Recovering from a concussion even more difficult in baseball

Concussions are typically associated with high-velocity collision sports. Although baseball is a limited-contact sport, athletes who suffer concussions have a difficult challenge when attempting to return to their pre-injury level of performance.

A concussion is a clinical syndrome of neurological impairment that results from a biomechanical force that is applied to the brain. It is a disruption of the complex circuitry that makes up the human nervous system.

Typical symptoms include headache, dizziness, visual changes, loss of consciousness and incoordination. Symptoms typically improve within 10 days of the injury if there are no other conditions that may prolong recovery.

In a recent study, functional MRI images were performed while an athlete was trying to identify what pitch was being thrown. This study demonstrated that multiple regions of the brain must be involved in a hitting decision. The number of areas involved increases as the number of potential pitches increases.

Since 2011, Major League Baseball has been tracking concussions in both the major and minor leagues. Two recent publications looking at this data have both confirmed previous beliefs and raised new questions.

In the 2011 and 2012 seasons, 41 concussions were reported in the major leagues and 266 in the minors. Fielding injuries accounted for 163 of the concussions with catchers being disproportionately at risk with 40.8% of concussions in the majors and 47.6% in the minors. The average time to return was between eight and 10 days.

In another study, concussed batters were compared to a control group. Interestingly, batting averages, on-base percentages and slugging percentages were significantly lower in the concussed group. These numbers did not recover to the pre-concussion performance level until four to six weeks after return.

Although recovery time for concussed baseball players is consistent with other sports, regaining the skill to effectively hit a baseball may require significantly more time.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Bioengineering could help orthopedic injuries

Bioengineering is the term best used to describe the utilization of multiple disciplines to solve a health-related problem. The incorporated disciplines involved often include medicine, life sciences, mathematics and engineering.

Most recently, bioengineering has emerged as a potential solution for many orthopedic injuries, including those related to sports. Some of the most promising research has been in the area of tendon and ligament regeneration.

Anterior cruciate ligament injuries are among the most common and disabling sports-related injuries. According to the American Orthopedic Society for Sports Medicine, there are approximately 150,000 ACL tears each year. These injuries account for approximately $500 million in health care costs annually in the United States.

The knee is a hinged joint where the femur and tibia articulate. The bony surfaces are cushioned by cartilage. Four main ligaments hold the entire joint together: the ACL, posterior cruciate ligament, medial collateral ligament and the lateral collateral ligament.

ACL injuries are most common in high-intensity sports, including soccer, football and basketball. Damage can result from sudden changes in direction, landing awkwardly after jumping or direct impact from a collision.

Bioengineering is being used to build new ligaments by applying stem cells to a scaffold and allowing the cells to generate a new ligament or through the application of stem cells to allow a ligament to be repaired.

"The use of stem cells, osteobiologics and biodegradable synthetic polymers is the frontier of sports medicine surgery and surgical augmentation," said Dr. Cory Edgar, assistant professor of orthopedic surgery and UConn team physician. "These approaches will significantly impact surgery success rates, recovery times and return-to-play timelines."

The routine use of bioengineered tendon repair may not be far off.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Rib fracture is most common serious injury to chest

Fractured ribs are commonly associated with collisions, falls or other forms of trauma. These injuries can lead to extended periods of disability in athletes.

The human rib cage consists of 24 ribs (12 on each side) connected to a bone in the center of the chest called the sternum and attached in the back to the thoracic vertebrae. There are muscles, nerves and connective tissue located between the ribs.

The rib cage is designed to protect vital organs including the heart, lungs and major blood vessels. It is also an important functional component as part of the respiratory system. The rib cage will expand and contract with each breath.

Fractured ribs in adults are most commonly the result of falls and motor vehicle accidents. In young people these injuries result from blunt trauma associated with athletic injuries. The middle and lower ribs are most often injured. The involved trauma is often a sudden, high impact to a small focal area such as that inflicted by an elbow or a baseball.

Rib fractures are the most common serious injury to the chest. Severe fractures can result in a punctured lung. Multiple fractures can cause a condition called flail chest that will diminish the ability to effectively exchange air. Intense pain is the most common initial symptom. The pain intensifies with breathing, coughing or any activity that requires movement of the chest wall.

