Back Health While Traveling – By Ian Armstrong, M.D.

School’s out and that’s usually accompanied by lots of traveling and long hours spent in cars and airplanes. Sitting for long periods of time in a car or on an airplane can cause undue pressure on your back. Here’s how to alleviate some of that pressure:

• Before traveling, do some stretching exercises

 

• While traveling, be sure to take frequent breaks from your sitting position – preferably every 45 minutes

• Sit firmly against the back of the seat. Keep the knees higher than the hips by adjusting the height of the seat or by resting the feet on a prop that elevates the knees

• While sitting, try and maintain a balanced position with both feet placed firmly on the floor (if you’re not driving). Arm rests and tilts help

• Regular exercise is the best way to maintain peak health and the back is no different. Specific exercises that strengthen the stomach and lower back muscles are essential for long-term back health. Conditioning those core muscles and building your core strength will go a long way towards preserving your back

Saving your Back during Prolonged Periods of Standing

• When standing for a long time, bend knees slightly and shift position frequently. Avoid standing bent over for an extended period {to brush your teeth, apply cosmetics, etc.) as this increases pressure on the back.

Preventing Back Injury

• Reaching and Picking Up Things:

To prevent back injury, turn and reach properly for something you’re about to pick up. In other words, turn your entire body, rather than turning just at the waist, since back joints are not designed for twisting. Reaching for an overhead object eliminates the body’s natural curves and strains the back, so use a stool instead.

Picking Up Children

We’ve all heard the advice, “lift with your legs,” and this guidance is especially true when picking up children. Simply put, our leg muscles are stronger than our back muscles, so use them! Below are some simple techniques that will help keep your spine healthy:

• Always use your legs when lifting. Bend at the knees, not from the waist

• Squat down or kneel to pick up your baby and other items off the floor

• Hold objects close to your body as you carry them.

• While holding your baby (or other items) in your arms, avoid twisting from the waist. Turn your entire body instead.

• Avoid carrying your baby on one hip. This creates poor posture

• Adjust your stroller and work areas, such
as changing tables, to a height that allows
you to stand up straight without leaning over

• While nursing, use a pillow or armrest so that you can sit upright in a relaxed posture without slouching.

• Exhale and tighten your abdominal and pelvic floor muscles as you lift

• The joints of a pregnant and postpartum woman are greatly affected by an increase in the hormone Relaxin. The lower back and sacroiliac joints (located at the lower back on each side of the spine) are particularly vulnerable. Twisting or lifting objects (and baby) incorrectly can place undue stress on this area of the body, which is already susceptible to injury, aches, and pains. For these reasons, it’s essential that every woman learns how to use the mechanics of her own body to her advantage, whether picking up a toy off the ground or lifting baby out of his/her car seat or crib.

Preventing Head and Neck Pain

• Don’t keep your head and neck in one position for too long

• Any type of repetitive motion, such as talking on the phone, or keeping your head bent forward while using your cell
phone – can cause neck pain. Again, you are stressing your neck muscles and ligaments. Wearing a head set is recommended and also taking breaks is important as well.

The Best Ways to Relieve Back Pain

1. Apply ice as tolerated for 48 hours

2. Take an anti-inflammatory like Advil or Nuprin, as directed

3. Exercise. Studies show it’s better than bed rest for simple back pain. Next time you have a back attack, try these exercises.

• Start with 10 repetitions and hold each position for 10 seconds.

• Lie on your back. Lift one knee, then the other to your chest.

• Lie face down. Using your arms, press up and back, arching the back.

• Lie on your back with shoulders flat and knees bent. Slowly drop your knees to one side and extend your top leg.

Ian Armstrong, M.D.
Spinal Neurosurgeon
Medical Director: Southern California Spine Institute
www.southerncaliforniaspineinstitute.com
(805) 496 1717
(310) 557 0741

Dr. Ian Armstrong is the Founder and Medical Director of Southern California Spine Institute in Westlake Village, Los Angeles and Bakersfield. He was the Medical Director of Neurosurgical Trauma at Century City Hospital for over 10 years. As well as being Director of Neurosurgical Trauma at Midway Hospital in Los Angeles, he was also a Staff Trauma Neurosurgeon at Cedars-Sinai Hospital – where he was involved with teaching the Surgical Residents.

In another appearance on Fox TV’s “The Doctors” Dr. Ian Armstrong performs spine surgery using a revolutionary lateral approach technique.

Ian Armstrong, MD makes another appearance on Fox TV’s The Doctors to perform a delicate neck “fusion” surgery.

Dr. Ian Armstrong is interviewed about the reasons that compelled him to go to Haiti to aid the earthquake victims, and his experiences while there.

“Every time I have a meeting at a tent camp, there are at least 30 or 40 people begging me to take their kids,” said Vance Simms, 50, of Ojai.

Such are the conditions in Haition the two-year anniversary of the Jan. 12, 2010, earthquake. Simms and his wife, Cheryl, 43, are among theVentura County residents who have not forgotten Haiti’s plight after the 7.0 earthquake and the cholera epidemic that followed.

The Simmses helped open an orphanage and school there. Dr. Ian Armstrong, a Thousand Oaks spinal neurosurgeon, is lending his support and services to the New Life Children’s Home, an orphanage nearPort-au-Prince. And organizations such as Calvary Community Church and the Transformational Development Agency, both based in Westlake Village, are still helping Haiti.

“After the ‘voluntourism’ was over, we maintained our commitment, (including) the challenge of finding those willing to go,” said Dr. Ayoade Olatunbosun-Alakija, who founded the Transformational Development Agency with her husband, Rikki Alakija.

The surge of volunteers who wanted to help in January 2010 slowed to a trickle after the media organizations packed up and moved on.

