Contributed by Helen Rousso, Medical Exercise Specialist

Following a brain injury, individuals who exercise are typically less depressed and report better quality of life than those who don’t exercise.

A safe and effective exercise program can play a very important role in the rehabilitation process following a brain injury.  Regular physical activity can help improve your balance and coordination, reduce reliance on assistive devices, and enhance your ability to do daily activities and thus remain independent.

The key is to determine what type of exercise is best for you and to follow a program that accommodates and addresses your special medical concerns.

Range of motion exercises are a type of physical therapy that keeps the joints mobile and functioning. Range of motion exercises can be done by the individual, or with help from physical therapies in a method known as passive range of motion. Range of motion exercises help maintain strength and can be separated into short or long term goals.  Such exercises as simply extending and flexing the forearm or the lower leg help to maintain muscle tone and functioning ligaments and tendons that enable you to gradually regain strength or function of the limb over time.

One may recover from a traumatic brain  injury (TBI) more quickly if they exercise. As “The New York Times” reported in 1997, TBI patients who exercise are “significantly less depressed, better at cognitive thinking and physically healthier” than those who do not. Neuropsychologist Wayne Gordon indicates that patients who maintained their exercise routine had to display discipline, focus and motivation – attributes that carried over to the rest of their rehabilitation.

In one of his studies, A sample of 240 individuals with traumatic brain injury (TBI) (64 exercisers and 176 nonexercisers) and 139 individuals without a disability (66 exercisers and 73 nonexercisers).

It was found that the TBI exercisers were less depressed than nonexercising individuals with TBI, TBI exercisers reported fewer symptoms, and their self-reported health status was better than the nonexercising individuals with TBI. There were no differences between the two groups of individuals with TBI on measures of disability and handicap.

In conclusion, the findings suggest that exercise improves mood and aspects of health status but does affect aspects of disability and handicap.

Getting Started

-Talk with your healthcare provider before starting an exercise program and ask for specific programming recommendations.
-Take all medications as recommended by your physician.
-The goals of your program should be to improve cardiovascular fitness, increase muscle strength and endurance, improve flexibility, and increase independence, mobility and ability to do daily activities.
-You may find that it is easier to focus on your exercise if you avoid busy, crowded locations.
-You may need to do some exercises such as cycling or walking with a work-out buddy if you have difficulty with balance or with finding your way throughout a community.
-Choose low-impact activities such as walking, cycling or water exercises, which involve large muscles groups and can be done continuously.
-Start slowly and gradually progress the intensity and duration of your workouts. -If your fitness level is low, start with shorter sessions (five to 10 minutes) and gradually build up to 20 to 60 minutes, three to five days per week.
-Perform resistance-training and stretching exercises two days per week.
-Take frequent breaks during activity if needed.

Exercise Cautions

-Avoid exercises that overload your joints or increase your risk of falling.
-Begin each exercise in a stable position and monitor your response before proceeding.
-Reduced motor control in your limbs may restrict your ability to do certain exercises.
-Exercise equipment may need to be modified to accommodate your specific needs.
-Always wear protective headgear when cycling or doing any other activity in which a fall is possible because the rate of a second head injury is three times greater after you have had one head injury.
-Don’t hesitate to ask for demonstrations or further explanations about how to perform exercises properly.
-Your exercise program should be designed to maximize the benefits with the fewest risks of aggravating your health or physical condition.

Serves Two

Preparation 10 Minutes

Cooking 20 Minutes

Ingredients

100g brown rice

2 slices lemon

2 slices orange

2 skinless salmon fillets (about 175g each)

1 tbsp roughly chopped fresh dill

1 tbsp sun-dried tomatoes in oil, roughly chopped, plus 1/2 (half) tbsp oil from the jar

75ml dry white wine

Method

1. Preheat the oven to 200C (gas mark 6). Place the rice into a large saucepan with 200ml of cold water. Bring to the boil over a high heat and leave to simmer for 20 minutes or until tender. Remove from the heat, season with sea salt to taste, and cover with the lid. Leave to stand for 10 minutes.