Treatment involves the use of rest, ice and pain medication. Pain medication can range from non-steroidal anti-inflammatory medications to narcotics.

An ongoing study at St. Francis Hospital and Medical Center in Hartford involves the comparison of current medical treatment including narcotics versus marijuana administered in a fixed-dose pill form.

"Rib fractures are an excellent condition for this trial since it fairly predictably results in pain that improves in six weeks and resolves in eight weeks," reports Dr. James Feeney, associate director of trauma and principal investigator for the study.

Returning to sports after a rib fracture can be expedited with early recognition and effective treatment.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Avoid long-term use of narcotics for chronic nerve pain

Chronic pain has become an accepted complication of a career in high-velocity collision sports and combat sports. Unfortunately, the pain doesn't end with retirement and in fact can intensify with age. Novel approaches to treatment are needed to avoid chronic use of opiate medications.

The human nervous system is divided into the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and spinal cord. The peripheral nervous system is made up of the nerves that extend from the spinal cord to the muscles, joints and skin.

Pain is transmitted via signals from peripheral receptors to the brain where they are interpreted. Peripheral nerve pain from contact sports is often the result of direct trauma or stretching of large nerve trunks.

Trauma to sensory nerves can result in sensory loss. Often, injured sensory nerves will typically transmit misinformation called paresthesias. These "perversions" of sensation are typically described as burning, crawling, tingling or pins and needles. They can escalate from being an annoyance to debilitating.

The key element in treating chronic pain is to avoid the use of narcotics or other habit-forming medications since they are not a long-term solution. Opiates and other narcotics are designed for short-term therapy only.

Non-pharmacologic treatments in the form of mindfulness meditation, regular aerobic exercise and yoga are accepted approaches. Acupuncture also has been reported to show significant benefit in reducing pain for some patients.

Non-narcotic medications are often successful in treating chronic pain. Antiepileptic drugs as well as antidepressants are designed to treat conditions that affect the brain by altering brain chemistry. These medications also are effective in treating chronic pain.

Non-narcotic treatment of chronic pain demands a multidimensional approach for the best chance of success.

Further research into innovative approaches for the long-term treatment of pain, including the role of cannabis, is necessary.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Oregon athletes show dangers of overtraining

Athletes can sometimes become so focused on accomplishing a particular goal that the warning signs of potential injury are ignored. This was the case last week at the University of Oregon where four football players were hospitalized after an offseason workout.

Organized training during the offseason has become common at many levels of sport. Gone are the days when athletes would shift their focus to work and school after a season ended only to resume activity several months prior to the upcoming regular competition.

Much of the responsibility for the physical training of athletes has fallen into the hands of a growing group of strength and conditioning coaches. Credentials for these specialists fall into a variety of realms, including highly trained exercise physiologists, athletic trainers and physical therapists. 

Unfortunately, it is an area where certifications and appropriate credentials are not monitored and no state licenses or liability insurances are required for practitioners.

Prescribed workouts should not be one-size-fits-all recipes for making an individual or a team tougher and able to perform herculean tasks. Although many cite the military as the model for extreme workouts, they fail to note that there are severe consequences for commanding officers who ignore the human limits to training that result in permanent injury or death of a recruit.

In the case of the athletes in Oregon, it appears that the workouts crossed the fine line between training and torture. Those athletes' muscles began to break down due to increased energy demands and inability to supply necessary nutrients to large muscle groups. This resulted in a condition known as rhabdomyolysis where the muscle breaks down and the toxic products of that breakdown cause kidney failure. A key sign of this condition is darkened urine.

Many parents have bought into the belief that intense offseason workouts will increase their child's chances to play sports at a high level. Although this may be true, interviewing the person leading these workouts, checking their credentials, and making sure a child is enjoying these activities can avoid a potential disaster.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Safety, preparation vital for combat sport participants

Combat sports are among the fastest growing sports worldwide. Previously, this category of sports was restricted to boxing but has now expanded to karate, jiu-jitsu, kickboxing, judo and wrestling. These additional disciplines have come to be known as mixed martial arts (MMA).

