THE OFFICIAL JOURNAL OF THE MISSISSIPPI ASSOCIATION FOR HEALTH, PHYSICAL EDUCATION, RECREATION, AND DANCE
Volume 10, Issue 1
June 2023
Jerry Mayo
Brian Lyons
Todd Davis
Britnee Smith
Tomeka Bradley
Laura Prior
Alicia Stapp
Brandi Pickett
Jackie Jackson
*Troy Coppus, EdD, LAT, ATC, CSCS Assistant Professor
Department of Kinesiology and Health Promotion
Troy University
3212A Veterans Memorial Stadium Tower
Troy, Alabama, 36082 Phone: 334 670 5818
Email: tcoppus@troy.edu
Katie Delinsky, DHSc, LAT, ATC Assistant Professor
Department of Kinesiology and Health Promotion
Troy University
Callie Addison Graduate Student
Department of Kinesiology and Health Promotion
Troy University
Dawood Hameed Graduate Student
Department of Kinesiology and Health Promotion
Troy University
Mozorl Louidor, LAT, ATC Graduate Student and Athletic Trainer
Department of Kinesiology and Health Promotion
Troy University
J. Brandon Sluder, PhD Professor
Department of Kinesiology and Health Promotion
Troy University
*Represents corresponding author
Modalities are an essential part of any comprehensive rehabilitation program for numerous orthopedic conditions. The best treatment for conditions, ranging in severity from ACL reconstruction to ankle sprains, is to implement some form of interrupting modality, such as electrical stimulation or therapeutic ultrasound. These modalities are utilized by athletic trainers (ATs) and physical therapists (PTs). Dry needling is a modality, like electric stimulation and therapeutic ultrasound, but its application is being hindered by state restrictions inhibiting athletic trainers from using the technique even when trained. Many insurance companies frame the practice of dry needling as experimental, and most policies do not provide coverage. This disincentivizes the practice among physical therapists. This article demonstrates the value of dry needling as an effective modality compared to other accepted non-experimental modalities, and why it should be a less restricted practice amongst allied health professionals.
During injury rehabilitation, it is imperative to regain the full range of motion of the injured body segment and decrease overall pain, especially amongst post-surgical patients. Dry needling is a skilled intervention using a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular tissues, and connective tissues for the management of neuromusculoskeletal pain and movement impairments (Zylstra & Maywhort, 2017). The technique has shown a significantly positive effect, which correlates to improved injury outcomes. The treatment is also cost-effective and has minimal adverse effects. Less restriction on the practice would allow greater access to the treatment for the patient populations who would benefit the most.
The practice of dry needling has recently proven to be a sufficient tool to treat pain in various chronic or acute orthopedic conditions. In a clinical trial of 16 patients with shoulder pain that presented after a stroke, all patients had decreased pain when they received a session of trigger point dry needling in addition to standard physical therapy (Mendigutia-Gomez et al., 2020). Similar trials with 30 patients presenting with neck pain and active trigger points in their scalene muscles reported lower pain intensity within a month of the dry needling session (Arias-Buria et al., 2020). Dry needling is often considered an experimental treatment due to its origins in the ancient practice of acupuncture, yet in a randomized controlled trial with 40 subjects, significant segmental anti-nociceptive effects followed the needling of trigger points in subjects (Srbely & Dickey, 2007). The study concluded that this effect was like ultrasound trigger point stimulation, a more contemporary modality (Srbely & Dickey, 2007). A randomized controlled trial was conducted to evaluate the effects of adding dry needling into a program of manual therapy, exercise, and ultrasound on pain, function, and related disability in patients with plantar fasciitis (Dunning et al., 2018). The study found integrating dry needling into a program of manual therapy, exercise, and ultrasound has a significant effect in reducing pain and improving function and related disability greater than manual therapy, exercise, and ultrasound alone in patients with plantar fasciitis (Dunning et al., 2018).
Not only has dry needling been proven to decrease pain intensity in the short-term, but it has also shown long-term benefits (Cerezo-Téllez et al., 2016). In a trial with 33 patients presenting with upper trapezius pain and active trigger points, there was a significant difference in pain intensity after 3 months between the dry needling group and the trigger point compression group (Ziaeifar et al., 2014).
In addition to decreasing muscle pain, dry needling has also provided other types of pain relief. Headache pain, duration, and frequency were found to be affected in a positive way by trigger point dry needling (Gildir et al., 2019). Gildir et al. (2019) found that their clinical trial results suggested trigger point dry needling in patients with chronic tension-type headache was effective and safe in reducing headache intensity, frequency, duration, and increased health-related quality of life. Overall, trigger point dry needling is an effective way to decrease pain intensity in various locations of the body.
Certification from one of many courses approved by the American Physical Therapy Association (APTA) or the Board of Certification (BOC) is required for an individual to be considered competent to perform dry needling. The same standards need to be met by ATs and PTs. Through the culmination of expert opinion and a review of current athletic training curriculum, Hortz et al. (2019), found that 89% of the 123 individual tasks required to adequately perform dry needling were satisfied by both the 5th Edition of the National Athletic Trainers’ Association (NATA) Athletic Training Education Competencies and the Commission on Accreditation of Athletic Training Education (CAATE) 2020 Standards. Tasks included, but were not limited to, positioning the patient to manage needle removal complications, assessment of scar tissue characteristics, and emergency response to clinician injury sustained from needling, all of which fall within the scope of athletic training competencies in the management of abnormal trauma and emergent wound care (Hortz et al., 2019). Current athletic training education appropriately prepares athletic trainers to learn dry needling as an advanced modality (Hortz et al., 2019). The notion that needling is far too advanced or invasive a technique to be performed by anyone other than a physical therapist is a gross underestimation of the abilities of athletic trainers; it is very clear no single profession owns any procedure or intervention (Hortz et al., 2019). States that deem physical therapists as capable of performing this procedure should hold athletic trainers in similar regard due to the requirement of both professions to be certified beyond their entry-level educations to perform this technique.
