Monday, February 17, 2020

The Evolving Knowledge of Movement - Part VIIB What We Know Now

Over the last couple of weeks, we have discussed frontal plane motion.  Not only the impact that this motion has on injury risk but also the impact it can have on performance.  We also discussed how to visually assess this and how what we are seeing on this visual assessment can lead to some assumptions about risk. 

This week, we are going to discuss some targeted training to help improve these movements.  Prior to talking about training, I want to be clear that what is discussed here is not the end all be all.  There are multiple exercises we can do that will impact this which we can all do.  However, we have found some common patterns with what we see in the movement assessment with exercises that make specific changes to control of frontal plane motion.  Keeping in mind, the majority of these are tested during single limb motion.


Larger varus motions - although the motion that we are recording is not a "true" varus at the knee, it still creates a varus stress to the lower limb.  As depicted here, these athletes tend to have a lot of frontal and transverse plane motion at their hips.  When the center of mass is moved laterally on a planted foot, this creates this lower limb varus stress.  Considering, this is primarily (not all) driven from the inability of the core to stabilize and control the center of mass during single limb performance as well as the hip musculatures inability to stablize.  With these folks, focusing on core stability (planks and side planks) as well as frontal and rotational stability of the hips and core in single limb performance is critical. 

Larger of valgus motion - for those that fall into a large valgus in the absence of loss of pelvic control, we will typically focus in on the gluteus maximus and gluteus medius.  The gluteus medius and maximus are high endurance muscles and are active with every step that we take.  Research indicates when these muscles fatigue, that there is a corresponding increase in frontal plane motion (Weist et al Am J Sports 04).  Considering, I tend to focus a lot of pushing endurance and fatigue resistance with these muscles.  Combining motions that pull the limb into the dynamic valgus position under resistance (depicted here) can help facilitate the function of these two muscles to resist that motion and aid in increase recruitment of. 

Large valgus motions with high speeds - when there is a combination of a large increase in motion and speed, this is often associated with a weakness of the hip (gluteus medius and maximus) as well as core.  When speeds exceed 200 degrees/sec, we tend to see this as whole kinetic chain (meaning from the foot to the core).  Typically, one of the links in the kinetic chain will prevent the athlete from falling into these motions at such high rates of speed.  As weakness of the entire kinetic chain increases, so do the speeds of valgus because there is less resistance along the chain to slow it.  In these cases, I will do a lot of core, hip and ankle stability exercises in isolation and in single limb performance. 

Before we get into specific exercises, I would like to discuss how BFR (blood flow restriction) can be implemented to address a lot of these issues.  Although most think BFR is a fairly new, it has actually been around since the 60s and was used a lot in bodybuilding.  As a avid weightlifter for 40+ years, I vividly remember doing some form of this as a younger lifter using straps and bands (not recommended but what we did at the time).  BFR has had a resurgence in sports medicine with a variety of new products coming on the market and a lot of new research in the area.  Aside from the impact on growth hormone (GH), insulin-like growth factor 1 (IGF-1) and myostatin, there is also an up-regulation of motor units.  In addition, studies show you can have an impact on VO2Max and stroke volume with BFR.   

Considering these findings, there is a lot of application to control of frontal plane motion.  As such, some of the exercises we will discuss include the application of BFR.  This allows us to maximize the benefit of the exercise in a shorter training session.

Side planks with CLX - this is a great exercise which brings in the entire upper and lower kinetic chain.  In the side plank, the ankle everters must be every active to in an isometric and eccentric fashion in order to prevent the foot from falling into a inverted position.  With the combination of the CLX, this brings a cross link of lower kinetic chain to core to upper kinetic chain.  While the gluteus medius (on the down leg) must actively stabilize at the hip, the contralateral glut is working in a concentric and eccentric fashion.  At the same time, by drawing in the upper shoulder girdle movement and stability, this adds increased complexity to the core and lower kinetic chain. 



Next week, we will continue this discussion with looking at some specific exercises that incorporate some of the concepts we discussed with BFR to continue to push controlling frontal plane motion.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, February 10, 2020

The Evolving Knowledge of Movement - Part VIIA What We Know Now

Last week, we looked at the lack of frontal plane control and the impact on both performance and injury risk.  We also spoke about the control of frontal plane motion means controlling how much the knee moves and how fast it moves in that direction.