“When it comes to building steps for the long haul, people lose interest and go to the next crisis,” said Brian Field, mission director for Calvary. “We want to invest more into the Haitians who can be there day in and day out.”

The church helped build a water reservoir in a mountain community and hopes to construct a school. The Transformational Development Agency helped government officials dispense health information during the cholera epidemic, trained numerous health workers and got about $1 million worth of medical supplies delivered to Haitians.

Olatunbosun-Alakija said her group has “tried to steer away from simply providing handouts, which have a tendency to create a dependency on outside input and aid.”

The Simmses agree that helping Haitians help themselves is the key.

Education is the cornerstone behind the orphanage and school they helped open. Cheryl, a hairstylist, calls herself the big-picture person. As a contractor, Vance knew how to take the ball and run with it.

“I figured if I can deal with thecountyofVentura, I can build an orphanage,” he said.

Their interest inHaitiactually began six months before the earthquake. Cheryl and daughter Hailey, now 19, traveled there on a mission trip with the idea of building a children’s sports camp. The need was so great, Cheryl realized her husband might be interested in helping.

“I knew this was for Vance,” she said. “I knew this was what his heart needs.”

Then the earthquake reduced much of the nation to rubble. Just as Vance was packing up to go there, a Haitian minister named Benite Jeune came to Ojai to speak about how his organization, Changing Tides Ministry, had been destroyed.

He and Vance met and clicked, staying up until the wee hours developing a plan for an orphanage and school. Beginning in September 2010, Vance traveled to Haiti every other month, using the couple’s own money.

“We’re not rich,” he said. “We’re middle-class. We just took the money we would use for vacations and such.”
In July, the Changing Tides Orphanage and Academy opened in Jacmel, a three-hour drive fromPort-au-Prince. A three-person staff oversees about 15 children who live there, although they feed as many children as they can.

“We had kids come to us at death’s door,” Vance said. “They’re barely able to lift their heads. They were eating one meal a day.”

There are many images that haunt Vance, including the pregnant 12-year-old girl and the man close to his own age who begged him for a job at the orphanage.

“This guy was sweating the whole time,” Vance said. “He said he couldn’t listen to his kids cry one more day because they were hungry.”

Vance does not know the circumstances of the pregnant preteen but knows minors will remain in danger and adults in misery until Haitians learn to develop roads, bridges, jobs, sanitation, water and other infrastructure.

The Simmses hope to add one grade a year until their school has 12 grades. Then they hope to bring graduates to the United States to get a college education, with the understanding that they will return to Haiti to help the nation help itself.
Armstrong traveled to Haiti right after the earthquake and stays connected to New Life. After his first visit, Armstrong offered medical services, then helped establish a clinic at the orphanage. He has offered regular consultations for the 130 children there, including a dozen who are severely handicapped.

“That’s where the iPhone came in handy,” Armstrong said. “They could send me photos, and I could diagnose them.”

Like the Simmses, Armstrong thinks the answer to Haiti’s future lies with the education of its children.

“They are teaching them life skills — how to farm, how to raise fish in little ponds, how to raise rabbits and chickens,” Armstrong said. “By making them self-sufficient, you are going to change Haiti from the bottom up.”

Start by Taking Care of Your Spine — Spine-healthy Lifestyle By Ian Armstrong, M.D.

Developing a Spine-Healthy Lifestyle
This is the time of year to embrace new healthy habits and establish daily routines with healthful benefits. It is the time of year we try to make positive change, attack old problems with new-found vigor, and eliminate bad habits and create new healthy ones. The fact is that spine problems are one of the most common ailments known to man, and spine problems have an estimated national cost of $100 billion per year. 90% of us will suffer from back or neck pain and seek medical attention from our family doctor, chiropractor or spinal surgery specialist. Spine problems are one of the most common causes of disability and lost time at work. The most significant effect I see in my practice is the personal devastation that is created by a chronic spine problem. Spine problems can make a patient a prisoner of their own pain because the spine is involved in everything that we do. It makes sense, therefore, to do everything we can to prevent the onset of spine problems. The problem usually affects the middleage worker or athlete who is frequently in the prime of their career. Everything that they do can literally come to a screeching halt – as many back-pain sufferers know. It’s as severe as that.

But the positive news is that 80 – 90% of all episodes of back or neck pain resolves itself within a few days to a few months. This is true even with significant problems like a herniated disk. Treatments can be confusing; that’s why knowledge is important – so that we can modify our behavior. The majority of spine problems are avoidable and preventable through education, understanding and awareness. Remember: Prevention is far better than Reaction.

Contributing Lifestyle Factors That Are Associated with Back Pain

The major contributing factor to back and neck pain is de-conditioning – where the support muscles of the spine weaken over time. Acute onset of back pain is not from a singular event, but from a sequence of events that lead up to the ‘back attack’. These events are: Stress at work over a protracted period of time; extensive travel; long work hours that necessitate foregoing gym time or healthy physical activity; weight gain; long hours of sitting and bad posture. Once you’ve drawn up a picture of the sequence of events that led to the pain, behavior modification and the adoption of healthy habits can be appropriately initiated.

Impact sports or long periods of uninterrupted sitting or standing, repetitive bending and lifting, repetitive twisting or rotation of the spine (as in golf) may be contributing factors. Implementing new habits or activities that will help recondition the support for the spine – is important. While a physical therapist, chiropractor may be necessary for more serious injuries, most of the spine problems I see can be avoided by a simple 30-minute daily walking regime – followed by 10 or 15 minutes of light exercise.

Spinal Balance: Good Posture versus Bad Posture

The spinal column is the main structural support for our bodies. It isn’t straight; it has 3 normal, gentle curves. One of the major jobs of the spinal musculature is to support the spine and to maintain these curves. Changes in spinal curvature (poor posture) affect the balance – the muscular effort needed to stand or sit, and the forces across the vertebrae and disks. Therefore, when a spine is not in balance and reflecting good posture, it is more susceptible to injury and strain. It is important to realize that one must consider both 1) active posture – which is posture while lifting and bending, and 2) passive or resting posture. It is important to maintain a balanced spine under both circumstances to decrease the likelihood of spinal injury and spine pain. Resting posture can be greatly affected by chairs, mattresses, shoes, and work-place ergonomics.

Eliminating or Modifying Activities

The spine is an elegant biomechanical model that must be maintained diligently and cared for properly. The myth of the spine being poorly engineered is just that – a myth. Its form and function are exquisitely elegant. Problems develop as a result of genetics and lifestyle; improper maintenance and lack of conditioning. The more miles, the more years, and the older the equipment – the more critical is the maintenance program. A compounding problem that is associated with aging is weight gain and lack of physical activity. The support weakens as a result and the spine becomes more susceptible to injury.

Eliminating or modifying activities that contribute to back and neck problems is crucial. The spine is intended to bend, twist and extend – all the while protecting the delicate spinal cord and the nerves that exit the spine and branch out to the entire body. The spine sits within the core of the body – offering support much like the mast of a sail boat. Much like a mast that is dependent on the stays or surrounding supports for structural strength, the spine is dependent on the muscles surrounding it for much of its strength.

Weight Gain

Weight gain can potentially cause a myriad of problems, and with the spine, its negative impact is direct and simple. The 15 extra pounds that you’re carrying is like carrying a 15-pound backpack. By the time the back pain has set in, you will have to consult a specialist to determine a solution. Pain leads to less activity, which means the problem of weight gain is being compounded. Breaking out of this self-perpetuating cycle is crucial.

When to Seek Medical Evaluation

Problems that are associated with neurological deficit such as weakness, numbness or bowel or bladder problems require medical evaluation. The goal here is to rule out red-flag problems – medical problems that can be associated with and cause back pain such as infections, abdominal aneurysm, kidney problems, tumors or other medical issues. Once these things have been ruled out and the pain continues, the goal becomes determining the specific pain generator in the spine. This may involve an MRI, Xrays , a nerve study, EMG, bone scan, CAT scan, or myelogram.

In more complex problems, a pain management specialist is sometimes brought in – to complete diagnostic injections to determine the precise pain generator in the spine. One process that is used is a discogram. A dye is injected directly into the disk under mild pressure to see if a disk is painful. Facet injections directly into the joints of the spine can help determine whether the pain may be coming from the facet joints. Nerve blocks can determine whether a specific nerve is involved. These injections may also alleviate and treat the pain as well.

Diagnosis and Treatment

Only about 2% of spine problems require surgery. Adopting the principles of a spine-healthy lifestyle early in life is crucial. However, if surgery is required, spinal surgery has improved greatly over the last decade. We are able to now use minimally-invasive techniques that involve functional restoration of the spine. New technologies allow the advantages of being able to implant artificial disks as well as utilize adult stem cell biology. But despite revolutionary advances in spinal surgery, the philosophical position of spine surgery for the treatment of spine problems remains relatively unchanged. Spine surgery is considered as a last resort when conservative management has failed and the patient has neurological deficit or incapacitating pain. In these situations spine surgery now offers more effective and more successful outcomes.

The best way to deal with an acute episode of back or neck pain is to avoid strenuous and pain-provoking actives or impact sports where you impact the ground. Running, playing football, tennis or basketball are examples of impact sports.

Ice the area for the first 24 hours and use heat thereafter. Anti-inflammatories such as Advil or Motrin can be helpful. There is no need for bed rest. In fact, activity as tolerated is usually beneficial. A visit to the chiropractor or physical therapist could be very helpful during this acute period.

One of the obstacles in the treatment of spine problems is that we all want a quick fix: a pill, a shot, a new form of traction, laser therapy, a mattress, a brace, or even surgery. The air waves and internet are saturated with these promises of instant cures and prey on this desire. Unfortunately, even though some of these treatments may be helpful, the real solution involves the patient understanding the anatomy of the problem and the factors that contributed to the onset of the spinal pathology and pain. Adopting a lifestylethat can help reverse and avoid some of the contributing factors is your best choice.

Ian Armstrong, M.D.
Spinal Neurosurgeon
Medical Director: Southern California Spine Institute
www.southerncaliforniaspineinstitute.com
(805) 496 1717
(310) 557 0741

Dr. Ian Armstrong is the Founder and Medical Director of Southern California Spine Institute in Westlake Village, Los Angeles and Bakersfield. He was the Medical Director of Neurosurgical Trauma at Century City Hospital for over 10 years. As well as being Director of Neurosurgical Trauma at Midway Hospital in Los Angeles, he was also a Staff Trauma Neurosurgeon at Cedars-Sinai Hospital – where he was involved with teaching the Surgical Residents.

Taking Personal Responsibility for our Health in 2011
As we start a new year, many of us are thinking of our health, weight, vitality, and longevity. Plans are being made to join expensive gyms and embark on complex exercise regimes that will probably fall by the wayside. We look to consult with gurus, psychologists, life coaches and nutritionists to help us begin a healthier new year. We even have our eyes set on some new piece of exercise equipment that we hope will make us look like the guy or girl on late night TV who is using it. The more expensive and complex the equipment or plan, the more we are attracted to it.