The popularity of MMA should not come as a surprise. It has broad appeal to practitioners of these various combat forms as well as fans. Interestingly, the origins of combat sports in general date back to 400 B.C. when the participants were primarily slaves who were trying to win their freedom. Those contests often ended with the death of one opponent.

The ancient practice was eventually banned, not due to safety issues but because the contests had become so popular that spectators were not getting any work done.

Despite today's concern over the safety of these sports, there is a wide variation regarding regulation in the United States and internationally. Connecticut has become one of the strictest states to obtain a license to fight professionally. These regulations have evolved over years of experience at the state level and, more recently, at the Mohegan and Mashantucket Pequot Tribal nations.

The health regulations include blood screening for HIV, Hepatitis B and Hepatitis C every six months. Annual physical exams in addition to those performed at the fight venue are required. An EKG must also be performed annually. This encourages combat sport athletes to establish care with a primary care physician.

Particular attention is paid to neurologic impairment. Participants are required to have either an MRI or CT of the brain at some time in their career. In addition, an annual examination by a board-certified neurologist is required to assess any previous brain damage.

"Establishing a core set of health requirements and sharing them with other jurisdictions has been a priority," reports Mr. Michael Mazzulli, Director of the Mohegan Tribe Department of Athletic Regulation. Mr. Mazzulli and his team now travel internationally to regulate MMA events.

Safety and careful preparation are imperative for combat sports participation at any level.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Regular exercise should be part of any New Year resolution

The human body works most efficiently when it can attain a regular rhythm. A daily pattern should consist of sufficient sleep, regular nutritious meals and periods of exercise. This last component has become increasingly important in maintaining good general health. More recently, exercising regularly has been shown to possibly avoid several chronic conditions.

The definition of "regular" exercise also has presented a dilemma. Recommendations have varied in regard to the amount of time, intensity and type of activity.

Aerobic activities include walking, swimming, running and biking. Resistance fitness consists of lifting weights, using stretch bands or using body resistance. Walking or swimming at a slow pace is considered moderate exercise while running is classified as intense.

The current federal recommendations suggest 150 minutes of moderate exercise each week or 75 minutes of intense exercise as a maintenance amount for fitness. Those numbers should double if weight loss is a goal.

In addition to medication, regular exercise has been part of the prescription for patients suffering from type 2 diabetes, hypertension and heart disease. The latest data indicates that these disorders can actually be avoided through regular exercise even in patients who have a family history.

Among the most feared chronic illnesses is dementia. Current estimates indicate that 5.1 million Americans suffer from Alzheimer's disease. This number continues to grow as baby boomers age. Several recent studies have demonstrated that Alzheimer's disease and other cognitive conditions may be avoided through regular exercise.

The protective mechanism is both a direct effect as well as a secondary benefit of increasing blood flow to the brain. Ideally, a regular fitness regimen should begin in mid-life or sooner for maximum benefit.

The arrival of a new year encourages many people to begin a weight loss regimen. Adding an exercise component to that regimen for any length of time may have an added longevity benefit.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Early recognition can help prevent serious eye injuries

Approximately 20 percent of all eye injuries are sports-related. These account for 42,000 emergency department visits in the United States each year. Prevention and early recognition can avoid permanent visual impairment.

The eye is divided into the anterior and posterior segments. The major components of the anterior segment, including the lens, pupil, iris and cornea, serve to focus an image on the posterior segment. It accomplishes this by changing the shape of the lens and allowing adequate amounts of light into the eye.

The posterior segment receives the image on the retina and transmits the information via the optic nerve to the brain where it is identified.

Excessive exposure to sunlight is common in athletes who participate in outdoor sports. Ultraviolet light exposure will damage the anterior segment of the eye and cause premature cataracts.

Blue light frequencies of sunlight will penetrate further into the eye resulting in damage to the posterior segment and potentially causing permanent visual loss from conditions such as macular degeneration.

Sunglasses with the appropriate filtering mechanism should be worn whenever possible to avoid these conditions.

Lacerations involving the eyelid have attracted recent attention due to their severity and potentially successful treatment. The eyelid contains a system of intricate glands, ducts and blood vessels that protect and nourish the eye.

