Warm-Ups & Stretching

Physical therapist assistant Kim Barb, OPTA, of Cook Children’s Pediatric Specialties Walsh Ranch, says it’s important to stretch and warm up before playing or practicing, as doing so prepares the body for fitness. After a game or practice, incorporate flexibility stretches with static stretches and holding positions, like the typical hamstring stretch, calf stretch and quad stretch. A five- to eight-minute dynamic warm-up prepares the muscles for a better stretch.

Why?

• To increase blood flow
• To improve muscle flexibility
• To prevent injury and tearing of muscles, sprains and strains
• To improve performance

Agility drills prepare the muscles and joints for running, jumping, cutting and footwork.

Examples of agility drills are:

• Soldier kicks
• Knee hugs
• Hamstring scoops
• Skipping
• Hip openers

ACL-Injury Prevention for Soccer Players
Barb recommends strengthening large muscle groups typically used in soccer, such as the hamstrings, quadriceps and the gluteals (including the glute medius, minimus and maximus), with exercises such as squats, lunges and hamstring curls.

Strengthening exercises can help prevent the risk of injury by teaching muscles and joints to be stable and strong. Strengthening hip and core muscles also helps with the reactive forces created when making contact with other players.

Single-leg balance drills increase stability by training your body to stay balanced on one foot while moving, cutting and changing directions.

Examples of single-leg balance drills are:

• Stand on one foot and pass the ball.
• Stand on one foot and head the ball.

Plyometric drills teach athletes how to land with control – a skill that boosts the body’s ability to absorb impact and protect the joints. According to Barb, landing with poor alignment can cause the knees to cave inward, a position known as “knee valgus.” This inward collapse is a common culprit behind serious injuries, making proper landing technique an essential part of any training routine.

Examples of plyometric drills are:

• Box jumps
• Lateral bounds/skater lateral hops
• Depth jumps

Turf Burn Prevention & Treatment

These raw, red friction burns can be very painful, says Cook Children’s physical therapist Jessie Fernandez, PT, DPT, OCS, COMT, of Cook Children’s Rehabilitation (South).

If you have turf burn:

• First, be sure to clean it with soap and water to rinse out any dirt or debris and help to prevent infection.
• Next, treat the burn with an injury ointment, such as Neosporin.
• Cover it with a dressing or bandage. Waterproof bandages can help prevent the bandage from falling off during exercise.

Players can wear tighter-fitting, sliding shorts underneath their regular shorts to reduce the risk of skin damage when sliding on the field. Staying hydrated and keeping skin moisturized can also help reduce the risk of turf burn.

Whether your child plays on a natural grass field or turf, it’s important to continue practicing on the same surface so the athlete can get used to controlling their body on it. Turf fields absorb shock less effectively than natural grass, so running, jumping and playing on them will feel different.

What to Know About Concussions and “Second Impact Syndrome”
The American Academy of Pediatrics (AAP) defines a concussion as “a type of mild traumatic brain injury (mTBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.”

This sudden movement can cause the brain to move or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. 

A concussion can sometimes be hard to spot. After all, it’s an internal injury.

There are times when a concussion is more easily identified, such as if an athlete loses consciousness. But it’s important to know that anytime there is a blow to the head, a concussion is possible.

“Monitor the athlete immediately after but be aware that sometimes it can take one to three days for symptoms to come on,” Fernandez said.

Immediate symptoms to watch out for and not to delay emergency medical treatment:

• Severe headache
• Blurred vision
• Trouble walking
• Confusion
• Slurred speech
• Unresponsiveness

Symptoms to watch after one to three days:

• Dizziness
• Headache
• Nausea
• Sleep changes, like sleeping too much or not enough
• Changes in mood or emotions
• Difficulty concentrating

Symptoms often resolve on their own, but one extremely important thing for parents to know about is second impact syndrome, which is when a person has a second concussion occur prior to resolution of symptoms from a previous concussion. This is the reason children and teens must sit out of a sport while recovering from a concussion.

“Playing through something like a knee injury is not ideal, but playing when you have concussion symptoms can be extremely dangerous, and can cause permanent brain damage or even death,” Fernandez said. “It’s just not something to mess around with.”