We are a nation of “quick fixers.” We abdicate our personal responsibility for our health as we search for a pill, a shot, a potion or a new gimmick that we hope will be that “quick fix”. Even though I am a physician, a scientist and a skeptic, I still find myself buying into some of the health marketing we are all bombarded with. However, accepting responsibility for our own well-being is the first critical step to a healthier life. Quite simply, a daily walking regime is an important first step to a healthier you.

Another aspect of health that we are faced with at this time is our nation’s health care issues. A new Congress is moving in on Washington and we read of a failing Medicare system, an overburdened healthcare system stretched to its financial and physical limits; the uninsured and the over-paid. I hear the questions asked about how our government will solve all of these problems; about how the insurance giants and workers’ compensation programs will help fix all of these issues. In other words, the responsibility of solving our healthcare problems usually centers around “what can THEY do to solve our health care issues”. Here again we tend to abdicate our responsibility for our health system to others. The fundamental problem is cost and not enough money to fix everyone’s health problems. There is a misperception that it is the government’s job to keep us healthy.

The harsh reality is that there just isn’t enough money in any national budget to keep a nation healthy. Therefore, taking personal responsibility for our own health is the first and most important step in changing and solving many of the health care issues we face as a nation. Taking greater responsibility for your own health will have a massively positive effect on a national crisis. We only need to look at some of the environmental issues we face as a global community to understand the answers. The Green Movement has been a grass roots effort led by the efforts of all of us who recycle and make smart choices in our daily lives – from the cars we drive to the products we buy.

The Effects of Obesity on our National Health Budget

Around 80% of our national healthcare budget goes into treating obesity, coronary artery disease, diabetes, congestive heart failure, asthma, depression, spine problems, back pain, and strokes. Diabetes type 2 or adult onset diabetes is one of the fastest growing diseases in America and is as a result of a blend of genetics, bad diet and obesity. Some call it a lifestyle disease. If one were to cut the number of Medicare patients from getting this disease in half, we would save the Medicare system (alone) billions of dollars. Here’s how you make that cut: By walking for one hour a day. In fact, virtually all the medical problems I’ve listed above can be greatly reduced by a simple, daily walking program. Even if we were to cut only one to two percent of people with those health issues, we would save approximately a 100 billion healthcare dollars annually. Studies in the workforce have shown that unhealthy habits account for 60% to 70% of the health care costs. Programs that encourage the elimination of smoking as well as weight reduction with light exercise – have saved companies millions in health care costs. Walking is always a key component of this type of program and cost-saving goal.

Spine care alone in this country has an estimated $90 billion to $100 billion price tag. As a spine specialist seeing thousands of patients over the last 20 years, I would estimate that more than 50% of the visits to my office could be eliminated by a simple, daily one-hour walking regime. Dr. Scott Blatt, a prominent Westlake chiropractor says “Walking and hiking plays an important role in many of our rehab programs”.

Accepting personal responsibility for our own health is the key to health, wellness and vitality. We have the power to take care of our health (and positively affect health care nationally) through a simple daily walking regime – Wellness Walking. Why walking? It’s one of the best comprehensive exercise activities. It works all of the major muscle groups, affects the heart and circulation, the lungs, the core muscles that support the spine, the bones and it helps to prevent osteoporosis. It burns calories, thereby reducing excess weight and the chances of developing Diabetes type II. It has also been shown to affect our mood and mental health because of the neuro-transmitters in the brain which release serotonin, dopamine and endorphins. Walking outdoors in the sunlight is also beneficial because it helps us to produce Vitamin D. Walking has also been shown to decrease blood pressure and to reduce the incidence of strokes.

Our bodies were created to walk. It is low impact – thus preserving the back, the hips and knees. One of the most common reasons for someone to fall off the exercise wagon is injury. There is little chance of injury while walking. Most importantly, there is seldom any excuse NOT to walk. You can do it slowly or fast – just so long as you walk!

Walking Facts

• It takes a loss of approximately 3,500 calories to lose 1 pound. Walking moderately for 45 minutes for the average-sized individual burns around 200 calories.
• One can add hand movements and try Speed Walking to burn calories at a higher rate. Most of us with relatively sedentary lifestyles walk approx 2500 steps a day. In order to lose weight it is recommended that we walk 8,000 to 10,000 steps a day. An inexpensive pedometer can help keep track of this.
• For those of us who like gadgets, a pulse meter is also helpful to keep our heart rate in our target zone to optimize our walking experience (as well as keep track of the actual number of calories burned).

As we set out to follow our New Year health resolutions we should realize that the simplest solution is sometimes the best. Solving our national healthcare issues starts with each of us. Our health, lives and longevity can be changed with a simple, uncomplicated, daily walking regime. For more information and help go to: medicalwellnesswalking.com

Ian Armstrong, M.D.
Spinal Neurosurgeon
Medical Director: Southern
California Spine Institute
www.southerncaliforniaspineinstitute.com
(805) 496 1717
(310) 557 0741

Dr. Ian Armstrong is the Founder and Medical Director of Southern California Spine Institute in Westlake Village, Los Angeles and Bakersfield. He was the Medical Director of Neurosurgical Trauma at Century City Hospital for over 10 years. As well as being Director of Neurosurgical Trauma at Midway Hospital in Los Angeles, he was also a Staff Trauma Neurosurgeon at Cedars-Sinai Hospital – where he was involved with teaching the Surgical Residents.

Ten percent of college football and 20 percent of high school football players suffer from significant head injuries and/or concussions. Approximately 85 percent of deaths in football are a result of significant head or neck injuries. Modification of tackling techniques has decreased head injuries. Despite proper equipment and technique, however, significant head injuries do occur. Head injuries must be fully evaluated on the sideline by trained personnel. Inappropriate return to play with a reinjury can result in the sudden death of the athlete.

