Physiatry in Motion Issue 16, Fall 2019

Adaptive Surfing and Surf Therapy: Using the Power of the Ocean to Heal

by Tiffany M. Lau, MD

Marine Corps veteran Sgt. Toran Gaal poses for photo with his custom surfboard which allows him to surf despite being a double amputee during the Naval Medical Center San Diego surf therapy clinic in Del Mar, CA. DoD photo by EJ Hersom.

The sounds of the waves as they crash into the beach, the ambience of the ocean air, and the taste of the salty water; these are just a few of the sensory experiences of the sport of surfing. The glide of the surf board on the wave, gives the surfer the feeling of elation and excitement. Surfing puts you in the moment. You are unable to focus on anything else but what you are doing at that time. It is easy to see where the surfer’s “stoke” comes from. For many that love this sport, surfing would be something difficult to give up. However, life is unpredictable and some individuals undergo earth- shattering injuries or events that make traditional surfing a challenge; enter Adaptive surfing. Adaptive surfing is formally recognized by the International Surfing Association (ISA) (an organization with a mission to develop the sport of surfing in all of its forms across the globe). ISA has been crowning champions with physical challenges across multiple divisions and categories since 2015. In addition to the ISA there are many organizations (e.g. Disabled Sports USA) that work to coordinate surfing events as well as promoting the well- being of people with handicaps, impairments or disabilities though surfing.

There are many stories about how surfing and/or the return to surfing after a life-altering injury or event has pulled individuals out of a deep depression, given them will power, determination or a little more acceptance of their current level of function. One example is Jesse Billauer: “Many years ago, I was one of the top 100 junior surfers in the world, weeks away from turning professional. On March 25, 1996, on a morning like any other Malibu morning, I pulled inside a barrel and got thrown headfirst into a shallow sandbar. The impact broke my sixth vertebrae and I instantly became a quadriplegic.” Jesse Billauer is founder and CEO of Life Rolls On. Life Rolls On is a nonprofit organization dedicated to improving the quality of life for people living with various disabilities. Jesse Billauer turned his own peripeteia into the epitome of altruism. This organization coordinates adaptive surf and skate events around the United States.

Another example is Elsje Neethling: “For some brief moments there is nothing in the world but you, the board under you, and the wave. You forget that you are differently abled, broken, sick or hurt. The waves cleanse your head, heart, body and mind. It’s quite a spiritual experience to lie on your board in the backline, waiting in anticipated silence and focus for that one perfect wave. Surfing has given me wings, it has shattered all the odds brain cancer and disability have stacked against me. Surfing has not only given me boundless confidence to take on life, it has given me hope. Hope that there really isn’t anything you can’t do. If you can visualize it and muster up the courage and optimism, then you definitely can do it.” She is an adaptive surfer who had choroid plexus carcinoma that caused an incomplete spinal cord injury.

Adaptive surfing is growing worldwide, more and more people with different abilities are discovering the joy of gliding on an ocean wave. There have been case reports of prostheses that have been developed specifically for the physicality of surfing. It is also gaining popularity as a competitive sport. Surfers are classified based on their ability levels. Some examples of these levels are: surfers who ride in a kneeling or standing position, surfers who ride in a seated position on a wakeski, surfers who ride prone, surfers who ride in a non-standing position and need assistance to paddle into waves, and also surfers who have a visual impairment.

The mindfulness surfing requires lends it well to be used as a meditation and a type of therapy. Surf therapy is defined as a physical activity that utilizes surfing as a vehicle to achieve positive change. Surf therapy combines therapeutic elements of the ocean with the adventure of surfing to positively impact physical and metal well-being of individuals. There is a growing body of evidence that demonstrates that surf therapy is effective in improving comparable mental health outcomes across different populations in a wide range of contexts including vulnerable young people. These studies demonstrate a strong association between surf therapy and positive mental health outcomes. However this evidence still has some limitations and further research needs to be conducted. The International Surf Therapy Organization (ISTO), a nonprofit organization dedicated to advancing the use of surf therapy, has united over 22 different organizations around the world using surfing as a form of therapy. The ISTO created and follows best practice requirements and run programs following priority areas like: mental health, disability, adverse environments, and marginalized communities.

The ocean has long been regarded by many different cultures as a place of healing with therapeutic functions and usages. Adaptive surfing and surf therapy bring home the notion of inclusivity by harnessing this healing power. Surfing is this idiosyncratic mix of serenity and adrenaline and often allows surfers to practice mindfulness. Elsje Neethling summed it up best, “It’s the best medicine for any ailment.” The waves do not discriminate, if you have mental health illness, are differently-abled, or able bodied the waves of the ocean wash over you the same.


  1. Adaptive Surfing -. International Surfing Association. https://www.isasurf.org/development-programs/adaptive-surfing/. Published 2019. Accessed August 10, 2019.
  2. Life Rolls On. Life Rolls On. https://liferollson.org/. Published 2019. Accessed August 10, 2019.
  3. When disability fades away in the water: three women who surf in spite of the odds. Marie Claire — South Africa. http://www.marieclaire.co.za/mc-recommends/adaptive-surfing-cape-town. Published 2019. Accessed August 10, 2019.
  4. “Adaptive Surfing Is The Best Thing That’s Ever Happened To Me.” Women’s Health. https://www.womenshealthsa.co.za/life/elsje-neethling-adaptive-surfing/. Published 2019. Accessed August 10, 2019.
  5. Schvirtz, E., Bensoussan, L., Tourret Couderc, B., Viton, J.-M., Delarque, A., & Kerzoncuf, M. (2018). Return to surfing using an adapted prosthesis: A case report. Prosthetics and Orthotics International, 42(4), 455–459. https://doi.org/10.1177/0309364618757785
  6. Marshall J, Kelly P, Niven A. “When I Go There, I Feel Like I Can Be Myself.” Exploring Programme Theory within the Wave Project Surf Therapy Intervention. International Journal of Environmental Research and Public Health. 2019; 16(12):2159.

Tiffany Lau is a PGY3 in the Department of Physical Medicine and Rehabilitation at Burke Rehabilitation Hospital. Follow her on Twitter @TiffanyMLauMD

Understanding the Backlash to Gaming Disorder

by Lindsey Migliore DO

The World Health Organization (WHO) recently announced the 11th revision of the International Classification of Diseases will have a new code: gaming disorder.

For those who eagerly await play-by-play updates to ICD codes, this may be old information. Others may have noticed the brief, but sensational media blip created in June after a few news outlets tasked their hippest interns to tackle the insurmountable task of educating the world on what exactly esports is and there now being a disorder associated with it. If you need help with the former, here’s a quick synopsis of E-sports.

For those inside the gaming world, the announcement, and the subsequent outrage by the community, was hard to miss.

Ready to move on? Let’s find out what all the fuss is about.