2. Meanwhile, in a large shallow baking dish place 1 lemon slice and an orange slice, just overlapping, next to each other. Repeat with the other 2 slices.

3. Sit each salmon fillet on its own bed of citrus. Season each fillet with salt and pepper. In a small bowl mix the dill, sun-dried tomatoes and tomato oil together. Spoon the mixture over the top of the salmon fillets. Drizzle with the wine.

4. Place the baking dish into the oven and cook for 8 – 10 minutes or until the salmon is opaque.

Serve drizzled with the cooking juices and the prepared rice.

Canadian Institute for Health Information press release

Number of cycling injuries remains stable over past decade but head injuries on the decline

July 28, 2011— Every day of the summer, an average of 45 Canadians are hospitalized for an injury resulting from a wheel- or water-based sport or recreational activity, according to new data from the Canadian Institute for Health Information (CIHI). Wheeled sports include cycling, roller skating, skateboarding and using scooters, while water-related activities include swimming, diving, kayaking and boating, among others.

“Summer is a great time to be active and enjoy the outdoors, but it is also a peak period for motor vehicle injuries and trauma related to wheel and water sports,” says Greg Webster, Director of Primary Health Care Information and Clinical Registries at CIHI. “It’s important to ensure that individuals and their family members use the proper equipment, follow the rules of the road or water and play safe while being active this summer.”

CIHI data shows that cycling injuries are by far the most common injury from summer sports and recreational activity, accounting for half of all hospital admissions in this category. In 2009–2010, 4,324 Canadians were hospitalized as a result of a cycling injury, with close to half of these injuries occurring in June, July and August.

While the annual number of cycling injury hospitalizations remained relatively stable between 2001–2002 and 2009–2010, the number of cycling-related head injuries decreased significantly, from 907 to 665, over the same period. Among the most severe cycling injury admissions of the past decade (those requiring admission to a special trauma centre), 78% of those hospitalized with a head injury were not wearing a helmet when their injury occurred.

“While the number of cycling injuries has remained static over the past decade, the good news is that many studies are showing that the widespread use of helmets has resulted in fewer serious head injuries among children,” says Pamela Fuselli, Executive Director of Safe Kids Canada. “Even with the proper equipment, however, cyclists and motorists need to remain vigilant when they are out on roads and recreational trails. It’s really important to get outside and play, but it’s equally important to do so safely.”

Between 2001–2002 and 2009–2010, hospital admissions for cycling injuries were most common among children and youth younger than 20 (42%), with 10- to 14-year-old boys hospitalized the most frequently.

Among the provinces, in 2009–2010, cycling injury age-adjusted hospitalization rates were highest in British Columbia and Alberta and lowest in Ontario and Nova Scotia.

Other highlights from CIHI’s most recent trauma data:

During June, July and August, an average of 194 deaths occurred every year in Canada from all motor vehicle collisions, all-terrain vehicle (ATV) collisions and summer sports and recreational activities.
The number of serious injuries involving ATVs is growing faster than that for any other major type of wheel- or water-based activity. In 2009–2010, there were 3,386 hospitalizations for ATV injuries across Canada—a 31% increase since 2001–2002. Those at highest risk of injury were young men age 15 to 24.
Motor vehicle collisions still represent the number two cause of injury in Canada, second only to falls, with 18,964 hospitalizations in 2009–2010. However, this number has declined significantly (21%) from 2001–2002. The summer months, August in particular, and the Christmas season represent peak periods for motor vehicle collisions.
The number of water-related injuries has remained relatively stable since 2001–2002, with 331 injuries occurring in 2009–2010.

The afternoon of June 8, 1995 would change our lives forever. A mother gets up in the morning and goes about her day, often not thinking about what could happen later on. I have a different perspective now and am grateful for every moment I have with my children and family. I will never take that for
granted again.

My oldest son, Matthew, who was then 17 and excited about summer holidays and exploring work opportunities, crashed his motorcycle. The accident happened in the parking lot outside our apartment; he wasn’t wearing a helmet and his then 15 year old brother Michael watched it happen. A neighbour rushed
to the scene and with Mike’s help, kept Matt alive until the ambulance arrived.

The local newspaper report the next day stated that the young man “suffered non-life threatening injuries.” Anyone who has observed a family member in a
coma and on life support understands that this is definitely life threatening!! To this day I can visualize the emergency room when I got there-my son, on a stretcher, covered in blood, clothes cut away, a nurse pushing air into his lungs with a bag, in a comatose state. I touched his arm, praying silently, tears streaming down my cheeks, that Matt would live. Michael was devastated and inconsolable, blaming himself for not, somehow preventing the accident.

The social worker assigned to our family was calming, but calling family and friends was a huge test of emotional strength. Matthew had sustained a
traumatic brain injury, with extreme damage to all lobes. He had a skull fracture, an epidural hematoma (removed two days later in surgery), and
multiple other open wounds and breaks. He was on life support and the scans showed that there was not much brain activity. Before long, infection started
in all the open wound areas and nothing was working to get that under control.

The I.C.U. waiting room was soon filled with Matt’s many friends and our family, all struggling to come to terms with the extent of this situation. Mike’s grief was overpowering and he spent countless hours near his brother, as if to will him back to life.

The question was then asked of us, to pull life support or not? We all knew Matt as an intelligent, athletic, fun, hard working young man and knew he would never want to live in a prolonged, non-functioning state. But, what if there was a chance for getting better, for Matt’s brain to heal? What
to do? We prayed, we talked, we begged God and we waited, putting off the BIG decision. In my optimistic way I thought I could deal with the outcome,
hoping we could bear it, no matter what. First we had to get through this period. And Matthew did.

My journal entries during that time record the steps along the way, theanguish, the excitement and the pain.
* Day 22-out of ICU, moved to another wing, not breathing alone, moving arms and legs erratically
* Day 25-IV out, nourishment by feeding tube still
* Day 30-breathlng alone, eyes open, no focus
* Day 40-eatingjelled foods, no bladder control, recognizes us!!!, very fearful, loud noises create outbursts, cursing and very angry, hitting out
* Day 45-relearning colours, numbers, left/right, some bladder/bowel control, restless, walking with help, 24 hour attendants started to assist with behaviour control
* Day 60-brushlng teeth/shaving alone, angry and agitated, dressing with help, paces constantly, unaware of surroundings,
* Day 75-using phone to call home (remembers that number!!), writing with both hands, showering alone, finally asking about what happened.

And on it went for the next 2 years. The case manager assigned to Matt’s case tried her best to assist with needs and the steps of rehab. I could never have negotiated the system without her and am so blessed that my insurance provided her for Matthew. Often I asked myself if I could handle the next crisis, the pain, the lack of sleep, the worry, the long rehab process. Somehow Michael and I got through, often one moment at a time.

Many would disagree with me, but not “pulling the plug” would be a decision I would do differently today. Although Matt has made an amazing recovery,
every day is a huge struggle for him and the deficits make life very difficult for him.

I believe that his amazing recovery can be attributed to a few things: God made a miracle happen. Matt has inner strength and will power to outwit the
injury. The case manager implemented a great rehab programme and personnel to work with Matt. The nursing care was beyond exceptional. Mike and I gave the situation our undivided attention, filling in for hours when staff was not available, pushing and working with Matt to relearn and adapt. We both became very brain injury savvy!