Head trauma and hockey are becoming common sports news items. In the recent past, the news has reported the cases of Tony Granato and his brain surgery resulting from a head trauma suffered playing hockey; the mandatory retirement of Brett Lindros from five concussions over a one-and-a-half-year period; the retirement of Pat Lafontaine because of repeated head trauma; Paul Kariya’s concussion after a cross-check to his head; Eric Lindros’s career-interrupting concussions after being checked into the boards; and the playoff-ending concussion of Ron Francis.

Anatomy

The brain is certainly one of the most delicate structures in the body and one of the most critical. Hence, it has been carefully protected by the surrounding bony structure of the skull. A thick covering called the dura surrounds the brain. The brain floats in a lake of cerebrospinal fluid. This anatomic configuration offers maximal protection for the brain.

Mechanisms/Types of Brain Injury

Head injuries can occur as a result of a direct blow to the skull causing local trauma to the skull. This may manifest as a contusion or fracture and cause injury to the brain. A sudden acceleration or deceleration, without a direct blow to the head, can make the brain strike against the surrounding hard skull causing a brain injury. A player can receive a blow to one side of the head but actually sustain a brain injury on the opposite side of the head. In this type of trauma, the brain will strike the opposite side of the skull and result in a brain injury on the side opposite the direct blow. This is known as a contra-coup injury. Another type of brain injury is called a diffuse axonal injury. Rotary forces, or tangential forces, cause a shearing effect in the deep substance of the brain causing confusion or bleeding within the brain.

Concussion

A concussion is an alteration of mental status or mental function as a result of trauma to the brain. It may be the result of a direct blow, acceleration and deceleration forces, or a contra-coup injury. The hallmark signs of a concussion are confusion and amnesia. An athlete does not have to have loss of consciousness to have a concussion.

Classic Characteristics of a Concussion
The classic characteristics of a concussion include the following: blank stare; delayed verbal response to questions; delayed ability to follow instructions; inability to focus attention; apparent distraction by the patient; inability to follow a conversation; disorientation; walking (or skating) the wrong direction; loss of awareness of place, time, or date (not knowing who the opposing team is or at which rink they are skating); slurred speech; poor coordination with stumbling; poor balance; and inability to walk a straight line (drunk test or heel-to-toe test). More subtle signs include emotionality (i.e., crying for no apparent reason), memory loss, and poor intellectual function.

Early complaints by the athlete with a concussion may include headaches, dizziness, lack of awareness of surroundings, nausea, and vomiting.

Later complaints include persistent low-grade headaches, light headaches, inability to concentrate, memory dysfunction, excessive fatigue, irritability, intolerance to bright lights, intolerance to loud noises, or ringing in the ears. Some of these symptoms may develop that were not present during the early complaint stage. As an example of this, the newspapers reported that Tony Granato’s headaches were becoming intolerable. He arose from bed due to pain from the headaches. As he walked around downstairs, he looked at framed photographs of family and friends, which were placed on the piano. Tony did not recognize half of the people in the photographs and realized that he was in trouble. Tony was lucky to recognize his deficit. Many times, the athlete with the concussion is completely unaware of his or her deficits.

Classification of Concussion
There is not an absolute standard of grading and managing concussions. However, there are three guidelines that are referenced most frequently. The first is the American College of Sports Medicine (ACSM) Guideline, which is sometimes referred to as Cantu’s Guideline. The second is somewhat more conservative and is known as the Colorado Guideline. The third is the American Academy of Neurology (AAN) Guideline. I will refer to the AAN Guideline. Concussions are defined as mild (grade I), moderate (grade II), or severe (grade III). I also utilize my own clinical experience in neurosurgery, so at times my opinions may be even more conservative.

• Grade I Concussion. A grade I concussion is the most common type of concussion and is certainly the most difficult to recognize and diagnose. The athlete does not have any loss of consciousness or amnesia but has a brief period of confusion. The confusion can present as inattention or as the inability to maintain a coherent stream of thought and carry out goal-directed movements. Most players who have a grade I concussion refer to this as having their “bell rung.” There may be minimal evidence for the grade I concussion. It is only after careful observation and questions to the athlete by sideline medical personnel that this diagnosis will be evident. The symptoms usually resolve in 15 minutes.

• Grade II Concussion. A grade II concussion will also exhibit transient confusion and amnesia but will not have loss of consciousness. The patient may have amnesia for the events following the injury (post-traumatic amnesia or anterograde amnesia) or amnesia for events that preceded the injury (retrograde amnesia). A thorough neurological evaluation must be performed. The player may not return to the game.

• Grade III Concussion. Any loss of consciousness will automatically be defined as a grade III concussion. Loss of consciousness even for only a few seconds is still considered a loss of consciousness according to the AAN Guideline. A grade III concussion requires immediate removal from the game, and the athlete must be transported to a hospital for evaluation. A CT scan or MRI of the brain must be performed on any athlete rendered unconscious for any period of time.

AAN Guidelines for Return to Competition Following a Concussion
• Grade I Concussion. An athlete must be removed from the game and examined immediately and every five minutes for postconcussion-syndrome symptoms. If the athlete is symptomatic, he may not return to the game. Symptoms may include headache, dizziness, impaired orientation, impaired concentration, or memory problems. In order to return to play, symptoms must resolve while at rest and with exertion. Exertion or provocation testing is usually done on the sidelines in football and may be done in the locker room/training room for hockey. Again, return to play is allowed after a grade I concussion only if amnesia does not appear and the athlete is asymptomatic (without symptoms) during rest and exertion within 15 minutes.