The WHO classifies gaming disorder as, “a pattern of gaming behavior characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.”

For those reading this who have never truly experienced the joy of video games outside of Mario Kart and Ms. Pac-Man, in order to genuinely understand the negative reaction this classification system has aroused in the gaming community, it is first essential to comprehend fundamental aspects of multiplayer gaming.

Gamers have evolved far beyond the overweight nerd in mother’s basement stereotype they have been so unfairly portrayed as.

First and foremost, gaming is a social experience. Nowadays, most titles are online, multiplayer experiences, meaning you work as a team with real people, using your microphone and headset to communicate constantly. Subsequently, social circles are cultivated, either comprised of real-life friends who you log on with reliably every few nights, or new friends met online, and strengthened after spending multiple months or years gaming together.

Whether your online social circle consists of those you have or have not met IRL (in real life), the social aspect is intoxicating. Often times, your success in the video game is directly related to your communication and teamwork. For example, in the widely popular video game Fortnite, you work with a squad of four in a Hunger Games scenario to eliminate your opponents and be the last remaining in matches of approximately twenty minutes. Traversing the enormous map of mixed tundra, gathering weapons to fight, materials to defend, all while remaining vigilant for enemies with the same objectives requires flawless communication, constant attention, and impeccable collaboration. The rush of adrenaline is intoxicating, the sense of accomplishment riveting, and the best part of all, you share it with your friends.

If this has conveyed even a tenth of the exhilaration (and dopamine) that gaming provides, is it so hard to see why “gaming takes precedence over other interests and daily activities”?

Gamers play Call of Duty instead of reading a trashy summer novel, log on to League of Legends rather than crafting miniature airplanes, and build cities in Minecraft in lieu of sipping discount margaritas at happy hour. Under this definition, if a gamer chooses to collaboratively game with friends, strengthening mental processing, teamwork, and hand-eye coordination rather than binging three hours of Netflix, they may now be diagnosed with a disorder?

Second, the handling of esports by the medical community risks treating gaming like a drug rather than what it truly is: a booming industry and viable career option. Esports is set to make over one billion dollars in revenue in 2019. By 2021, viewership will top 557 million (toppling every other sport besides the NFL). Would the WHO consider dropping out of community college to play video games a negative consequence? Most certainly.

However, Tyler “Ninja” Blevins and his 22 million YouTube subscribers would vehemently disagree. Skilled gamers, their craft honed by thousands of hours of practice, are earning salaries akin to NBA superstars. Colleges now offer scholarships to esports athletes, opening up educational opportunities that might have otherwise not been available. Furthermore, with the growth of the field, countless career opportunities, unrelated to gaming prowess but very related to familiarity with the industry, are popping up.

Despite the flagrant advocacy for gaming evident in this article, you do not need to look far to see the negative consequences of gaming. Awareness of the esports industry by the medical community can and will be beneficial. Esports athletes are susceptible to a unique set of injuries due to their lifestyles, and are desperate for educated and informed healthcare professionals.

However, certain interpretations of the WHO’s abstract wording of this disorder may further stigmatize gamers, pushing an already medically-wary population further from treatment.

Lindsey Migliore is a physiatrist and can be reached on Twitter @DrMigliore.

The Right Way to Play: The Controversy Behind Early Sports Specialization

by Robert Pagán-Rosado, MD & Walter Alomar-Jimenez, MD, JD

Sports specialization is defined as choosing a single sport and/or quitting others to focus on one sport for more than eight months per year.(1) Year-round training and focused participation in a single sport has become more common among young athletes around the world. In most cases, this type of practice is driven by the pursuit of scholarships, strong desire of talent recognition, and a goal of reaching the elite level.(2) Sports that strongly require technical skills such as diving, swimming, figure skating, and gymnastics first led to early sports specialization in Eastern Europe many years ago. This led to earlier recruitment of future champions in the primary school years, and subsequently introducing them to development programs intended to increase chances of success.(3,4) Although these programs produced world-renowned Olympians and highly-paid professional athletes, there is great controversy regarding the potential effects of early sports specialization in young athletes. Interestingly, there is still a strong debate to determine whether early sports specialization is required to become an elite athlete.(5)

One of the undesirable consequences that early sports specialization may have on young athletes is the incidence of overuse injuries due to the lack of musculoskeletal maturation and neuromuscular skills. Over-scheduling competition, lack of rest, and higher volume of intensified specialized training are some of the main factors associated with injury.(2, 5) Equilibrium, hand-eye coordination, overall muscle strength, flexibility, and rest from repetitive use of the same body segments may be acquired by diversifying physical activity at an early age, thus providing protection against overuse injuries. Specifically, literature has shown that engaging in multiple sports during childhood provides much of the above mentioned benefits as well as other cognitive and behavioral skills. But aside from physical consequences, the excessive psychological stress that specialized high-intensity training may have on a young athlete may translate to burnout, frustration, and premature sport abandonment.(6) On the other hand, one must be careful along the way and not discourage sports participation since quitting recreational sports at an early age may lead to physical inactivity that could later in life translate to preventable chronic health issues.(7)

Current evidence suggest that early specialization does not guarantee elite sport performance.(10) A study in which 35,000 young Russian athletes were selected to train in sport schools found that only 0.14% reached high-level status.(8) Another study involving NCAA Division 1 athletes found that approximately 70% did not specialize in their sport until at least age 12 years, and 88% had participated in more than one sport.(9) Moreover, these university athletes specialized at an older age compared with non-athlete students at the same university. Athletes dedicated to team sports such as baseball, basketball, and volleyball tend to have participated in different sports at younger ages and specialized later during adolescence.(10) Regarding individual sports such as tennis, gymnastics, and swimming, early specialization may be beneficial to reach the elite level.(9,10)

Among national sports organizations, new proposals are being introduced for future sport development projects.(11) These stratify an athlete’s development to direct the way they should be trained. One of the goals is to keep them participating in a safe manner, which may increase their chances of reaching a competitive level. For example, the United States Tennis Association divides sports participation in three phases:

  1. Age 12 years and under: Athlete discovers the game, enjoys it, develops basic skills while he or she engages in other sports.
  2. Ages 12–15: Athlete further understands the sport and the importance of specialized training to prepare for competition.
  3. Ages 15–18: Athlete is fully involved in the sport, dedicates full time to training, and prepares for competition in order to become an elite player.

These phases take into account social, psychological and physical aspects that influence the transition from recreational to competitive sports in a typical young athlete. Moreover, these guides may help decrease the incidence of overuse injuries, burnout, and sport abandonment in young athletes.

