Electrotherapy for patient care: Evidence-based practice
to help you stay “current” by Dr. David Draper, EdD, ATC, LAT, PRT-c®
This course discusses theory, application and research of electrotherapeutic devices used in sports medicine.

Offered as a live course and will be available on-line in 2018!
 

In 2016, Drs. Regis Turocy and Paula Turocy presented several positional release therapy seminars to traditional medicine practitioners and students in Shanghai China. The visit resulted in Shanghai University of Traditional Chinese Medicine to send a Professor from the University, Cui Jiawen, "Cathy" to us for training and Certification.

Cathy is our first internationally certified Positional Release Therapist (PRT-c®)!

Click the video to hear what Cathy had to say about her experience at PRT-i®
Since Cathy's visit, we have collaborated on a case report and plan to do more research with the University as well as training and certification for their students.

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Case Study of a D1 Female Diver with a Concussion

History

Athlete is an 18 year old female D1 collegiate diver (athlete was 17 at DOI, had birthday while injured). Athlete was performing a reverse dive on 9-8-17 when she landed on the back of her head and shoulder area. Claims to have landed more on her right side. Upon coming out of the water she reported symptoms of dizziness and a headache. Other symptoms included fogginess, feeling slowed down and difficulty concentrating. No retrograde amnesia; no previous history of concussions, migraines, ADHD, anxiety or depression; no significant family history.

Athlete was significantly point tender around the suboccipital and upper cervical paraspinals. Neuro testing was done and CN2-12 were intact. Testing was done by having athlete touch finger to nose. Provocative testing was done by having the athlete rapidly move her eyes by alternating between left and right and up and down while watching the examiner’s finger. She was initially able to track the motion with her eyes but this significantly reproduced symptoms. She was evaluated by a team physician who diagnosed her with a concussion. Secondary diagnoses made were a neck strain and sinusitis (athlete was recovering from a cold). The SCAT5 concussion test was used to confirm a diagnosis of a concussion. Did not perform a reassessment of the athlete’s baseline test at time of initial injury. Also of note is the athlete had a history of insomnia and was given Ambien by family physician. Team physician stated it was ok to continue to take as prescribed to maintain a normal sleep cycle.

Treatment Plan

Upon returning to campus reviewing the physician’s notes and evaluating athlete for myself signs and symptoms of a concussion were evident. After speaking with the athlete about a treatment plan it was decided to perform positional release therapy to aid in the healing process in addition to traditional treatment for a concussion such as cognitive rest, removal from sport and modification of the athlete’s class schedule. PRT treatment areas primarily focused on upper trapezius, suboccipital, digastric and temporalis. Other areas of focus for PRT sessions included the rhomboids, scalenes and over the frontal bone. The procedure for her treatment program was to perform a symptom checklist prior to each PRT session which would focus on 3-5 areas. This was followed by palpating the areas of treatment and asking athlete for a numerical pain scale, 1- 10 with 10 being the most painful. PRT would be performed and the effectiveness of treatment would be reassessed using the numerical pain scale. In addition a symptom checklist was completed by the athlete to see if there was a reduction or relief of symptoms. Additional therapies as suggested by team physician were fish oil (1600 MG) once a day, melatonin (10 MG) and Tylenol as needed. Hot packs were also used on occasion but were not a consistent part of the treatment plan.
 

PRT Procedure

The PRT procedure consisted on finding the area of most tenderness and using the Fasiculatory Response Method (FRM) as proposed by Dr. Speicher(1). A very strong fasiculatory response was noted when palpating the athlete. Upon finding the fasciculation the athlete would be moved into proper position until fasciculation subsided or was reduced.
 
Upon completion of a PRT session athlete would note a reduction in symptoms as well as a reduction of symptom severity. In addition the area of the tender or trigger point would typically have pain reduced, decreased muscular hypertonicity and point tenderness (Table 1). The reduction of pain ranged from 100% to 17% with the average being an 88% reduction of pain following treatment. The decrease in symptom severity would range between 92% to 59% with an average of 74% reduction of symptom severity. PRT was performed 4-5 times per week with a focus on different areas of tenderness and identifying new areas of problem.