Unfortunately, this movement pattern is all too common in our athletes.  We may think we may only see this in the untrained or lower level high school athlete.  The reality is that we see this across the entire spectrum from high school athlete, to college, to Olympic to professional athlete.  Part of the reason we often don't see it is that we are not assessing for it or recognizing it during training.

The severity of the of the frontal plane motion (both amount and speed) can dictate how much this will impact an athlete's risk and the impact that this will have on performance.  So as the increase in magnitude or speed of valgus increases, so does the risk and the impact on performance.  The impact of frontal plane control is not only determined by how much and how fast the athlete moves into valgus but at which point during your assessment.

For example, compare the following athletes.
  • Athlete A starts to fall into valgus on rep one
  • Athlete B starts to fall into valgus on rep one at a high rate of speed
  • Athlete C starts to fall into valgus at rep 8
In this scenario they are all at risk however, I think we would all agree that athlete B is at the highest risk followed by A and then by C.  This can help us not only from an assessment perspective but can also guide the intervention or the starting point for the intervention.  In this scenario, with no further information, I am going to start Athlete B in a single leg squat in a staggered stance (provides increased base of support and stability) and work on controlling frontal plane motion throughout the range of the exercise.  Athlete A, I might start in a single leg squat with contralateral leg in the athletic position and work on them controlling frontal plane motion.  Athlete C, I might start in some hops until they can't control frontal plane motion and regress to single leg squat while controlling frontal plane motion.  

So, although it is the same motion, it is the severity of the motion (magnitude vs. speed and magnitude vs. control till some fatigue sets in) that dictates the exercise or level of exercise we would do with the athlete.  End of the day, any exercise that is performed where the athlete is "allowed" to train without controlling these motions will simply reinforce the default motor pathway that led to the faulty movement pattern in the first place.  Training in this pattern will result in this being the default they move to when demands are highest and they are fatigued.

For control of frontal plane motion, we traditionally think of this as just a gluteus medius weakness.  However, what we now know is this is a little more complex than that.  We often see those who have immediate inability to control motion and speed to have components of gluteus medius and gluteus maximus weakness and poor core control.  These individuals often have inability to sustain and controlled plank position for one minute and often perform poorly on side planks.  With side planks, these individuals are not only challenged with maintaining the position but also have an inability to control trunk rotation during.  

Obviously, there are over a 1000 ways to address frontal plane control and is something we are all capable of doing.  Biggest thing for us all to keep in mind:

  1. Training needs to include single limb training - ensuring to put the athlete in positions that allow them to successfully control frontal plane motion.  If this is a single leg squat in a stride stance or single leg squat with contralateral leg in the athletic position or single leg plyos doesn't matter.  As long as the athlete is controlling frontal plane motion.  When they can no longer control that frontal plane motion, then should move to a lower level of the exercise to allow them to keep training while controlling that motion.
  2. If there is high amounts of valgus and at high speeds, then there is the need to make sure to include core training and focusing on maintaining control at the hips.  Control of the hips means we want to prevention the athlete from falling into a trendelenburg, retro-trendelenburg or cork screw.

  3. We need to train for some level of fatigue in single limb training.  We know that fatigue impacts lower extremity mechanics and force attenuation in runners (Weist et al Am J Sport Med 04) and there is an increase in frontal plane motion with fatigue (Brazen et al Clin J Sport Med 10).  Therefore bringing fatigue into the equation is needed and to keep them training in this fatigued state with good mechanics.  This ensures that when they are fatigue in competition or practice that they are moving better and at decreased risk for injury.
  4. Train in the athletic position.  There is a trend to train folks in a pistol squat position or with the leg in the forward position (Position A).  Studies show that this is an effective position for strengthening the quads.  However, this is not the position that athletes injure themselves in competition.  The core, the limb and center of mass are positioned in a different position.  Therefore, from a specificity, it makes sense to train in more of an athletic position (Position C).  This position has a lot more core, pelvic and glut activation. 