The process was rocky and one of the hardest things we have gone through together. Matt was left with lots of scarring which was mostly fixed with
plastic surgery. He has a short term memory deficit and compensates with electronic devices to keep his life on track. He tends to have a “mask” face,
which comes across as angry and he works at using appropriate expressions. He can usually control the angry outbursts and is sometimes almost
indifferent. Fatigue is a huge factor, along with ongoing pain. He has learned to manage his lack of control over appetite and temperature. Matt has
pushed the limits of his brain injury and surpassed things the medical team said were impossible.

Matt works successfully at a trade, owns a home, built his own backyard deck, scuba dives and travels. He works out daily and pushes himself to be the best he can be. I got my son back in body, but a totally different person and with a whole unique personality. That has been very hard to adjust to and deal with emotionally. For Michael, the trauma of watching the accident and then working with me, putting our lives on hold, has created Post Traumatic
Stress Disorder, with years later effects. Financially we struggled through that period and the cost to the system and insurance was incredibly high. It did bring a huge awareness for our family, of the need for helmets.

For Matthew though, the price has been high. We saved his life, but at what price? He has the biggest daily life struggle imaginable and I can’t do it
for him. He often does it alone. As time goes on he is able to become more fulfilled and a participating member of society, giving back when able. For the rest of us, we love him, try to connect however we can and hold the guilt at bay.

(M.D.) – The Physiatrist is a physician who is a specialist in physical medicine and rehabilitation. The physiatrist is the Team Leader who directs your care.

(RN) – Your Nurse is also a very important person. She/he will:

• Assess you physically and obtain pertinent information necessary to design your personal care plan
• Take care of you and instruct you and your family so that you will be as independent as possible. The concept of independence is very important for you and your family to understand, as nursing care is based on this goal. Your nurse will encourage you to do as much for yourself as possible – and then some!
• Follow through with your other therapists’ recommendations for your care. After the first few days, you will be given a daily therapy schedule. You will be expected to keep your therapy appointments on your own whenever possible. If you are unable to get to your therapy appointments independently, a transporter will assist you.

Ingredients:
9 Whole Wheat Lasagna Noodles
1 tsp Olive oil
1 cup Red Onion
4 cups Mushrooms Sliced
3 cloves of Garlic minced
1 bag Baby Spinach, washed and dried
1 jar Tomato Sauce
1 cup Light Feta Cheese
1 container Light Ricotta Cheese
2 cups Light Mozzarella Cheese, shredded

Directions
1. Preheat oven to 375 F (190 C)
2. Cook Lasagna Noodles according to package directions. Drain and set aside.
3. For sauce: Heat oil in large sauce pan over medium heat. Add onions and mushrooms and cook for 10 minutes. Add garlic and spinach. Cover and cook until the spinach is wilted-about 5 minutes. Uncover and cook on medium heat for about 10 minutes or until most of the liquid has evaporated. Add the tomato sauce and some pepper.
4. To make the lasagna: Line the bottom of a 9×13 inch baking dish with 3 noodles. Top with 1/2 of the ricotta cheese, 1/2 of the sauce and 1/2 of the feta cheese. Repeat. Place the final 3 noodles on top and cover with mozzarella cheese.
5. Bake for 30 minutes or until the cheese is starting to brown.

Article reproduced from the Ontario Brain Injury Association newsletter, written by Jo Innes.

There can’t be a hockey discussion without a head injury discussion. It’s no surprise that day one of NHL GM meetings in Boca Raton has already produced policy changes that aim to increase player safety and reduce injury. Some of the changes will go into effect almost immediately; some will be implemented at the beginning of next season. Commissioner Gary Bettman laid it out in five steps:

1. Equipment changes – reduce the size without reducing the safety.
2. Revise concussion management protocols – have a doctor (not a trainer) make immediate return to play decisions.
3. Hold club and coach responsible for players with repeated offenses leading to supplemental discipline.
4. Study changes to rinks that can improve player safety – implement short-term fixes now, get rid of seamless glass for next season.
5. Establish a committee dedicated to continued study of the issue.

