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Daily Dose

Twisted Neck?

1:30 to read

Under the heading of “continuing to learn” every day…comes a new case.

 

A patient of mine who is 4 years old was playing with his brother the other morning while his mother was making their breakfast. He was a “well child” and woke up in a good mood, ready to eat and go to preschool.  She could see the boys playing while she was cooking and then suddenly the 4 year old started to scream and cry that his “neck hurt”.  At first she thought “he was pretending or over reacting” as there did not overtly seem to be anything wrong. The only thing she noticed is that he refused to turn his neck and held his head in an awkward position.

 

He continued to cry and actually scream - so she tried to calm him down and gave him some ibuprofen as well. Despite this he would not move his neck and was unconsolable, to the point that she almost took him to the ER but instead she brought him to the office.  He was noted to be crying and seemed uncomfortable and refused to move his neck at all.  His exam was otherwise normal. Even with careful questioning there was no history of trauma. He had slept through the night before this had occurred. He had a cold several weeks before, but had since improved. He did not have a fever.

 

He seemed to be in such pain that he was sent for neck X-rays which were read as normal. But he continued to be miserable….so who do you call?? 

 

I spoke to a pediatric orthopedic surgeon and he said he really did not have any ideas. Next call, the pediatric neurosurgeon. After hearing the symptoms he immediately said that he thought this little boy had “rotatory dislocation/subluxation” of the two upper cervical vertebrae in his neck (C-1 and C-2). He explained to me that in most cases the displacement resolves spontaneously, but in some cases the child continues to be uncomfortable as there is associated spasm of the sternocleidomastoid muscle, which causes the torticollis. (twisted neck).It may be seen in children after a recent upper respiratory infection and is then called Grisel Syndrome.

 

Treatment for the acute condition…pain control and muscle relaxation.  This was all news to me and I had to go to textbook (online of course) to even read about the condition.  The neurosurgeon walked me through treatment and the child was sent home on a very low dose of valium and continued ibuprofen. When I spoke to the mother later that evening the child was already more comfortable and had started to move his neck. 

 

I called her the following morning and she said that he had not required any further valium and slept well and was actually on his way to preschool! WOW….I was thrilled he was better so quickly and that I was that much “smarter”. Wonder if I will ever see rotatory subluxation of the cervical vertebra again? I’ll be ready.

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Concussions

Concussions & Young Athletes

Your Child

Kids Who Specialize In One Sport Have More Injuries

Kids who came to the clinic with injuries played organized sports an average of 11 hours a week, compared with fewer than nine hours in the uninjured group. Although the researchers did not specifically look at this, Jayanthi said he has noticed that more highly specialized sports such as tennis, gymnastics and dance tend to be linked to more severe overuse injuries.Because a child’s body is still growing, children who specialize in only one sport suffer repetitive injuries more often, a new study says.