Next week, we will continue that discussion with looking at some specific exercises that we find aid in controlling frontal plane motion.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, February 3, 2020

The Evolving Knowledge of Movement - Part VII What We Know Now

Last week, we talked about the impact concussion has on movement and how this can influence some corrective techniques we can do to influence these movements.  This week we want to get into looking at control of frontal plane motion.

As clinicians, when we see athletes presenting like this, we think of all the musculoskeletal injuries that could happen as a result of the way that this athlete is moving.  However, as a strength or performance coach, we might see an athlete who's vertical jump or explosive power is going to be impacted.  The reality is that both answers are right.  In jumping sports, the lower extremity has to attenuate anywhere from 4-8 times body weight (Nordin et al Basic Biomechanics of the Musculoskeletal System - 4th Edition).  If one of the joints is not moving optimally (example here moving into excessive valgus) then there are structures that are stressed at that joint and the joints distal and proximal to.  This can add to a plethora of non-contact musculoskeletal injuries.

At the same time, these same movement patterns lead to a loss of kinetic energy across the system which lends to a loss of explosive power.  After assessing 1000s of athletes, some of the things we have seen is that explosive power is impacted by:

  • Magnitude of frontal plane motion - the greater the increase in frontal plane motion, the greater the impact on explosive power.  As the magnitude of frontal plane motion is improved, there is an equivalent improvement in explosive power.
  • Speed of frontal plane motion - the greater the speed of frontal plane motion, the greater the impact on explosive power.  If there is a decrease in speed of frontal plane motion, irrespective of change in magnitude of motion, there is an equivalent improvement in explosive power.  
The sad thing about these findings is that a LOT of athletes train without controlling these factors.  They will focus more on the loads lifted or the volume of exercise and not necessarily the quality of the movement.  Although load and volume are critical, this should never be at the expense of controlling frontal plane motion.  From a simple motor learning perspective, if an athlete is allowed to train with with poor frontal plane control under heavier loads or with increased volume then what happens is this is the pattern they resort to under these kind of demands or in a fatigued state.  

As depicted here, control of this frontal plane motion can can mean the difference between simply lifting or obtaining a PR.  The best part of all is that once this is identified, you can change it through directed corrective exercises.   The first step is knowing how to assess it.  Studies show that identifying these movement patterns in bilateral tasks (squatting motion or bilateral box jump) is difficult to do (Krosshaug et al Am J Sport Med 2016).  Although these biomechanical flaws (decreased control of frontal plane motion) may not be easily assessed in bilateral activities, they can be easily assessed in single limb activities (King et al Am J Sport Med 2019).  That said, the movements that we see that are the most telling is the single leg squat and the single leg hop plant.  
  • Single leg squat - the athlete stands on one leg, with the contralateral leg in a slight hip extension with knee flexion (the athletic position requires greater glut control and mimics running).  The athlete performs 10 single leg squat on each side without touching the contralateral limb to the floor at anytime during the test.  During the test, you are recording the number of reps where there is not frontal plane motion control vs. successful reps and the number of losses of balance (where they touch down the contralateral foot).  You can use that to determine symmetry between the right and left. 
  • Single leg hop plant - the athlete stands on one leg, with the contralateral leg in a slight hip extension with knee flexion (the athletic position requires greater glut control and mimics running).  The athlete jumps in the following sequence: forward, backwards, lateral and medial.  This is repeated for 2 cycles on each side without touching the contralateral limb to the floor at anytime during the test.  During the test, you are recording the number of reps where there is not frontal plane motion control vs. successful reps and the number of losses of balance (where they touch down the contralateral foot).  You can use that to determine symmetry between the right and left.  

 *Use caution with the hop plant.  To do all directions and reps is a clinical decision based on how safe you feel the athlete is to perform the task.*  These movements are within the standard of practice and less stressful than what they will go through with sport but the medial hop tends to be very revealing to inability to control frontal plane motion.  Therefore caution should be used and close observation should be provided.

Once these tests are complete, you can then have a baseline measure of how the athlete is performing and this will give you something you can compare to after targeted training has been provided.  According to the research, you should give 6-8 weeks of training between testing in order to observe clinically meaningful improvements (Bodkin et al Am J Sport Med 2020).