This is why Fernandez says that if there are any symptoms or concerns, the athlete should wait to return to play until they resolve. Usually, return-to-play protocols are overseen by a physician, athletic trainer, or physical therapist to work on the step-by-step process.

While neck strengthening and stability exercises can help prepare players for planned contact, like heading the ball, Barb notes that many concussions are harder to prevent because they stem from unexpected collisions that a player can't brace for.

“If you go up for a ball and someone hits you on the side of the head, you’re not prepared for that or it’s likely that you’re not stabilizing your neck muscles and that’s when the problem arises.”

Big Crowds Anxiety

Excitement and anxiety can sometimes look similar in children before a major event. A child with “excited jitters” may still eagerly talk about the game and respond well to reassurance, while a child experiencing genuine anxiety may become consumed by worry or even try to avoid attending altogether.

Physical symptoms can also appear in anxious children, including headaches, stomachaches and trouble sleeping leading up to the event.

“Excited jitters usually come and go, but anxiety tends to stick around and interfere with daily routines,” said Amanda Jordan, PsyD, psychologist with the Cook Children’s Psychology Department.

Preparing children ahead of time by showing them videos or photos of the stadium, discussing what they can expect and creating a clear game-day plan, can help prevent anxiety symptoms. Parents can also use “first-then” language to help children mentally organize the experience.

For example: “First we’ll find our seats, then we’ll get a snack.”

Families can also benefit from creating a safety plan before arriving at the venue, including identifying meeting spots and teaching children how to find stadium employees for help. Creating a funny family code word for moments when a child feels overwhelmed can also ease stress and remind children it’s okay to ask for a break.

Stadiums Sensory Impact

For many children, sport venues can overload the senses with bright lights, loud music, strong smells and tightly packed crowds. Dr. Jordan says sensory overload can trigger the body’s “fight, flight or freeze” response, making emotional regulation difficult. Children experiencing sensory overload may become irritable, restless or emotional. Others may withdraw, stop talking, cry or struggle to make decisions.

Several sport venues, especially the newest stadiums, now feature dedicated sensory rooms or quiet spaces designed to help guests decompress. Dr. Jordan encourages parents to research venues ahead of time to learn what accommodations are available and where they are located.

Even if a stadium does not offer a formal sensory room, quieter areas such as patios, hallways or less crowded sections may provide children with a chance to reset before returning to the event.

“These spaces can help lower anxiety and give children a place to regulate during stressful moments,” Dr. Jordan said.

Behavioral Challenges

Emotional outbursts during games can happen when children become overstimulated or overwhelmed. In those moments, Dr. Jordan says parents should focus less on discipline and more on helping children feel safe and calm. Getting down to the child’s eye level, speaking in calm tone and validating the child’s feelings can help them decompress and rebalance their emotions.

Parents can also use grounding techniques, such as deep breathing exercise or offering simple choices to help restore a sense of control.

For example: “Would you like to sit with me for a minute, or would you rather go walk around for a little bit?”

Dr. Jordan also encourages families to discuss coping strategies before the event so children know what support may look like if emotions escalate.

The emotional energy inside a stadium can also affect how children interpret social situations. Aggressive reactions from adults or fans may increase a child’s anxiety or sense of insecurity.

“Kids learn how to respond by watching the adults around them,” Dr. Jordan said.

Parents can help by calmly explaining emotional reactions happening around them, such as cheering after a goal or frustration following a penalty call.

Practical Advice

It is recommended to pack a few “mental health essentials” before attending a major sporting event with children.

Some of these items can include:

• Noise-canceling headphones, or earplugs
• Comfort items like a soft blanket or a plush toy
• Sensory or fidget toys
• Snacks

 These items can help children self-regulate and make the big game day more enjoyable.

Parents should also recognize when it might be time to leave early. If a child cannot recover emotionally after taking breaks or using calming strategies, it is time to prioritize the child’s wellbeing and step away from the event.

It’s also important to emphasize that sensory sensitivities are not limited to children with Autism spectrum disorder (ASD). Children with attention deficit hyperactivity disorder (ADHD), anxiety or trauma histories may also struggle in overstimulating environments.

“Sensory overload can affect many different children – and sometimes even parents too,” Dr. Jordan said.

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• Cook Children’s Sports Medicine Physician Heals Young Athletes Through Pickleball Medicine Program

Last night, NBC 5 Investigates released an enlightening report looking at the rates of concussions in North Texas districts. This report showed a much higher rate with more than 2,500 concussions reported in just 41 districts.

There are still a lot of misconceptions about concussions, what they are and what they might mean to your student athlete.

Here are 5 concussion MYTHS:

1. It was just a “mild” concussion.

Concussions are brain injuries, period.

One might classify a concussion as mild if symptoms were brief and not severe. However, you cannot predict whose symptoms will be severe based on the way the child was injured or even the symptoms right after the injury.

Even seemingly minor trauma can cause headaches and other symptoms for weeks.

2. If the child/athlete didn’t lose consciousness, it wasn’t a concussion.

Symptoms of concussion vary from child to child but passing out or blacking out are not required to make the diagnosis. Basically if a child has a fall or other injury that results in any neurologic symptoms, they can be diagnosed with a concussion.

Some examples of concussion symptoms are headache, nausea/vomiting, vision changes or problems with concentration and memory. Some of these symptoms may take time to develop, so it’s possible to diagnose a concussion a few days after the injury.

3. Concussions are only a problem for football players.

Almost all sports can cause concussions, including the cheerleaders on the sideline of the football games. Some other sports that are known to have higher incidents are soccer, baseball and softball. Other common causes are kids riding bikes and falling off playground equipment.

4. All concussions need either an MRI or CT of their head.

Most concussions can be diagnosed based on telling your doctor the story of the injury and the related symptoms along with a physical exam. Imaging is not necessary because a CT or MRI will most likely be normal even in the midst of a severe concussion.

Also remember that a CT of the head does not come without risk. While we should perform them when necessary, we should make sure we are not using them in situations where they will not provide useful information.

5. Don’t let your child sleep after a concussion.

Treatment of concussions is evolving. If you suspect your child has sustained a concussion, you should immediately seek medical attention and advice from a doctor about how you should treat your child’s symptoms.

There have been some changes in the treatment of concussions. First, we no longer require that you keep someone with a concussion awake for a set period of time. In fact, after their evaluation, the doctor may recommend that you allow them to sleep in order to help their brain heal. Your doctor might also prescribe some time away from TVs and other screens, school or homework or other activities that might cause their brain to work harder.

Concussions are much more common than we previously thought. I believe that the UIL will make changes to better track the risk of concussions for our high school athletes, which will hopefully lead to better ways of evaluating and treating concussions. In the mean time, don’t buy these common concussion myths.

Richard Roberts, M.D., a neurosurgeon at Cook Children’s, wonders what it’s worth for your child to play sports with a reputation for head trauma.

“I think the fact that when the NFL players sued the league initially and won, the judge said the settlement (more than $700 million) wasn’t big enough,” Dr. Roberts said. “That says a lot about this growing issue more so than anything else.”

The issue discussed in the NFL cases has been CTE (chronic traumatic encephalopathy), a progressive, degenerative brain disease that has been found in some athletes with repetitive brain trauma.

Research is currently being done to study just how playing contact sports such as football mainly, but also soccer, can cause damage to an athlete’s head. But is it worth it for parents to wait for the results of this work.

“Amateur sports are different than professional sports because no one is feeding their family with the activity that they are doing,” Dr. Roberts said. We need to look beyond the short term and really understand what could happen in the long term. That potential for long term problems should be the primary thought, not the secondary thought.

“What is the actual incidence? We don’t know. But if it was your kid, how much would you be willing to risk? Even if it was 1 in 10, would you roll the dice on your own kid?”

Dr. Roberts has previously worked at Children’s Hospital in Philadelphia and Charity Hospital in New Orleans. While he saw concussions at the other hospitals, he’s never seen parents argue with him about concussions as he has seen at Cook Children’s.