In fact, kids are twice as likely to get hurt –playing just one sport- as those who play multiple sports said Dr. Neeru Jayanthi, medical director of primary care sports medicine at Loyola University Chicago Stritch School of Medicine. "We saw a pretty significant difference with this intensity of training, along with specialization," said Jayanthi. The findings are slated to be presented Monday at the American Medical Society for Sports Medicine annual meeting in Salt Lake City. Research presented at medical meetings should be viewed as preliminary. "It's been accepted for the last five years or so that kids who are not super-specific do better. They're cross-trained, so they're conditioned for other movements," said Dr. Kory Gill, an assistant professor at Texas A&;M Health Science Center College of Medicine. Jayanith’s research team had done earlier studies on 519 junior tennis players and found that the kids who only played tennis were more likely to get hurt. Jayanthi wanted to see if the same findings extended to other sports. "As a physician, you get frustrated seeing kids come in with injuries that keep them out for two to three months. It's devastating," said Jayanthi, who recently saw a young gymnast with a knee injury that will keep her off the mat for at least three months. Here, the researchers looked at 154 young athletes, average age 13, who played a variety of sports. Eighty-five of the participants came to the clinic for treatment for a sports injury, while 69 were just getting sports physicals. The investigation ranked each athlete on how specialized they were, basing the score on factors like how often they trained in one sport, whether they had given up other sports to practice just one, and if they trained 8 months a year or more to compete more than 6 months a year on one sport. What they discovered was that 60.4 percent of the athletes who had been injured were specialized in one sport, compared with only 31.3 percent who came in for physicals. Kids who came to the clinic with injuries played organized sports an average of 11 hours a week, compared with fewer than nine hours in the uninjured group. Although the researchers did not specifically look at this, Jayanthi said he has noticed that more highly specialized sports such as tennis, gymnastics and dance tend to be linked to more severe overuse injuries. Why did these injuries occur? "One reason is repetitive use of the same muscle group and stressors to growing areas, for example, the spine," explained Jayanthi, who stressed that the findings were preliminary. His team, in collaboration with Children's Memorial Hospital in Chicago, plans to enroll more athletes in follow-up research, and those athletes will be evaluated every six months for three years, to look more closely at how intense training can affect a young athlete's body during growth spurts. "Second is exposure risk," he added. "If you're getting really good at one sport, the intensity increases because you are getting better. People are developing adult-type sports skills in a child's body. The growing body probably doesn't tolerate this." Younger children -- those who have not entered high school -- tend to be especially vulnerable as their bodies are still growing, said Gill, who recommended that kids cross-train and condition for other movements, or just play another sport. "I tell parents to let kids be kids and play multiple sports," he said. "See what they're good at and what they enjoy." By high school, when bodies are more mature, specializing is safer, he added. When children play different sports in different seasons, they are using a wide range of motions and muscles. But when they begin playing one sport year-round, the risk of overuse injuries increases.

Your Teen

Websites May Encourage Self-Injury

1.45 to read

The videos may be a focus for communities of youth in which self-injury is encouraged and viewed as normal and exciting, which could potentially increase the risk for self-injury.Some at-risk teens are finding new ways to hurt themselves thanks to a popular website with videos that glorify self-injury.

Young adults and teens may believe that hurting themselves is normal and acceptable after watching videos and other media on Web-sharing sites like YouTube, new research indicates. The findings, published in the journal Pediatrics, warn professionals and parents to be aware of the availability and dangers of such material for at-risk teens and young adults. Deliberate self-injury without the intent of committing suicide is called “non-suicidal self-injury” or NSSI. An estimated 14% to 24% of youth and young adults engage in this destructive behavior, according to the study. NSSI can also include relationship challenges, mental health symptoms, and risk for suicide and death, the study noted. Common forms of self-injury include cutting, burning, picking and embedding objects to cause pain or harm. While other studies have looked at the availability of online information about self-injury, the authors focused on the scope of self-injury in videos uploaded on YouTube and watched by youth. They described their work as the first such study and noted that their findings could be relevant in risk, prevention and managing self-injury. The authors focused on YouTube because, according to the site, since its inception in 2005 “YouTube is the world's most popular online video community, allowing millions of people to discover, watch and share originally-created videos.” Using the site’s search function the researchers looked for the terms “self-harm” and “self-injury,” identifying the site’s top 50 viewed videos containing a live person, and the top 50 viewed videos with words and photos or visual elements. The top 100 items that the study focused on were viewed over 2 million times, according to the analysis, and most – 80% - were available to a general audience. The analysis of the self-injury content found that 53% was delivered in a factual or educational tone, while 51% was delivered in a melancholic tone. Pictures and videos commonly showed explicit demonstrations of the self-harming behavior. Cutting was the most common type of behavior; more than half of the videos did not contain warnings about the graphic nature of the behavior. The average age of uploaders of the self-injury material was 25.39 years, according to the findings, and 95% were female. The authors surmise that the actual average age is probably younger because many YouTube users say they are older in order to access more content. The study concludes that the findings about the volume and nature of self-injury content on YouTube show "an alarming new trend among youth and young adults and a significant issue for researchers and mental health workers." The videos may be a focus for communities of youth in which self-injury is encouraged and viewed as normal and exciting, which could potentially increase the  risk for self-injury. The study warns that health professionals need to be aware of this type and source of content, and to inquire about it when working with youth who practice self-injury because sites like YouTube can reach youth who may not openly discuss their  behavior. Self-harming is not typical behavior for otherwise untroubled teens and young adults, explained Dr. Charles Raison, an Emory University psychiatrist and CNNHealth.com's mental health expert. It’s an action that kids with psychiatric problems may try. “NSSI is a young person’s affliction…one in ten will kill themselves," he said.   "A lot of people will outgrow the behavior.” Raison said that it’s common for troubled young people to share information about hurting themselves. Treatments can include antidepressants, antipsychotic drugs and psychotherapy.

