Catastrophic Head Injuries in High School and Collegiate Sports

OBJECTIVE: To describe the incidence of catastrophic head injuries in a variety of high school and college sports. DESIGN AND SETTING: Data on catastrophic head injuries were compiled in a national surveillance system maintained by the National Center for Catastrophic Sports Injury Research. The data were compiled with the assistance of coaches, athletic trainers, athletic directors, executive officers of state and national athletic organizations, a national newspaper clipping service, professional associates of the researchers, and national sport organizations. SUBJECTS: Data included all high school and college athletic programs in the United States. MEASUREMENTS: Background information on the athlete (age, height, weight, experience, previous injury, etc), accident information, immediate and postaccident medical care, type of injury, and equipment involved. Autopsy reports were used when available. RESULTS: A football-related fatality has occurred every year from 1945 through 1999, except for 1990. Head-related deaths accounted for 69% of football fatalities, cervical spinal injuries for 16.3%, and other injuries for 14.7%. High school football produced the greatest number of football head-related deaths. From 1984 through 1999, 69 football head-related injuries resulted in permanent disability. Sixty-three of the injuries were associated with high school football and 6 with college football. Although football has received the most attention, other sports have also been associated with head-related deaths and permanent disability injuries. From 1982 through 1999, 20 deaths and 19 permanent disability injuries occurred in a variety of sports. Track and field, baseball, and cheerleading had the highest incidence of these catastrophic injuries. Three deaths and 3 injuries resulting in permanent disability have occurred in female participants. CONCLUSIONS/RECOMMENDATIONS: Reliable data collection systems and continual analysis of the data can help us to reduce the number of catastrophic head-related injuries. I include additional recommendations for injury prevention.     

Minimizing liability risks of head and neck injuries in football

Although catastrophic head and neck injuries in football occur infrequently, their occurrence is almost always followed by litigation. The athletic trainer has to be sure he/she has adequate liability insurance to cover the costs of a defense and a possible judgment. General claims filed against athletic staffs usually deal with instruction, equipment, matching of participants, supervision, and/or postinjury care. The defenses to these claims include: statutory immunity, assumption of risk, releases or waivers, and the reckless disregard standard. The athletic trainer plays a key role in head and neck injury prevention and care, and must be aware of litigation possibilities, along with methods of risk management. We present recommendations aimed at minimizing the risk of head and neck injuries and the risk of liability. The areas covered are: preparing for head and neck lawsuits, preventing head and neck injuries, and postcatastrophic injury care. We base these recommendations on principles that the athletic trainer can easily apply to other areas, broadening the risk management concept presented.     

Psychosocial Factors in Athletic Injuries: Development and Application of the Social and Athletic Readjustment Rating Scale (SARRS)

Abstract

The possible role of psychosocial factors in athletics, namely football injuries, is examined. Initially Holmes and Rahe's Social Readjustment Rating Scale (SRRS) was modified to the Social and Athletic Readjustment Scale (SARRS). Additions to the scale and differences in football players from the general population are discussed. Life change scores over one- and two-year intervals were obtained for college varsity football players. Players suffering major time loss injuries had significantly higher predictive scores than noninjured players.     

A comparison of Gaelic football injuries in males and females in primary care

The Ladies Gaelic Football Association has a playing population of 150,000 of which 33% are adults. A number of studies have been published on rates of injury among male athletes but none on female athletes in Gaelic football. A retrospective review of insurance claims, submitted under the Gaelic Athletic Association Player Insurance Injury Scheme. 405 injuries were recorded, 248 [107 (70%) male, 141 (58%) female] to the lower limb, 91 [33 (21%) male, 58 (23%) female] to the upper limb. The majority of lower limb injuries [56 (52%) male, 56 (40%) female] were to muscle. Almost a third of upper limb injuries were fractures [10 (30.3%) male, 33 (57%) female]. injuries/1000 hours playing was 8.25 for men and 2.4 for women. The injury rate in ladies Gaelic football was found to be significantly lower than in men's Gaelic football. Lower limb injuries accounted for the majority of injuries in both sports.     