Next week, we will continue this discussion as we look at on how we change these movements through movement guided interventions.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #ViPerformAMI #ACLPlayItSafe

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, January 27, 2020

The Evolving Knowledge of Movement - Part VIB What We Know Now

This is a continuation of the series we initially started back in December 2019.  We interrupted with my annual plea to make this the year we make change, so I thank you for indulging me in that.   As a refresher, we started Part IV talking about what movement patterns we are seeing associated with concussion.  We discussed some of the impact we are seeing that concussion has on lower kinetic chain movement during single limb testing.  These included:

  • Increase in frontal plane motion at the knee
  • Increase in frontal and transverse motion at the hip
  • Increased time to Stability
  • Increase in loss of Balance 
  • Larger displacement of landings on a scatter plot

Conceptually all of these make a lot of sense when you think of the signs and symptoms we usually see with our concussed athlete.  Although we have not seen the above consensus validated in the the research yet, we do know that athletes with concussion are at greater risk for lower extremity injury (McPherson et al Am J Sports Med 19) and those with a loss of pelvic control (or dynamic stability) are more likely to be concussed (Johnston et al Am J Sport Med 19).  Considering, the above, the measurements we are seeing could be potential mechanism or root cause for the why we are seeing increased risk post concussion.

No matter what your stance is, the evidence is pretty clear that this should now be a part of our concussion protocol or treatment as we get the athlete ready to return to sport.  Based on what we are measuring, we have seen some significant improvements in the above measures when we include the following into our concussion rehab.  With each exercise we will discuss some technical points.  Although this may seem rudimentary I see patients all over the US in high level clinics doing these exercises wrong.  Some simple technique corrections will have a huge impact on the motor plan that is trained and the one they will revert to as their default.

  1. Single limb training - when symptoms allow, the athlete should start single limb training.  Below is a recommended single leg progression along with some technical points to improve the measures we see altered in our concussed athlete.
    • Single leg squat - the athlete should be able to perform 10-20 body weight reps per leg.  The position is the "athletic position" with the contralateral leg off the ground with the knee flexed and in slight extension.  Technical notes include:
      • Control frontal plane motion and speed - they should maintain limited frontal plane motion and speed of valgus of the knee during performance of the exercise.  As noted here, this athlete is not able to do that.  In this case, I would step him back to a stride stance (contralateral leg behind and in contact with floor) and decrease the range of motion to allow him to build the stability there.  From there I would progress to performing without contralateral limb touching.  
      • Control loss of balance - they should not touch the contralateral (opposite) leg down at any time during performance of the recommended reps.  Touching down with the contralateral leg is considered a loss of balance and with an increase in frequency in this comes an increased risk of injury.  In this picture the athlete is touching his foot behind him to create more stability.
      • Control of pelvic motion - all too often when an athlete performs a single leg squat, we let them have excessive movement of the pelvis and trunk (in the frontal and transverse plane).  This will appear as a trendelenburg, retro-trendelenburg or cork screw.  Many times the athlete will get into the habit of doing this as this change in center of mass (or gravity) will create more stability at the hip and allow them to perform the single leg activity.  It is important to correct this and step back the activity to a easier form until they can perform while creating stability of the trunk and pelvis in the frontal and transverse planes.
    • Single leg hop - performing a vertical single leg hop is a great next level of progression.  Due to the increased power demand with takeoff and increase in force attenuation during landing, this is much harder to stabilize than a single leg squat.  The position should again be done in the "athletic position".  Technical notes include:
      • Control frontal plane motion and speed - there will be an increased difficulty creating this stability in single leg hop.  If they are unable to do without excessive frontal plane motion and speed, we can do sets they are able to perform correctly and as they lose control move back to a single leg squatting position.
      • Control loss of balance - as we increase in demands, maintaining stability will be increasingly more difficult.  A lot of times if the athlete is not able to stabilize the pelvis during explosive hops they will loss their balance.  So it is important to determine if this is more result of a proprioceptive issue or loss of control of the pelvis.
      • Control of pelvic motion - this is harder to see in hopping activities.  If you video tape the athlete using a device that is at 90 fps or greater, you should be able to clearly see if they are having excessive pelvic motion.  Lot of times this will happen if they have a lot of quadriceps weakness and inability to generate the power needed.
    • Multidirectional Hops - moving from a straight vertical hop to multidirectional hops takes the athlete to a much more sport specific type of activity.  This can be anterior, posterior, medial, lateral or diagonal.  Of all the directional hops we do, the one that we see athletes have the most difficulty with is the medial hop.  Hopping on one leg in the medial direction (toward midline).  This requires a tremendous amount of strength and endurance at the hip and lower extremity to stop the center of mass from moving medially upon landing all while stabilizing the knee and hip at the same time.  
    • Collision Hops - there is some emerging research coming out of Australia that indicates that a lot of the non-contact injuries that occur in athletics have some form of initial contact with another player in the air.  What happens is that the contact in the air alters where the athlete lands relative to their center of gravity and they try to cut or stop which places excessive stresses on the lower extremity resulting in injury.  Considering this, we can perform perturbations to the athlete in the air during their single leg hops.  This does not take an excessive amount of force but does require then to readjust prior to landing.  
  2. Core training - is has become much more evident that lack of core stability or "dynamic stability" of the core is a factor that is impacted with concussion and when improved reduces the risk of concussion.  DeBlaiser et al Am J Sport Med 2019 showed that impairments in core stability adds to increased risk of lower kinetic chain injuries.  As such, two exercises shown to have the largest influence on core stability are the plank and side planks.  These are the two exercises I see performed incorrectly most of the time.  Some key notes:
    • Sideplank - keep your feet on top of one another and hand on hip.  This prevents from reaching hand forward and rotating the spine.  You should be able to draw a straight line from your between your feet, between your legs along the spine and bisecting the head.  Letting your hips rise of fall or rotate will alter this alignment.  Should also make sure your shin on the down leg is NOT resting on the floor.  This is an indication of ankle weakness and allowing it in training will increase.   Athletes should be able to maintain this position easily for one minute.
    • Plank - feet should be placed all the way together.  Your hips and spine should be in a
      neutral position and your gaze downward but with a neutral cervical position.  Looking up lengthens the anterior structures and places the cervical spine in extension.  Most often, athletes will get the spinal position correct but not the hip position.  The hips will either be up in the air or down.  The idea is to create stability with the hip in a semi-neutral position.  Athletes should be able to maintain this position easily for one minute.

I hope this has given you some new things to consider with your concussion patient.  Next week, we will continue this discussion to look at how movement impacts athletic performance.  Stay tuned as I am super excited to share with you.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  Train hard and stay well.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, January 20, 2020

Make 2020 The Year Of Change - Part IV

In our last blog, we highlighted a previous research project with women's volleyball players.  This last study that we will talk about is with Division II women's soccer.

With all our projects, whether official research or just what we normally do as a part of our business of sports medicine, we are constantly trying to compare our results and see what we can do better.  This means:
  • Critically evaluate our processes for inefficiencies so we can constantly improve the process.
  • Track our results and see the impact on:
    • Number of total lower kinetic chain musculoskeletal injuries
    • Total number of days on the disabled list
    • Total number and dollar amounts spent on insurance claims
Tracking this information not only helps us do what we do better, but also provides the school/university with objective data that helps us show the value that we add to the school, the program and the athletes.

Historically, prevention programs have shown to have an impact on injury rates.  In a systematic review by Lopes et al Am J Sport Med 2017, the authors showed that performing injury prevention programs had an impact on improving the lack of frontal plane control of the knee.  This lack of control is one of the biomechanical factors that put the athlete at risk for injury.  This further led the authors to suggest that these programs maybe enhanced by targeting participants's baseline profile deficits.  Taking this knowledge, we have applied this to what we do.

During pre-season physicals, we perform baseline movement assessment on each athlete and based on their results on the assessment, we assign them to level I - IV on the ACL Play It Safe Program.  In the following project, this is exactly how we approached it.

Before we begin however, I must say one thing about injury prevention programs.  Simply stated, we have to STOP calling them injury prevention programs.  The reality of all this is that teams, coaches, athletes and parents are LESS compliant with an injury prevention program than they are a performance enhancement program.  I think we would all agree that the athlete pictured here is at risk for a knee injury (as well as ankle, hip and low back injury).  But this same athlete, with these exact same biomechanics is NOT going to maximize her vertical jump, explosive power or speed with those mechanics.  These biomechanics result in a significant lose of kinetic energy, force and power.  Considering this, this is the same biomechanics that are improved with a injury prevention program.  So, I say we stop focusing on injury prevention and start calling it performance enhancement.