“Part of what I’ve seen which is different here than other places is that I do get push back from parents who I think underestimate the severity of some of these injuries,” Dr. Roberts said. “Some of it is that they want their kids to play and I think some of it is the short term nature of some concussions.”

Children get concussions and they do well relatively quick, so opposed to having a broken arm which is in a cast or needing surgery and having stitches for three weeks, kids hurt their heads, they are knocked unconscious for five minutes, but then feel essentially better soon after. This apparent sign of improvement makes it difficult for some parents to grasp that their child may have a fairly significant brain injury.

“The more we understand concussions and the more we see people who have hurt their heads for various reasons, soldiers, professional athletes, anyone who has suffered a head injury, I think that we are seeing that in adulthood they are starting to have more cognitive issues,” Dr. Roberts said. “Now the science is not perfect yet. We can’t say to a football player you had three concussions and that’s why you have dementia. We can’t say to the soldier you were exposed to be a bomb blast and that’s why you have dementia because it could be multifactorial. It could be that you have the right genes to make you this way later on. But the percentage seems higher in people who have had traumatic brain injuries.”

Dr. Roberts says parents should be concerned after head injury one. He knows you have to let kids live their lives and be kids, but the brain wasn’t made to get beat up like happens sometimes in sports.

It’s not known for sure that after one concussion, people are more likely to get more, but Dr. Roberts’ suspicion is that it is likely the case.

And when does he have a serious heart-to-heart with the parents and the athlete?

“After two. We discuss no longer participating in the activities which could cause further injury because the likelihood of you having a head injury in your lifetime is still pretty high,” Dr. Robert said. “You are going to hit your head on a tree branch or you are going to fall off your bicycle or someone is going to run into you. You are going to be stepping out of the car and slip or walking across ice and fall down. My opinion after behavior has shown us that you are going to get injuries in a particular sport, you should probably not be playing in that sport because you are not able to protect your head.”

Dr. Roberts has seen strong reactions from both the parents and the kids after being told he or she should quit playing their respective sport. And it’s not just football as most people expect. It’s with the gymnast who has fallen off the bars and knocked herself out or the soccer player who has headed the ball and gotten knocked unconscious.

But football still remains king in Texas – in popularity and in concussions.

So what can be done about it?

Dr. Roberts is not sure there’s a good answer to that question. Building better equipment helps, but then armoring players probably makes them feel invincible and they hit harder. If you take away the facemasks or hard shell football helmets, he expects you will return to the old days – less concussions, but more skull fractures and in the process, immediate deaths on the playing field.

For now, Dr. Roberts wants parents to monitor their kids closely and to take the recommendations from their doctor closely. If they say it’s time to stop – stop!

“All the steps that sports are taking to make it safer are positive,” he said. “I think that everybody involved has to think less about return to play and more about long term health.”

About the source

Richard Roberts, M.D., is a neurosurgeon at Cook Children's. When a child with a neurological disorder requires surgery, the experts at Cook Children's Medical Center offer comprehensive care and state-of-the-art technology. With the help of such state-of-the-art equipment as the revolutionary intraoperative MRI (iMRI), our neurosurgeons are able to determine effectiveness of surgical procedures for cranial and spinal nerve disorders and tailor the treatment to each child's unique needs.

After a child sustains a concussion, he or she should be removed from the game or practice in order to allow the brain to rest. While the importance of rest following a concussion has been scientifically validated, the definition of "rest" has not been well-established. As such, an individualized approach to concussion management is preferred. While limiting physical activity is often the first area considered when a child is instructed to rest, limiting stress in other areas of life can be equally important. In addition to physical rest, cognitive and emotional rest is also important following a concussion.

Although an extreme approach to cognitive rest is sometimes recommended, studies suggest that a more moderate approach results in better long-term outcomes. In fact, scientific evidence documenting the benefits of cognitive rest is limited. Nevertheless, limiting cognitive exertion can decrease the frequency or intensity of other symptoms, such as headache.

School is the most cognitively demanding activity for most student athletes, and their baseline level of academic functioning should be considered when creating a treatment plan. Students with more severe symptoms may benefit from staying home from school for 1 to 2 days.