In Summary, recent evidence has converged to advise the following recommendations for parents and coaches:(10)

  1. Unstructured play should be provided to youth for development of motor skills throughout growing years.
  2. Encouragement of participation in a variety of sports, specially those that the child enjoys.
  3. Close monitoring for those children who engage in more than 16 hours per week of intense training.
  4. Youth who are specialized in sports activities should be monitored for overuse injuries and burnout.
  5. Strength conditioning should be included in the training regimen of all youth for competitive participation preparation, specially for those specialized in a single sport.


  1. Jayanthi N, Pinkham C, Dugas L, Patrick B, Labella C. Sports specialization in young athletes: evidence-based recommendations. Sports Health. 2013; 5:251–257.
  2. Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015;43:794–801.
  3. Mostafavifar AM, Best TM, Myer GD. Early sport specialization, does it lead to long-term problems? Br J Sports Med. 2013;47:1060–1061.
  4. Finley B. A single goal in common. New York Times. December 17, 2006. http://www.nytimes.com/2006/12/17/nyregion/nyregionspecial2/17Rsports.Accessed November 13, 2019.
  5. Myer GD, Jayanthi N, Difiori JP, Faigenbaum AD, Kiefer AW, Logerstedt D, et al. Sport Specialization, Part I: Does Early Sports Specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Young Athletes Sports Health. 2015;7(5):437–42.
  6. American Academy of Pediatrics. Intensive training and sports specialization in young athletes. Pediatrics. 2000; 106:154–157.
  7. Biddle SJ, Pearson N, Ross GM, Braithwaite R. Tracking of sedentary behaviors of young people: a systematic review. Prev Med. 2010;51:345–351.
  8. Ljach W. High-performance sport of children in Russia. Leistungssport. 1997;27:37–40.
  9. Quitiquit C, DiFiori JP, Baker R, Gray A. Comparing sport participation history between NCAA student-athletes and undergraduate students. Clin J Sport Med.2014;24(2).
  10. Myer GD, Jayanthi N, DiFiori JP, Faigenbaum AD, Kiefer AW, Logerstedt D, et al. Sports Specialization, Part II: Alternative Solutions to Early Sport Specialization in Youth Athletes. Sports Health. 2016;8(1):65–73.
  11. Micheo, W. Especialización deportiva temprana en tenis: Riesgos y Beneficios https://www.usta.com/es/home/stay-current/caribbean/virginislands/early-sports-specialization-in-tennis--risks-and-benefits.html. Accessed November15, 2019.

Robert Pagán-Rosado is a PGY1 at Hospital Episcopal San Lucas & incoming PM&R Resident at Mayo Clinic Department of Physical Medicine and Rehabilitation. Follow him on Twitter @rdprMD.

Walter Alomar-Jimenez is a clinical lecturer at the University of Michigan Department of Physical Medicine and Rehabilitation.

Space: The Next Frontier in Physical Medicine and Rehabilitation — Part 2

by Luke Brane, MD

This is the second part of a three-part series on Aerospace Medicine.

In the previous article, we briefly covered some interesting medical and physiologic challenges facing the space faring human, why they matter to the development of a new space economy, and where physical medicine and rehabilitation might fit in. In this article we will delve a little more deeply into the pathophysiology — as it is understood to date — as well as some current mitigation strategies. We will focus on the aspects of spaceflight physiology that also have significant cross-over with our terrestrial populations.

As we consider the pathophysiology involved in these spaceflight-associated syndromes, remember that our entire evolutionary history and all our physiologic antecedents developed in a particular gravitational environment, which has not changed since the first forms of live emerged on Earth. Terrestrial life has always been able to rely on a constant gravitational force which provides an “up” and “down” and dictates how gas and liquid behave. Consequently, all Earth’s land-dwelling organisms who rely on a circulatory system, have one evolved with the assumption that gravity will always be there, and that “up“ and “down” are a universal constant. Similarly, when an organism requires locomotion for survival, gravitational force is assumed to represent the minimum force that its musculoskeletal system must be able to overcome in order to move about its environment and this places limits on how far and fast a creature can move. Terrestrial body plans, like that of humans, developed within a constant gravity field, with compensatory mechanisms designed to help optimize them. However, we are now on the precipice of a gravity-free setting that nullifies this force and confuses the body’s normal adaptive mechanisms. These adaptive mechanisms, which typically help our bodies respond to differing workloads (i.e. fluid shifts during changes in position), while maintaining the utmost of efficiency (catabolizing unused muscle and bone) now begin to work against us. The closest analogous state on Earth to a long duration spaceflight is prolonged bedrest. Most of our inpatients who visit inpatient PM&R have experienced this prolonged bedrest to one degree or another.

Another important thing to keep in mind when considering our knowledge of the inherent physiologic toll of long-duration spaceflight and off-planet living is that much of what we currently know about its effects had been confined to gravity-free exposure of only weeks to a few months. Humans were spending hours to days in space with the Gemini and Apollo missions, and there were a few stretches of between 4 weeks and 3 months on Skylab, with some longer times (up to 437 days) on the Russian space station MIR. Unfortunately, these missions took place between the 1970’s and 1990’s, and the quality of physiologic data at the time left much to be desired. The missions shortened again with the shuttle program, having mission durations of days to a few weeks. ISS mission started to stretch out to 4 and 6 months, then 9, with the longest to date being Scott Kelly from the USA and Mikhail Korniyenko from Russia, with ~12 months ending in 2016. However, to date — only 3 individuals have withstood a continuous year in space since humans became a space faring species. What have we learned from this, and how can we extrapolate the data to prepare ourselves for much longer durations?

Since most off-planet excursions (with the exception of lunar missions) will require transit times well beyond our current ISS mission, there are some very important and interesting unknowns that still await us. For example, a mission to the surface of Mars would take between 6–9 months in microgravity (uG) on the way there, 16–18 months on the surface at 3/8 earth standard gravity (due to the constraints of orbital mechanics on the return journey), and then another 6–9 months in uG to return to Earth.

With these realities of unprecedented uG and prolonged low-G exposure, let’s examine more closely the known and potential breakdown of these physiologic systems, and what has been done to combat this to date.

We will first revisit the musculoskeletal system, which will be presented as a unit, since many of the factors that induce their degradation are complimentary. Consequently, the mitigating strategies employed so far tend to work for reasonably well for both skeletal muscles used in posture and locomotion, and for maintenance of bone density and bone strength.

It is fairly well established that unloaded human skeletons experience 1–2.5% loss in bone mineral density (BMD) per month, depending on which skeletal site is surveyed. This holds true for both the bed-bound and the astronaut.[1] To put this in perspective, the average postmenopausal woman loses about 1.3–1.5% of their BMD per year. So, an astronaut or completely bed bound person losses their BMD between 8 and 20 times faster than the highest-risk terrestrial population. We see an equivalent phenomenon in our patients with spinal cord injuries, who can lose bone density at a similar rate to the bed bound and astronaut populations. The theory behind this pathological adaptation lies in the notion of the mechanostat. The ’mechanostat theory‘ is a feature of our skeletons that, to date is not fully characterized, but essentially acts as a cellular mechanism that senses loading force. The sensation of this force has a central role in the activation or deactivation of the osteoblast/osteoclast system. The biomolecular and cellular mechanisms so far identified are beyond the scope of this article but suffice it to say the sensing of skeletal load directs remodeling and appears to do so in a very localized fashion. This allows bone remodeling to occur in specific areas which allow for reinforcement of bone architecture in the areas experiencing the most strain. Conversely, those areas no longer experiencing as much strain tend to break down their ’extra support’ in favor of mobilizing substrate. In complete unloading, like uG, para- or quadriparesis, and long-term bed rest, the bones’ mechanostat feature begins to work against the body. It happily mobilizes the ‘extraneous substrate‘ of skeletal calcium and phosphate that are apparently no longer needed. Unfortunately, this is happening everywhere in the skeleton not under load, except for the skull.

The well-established idea of muscle loss in the setting of disuse is a perennial problem in rehabilitation medicine, as well as for the astronaut. Our rehab patients have come out of long stays in the ICU, or after surgeries with long recoveries, and their deconditioning is a profound barrier to overcome. Now imagine if you had not endured a stay in the ICU, or had prolonged surgical recovery, yet you still developed that same level of deconditioning, merely because the gravitational environment you dwell in does not stimulate your body to maintain its natural condition. We have seen the changes in muscle fiber type composition, changes in muscle cross-sectional area, and most importantly, changes in functional capacity.[2] The understood mechanism for this lies in the interplay between the skeletal muscle energy utilization/storage and functional capacity. When a muscle as a unit undergoes firing in response to load, it activates its cellular system for bringing in and metabolizing glucose via insulin; this also up-regulates the system’s to insulin-like growth factor IGF-1 mediated protein anabolism, in preparation for muscle repair and regeneration. Incidentally, that ’load‘ could be just the effort of walking around at a normal pace in Earth’s gravity. Conversely, when muscle is totally unloaded, it suppresses this system through insulin resistance, down-regulating protein synthesis and up-regulating catabolism.[2]

Not only does this lead to an overall loss of muscle fiber cross-sectional area and ultimately functional strength, but this unloading can also precipitate a gradual change of fiber type predominance. In humans, fast-twitch fibers (Type II) are generally hit harder through selective degradation than type I. However importantly, Type I (slow fibers) show a type of maladaptation where their slow myosin is degraded and replaced by faster MHC isoforms, mostly IIX. This creates a new hybrid slow/fast fiber which is smaller, has less strength overall and contracts faster — therefore fatiguing more quickly.[3] This may not seem particularly important, but our body’s proportion and distribution of muscle fibers evolved as it did due to the specific evolutionary pressures, namely, the gravity field our ancestors resided in all through their evolution. When the loss of slow twitch fibers reaches a certain point, it severely degrades endurance for even routine functions like ambulation.[4] Finally, much like the inpatients who spend weeks at a time not fully mobilizing a joint, and then attempting to use it in a full range of motion, many astronauts experience calf and hamstring pain, as well as plantar fasciitis upon returning to Earth.[5] Their joints and muscles having developed what amounts to essentially disuse contractures in the unloaded environment of uG. How will these effects magnify with even longer-duration space flight?

When we consider the skeletal remodeling and muscle degradation that takes place in uG environments, it is important to remember that these systems respond not just to load, but also to other critical environmental factors, like the endocrine milieu they find themselves in. Astronauts on the ISS have been shown to have elevated cortisol levels on orbit, which can independently enhance muscle and bone breakdown.[6] Additionally, low light levels and high ambient CO2 concentrations can have a profound effect on the skeleton by lowering vitamin D levels and promoting an acidotic environment which also speeds bone density loss. Within a few days of entering weightlessness, urinary calcium excretion increases by 60–70%,[3] similar to that of a newly quadriplegic patient. This increased calcium load can likewise cause an imbalance in protein metabolism and activate muscle catabolism.[2]

The issue of muscle and bone loss was identified early in human spaceflight, and counter-measure programs were begun to help mitigate these changes. However, it has proven quite difficult thus far to truly stave off the effects of long term uG. At minimum, a heroic effort is required from astronauts who must become exercise fanatics upon entering uG, with current countermeasure plans requiring 2–2.5 hours of exercise 6 days a week. Even with this effort, the astronauts only manage to maintain an approximation of normal muscle strength and composition, but still had measurable losses.[4] Variations in countermeasure programs have evolved over the years, with the first efforts being a type of cycling device, then rubber band-like devices, providing for some resistance exercises, then finally the advanced resistive exercise device (ARED), which allows for weight-lifting like maneuvers to take place in uG using a clever series of vacuum tubes and hinges. Barbells, as one might imagine, aren’t quite as useful without gravity. In addition to these exercises, other pharmacologic countermeasures have been employed for reducing bone density losses in uG, like the use of bisphosphonates. In the right combination, exercise involving heavier load bearing exercises with ARED, good nutritional support and bisphosphonates have been shown to mostly stave off bone mass losses in long duration flight.

The cardiovascular system similarly adapts to an environment that asks much less of it. Our circulatory system came into being over the countless evolutionary iterations, and it did so with the constant assumption of gravity. The strength of the pumping action of our hearts, the ability of our vasculature to dilate and contract to maintain pressure, the one-way valves in the veins of our limbs, the baroreceptors in our carotid arteries: all these features exist as a direct response to gravity as an evolutionary pressure. In uG the heart shrinks, as it no longer must pump against the same fluid column that it did on Earth.[7] Additionally, there is a profound fluid redistribution that results in a ~15–20% loss of total intravascular volume, hypothesized to occur because there is no longer a direction of “down” pulling blood away from the brain.[3, 7] This means the vasodilation and vasocontractile feedback systems become lazy, they aren’t activated to constrict the intravascular volume when hypovolemic, or to relax in response to increased intravascular volume. This results in several unwanted consequences. Upon returning to a gravity field, (so far this only includes Earth’s G field), astronauts experience orthostatic intolerance, becoming profoundly dizzy and lightheaded with any postural change; significant, and sometimes severe, lower extremity edema; and a reduced exercise capacity. This is the case, even when maintaining an incredible 15 hours a week of dedicated exercise time.[7] The recovery time is somewhat proportional to the time spent uG, but can be weeks before the astronaut regains a semblance of ‘normal’ functionality, and months before they can feel back to the way they were before their mission. So far, the methods of using salt tablets, aggressive hydration, and lower body compression garments can ward off the worst of the orthostatic hypotension upon returning to Earth. However, a new kink in the cardiovascular consequences of a weightless environment has only just made itself known. A recent study has shown that the uG environment has the concerning ability to allow for clot formation in the jugular vein.[8] This thrombosis was discovered during a study looking at the vessels of the neck during spaceflight. What the study revealed was a disconcerting stasis within the jugular vein in 5 of the 11 study subjects, and in one, a clot. So far, spaceflight has not shown a greater propensity for DVT formation in the limbs, but this is unsurprising. Afterall the astronauts are performing hours of rigorous exercise daily and the skeletal muscle pumping involved is enough to ward off DVT, even when they spend the remainder of their day completely unloaded. Similarly, mere ambulation on Earth normally accomplishes this same preventative measure. There is an important difference in this case though: the vessels of the neck don’t require skeletal muscle pumping to prevent stasis on Earth, and for all of humanity’s evolutionary development, gravity ensured that there was no venous stasis in the veins of the head and neck. This is important because there is no easy countermeasure to employ, like exercise, that can remove the thrombosis risk for the veins of the head and neck in an environment that produces venous stasis. In the case of this thrombosis event, the astronaut, who was asymptomatic, was treated with the appropriate anticoagulation and removed from the study.

Acknowledging the importance of our body’s relationship to fluid columns, another potential issue is starting to take shape. Long-term uG exposure appears to be causing spaceflight associated neuro-ocular syndrome, or SANS. This is the constellation of symptoms including optic disc swelling elevated intra-ocular pressure, microvascular infarcts and globe-flattening which are presumed to be, related to if not the cause of, astronauts losing their near-distance vision. It has been known for some time that astronauts can experience decrements in their near vision in as little as a couple weeks on orbit. So much so that they often arrive on orbit with ‘space anticipation glasses’ to correct their impending near-vision loss. Now we have increasing evidence that not only does the eye change shape, but some concerning findings relating to the brain and its own fluid column of CSF are also starting to become evident. Optic disc swelling can be a sign of elevated intracranial pressure (ICP). Elevated ICP can lead to a host of other issues, as those of us used to caring for patients with brain injuries and strokes are all too familiar with. Elevated ICP’s have been measured on many astronauts upon returning from long duration flights. Noted decrements in cognitive performance after long duration missions speak to the fact that something has affected the brain in a more global sense. It is unclear if there is a relationship to these cognitive impairments with the changes seen in the brain. Recent studies show the changes in the brains of astronauts after exposure to uG where there seems to be compression leading to apparent disruption of normal CSF flow and even remodeling between pre and post-flight MRI images.[9, 10] An additional consideration not yet explored, is that if we can already see changes in the way the CSF moves around the central nervous system, this might also imply a glymphatic disruption. The glymphatic system is the recently characterized lymph-like (glia-lymph) fluid that activates on a cyclic pattern, usually during the sleep cycle, carrying away waste products like metabolites and proteins, notably beta-amyloid. Disruption of the glymphatic system is thought to play a role in many brain disorders like Alzheimer’s and other amyloidopathies. Additionally, some have hypothesized there might be a significant role of the glymphatic system in the recovery, or subsequent failure thereof, after a traumatic brain injury. All of these are promising avenues of research, with important crossover from space medicine to terrestrial care, including PM&R.


One of the candidate countermeasures so far employed for combating this fluid redistribution are some rather comical looking trousers called Chibis that look like they belong in a Wallace and Grommet movie. They are also known as lower body negative pressure devices (LBNP). These negative pressure pants do just as their name implies, they provide a negative pressure around the wearer’s legs that result in a type of forced vasodilation, like the way an old iron lung caused expansion of the chest by negative pressure around the thorax. This in turn is hypothesized to draw the fluid column away from the head by creating a net flow towards the legs. So far, this device has had mixed results, but does show some promise in the short term for alleviating some of the fluid shift. More data will be required to see if it is useful at counteracting the effects of these caudal fluid shifts in the long term and if this is protective against SANS.

These interesting pathologies associated with spaceflight are significant and important to acknowledge, but they are not insurmountable. The human tendency is to explore, continually pushing the boundaries of our current capability. This drive for exploration, for seeking the novel and the unknown “to boldly go where no one has gone before,” provides a fertile ground for innovation and the rethinking of old problems. Space exploration provides the ultimate challenge, a continually renewing frontier whose secrets bring us closer to understanding our universe. In the 3rd and final article in this series, we will explore some of the future directions and upcoming research into space medicine and physiology, the necessary innovations to enhance survivability and what it means for the viability of future, more challenging human spaceflight.


  1. Vico, L. and A. Hargens, Skeletal changes during and after spaceflight. Nat Rev Rheumatol, 2018. 14(4): p. 229–245.
  2. Gao, Y., et al., Muscle Atrophy Induced by Mechanical Unloading: Mechanisms and Potential Countermeasures. Front Physiol, 2018. 9: p. 235.
  3. Buckey, J.C., Space physiology Oxford University Press, 2006: p. 4.
  4. Fitts, R.H., D.R. Riley, and J.J. Widrick3, Functional and structural adaptations of skeletal muscle to microgravity. The Journal of Experimental Biology, 2001. 204: p. 3201–3208.
  5. Barret, M.R. and S.L. Pool, Principles of Clinical Medicine for Space Flight. Springer, 2008: p. 299–300.
  6. Nicogossian, A.E., et al., Space Physiology and Medicine From Evidence to Practice. Springer, 2016.
  7. Shen, M. and W.H. Frishman, Effects of Spaceflight on Cardiovascular Physiology and Health. Cardiol Rev, 2019. 27(3): p. 122–126.
  8. Marshall-Goebel, K., et al., Assessment of Jugular Venous Blood Flow Stasis and Thrombosis During Spaceflight. JAMA Netw Open, 2019. 2(11): p. e1915011.
  9. Roberts, D.R., et al., Effects of Spaceflight on Astronaut Brain Structure as Indicated on MRI. N Engl J Med, 2017. 377(18): p. 1746–1753.
  10. Riascos, R.F., et al., Longitudinal Analysis of Quantitative Brain MRI in Astronauts Following Microgravity Exposure. J Neuroimaging, 2019. 29(3): p. 323–330.

Luke Brane is a PGY2 in the Department of Physical Medicine and Rehabilitation at the University of Pittsburgh Medical Center (UPMC). Follow him on Twitter @LBraneMD

An Update on Regenerative Medicine

by Brandon Barndt, DO

The State of the Art: Where are We with Orthobiologics?

Can we potentially replace some traditional drug therapies and surgical interventions with orthobiologics? Where are we as it pertains to the safety, efficacy, and cost of these treatments? This is an important issue as musculoskeletal (MSK) conditions cost an estimated $1 trillion dollars annually and many patients are looking for non-operative, new treatments (1). A recent Washington Post article examining how people suffering from knee pain are investigating alternatives to surgery suggested that those with MSK conditions are also hesitant about the prospects of surgery (2). Orthobiologics are a promising therapy that may effectively and safely treat common MSK conditions.