Can we talk about step 2?
Currently, players with suspected concussions are evaluated by the trainer, generally on the bench. The trainer’s evaluation has two possible outcomes – no concussion suspected and the player returns to the game immediately, or there is a suspected concussion and the player is removed to the dressing room and evaluated by the team physician. If the physician’s evaluation is suspicious for concussion, the NHL Protocol for Concussion Evaluation and Management kicks in and the player is kept out of play pending certain testing. The length of time is determined by the patient’s performance on neuropsychological tests (be patient, we’ll get into what those are), and the team physician makes the ultimate decision as to when the player can return.

The current NHL protocols are stringent with regards to keeping players off the ice once they’ve had a concussion, but don’t go far enough to get them off the ice in the first place – a determined player could insist to the trainer that he’s fine and end up back on the next shift.

The new protocol requires that the player be evaluated by a physician if he exhibits any of the following:
* Loss of consciousness
* Motor incoordination/balance problems
* Slow to get up following a hit to the head
* Blank or vacant look
* Disorientation
* Clutching the head after a hit
* Visible facial injury in combination with any of the above

The physician will perform the evaluation in “…a quiet place free from distraction” (i.e. not the bench), and will use a standardized assessment tool
– the NHL SCAT 2 (sports concussion assessment tool). After training the trainers and doctors in the specifics of the new concussion policy, Bettman
stated he expects it to go into effect by the end of the week.

Neuropsychological testing? What?

Neuropsychological testing is a way of determining if someone’s brain is working properly by testing their ability to answer questions and perform simple
memory and physical tasks. The roadside sobriety tests that cops perform are a great example of simple neuropsychological testing. The big deal here is that players are going to be evaluated immediately using the SCAT 2, and not by being asked “Are you okay? You good to go back out?”. The SCAT 2 is a series of (neuropsychological) tests that was developed in 2008 at the 3rd International Conference on Concussion in Sport, and represents revisions to
previous concussion assessment protocols. The SCAT 2 was designed for use by physicians, athletic trainers and other medical professionals. If you’d like
to have a copy of your own, it’s available for free download (The NHL is already using the SCAT 2 (as are the IIHF, FIFA, and several other big name sports organizations), but the bench is absolutely the wrong place to do it, and it likely wasn’t happening unless the trainer made the decision to
pull the player for physician assessment.

SCAT 2 Explained

Symptom evaluation: The patient is asked if he has any of 22 different symptoms that you’d normally associate with a concussion (nausea, dizziness,
headache, etc.), and grades them on a scale of 0-6 (none to severe). This assigns him a symptom severity score.

Cognitive and physical evaluation:
* Number of symptoms (out of 22)
* Physical signs: loss of consciousness or balance problem.
* Glasgow coma scale: Measures the ability to properly verbalize, follow motor commands, and open one’s eyes. This is a test commonly used on trauma patients to get a quick assessment of their overall level of consciousness. This is also a gross simplification on my part.

Want to know more?
* Maddocks’ questions: A set of questions related to the game at hand and recent sport-related events (Where are we playing? What period is it? What team did we play last?”) that provides another gross overview of orientation and mental status.
*C o g n i t i v e evaluation: Includes orientation (Day, Date, Year, etc.), immediate memory (give the player a list of words and ask him to repeat them back to you), concentration (give the player a list of numbers, have him repeat them back in reverse order; have the player say the months of the year in
reverse order). Balance testing: The player is asked to close his eyes and is given three 20-second standing trials – feet together, on one foot, and heel to toe. Coordination testing: The player is asked to sit with one arm outstretched to the side. He’s then asked to bend at the elbow and touch his nose five times in quick succession. More cognitive testing: The player is asked to recall the list of words from earlier in the test.

On my best day I’m not convinced this is a test I could ace. It should be pretty clear now why it’s essential that this be performed in a quiet area with no distractions. The SCAT 2 assigns the player a score, which is actually not used to determine if he can return to play. What it does do is provide a great way to keep track of the player’s deficits over serial tests (i.e. give the same test multiple times and track the scores over time).

