of winging, and his score on the Neck Flexor Muscle Endurance test increased to > 30 seconds. The quality of the patient’s coordination improved and his movements were performed in a smooth controlled manner. His increased susceptibility to fatigue and decreased tolerance to activity improved but still need to be addressed before taking part in a Return-to-Play program. When performing the Balke Treadmill test in week 4, the

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patient was forced to stop at 9 minutes due to onset of headache and dizziness, and shortness of breath. The patient self-reports not feeling as “foggy” as he used to. The patient discussed ongoing occasional bouts of anxiety and lethargy. A referral was provided to him for a neuropsychologist to address these issues. It is this researcher’s recommendation that the patient take part in an additional 4 weeks of physical therapy working on strategies that were targeted in the 4th week of the program; posture and core strengthening as well as cardiovascular endurance training. At the end of the 2nd week, the patient should be reassessed, and if he is found fit to participate, a Return-to-Play protocol should be followed and monitored by a medical professional before participating in competitive fighting again. Future Recommendations: Team Approach to Management As evidenced-based concussion management gains momentum, the standard of care is moving toward an individualized approach to assessment and treatment. Patients suffering from post-concussion syndrome are better served through access to a wide range of health care professionals including; the primary physician, nursing staff, physical therapists, athletic trainers, and neuropsychologists to provide care and advocacy as the medical team. In addition to the principal medical team, academic and employment personnel are fundamental to concussion management as well. Social workers, school guidance counselors, numerous teachers, coaches, and family members could all play an essential part in the recovery process. (Stewart et. al., 2012) Even when symptoms of concussions appear mild, they could greatly detract from the athlete’s ability to function physically, cognitively, and psychosocially. Academically, it may be necessary to review the prior functioning levels of a student

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athlete to determine if there were previous learning disabilities, any history of problems with social behavior in the classroom, with peers, and with authority figures. For adult patients the same should be done to look into work history, any history of concomitant substance abuse, and the athlete’s level of job performance and independence prior to the injury (Stewart et. al., 2012). Finally, a truly comprehensive assessment designed to best help the patient should consist of not only a functional assessment, but also an evaluation of that patient’s family and peer support system resources, namely, repeat physician visits and additional diagnostic tests (American Academy of Neurology 2013). It is the author’s opinion that in consideration of the wide array of services necessary for optimal care, and knowing the cognitive deficits that can accompany post-concussion syndrome; a medical professional designated to be a Concussion Care Coordinator would be a beneficial addition to the health care system. In addition to the myriad of necessary appointments, the Concussion Care Coordinator would be able to provide patients with a list of both signs and symptoms that may indicate a decline in the patient’s status that would warrant emergency medical care, as well cataloguing the daily intensity, duration, and number of symptoms through phone conferences and providing that information to the primary care physician or physical therapist.

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References American Academy of Neurology. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology. 1997;48(3):581–585. Berkoff, D., Cairns, C., Sanchez, L., & Moorman, C. (2007). Heart rate variability in elite American track-and-field athletes. Journal Of Strength & Conditioning Research (Allen Press Publishing Services Inc.), 21(1), 227-231. Bishop, D., Girard, O., & Mendez-Villanueva, A. (2011). Repeated-Sprint Ability — Part II. Sports Medicine, 41(9), 741-756. Broglio, S., Cantu, R., Giolo, G., Guskiewicz, K., Kutcher, J., Palk, M., McLeod, T. C., (2014). National athletic trainers’ association position statement: management of sport concussion. Journal of Athletic Training. 49(2);245-265 Buse, J.G. (2006). No holds barred sport fighting: a 10 year review of mixed martial arts competition. British Journal of Sports Medicine, 40, 169-172. Guskiewicz K., (2007) Concussion and post-concussion syndrome: when to rest, exercise, or return to sport APTA Annual Meeting Traumatic Brain Injury-CES. Goodman, C. C., Boissonnault, W. G., & Fuller, K. S. (2003). Pathology: Implications for the physical therapist. Philadelphia: Saunders. Harmon KG, Drezner JA, Gammons M, (2013). American Medical Society for Sports Medicine position statement: concussion in sport. British Journal of Sports Medicine: 47, 15–26 Kochhar, T., Back, D., Mann, B., & Skinner, J. (2005). Risk of cervical injuries in mixed martial arts. British Journal of Sports Medicine, 39, 444-447. Kordi, R., Heidarpour, B., Shafiei, M., Shafiei, M., & Mansournia, M. A. (2012). Incidence, nature, and causes of fractures and dislocations in olympic styles of wrestling in Iran: a 1-year prospective study. Sports Health: A Multidisciplinary Approach, 4, 217-222. Majerske, C., Mihalik, J., Ren, D., Collings, M., Camiolo, C., Lovell, M., Wagner, A., (2008).Concussion in Sports: Postconcussive Activity Levels, Symptoms, and Neurocognitive Performance. Journal of Athletic Training: 43(3):265–274

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McCrea M., Hammeke T., Olsen G., Leo P., Guskiewicz (2004) Unreported concussion in high school football players implications for prevention. Clinical Journal of Sports Medicine McCrory, P., Meeuwisse, W., Aubry, M., Cantu, R., Echemendia, R., Engenbresten, L., Johnston, K., Kutcher, J., Ragtery, Marting, Sills, A., Benson, B., Davis., G., Ellenbogen, R., Guskiewicz, K., Herring, S., Iverson G., Jordan, B., Kissick, J., McCrea, M., McIntosh, M., Maddocks D., Makdissi, M., Purcell, L., Putukian, M., Schneider, K., Tator, C, Turner, M., (2009). Archives of Clinical Neuropsychology Concussion Symptom Inventory: An Empirically Derived Scale for Monitoring Resolution of Symptoms Following Sport-Related Concussion: 24; 219–229 McPhearson, M., & Pickett, W. (2010). Characteristics of martial art injuries in a defined Canadian population: a descriptive epidemiological study. BMC Public Health, 10(). Meehan, W., Hemecourt, P., Comstock, D., (2010). High School Concussions in the 2008–2009 Academic Year: Mechanism, Symptoms, and Management Am J Sports Med. 38(12):2405–2409 Shadgan, B., Feldman, B. J., & Jafari, S. (2010, June 3). Wrestling injuries during the 2008 Beijing olympic games. American Journal of Sports Medicine, 38, 18701878. Shively S., Scher A., Perl D., Diaz-Arrastia R., (2012) Dementia resulting from traumatic brain injury JAMA Neurology 69(10):1245-1251. Stewart, G., McQueen-Borden, Bell, R., Barr, T., Juengling, J.,(2011) Clinical commentary comprehensive assessment and management of athletes with sports concussion. The International Journal of Sports Physical Therapy: 7(4); 433-445 T R Zazryn, C F Finch, P McCrory. (2003). A 16 year study of injuries to professional kickboxers inthe state of victoria, australia. British Journal of Sports Medicine, 37, 448-451.

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Appendix: Tables Table 1: Compilation of the classification of reported injuries in 2013

Fighter’s Name

Injury

Date

Cat Zingano

Rt. ACL and meniscus tear

May 2013

Roger Hollett Anderson Silva

Bicep Tear Lft. broken tibia and fibula

January 2013 December 2013

Manny Gamburian Thumb and Elbow Rory McDonald Neck Johnny Eduardo Alistar Ovareen Santiago Ponzinibbio Dan Hardy Alexander Gustavson Gunner Nelson Eric Perez Nick Catone Constantinos Philippou Renan Barao Isaac Vallie-Flagg Antonio Rogerio Nogueira Anthony Pettis Robert Drysdale Clinton Hester Phil Harris Stephan Struve

Notes Occurred in training during plyometric jumps 6-9 months rehab post-surgery Injured in training Occurred in competition while checking an opponent’s leg kick Injured in training

Shoulder Quad tear Broken hand

February 2013 February 2013 March 2013 March 2013 March 2013

Heart Condition Cut on face

March 2013 March 2013

Discovered while training Injured in training

Knee Knee infection Dehydration Cut on face

March 2013 April 2013 April 2013 April 2013

Injured in training Injured in training Rapid weight loss prior to fight Injured in training

Foot Back Back

May 2013 May 2013 May 2013

Injured in training Injured in training Injured in training

Knee Meniscus Staff infection Broken Ribs Broken Orbital bone Heart condition: Leaking aortic valve

June 2013 July 2013 July 2013 July 2013

Injured in training Contracted it while training Injured in training Injured in training

August 2013

discovered while training

Injured in training Injured in training Injured in training Injured in training

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

47

Table 1 (Continued): Compilation of the classification of reported injuries in 2013

Fighter’s Name

Injury

Date

Notes

Broken orbital bone and dislocated shoulder

August 2013

Occurred in competition

Connor McGregor

ACL

August 2013

Occurred during competition

Wanderlei Sylva TJ Grant

Back Concussion

Injured in training Injured in training

Luke Rockhold

Knee

Michael Bisping

Eye

Charles Olivera Rodrigo Damm Cain Velasquez

Strained thigh muscle Kidney failure Shoulder surgery

August 2013 September 2013 September 2013 September 2013 October 2013

Rapid weight loss prior to fight Occurred in competition

Anthony Pettis

Knee

Jake Ellenburger

Hamstring

Erick Silva

Elbow and infection in leg Mouth

October 2013 November 2013 November 2013 November 2013 January 2013 January 2013

Injured in training

Chan Sung Jung

Buddy Roberts

Injured in training Inured in training Injured in training

Re-injured in training Injured in training Injured in training

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

Table 2: Category, number and percentages of recorded injuries in 2013 Category

Number of Injuries

Head/Face (including lacerations, broken bones, etc.) Concussions Neck and Back Shoulder (GH) Upper Extremity Broken Bones Upper Extremity Musculotendinous Lower Extremity Broken Bones Lower Extremity Musculotendinous Knee (ACL, PCL, Meniscus, MCL, LCL) Other: Includes; infections, heart, and other organ-associated dysfunctions

5

Percent of Injuries Reported 14%

1 4 3 3

3% 11% 9% 9%

1

3%

2

6%

3

9%

7

20%

6

17%

48

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

Table 3: Common Symptoms Associated with Concussions

▸ Physical – Headache – Nausea – Fatigue – Visual problems – Sensitivity to noise – Numbness/tingling ▸ Cognitive – Feeling mentally ‘foggy’ – Feeling slowed down – Difficulty concentrating – Difficulty remembering conversations ▸ Emotional – Irritable – Sadness ▸ Sleep – Drowsiness – Sleep more than usual – Sleep less than usual – Difficulty falling asleep

– Balance problems – Vomiting – Dizziness – Sensitivity to light – Dazed – Stunned

– Repeats questions – Answers questions slowly – Confused about recent events – Forgetful of recent information and

– More emotional – Nervousness

49

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

50

Table 4: Influences that Impact Risk of Concussion and Duration of Recovery Factors Symptoms Signs Sequelae Temporal Threshold Age Comorbidities

Medications Behaviors

Sports

Variables Number of symptoms Duration of symptoms (,=) 10 days Amnesia Loss of consciousness (LOC) > 1 minute Seizures Convulsions Frequency of incidents Time since last concussion Successive events tend to require less impact and show a longer recovery period Women > recovery time than men Children < 18 years old Pre-existing; migraines, headaches, depression, anxiety, sleep disorders, and other learning disabilities such as ADHD Anticoagulants Psychoactive medications Dangerous or risky behaviors including heightened aggressiveness without consideration of bodily harm while participating in sport Collision and high-contact sports High-risk or “Extreme” sports

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

Table 5: Red Flag Signs: Requiring Immediate Medical Attention

•

Extensive loss of consciousness greater than one minute

•

Decreasing level of consciousness

•

Amnesia

•

Deterioration over time instead of progress

•

Increasing confusion or irritability

•

Numbness in the arms or legs

•

Pupils that are uneven in size

•

Repeated vomiting

•

Seizures

•

Slurred speech or inability to articulate

•

Inability to recognize people or places

•

A headache that becomes progressively worse over time

51

CONCUSSIONS AND OTHER MIXED MARTIAL ARTS INJURIES

52

Table 6: Return-to-Play Protocol Stage 1. No Activity

2. Light Aerobic Activity

3. Sport-specific Exercise

4. Non-contact Drills (sport-specific)

5. Full Contact Practice

6. Return to sport

Recommended Exercises Mild to moderate activities of daily living No activities that require stressful cognitive demands like school or work Light aerobic activities such as walking, jogging, etc. that are performed at < 70% of the calculated Heart Rate Maximum. Running, skating, swimming with rapid turns and jumps at increasing intensities but do not require contact. Incorporation of more complex training drills that require the inclusion of fine and gross motor skills without demanding contact (Ex: passing routes in football, puck-handling and shooting drills in hockey, resistance weight training) Normal practice activities (should be monitored) and only after receiving medical clearance No limitations