There are other potential benefits of dry needling as a therapeutic modality. A study involving the effects of dry needling on post-stroke spasticity, motor function, and postural control concluded that adding dry needling into treatment sessions helped to reduce spasticity and improved balance, range of motion, and postural control, in turn promoting a higher quality of life for patients (Sánchez-Mila et al., 2018). Another study was conducted to evaluate the effects of deep dry needling on tremor severity and functionality in another group of stroke patients. The authors found that a single session of dry needling was effective to reduce tremor severity and improve functionality, manual dexterity, and hand strength of the affected limb (Ortín et al., 2021). A third study investigated the effect of dry needling in the treatment of lateral epicondylitis compared to the first line of treatment of icing, anti-inflammatory drugs, and bracing. The study concluded that dry needling had a lower complication rate and was a safer, more effective treatment option compared to the first-line treatment (Uygur et al., 2017). This treatment is used often amongst upper extremity athletes such as baseball players, volleyball players, and javelin throwers to release the muscle tension that is believed to cause ligament irritation around the epicondyle (Uygur et al., 2017). Another study investigated the effects of exercise therapy alone and exercise therapy plus gluteus medius (GM) and quadratus lumborum (QL) deep dry needling on pain and function in female athletes presenting with patellofemoral pain syndrome (Zarei et al., 2019). It was found that the inclusion of GM and QL deep dry needling into a program of exercise therapy had a significant effect in improving pain and function, compared to exercise therapy alone, in female athletes with patellofemoral pain syndrome (Zarei et al., 2019).
Positive dry needling outcomes have been found amongst post-surgical patients. Velázquez-Saornil et al. (2017) utilized dry needling to reduce myofascial pain intensity following anterior cruciate ligament (ACL) reconstruction. While pain immediately following treatment was greater, results showed short-term range-ofmotion increased and functionality short-term and mid-term increased (Velázquez-Saornil et al., 2017). No further pain was noted the immediate response to dry needling treatment.
In addition to these benefits, the technique has been shown to have very few adverse effects, including bleeding, bruising, and pain during needling (Boyce et al., 2020). No significant correlation was drawn between the prevalence of adverse effects and clinicians’ level of education, years in practice, level of training, or the number of patients (Boyce et al., 2020).
In multiple studies, most patients that presented with various levels of pain had a significant decrease in their pain severity when dry needling was introduced into their therapy regimen (Arias-Buria et al, 2020; Dunning et al., 2018; Mendigutia-Gómez et al., 2016; Srebly & Dickey, 2007). Another study examined the long-term effects of trigger point dry needling and found pain intensity was lower up to three months post-treatment (Ziaeifar et al.,
2014). Dry needling not only decreased pain intensity post-injury, but it also decreased pain associated with other maladies. A study showed dry needling had a significant effect on reducing the symptoms that come with having chronic tension headaches (Gildir et al., 2019).
It appears that the practice of dry needling has been marred in bias. The authors of this review believe current research shows improved patient outcomes by undergoing consistent dry needling intervention complementing conservative orthopedic rehabilitation when compared to the outcomes of conventional modalities under similar circumstances. These benefits include decreased patient pain perception and increased objective function, such as range of motion. The studies highlighted may serve to educate state licensing boards on the status of athletic training competencies, allowing for the more accurate evaluation of educational preparation of an athletic trainer regarding this advanced practice skill.
Conclusion
In conclusion, dry needling has proven to be an effective modality to treat pain. This can be post-injury, post-surgical, or chronic pain. For patients attending orthopedic rehabilitation, it is imperative for them to return to full activity. This requires regaining baseline strength, range of motion, and use of the involved limb, regardless of an athletic trainer or physical therapist using the modality. The use of dry needling decreased pain in most scenarios in just a few sessions. It aided in pain relief and minimized the effects of several syndromes and chronic conditions such as a stroke, epicondylitis, and adhesive capsulitis. Studies have also shown that dry needling is a cost-effective and minimally invasive procedure that will change traditional therapy in a positive way. Dry needling has proven to be a successful modality regardless of the clinician who applies it. The authors believe state regulatory boards for various allied health professions can use this article to educate themselves on the practice and allow all appropriate clinicians to implement it with more patients.
Arias-Buría, J. L., Monroy-Acevedo, Á., Fernández-de-Las-Peñas, C., Gallego-Sendarrubias, G. M., Ortega-Santiago, R., & Plaza-Manzano, G. (2020). Effects of dry needling of active trigger points in the scalene muscles in individuals with mechanical neck pain: A randomized clinical trial. Acupuncture in Medicine, 38(6), 380-387.
Boyce, D., Wempe, H., Campbell, C., Fuehne, S., Zylstra, E., Smith, G., ... & Jones, R. (2020). Adverse events associated with therapeutic dry needling. International Journal of Sports Physical Therapy, 15(1), 103-113.