If the player has a second grade I concussion in the same contest, this player is eliminated from competition for the day. A CT scan or MRI scan is recommended in all incidences in which a headache persists. These players should be given a head injury precaution information sheet for them to follow at home. The patient should be evaluated over the next 24 hours for signs of evolving intracranial problems. The family needs to have explicit, written information about warning signs and instructions to follow if the athlete becomes worse. The patient is removed from contact sports until he or she is asymptomatic for one week at rest and with exertion. A CT scan or MRI is recommended for those who have headaches or symptoms for more than one week. The AAN recommends that after a second grade I concussion, the player should be pulled from contact sports and returned only after having been asymptomatic for one week. I believe that it is not inappropriate to wait even longer for return to play, perhaps at least one month, and termination of the season should be considered. There is a problem known as second-impact syndrome that needs to be avoided if possible. I believe that termination of the season is mandated after a third grade I concussion. The athlete with three grade I concussions in a season must have a formal neurological evaluation before being considered for return to play.

• Grade II Concussion. The player with the grade IT concussion may not return to play, and frequently repeated reexaminations in the locker room need to be performed. The athlete needs to be examined the following day. I believe that a CT scan should probably be performed. Two grade II concussions in a season keep the player out until the athlete is asymptomatic for two weeks. I would consider terminating the season for the player, and he or she should have a follow-up MRI or CT scan. The player should have a complete neurological examination prior to returning to play the next season.

• Grade III Concussion. Any loss of consciousness necessitates removal from the game, transfer to a hospital, neurological examination, and CT scan or MRI of the brain. The AAN Guideline indicates an athlete should be held from contact sports until he or she is asymptomatic for two weeks after a grade III concussion. I believe it would not be inappropriate to wait one month or to terminate a season.

A second grade III concussion requires the athlete to be asymptomatic at least one month and perhaps longer, based on the physician’s opinion. It is never wrong to err in the conservative direction, so it would not be unreasonable to terminate the season for a second grade III concussion. The player must have a full neurological exam prior to the next season.

Sideline Evaluation of Concussions

History
1. Check the orientation of the athlete to person, place, time, and purpose. For example, ask the athlete these questions: What is your name? Where are you? Why are you here? Whom are you playing? A few years ago, one NHL player scored a game-winning goal in overtime against the Calgary Flames. Two days later, he received head trauma while playing the Edmonton Oilers. He was removed from the game. His teammates reported that in the locker room after the game, when he was asked where he was, he replied, “We’re in Calgary and I just scored the game-winning goal.” This player lost two days of memory preceding the trauma (retrograde amnesia).

2. Concentration may be evaluated with a counting test such as counting backward or naming the months of the year in reverse order, or a memory test such as naming the president of the United States or remembering three words or objects right away and five minutes later.

3. Ask the athlete about the events in the game and his or her own trauma.

Neurological Testing
1. Check the pupils for asymmetry and reaction to light.

2. Test coordination by asking the athlete to walk heel-toe (drunk-driving test) or to rub one heel up the opposite shin. This also helps determine if the athlete can follow directions.

3. Ask the athlete to touch his or her finger to the nose with eyes dosed.

4. Ask the athlete to hop on one foot.

If the athlete passes these tests and does not have headaches or dizziness and has clear mental function, then this is a grade I concussion. The examiner should test the athlete with exertional movements. An easy battery of exertional tests in a training room for a hockey player could include five sit-ups, five push-ups, five knee bends, and a short (few steps) maximum sprint effort. If a headache, nausea, dizziness, or other mental changes reappear, the athlete may not return to play.

The following covers other terms that those involved in trauma sports such as hockey should be familiar with.

Diffuse Axonal Injury (DAI)

Diffuse axonal injury takes the form of a prolonged traumatic brain coma with loss of consciousness lasting more than six hours. Residual neurological, psychological, or personality deficits often result because of the structural disruption of numerous axons in the white matter of the cerebral hemispheres and brain stem.

Postconcussive Syndrome

Postconcussive syndrome refers to the constellation of signs and symptoms that characterize the period of recovery from acute brain injury. Headache, dizziness, tinnitus, memory disturbance, and difficulty with concentration are hallmarks described by most victims. While these sequelae invariably follow moderate or severe brain injury, they have also been shown to result from minor head trauma. Willberger reported that more than half of high school football players complained of fatigue, dizziness, poor attention, or memory disturbances after minor head injury. Approximately 8 percent of the athletes suffered mild head injuries identified by the team physician or head trainer over the four-year testing interval. Only 4.7 percent of the injuries involved a positive loss of consciousness, none longer than five minutes. The head-injured players had more complaints of headache and dizziness than their middle-age-matched controls at one and five days after injury, while complaints of difficulty with memory persisted to ten days posttrauma.

Intracerebral Hematoma and Contusion

Intracerebral hematoma and contusion occur in patients with a significant intracerebral (within the brain) pathologic condition who have not suffered loss of consciousness or focal neurologic deficit but who do have persistent headache or periods of confusion after head injury and posttraumatic amnesia. As with any patients who have suffered head injuries, athletes with such symptoms should undergo a CT scan to permit early differentiation between solid intracerebral hematoma and hemorrhagic (bleeding) contusion with surrounding edema (swelling).

Epidural Hematoma

Epidural hematoma results when the middle meningeal artery tears as a result of a skull fracture. Because the bleeding in this instance is arterial, accumulation of dot continues under high pressure and, as a result, serious brain injury can occur. The classic description of an epidural hematoma is that of loss of consciousness at the time of injury, followed by a recovery of consciousness in a variable period after which the patient is lucid. This is followed by the onset of increasingly severe headache, decreased level of consciousness, dilation of one pupil, and decerebrate posturing and weakness.

