Traumatic Brain Injury: Concussions, Recovery, and Return to Learn/Play

So, high school football season is coming to a close and professional football season is just gearing up, and I love sports and sports safety (obviously), so I thought a great topic for discussion this time of year would be the topic of concussion. It's not just a football injury, folks! I'm currently doing an elective in Sports Medicine, and I have to tell you, we are seeing 6-8 of these injuries a day! Anyone who experiences head trauma can end up with a concussion. This means everyone is at risk, but the athletes playing football, hockey, lacrosse, and soccer are particularly at risk because they get their heads hit (by other players and by the ball) often. Even horseback riders are at risk because they can fall and hit their heads.

What is a concussion?

To explain what a concussion is, I think we first have to start with the brain. And you

know how much I love the brain and what it can do, which is why I recommend helmets for preventing Traumatic Brain Injury. The brain is special. It is a magical organ that contains neurons and blood vessels and is in charge of our entire body and what it can do. Some have likened it to the soul because so much depends on the brain: emotion, personality, intelligence, learning, memory. It's amazing, right? But what happens when it gets damaged? 

Injury to the brain can be present in 3 main forms:  1. hemorrhage, 2. fracture, 3. concussion. Those are a bunch of fancy medical words, but basically, when you have injury to your brain, you can have an intracranial bleed or hemorrhage, you can break part of your skull bone (fracture), or you can have a good old-fashioned bruise (concussion).

What's the mechanism?

A concussion is in fact a form of Traumatic Brain Injury. It’s an injury to the brain that changes a person’s behavior, thinking, or physical functioning. This injury can be caused by forceful blow to the head or body that causes rapid movement of the head. The brain is encased by a skull, the bones of your head, and when quick movement of the head occurs, the brain moves around within the skull and can get bruised, resulting in a concussion.

Does a helmet protect you? 

No, it actually doesn’t. Not even the new fancy ones that they hoped would help to protect better against concussion. Helmets can protect you against fracture and hemorrhage, but they won’t protect you against a concussion because the mechanism for concussion depends on whether the brain gets knocked around inside the skull, and a helmet does not keep that from happening. Slowing players down or lightening them up so they do not hit each other with as much force (That guy Newton said Force = mass x acceleration, remember? He was a smart guy.) would help lessen the risk concussion. But until we can get our athletes to weigh less, or until we can get them to slow down (Probably unlikely, right?), then we need to know how to handle concussions.

Does my child need a CT or a cat scan?  An MRI?

This is an important question, and it is one that depends on clinical judgment and your child’s symptoms. If there is prolonged loss of consciousness after head trauma, if your child is not acting normally, if he or she is vomiting, if there is something concerning on his or her neurological exam, these are all things that the physician evaluating your child will consider when deciding if a CT or MRI is necessary. Please keep in mind that a CT is a lot of radiation, way more radiation than a simple x-ray, and in pediatrics, we try very hard not to perform a CT or cat scan unless it is absolutely necessary. Most emergency room departments will observe the child for 6-8 hours following the head trauma if there are no focal abnormalities on the neurological exam. An MRI has less radiation than a CT, but it is not a test that can be done emergently. Once your child is out of the first window of danger after concussion, those first 6-8 hours of observation and into the next 24 hours, if he or she is still having the symptoms that we will discuss later in this blog, it does not mean that he or she needs a CT or an MRI. It means that your child has a concussion and needs to be followed clinically by pediatrician or concussion specialist to manage his or her symptoms. An imaging test at that point is not what is needed because the diagnosis can be made clinically based on symptoms.

Do I need to wake my child up to make sure he is not confused after head trauma?

Pediatricians actually recommend that you do NOT do this. This used to be what was recommended, waking the athlete up every few hours and asking them questions to see if they knew where they were, who they were, what day it was, etc. But some confusion after a concussion is possible, and let’s be honest, if someone wakes you up at 3am, do you really know what day it is and where you are, even if you haven’t had head trauma? Some of us are heavier sleepers than others. However, if your child is vomiting, if your child’s pain is worsening, or if she is not acting like herself, then you need to bring her back to the emergency room for additional evaluation, and your ER physician should review these important signs with you before you leave the ER after your first evaluation.

Symptoms of Concussion:

Headache

Neck pain

Sensitivity to Light

Sensitivity to Sound

Nausea

Dizziness

Confusion

Feeling “in a fog”

Fatigue – needing 12-13 hours of sleep per night, needing naps throughout the day
Difficulty concentrating 
Difficulty remembering
Changes in behavior

Your doctor should be evaluating these symptoms at each visit and whether or not they are getting worse. This is sometimes part of something called Impact Testing which evaluates overall how well you are recovering from concussion; it can help determine when you are ready to start gradually reincorporating some of these activities that use your brain.

What's the treatment for concussion?

The AAP just released a statement on concussion and has based its report primarily on expert opinion as well as adaptation from a concussion management program developed at the Rocky Mountain Hospital for Children, Center for Concussion in Denver, Colorado. 