Platelet-Rich Plasma

One of the biggest players in the orthobiologic space is platelet-rich plasma (PRP), which is an autologous plasma product that contains a concentration level of platelets that is higher than what is normally in blood. It is obtained by drawing blood from a patient, spinning it down with a centrifuge to concentrate and separate out the platelets from the plasma and red blood cells. Since its first reported usage in the 1980s, it has continued to be used to help promote healing of tissues. More recently, PRP has found a potential niche in MSK medicine where it is used to promote the healing of connective tissue. Connective tissue has a notoriously slow healing process due to low vascularity and slow cell turnover. PRP may help in this regard because of the healing and angiogenic effects of the growth factors contained in the alpha granules of platelets, which, as mentioned, are in supraphysiologic concentration in PRP.

Physiatrists out of Spaulding Rehabilitation Network performed a review of the usage of PRP in MSK, and discussed at length the evidence for the usage and efficacy of PRP for MSK indications (3). In general, PRP investigations have revealed mixed results, with RCTs demonstrating either favorable or unfavorable results for usage in various tendon, ligament, and cartilage injuries and pathologies. Results tend to be highly variable, even when considering the same pathology, suggesting the potential for issues with standardization of the treatment and patient selection. Researchers out of Weill Cornell and Columbia, among others, have supported this notion by publishing critiques about the lack of standardization of the process to create the PRP used in studies, issues with adoption of classification systems to measure and classify PRP composition, and the lack of proper patient selection (4,5). As many private companies have moved into the PRP space to sell their own products and supples, it may come as no surprise that there tends to be a lack of transparency in reporting of creation processes and PRP composition. Add this to the fact that PRP itself is still a relatively young therapeutic technology, and it stands to reason that there may be important technical challenges at this stage. That being said, PRP has an attractive mechanism of action (i.e., facilitating the body to heal itself) and a low rate of adverse reactions, thus there is great incentive to create a transformative healing modality using it.

Bone Marrow Mesenchymal Stem Cells

Another major orthobiologic is stem cells. Stem cells enjoy a nearly mythical image in popular science and the media, where they may be viewed as a panacea for various ailments. We all have stem cells in various locations throughout our bodies working to regenerate tissues and maintain homeostasis. The idea that we can take stem cells from one part of the body and inject them into another so that they will differentiate into the cell type of the surrounding tissue is likely too good to be true. When mesenchymal stem cells (MSCs) are introduced into an injured tissue, it appears that they may promote healing of the existing tissue through immunological recruitment, rather than the replacement (regeneration) of lost tissue.

The primary type of MSC that is used for MSK pathology is bone marrow mesenchymal stem cells (BM-MSCs). A research group out of New York University recently completed a review of BM-MSCs for MSK conditions (6). They compiled a total of 29 studies where either BM-MSCs or concentrated bone marrow aspirate (cBMA) was used for the treatment of MSK pathologies. Only 13 of the studies used BM-MSCs and most of these, which primarily looked at treatment of osteoarthritis, did not contain a proper control group. While the results of these studies were largely positive, the outcome measures and procedures varied widely. Generally, patients had improved functional and pain outcomes. Additionally, the review contained studies using BM-MSCs to treat focal cartilage defects and yielded mixed results. The lack of control groups and low evidence rating of studies remains an obstacle that must be addressed with higher quality research.

Like PRP, there is heterogeneity in the literature in regard to processing and composition of BM-MSCs used in injections, co-injection compounds, culture expansion protocols, volume of injected cells, and other variables that are of paramount importance when it comes to ensuring patient safety and therapeutic efficacy. A consensus recommendation was made in 2018 by the American Academy of Orthopaedic Surgeons and the National Institutes of Health that emphasized the importance of standardization of investigations into the usage of stem cell therapies.

Adipose Stem Cells

Another example of the usage of stem cells for MSK pathology is adipose tissue derivatives (ATDs). Researchers out of the University of Pittsburgh published a review in 2019 examining ATDs as a therapeutic option (7). ATDs contain adipose stem cells (which are mesenchymal cells) and can differentiate into connective tissue. ATDs may consist of micro-fragmented adipose tissue [MFAT] or stromal vascular fraction [SVF]). Adipose stem cells can also be isolated, but they lack the other cells which are thought to support their healing properties via growth factor release. According to the 2019 review by Schroeder et al., there is only one RCT with ATDs, but it was comparing ATDs to PRP in non-insertional achilles tendinopathy. Beyond this, there are 19 other papers, which are case reports or case series, that are mostly concerning knee pathology, with few papers on hip, shoulder, or ankle pathology. This remains another area that is ripe for quality clinical investigation.

As is a recurring theme of orthobiologics, there is ambiguity and heterogeneity in the literature concerning methods of production and composition of ATDs, as well as indications, amount of product used, guidance of injection, use of other injectables (e.g. PRP, corticosteroid) or procedures (e.g. tenotomy) with the ATD, and post-injection rehabilitation. Despite this, existing studies report positive results with improved pain and function and an absence of significant adverse events. ATDs are a promising and increasingly studied modality for MSK conditions that deserve further investigation and standardization.


The growth of orthobiologics continues with nearly 900 regenerative medicine companies across the world and over 650 clinical trials underway (8). Patients, physicians, and companies are in search of safe and effective therapies for MSK conditions that comprise a nearly $1 trillion dollar (~$373 billion in osteoarthritis alone) economic burden. Medicine thrives on its imperative to seek and discover new, efficacious, cost-saving treatments. Orthobiologics offer a potential benefit that will require further research for its elucidation as we continue to refine our preparation methods, injection procedures, and ultimately establish best practice guidelines.


  1. Total Economic Impact on the US Economy. (n.d.). Retrieved from https://www.boneandjointburden.org/fourth-edition/viiie1/total-economic-impact-us-economy.
  2. Squires, S. (2019, November 17). Suffering from bad knees, some look for alternatives to surgery. Retrieved from https://www.washingtonpost.com/health/suffering-from-bad-knees-some-look-for-alternatives-to-surgery/2019/11/15/d286d862-dfd7-11e9-be96-6adb81821e90_story.html.
  3. Wu Peter I-Kung, Diaz Robert, Borg-Stein Joanne. Platelet-Rich Plasma. Physical Medicine and Rehabilitation Clinics of North America. 2016;27(4):825–853. doi: 10.1016/j.pmr.2016.06.002.
  4. Amin I, Gellhorn AC. Platelet-Rich Plasma Use in Musculoskeletal Disorders: Are the Factors Important in Standardization Well Understood? Physical medicine and rehabilitation clinics of North America. 2019; 30(2):439–449. DOI: 10.1016/j.pmr.2018.12.005
  5. Chahla J, Cinque ME, Piuzzi NS, et al. A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting The Journal of Bone and Joint Surgery. 2017; 99(20):1769–1779. DOI: 10.2106/JBJS.16.01374
  6. Kingery MT, Manjunath AK, Anil U, Strauss EJ. Bone Marrow Mesenchymal Stem Cell Therapy and Related Bone Marrow-Derived Orthobiologic Therapeutics. Current reviews in musculoskeletal medicine. 2019. DOI: 10.1007/s12178–019–09583–1
  7. Schroeder A, Rubin JP, Kokai L, Sowa G, Chen J, Onishi K. Use of adipose‐derived orthobiologics for musculoskeletal injuries: a narrative review. PM&R. 2019. DOI: 10.1002/pmrj.12291
  8. Mautner K, Carr D, Whitley J, Bowers R. Allogeneic versus autologous injectable mesenchymal stem cells for knee osteoarthritis. Tech in Ortho. 2019; 34(4):244–256.