Acute Subdural Hematoma

Acute subdural hematoma raises the image of a large collection of clotted blood in the intracranial cavity, compressing the brain substance and causing compromise due to the space occupied by the hematoma. This is not an infrequent consequence of closed head trauma, but this type of subdural hematoma is more common in adults who have a degree of cortical atrophy. Athletic head injuries result from inertial loading, which is lower than that of serious head injuries caused by vehicular accidents or falling from heights. Patients with an acute subdural hematoma typically are unconscious, mayor may not have a history of deterioration, and frequently display focal neurological findings. It is necessary to obtain a CT or MRI scan to diagnose an acute subdural hematoma.

Second-Impact Syndrome

Multiple injuries have been noted to increase the duration and magnitude of postconcussive syndromes. It was found that headache, dizziness, and memory deficit persisted longer in head trauma victims with a history of previous concussions. Many isolated case reports detailing malignant brain swelling following relatively minor blows in the setting of recent mild head injury have been documented. The pathophysiology of this entity is believed to involve subclinical brain swelling from a traumatic insult that makes the brain more susceptible to further injury. It is postulated that the first insult disturbs the brain’s autoregulatory mechanisms, with consequent vascular congestion and poor brain compliance.

Emergency Management of Head and Cervical Spine Injuries

Although all athletic injuries require careful attention, the evaluation and management of injuries to the head and neck should proceed with particular consideration. An intracranial hemorrhage may initially present with minimal symptoms yet follow a significant downhill course, whereas a less severe injury, such as a neuropraxia of the brachial plexus (“stinger”) that is associated with alarming paresthesias (tingling and numbness) and paralysis may resolve swiftly and allow for quick return to activity.

Individuals responsible for athletes who may sustain injuries to the head and neck should consider several principles:

1. The team physician or trainer should be designated as the person responsible for supervising on-the-field management of the potentially serious injury. This person is the “captain” of the medical team.

2. Prior planning must ensure the availability of all necessary emergency equipment at the site of potential injury. At a minimum, this should include a spine board, stretcher, hard collar, and equipment necessary for the initiation and maintenance of cardiopulmonary resuscitation (CPR).

3. Prior planning must ensure the immediate availability of a properly equipped ambulance as well as a hospital equipped and staffed to handle emergency neurological problems.

4. Prior planning must ensure immediate availability of a telephone for communicating with the hospital emergency room, ambulance, and other responsible individuals in case of an emergency.

Managing the unconscious or spine-injured athlete should not be done hastily or haphazardly. Being prepared to handle this situation is the best way to prevent actions that could convert a repairable injury into a catastrophe. A means of transporting the athlete must be immediately available in high-risk sports such as hockey and football and “on-call” in other sports. Having the proper equipment is essential! A spine board is necessary and is the best means of providing a supporting splint. By splinting the body, the risk of aggravating a spinal cord injury is reduced.

On-Site Management

Properly trained personnel must know who is the person in charge; CPR; proper procedures for movement and transportation of the injured athlete; how to use emergency equipment; and procedures for activating the emergency support system.

Prevention of further injury is the single most important objective. Do not take any action that could possibly cause further injury. The first step should be to immobilize the head and neck by supporting them in a stable position. If the victim is breathing, maintain the airway. If not, the airway must be established. If the athlete is facedown when the ambulance arrives, change his or her position to faceup by log-rolling him or her onto a spine board. Once the athlete has been moved to a faceup position, quickly evaluate the breathing and the pulse. The jaw-thrust technique is the safest first approach to opening the airway of a victim with a suspected neck injury. If the jaw thrust is not adequate, the head tilt-jaw lift should be substituted. The transportation team should be familiar with handling a victim with a cervical spine injury, and they should be receptive to taking orders from the team physician or trainer. It is extremely important not to lose control of the care of the athlete; therefore you should be familiar with the transportation crew being used. Lifting and carrying the athlete requires five individuals: four to lift and the leader to maintain immobilization of the head. The leader initiates all actions with clear, loud verbal commands.

In summary, any athlete who has suffered loss of consciousness from head injury for more than one minute, or who has persistent headache with confusion or any disorientation that persists longer than one hour after trauma, or who has had more than one episode of unconsciousness, however momentary, during anyone playing season, should be referred for neurological examination and a CT scan.

New data are always emerging on the management of concussions. Research presented at a medical conference by Dr. Hovdaa, neurophysiologist at UCLA, involving PET (positron emission test) scans indicated that complete rest may be the most effective method to manage a significant concussion case. PET scans revealed that there was decreased uptake of glucose (blood sugar) in the area of the brain that received the concussion. Studies with rats that were given concussion revealed that if they were kept physically active, the recovery was delayed.

So, the concept of preventing deconditioning in the concussion athlete may be erroneous.

An estimated 23.6 million people in the United States (or almost 8% of the population) have diabetes. For the population 65 years and older, the figure is exponentially higher – 10.9 million or 26.9% . It is the seventh leading cause of death in North America. 90% of diabetics in this country are Type 2 diabetics (adult-onset diabetes).

3 Types of Diabetes

Diabetes is a disease associated with abnormally high levels of blood glucose. There are basically three types of diabetes: 1) Type 1 – which is also referred to as childhood onset diabetes; 2) Type 2 – which is the most common type of diabetes and has been referred to as adult onset diabetes. 3) Type 3 diabetes is gestational diabetes and is associated with pregnancy only.

Type 2 Diabetes on the Rise

An alarming trend is the rapid rise in the number of individuals below the age of twenty that are being diagnosed with Type 2 diabetes. Many scientists have correlated this rise with the rapidly increasing levels of obesity in this same age group. 90% of diabetics have Type 2 diabetes.