"A laceration involving the margin of the eyelid or the tear drainage system should ideally be repaired by a physician with expertise in reconstructive surgery of the eyelid," reports Dr. Kira Segal, an ophthalmologist specializing in oculoplastic surgery at the University of Michigan. "If a specialist is not immediately available, simply place antibiotic ointment and a patch over the laceration. Repair can be delayed up to 72 hours from the time of injury as the eyelid's highly vascular structure decreases the risk for infection."

Serious eye injuries can be prevented with appropriate protective eyewear. Every eye injury should be taken seriously.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN.  He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Athletes particularly susceptible to migraine headaches

Approximately 38 million Americans suffer from migraine headaches. These episodes often interfere with work and social activities. Athletes are not immune from this disabling condition.

Migraine headaches are best defined as throbbing headaches that last from four to 72 hours, often accompanied by additional symptoms including nausea, vomiting, visual disturbances, light sensitivity and sensitivity to sound.

These headaches may be preceded by periods of neurologic impairment lasting approximately 30 minutes before the actual pain begins. These symptoms are often referred to as an aura and may include loss of vision, weakness and numbness on one side of the body and difficulty with speech. Due to the nature of these symptoms, the episodes can be confused with the onset of a stroke. 

Changes in sleep schedule, diet, frequent travel or changes in climate can trigger a migraine, making athletes particularly susceptible. Contact sport athletes face the additional complication of head trauma.

Headaches can develop with exertion, independent of head trauma. These headaches typically last from five minutes to 24 hours. Head trauma can precipitate a migraine in a migraine-prone individual. The onset of any headache during competition in a contact sport can create confusion with whether it is contact-related and necessitates removal from a contest and a prolonged return-to-play protocol. 

Treatment of migraine headaches in athletes can involve symptomatic treatment with medications taken at the onset of headache or preventive treatment with medications taken on a regular schedule. Unfortunately, the list of medications that can be used in athletes is limited by effects they may have on performance.

“Headache is well known to have serious effects on productivity. Absenteeism and even "presenteeism" (showing up for work but being far less productive) may have far greater implications for athletes than in the general population,” reports Dr. Vernon Williams, Director of Sports Neurology at the Kerman-Jobe Clinic. “The culture of competition and athletics typically doesn't tolerate headache as an acceptable excuse or explanation for poor athletic performance.”

Adequate evaluation and treatment of headaches can improve enjoyment and performance for athletes at all levels.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Insulin pumps becoming popular among diabetic athletes

Diabetes affects more than 29 million people in the United States. Often the most effective treatments consist of a combination of insulin, diet and exercise. Ironically, achieving a balance between insulin and exercise can often be a challenge, especially for high-level athletes.

Diabetes is classified as type 1 or type 2 based on the body’s response to insulin, a hormone produced in the pancreas. Insulin enters the bloodstream in response to variations in the blood glucose level. Insulin allows glucose to enter cells and produce energy.

Type 1 diabetes occurs when the pancreas can't produce enough insulin. It is typically identified in childhood or adolescence but can be seen at any age.

Type 2 diabetes occurs when the body becomes resistant to the insulin available or the pancreas cannot produce enough insulin to keep up with demand. This type is usually seen in adults who have become obese. Unfortunately, it is now being seen more often in adolescents.

The goal of diabetes treatment is to create balance in the blood glucose level. This is done by decreasing the intake of glucose, burning more glucose through exercise, increasing the sensitivity of cells to insulin and the administration of insulin by injection. Often a combination of these strategies is applied.

Any attempt to properly regulate blood glucose levels in diabetes requires daily planning, especially for athletes. Insulin pumps are becoming increasingly popular.

Insulin pumps are wireless devices that can be programmed to infuse insulin via a small tube placed under the skin. Athletes can adjust the rate based on their level of activity even during a long-distance event.

"The use of insulin pumps in athletes is a convenient and efficient way to deliver insulin to the body that more closely mimics the way insulin is produced in a normal pancreas,” states Dr. Deena Casiero, Head Team Physician at UConn. “Insulin pumps also tend to lead to more well-controlled blood sugars overall, which is important for any athlete.”

Hopefully, the use of insulin pumps encourages more diabetics to participate in sports at a high level. 

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu