Return to Play Protocols: What Every Coach and Player Must Know

This is Sharpening youg Edge with Chuck and Eric.

In this episode, we'll be speaking with Dr. Chris Serraro.

He is a doctor of physical therapy and strength conditioning coach with experience in concussion rehabilitation as well as orthopedic and sports physical therapy.

He is the president and primary physical therapist for RPE Physical Therapy in Pittsburgh, Pennsylvania, where he was born and raised.

Welcome to episode four of Sharpening youg Edge presented by CB3 Hockey Development.

I'm Chuck Vertolino along with my co host Eric Melanson.

And today we are very excited to bring on Dr. Chris Soreo.

Lot to unpack here tonight.

We have covering a bunch of stuff, concussion rehab, orthopedic and sports rehabilitation and strength and conditioning.

So Dr. Chris, welcome to the show.

Yeah, thank you guys for having me.

I'm super pumped to be here.

All the episodes so far have been fantastic, so I'm excited to see what we're going to get into.

Hey, thanks Chris.

It's, it's great to finally get you on the show.

I know it's been a long time in the coming.

Ever since we had the, the idea of it.

I was like, got to get Chris on.

Gotta get Chris on.

Yeah, I feel like we've been talking about it for a while, so.

I know.

Yeah.

So for, for folks listening out there, personal connection.

Chris has been my physical therapist for probably the past about three years now.

He's got me, he's got me feeling good.

So he definitely, I can, I can vouch for his, his creds.

He, he definitely knows his stuff.

He was also my son's physical therapist for, for a short while too.

Got him returned to play, which is, is extremely important.

But yeah, like Chuck said, we got a lot to unpack.

Chris, you got a, a wide range of, of things to cover here, so I'll jump right into it.

And you know, having worked in Frederick there, I'm not sure how many hockey players you're able to treat because, you know, like a lot of the areas in the, the dmv, the, the Maryland, dc, Virginia area, it's up, up and coming with hockey.

But I know that there are a ton of athletes in and out of the clinic.

So were there a certain, you know, common mechanism for a concussion that you saw, particularly in some of those, you know, youth to like high school age athletes, did they differ for sport or was it just, you know, bad luck?

Yeah, no, I mean, awesome question.

We do see a decent amount here still.

I actually just discharged somebody yesterday who was a high school hockey player.

She actually got hit in the head directly with a stick.

But whenever we're looking at mechanisms of injury throughout everything here, a lot of times it is direct contact to the head.

That can be direct contact from a, another player, whether that's on the other team or on your team or from a trip and fall or hit into the boards.

For sure.

That's what we look at whenever we get a little bit more experienced.

Now some of the, the younger kids, right.

When we're first just learning how to skate, it seems like we see more of the mechanism of injury coming from falls.

Right.

Falls or direct hits to the head on the ground overall.

Does that change from sport to sport?

Yeah, obviously to an extent, but for the most part you're going to be getting some sort of direct hit.

Sometimes that's a direct hit to the head and it causes that acceleration deceleration injury.

Sometimes that's a hit to the body and you get that kind of whiplash mechanism.

And, and the same thing goes on in the brain that acceleration deceleration injury.

Awesome.

That's good to hear that.

I mean it's, it's good I guess in a sense that you're treating lots of hockey players.

It's bad in the sense that, you know, the, the injuries are popping, but at least they're going to the best in the business to get fixed up there.

So that's a good thing.

So life in the hockey world is a lot different now than it was back in the day in relation to concussions and concussion protocol really wasn't a thing back in the day.

Today a lot of coaches take the courses, take the clinics, but maybe, maybe they're misinformed.

I remember back when I played, I think it was Peewee's crash in the net and I think I got cross checked or hit.

And then the next thing I remember is waking up with my coach over me.

And I guarantee you there was no concussion protocol going on.

So how do you structure your initial assessment for a suspected concussion in a hockey player?

Maybe on and off the ice?

Yeah.

So there's a lot of different validated tools that we have out there both for experienced providers and just the lay individual.

Right.

A coach or somebody that doesn't have medical experience.

For me Personally, there's the SCAT6.

Right.

A sport concussion assessment tool is a sixth rendition of it and it goes through a whole bunch of different questions, tests, things to look at that we can take a look at immediately following a concussion.

Again, that will be more of my on ice side of things.

Whenever they come in to the Clinic, there's the scope 6.

Right.

The sport Concussion Office Assessment Tool.

Same thing.

A large, fast, very, very thorough testing procedure that looks at a number of different things.

Now, taking a small step back, in order to diagnose a concussion, all that you really need is one mechanism of injury and one brand new symptom that comes up right after that.

Right.

Some of the symptoms that we can look at, very common.

Headaches, dizziness, loss of balance, obviously, loss of consciousness, seizure, vomiting.

And the list can continue to go on and on again.

For the lay provider, we have the CRT6.

Right.

Or the Concussion Recognition Tool.

That's something that's very easily able to be pulled up online and you can go right through it and it'll just look at some very visible clues of a suspected concussion.

And then it can take you through the symptoms, some of what I just listed, and even a little bit more.

And then there are a couple other questions that relate to immediate awareness.

So something that's really good for coaches, parents, just the lay provider to have in their back pocket.

Is that CRT6.

That's awesome.

I'm glad to hear that.

The kind of, you know, it's, it's a very long procedure to go through just to make sure, because I know that, you know, there's a lot going, a lot involved, right.

Because it's the brain and motor function and everything else.

One thing you mentioned was, you know, that stuck out to me was loss of consciousness.

Now, I know there's tons of myths and misconceptions around concussions back from, you know, what it used to be to what it is now and how we treat it, et cetera.

But for the loss of consciousness piece, does that, does loss of consciousness during, you know, an injury like an impact to the head or a fall, does that always necessarily mean likely concussion, or is it.

You still gotta go through the procedures.

A loss of consciousness will always result in a concussion.

If you have a loss of consciousness greater than a minute, that'll be concussion plus.

Go, go directly to the er, get some energetic.

But loss of consciousness less than a minute, it still can, is considered a concussion.

And they should still go through the formal testing and return to sport, return to play, return to learn protocols from all of that.

Okay, that's perfect.

That actually kind of right to my next question.

So obviously the test to make sure you have a, have a concussion is quite long.

What is the, you know, return to play procedures?

What, what, how, how does that go on?

You know, what are the Markers that you look for.

And okay, hey, you've completed X, Y and Z.

Is it a period of time?

Is it some combination thereof?

Yeah.

So whenever we look at concussion, just like you had mentioned, you know, it's the brain, it controls everything in the body.

And there are a lot of different kind of sub.

Sub thresholds or I guess sub categories that can be influenced by concussion.

Right.

So we have to break each one of those up separately and see what we can assess and what we can treat.

And then what we can test ultimately return somebody to sport.

See, and if we look at the vestibular and ocular system, right.

So your inner ears and your eye system, whenever you look at the brain, roughly 50% of the kind of real estate of your brain is actually, the neurons are actually dedicated to your inner ear and your eye movement.

Right.

So a lot.

Right.

So just about anytime that you get a concussion, one of those things or both are probably going to be affected.

So a skilled provider can test that, treat it, and then use some tests to allow somebody to return to sport from there.

Another big one that we can take a look at too, is that kind of cardiorespiratory system or exertion system or aerobic system.

You'll hear it called a couple different things.

What we can look at with that is, hey, if I work out, do I get symptoms?

And some people it's no, you know, I can get my heart rate as high as I want, and that itself is not causing symptoms.

And there's a few different tests that we can take a look at for all of that as well.

But that is its own test treatment and then retest for potential return to sport and other things that at least as a physical therapist that I'll primarily focus on is the neck.

So whenever you get a concussion, at least in adults, let's say it takes 98 GS of force, roughly.

Right.

Or 98 times the force of gravity to cause a concussion.

Right.

For some people, that goes up to, you know, 120, 140, whatever.

For some people, that's a little bit lower, depending on genetics and such.

And for kids, that.

That whole window kind of shifts a little bit lower as well.

Right.

But whenever you take a look at the force that it takes to cause a whiplash injury or a neck injury, that, that, that's not 98 G's of force.

Right.

I've seen very frequently it's.

It's in the low 20s, but I've seen some studies say as low as 7 g's of force it takes to cause a concussion, right?

So what I'm getting at with this is every time we get a concussion, we also get some sort of neck injury, right?

What makes things a little bit Harry here is that the symptoms of concussion and the symptoms of neck injury or whiplash disorder really, really overlap.

Even with whiplash.

You can get headache, you can get dizziness, you can get fatigue, you can get ears ringing and so on and so on.

So again, another thing that a skilled provider will be able to help out with is to say, hey, is this concussion?

Is this neck injury?

How do I treat this?

Right?

So those are three of the five systems that can kind of be influenced by concussion.

The other two things to keep in mind are kind of that fight or flight system generally.

So anxiety is something that really, really goes along with concussion, right?

Sometimes concussion can exacerbate anxiety and then anxiety can exacerbate concussion.

From my side of things, we know exercise helps anxiety.

And from another side of things is I may refer out to a mental health practitioner to help out with that as well.

And then finally, the very last piece is, believe it or not, actually like the gut, right.

There's a really close link between your stomach and your brain, right?

So super, super, maybe I'm a nerd, but I find this super interesting is something within like three hours of when you get a concussion, your gut microbiome actually changes and you can digest foods differently and different things can happen there.

So maybe, you know, personally I'm a little lactose intolerant, but I don't always listen to it, right.

So I'll have some dairy and that can send off this pro inflammatory response throughout the body, but also specifically to the brain, right?

So just something, you know, this is a little bit of an aside, but something else to just be very mindful of is after a concussion it's definitely going to be worthwhile to, to adjust.

The diet you gave me like one more thing I just wanted to ask before I, I let check talk for a minute.

But if you get a concussion, right, I know the, the old myth of like you break a bone, it'll be harder to break that next time because all the, the calcium.

But when you get a concussion now, are you more prone to concussions in the future or no.

Or is there a period of time.

I guess so.

Really, really good question.

A really interesting answer too.

There's a lot of different research out there that will show you both ways.

So I'm going to tell you a little bit about one portion of the research and why I think it's somewhat flawed.

And then we can go the other way.

So some research papers you'll read that'll say, hey, I got a concussion and then I'm now more susceptible to a concussion in the future.

There are a few things that those papers don't really take into account, just other confounding variables.

Right.

So they don't take into account the type of player you are, type of fighter you are, the type of person you are.

Right.

Are you someone that is, you know, more risk adverse?

Are you going headfirst into things?

Do you not care how you tackle somebody?

Do you not look around and see if someone's going to check you?

Right.

So there's a very, very high chance that you're just a person or a type of player that is going to get a concussion.

Right.

And then the other side of things that goes with that is they don't take into account kind of the, the positions that you're playing or your size.

You know, am I, am I, you know, tiny little guy that's skating around with these big hulking people and, you know, they're going to hit me with that 98 GS of force or whatever the equivalent may be.

So I think that's, that's something to really be mindful of.

Now from other side of research, what I ascribe to more so and what I tell all my patients is that 98G is a force.

If you, if it takes you 98G's of force to cause a concussion and you get a concussion, it does in the short term drop to whatever, 40, 50, 60, whatever it might be.

But if you wait the appropriate time period, you pass the appropriate tests, you do the appropriate rehab, that 4,000, 5,060 does make its way back up to 98 or whatever it might be.

And you should be at no greater risk of sustaining a concussion than you were if, you know, you've never had a concussion before.

That is the best answer I've ever heard.

And I think I aspire to your line of thought just given all those variables that are very hard to track.

Right.

It would be a million different studies and they probably say a million different things.

Yeah, that was, that was awesome.

So going back to my earliest story about when I was a peewee and I got hit from behind and crashed into the net.

Woke up with the coach looking over me.

I guarantee you I did not take any time off after that.

I was probably out there the next shift or next period.

Again, research has changed A bit.

The goal of this podcast is to educate the audience, whether it's a coach, a player, parents, on all these issues.

And this is a hot topic, especially in a contact sport like hockey.

So what's the biggest mistake that you see athletes, coaches, parents making during concussion recovery?

Yeah, there's, there's quite a few that can go along here.

Again, one is, you know, I see in, in really any sport is that some people don't take it seriously.

Even with all this new research that's out there and all these stories that you can hear and all the things that you see on the news and with the professional leads, people still don't take it seriously.

And more often it is the, the athletes than the, than the parents or coaches.

Right?

Again, the athletes are athletes, they want to play.

And I've had people, and I guarantee straight up lied to my face and say, no, no, I'm fine.

You know, the trick is I put them through some of the tests and then I've realized that they're not fine.

But taking it seriously is obviously something that's very important, right?

Especially with the youth, right?

You want to make sure that that brain is going to follow you the rest of your life.

You want to make sure that that thing is good to go and that you're following all of the appropriate recommendations and return to support processes that, that you're recommended to do.

Now, another thing goes along with all that as well.

I'll give you a little bit more information on this because it is a little bit, you know, a little bit abstract.

So in the actual literature, in what is recommended to doctors and physical therapists, physique, you know, everything like that.

There is no hard set time constraint on how long you can wait till you go back to sport.

You do have to be able to pass the tests and be completely asymptomatic before you go back to your sport.

Now, there is another bit of research that actually looks at this kind of inflammatory marker of the central nervous system, right?

It's called N acetyl aspartate, right, Or NAA plus.

And to give you a super quick rundown, right, they've taken humans that get a concussion and they look at this NAA plus at different time points, right?

Day one, day seven, day 15, day 22, day 30, day 45, day 90, and, and so on.

And what they found is that this N acetyl aspartate, it doesn't go back to baseline until at least 22 days following a concussion.

So vast majority of people are going to be completely asymptomatic.

I mean some at, at, at day three, four, five.

Right.

For the most part, day 14 is when you become completely asymptomatic.

And some people, it, it, it does last longer, right?

Some people, it's three months, nine months, years.

But one of my recommendations to parents especially is to just wait that 22 days.

Right.

And I always use the broken bone analogy.

We talked about it earlier.

A broken, if I break my arm, the doctor is going to put me in a cast and they're going to say, hey, don't do anything for whatever bone before six, eight weeks, it's going to stop hurting after a week.

Right.

Are you going to go and just cut that cast off and then go right back to playing?

No, you're going to wait for the body itself to actually heal.

Even though it feels good, doesn't mean that it's healed.

So again, that's not what is hard set in the literature that you absolutely have to follow.

But it's something that I educate all of my athletes and educate all of the parents on so that they can make their, their own informed decisions.

I, I can't legally hold somebody from going back to sport just because of that if they pass all of the other tests.

So I think those are, those are kind of the big, the big ones.

And then secondary to that, not, not that this should take a backseat, but athletes not focusing on their sleep, their hydration, their diet quite as much as they should be.

And that's obviously very important as an athlete generally.

But whatever you are trying to recover from a concussion that just compounds.

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That's awesome.

I mean, the 22 days mark I think is going to be huge for people, right?

And I do like the analogy to the bone.

It makes complete sense.

And the brain is a lot more complex than a bone.

So all good information out there.

My question now is kind of two part.

So is there a number of concussions that, hey, after you get three, four or five, like maybe think about not playing, you know, such a contact sport.

And with that, you know, CTE is something that's becoming unfortunately a lot more prevalent.

But I guess fortunate in that there's, there's research going into it now.

Obviously you've heard more NFL athletes post mortem being diagnosed with cte.

You're seeing more and more NHL athletes, some of those who kind of fizzled out in their career and turned to drugs and alcohol and tragically lost their life to suicide.

Can you go in at the end a little bit to what exactly CTE is and is that linked obviously to multiple significant concussions?

Yeah.

So the first question, right, how many is too many?

There's been a lot of same thing, a lot of research papers that have come out here, and there hasn't been a single one that has said, hey, you get three and that's it, right?