Most kids recover from concussion in 3 weeks. However, some athletes may take 3 months to recover, depending on history of previous concussion, how severe their symptoms were immediately following concussion, and the progression thereafter. If symptoms are severe, some students may need to stay home from school after a concussion.

The hardest part about having enough symptoms that your child needs to stay home from school is that the reason your child is home is because he or she needs cognitive rest. Cognitive rest is rest for your brain, and resting for your brain is a lot of nothing! This is really hard for most people, but especially for kids. What does rest mean for concussion recoverers? No brain stimulation of any kind. Remember that even while you are sleeping, your brain is still active.

When awake, your brain is constantly working to process the world around you and perform whatever tasks you are doing. So, when you have a concussion, even eating, talking on the phone, texting, watching TV--all things we swear kids do without any thought being used--are activities that work your brain. For this reason, some kids cannot go back to school immediately following a concussion. Depending on symptoms, you may need to stay home and not even play video games (!) which we know to any school-aged kid or teenager seems to defeat the purpose of being home from school, but your brain really does need to rest and avoid stimulation.

So, rest for a concussion is different than rest for your femur fracture or your wrist fracture where you can just not use that appendage. Your brain is an appendage that you use for everything. When your doctor tells you to rest your brain, they really mean:

-no TV

-no video games

-no reading

-no school

-no homework

-no physical activities

-no social activities, i.e. no trick-or-treating for some folks if they are having too many symptoms, no sleepovers because concussion sufferers really need actual sleep

 (Man, concussions really suck!)

This can be so hard for teachers, parents, and coaches to understand, which is why, if you or your child suffers from a concussion, you really need to be followed closely by your doctor, preferably by a Sports Medicine doctor who has experience helping kids recover from concussions. This is a step-wise process, and every concussion, just like every child and every athlete, is different. Some kids who are having few symptoms can return to school on a modified schedule right away, and some need to stay home from school and avoid reading, TV, video games, etc. because all of these things, whether you realize it or not, are actually using a lot of your brain and can be very taxing for someone recovering from brain trauma. Remember, you have a bruise in your brain, and all bruises take time to heal. Healing requires a step-wise progression to returning to all of the activities you did prior to your concussion, not just playing your sport, and it depends on your symptoms and the recommendations of your doctor.

Return to brain-stimulating activities

Your doctor will recommend a schedule for you to return to some of these activities after the first few days of rest, and how fast you return depends again on your symptoms. I guess this goes without saying, but during your REST, you also need to SLEEP. A lot. 12 hours a night is not unreasonable to recover, and a nap after any sort of return to cognitive activity is also recommended. Some kids are even sensitive to light and sound and have to be in a dark quiet room even while awake during the day. If your child is better, and your doctor recommends trying 20 minutes of reading or video games, a nap in the afternoon to recover from that new brain stimulation is warranted. If these activities are going well with no worsening of symptoms, then tutoring at home can be set up in 30-minute to 1-hour intervals, again with naps and rest in between. And once returning to school, partial days and coming home to take a nap is also necessary for recovery.

Return to School or "Return to Learn"

Coaches, parents, and athletes are all often very focused on what they feel is the most important part of recovery from a concussion-Return to Play. However, we are focusing more now on something that is equally if not more important because it is essential to a child's development and also an important step towards Return to Play, and that is cognitive rest and Return to School or "Return to Learn" as it is now being called by some specialists in the field.

When recovering from a concussion, the brain has trouble with tasks that are very important for school and learning. For example, thinking, concentrating, remembering, and processing and retaining new information can be halted to various degrees depending on the severity of the brain trauma. If symptoms are mild or tolerable, the student/athlete may return to school on a half-days schedule with special accommodation. No non-core classes and no activities with the potential for loud noises or for getting hit again – so no gym, no band, no recess. Your child should eat lunch in the nurse’s office or in a quiet place like the library to avoid loud noises and stimulation during the first part of return to school.

Return to Play 

Troy Aikman of the Dallas Cowboys had
10 concussions in 12 NFL seasons.

Most schools now have their own protocols for return to playing sports after concussion. Your doctor will be able to tell you when you are ready for return to play protocol. You should be going to school for full days without symptoms and maybe doing some walks or slight aerobic activity of short duration also without symptoms before you progress to Return to Play. Most of these protocols involve a gradual return to physical activity with close monitoring of symptoms. A plan might be something like: Day 1: bike 20 minutes; Day 2: bike and run; Day 3: non-contact practice with team; Day 4: contact practice with team; Day 5: if no symptoms, ready to return to play. If at any point, the athlete is experiencing symptoms such as headache, dizziness, etc., he or she needs to rest and re-start the protocol when no longer having symptoms.

When to see a specialist:

Your general pediatrician should be able to follow most athletes with first concussions. However, if symptoms are very severe, or if it is taking longer than 3 weeks to recover, seeing a concussion specialist (This usually falls under the category of Primary Care Sports Medicine) is warranted. Also see a specialist if the athlete has had multiple concussions, particularly within a few months or less of each other. IMPACT testing is now done at many schools, which is a baseline test to determine cognitive abilities prior to concussion and then also to follow athletes during recovery from concussion. A specialist will also do these tests to evaluate your child and can send he or she for vestibular therapy (a subset of physical therapy) and/or occupational therapy if these are needed to recover.

Resources for Parents:

Concussions 101 video: www.myfavouritemedicine.com/concussions-101/

From the AAP on slow return to school: http://aapnews.aappublications.org/content/34/11/24.6.full

Healthy Children.org: http://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/After-a-Concussion-When-to-Return-to-School.aspx

For Schools/Teachers:

Heads Up for Schools: www.cdc.gov/concussion/headsup/schools.html

Fact sheet by the CDC for Return to Learn strategies: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf

For pediatricians:

REAP Concussion Management Program: www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/reap-guidelines.htm.

Template for Return to School restrictions: http://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Documents/returntoschool.pdf

School daze. Students recovering from a concussion often need academic, environmental adjustments. Jessica Pupillo. AAP News 2013; 34:4; doi:10.1542/aapnews.20133411-4. http://aapnews.aappublications.org/content/34/11/4.full

For the college athlete:

The NCAA, as do pediatricians and the medical community, recognizes concussion as traumatic brain injury. More on concussions from the NCAA: http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Concussion+homepage/

The AAP is putting out a policy statement in the November issue of Pediatrics regarding Sports Medicine  practices for secondary schools and colleges, so stay tuned.

hello, is anybody out there?

Hi folks,

Just a tiny update on a few past blogs before we enter a new season of different sports!

HELMETS:
So I have to say that I have been entertaining myself over the last couple months during my longer runs by counting the number of cyclists I see wearing and not wearing helmets. If you are a distance runner, you'll understand. Sometimes you don't want to listen to music or to a training partner or to all the noise that's going on in your own head about the stresses of your everyday life--sometimes you just need a little mind activity to distract you. So, that's what I've been doing. So let's call this a little anecdotal evidence since my study numbers are a little low, but let me tell you, they were pretty consistent. 

During three 70-75 minute runs in the Bronx on Monday/Tuesday/Friday evenings, I noted that 16 of 48, 11 of 32, and 7 of 24 riders were wearing their helmets. All together that's 32.7%. That's actually better than I thought we'd be, BX! But it's still not good enough! This was on a bike path where you hopefully have less chance of being hit by a car, but you can still crash. We need those helmets! 

In White Plains during my longer runs, the numbers were a little better, but again it was on the bike path and not on Bicycle Sunday when I was so bothered by how few helmets I saw that I decided to write that first helmet blog. I repeatedly also saw little kids wearing helmets while the adults who were with them were not. Don't you want to live a long and healthy life and see your kids go on to be President or the next King James or whatever their dreams may be? Where a helmet!

Interestingly, there was just a study in L.A. that showed that even with a helmet law, only 11% of kids were wearing helmets while riding their bicycles. http://health.usnews.com/health-news/news/articles/2013/10/26/too-few-kids-follow-bike-helmet-laws-study-finds That's really unacceptable folks! Let's get to work on this. Remember, you like your brain, it does amazing things for you. Let's protect the future brains of America!

INPATIENT WORKOUT CHALLENGE:
In my last blog, I set a goal to get a tiny bit of exercise, even if only 15-30 minutes a day, each day while on the inpatient service. I'm happy to say that that blog motivated one of my co-residents to take the stairs each morning coming into work! So, a huge shout-out to Marianne for walking up 6 flights every day even when sometimes that day was going to be a 28-hour shift!!! :) As for me, I had some nice quick evening runs in the Bronx, including one naked moonlit run. No, I did not run without clothes in the Bronx at night--I'm not a total moron. But I did run without any gadgets, no Garmin, no iPod, just me and the moonlight and the evening sounds, and it was really nice. I highly recommend doing this every once in a while to find your center or your runner's Chi or whatever you want to call it. I think it's healthy. As for my challenge, I was doing a lot more of those 15-minute pre-call workouts than I would've liked, but in the end, there were 2 days in the month that I just did no exercise--2 nights when I stayed at work till 9:30 and 10:30pm but wasn't on call, so I hadn't worked out in the morning and wasn't going to go home and workout at 11pm when I had to be up again at 5am the next day. Stuff like that just seems silly when you aren't training for an event, and even I will agree that sometimes sleep is more important. So, a pretty good month overall. 

ON DECK:
*Concussions
*Seasonal Affective Disorder
*New York Marathon Update
*Women's Health Month (I'm making November Women's Health Month because it's my birthday month and just because this is my blog and I can do what I want :-P)

Until next time, folks, stay motivated and stayed fit!!!

The Short & Sweet Path to Fitness

Okay, there is no short and sweet path to fitness, but the idea is, a little bit of exercise a day keeps you feeling better and helps you receive the cardiovascular benefits that most of us want out of our workouts. Obviously, if you want more (weight loss, improved speed, improved strength, etc.), you have to work harder and longer. Most of us get stuck into this line of thinking that if we don't have time for an hour or more at the gym, then we may as well not go, and what it boils down to is, that is just not the case. Those shorter workouts are just as important as the longer ones when you are training for something, and even if you're not, any workout is better than no workout at all! ...Right?

Recently I started back on the inpatient service at work. And it’s exhausting. It’s 12- to 14-hour regular days (16-hour ones if things really go sour) mixed in with a 28-hour call shift every 4^th day, and it’s significantly harder than it was when I was a sub-intern and did the very same schedule for 2 months. So, hot off the press, folks—I’m getting older. I’m getting older, but luckily for me, I’m finally getting a bit wiser with the older age. The long hours and the coming of autumn has taken away my ability to go enjoy those morning sunrise and evening sunset runs that I used to relish in. But just because you don’t have an hour--or 5 hours (some of us have different ideas about what it means to exercise and to stay fit)--to work out every day, doesn’t mean you can’t do something active and healthy for yourself each day.

As one of my co-residents recently pointed out, do you have time to bathe? (One of the interns said she didn’t. I’m pretty sure that was a joke.) Then you have time to exercise every day. And I have to admit, he makes a lot of sense. The thing that used to really annoy me about Ironman training and 2-3 workouts in a day was the 2-3 showers in a day. To quote a popular expression, “I ain’t got time for that!” But, seriously, as much as I love training for an Ironman, I have other priorities now that are more important than 5 hours of training a day. However, I know myself, and I know that some form of exercise each day is what enables me to do my job well, to be a happy person, and to feel good about my life. So this month I have made the goal to do a short workout every single day. And sometimes that means one extra shower, but, hey, a little extra showering never hurt anybody.

Exercise every day is a simple idea. But, it’s challenging, especially now as a senior resident. Especially because…I really love sleep. Sleep is great. But as one of my mentors pointed out to me not too long ago, “If you are the kind of person who needs an extra 15 minutes of sleep every day, you are in the wrong field.” She wasn’t being mean; she was just being honest. And the funny thing is, she wasn’t even talking about fitting in exercise! She was just talking about being a doctor and caring about doing what’s best for your patients. So, I do love sleep, but I also go without it every 4^th day so I can make sure my asthmatics aren’t decompensating and I can sleep-walk into a room and feel for a spleen and hope it hasn’t ruptured yet.

With all that stress on my brain, exercise is just essential. I love my job, but I also love that recently when I leave the hospital, I tell myself that even though it’s been a rough day, and even though I just want to go to bed and sleep before I am up to do it over again, I will feel much better if I just get moving and breathe hard for a bit and have some fresh air. So I have been running at dusk in the Bronx. It’s really not the best idea. So soon I’ll transition to what I like to call the dreadmill. I’m just not ready for the dreadmill yet. It reminds me of my Surgery rotation and marathon training and it being dark any time I was out of the hospital and having to work again 14 hours and then run my mid-week 5-8-miler on the treadmill inside (my least favorite form of running). Thank goodness now I’m wiser and I’ve realized a few things…and I’m going to write it all down so we can all benefit.

• Make the most of the extras.
• Take the stairs. Park farther away from wherever inside is. Walk to run errands instead of driving. Actually RUN errands. I actually do the last one sometimes when I really want to run, but I also have other annoying things I have to do like go to the grocery store.
• Buy a gadget! 
• There’s a lot out there from Nike and Garmin sports watches to FitBit to Jawbone. My friend, also into fitness and nutrition, recently wrote a blog reviewing the different ones. http://gritbybrit.com/2013/09/23/my-up-life-up-by-jawbone-product-review/ Check it out! And follow her! She’s awesome!
•  Make the most of what you have.
• This last one I will elaborate on because I really believe in it, and I just think it’s what we have to do. As we get older, we have more and more priorities, but what we don’t realize is that these priorities give us the opportunity to make the most of what we have. The other night, I had maybe 30 minutes before it got really, not-safe-dark in the Bronx, so I used that opportunity to do a speed workout instead of just the long run I had planned. And do you know what? I was so happy afterward! 
• Exercise is exercise, and it gives you great endorphins. Shorter workouts work! I forgot about that because I’ve been doing endurance for so long, but I'm trying to remind myself again, thanks to my residency schedule.

Just a little bit about what the experts are saying about shorter workouts…

From the American College of Sports Medicine: The 7-Minute Workout:

http://well.blogs.nytimes.com/2013/05/09/the-scientific-7-minute-workout/?_r=0

I think doing it x2 with 60 second rest in between makes it even better! Then you are getting 15 minutes of intense exercise ;) I also like to add kettle bell swings, kettle bell goblet squat in place of the squat, and sand-bag lunges in place of the lunges. Haven’t heard about sand bags yet? Check out the Ultimate Sand Bag: http://ultimatesandbagtraining.com/

Still having trouble finding motivation after knowing that even something short is pretty good for you?

http://www.runnersworld.com/runners-stories/101-kicks-in-the-butt?cm_mmc=NL-Womens-_-1423164-_-09112013-_-101-Kicks-in-the-Butt

http://abcnews.go.com/Health/Wellness/exercise-addict/story?id=20397942#

So, my goal is to work out every day (I may cheat and count some of my 28-hour calls as just one day even though they are two. I know, I am a slacker.) this inpatient month. Stay tuned for updates on this goal and more exciting updates on that helmet blog and some other wellness topics :)

Until next time, stay energetic, stay healthy, and stay fit, even if it's 15 minutes a day!

