BRACHIAL PLEXUS REHABILITATION ‘plexus’.

Satisfactory completion of these

exercises would lead to the introduction of speed into the technique session.

Further completion of these speed exer- cise drills would lead to supervised con- tact training. In rugby this would be supervised tackling or scrummaging to ensure correct technique.

7. Provide psychological support In psychological terms injuries affect a players ‘psychological arousal’ level. Often a traumatic injury to the cervical spine may lead to some muscle imbalance and the player feels tension in certain muscle groups. This alteration in muscle tension may affect the skill acquisition by the inability of the player to relax.

This altered muscle tension may also affect the ability of the player to concentrate in key situations. Similarly a player ‘too aroused‘ may become ‘wreckless’ and make poor skill decisions. Due to lack of ‘self control’ in collision sports this is a poten- tially dangerous situation as the player may damage himself or an opponent (16).

One method of controlling this situation is to reassure the player that all appropri- ate investigations have been carried out as necessary for that particular injury. The player must be confident that he has fully recovered from the ‘stinger’ injury by following a comprehensive rehabilitation programme.

Return to sport following a brachial plexus ‘stinger’ injury In rugby union there are no proven valid functional tests for return to playing fol- lowing a ‘stinger injury’. Physicians will use as a guideline examination of: a) range of cervical spine movement b) full muscle power with no abnormal neurological deficits on EMG c) completion of a full rehabilitation pro- gramme

Recurrent ‘stingers’ must be fully investi- gated by diagnostic imaging to exclude canal stenosis. If a player presents with canal stenosis following diagnostic imag- ing, return to collision sport must be an informed decision between the specialist consultant and the player regarding risks of potential serious spinal injury by returning to a collision sport.

References for pages 9-12 1. Keenen TL and Benson DR. Initial evaluation of the spine injured patient. In Browner BD, Jupiter JB, Levine AM, Tafton PG (eds): Skeletal Trauma, Philaldelphia, WB Saunders,1992;585-603 2. Scher A. Rugby injuries to the cervical spine and spinal cord. Clinics in Sports Medicine 1998;17(1):196-205 3. Scher A. Rugby injuries to the cervical spinal cord. South African Medical Journal 1997;51:473-475 4. Milburn P. Biomechanics of Rugby Union Scrummaging:Technical and Safety Issues. Sports Medicine 1993;16(3):168-179 5. Portnoy H, McElhaney J et al. Mechanism of cervical spine injury in auto-accidents. Proceedings of the 15th Conference of the American Association for Automotive Medicine 1972 6. Roaf R. International classification of spinal injuries. Paraplegia 1972;10:78-84 7. White AA and Panjabi M. Clinical Biomechanics of the Spine. Philadelphia, J.B.Lippincott 1978 8. Allen N, Nushholtz G et al. Head and neck responses to axial impacts. Spine 1982;7:1- 27

9. Winkelstein B and Myers B. The biomechan- ics of cervical spine injury and implications for injury prevention. Medicine & Science in Sport & Exercise 1997;29(7):246-255 10. Nightingale R, McElhaney J et al. Dynamic response of the head and cervical spine to axial impact loading. Journal of Biomechanics 1996;29:307-318 11. Wetzler M, Akapata T et al. Occurrence of cervical spine injuries during the rugby scrum. American Journal of Sports Medicine 1998;26(2):177-181 12. Secin F, Poggi E et al. Disabling injuries of the cervical spine in Argentine rugby over the last 20 years. British Journal of Sports Medicine 1999;33: 33-36 13. Milburn P and O’Shea B. The Sequential Scrum Engagement: A biomechanical analysis. The Australian Journal of Science and Medicine in Sport 1994;26:32-35 14. Clark D, Roux C et al. A prospective study of the incidence and nature of injuries to adult rugby players. South African Medical Journal 1990;77:559-562 15. Garraway M, Macleod D et al. Epidemiology of Rugby Football injuries. The Lancet 1995;345:1485-1487 16. Bird Y, Waller A et al. The New Zealand Rugby Injury and Performance Project: V. Epidemiology of a season of rugby injury. British Journal of Sports Medicine 1998;32:319-325 17. Wilson B, Quarrie K et al. The Nature and Circumstances of Tackle injuries in Rugby Union. Journal of Science and Medicine 1999;2(2):153-162 18. Watkins R. The Spine in Sports. St. Loius, Mosby 1996 19. Torg J and Ramsey-Emrhein J. Cervical Spine and Brachial Plexus Injuries - Return to play Recommendations. Physician and Sports Medicine 1997;25(7):61-88

References for pages 13-17 1. Pavlov H, Torg S et al. Cervical spinal stenosis; determination with vertebral body ratio method. Radiology 1987;164:771-775 2. Herzog R, Weins J et al. Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players. Spine 1991;16:178-186 3. Cantu R. (1998). The Cervical Spinal Stenosis Controversy. Clinics in Sports Medicine 17(1) 4. Berge J, Marque B et al. Age-Related Changes in the Cervical Spines of Front Line Rugby Players. The American Journal of Sports Medicine 1999;27(4):422-458 5. Torg, J and Ramsey-Emrhein J. Management Guidelines for Participation in Collision Activities with Congenital, Developmental , or Post injury Lesions Involving the Cervical Spine. Clinical Journal of Sports Medicine 1997;7(4):273-280 6. Panjabi M. The stabilising system of the spine, Part 1, Function, dysfunction, adaption, and enhancement. Journal of Spinal Disorders 1992;5: 390 - 397 7. Richardson C, Jull G et al. Therapeutic Exercise for Spinal Segmental Stabilisation in Low Back Pain. Sydney, Churchill Livingstone 1997 8. Johansson H, Sjolander P et al. A sensory role for the cruciate ligaments.

Clinical

Orthopaedics and Related Research 1991; 268:161-168

9. Jull G. Deep Cervical Flexor Muscle Dysfunction in Whiplash. WAD 1999;1-16 10. Silverman J, Rodriquez A et al. Quantitative Cervical Flexor Strength in Healthy Subjects with Mechanical Neck Pain. Archives Physical Medicine and Rehabilitation 1991;72:679- 681

11. Grigg P. Peripheral Neuromechanisms in Proprioception. Journal of Sports Rehabilitation 1994;3:2-17 12. Zachazewski J and Geissler G et al. Traumatic Injuries to the Cervical Spine in Athletic injuries and Rehabilitation by J Zachazewski, D Magee and W Quillen 1996;410-411 13. Thein L. The Child and Adolescent Athlete in Athletic Injuries and Rehabilitation by J. Zachazewski, D. Magee and W. Quillen. Philadelphia, W.B.Saunders 1996;933-958 14. Revel MC, Andre-Deshays et al. Cervico cephalic Kinesthetic Sensibility in Patients with Cervical Pain. Archives Physical Medicine Rehabilitation 1991;72:288-292 15. Taylor, J. and D. McCloskey. Proprioception in the neck. Experimental Brain Research 1988;70:351-360 16. Bruckner P and Khan K. Clinical Sports Medicine. Roseville, New South Wales, McGraw Hill 1994

Bernard Kenny MCSP, SRP, M.Phty (Sports) is a chartered physiotherapist and superinten- dent physiotherapist at Charing Cross Hospital London. He is the current England Rugby Union team physiotherapist. In 1999 he completed a masters degree in sports physiotherapy at the University of Queensland, Brisbane, Australia. He lectures widely on sports medicine in the UK.

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