They all come back to saying, hey, informed consent for the person that's getting a concussion, right?

These are the risks.

This is what's going on.

You really want to continue Now?

I really bring about that second part, the part that we were just talking about where we Talked about that 22 days, where I would argue that there's probably quite a few people that, you know, they got a concussion, they were feeling better at day seven, they didn't get checked by a provider, they went right back into it and, and then probably very easily got another concussion, right?

We talked about that.

98 going down to 60, right?

So now it's much easier to get a concussion.

And now, oh man, I got another One, right.

And the, the crazy thing here to, to take it back to the, to the nerdy stuff again is that N acetyl aspartate, again, when you get the first concussion and completely recover, right, it's 22 days.

If you get another concussion and you haven't waited that 22 days yet, it doesn't just still take 22 days from the first concussion rate.

It doesn't Even just add 22 days from where you're at.

It exponentially increases to.

I admittedly can't remember off the top of my head.

It's something like 80, 90 days, right?

Then you get another concussion there.

It's not 80, 90 today is, it's 220, you know, and it just keeps going up, right?

So my argument is going to be for a lot of these things that at the very least you need to take time off to allow that N acetyl aspartate to recover and therefore the central nervous system to kind of decrease inflammation.

Now, whenever we look at cte, right, or Chronic Traumatic Encephalopathy, there's not a whole lot of research on it yet that is incredibly conclusive, right?

There's a lot of correlative information that says, hey, you get multiple concussions in your lifetime, you're at a higher risk for this or even you get multiple sub concussive blows, right?

So not meeting that 98 GS of force.

But hey, I am constantly getting hit with 20, 30, 40, 50, 60 GS.

And those little things can build up and potentially cause cte.

The other side of things that goes into that as well is kind of the lifestyle factors of those that end up getting it right.

So you look at some of these professional sports and you know, obviously can't blanket statement this for everybody, but there is a certain level of, not necessarily narcotics and drugs, but you know, painkillers and things that can kind of go into this, right?

Or, or maybe on the other side of things, you know, maybe on illicit drugs as well and certain amount of drinking that might go into all this too, right.

And we know those things can set up a very poor environment for the brain generally.

And now we're adding on top of this, multiple hits, multiple hits, multiple hits.

So I don't know that I can speak too much on CTE generally outside of right now.

I think we need to keep taking a look at the research and keep, ideally the research keeps progressing to the point where we can identify exactly what is causing this and how we may help it long term.

That's awesome.

And I think, you know, there was a lot to take away from, from that, all that stuff.

Most important thing for me is parents, coaches, athletes, just wait till 22 days, right?

It's not worth it.

You're only going to make it worse for yourself.

And then, you know, please get actual, like go see a provider and make sure you're getting treated appropriately.

You know, small anecdote, and I'll share it just because I coach his son.

But Chuck's son Gavin actually got a, got a concussion, oddly enough, while we were playing in Pittsburgh at the upmc.

Right.

But I do so all that said to give a shout out to the amazing athletic trainers there that we were able to, you know, they have one on, on, on the ready for every single game that they play, probably because they're right, you know, attached right to UPMC Medical there.

But yeah, they came over, gave the, they gave them the, the tests and yeah, we very, very grateful for them.

A lot of great information, Chris, on concussions and the breakthrough and all the research coming through.

Like Eric said, The 22 day rule, I guess you can say to get back.

It's going to be interesting to see even with the research, if it starts becoming mainstream and how many coaches or parents are actually going to abide by it.

You know, that's always the sticky part.

Yeah.

Just one question, Chuck and I, only because I know it's one of the only things I've seen out there.

And Chris, you and I have had this conversation before.

The cue collar, right.

We're not sponsored by him yet.

Maybe this will be a leeway, you know, a segue into that.

That'd be great.

But is there some positive research on the cue collar?

It's really the only one I've seen to help.

I don't want to say prevent because you're not going to be able to prevent it, but make your chance smaller.

Does it increase that G level?

Does it just make you less susceptible?

Is that something that once age appropriate parents should look into for those playing contact sports?

Yes.

Now, again, looking at, all that I can really pull from is research that has come out and kind of my clinical knowledge, clinical experience.

So taking one small step the other direction, you know, if we look at devices that go on the outside of helmets or the outside of heads, just generally there is no research right now that definitively supports the fact that putting something on your head will reduce your risk of concussion.

And that even means wearing a helmet.

Right.

Usually we think, oh, we're going to wear a helmet to limit A concussion.

But even helmets in hockey, football, things like this, they do not attenuate the forces enough to make sure that you don't get a concussion.

Right.

They're there, they're safe.

I need you to use them because they're going to limit fractures and lacerations and things like that, but those themselves are not going to attenuate the forces quite enough.

Again, that goes for helmets in sports.

That goes for headgear in boxing and mma.

That goes for devices that go on the outside of your helmets in any of those other sports.

So be mindful of that.

At least that's what the research tells us right now.

Now, on the side of the cue collar, when we think about it, just from a understanding of neuroanatomy, what that does for those that don't know, it's a small device that'll go around the outside of your neck and it'll actually put a little bit pressure, a little bit of pressure on the vessels in the neck, a safe amount that is going to leave a little extra blood up in the brain and give it a cushion for whenever we do experience those, let's say, 98 G's of force.

Now, there is positive research out there that can say that Q Collar itself can reduce the risk of getting a concussion for the most part.