Cerezo-Téllez, E., Torres-Lacomba, M., Fuentes-Gallardo, I., Perez-Muñoz, M., Mayoral-del-Moral, O., Lluch-Girbés, E., ... & Falla, D. (2016). Effectiveness of dry needling for chronic non-specific neck pain: A randomized, single-blinded, clinical trial. Pain, 157(9), 1905-1917.
Dunning, J., Butts, R., Henry, N., Mourad, F., Brannon, A., Rodriguez, H., ... & Fernández-de-Las-Peñas, C. (2018). Electrical dry needling as an adjunct to exercise, manual therapy, and ultrasound for plantar fasciitis: A multi-center randomized clinical trial. PloS one, 13(10), e0205405.
Gildir, S., Tüzün, E. H., Eroğlu, G., & Eker, L. (2019). A randomized trial of trigger point dry needling versus sham needling for chronic tension-type headache. Medicine, 98(8), e14520.
Hortz, B. V., Falsone, S., & Tulimieri, D. (2019). Current athletic training educational preparation for dry needling. Journal of Sports Medicine and Allied Health Sciences: Official Journal of the Ohio Athletic Trainers Association, 4(3), 5.
Mendigutía-Gómez, A., Quintana-García, M. T., Martín-Sevilla, M., de Lorenzo-Barrientos, D., Rodríguez-Jiménez, J., Fernández-de-las-Peñas, C., & Arias-Buría, J. L. (2020). Post-needling soreness and trigger point dry needling for hemiplegic shoulder pain following stroke. Acupuncture in Medicine, 38(3), 150-157.
Ortín, J. A., Bravo-Esteban, E., Ibáñez, J., Herrero, P., Gómez-Soriano, J., & Marcén-Román, Y. (2021, January). Effects of deep dry needling on tremor severity and functionality in stroke: A case report. In Healthcare (Vol. 9, No. 1, p. 5). Multidisciplinary Digital Publishing Institute.
Sánchez-Mila, Z., Salom-Moreno, J., & Fernández-de-Las-Peñas, C. (2018). Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomized clinical trial. Acupuncture in Medicine, 36(6), 358-366.
Srbely, J. Z., & Dickey, J. P. (2007). A randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity: novel applications in myofascial therapy? Clinical Rehabilitation, 21(5), 411-417.
Uygur, E., Aktaş, B., Özkut, A., Erinc, S., & Yilmazoglu, E. G. (2017). Dry needling in lateral epicondylitis: A prospective controlled study. International Orthopedics, 41(11), 2321-2325.
Velázquez-Saornil, J., Ruíz-Ruíz, B., Rodríguez-Sanz, D., Romero-Morales, C., López-López, D., & Calvo-Lobo, C. (2017). Efficacy of quadriceps vastus medialis dry needling in a rehabilitation protocol after surgical reconstruction of complete anterior cruciate ligament rupture. Medicine, 96(17), e6726.
Zarei, H., Bervis, S., Piroozi, S., & Motealleh, A. (2020). The added value of gluteus medius and quadratus lumborum dry needling in improving knee pain and function in female athletes with patellofemoral pain syndrome: A randomized clinical trial. Archives of Physical Medicine and Rehabilitation, 101(2), 265-274.
Ziaeifar, M., Arab, A. M., Karimi, N., & Nourbakhsh, M. R. (2014). The effect of dry needling on pain, pressure pain threshold, and disability in patients with a myofascial trigger point in the upper trapezius muscle. Journal of Bodywork and Movement Therapies, 18(2), 298-305.
Zylstra, E. & Maywhort, K. (2017). Dry Needling. In Placzek, J. & Boyce, D. Orthopedic Physical Therapy Secrets. (3rd ed., pp. 277-282). Elsevier.
*Linda K. Delinsky
Department of Kinesiology and Health Promotion
Troy University
212D Stadium Tower
Troy, Alabama, 36082
Phone: 334-670-3468
Email: ldelinsky@troy.edu
Troy A. Coppus
Department of Kinesiology and Health Promotion
Troy University
Maranda G. Brown
Department of Kinesiology and Health Promotion
Troy University
Brandon J. McNeal
Department of Kinesiology and Health Promotion
Troy University
J. Brandon Sluder
Department of Kinesiology and Health Promotion
Troy University
Michael S. Green
Department of Kinesiology and Health Promotion
Troy University
*Represents corresponding author
There is currently a lack of protocols in place returning a secondary school student athlete to athletics and academia after sustaining a mild traumatic brain injury (mTBI). The purpose of this manuscript is to educate athletes, parents, coaches, and associated personal on the importance of pursuing implementation of return to learn protocols in the secondary school setting. Mild traumatic brain injury, or concussion, can be defined as a direct blow, indirect blow, or impact to the head region causing the brain to move violently within the skull producing semi-permanent to permanent tissue damage. Some common signs and symptoms that occur with this injury are headaches, difficulty concentrating, cognitive impairments, vision problems, nausea/vomiting, mood changes, and excessive fatigue. These signs and symptoms can have an acute or chronic effect on an individual based on severity. A certified athletic trainer is a healthcare professional trained to identify such injuries and refer to a physician for further evaluation. An athletic trainer is well-versed in returning athletes to sports after injury, but they can also have a critical role in returning the athlete to the academic setting. A team of individuals should be assembled to assist the athlete with both athletic and academic accommodations post-injury.