Daily Dose

Ice Burns!

1.00 to read

Many schools are in spring sports or playoff season which means I'm seeing a few strains and sprains in the office. 

The treatment recommendation for a sprain or strain is usually RICE which stands for rest, ice, compression, elevation.  I just saw an adolescent volleyball player who had started back to her volleyball work outs and “pulled a muscle”. So, she followed her coaches directions to “ice it”.  Unfortunately, she just put the ice pack directly onto her skin and she came in with an ice burn! OUCH!

Yes, ice can burn the skin and cause frostbite as well. When treating an injury with ice you need to make sure that you put a towel or sheeting between the ice and your skin.  In this patient’s case the ice burn looked similar to a sunburn, and did not blister or cause any severe damage. In fact, when she pulled up her pants to show me her leg she “quizzed me” to see if I could guess what had caused the redness.......guess what, knowing that she was an athlete helped me guess correctly!

The picture above shows her injury as well.

The treatment is similar to a thermal burn, apply a lubricant like Aquaphor or aloe vera, and let the skin slowly heal.  If it is blistered or has had severe damage to the skin you may need to see your doctor.

Remember, ice is good for injuries but cannot be applied directly to the skin.  

Daily Dose

Young Athletes and Overuse Injuries

I see more and more kids who come in with complaints of back pain, knee pain, ankle and elbow pain often secondary to repetitive motion from sports.We had a pediatric orthopedic surgeon on the show recently and we discussed overuse injuries in adolescent athletes. I see more and more kids who come in with complaints of back pain, knee pain, ankle and elbow pain often secondary to repetitive motion from sports.

They usually don't have a lot of swelling, and they complain of pain with their activity, but otherwise are fine. When taking a history their biggest complaints occur during the sport or immediately after, and they usually feel better after resting overnight.The pain re-occurs once they resume their work out the next day. The cycle is continuous. The best treatment for overuse injuries is to follow the pneumonic RICE: Rest, Ice, Compression and Elevation. For further relief of pain add an anti-inflammatory medication such as Aleve, Motrin or Advil. If the athlete can play through the pain, it does not awaken them throughout the night and they are fine attending school and other activities, they are probably fine to continue in the sport. If the pain becomes persistent during the day, disrupts their sleep etc, then they will need to have further evaluation. For persistent stress-related injuries rest may be the next step. Many times it is just necessary to let the body have some "time off" and may also involve stretching exercises to strengthen their core muscles, or yoga and Pilates to improve flexibility and strength. This is usually a four to six week period away from their sport. One caveat that was discussed was the importance of watching for depressive symptoms in an athlete who has had to take time off from their activity. Parents need to recognize not only the physical pain their child is experiencing, but also the child's emotional pain related to stopping their sport. Many of these kids have such passion for their sport and also gain a great deal of self worth from their participation. To take that away from them is emotionally devastating, and their young minds are not cognitively developed enough to deal with the loss of their athletic endeavors, even for a short time. Watch closely and be supportive and acknowledge their feelings. It is just as important to seek help for their mental health if that seems necessary. That's your daily dose, we'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Athletes & Injuries

1.30 to read

I see a lot of athletic teens, and while many of them participate in several sports more and more tweens and teens are “specializing” in one sport. In other words, they may only play soccer or basketball, or be a gymnast or a dancer.  In some cases they practice or compete almost 365 days a year. (I think they often are only off on the 6 holidays/year that our office is closed!).  They too work really hard.