Right now, that research is mainly done by Q Collar or sponsored by Q Collar.

So we want to take it generally with a grain of salt.

But from a, again, neuroanatomy standpoint, it makes much more sense to me to cushion from the inside so that the brain itself doesn't undergo those forces, as opposed to try to put a pad on the outside that isn't going to change the forces.

Okay, that makes total sense.

I greatly appreciate it.

That's.

I think that's great advice for everybody out there.

And interesting that, you know, the.

About the helmet piece, that's something I was probably not aware of.

But like Chuck said, lots to unpack with you.

Right.

Because you're a wealth of knowledge.

So I don't want to spend the entire time talking about concussions, although I'm sure we can.

But I think now we can kind of roll in because you also are a certified strength and condition specialists as well.

And I know fitness and stuff is something you're extremely passionate about.

Right.

And I think it's important to athletes as well to see, you know, good physical therapy clinics and good physical therapists that have that background, because we're not just talking about physical therapy as it was years ago, where you're going to go in there, get some stretches from the physical therapist and be on your way.

I know at least when, you know, for the three years that I've been with you, every time I'm in there, I'm doing some of that stuff.

You're beating me up pretty good and then you're making me do a workout.

Right.

Because we're.

You are injured but you're not dead.

So you're going to do something and move the body and then.

So I think we can, we can segue into that joke.

So on episode two, we talked to Tony Cassenza with total empowerment training about the increase in injuries, especially to 8 to 10 year olds before kids even hit puberty, which was kind of again, unheard of back in the day.

We're seeing more and more in that today with, with younger kids specific to hockey and goaltenders at 8 to 10 years old, we're seeing groin injuries, hip injuries.

What are most common orthopedic injuries you see in hockey players and how do they differ from other sports?

Yeah, it's.

You really hit the nail on the head and we've kind of mentioned the main two so far, right?

One concussion and two, what you had just said is kind of those hip and groin injuries, those are going to be different than other sports mainly because of either positions that hockey players have to get themselves into, mainly whether or I guess say mainly goalies, but also the kind of method of locomotion for hockey players.

Right.

We are spending pretty much all of the time on the ground.

Right.

Air quotes.

Right.

On the ground and pushing off medially.

Laterally.

Medially.

Laterally, Right.

Whereas you know, in other court sports or things like that, it's sprinting, short time on the ground, change of direction where the feet may come off the ground and it's going to use completely different muscles.

So for the most part, yeah, we're going to see a lot of different hip and groin injuries specifically related to that adductor muscle group.

Right.

So the inside of the thighs and that's something to keep a super, super close eye on as a strength conditioning coach, as a pt, as a personal trainer, as an athlete yourself is if you're neglecting working the inside and the outside of your thighs, you should probably start.

Right.

We all know squats and deadlifts and bench press and pull ups and things like that.

But for hockey players especially, same thing going on, that line of, of thinking specifically, we are much more unilateral.

Right.

Just, you know, we are, we're going to be Passing for the most part on like a dominant side, right.

Or hitting a shot.

Right.

For the most part on a dominant side, right.

If we're going to, in a slap shot, right, we are going to power up from one side, right.

So our hips will undergo different forces, our shoulders will undergo different forces.

Our thoracic and lumbar spine will go under forces, our cervical like every, you know, you can, you can pick pretty much everything from the feet up and it's going to be a little bit different than most other sports.

So I think big things to be on the lookout for is the hips, right.

In some sort of impingement syndrome, the adductors, right.

Some sort of strains and the abdominals just, I mean, it all ties in right there.

I think we saw that in Florida's end of their season and now at the beginning of their season with Matty Chuck, he said, I'm pretty sure that's, that's the injury that he suffered and so much so that, you know, he heard it during four nations cup, tried to come back, couldn't come back, really.

And now he had to have surgery and he's out till January.

Right.

So so far I've learned, you know, wait your 22 seconds and hockey players pay attention to your hips and your adductors.

So with that, you know, the strength training piece of it, if an athlete comes to you and hopefully they're in some sort of in season programming, right.

They're working out regularly.

And like I mentioned when I, you know, every time I go see you, a reputable physical therapist, you're going to go in there and you're going to move your body at least a little bit for someone coming to you.

And obviously it's, it's limb dependent and situation dependent, but are you going to tailor that workout a little bit?

And they say, hey, you're, you're good, kind of let pain be your guide.

Is it different obviously for the orthopedic side vice, maybe a concussion side?

Yeah.

Well, as a physical therapist, we'll absolutely tailor that to, to what you need.

Right.

So, you know, I, I again was fortunate enough that I got to work in the private sector of strength and conditioning for a while, did internships, the University of Pittsburgh and Carnegie Mellon University, and then obviously been a physical therapist for the past few years.

So I kind of have seen both sides and I really love to put strength and conditioning and physical therapy on a slider scale, not two different scales, right.

And say, hey, you know, whenever we're, we're healthy or getting Back to sport, we lean a little bit more towards strength and conditioning.

And whenever we're hurting, or maybe as a physical therapist, maybe if you're getting your strength and conditioning elsewhere, we get to focus a little more on the, on the PT side of things.

So I, I think taking a big step back and looking at what we find as your impairments, right, so probably some sort of hip internal rotation deficit.

We'll see.

There will probably be some, some deficits up at the upper body as well with rotation at the shoulders, thoracic sp spine, again, lumbar spine, like what we had talked about.