Keywords: concussion, return to learn, academic accommodations
Introduction
The purpose of this manuscript is to focus on the need for proper protocols for the return to academics and return to athletics following mild traumatic brain injury (mTBI) for secondary school students. Also known as a concussion, mTBI occurs when a blow to the head results in various symptoms such as headache, nausea, possible loss of consciousness, vomiting, irritability, fatigue, ringing in the ears, and cognitive impairments. It is the duty of the athletic trainer and other qualified staff to recognize these injuries and aid students in their return to academics and athletics through appropriate protocols.
The authors reviewed various research articles and journals on best practice protocols for returning a student to class and sport activity following a mild traumatic brain injury in secondary school students. Databases used for finding articles included MEDLINE and SPORTDiscus, and some of the journal articles searched were from The Journal of Athletic Training and NASN School Nurse Journal. Each resource found in this educational review are scholarly, peer-reviewed articles published within the past ten years. Our goal is to educate professionals working among the fields of athletic training, nursing, school administrators, and teachers.
The authors research yielded a total of 10 articles representing the best practices for evaluating and emphasizing the importance of a gradual return to academia and athletic platforms with symptomatic concern associated with mild traumatic brain injury. Each of the articles had different sample sizes based on the number of injuries included in the study. Of the populations included, there were an average of 24 ±10 days prior to the resolution of symptoms before return to classroom and sports were allowed. Results are limited due to the lack of a standardized testing measurement tool for individuals who have sustained mTBI. Each research study group chose different approved measurement tools to assess quality of life after sustaining mTBI.
An important topic of discussion starting to impact more than just professional sports settings is mild traumatic brain injury (mTBI), better known as sport-related concussion, and how adolescents handle the return to the classroom (Kasamatsu et al., 2016; Keenan et al., 2018; O’Connor et al., 2017; McLeod et al., 2017; Williams
et al., 2015; Williamson et al., 2018). One theory surrounding the increase in mTBI is starting athletic participation at a young age when the brain has not fully formed and surrounding neck musculature is weak (Keenan et al., 2018). Mild traumatic brain injury, overall, has gained more attention due to concussions being one of the only injuries purely based on signs and symptoms with no observable deformities or malignancies (McLeod et al., 2017; Williamson et al., 2018). The ideal situation would be for a student-athlete who sustains a concussive impact to be identified and assessed by the school’s athletic trainer and refer to a physician for further diagnosis. Typically, after being diagnosed with mTBI or concussion, a secondary school student returns to the classroom a few days later with a doctor’s note stating “activity as tolerated” (McNeal & Selekman, 2017). The physician may not provide any direction as to how serious the injury is nor how to proceed with the student. The Center for Disease Control and Prevention (CDC) and the Consensus Statement on Concussion in Sport agree returning to the role of a student is first and foremost before returning to athletic activity (McNeal & Selekman, 2017).
Cognition and Academics
Cognitive and academic difficulties should be considered when developing a management plan for individual student-athletes (Kasamatsu et al., 2016; Williams et al., 2015). Current recommendations suggest individuals who have sustained concussions require rest because both physical and mental activity can exacerbate symptoms (Williams et al., 2015). Overall, 84.1% of athletic trainers recommend a gradual return to learn, but only 43.7% reported having a return to learn policy in place (Kasamatsu et al., 2016). The remaining 15.9% of athletic trainers who reported not having recommendations in place stated it was mostly due to the lack of school professionals understanding concussion (Kasamatsu et al., 2016). As stated by Lopez et al. (2017), implementing a plan begins with communication between the student, athletic trainer, and members of the concussion accommodation team.
Academic Accommodations
Academic accommodations (AA), along with restrictions to education and sports, should be enacted by a team of individuals at the school. The academic accommodations team should include the following members: athletic trainer, directing and/or referring physician, principal/school administrator, athletic director, school nurse, at least one teacher, and a school counselor (McLeod et al., 2017). Each member brings a unique perspective of day-to-day requirements for students. “Anticipatory guidance” refers to a team of individuals working with the student-athlete to include best measures in post injury management (Bacon et al., 2017; McLeod et al., 2017). Coaches and parents are not listed as a part of the academic accommodations team due to their inexperience as it relates to concussion management or accommodations (McLeod et al., 2017). To ensure whole-person health care, including the patient’s needs; goals; and desires, it is important for athletic trainers to be more informed regarding the significance of AA and the process for implementation of formal accommodations (Bacon et al., 2017; McLeod et al., 2017; Kasamatsu et al, 2016; Williams et al., 2015).
Academic Accommodations Team
Eighty percent of the student-athletes diagnosed with a concussion may experience an increase in severity or number of symptoms within two weeks of returning to school (Bacon et al., 2017). In recent years the athletic trainer’s role in secondary schools has shifted. Previously, the athletic trainer’s role was to return the studentathletes to their sport with little focus on the classroom (Bacon et al., 2017; McNeal & Selekmen, 2017). Now, the athletic trainer should play a major role in the return to learn component of concussion management (McLeod et al., 2017; Williams et al., 2015). Because athletic trainers possess the appropriate knowledge about concussions, it is apparent they are an important piece of the accommodation team (Bacon et al., 2017; Kasamatsu et al., 2016). The school nurse and athletic trainer have great access to many tools such as the Colorado “Reduce, Educate, Adjust, Pace” plan, the CDC “Heads Up” toolkit, and sample accommodation plans (see Table 1) to aid in the guidance for returning to the classroom (Kasamatsu et al., 2016; Lopez et al., 2017). Few states have included return-to-learn policies in their state legislation regarding concussion management, although more states are expected to follow suit (Lopez et al., 2017).