Epidemiology of Injuries in National Collegiate Athletic Association Men's Football: 2014–2015 Through 2018–2019

ContextFootball is among the most popular collegiate sports in the United States, and participation in National Collegiate Athletic Association (NCAA) football has risen in recent years.BackgroundContinued monitoring of football injuries is important for capturing the evolving burden of injuries in NCAA football. The purpose of this study was to describe the epidemiology of football-related injuries among men''s NCAA football players during the 2014–2015 through 2018–2019 academic years.MethodsExposure and injury data collected in the NCAA Injury Surveillance Program were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios were used to examine differential injury rates.ResultsThe overall injury rate was 9.31 per 1000 athlete-exposures. Most injuries occurred during general play (17.5%), blocking (15.8%), and tackling (14.0%). Concussions (7.5%), lateral ligament complex tears (6.9%), and hamstring tears (4.7%) were the most commonly reported injuries.ConclusionsResults of this study were generally consistent with previous findings, though changes over time in rates of commonly reported injuries warrant attention. Continued monitoring of injury incidence is needed to appraise the effectiveness of recently implemented rules changes.     

Analysis of cerebral concussion frequency with the most commonly used models of football helmets

Data on helmet models used and occurrence of cerebral concussions over five seasons were collected from a representative sample of college football teams including a total of 8,312 player-seasons and 618,596 athlete-exposures to the possibility of being injured in a game or practice. Results showed that players with a history of concussion any time during the previous 5 years were six times as likely to suffer a new concussion as those with no previous history. In light of previous studies showing cognitive deficits for up to 30 days following even minor head injuries, and the growing awareness of “second impact” fatalities, these data support a need for reconsideration of the common practice of immediate return to play following non-loss-of-consciousness head injuries. Results on concussion frequency in ten models of football helmets indicated a significantly lower than expected frequency in the Riddell M155 and a significantly higher frequency in the Bike Air Power. All other models performed within expectations. This study demonstrates the need for monitoring on-the-field performance of football helmets through continuing epidemiological studies to supplement laboratory test data, which cannot duplicate all the factors involved in actual helmet performance.     

A national survey about parent awareness of the risk of severe brain injury from playing football

A survey was conducted to determine the level of awareness among parents of high school football players about the risk of severe brain injury. A national sample of 1007 randomly selected households was interviewed by telephone during February, 1992. All interviewees were parents of high school football players who either were currently playing football or had played within the previous 5 years. Survey questions measured the extent to which parents were aware both of the risks associated with playing high school football and the existing helmet warnings about those risks. Overall, the survey results demonstrated that parents of high school football players were uninformed about both the risk of severe brain injury from playing high school football and the football helmet warnings about that risk. Specifically, unprompted, most parents mentioned broken bones, knee injuries, sprains, or shoulder injuries as hazards associated with playing football. Few parents mentioned severe brain damage, even when prompted. Further, the overwhelming majority of parents incorrectly believed that wearing a football helmet generally eliminated the risk of severe brain injury. Very few parents had received information from any source about the risks of head injury or had heard that no football helmet can provide complete protection against this hazard. Few parents were aware of the warning label on the helmet or knew what the label said, even when prompted. In short, parents were unaware of the risk of severe brain damage, misinformed about a football helmet's ability to protect against this risk, and uninformed about the football helmet warning label about this risk.     

Laryngeal fracture in a high school football player

Laryngeal injuries are rare in the athletic setting, but such sports as football, basketball, and hockey often place the athlete in a position to receive blunt trauma to the throat area. Such an injury has the potential of developing into a life-threatening situation. A high school athlete sustained a fractured larynx during a football game. The injury required surgical repair. Unfortunately, because this type of injury is uncommon in sports, many athletic training books do not extensively address soft tissue and cartilaginous injuries to the structures of the anterior neck. Athletic trainers must be able to recognize the signs and symptoms of a laryngeal injury and refer the athlete for immediate medical attention.     

A systematic review of prophylactic braces in the prevention of knee ligament injuries in collegiate football players

OBJECTIVE: To determine the relative risk reduction associated with prophylactic knee braces in the prevention of knee injuries in collegiate football players. DATA SOURCES: An exhaustive search for original research was performed using the PubMed, SportDiscus, and CINAHL databases from 1970 through November 2006, with the search terms knee brace, knee braces, knee bracing and football, prophylactic brace, and prophylactic knee braces. STUDY SELECTION: Seven studies comparing knee injuries among braced and nonbraced collegiate football players were included. Study methods were assessed using the Physiotherapy Evidence Database (PEDro) scale. PEDro scores ranged from 2 to 5. DATA EXTRACTION: The number of participants and frequency of knee injuries were used to calculate the relative risk reduction or increase. DATA SYNTHESIS: We found a relative risk reduction for 3 studies with point estimates of 10% (36% to -26%), 58% (25% to 76%), and 56% (13% to 77%). Four studies demonstrated an increased risk of injury, with point estimates of 17% (19% to -71%), 49% (-31% to -69%), 114% (23% to -492%), and 42% (-18% to -70%). CONCLUSIONS: Data from existing research are inconsistent. Based on a Strength of Recommendation Taxonomy level of evidence of 2 with a grade B recommendation, we cannot conclusively advocate or discourage the use of prophylactic knee braces in the prevention of knee injuries in collegiate football players.     

Clinical Features of Repetitive Traumatic Brain Injury and Chronic Traumatic Encephalopathy

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by a distinct pattern of hyperphosphorylated tau (p‐tau). Thought to be caused by repetitive concussive and subconcussive injuries, CTE is considered largely preventable. The majority of neuropathologically confirmed cases have occurred in professional contact sport athletes (eg, boxing, football). A recent post‐mortem case series has magnified concerns for the public's health following its identification in six high school level athletes. CTE is diagnosed with certainty only following a post‐mortem autopsy. Efforts to define the etiology and clinical progression during life are ongoing. The goal of this article is to characterize the clinical concepts associated with short‐ and long‐term effects of repetitive traumatic brain injury, with a special emphasis on new clinical diagnostic criteria for CTE. Utilizing these new diagnostic criteria, two cases of neuropathologically confirmed CTE, one in a professional football player and one in a professional boxer, are reported. Differences in cerebellar pathology in CTE confirmed cases in boxing and football are discussed.     

Heading in Soccer: Integral Skill or Grounds for Cognitive Dysfunction?

OBJECTIVE: To critically review the literature concerning the effect of purposeful heading of a soccer ball and head injuries on reported cognitive dysfunction in soccer players. DATA SOURCES: We searched MEDLINE (1965-2001) and SPORTDiscus (1975-2001) for refereed articles in English combining key words for soccer (eg, soccer, football, association football ) with key words for head injuries (eg, concussion, head injury). In addition, literature on cognition and head injuries was obtained. We reviewed reference lists of current literature for pertinent citations that might not have been found in the search procedures. DATA SYNTHESIS: The fact that soccer players (and other athletes) have selected cognitive deficits is not questioned, and the popular press is quick to publicize results of questionable validity. The reasons for such deficits are many. Much of the early data implied that heading was the culprit; however, subsequent research has suggested that other interpretations and factors may be potential explanations for these deficits. The current focus is on concussions, a known factor in cognitive dysfunction and a common head injury in soccer. CONCLUSIONS/RECOMMENDATIONS: It is difficult to blame purposeful heading for the reported cognitive deficits when actual heading exposure and details of the nature of head-ball impact are unknown. Concussions are a common head injury in soccer (mostly from head-head or head-ground impact) and a factor in cognitive deficits and are probably the mechanism of the reported dysfunction.     

National Athletic Trainers' Association Position Statement: Head-Down Contact and Spearing in Tackle Football

OBJECTIVE: To present recommendations that decrease the risk of cervical spine fractures and dislocations in football players. BACKGROUND: Axial loading of the cervical spine resulting from head-down contact is the primary cause of spinal cord injuries. Keeping the head up and initiating contact with the shoulder or chest decreases the risk of these injuries. The 1976 rule changes resulted in a dramatic decrease in catastrophic cervical spine injuries. However, the helmet-contact rules are rarely enforced and head-down contact still occurs frequently. Our recommendations are directed toward decreasing the incidence of head-down contact. RECOMMENDATIONS: Educate players, coaches, and officials that unintentional and intentional head-down contact can result in catastrophic injuries. Increase the time tacklers, ball carriers, and blockers spend practicing correct contact techniques. Improve the enforcement and understanding of the existing helmet-contact penalties.     

Time-loss and non-time-loss injuries in youth football players

CONTEXT: Estimates suggest that more than 5.5 million youths play football annually, and 28% of youth football players (age range = 5 to 14 years) are injured each year, resulting in more than 187 000 emergency room visits. OBJECTIVE: To analyze time-loss (TL) and non-time-loss (NTL) injury patterns across age groups in youth football players. DESIGN: Two-year observational cohort. SETTING: Two midwestern communities, including players from the fourth through eighth grades and between the ages of 9 and 14 years. PATIENTS OR OTHER PARTICIPANTS: A total of 779 players participated, including 296 in grades 4 and 5; 203 in grade 6; 188 in grade 7; and 92 in grade 8. (Players in the fourth and fifth grades participated on the same teams, so we considered them as a single group.) MAIN OUTCOME MEASURE(S): Injury frequencies and exposures were collected by certified athletic trainers present at each practice and game and used to calculate injury rates with 95% confidence intervals (CIs) for both TL and NTL injuries across age groups. RESULTS: A total of 474 injuries and 26 565 exposures were identified. Injuries were reported by 36.5% of the players, with 14.4% reporting more than 1 injury in a season. The overall injury rate per 1000 athlete-exposures (A-Es) was 17.8 (95% CI = 16.3, 19.5). The injury rate increased with each succeeding grade from 14.3 per 1000 A-Es (95% CI = 12.1, 16.9) in grades 4 and 5 to 21.7 per 1000 A-Es (95% CI = 17.2, 27.3) in grade 8. A total of 58.6% of all injuries were NTL. Non-time-loss injuries accounted for 70.1% of the injuries reported by fourth and fifth graders, 55.1% by sixth graders, 64.0% by seventh graders, and 33.8% by eighth graders. The cumulative NTL injury rate was 10.5 per 1000 A-Es (95% CI = 9.3, 11.8), and the TL injury rate was 7.4 per 1000 A-Es (95% CI = 6.4, 8.5). CONCLUSIONS: Youth football players sustained more NTL injuries than TL injuries. We recommend that a first-aid-certified coach or league official be present at all games and practices.     

Tibial and peroneal nerve conduction studies in ankle sprain

BACKGROUND: Lower limb injuries and ankle sprain occur frequently among football players, due to the high incidence of physical contact. As a result, lower limb nerves are subject to injury. This project aims to evaluate the lower limb nerve conduction among students playing football to investigate the probable relationship between ankle sprain in football and nerve conductivity. MATERIALS AND METHODS: Fifty volunteer students aged between 19 and 25 were studied. They fell into three groups; one comprising of 20 healthy football players whose football experience exceeded three years, the second group with 15 football players who had suffered ankle sprain and the last group with 15 healthy non- sports students. Initially, the surface temperature of the foot skin was recorded. Then, the latency and the conduction velocity of deep peroneal and tibial nerves were recorded, statistical data analysis was conducted using statistical tests, i.e., "Independent sampleT", and "Paired T test". RESULTS: In the football player group, student with Hx of ankle sprain, the deep peroneal and tibial nerves distal latencies were significantly longer than the other two groups (P < or = 0.05). In addition, the nerve conduction velocity of the deep peroneal motor and tibial nerves showed a significant decrease in comparison with the other two groups (P < or = 0.05). CONCLUSION: Harming the lower limb nerves, football may increase the nerve latencies and hence decrease the conductivity in lower limbs. Therefore, in electrophysiologic tests of the football players lower limb nerves, especially those with lower limb injuries, one has to consider the fact that the decrease in the clinical neuroconductivity may be preexistent. Thus care should be taken in diagnosing neuropathy, in this group.     

The incidence of spearing by high school football ball carriers and their tacklers

This study established the cumulative incidence per season of ball carrier spearing and concurrent defensive spearing by tacklers on a New Jersey high school football team. Spearing, which involves flexing the neck and initiating contact with the top of the helmet, is a significant cause of injury to the head and neck of a football player. To reduce the risk of head and neck injuries in football, all avenues of spearing must be explored. Nine game films from the 1989 football season were reviewed to determine the incidence of ball carrier spearing and concurrent defensive spearing. There were 167 incidents of ball carrier spearing (1 per 5.1 plays) and 72 incidents of concurrent defensive spearing (1 per 2.3 ball carrier spears), although no spearing penalties were called. This study detected a surprisingly high cumulative incidence of ball carrier spearing and concurrent defensive spearing, along with poor enforcement of the rule banning spearing.     

The effect of playing surface on the incidence of ACL injuries in National Collegiate Athletic Association American Football

BackgroundArtificial playing surfaces are widely used for American football practice and competition and anterior cruciate ligament (ACL) injuries are common. This study analyzed the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) men's football ACL injury database from 2004–2005 through 2008–2009 to determine the effect of playing surface on ACL injury in NCAA footballathletes.MethodsThis database was reviewed from the 2004–2005 through 2008–2009 seasons using the specific injury code, “Anterior cruciate ligament (ACL) complete tear.” The injury rate was computed for competition and practice exposures. Ninety-five percent confidence intervals were calculated using assumptions of a Poisson distribution. Pair-wise, two-sample tests of equality of proportions with a continuity correction were used to estimate the associations of risk factors.ResultsThere was an incidence rate of 1.73 ACL injuries per 10,000 athlete-exposures (A-Es) (95% CI 1.47–2.0) on artificial playing surfaces compared with a rate of 1.24 per 10,000 A-Es (1.05–1.45, p < 0.001) on natural grass. The rate of ACL injury on artificial surfaces is 1.39 times higher than the injury rate on grass surfaces. Non-contact injuries occurred more frequently on artificial turf surfaces (44.29%) than on natural grass (36.12%).ConclusionsNCAA football players experience a greater number of ACL injuries when playing on artificial surfaces.     

National Collegiate Athletic Association Division I Football Players' Perceptions of Women in the Athletic Training Room Using a Role Congruity Framework

Context:

Previous researchers have demonstrated that male and female athletes feel more comfortable with treatment by a same-sex athletic trainer for sex-specific injuries and conditions.

Objective:

To address football players'' comfort with care provided by same-sex and opposite-sex athletic trainers for sex-specific and non–sex-specific injuries and conditions through the lens of role congruity theory.

Design:

Cross-sectional study for the quantitative data and qualitative study for the qualitative data.

Setting:

Two National Collegiate Athletic Association Division I Football Bowl Series university football programs.

Patients or Other Participants:

Male football players within the 2 university programs.

Data Collection and Analysis:

We replicated existing methods and an existing survey to address male football players'' comfort levels. Additionally, an open-ended question was used to determine male football players'' perceptions of female athletic trainers. Paired-samples t tests were conducted to identify differences between the responses for the care given by a male athletic trainer and for the care given by a female athletic trainer. Three categories were analyzed: general medical conditions, psychological conditions, and sex-specific injuries. The qualitative data were coded and analyzed using content analysis.

Results:

Male football players were more comfortable with treatment by a male athletic trainer (mean  =  3.61 ± 1.16) for sex-specific injuries and conditions than they were with treatment by a female athletic trainer (mean  =  2.82 ± 1.27; P < .001). No significant results were found for comfort with overall psychological conditions, although a female athletic trainer was preferred over a male athletic trainer for the treatment of depression (mean  =  3.71 ± 1.07 versus mean  =  3.39 ± 1.16, respectively; P < .001). Qualitative data provided support for role congruity theory.

Conclusions:

Both quantitative and qualitative evidence were provided for the support of role congruity theory.     

Injuries in a Japanese Division I Collegiate American Football Team: A 3-Season Prospective Study

Context:

Previous research on American football injuries in Japan has focused on incidence proportion in terms of the number of injuries divided by the number of players. This is the first study to examine injury rates over several seasons.

Objective:

To conduct a prospective study of injuries in a Japanese Division I collegiate American football team over the 2007 through 2009 seasons.

Design:

Cohort study.

Setting:

Collegiate football team at Doshisha University, Kyoto, Japan.

Patients or Other Participants:

All 289 athletes who played on the collegiate Division I football team during the 2007 through 2009 seasons.

Main Outcome Measure(s):

A certified athletic trainer kept a daily record of all practice and game injuries. Injury rates were calculated according to season, injury type, body part, severity, and mechanism. Injuries were also analyzed according to position of player, school year, and playing experience.