I have recently had more than a handful of elite athletes, especially girls who are gymnasts, cheerleaders and dancers, who have come to me complaining of back pain.  In most cases lower back pain is musculoskeletal in nature and will resolve with some anti-inflammatories (like ibuprofen), alternating ice and heat to the back and a few days of rest. But in some cases the back pain worsens, especially with activity and further work up is required.

In several cases the ongoing back pain is due to a spondylolysis, which is a fracture of the pars interarticularis of the vertebrae. It is akin to a stress fracture in other areas.  It is most commonly found in the pediatric population and is thought to be due to mechanical stress of the trunk with repetitive flexion, hyperextension and trunk rotation.  All of those maneuvers are the “usual” for a cheerleader doing back flips or a gymnast doing exercises with hyperextension.  Athletes who are into weight lifting (seems they all do this now) and even children who carry heavy backpacks may be at risk for a “spondy”.

The spondylolysis may show up on a plain X-ray of the back or may require a CT scan to see the fracture.  

In our community there is some difference of opinion on how best to treat the condition.  Unfortunately, it seems that the best treatment is rest which may be for weeks-months.  This is NOT what they competitive gymnast or star football player wants to hear.  

Once the pain has resolved a structured physical therapy program seems to be of benefit as well.  If conservative management for over a year does not help some orthopedists would recommend surgery. Again, there are several different views as to the benefits of surgery in this age group.

But if your child has persistent lower back pain that worsens with activity and hyperextension you should think about this condition and talk to your doctor. It is becoming more prevalent as our kids compete at higher and higher levels.  

Daily Dose

Why Kids Should Wear a Helmet

1:30 to read

Accidents in children are always an ever present problem. From scraped knees, to bumped heads, broken arms and stitches there are always injuries in our children. Accidents in children are always an ever present problem. From scraped knees, to bumped heads, broken arms and stitches there are always injuries in our children. Thank goodness most of them are traumatic at the moment, usually more to the parent than the child, and the child quickly recovers and is on to the next thing.

One way to help protect our children is by using protective "gear" when appropriate. We are really good about using car seats, child proofing houses and pools for the toddler set, but as the children get older there are other dangers lurking around with the bicycles, scooters, skateboards and the newest rip stick. All of these "wheeled" devices pose dangers for falls and "wipe outs" that may lead to things as mild as cuts and scrapes or as serious as a head injury. The hardest thing to get a school age child to understand is the meaning of the word ACCIDENT.

They do not understand that even if they think they have mastered the bike or rip stick, an accident can happen at any time. When I am talking to the elementary school set and ask them about mastering a bicycle on two wheels they are so proud to tell me of their accomplishments. But when I ask them what they are wearing on their head while riding, I don't always hear "a helmet". Children and adults on bicycles need to wear helmets at all times. I see kids riding their bikes to school (great exercise), but not a helmet in sight on their head. Don't let your child on their bicycles without a helmet, insist on a helmet just like a seat belt. If they become accustomed to always putting on a helmet before hopping on that bike or skateboard it will just become second nature. If they choose not to wear their helmet, then put the bike in "time out" for awhile to let them know that you are not going to allow them to ride without protection. Knee pads and wrist guards are great, but we can usually set a wrist fracture, or stitch up a knee. A head injury is another story!

That's your daily dose, we'll chat tomorrow.

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