At the secondary school level, the school counselor should also play a major role in creating accommodation plans due to their extensive knowledge of behavior and school policy (Williamson et al., 2018). Counselors and athletic trainers should collaborate to create cohesive protocols for student-athletes (Kasamatsu et al., 2016). A responsibility of the athletic trainer is to research current scholarly resources on how to care for the mental health of the student-athlete (Williamson et al., 2018). If a student is struggling with a mental health issue, the school’s
guidance counselor should not be the sole point of contact (Williams et al., 2015). The student-athlete should be referred to a psychologist when necessary (Williams et al., 2015; Williamson et al., 2018).
Implementation of accommodation plans starts with the entire team understanding the symptoms and risk factors associated with protracted recovery (Lopez et al., 2017; Williamson et al., 2018). This allows team members to quickly identify high-risk student-athletes who are more likely to struggle in school after sustaining mTBI (Lopez et al., 2017). In some situations, students and their parents may not be very open to receiving accommodations (Lopez et al., 2017). Usually, this is due to a lack of knowledge regarding post-concussion recovery (Lopez et al., 2017; Williams et al., 2015). Student-athletes want to return to their sport as quickly as possible, especially if symptoms are mild (Lopez et al., 2017; Ransom et al., 2015). The University of Miami’s UConcussion Program clinic’s research shows limiting cognitive and athletic overexertion can actually help expedite recovery time (Lopez et al., 2017).
Secondary school can be considered a primitive stage in any adolescent’s life (Keenan et al., 2018; Ransom et al., 2015). When it comes to post-concussive side effects, academic performance can be influenced (Bacon et al., 2017; Ransom et al., 2015; Williams et al., 2015). A study by Ransom et al. (2015) was completed to determine what kind of academic hardships students faced with post-concussive injury. The study included a sample of 349 children ranging in ages from 5 to 18 (Ransom et al., 2015). Data was collected via a parent-reported questionnaire within the first four weeks of injury (Ransom et al., 2015). Results of this study were based on status of recovery (asymptomatic or highly symptomatic) and the grade or level of academia (Ransom et al., 2015). Secondary schoolaged children showed more symptomatic tendencies than other levels, as well as slower recovery than younger populations (McLeod et al., 2017; Ransom et al., 2015). Researchers concluded that parent-led data collection made it difficult to manifest school-related outcomes (Ransom et al., 2015). In an attempt to minimize this effect, Ransom et al. (2015) suggested specialized recommendations with a support-based management protocol for the student post-concussion. These plans will benefit recovery timelines, promote academic performance, and ease the distress of parents and students (Ransom et al., 2015).
In the secondary school realm, sports play a major role in many students’ lives (O’Connor et al., 2017; Williams et al., 2015). According to O’Connor et al. (2017), sports with the highest exposure to sport-related concussions were football, boys’ lacrosse, and girls’ soccer (O’Connor et al., 2015). Females were more likely to report concussive symptoms, with rates 56% higher than males (O’Connor et al., 2017). An explanation is the age of the student-athletes and the heightened hormonal imbalances between females and males (O’Connor et al., 2017). O’Connor et al. (2017) focused on the epidemiology of sport-related concussion within the 2011-2012 and 2013-2014 school years. It has been established that high school athletics makes up the largest single group of athletes in the United States (McLeod et al., 2017; O’Connor et al., 2017; Williams et al., 2015).
Mild traumatic brain injury accounts for 15% of all high school sport injuries (O’Connor et al., 2017). It is apparent that student-athletes often do not report symptoms for fear of not playing and losing their starting position or other extrinsic ridicule (O’Connor et al., 2017; Williams et al., 2015). It is important to note sportrelated concussions were more observable during competition play versus scheduled practice times (O’Connor et al., 2017). The data from O’Connor et al. (2017) differs from the NCAA data showing ice hockey and wrestling having increased rates of SRC compared to high school football data. With this information, athletic trainers and coaches should work together to be aware of the increased rate of sport-related concussion signs and symptoms at the high school level (McLeod et al., 2017; O’Connor et al., 2017).
In one cohort study by Keenan et al. (2018), researchers took 519 children with either mTBI or another probable orthopedic head injury. The ages ranged from 2.5 to 15 years old and each subjects psychosocial and overall functionality was examined at 3- and 12-months post-injury (Keenan et al., 2018). In the study, 144 qualified under the mild TBI scale, 130 with a complicated mild TBI, 26 with a moderate TBI, and 86 with a severe TBI (Keenan et al., 2018). The primary cause of injury was reported or observed falls and motorized vehicle crashes was the secondary mechanism (Keenan et al., 2018). Symptoms were observed through various scoring and rating
systems such as Child Behavior Checklist (CBCL), Strengths and Difficulties Questionnaire (SDQ), and Behavior Rating Inventory of Executive Function (BRIEF) (Keenan et al., 2018). All were validated measures recommended by the National Institute of Neurologic Disorders and Stroke (Keenan et al., 2018). Keenan et al. (2018) obtained their results by asking parents to fill out the rating scales as it pertained to their child. A common result reported was children with severe cases showed improvement in the hyperactivity ratings, but experienced an increase in anxiety levels from the 3- to 12-month marks (Keenan et al., 2018). Constant or cohesive attention to detail is recommended when dealing with children who have sustained mTBI in order to observe and amend skills and learning over time (Keenan et al., 2018; Ransom et al., 2015). The researchers concluded students-athletes who sustain any form of concussion injury are more prone to fall behind in academics, limiting their ability to learn new skills or improve cognitive pathways (Keenan et al., 2018; McNeal & Selekmen, 2017; Ransom et al., 2015). Emotional functioning, behavior regulation and metacognition indices are all contributors to academic success and later in life skills where younger populations with past history of concussion can run into problems (Keenan et al., 2018).
There are various psychosocial aspects secondary school students face after sustaining mTBI (Kasamatsu et al., 2016; McLeod et al., 2017; Williamson et al., 2018). One study conducted by McLeod et al. (2017), found adolescent student-athletes who were status-post concussive injury were more prone to detrimental emotional health and well-being compared to non-injured subjects. McLeod et al. (2017) interviewed four females and eight boys, all post mTBI and between 15 and 30 days, and recorded qualitative themes when it came to heightened difficulty with their own emotions. More often than not, clinicians and administrators are more concerned with the physical and mental capacity of a student-athlete and overlook the emotional capacity high school aged students still endure (McLeod et al., 2017). This can lead to students becoming frustrated at school or within their social environments, including team sports (Keenan et al., 2018; McLeod et al., 2017; Williamson et al., 2018). Dealing with these stressors can impact the way they minimize or mask their emotions in order to be more accepted (Keenan et al., 2018; McLeod et al., 2017). It is important to note that not only is returning to academia and sports important, but aiding in the adjustment of emotions and quality of life is imperative (McLeod et al., 2017).
The research concludes there is an importance for protocols to be in place for not only return to athletics but also a return to academics. These protocols would also benefit each student psychologically and emotionally. Each mild traumatic brain injury, or concussion, is different and there is no clear direction in predicting a timeline for a secondary school student-athlete to become asymptomatic or fully recover. A proper set of guidelines should be implemented, by each individual institution, to allow optimal recovery of the injury and to prevent a decline in academia, quality of life, and overall emotional health. The goal was to push for further education and recognition of return to learn protocols across the United States. Few states have legislation in place for such protocols. It would behoove the rest of the country to follow the listed states in order to benefit the student-athlete’s overall mental health and success in academia.
The National Athletic Trainers Association provides position statements for help guiding the return to participation, including a position statement for management of sports concussion published in 2014. The timeline for updating current position statements is variable. There is currently no position statement for return to academics following concussion. A suggestion for future research would be provide examples of a return to learn protocol. Institutions could then utilize the guidelines as a template for their own school system and for the safety of their student-athletes.
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*Troy Coppus, EdD, LAT, ATC, CSCS Assistant Professor
Department of Kinesiology and Health Promotion
Troy University
3212A Veterans Memorial Stadium Tower
Troy, Alabama, 36082 Phone: 334 670 5818
Email: tcoppus@troy.edu
Katie Delinsky, DHSc, LAT, ATC Assistant Professor
Department of Kinesiology and Health Promotion
Troy University
Tyler Martin, PhD, CSCS Professor
Department of Kinesiology and Health Promotion
Troy University
Michael Green, PhD Professor
Department of Kinesiology and Health Promotion
Troy University
J. Brandon Sluder, PhD Professor
Department of Kinesiology and Health Promotion
Troy University
Linsey Basford Graduate Student
Department of Kinesiology and Health Promotion
Troy University
*Represents corresponding author
Weight lifting has been a popular form of exercise for years among all age ranges. When examining barbell back squats, flat barbell bench press, and barbell deadlifts, there are many accomodations to exercises for customization to the weight lifter to ensure optimal performance and decreased injury risk. Despite this, injury rates continue to increase. The most common injuries sustained among athletes involve the back, shoulder, and knee. Improper form is one of the main causes of weight lifting injuries, stemming from lack of education, or the result of improper exercise dosage. Providing a proper foundation for weight lifting techniques will allow studentathletes to not only shape their bodies, but also their futures. The purpose of this investigation is to educate coaches, parents, and student-athletes on the importance of teaching and performing the proper technique during weight training to avoid injury. The researchers systematically analyzed literature contained in peer-reviewed academic journals from 2002–2022 on weight lifting injuries, adolescents, and proper technique via multiple databases.
Literature Review
Introduction
Weight lifting is defined as exercise requiring contraction of skeletal muscles in order to develop strength and power, and performed for the purpose of improving sporting performance or exercise for general well-being (Cambridge University Press, 2022; Merriam-Webster, Inc., 2022). Like any form of physical activity, there is an inherent risk for injury while strength training. Despite this, the overall injury incidence for strength training is relatively low and the risk is even lower with qualified supervision and instruction (Faigenbaum & Myer, 2010). When weight lifting injuries do occur, the shoulder, lower back, and knee are areas most often injured (Butragueño et al., 2014; Keogh et al., 2006; Myer et al., 2009). Figures 1 and 2 show weight lifting injuries reported to United States hospitals’ emergency departments from 2002 to 2005 (Myer et al., 2009). As participant ages increase, sprain and strain injuries increase (Myer et al., 2009). These non-accidental weight lifting injuries in older populations are typically caused by overreaching with excessive resistance or poor technique (Faigenbaum & Myer, 2010). Experienced weight lifters commonly perform advanced exercises and/or lifting heavier loads, so they need to be encouraged to have appropriate spotters to maintain a safe environment while also monitoring technique (Haff & Triplett, 2016). Nearly two-thirds of the injuries sustained in youth weight lifters were to the hand and foot and often listed ‘‘dropping’’ and ‘‘pinching’’ in the injury descriptions (Myer et al., 2009). These findings suggest many youth resistance training injuries come from preventable errors, which may be remedied with use of spotters and communication and awareness between weight lifters (Haff & Triplett, 2016).