Results:

The game injury rate (GIR; 32.7 injuries/1000 athlete-exposures) was higher than the practice injury rate (PIR; 10.9 injuries/1000 athlete-exposures) over the 3 seasons (P < .05). The PIR was higher among Japanese players than the comparable United States collegiate football injury rates (5.8–7.0 injuries/1000 athlete-exposures). Ankle and foot injuries occurred more frequently during games, whereas thigh and gluteal injuries occurred more frequently during practices.

Conclusions:

Our data show differences between games and practices in terms of injury rates, body parts injured, and positions of players injured. The high PIR in Japan may be due to the increased contact during practices and length of practices compared with the United States. Further research involving multiple teams is recommended to validate the trends noted in this study. The expanded data set could assist in the development of safety regulations and preventive interventions for Japanese football.Key Words: Japanese football, American football, college football, injury rates

Key Points

• The practice injury rate for Japanese collegiate football players was higher than in the United States. This may be explained by the increased contact during practice and unregulated practice length in Japan.
• Ankle and foot injuries occurred more often during games, whereas thigh and gluteal injuries were more frequent during practices.

American football is 1 of the most popular sports in the United States, played by more than 60 000 college-level male athletes in 2008 and more than 1 million high school male athletes in 2009.^1,2 Football has a high injury risk,³ and as the number of players has grown, so has the number of injuries experienced.⁴ Previous researchers^3,5–13 have examined football injuries in a variety of conferences, divisions, and schools. Football had the highest number of reported injuries among the 5 fall collegiate sports.³ The National Collegiate Athletic Association (NCAA) reported 266 943 injuries during the 2004–2005 through 2008–2009 seasons. Hootman et al¹⁴ noted that football had the highest number of serious sport-related injuries (eg, anterior cruciate ligament injury, concussion) among the 15 collegiate sports. Ramirez et al¹³ found that the estimated cost per football injury increased by approximately 20% from 1977 to 1986. Injured athletes may also experience psychological trauma such as fear of reinjury or surgery.¹⁵ The NCAA has implemented measures to reduce injury risk. In 1998, limits were placed on the number of practices and the number of contacts allowed during spring football practices in an attempt to reduce the injury rate, which was twice as high during spring football practices as during fall practices.⁵Data released in 2008 by the Japanese Football Association¹⁶ indicated that approximately 20 000 football players participated on 402 teams, including 11 junior high school teams, 112 high school teams, 218 university teams, and 61 adult club teams. Despite the relatively large number of players, research regarding football injuries in Japan is limited.^17–21 Moreover, unlike in the United States, no evidence-based rule changes have been implemented to try to reduce injuries in Japanese football.Previous Japanese studies have focused on incidence proportion, calculated as the number of injuries divided by the number of players. Although incidence proportion can directly measure the risk of injury, which is useful information for the general public, this value is rarely used in the sport-injury literature and is difficult to compare among different sports.²² Injury rate is easier to compare among different sports and permits comparisons within the sport, both nationally and internationally.Only 1 Japanese study²⁰ has examined injury rates according to athlete-exposures (AEs). However, that study was conducted during a single season, and no studies have followed a team over several seasons. In comparison, research in the United States has examined injury rates based on multiple-year records.^{5,7,10,11,13,14} We aimed to examine practice and game injury rates according to season, injury type, body part, severity, and mechanism in a Japanese Division I collegiate football team over 3 consecutive seasons. Injuries were also analyzed according to position of player, school year, and playing experience.     

Liver laceration in an intercollegiate football player

Serious abdominal injuries in athletics, including liver trauma, are relatively rare. When they do occur, the athletic trainer and the team physician must be able to recognize the signs and symptoms and employ the appropriate first aid and follow-up care. In this paper, we present a case study of a football player who suffered a lacerated liver as a result of a forceful blow to the right side of the chest. Although his case was typical of most isolated liver injuries and he did not experience massive internal bleeding, the potential for life-threatening exsanguination exists and must be recognized by by sports health care practitioners. Most isolated liver injuries can be treated nonsurgically. However, those patients with multiple organ trauma, deteriorating vital signs, or diminishing hemodynamic stability generally require immediate surgery. Athletes with persistent right upper quadrant pain, especially when accompanied by referred pain to the right shoulder, abdominal rigidity, guarding, or rebound pain should be considered to have a liver injury until ruled out by CT scan and liver enzyme studies. Our subject was typical of most athletic liver patients and he was able to resume light exercise after 5 weeks and full activity after 3 months.