We'll tailor that specifically to you for your sport.

But another set of things that I think is important to think of is, is what I, what I call, I call it a bucket of body competency.

Right?

And it's kind of your, it's globally encompassing.

It's kind of your body's ability to control itself in multiple ways, right?

Multiple planes.

And whenever you do one sport, right.

You can get really, really good at doing this one thing, right.

But your body can adapt to that and start to lose its ability to do a number of other things, right.

It can lose its ability to rotate one certain direction.

Right.

It can lose its ability to be stable on a solid surface.

Right.

I know hockey players spend a lot of time obviously on the ice, but you still spend quite a bit of time on solid ground, right?

Whether that's, you know, as a youth athlete, going to school, playing with your friends, doing your strength and conditioning workouts.

So part of the physical therapy side of things is also giving you what you don't have, right?

It's great to work on, on what you need and what you have and get muscles strong and get your mobility there for, for what you need, right.

For certain hip rotations and things like that.

But you also need to have the ability to move in all these different ways.

So I guess hot button topic right now amongst probably every youth sport community.

But I want to give your just, you know, hot quick 5 second answer.

Should these youth athletes, right, be playing multiple sports or are you seeing a trend where they're starting to specialize too early in one sport or not, you know, moving their bodies in multiple different ways so you're seeing the injury kind of rate increase because, you know, they're, they're just tied to one sport, move their body one way.

Yeah, that's a perfectly timed question.

I think that goes exactly along with what we were just saying is I, I do highly recommend kids to be playing more than one sport, especially when I'm still saying kids, right, it's going to be really beneficial for them to develop the ability to move their body in multiple different ways and that'll one, keep them healthy.

But two, again, if you have the ability to move these ways that you don't normally move in your sport, when it is time to move that way in your sport, that one off chance you're ready, you're prepared, you're kind of good to go.

So I know off the top of my head I remember hearing a stat at one time.

It was the, like the NFL players in the super bowl they, it was something like in the 90 plus percent of the players that played in the super bowl they had all done more than once for right Prior to this.

I looked up too with the, with the NHL players it's something like 88% if I remember correctly, like 88% of those players that make it to the NHL grew up doing more than one sport.

So not just me saying this, listen to the facts, right?

And, and athletes get your body moving in all these different ways and own those movements.

Awesome.

I love it.

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so I had a question along the same lines.

Not to beat a dead horse about back in the day, but back in the day we were on the ice from September to March and then we went and played our spring sport or summer sport.

We maybe went on the ice once a month in the summer.

Do you think there's a direct correlation with the overuse of one sport or the overuse of now seeing hockey players again, the youth players, 8 to 10 to 12 years old on the ice year round?

Are you, are you seeing a direct correlation with injuries and, and load man load management and overuse?

Yeah, we definitely do.

And we see that across all sports, right?

We see that in hockey, we see that in baseball, we see that in soccer, right?

These people that are playing year round and, and not taking any breaks, that's just going to be repetitive overuse to an area that, that isn't, that isn't quite ready for it, right?

And then on top of that, if they're not in some sort of strength conditioning program, that, that can also just lead to further injuries and things like that.

So being mindful of that, you should have a very competent strength and conditioning code and coach.

And you need to be aware of this as parents that to do the same thing year round without taking a break, you're probably going to injure something.

And if even if you do, it's like, oh, we're definitely sports specializing, this one sport at least have some sort of competent strength conditioning coach that can say, hey, I will give you these things that you don't have, right?

I'm going to build you up for the things that you need, but I will also give you these things that you don't have.

We will make sure that you are resilient and not going to succumb to these overuse injuries.

So yeah, really good question and I think really good point to hammer home is, is ideally you're playing more than once or if you are in it year round.

We are seeing, I'm seeing with my experience as a physical therapist and in the research that there is a higher chance of these overuse injuries if you're playing your rep.

Awesome again, I love it.

Right.

Your, your thinking is directly in line with me and I promise that's not why I recommended that we bring you on so I could just echo my own thoughts.

But no, this is great information.

So I mentioned earlier about how UPMC had that trainer on site, right.

And they've got them there for all, at least all the hockey games I've been to there, which are quite a few, made more trips to Pittsburgh than I ever thought I would imagine.

That's neither.

I've learned it is very hilly city but that's neither here nor there.

So in that, you know, we're seeing it more so a lot in the high school, you know, levels more than at least when, when I was playing or when you were playing.

But how can organizations, you know, specifically these youth organizations, be it football, hockey, lacrosse, etc, better integr like a PT or CSCS type professional into their development model?

I think it's great to have somebody on for, for literally every team and it can be very beneficial at every age group.

Right.

Every time point.

I've seen some organizations whenever I was strength conditioning the private sector, they would bring their whole team specifically to us at our location and we would work with them and we would start by exactly what said we had tested and seen, hey, what are we lacking here?

We understand their sport and say hey, what do we need?

And then we could group them and say hey, let's do, you know, this kind of thing for these people, this kind of thing for these people because this is what they need.

So I think one option for, for different teams and leagues is to say hey, you know, or we're going to fundraise and we're going to go and do this right?

Or the other side of things is hey, can you bring this strike and conditioning professional to us?

Right.

I've been contracted out at high schools and things like that before I go to the school and we put them through, you know, one, you know, one hour sessions, you know, two or three times a week and we get to build up what they need, right?