The First Symptoms of Type 2 Diabetes

Aaron had not noted the mild symptoms that his doctor had been concerned about and he had never really paid attention or connected the dots. Sure he was fatigued but he had a stressful job and long hours. In retrospect he did have to urinate more frequently but he assumed that this was just an age thing. He was also thirsty all the time but this was Southern California and wasn’t it always hot and dry? His vision was a little blurry but the drugstore reading glasses had take care of most of this. And the tingling in his feet he had written off to his on-again off-again sciatica that he had had for years but that was never a major problem. He had always been relatively healthy. How did he become a diabetic?

Diabetes – An Overview

Diabetes is broadly characterized by the body’s inability to handle sugar or glucose. It is marked by high levels of sugar in the blood stream. After a meal, food is broken down and utilized by the body for energy. Glucose is a source of energy for the body. When glucose enters the blood stream, the pancreas produces insulin in response. The role of insulin is to act as a gatekeeper and allow glucose into the cells of the body where it can be utilized. Without insulin, glucose cannot get into the cells and remains circulating in the blood stream where abnormally high levels of glucose can cause damage to the body and tissues.

Diabetes and high blood sugar can result from: 1) The pancreas not making enough insulin in response to a meal – or perhaps none at all. 2) Or the cells of the body do not respond to insulin normally. In this situation the body may produce insulin but the cells are resistant to insulin.

Type 1 diabetes is usually diagnosed in childhood. Here, the body makes little or no insulin. The cause may be complex but genetics, autoimmune problems and viral causation have been implicated. Daily injections of insulin are needed.

Type 2 as previously stated is far more common and the incidence has increased over the last decade. More troubling is the fact that young people are increasingly being diagnosed with adult onset diabetes. This increased incidence in young people correlates with an increasing diagnosis of childhood obesity. The pancreas does not produce enough insulin to keep blood glucose levels normal – or insulin is produced but the cells are resistant to insulin so despite the presence of insulin, the glucose remains in the bloodstream.

There is an estimated 40 million Americans who are prediabetic with only occasional symptoms or mild early signs.

Type 1 diabetes must be dealt with medically, and the good news is that there have been many great advances in this area over the last 10 years. However, more research and funds are needed to eliminate this life-long disease. (www.jdrf.org)

Type 2 diabetes does have some genetic component (although the complex causes have not been entirely worked out) but it is definitely referred to as ‘Lifestyle’ diabetes because the cause, effect and treatment are correlated with diet, exercise, obesity and sedentary lifestyles.

Risk Factors for Type 2

Symptoms of Type 2 Diabetes

Diagnosis of Type 2

Urinalysis may be used to look for glucose and ketones. Ketones come from the breakdown of fat – an alternate energy source when glucose metabolism is not normal. In most cases, however, the urine test alone is not adequate enough. Fasting blood glucose – if higher than 126mg/dL on two occasions – can also be seen in prediabetes. Hemoglobin A1c test has been used to help patients monitor control of their diabetes and is now a part of diagnosis of diabetes. An Oral glucose tolerance test is sometimes necessary to confirm the diagnosis. An eye exam is also important if diabetes is suspected. The eye doctor looks for “diabetic changes” in the retinal as well as any visual changes.

Complications

Diabetes ultimately leads to high blood sugar levels – a condition known as hyperglycemia. Over time, hyperglycemia damages the retina of the eye, the kidneys, the nerves and the blood vessels. Diabetic retinopathy is the leading cause of blindness, damage to the kidneys, and diabetic nephropathy is the leading cause of kidney failure. Diabetic neuropathy is one of the leading causes of peripheral neuropathy, foot ulcers and wounds that can lead to amputation. Diabetes predisposes people to high blood pressure and high cholesterol and triglyceride levels.

This increases the chances of heart disease, vascular disease and stroke.

Treatment

Patients with type 2 diabetes can manage this condition with lifestyle changes. A healthy diet is the key to controlling blood sugar levels and preventing diabetes complications. Losing weight plays a big role in the control and prevention of diabetes. The alarming rise in childhood obesity in America is related closely to the rapid rise of type 2 diabetes in young people under 20.

1) Regular exercise in almost any form can reduce the risk of developing diabetes. Exercise also reduces the risk of developing complications from diabetes such as heart disease, stroke, kidney failure, blindness or leg ulcers. Even walking 30 minutes three times a week has been demonstrated to decrease development of diabetes and help prevent complications. It’s also recommended that patients decrease or eliminate alcohol intake.

Lifestyle Prevention and Treatment

The prevention of type 2 diabetes has a lot to do with developing a healthy lifestyle at an early age. The treatment of diabetes is complex and may require a team of knowledgeable experts: family doctor, specialist, nutritionist, diabetic nurse, and eye doctor. Many patients with type 2 diabetes can be treated with just exercise, diet change, weight loss and close monitoring of blood glucose. Some may need oral medications to help decrease and control circulating blood glucose levels. Some patients may go on to need injectable insulin.

Early diagnosis, education of the patient and family, modifying one’s lifestyle with regular exercise and weight loss – as well as adopting a healthy diet – are important components in the prevention, treatment and control of type 2 diabetes.

Ian Armstrong, M.D.
Spinal Neurosurgeon
Medical Director: Southern California Spine Institute
www.southerncaliforniaspineinstitute.com
(805) 496 1717
(310) 557 0741

Dr. Ian Armstrong is the Founder and Medical Director of Southern California Spine Institute in Westlake Village, Los Angeles and Bakersfield. He was the Medical Director of Neurosurgical Trauma at Century City Hospital for over 10 years. As well as being Director of Neurosurgical Trauma at Midway Hospital in Los Angeles, he was also a Staff Trauma Neurosurgeon at Cedars-Sinai Hospital – where he was involved with teaching the Surgical Residents.