This paper has two aims in order to educate stakeholders responsible for youth partaking in weight lifting. First, we will discuss three commonly injured body areas during resistance training: shoulder, back, and knee. The second aim is to educate on proper technique of common weight lifting exercises, along with discussing common errors found within these lifts. The three exercises to be discussed are the flat barbell bench press (BP), barbell
deadlift (DL), and barbell back squat (BS). These exercises are frequently used within strength training programs and are susceptible to performance errors leading to injury (Strömbäck et al., 2018).
Shoulder injuries occur during weight lifting because of technical errors, fatigue, and overloading (Golshani et al., 2018). This body area is commonly injured among experienced weight lifters performing advanced exercises, like the snatch, clean and jerk, overhead press, lat pull down, and others. (Butragueño et al., 2014; Keogh et al., 2006; Keogh & Winwood, 2017). There are acute shoulder injuries that can occur due to weight lifting, such as pectoralis major strains or ruptures. Most pectoralis major pathology happens during the bench press exercise (de Castro Pochini et al., 2010). Specifically, the pectoralis major muscle is injured acutely when the lifter is at
the transition from the eccentric to concentric at the bottom of the lift, and their shoulder is in forced horizontal abduction and maximal eccentric contraction (Golshani et al., 2018).
Shoulders are also susceptible to overuse injuries in the weight lifting population. Most authors agree that chronic repetitive loading of the shoulder complex leads to capsular strain, occult instability, and persistent pain (Golshani et al., 2018). Upper extremity resistance training exercises (e.g. bench press, overhead press, lat pull downs, bent-over rows) place emphasis on large muscles to create force while neglecting small muscles responsible for shoulder stabilization (Golshani et al., 2018). Disregarding the stabilizers may compromise force couples in the shoulder, such as the rotator cuff-deltoid force couple (Golshani et al., 2018). The combination of repetitive loading, unfavorable shoulder positioning due to poor stabilization, and redundant exercise selection creates joint and muscle imbalances that increase the lifter’s risk of labral tears, shoulder instability, and other conditions that may precipitate rotator cuff disease (Keogh & Winwood, 2017; Kolber et al., 2009).
Back Injuries
Literature consistently points to the lower back as the most commonly injured area during weight lifting among most populations (Butragueño et al., 2014; Faigenbaum & Myer, 2010; Kerr et al., 2010; Myer et al., 2009; Strömbäck et al., 2018). However, lumbar spine injuries may not be as prevalent in youth resistance training, only accounting for approximately 12.4% compared to 42.3% in young adults (Myer et al., 2009).
Lower back injuries while weight lifting tend to result from overloaded or improper performance of DL or BS exercises (Keogh et al., 2006). With the DL, utilizing excessive lumbar spine flexion results in a transfer of the load from muscles to inert tissue and thereby increases the risk of spinal disc herniation (Sjöberg et al., 2020). Injuries resulting from poor BS technique include muscle strains, ligamentous sprains, ruptured intervertebral discs, spondylolysis, and spondylolisthesis (Schoenfeld, 2010).
During lower extremity lifts like the BS and DL, poor technique can put the knee in a compromising situation. Allowing the femur to move below parallel and knees to track past the line of toes while performing the BS creates greater anterior displacement of the knees, which may increase stress on the knee ligaments and menisci (Comfort et al., 2018). However, the BS does not place excessive strain on the anterior cruciate ligament or posterior cruciate ligament of the knee, even though compressive and shear forces to the knee increase as knee flexion increases (Comfort et al., 2018). Because the direction of the pull in the BS is altered by flexion angle and displacement of the tibia, peak ligament forces do not always coincide with peak shear force, nor are the two necessarily proportional (Schoenfeld, 2010).
The patellofemoral joint also undergoes excessive stresses during the BS. Patellofemoral joint forces during the ascent (concentric phase) and descent (eccentric phase) of the BS have been shown to be greater than four times body mass (Comfort et al., 2018). Patellofemoral joint and tibiofemoral compressive forces are found to be higher when a BS is performed past 50° of knee flexion (Comfort et al., 2018). Over time, these forces could lead to degeneration of the underside of the patella (Schoenfeld, 2010).