And at the very least one they're doing exactly, you know what we're just Talking about, I think, I think of two different buckets, right?

One is give them what they don't have and two, build up what they need.

So I think those are two different ways to go there.

And bringing somebody in or going to see somebody I think is really beneficial.

Awesome.

Yeah, it's incredibly beneficial.

So Eric touched upon the organizational's role.

But how does Dr. Chris teach young athletes or what kind of advice do you give them about their body awareness and recovery habits, whether it's sleep, nutrition or mobility?

Yeah, going back to exactly what you said, going back to our concussions on that side of things.

I mean, as an athlete, generally that, that sleep, that hydration, that diet is, is so, so important.

And I feel like I, I really need to, especially with these young, young kids, is, is show them like, hey, why, like explain to them why, right?

It's not just, hey, get your sleep, hey, eat this much protein, hey, drink your water.

But, but talking about what that can do negatively for you, and I feel like I connect with the youth athletes much, much more when I relate it back to their sport and how it's going to help them.

Right.

I remember growing up in high school and they said, oh, we have the standardized statewide testing tomorrow.

Make sure you get a good night's sleep and eat a good breakfast.

And you know, I was a, I was a decent student.

I was in school for a very long time, so hopefully I was.

And I, you know, maybe should have listened, but you know, I was also an athlete.

So I said, I, you know, whatever, I'll do what I normally do.

But whenever it made its way back to sport and was like, no, no, no, no, I gotta, I gotta get to sleep on time, right?

I know I need to drink this much water so that I can perform longer whenever I am, you know, on the court, on the ice, on the field, whatever.

So I really think the really the basics of what all of us as adults know to be good, right?

Sleep, hydration, diet are kind of those three main pillars.

I think it's really important to relate it back to sport and development and performance for the kids, for them to be able to see, like, hey, I, I, you know, if I do these things, I will actually be a better athlete.

It's not just because my parents said so, right?

Or hey, I will recover from my concussion so I can get cleared and get back to where I need to be.

Or I will recover from my orthopedic injury and I'll get back to where I need to be.

That's perfect because it Tees up my next question wonderfully.

You know, you mentioned like, hey, you tie it to the performance benefits, right?

Like, hey, if you, if you do this stuff, you're going to get better, you're going to get better.

There's probably that threshold where some of these athletes think, well, if I do more of it, I'm going to get even better.

And if I continue to do more and more and more and they get wrapped around their nutrition, they get wrapped around being in the gym before practice, after practice.

What are some warning signs you can give to both athletes and coaches and parents to look for in that, that over like, hey, you're doing great now.

You're probably hitting into that, that over training window.

So from a, at least a strength, conditioning or PT coach side of things, you know, we'll have our objective metrics that we'll be able to track throughout your recovery.

And if those objective metrics start to fall behind, you know, it's, we'll take a look at our programming and say, hey, is this us?

But exactly what you said, there's a chance they're just overdoing it and now their central nervous system is feeling that and the output isn't as high as it, as it could be.

You know, other side of things, just basic easy ones, is to, for objective metrics that somebody can do at home, is your heart rate right?

Even just looking at that, right?

Especially as an athlete, where that resting heart rate should be or at least where it is.

And that can be something to monitor over time, right?

Just doing one heart rate every once in a while, not so much.

But you know, if we get a couple time points and I say, hey, at this time this week, at this time this week, at this time this week, at this time this week, and see how it fluctuates and see how training is there, right?

Because you can't, you can't fake that, right?

Other side of things, less objective is, is really mood, right?

A lot of times athletes and kids generally aren't going to say like, hey, I'm, you know, I'm, I'm more tired than usual.

They'll probably say, oh yeah, I'm tired because, you know, we hear that a lot.

But they're not going to come to you and say, hey, I am more tired than usual.

This feels off, right?

They're probably going to push through it.

But you as a coach or you as a parent can likely see either their ability when to perform, whenever they're actually on the ice, on the court, whatever, or their ability to perform in the classroom or just their mood around, you know, around the house, around everyday life.

Because those things will absolutely be affected by your training as well.

Chris, I'm a fellow nerd, too.

Right.

So we talked on the tech side of things.

Right.

You mentioned data and metrics.

Right.

And we are, as a society, we love our, our data and our metrics.

Right.

We already talked about the cue collar.

And, you know, even in hockey, they've got this sensor now you can put in your shoulder pads that tracks a myriad of different things.

Right.

And again, we're not a partner yet.

Maybe this will help, but because both my kids wear them.

Is that something that parents, you know, if there's some.

A piece of tech out there, and I know you don't know what, what it is, but if there's metrics that we could track for these things, like heart rate and something that's, you know, as simple as, you know, every watch has heart rate, are these things that we should kind of pay attention to, to, you know, because it's only going to be beneficial, but to a point where you don't really get too focused on it?

Yeah, that.

I mean, it can absolutely go the other way.

And like you had said, too, you know, you can become way too hyper fixated on some of these things, too, and to the point where it can even cause, you know, the athlete anxiety.

You definitely don't want to push it to that extent.

But I do think it's something that's worthwhile just as an athlete of any age, to.

To monitor.

Right.

Again, like you said, whether that's just a, you know, a basic watch that you might have or whether that is those more advanced fitness sensors or whether that is just, you know, putting, you know, putting a couple fingers down and trying to find the heart rate and seeing what the heart rate's at.