Return to Play

The SCAT 2 gives a great outline of a protocol that could be used to determine when a player could get back on the ice. First and foremost, it suggests that a player suspected of having a concussion should not return to play that same day (I’m looking at you, Crosby). It goes on to recommend that the player gradually resumes activity over a period of days (weeks, months, never) based on what he’s capable of doing – any limitation by symptoms means activity levels don’t progress upwards. The progression of activity would be:
* Complete rest until symptom-free
* Light aerobic exercise
* Sport-specific exercise
* Non-contact drills
* Full-contact drills after medical clearance
* Return to competition

The SCAT 2 and the NHL Protocol for Concussion Evaluation and Management leave plenty of room for the team physician to decide if the player is ready
to get back in action. That, of course is the art of medicine. That’s also fodder for another huge debate – whether team doctors are looking out for the athlete’s best interests, the team’s interest in getting their player back on the ice, or the athlete’s insistence that he’s fine, Coach. Just fine.

Feel free to have that discussion amongst yourselves. Until I’m a team doctor, I won’t be making assumptions.

This is one of those things that most people get annoyed hearing about because most of us have difficulty accepting the fact that our brains can weaken from incidents of trauma, disease and/or aging.

Its been said that brain development is similar to muscle development-it needs to be nurtured, restored and repaired whenever necessary.

While this is a difficult issue to think about, the bottom line is that our entire bodies require the essential foods that assist with keeping us both strong and cognitively aware of the world around us.

Canada’s Food Guide suggests that the following easy tips will assist with a healthy and nutritious diet profile:

1. Eat at least one dark green and one orange vegetable each day. Go for dark green vegetables such as broccoli, romaine lettuce and spinach. Go for orange vegetables such as carrots, sweet potatoes, and winter squash.

2. Choose vegetables and fruit prepared with little or no added fat, sugar or salt. Enjoy vegetables steamed, baked or stir-fried instead of deep fried.

3. Have vegetables and fruit more often than juice.

4. Make at least half of your grain products whole grain each day. Barley, brown rice, oats, quinoa, wild rice, grain breads, oatmeal and whole wheat pasta.

5. Have 2 cups of milk each day for adequate vitamin D. Skim, 1% or 2% is recommended. Drink fortified soy beverages is you do not drink milk. Select low fat milk alternatives such as yogurts or cheeses.

6. Have meat alternatives such as beans, lentils and tofu often. Eat at least two Food Guide Servings of fish each week. Choose fish such as char, herring, mackerel, salmon, sardines and trout. Meats should be lean and poultry should have skin removed. Use cooking methods such as roasting, baking or poaching for reduced fat options. Luncheon meats should be low in sodium and fat.

7. Unsaturated oils such as canola, corn, flaxseed, olive peanut, soybean and sunflower can be used sparingly for cooking, salad dressings, margarines and mayonnaise.

8. Drink water regularly! Add some lemon, lime, cucumber or orange wedges if desired. Eating out? Say yes when offered water or order water to drink with your meal.

9. Unfortunately most of the treats that many of us like to eat go against the healthy food guide’s principles so it is suggested that you contact them at www.hc-dc.gc.ca to review some healthier options when eating out or making a snack.

10. Various online nutrition articles suggest that some foods rich in antioxidants can assist in restoring brain function. Berries, apples, grapes and spinach are all noted for assisting in the areas of memory loss, balance and co-ordination. Omega-3 fatty acids also assist in improving brain function. Salmon and herring are rich in Omega-3, as well as walnuts. Also found in these foods is vitamin B-12, which promotes positive mental health.

Looking for a dietician or nutritional advice? Contact Eat Right Ontario at 1-877-510-5102.

Looking for a specialist in nutrition and medical exercise options? Contact Ms. Helen Roussos at Fitnesssever@hotmail.com.