Is Your Foam Roller Your Friend?

It should be! So, I have to confess, I have a new lasting relationship over the last few years, and it’s not with any human being; it’s with my foam roller. So, before I was going to write to all of you to tell you how great it is, I thought I should do some evidence-based medicine, and see what’s out there on the subject. But let’s start simple:

What exactly is myofascial release?

Are you new to this “fad” in training and conditioning? Don’t worry. That’s why I’m writing this blog! J It’s becoming more of a growing accessory to training. Somatic dysfunction can cause pain and restriction of motion. When you train intensely or when you work muscles that have not been used in a while (it happens, right, when we’re trying to get back into working out and then all the sudden the next day or the day afterward you wonder why you thought that it was such a good idea to start back with a full body lift at the weights you had done 6 months ago when you were training consistently), you end up with tighter muscles. 

The overlying soft tissue component that encases the muscles in your body is surrounded by fascia, connective tissue that supports your muscles. It’s awesome stuff, but it can get a little angry at you when there is inflammation. So there’s a form of soft tissue therapy that people are now using (and some would argue that it has existed in a certain form since the invention of massage techniques—whenever that was) to treat somatic dysfunction and prevent pain and restriction of motion.

Passive myofascial techniques include techniques when the patient stays completely relaxed. This would be if someone else is providing the myofascial pressure—this can be done with pressure points, with connective tissue massage, etc.  On the other hand, active myofascial techniques include techniques when the patient provides resistance as necessary, so foam rolling, active release therapy (ART), and strain-counterstrain techniques would fall under this category.

How does it work?

A study out of Japan that was published in the Journal of Strength and Conditioning earlier this year showed that self myofascial release techniques using a foam roller actually reduce arterial stiffness and improve vascular endothelial function. And what muscles need in order to perform at their best and also recover at their best is blood flow with adequate endothelial function to deliver nutrients and remove toxic chemicals. Amazing stuff!

So, do studies support that this stuff really works?

Myofascial release is something that entered the world of medicine through osteopathic medicine and complementary or alternative medicine (one could argue that acupuncture is even a varied form of this) and has now become the new trend in sports training over the last 10 years. But what studies have been done to support its use for athletes and the every-day healthful exerciser?

Guess what? Not a lot is very conclusive! In 2013, the Journal of Strength and Conditioning did a study on foam rolling and performance. They found no significant effect of foam rolling on actual performance of athletic maneuvers in comparison with the control group. However, they did find that post-exercise fatigue after foam rolling was significantly less than after the control group. The conclusion they came to was that the reduced feeling of fatigue when using foam rolling may allow athletes to extend acute workout time and volume, which can lead to chronic performance enhancement. So it hasn’t exactly been proven in the literature.

What do I think?

I think it’s awesome. I didn’t get it into until I started triathlon and realized that biking hard one day and running hard the next was giving me crazy knots in my quads. Foam rolling saved me. And then I started training smarter, got some better training plans in terms of coordinating workouts effectively, and I still realized that a foam roller either at the end of the day with stretching or pre-workout really helped maximize my ability to achieve the results that I wanted. It makes me wonder, what if we had known about this when we were playing college basketball back in the day?

The stuff that’s out there on the market:

Foam roller

http://www.amazon.com/Black-High-Density-Foam-Rollers/dp/B0040NJOA0/ref=sr_1_1?s=exercise-and-fitness&ie=UTF8&qid=1380468266&sr=1-1

http://www.amazon.com/ProSource-Discounts-Revolutionary-Roller-Purple/dp/B00AR1PNTK/ref=sr_1_15?s=exercise-and-fitness&ie=UTF8&qid=1380468302&sr=1-15

The stick

http://www.amazon.com/The-Stick-6628-Marathon/dp/B000P7NWLM/ref=sr_1_1?s=sporting-goods&ie=UTF8&qid=1380468337&sr=1-1&keywords=the+stick+roller+massager

How to use it:

Limit your foam rolling or whatever your chosen technique is to 30 seconds on each muscle, especially if you’re using an injured one. It’s like stretching in that regard; you don’t want to overdo it. The stick is good but doesn’t work for gluts and back unless you have a very loving training partner who’s willing to help you out. You can reach almost every muscle of interest with your foam roller, and you can use your body to help add the amount of pressure that you can tolerate.

Your IT bands and whatever other area of interest will scream bloody murder at you while you’re rolling, but later on, trust me, your body will thank you and give you the present of happier muscles and a stronger workout or competition, whatever you’re going for. I would argue that myofascial release has become the new ballistic stretching pre-workout, and I have to say, when part of a dynamic warm-up, it can’t be beat. It’s also a great addition to your agility workouts and to your flexibility routine if you have one (and you should).