Right.

As low tech as that.

I think things can be worthwhile to monitor.

Right.

Because they say what gets monitored gets managed.

Right.

If you don't know, you don't know without being too many cliches in a row here, but I think it's something that can be worthwhile and technology is coming a long way.

And I think there's going to continue to be a lot of good technology that comes out that we can monitor at any age, at any level, and it will be beneficial to us.

Awesome.

All right, so again, we talked about a lot of topics today.

Is there anything we didn't talk about that during this podcast that, that you might want to address or something that you might want to educate our audience.

About the only small piece that I was thinking about is whenever it comes to back all the way going back to concussions, right?

So again, kind of nerd whenever it comes to research, right?

So the number one, like, most positive prognostic factor, right?

Meaning how are you going to get the best concussion recovery?

The number one thing that you can do is after you get a concussion, it's how fast you go to see a specialist, a concussion specialist, right?

Somebody that knows what they're talking about because they're going to get you right on track early.

So I think that's an important thing to keep in the back of your head is I. I would.

Maybe I'm biased, but I would recommend everybody like, hey, you, you get a concussion, go find somebody that knows what they're talking about, that can assess you and lead you in the right direction.

That should get you back.

That should get you completely asymptomatic quicker.

And then once we get those 22 days, boom, you're good to go, right?

Or, hey, you've already been at 30 days and you're still symptomatic, still go see that provider.

I mean, they say trying to get there within seven days, but it's never too long and it's never too early to go see a provider for a concussion.

That said, and it ties in nicely with a couple of our other questions, is something that organizations should look into.

Should it be kind of having their organizations put through some sort of baseline concussion test?

Is that going to help, you know, look for things in the future?

So there are a number of different concussions, baseline concussion tests that are out there, right?

Some of those neurocognitive tests, right.

Where they pull them up on the computer and things like that.

You know, there are other ones that are just questionnaires or easy tests that you can go through.

The impact test was always a big one.

It might be something that some of your listeners have done, right?

And I had to do it in high school, where you go into the computer lab, you sit on a screen, and it tests memory and reaction time and pattern recognition and things like that.

And then if you do get a concussion, you come back and you take it again and it can help diagnose.

Now, specifically with the impact test, there's been a lot of research that has come out that has said, hey, this.

This doesn't do anything.

Don't do it.

Right?

And what I argue is, you know, to.

Against those research articles that say this doesn't do anything is it doesn't necessarily do anything in isolation.

And I always draw the analogy to, you know, if somebody had an ACL tear, right, and they got a reconstruction surgery and they came to see me at the very end, I have a list as long as your arm of what tests I'm going to put you through to make sure you're safe to go back to sport, right.

If I just picked one of those tests and put you through it, that is not enough in itself to say you're safe to go back to sport.

And I think those, what you said, the test retest side of things, when you read the research that says, hey, this doesn't do anything, I'm going to argue it's a piece of the puzzle, right?

I'm going to argue that it is something that's worthwhile, even if it's something as simple as some balance tests or things like that, right.

If you can't, you don't have the ability to use any of the technology or you can't get the whole team in to do this testing.

It's like, at least get some sort of baseline measures that you can take as a coach or take them to a provider where they maybe don't have to use all the equipment, but they can do some of the baseline tests there and then we can come back later.

So, again, I think it's a piece of the puzzle.

It's not the answer, admittedly.

I think if it, if it doesn't happen, it's not the worst thing in the world because we have so many good tests that we can do to say, hey, we are, we are safe to come back.

But again, it's a piece of the puzzle and every piece helps.

Oh, thanks.

That's wonderful information.

And because I know that, you know, that's something that you see in a lot of organizations and again, you shared a wealth of knowledge with us.

Appreciate it.

And you share a pretty good bit of this information as well as your, your, your burgeoning MMA career on your social media.

Is that something like you, you like to give out and share is your social media handle or, you know, if there's people that want to get in touch with you.

What's, what's the best way?

Yeah, I would, I would absolutely welcome followers or people that just want to check some of these things out.

Right.

My go to follow on Instagram, it's chris.sorao, dPT.

Right.

So just my last name and then some of my credentials and you can see me get punched in the face sometimes, whenever I'm doing my MMA and you can hear more about concussions and other orthopedic injuries.

So would love to have you.

Awesome.

Here's a question we ask all our guests at the end.

What is Dr. Chris's definition of development?

Whether mental, physical, or any other aspect of the word?

I think my definition of development almost just relates back to one other basic, simple word, and it comes back to progress.

Right.

And, and, and just improving.

Greater than.

Greater than what you were before.

Right.

Improving every day.

I know.

I think, I think with Coach Tony, y' all talked about the aggravation of marginal gains and things like that, and I think that was a super informative piece.

And just talking about, hey, can we get 1% better?

Can we be better?

Can we develop generally?

And I think that is all encompassing for, like you said, mentally, physically, emotionally, spiritually, all these things.

If we can progress from one day to the next and at least just strive to be at least 1% better, I think that is a.

My definition of development.

That is perfect.

And I agree.

All right, well, Chris, appreciate you having on.

You've been a friend for a long time.

This was.

This was amazing.

Tons of awesome knowledge.

I can't wait for this to come out.

So share with a friend, a coach, parent, or player if you think this is something they might be interested in, benefit from this podcast and make sure.

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Thank you for listening to episode four of Sharpening youg Edge, and we'll see you next time.