It is important for coaches to teach proper weight lifting techniques. This builds a strong foundation for the student-athlete’s career and will help avoid injuries in the future. The first lifting technique to analyze is the BP. The BP is an exercise regularly used for upper body strength and hypertrophy development in resistance training programs (Tungate, 2019). It can be performed with barbells, dumbbells, or machines, as along with different degrees of incline or decline (Tungate, 2019). Grip widths can also be varied (Tungate, 2019). The exercise entails the athlete starting by laying on a bench with the barbell racked and positioned at chest level with elbows extended (Haff & Triplett, 2016). The athlete initiates the exercise by concentrically lifting the barbell off the rack, typically with spotter assistance. Once the barbell is off the rack, the athlete eccentrically brings the resistance down to their nipple line (Haff & Triplett, 2016). The repetition is completed by the athlete concentrically contracting the pectoralis major and triceps brachii to return the resistance back to the start position with elbows extended above the chest (Haff & Triplett, 2016).
The weight lifter may choose to perform the BP with a flat, neutral spine (Figure 3A) or arched-back (Figure 3B). With a flat, neutral spine, there are five points of contact: head, scapulae, upper thoracic spine, and gluteals contacting the bench, and feet on the ground (Tungate, 2019). An arched-back position has the same points of
124
little wider and pushing into the ground forcefully to promote “leg drive” (Tungate, 2019). The
125 competitive advantage by decreasing the range-of-motion used to complete a maximal BP
arched-back position is only recommended for experienced lifters, as it is meant to create a
126 repetition (Tungate, 2019).
127
contact, but the lifter will inhale maximally to reach thoracic-lumbar hyperextension prior to initiating the lift, and the feet are a little wider and pushing into the ground forcefully to promote “leg drive” (Tungate, 2019). The arched-back position is only recommended for experienced lifters, as it is meant to create a competitive advantage by decreasing the range-of-motion used to complete a maximal BP repetition (Tungate, 2019).
128
129 A B 130
131 conditioning professionals for elite and recreational athletes to increase strength and hypertrophy
133
The DL is the next exercise to be analyzed. It is commonly used by strength and
132 of the leg, thigh, and back muscles (Sjöberg et al., 2020). The exercise starts wit
The DL is the next exercise to be analyzed. It is commonly used by strength and conditioning professionals for elite and recreational athletes to increase strength and hypertrophy of the leg, thigh, and back muscles (Sjöberg et al., 2020). The exercise starts with the weight on the ground. The participant will get in position with knees bent and a strong neutral spine as seen in Figure 4 (Haff & Triplett, 2016). While maintaining a neutral spine position, the athlete will pull the bar upward, performing ankle plantarflexion, knee extension, and hip extension until the body is in an upright position (Haff & Triplett, 2016). The repetition is completed when the bar is returned to the start position on the ground. The lower back tends to be the area most vulnerable to injury during the DL (Sjöberg et al., 2020). To minimize the risk of injury to this area, the spine must maintain a neutral position throughout the exercise (Sjöberg et al., 2020). Applying load to a flexed lumbar spine imparts stress on the passive structures of the spine that are susceptible to injury, and combining the flexion with a rotational component may lead to lumbar disc injuries (Sjöberg et al., 2020). Excessive forces with the spine in a hyperextended position may be related to the development of stress injuries to the vertebrae, namely spondylolysis and spondylolisthesis (Sjöberg et al., 2020).
The third lift to be analyzed is the BS. There are numerous variations of the exercise, but this analysis will focus on the traditional BS. Similar to the DL, this exercise is frequently used in many populations of weight lifters (Sjöberg et al, 2020). A traditional BS involves placing a loaded barbell on the shoulders. Proper technique begins with feet shoulder width apart, core engaged, head and neck facing straight ahead to protect the spine, and eyes focused straight ahead or upward (see Figure 5A). The action of the BS entails flexing at the hip, knee, and ankle joints and descending until the superior surface of the thigh at the hip joint is lower than the knee joint, as noted in Figure 5B (Keogh et al., 2006). The lifter then attempts to return to the starting position by extending the knee, hip, and ankle joints (Keogh et al., 2006). The knees remain in line with the toes to help prevent injury as the gastrocnemius, quadriceps muscles, and gluteals engage extension of the ankles, knees, and hips, respectively, to push the body back into the upright position.
Commonly, coaches and fitness professionals cue clients or athletes to keep their knees behind the line of the toes while performing the BS. This technique slightly decreases knee joint torque, but it results in exponentially greater hip joint torque and increased lumbar spine shearing forces (Comfort et al., 2018). Due to the disproportionate forces placed on the hip and lower back, restricted anterior knee displacement during the BS is not recommended (Comfort, et al., 2018).
Another potential squatting form error is excessive forward lean, or decreased torso-to-floor angle, of the trunk during the descent of the BS. This positioning puts excessive shear on the lumbar spine (Comfort et al., 2018). One cause of this incorrect posture during the BS movement is restricted ankle dorsiflexion (Comfort et al., 2018). This may be remedied by static stretching of the gastrocnemius and soleus between sets, weightlifting shoes that put the foot in a plantarflexed position, or use of a heel wedge while completing the BS exercise (Comfort et al., 2018). Another cause of this error is the lifter looking down when performing the movement (Comfort et al., 2018). Having the participant focus on an object at or above eye-level may resolve this common mistake (Comfort et al., 2018).
Conclusion
It is important for all coaches, athletic trainers, athletes, and parents to be educated on the proper techniques of the flat barbell bench press, barbell deadlift, and barbell back squat. Developing knowledge of proper and alternative techniques will help decrease the amount, and severity, of injuries sustained while weight lifting. Proper supervision, accompanied by teaching appropriate techniques to young students and athletes, will create a strong foundation for future weight lifting and lifetime fitness success with a reduced risk of injury.
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