Concerns
Difficulties encountered during this treatment where the reappearance of symptoms and areas of tenderness. After performing a PRT session athlete would typically get 6-12 hours of relief before symptoms such as dizziness, headaches or the reappearance of trigger points would begin to return. While symptoms would return, their severity was often diminished by several points on the rating scale. However, at times the athlete would report them as worse. It was explained to the athlete that the removal of stimuli such as loud noises or TV could help reduce symptoms and she appeared to be compliant with the idea. I was unable to determine why symptoms kept appearing other than the athlete was concussed and still recovering.
 
Athlete would also have the reappearance of pain upon palpating previously treated trigger point areas. Again pain would often be less than the day prior but could also appear higher at times. This could explain why the athlete had a reappearance of symptoms.
 

Return to Play

The athlete began to show improvements over the month with gradual reduction of symptoms and severity. She began a RTP program at the direction of the team physician. Time of injury to start of the RTP program was approximately 3 weeks. The program was a 5 step process of gradually increasing activity. She would follow up with ATC daily and physician 1-2 times per week. The RTP program included a vestibular rehab component to help retrain the vestibular system (2). The rehab consisted of exercises to provoke symptoms such as dizziness allowing the body to retrain the vestibular system in a controlled environment.
 
The athlete passed all concussion tests with scores at or above her baseline. Baseline testing and return to play testing was done using C3 Logix, a software program that aids in diagnosing concussions. She was still reporting occasional dizziness and headaches when performing activities which involved multiple flips such as diving. After speaking with team physician and after he evaluated her it was determined that she was cleared of her concussion and the residual symptoms were related to muscular tension type headaches. She missed

approximately 1 month from start to finish of treatment. I continued with PRT for muscular tension symptoms. Areas of focus were the frontal bone, subboccipitals, upper traps, masseter and temporalis.
 

Conclusion

Some factors I noted were the athlete was young, 17-18 years old, and female. Research notes that adolescent females typically take longer than their male counterparts to recover from a concussion (3). This could explain the return of her symptoms along with the length of recovery.
 
Another note was initial PRT treatment area focused on the upper quarter and cranium. This was eventually expanded to the spine. Perhaps if the spine area was treated sooner better results would have been achieved. This could also explain the return of symptoms. As muscle and fascial tissue are connected, release of one trigger point could activate a latent trigger point.
 
Concerns noted during the treatment are the return of symptoms and severity. My conclusions were that the return of symptoms may have been linked to her concussion however she was also dealing with tension headaches as stated by the team physician. The reasoning behind this is that while athlete still reported headaches, which can be concussion related, other signs and symptoms such as abnormal eye movement or light sensitivity were not present. The athlete had multiple conditions that may have played a factor in her recovery. Trying to differentiate between what was related to a concussion and what was related to other conditions was an area of concern when trying to return athlete to play.
 
In conclusion, PRT appeared to be a very valuable tool that aided in the RTP for this athlete. It was able to provide symptom and severity relief. While the athlete would typically get relief for 6-12 hours this was later prolonged as she began to return more fully to sport. PRT was also very effective at reliving symptoms of muscular tension headaches. The athlete responded very favorably to PRT and believed that it helped her return more quickly. The athlete has been cleared for full participation with no restrictions.
 

References

1. Speicher, T.E.  Clinical Guide to Positional Release Therapy, Human Kinetics, 2016.
2. Alsalaheen B, Mucha A. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy (June 2010) Vol 34 (2).87-93.
3. Covassin T, Elbin RJ. The Female Athlete: The Role of Gender in the Assessment and Management of Sport-Related Concussion. Clinical Sports Med 30 (2011)125–131.