For more ways to warm-up, cool-down, and stay fit in between, ask your trainer, ask your coach, ask my husband. ;) But that’s the science and the anecdotal evidence, folks. My advice? Just try it, and see how you feel! J

References:

Healey KC, Hatfield DL, et al. “The Effects of Myofascial Release with Foam Rolling on Performance.” J Strength Cond Res 2013 Apr 12.

Okamoto T, Masuhara M, Ikuta K. “Acute Effects of Self-Myofascial Release Using a Foam Roller on Arterial Function. J Strength Cond Res. 2013 Apr 9.

Lin MT, Chou LW, et al. “Percutaneous soft tissue release for treating chronic recurrent myofascial pain associated with lateral epicondylitis: 6 case studies.” Evid Based Complement Alternat Med. 2012 Dec 2.

Roach S, Sorenson E, et al. “Prevalence of myofascial trigger points in the hip in patellofemoral pain.” Arch Phys Med Rehabil. 2013 Mar;94(3): 522-6.

National Childhood Obesity Month

September is National Childhood Obesity Month, so I'm postponing my myofascial release blog another week because this is an important topic. I guess we could start by saying that it’s upsetting that we have to have a month dedicated to obesity in kids. This is not just an adult problem anymore. Neither is Type II diabetes. Or high cholesterol. Or high blood pressure.

What is obesity, what are the complications, and who is at risk? http://www2.aap.org/obesity/about.html  

Those are the details from the American Academy of Pediatrics, but basically, folks, obesity is bad, and it can give you old people problems at a young age. It can keep you from enjoying the life you want to live, it can give you more doctor visits, it means more medications, and it can shorten your life. And life is already too short.

The stats:

French fries...they taste yummy... but "french fries"
should not be in a toddler's vocabulary! I know,
he's so cute, you just want to give him whatever
he wants....but, don't.

¤ Childhood obesity has more than doubled in children and more then tripled in adolescents in the last 30 years

¤ Currently, more than 1/3 of children and adolescents are overweight or obese

¤ It is hard to predict the incidence of Type II diabetes in children because it can go underdiagnosed for a long time, but we are diagnosing it more and more

¤ 1 in 8 preschoolers in the U.S. is obese!!!! Preschoolers!!! AGE TWO to FOUR!!! 

¤ If you’re a minority, then that number goes up—1 in 5 black children and 1 in 6 Latino children are obese.

¤ These obese preschoolers are 5 times more likely as normal-weight preschoolers to be overweight or obese as adults

Adults:  you can watch how obesity has grown in America among adults since 1991 if you go to this page and scroll down: http://www.cdc.gov/obesity/data/adult.html It’s kind of like watching The Day After Tomorrow or some apocalypse movie where they show how the end of the world will occur in 72 hours after the storm of the century or the zombies or whatever encompasses more and more of the globe. We have an obesity apocalypse approaching… 

What is going ON, America??!!  Let’s fix it!

What the AAP recommends to help preschoolers: 

Some of my own tips…

Family Fitness: Be a Role Model, Encourage Your Whole Family to Lead an Active Lifestyle

1. Take the stairs and encourage others to do so. It’s not enough to lose weight (unless you work in a football stadium), but it’s not enough to curb those little extras that you don’t always account for, and it’s enough to get a mid-day energy boost and contribute to your goals of staying active and healthy. Feeling a little winded after 3 flights? Maybe that’s the extra motivation you need not to skip the gym tonight ;)

2. City commuters, get off your mode of transit (bus, subway, etc.) 2 stops early and walk the rest of the way home.

3. Commute with your bike in nice weather (Refer to last blog for helmet incentives and bicycle riding safety).

4. Get a real lunch break every day? Grab a co-worker and go for a walk/jog/run! You can eat a PB&J on the way and get some fresh air and sunshine AND feel more rejuvenated going into your afternoon when you might usually feel sluggish.

5. Take your kids to the park after work/school. A healthy and active lifestyle should be a family thing! Remember, parents are the ultimate role models for their kids, especially when they’re younger. Walk to the park together, play soccer, play football, walk or jog a loop at the park while your kid rides his scooter or bicycle. They love any time with you; why not make some of it the active time that you both need?

6. Sign up for a race! I signed up for my first race (a 5k) because I wanted to raise money for the American Heart Association. I had never ran more than a mile in a timed situation in my life, and after that first 5k, I was hooked. If you need a purpose, find an organization, find a friend, find a co-worker, join a team, start a club. Find what works for you and will get you training for your event on those snowy winter days or those dreary mornings when you would rather sleep in. A race gives you a deadline (some of us are just procrastinators and need that motivation to stay fit). Make a goal and go for it! (They have fun-runs and other races for kids, too! Look for later blogs on what exercises are best for what age kids.)

7. My new favorite—you have to think this is cool even if you don’t want one immediately…  Your phone lost its charge today? Go for a bike and recharge your phone as well as your body and mind J http://www.stickybottle.com/latest-news/video-this-is-perhaps-the-best-bike-related-invention-since-well-the-bike-truly-awesome/

It’s not all about exercise (although I am a huge fan of exercise). It’s also about nutrition. Having a healthy lifestyle means staying active AND eating healthily. Eating hamburgers and fries and drinking milkshakes catches up even to an Ironman athlete exercising 5-8 hours a day, trust me. A calorie really is a calorie, so apps for your phone like LoseIt and MyFitnessPal are great with figuring out how many calories you should have per day for your activity, body weight, and fitness goals. They’ll also help you keep track of how you’re doing each day, week to week, and over time. I highly recommend them for weight loss or for maintaining your current weight. You can add your activity and glasses of water per day, too. It’s like positive reinforcement, right on your phone, and you can add workout and weight-loss friends. Stay fit together! Here are some more tips…

Nutrition Tips:

1. Go Green

¤ if you can eat your 5 servings of vegetables a day, you are well on your way to eating healthily.

2. Add fruits for your sweet tooth.

¤ 2-3 fruits a day instead of those cookies and chocolate candies and ice cream you’ve been craving, and you will feel better and realize the wonder of nature’s own sugars! And, no, fruit juice ABSOLUTELY does not count, and no, you do not ever need it in your fridge. It’s the same thing as soda (BAD, sugary beverage, don’t drink it).

3. Know your weaknesses. And make your own remedies.

I have the worst sweet tooth known to man. It gets worse when I’m stressed out, working really long hours, working the night shift, or don’t find time for a workout that day. A dessert once a week won’t kill you (especially if you rev up your cardio that day or if you know that the rest of the day will be lots of low-calorie fruits and vegetables). So a dessert once in a while is my remedy…or a small piece of chocolate as a treat. I also have learned that if I eat all the fruits and veggies I am supposed to each day, I am honestly too full and have fewer dessert cravings. Hint, hint: fruits are actually sweet! Eat them J

4. Protein

It’s important, but don’t go nuts, folks. Protein bars and drinks can have a ton of extra calories that you don’t need unless you’re a body builder or trying to gain weight. Know your supplements, and know that you probably don’t need to supplement if you get your protein from a few servings of lean protein per day. How much do you need?

A general rule is 0.8g protein / kg body weight per day. If you are very active and do a lot of strength training, then 1.0-1.2 g protein / kg body weight is more like it.

Protein can help with sweet cravings, and it can also help you stay full longer, but, like in Indiana Jones and the Last Crusade, “choose wisely.” Chicken, fish, low-fat dairy, beans/legumes. Red meat is a treat, once per week or in small servings. Get your iron from leafy greens that are lower in calories.

5. Follow the new and improved food pyramid:

Or the food plate:

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid/

6. Stay active.

¤I like the pyramid because it actually includes what we talked about at the beginning—staying active.

¤ 30 to 60 minutes of moderate to high intensity cardiovascular exercise each and every day à seems easier said than done but start small and work up and you will realize that you feel better and actually eat healthier when trying to fit in workouts. Want a hamburger and fries for lunch? Probably not a good idea if you are meeting your friend for a run after work…your GI tract will thank you later for making a healthier choice! ;)

7. HYDRATE.

¤ Water is your friend! Avoid diuretics (coffee and tea make you pee!) and try to get in 10-12 glasses of water a day. You will feel much better, and you will realize that sometimes your brain is actually trying to tell you that it’s thirsty when you think it’s hungry. ;)

What the American Academy of Pediatrics recommends for fighting the obesity epidemic, one family at a time:  http://www2.aap.org/obesity/families.html?technology=1

Until next time, stay healthy my friends.

Do you like your brain? (then wear a helmet)

You have such a nice brain! Why not protect it?

I know, I know, I promised that my next blog would be about myofascial release, BUT, this past Sunday was the first Westchester Bicycle Sunday since June, and as I was out enjoying the PERFECT autumn weather and sunshine, I couldn’t help but notice how many people weren’t wearing helmets while riding their bicycles. Those of you who know me know that this is one of my one-woman campaigns—to make all the kids in the Bronx where bicycle helmets.

Don't worry. This was in New Zealand. That's why
I'm on the other side of the road. The cars do it too.

As a resident pediatrician, I have taken care of more kids than I would like to admit who were riding their bicycles in the Bronx without helmets and got hit by motor vehicles. Traumatic Brain Injury is a very serious thing. Some kids are luckier than others after being struck by a car (what normally happens in cities) or riding down a dangerous hill a little too fast (Let’s face it, we all love doing it) and taking a nasty fall. But what it boils down to is that if you like riding a bike, if you like running, if you like walking, if you like talking to your friends and eating food by mouth—all things this amazing thing called your brain helps you do—then wear a helmet.

The nitty gritty:

◊ The Centers for Disease Control notes that only 48% of kids age 5-14 years wear bicycle helmets while riding. Older children were even less likely to wear helmets.

◊ Data from 2010 shows that 800 bicyclists were killed, with an estimated 515,000 who sustained injuries requiring emergency department care.

◊ Lastly, each year, 26,000 of the children and adolescents who experienced bicycle related injuries actually developed TBI, traumatic brain injury.