Brandon Barndt is a PGY1 and graduate of Philadelphia College of Osteopathic Medicine (PCOM). He will attend Temple/Moss Rehab for his Physical Medicine and Rehabilitation residency as a PGY2. Follow him on Twitter @BrandonBarndtDO

How an Amputee Vietnam Vet Gives Back

by Michael Appeadu, MD

It was my first month working at the Miami VA hospital. As a second year physical medicine and rehabilitation (PM&R) resident, I had one afternoon a week during the rotation dedicated to working in the amputee clinic. I had no idea what to expect. Walking through the waiting area, I saw several men sitting down waiting to get called inside — some reading magazines, others on their phones. Many wore prosthetic legs, and some were in wheelchairs with coverings over amputated limbs. Their faces all wore the mutual hospital-waiting-room-expression: an unusual combination of eagerness and boredom. I noticed a man walk out of the clinic with a clipboard in hand to call patients inside. He wore a blue Polo shirt, khaki shorts, and two shiny silver lower extremity prostheses. He stopped to chat and laugh with a few patients, and I watched as their hospital-waiting-room-faces transformed into pure joy. That was the first time I saw Andy Perez.

I soon discovered that Andy is part of an amputee clinic team that is clearly a well-oiled machine. Rafael Hernandez, Dr. Xavier Aviles, and Ramon Leal see several patients, all at different stages in their journey from amputation to prosthesis, and afterwards. They take the time to check each patient’s residual limb-healing process, and examine how they are walking. Orders for prosthetic sleeves, elastic socks, protective dressings and any other materials needed are placed. A prosthetist is usually present to fit and make adjustments. I was impressed watching all the moving parts efficiently falling into place.

After Andy went out to the waiting room and called the next patient’s name, a man with a left leg prosthesis slowly stood up in response and walked toward the door. He stood in front of Andy and stuck out his hand expecting a handshake. Andy looked at him and said, “Are you lost, sir?” The man stood there and didn’t say a word. “Because it looks like you’re on your way to a rock ‘n roll concert,” he said pointing at his Metallica shirt. They both erupted in laughter. After some more back and forth banter, the man’s face became serious as he turned toward me. “This guy right here,” he said emotionally, pointing at Andy. “I would not be where I am without him.”

As my time at the VA continued, I had the opportunity to attend a session of the amputee support group. Over a dozen veterans filed into a well-lit, class-sized room, an hour before lunch. The group was facilitated by Dr. Laura Weinberg, a VA staff psychologist. Andy sat near the corner of the room in front of me. Many of the veterans opened up about personal challenges pertaining to their amputations. The length of time from surgery to placement of prosthesis alone can take several months. This is often marked by uncertainty about what the future will hold. Fortunately, those at later points in their journey were present to provide personal anecdotes and to encourage those who had only recently undergone their life-changing procedures. One veteran described his fears after a recent bilateral amputation. Another responded detailing what the last few years had looked like for himself. He turned to the corner of the room and explained that his motivation came from Andy, who then recounted, “There was never a moment where I thought that I would not walk.” The assembly of heads nodded understandingly.

Amputees are a growing population. In 2005, 1.6 million Americans were living with limb loss. That number is expected to reach 3.6 million by 2050. Approximately 1 million people under the age of 65 are living with the loss of a limb. These individuals will require prosthetic and other health services for years in order to ensure an active and productive life.[1] For aging veterans being cared for at VA facilities, diabetes or peripheral vascular disease, are the most common causes for lower limb amputation.[2] In 2017, there were more than 10,000 new amputations performed in the VA. Behavioral health is an important consideration in treatment, as depression, anxiety, and PTSD commonly occur. To optimize the functional independence and health outcomes of each patient, a multi-modal, transdisciplinary amputation care team approach is utilized, involving rehabilitation physicians, pain management specialists, surgeons, mental health providers, social workers, nurses, occupational and physical therapists, podiatrists, certified prosthetists, and others depending on individual patient needs.[3]

Andy told me about the events leading up to his lower limb amputations, detailing his history of cardiac problems starting in his 20s until cardiac valve replacement in 1998, and severe peripheral vascular disease years later. The 69-year-old Vietnam War veteran explained, “Everything had to do with Agent Orange — that’s where it all started.” In November 2013, he lost his right leg, and in January 2014, he lost his left. During the second amputation, he was in the hospital for a total of four months, the last of which included physical therapy. It was there that Andy met Rafael, who he currently assists in the amputee clinic. “Rafael was really tough. Kind of like a drill sergeant…A lot of people went out of their way to help me. There are people there who aren’t getting enough credit for what they do.” I came to realize that Andy strives to create the same inspiration for others that was once given to him.

“I typically wake up and put on my legs around 5:30 am. Then I have to stop and grab my Cuban coffee,” Andy says with a hearty laugh. When he gets to work he meets up with Rafael. “We talk about any new issues. He tells me about new patients, people who are unsure about amputation.” Then Andy makes his rounds, talking to all the amputees, answering any questions he can. “I’m only one person. You have all the doctors that talk to them and all of that, but a lot of these veterans don’t pay attention to some of that. They look at me, ‘Hey this guy’s lost his legs, let me talk to him,’ being very upfront with me. That’s just the way it is.” Andy has continued to broaden his role at the VA. “I used to help just amputees. But for the last three years, I help any veteran that needs help. That’s what keeps me so busy.”

Explaining benefits to patients is another way Andy strives to make an impact. “Half of them have no idea what benefits they have. Benefits is a big thing for veterans, especially amputees.” A good portion of his time is spent mingling with The Veteran’s Affairs Department, who he says are great to work with. He typically volunteers at the VA 3–4 days a week, spending anywhere from 4–8 hours working with patients. “It’s a good feeling. It’s therapy for me. By doing what I’m doing, I know it’s helping…I try to get involved to make sure the end results are little better than what they expected.”