However, because symptoms typically resolve within a few days, formal homebound education services are generally unnecessary because the amount of instruction provided is minimal (e.g., typically only about 4 hours per week). Furthermore, homebound school services are typically reserved for students expected to miss school for an entire month.

Immediately returning to school may be a better option for some students with mild symptoms as well as students who are likely to become severely distressed if they miss a day of school. In addition, when children are told to maintain complete cognitive rest (e.g., sit quietly in a dark room with no electronics), they may become overly focused on their symptoms and consequences of rest (e.g., having to make up multiple school assignments later).

It is also important to understand the role of electronics and technology in the lives of children, especially adolescents. While using a computer or texting on a telephone may trigger headaches, completely prohibiting a teenager from engaging in these activities can result in social isolation and contribute to emotional distress. Depending upon the assignment, prohibiting all use of electronics can result in a student being unable to complete homework requiring use of a computer.

When compared to other areas, less attention is typically given to importance of emotional rest. Particularly for teenagers, social and emotional situations can be a big concern. Limiting a child's exposure to volatile emotional situations (e.g., pressure from friends and coaches to return to play, arguments between parents) is important. In addition, peers and teachers often have a variety of reactions to a child's concussion.

For example, while most people will likely respond with understanding and support. Others, however, may discount the significance of the child’s symptoms and doubt whether the symptoms are "real" because the child does not look "sick."

When the validity of symptoms is questioned, a child will sometimes unconsciously exhibit persisting or worsening difficulties. An athlete may also feel pressure from peers, teachers, or parents to return to play before they are ready, which can lead to emotional distress as well as the appearance of persisting or worsening of cognitive symptoms.

A concussion often results in increased fatigue, particularly in the first few hours after the injury. Indeed, some scientific evidence shows that physical rest during the first 24 to 48 hours may result in an overall faster recovery. In addition, because other studies have demonstrated that a concussion sustained within a week of a prior concussion can result a longer duration of symptoms, avoiding high-risk activities (e.g., returning to play) in the days following a concussion may be best.

However, studies have also shown that extreme physical rest for more than 3 days can worsen symptoms and lead to deconditioning. Most children and adolescents who sustain a concussion will stop experiencing severe symptoms within hours to days and will completely recover within a few days to a couple of weeks.

Regardless of when a student returns to school, it is important that the school nurse and all teachers be informed that the student has sustained a concussion. Following a concussion, students may exhibit inattention, distractibility, slow thinking, and confusion as well headaches, vision difficulties, and fatigue.

Some temporary accommodations can include preferential seating in the classroom (e.g., at the front of the room and away from distractions), testing in a separate room, extra time to complete tests and assignments, shortened assignments, copies of teacher notes prior to lectures, note-taking services, rest breaks during the school day, and permission to eat lunch in a quiet environment.

Considering the typically rapid recovery following a concussion, a formal accommodations plan at school is usually unnecessary because, by the time a plan has been finalized, the student is no longer symptomatic.

If, however, a child is slower to recover, a more thorough medical evaluation may be necessary to further investigate and treat physical dysfunction (e.g., headaches, dizziness). In addition, a neuropsychological evaluation can be helpful in evaluating the specific areas of cognitive difficulty and severity of the deficits as well as provide guidance regarding the need for a more formal academic plan.

About the author

Carla Hearl Morton, Ph.D., is a pediatric neuropsychologist at Cook Children's. She is a licensed psychologist with expertise in how learning and behavior are connected to the development of a child's brain structures and systems. At Cook Children's, neuropsychologists work closely with a team of neurologists andneurosurgeons to provide the best treatments and interventions that meet the individual needs of each child.

Ball sports and games have many benefits for kids besides being a lot of fun. Playing ball helps kids develop skills:

Increased coordination with both hands

How?

o Stand in one place and dribble a basketball.

o Run while dribbling a ball.

o Playing/bumping a volleyball.

Increased hand eye coordination

How?

o Playing catch.

o Batting practice.

o Playing mini golf.

o Playing a racquet sport like tennis or ping pong.

Improved balance

How?

o Kicking a ball while standing in place.

o Kicking a ball while running.

o Jumping and reaching to catch a throw.