From the AAP, helpful tips to get your child to wear a bicycle helmet:

http://www.healthychildren.org/English/safety-prevention/at-play/pages/How-To-Get-Your-Child-To-Wear-a-Bicycle-Helmet.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

I know now more each day that I was very lucky to have the parents that I had growing up. One of the many things they did for me besides encouraging sports and staying active was that they encouraged safety, health, and nutrition. I never considered riding a bicycle without a helmet. Why? There was a law in the state of Georgia that all children under the age of 16 had to wear one in order to ride a bicycle. But, more importantly, my parents not only bought me a helmet when I got my first bike from Santa, but they also always wore helmets themselves. When you’re a little kid, you don’t make fun of your parents yet, so when they wear a helmet, you might actually model them and think that it’s the cool thing to do. Isn’t that a great opportunity that parents have? Model good behavior. Model safe bicycle riding. Explain rules. Kids want to learn this stuff; we just have to teach them J

Maybe we don’t need to argue about why kids should be wearing their helmets. I mostly see adults not wearing them when I am out running or riding myself. So, to adults, I say, don’t you like your brain? Doesn’t it do awesome things for you? Do you like being able to contribute to society, work at your job, play with your kids? Then wear a helmet. I know, I know, you just got the NYC Citi Bike to go downtown a bit. I love the idea of Citi Bikes and what this could do for healthy transit in NYC. I think they should also have helmets at each little station. But that’s just me. And yes, those fun hipster cycling hats look cooler than helmets, but they don’t do much to protect your brain! You’re going to have hat hair either way, so just wear a helmet.

The right fit for your helmet:

¤ Helmet should sit slightly above the eyebrows and not slide around the head.

¤ Should be worn level on the head with straps forming a Y shape immediately under the wearer’s ear.

¤ Strap should be securely fastened to the point where the helmet stays still on the ehad but without being painfully tight around the chin. When you open your mouth, your helmet should pull down tightly on your head.

Other safety concerns while riding:

Since more and more folks are using bikes to commute (YAY! Fight obesity, America!), I thought some riding rules would be helpful for novice and even seasoned riders:

1. No headphones! Being able to hear what is going on around you is half of the fun of being outdoors but more importantly it is for your safety! You need all your senses to alert you if a vehicle, runner, or other cyclist is approaching.
2. Obey traffic signs and signals just as if you were in a car.
3. Use hand signals to let drivers and even other cyclists know what you’re doing.
   
4. Ride on the right with traffic, not against traffic. (Unless you’re in Australia, New Zealand, Japan, or anywhere else where they like doing things a big opposite.)
5. Stop and look both ways before entering a street.
6. If on a path, make sure you ride to the right to allow others to pass. If on a road closed to traffic, the right lane is typically the slower lane. Be courteous of others.
7. Don’t ride side-by-side or multiple riders across. (Be courteous to others.)
8. Wear a helmet. (Sorry. I just didn’t think we had said it enough here.)

   

   The closest I could find to Gatorade out
   on the road in Chiang Mai.

9. Bring adequate nutrition/hydration. Always err on the side of over-estimation because we tend to underestimate what we need and sometimes go farther than we think we will. If you are riding with kids, bring a snack and beverage for each of them. You know they’ll need/want it; they want it if they go to run errands with you.
10. Wear sunscreen (trust me).
11. Wear protective eyewear. Eyes, like a brain, are pretty nice to have around.
12. Teach your kids! Make sure they know the rules before they go out of the parking lot or the backyard where they have been learning how to ride their bicycles.

On an even more personal note, I have ridden some crazy climbs in the mountains of Montana with sheer cliffs to the side of me, and I have ridden in the busy streets of Bangkok and Chiang Mai in Thailand. 

I have to say, I would not have done any of it without a helmet. During Ironman Texas, about mile 106 of the bike, I was so tired and dehydrated that I took my eyes off the road for a moment (Don’t do that, guys.), and I crashed. I was not going very fast at all because it was just after a nutrition station and I was adjusting water bottles, but I hit the ground and slid several feet, my head hitting a telephone pole. Guess what I was really glad I had on? My helmet. Thank you, Giro helmet, for cracking and withstanding the force that could have smashed my brain and kept me from going on to begin my residency in pediatrics. Here’s a photo of my cracked helmet.

Wouldn’t you rather have a cracked helmet than a cracked brain? I would.

This was a just a little glimpse of a huge topic in sports: sports related head trauma. Football season just started, so we will most surely be talking more about this! In the meantime, get out and enjoy this awesome weather, but if you’re on a bike (or skating or whatever you’re doing), wear a helmet. ;)

Megan Long, M.D.

More info:

CDC http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/headinjuries.html

Brain Injury Association of America http://www.biausa.org/brain-injury-children.htm

More on bicycle helmets from the AAP http://pediatrics.aappublications.org/content/108/4/1030.full

Buy affordable helmets: http://www.walmart.com/cp/Helmets-Protective-Gear-Bicycle/424506

Buying helmets for toddlers: http://www.babycheapskate.com/2012/03/21/essential-tips-on-choosing-bike-helmets-for-toddlers-and-kids/