As I sat down talking with Andy one day before clinic, he pulled out his phone and showed me a photo of him in winter gear, skiing. He told me about the trip to Colorado that around 20 veterans attend annually. In the beginning he was reluctant to go. “They kept asking me and I kept saying no. Then in 2017, I finally went. Going from Miami to Aspen, where everything is just hills and mountains. Next thing I look out the room at the ski lifts. It was scary for me at first, but let me tell you the first time I did it, that’s all she wrote. It’s such an adventure.” His words made me think about the interconnection between support and quality of life. I thought about Andy, who is supported by his family at home, and so many others at the VA. I thought about a patient who had come to the clinic who wanted to continue surfing, and was accommodated by receiving specialized prostheses. I thought about the length of time, range of emotions, and discipline it takes to reach that point. I asked Andy what was the most important piece of advice he could give to people who have just undergone amputation. He responded, “Be optimistic. Because everything falls in there. A can-do attitude is a must.” He then got up, and went to the waiting room to call in the first patient.


  1. Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050 Ziegler-Graham, Kathryn et al. Archives of Physical Medicine and Rehabilitation, Volume 89, Issue 3, 422–429
  2. De Luccia N, Pinto MA, Guedes JP, Albers MT. Rehabilitation after amputation for vascular disease: a follow-up study. Prosthet Orthot Int. 1992 Aug;16(2):124–8.
  3. Webster, J. B., Crunkhorn, A., Sall, J., Highsmith, M. J., Pruziner, A., & Randolph, B. J. (2019). Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense. American Journal of Physical Medicine & Rehabilitation, 98(9).

Michael Appeadu is a PGY2 Resident Physician in the Department of Physical Medicine and Rehabilitation at the University of Miami/Jackson Memorial Hospital. Follow him on Twitter @MikeAppMD

My Experience with TBI

by Noel Blanco, DO

Why at sixteen years old would I repeatedly surf on a car? And how would this end? Probably unfavorably. I suffered a traumatic brain injury (TBI) outside of a typical sporting environment. Reflecting on that event has inspired this essay to reflect on the changes of the Return to Learn and Return to Play protocols provided by the International Conference on Concussion in Sport (ICCS), American Medical Society for Sports Medicine (AMSSM), and the American Academy of Neurology (AAN).

Recalling to a cloudy October Friday of my Junior year in high school, I “car-surfed” for the last time. One afternoon, I hopped on my classmate’s parked sports utility vehicle’s running board with both feet and gripped the roof rack with my right hand. He quickly reversed the car into the lane, placed the car in drive, and hit the gas; and the next several minutes were a blur. Was it several minutes? I do not recall.

I slowly regained consciousness seeing a gray sky and a gentleman, maybe a firefighter or paramedic, who asked the standard orientation questions:

“What’s your name?”


“Where are you?”

“I do not know.”

“What time of the day is it?”

“I do not know.”

“Who is the president?”


Then, everything faded. I do not remember my parents coming to my side promptly as they intended to pick me up to attend my younger brother’s football game. Fortunately, his team won and he ran the ball exceptionally well.

The EMS staff took me to a familiar emergency department (ED). Two years earlier an orthopedic surgeon repaired my right humerus Salter-Harris fracture, and before medical school, this ED became my employer as an Emergency Medical Technician. Several hours later, I woke up with my parents and the ED physician excitedly crowding me. I only suffered abrasions, and fortunately, I had no intracranial bleeds or fractures. Approximately thirty minutes later, my parents drove me home, but we briefly stopped at a friend’s party to alert my friends of the events and my health before retreating home for rest.

Over the weekend, I watched TV, talked with my parents and brothers, and completed my homework assignments. As an eager and disciplined student with a strong desire to attend a great college, I returned to my typical rigorous learning environment of honor and advancement placement classes that Monday. On that morning’s announcements, I heard my school principal educating my classmates and I about my horseplay in the parking lot, which led me to embarrassingly hide my head into my books. That fall, I was not involved with any organized sports, and a return to play protocol was unnecessary. With permission from my parents, I opted against a follow up appointment as I only wanted to return to my school work.

One would say that this action was typical of a “role model” student of my high school: ASB Student Council, Honor Student, Football and Track athlete, multiple clubs, and maybe a single detention. My health history had no significant abnormalities: asthma, allergic rhinitis, atopic dermatitis, and minor musculoskeletal injuries.

Gratefully, I had a quick recovery and did not suffer any post-concussion symptoms or difficulties with my studies. In addition, I did not have any long-term effects from my TBI, such as seizures, headaches, or neurological deficits.

In the last several years, it has been exciting that physicians, mid-levels, athletic trainers, athletes, parents, teachers, and coaches were and are still learning about recognizing concussions, post-concussion syndrome, and the protocols to recovery. Cognitive and physical rest are given to patients to ease back into their learning and playing environments. During my time as an Army General Medical Officer, I attended multiple symposiums and conferences to apply Military Acute Concussion Evaluation (MACE) and neurobehavioral symptom index for my soldiers.

I do not plan to emphasize the acute management of a TBI but I would like to emphasize the focus on Return to Play and Return to Learn protocols. It would behoove medical health staff to include educational material for the patient’s family.

Each student athlete will require individualized plans for returning to learn and play. Recommendations from ICCS include this simple 4 step process to regular neurocognitive function and advance when asymptomatic:

  1. Home daily activities (i.e. texting, screen time, reading) that do not cause symptoms
  2. Outside school assignments such as cognitive activities, reading, or homework
  3. Part-time return to school or with increased breaks
  4. Full-time return to school to include missed work

For return to play, the patient should approach these 6 steps in order and advance each step when he/she have been asymptomatic for at least 24 hours:

  1. Recovery period of no activity
  2. Light aerobic activity (elevate heart rate) when the athlete has not symptoms
  3. Sport specific activity (incorporate movement) when the athlete has no symptoms
  4. Non-contact training drills (elevate exercise, attention, and coordination)
  5. Full contact practice (functional skills assessment and confidence)
  6. Return to play

I was fortunate to not suffer any long-term effects from my TBI. It is imperative as physicians that we provide clearly defined guidelines for our student-athletes and modify appropriately for each patient to prevent long-term complications.

*Disclaimer: This is the opinion of the author and does not reflect my employer, Geisinger.


  1. https://now.aapmr.org/sports-concussion/
  2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport — the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;0:1–10.
  3. https://www.uptodate.com/contents/concussion-in-children-and-adolescents-management?search=concussion&source=search_result&selectedTitle=2~74&usage_type=default&display_rank=2#H13513897

Noel Blanco is a PGY1 at Geisinger Commonwealth School of Medicine in the Department of Physical Medicine and Rehabilitation. He is also a veteran and American Ninja Warrior. He also has a blog. Follow him on Twitter @DrNoelBlanco.

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