There are great ball options for kids of all ages and abilities. 

For kids 3 and under

Once babies can sit on their own, they can begin to roll a medium sized ball. As they grow, they will begin to use two hands to attempt to catch by pulling a ball closet to their body. Kicking is something that we should start to see with toddlers. At first your little one will walk into a ball to move it forward. As your child matures they will begin to lift one leg to kick. This requires balance and is a good challenge for toddlers and preschoolers. As their balance improves they will be able to the kick the ball harder and farther and in a straight line.

For grade school kids

At this age, kids are ready to be challenged with balls of different shapes and sizes like soccer balls, footballs, baseballs and tennis balls. These balls can be thrown and caught, but also can be used in more complex ways as part of a game. A great way to get this age group active is to create a game that they can play with friends.

For the preteen and teenagers

If your child is not yet involved in a team sport, it is important to continue to encourage them to be active with their friends, including games that include ball skills.

Sports are beneficial whether played on formal teams or as part of pick-up game with friends. Sports not only challenge your child physically, but encourage them to work on things like taking turns and being a good sport. Activities like soccer, baseball, and basketball require children to coordinate their own movements with the movements of other children in order to be successful. Teamwork and compromise are great skills for all kids to work on and will benefit them in many areas of their life.

So whether it is on their own, with siblings and friends, or as part of a team, encourage your kids to be active this summer and get involved with ball games. Remember that all kids should be getting at least one hour of physical activity a day and they will need lots of water when playing outside in the Texas summers. 

About the author

Kate Mcgee, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

The answer is complicated.

Yes, it's very important for toddlers ages 1-3 to interact with other kids their age and challenge their balance, strength and coordination. Sports are a great way to promote these skills and literature shows that athletes who play sports at a younger age are more likely to be active adults than their peers who don't participate in sports.

However, organized sports  may not be the best solution for children 3 and under, and aren't the only way to teach our children these skills. The list below describes activities for toddlers and some benefits of these activities for their development.

Swimming: Helps strengthen the arms and legs, as well as improve coordination since the child has to use both arms and both legs at the same time. Learning swimming at an early age helps promote good water safety habits later in life. You can practice swimming in a "parent and me" swimming class. 

Dance: Improves balance, coordination, strength and flexibility. You can practice in a class setting or by having a "dance party" or playing a game of "freeze dance" at home.

Biking: Between ages 2 and 3, kids should be able to begin riding a tricycle. For young kids, there are tricycles that offer a parent guide bar to help kids move and steer. You can practice biking in your neighborhood or on trails.

Soccer: Most teams start between ages 3-5; however, kicking a ball in the backyard with your toddler is a great way to help them learn to run, develop core strength and balance on one foot for a short period of time.

Basketball: Helps kids develop hand-eye coordination when dribbling and shooting and improve running and jumping skills, as well. You can play with an adjustable hoop in the driveway, or sing up for a community team (which will generally begin between ages 3-5).

T-Ball: Teaches running, balll skills and coordination skills. Using larger balls for young children will help them be successful with catching and throwing.

Yoga: Helps improve flexibility, which is very important since toddlers are growing quickly and develop tight musles quickly. Yoga can also improve strength (especially in the core muscles) and balance. Several toddler yoga videos can be found online, and classes are available throught out the DFW area.

Gymnastics: Another way to gain strength, balance and flexibility, gymnastics is a sport that children can begin learning as early as 18 months old. Many gyms have special toddler and preschool classes, as well as "parent and me" classes.

Yard games: The old staples of "tag" and "hide and seek" are great for teaching turn taking and problem solving, as well as practicing and running and climbing. Taking your child to a local playground also offers a wide variety of ways to practice climbing stairs, running, swinging, balance, etc. 

With all of these, safety is a primary concern. Toddlers are at high risk of injury when practicing new things. Contact your pediatrician if you feel like your child is having difficulty learning new skills and they may refer you for evaluation by a physical therapist to evaluate your child and help them learn these new skills.

About the author

Jodi Burgett PT, DPT, CPST, is the clinical coordinator of Neurodevelopmental Physical Therapy at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.