In addition to the impact on the individual player, do you think these programs impact team performance?  The obvious answer is yes.  If you improve this individual players performance that will impact the team's performance.  But think of this.  Of the players on a team, which players are more likely to suffer injury.  What the research would tell us is that it is the athlete with more athletic exposures.  What athlete has more athletic exposures?  Obviously your better players because they are on the field more during practice, scrimmages and games.  That said, if you reduce injury rates then you end up keeping your better players in the game and season longer.  This means they are adding more to the team's overall seasonal performance.  So, let's all agree, in 2018, let make a move to move away from the term injury prevention and focus on the performance enhancement potential.

Methods:
This study included 21 female soccer players ranging in age from 17 years old to 21 years old from 2016 to 2017.  All the athletes were scholarshiped athletes and were freshman to seniors in their academic career.  Each athlete went through a baseline movement assessment (ViPerform AMI) as previously described.

At the conclusion of testing all athletes, the 3D data and video was reviewed with the team athletic trainer and strength coach.  The evaluator then assigned each athlete to level I - level IV of the ACL Play It Safe Program based on a predetermined set of criteria for each level assignment.  16 of the athletes' results had them assigned to level I exercises and 5 athletes were assigned to level II exercises.  Throughout the season, the athletes performed the ACL Play It Safe exercises as previously described.

The exercises were performed under the direction of the team coach and athletic trainer and done two times per week.  Each athlete performed these exercises throughout the season and compliance was tracked via the coaches attendance log.  Injury and claim submission data was tracked through the team's athletic training EMR over the 016/17 season.

Results/Discussion:

Hypothesis I - If a Division II soccer team performs ACL Play It Safe Program based on individual player VIPerform AMI results, there should reduction in days on the disabled list and recordable musculoskeletal injuries for the entire team.

For the purposes of this study and with a lack of a control group, the seasons with the intervention was compared with the previous 5 years of injury data collected for the football team.  When comparing non-contact musculoskeletal injuries, overall there was a 65.2% reduction in injuries to the:
  • Foot/ankle
  • Knee
  • Hip
  • Low back
This included sprains, strains, muscle pulls and ligamentous injuries.  As a result of the reduction in lower kinetic chain injuries, total number of days on the disabled list for the entire team was decreased by 69%.

In addition to the above results, there was also a significant reduction in health care claims submitted by the universities athletic department for this sport.  Comparing 2015 claims to 2016 claims, overall there was a $55,681 savings for the university.  Although this seems like an astronomical amount, considering the impact to non-contact musculoskeletal injuries and associated treatment and/or surgery, then it is easy to see how the cost savings adds up.

As with all our projects, it should be acknowledged that we identify and recognize several flaws with this study.  One is uncontrolled variables.  As with the other study, without a "true" control group, all we could do is compare results to the previous 5 years of injury data and claim submissions.  This introduces a lot of variables that are not controlled.  That said, the most important thing to us is that the university and the athletes see the benefit.  The results are what the results are.  The athletes are happy, the coaches are happy and the school is happy.  At the end of the day, research flaws or not, that is what matters.

So, as we close out this series, let me say, this is not the end all be all.  It is not rocket science.  It is simply the application of what the literature tells us and applying it.  Doesn't mean you have to use the ViPerform AMI or the ACL Play It Safe.  But you can take this approach and methodology and apply it with similar results.  Time and time again, it works.  We just have to do it.  So, how about you and I, work hand in hand and make 2020 the year of change.

Insanity = doing the same thing over and over and expecting different results.  

Stop the insanity and start doing things different today!  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on Instagram @ bjjpt_acl_guy and twitter @acl_prevention so we can continue to share some of the latest news.  If you happen to be at APTA Combined Sections this year, please come by and see us Thursday where we will be presenting on RTSport Following ACLR.  Train hard and stay well.   


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 


Monday, January 13, 2020

Make 2020 The Year of Change - Part III

In our last blog, we laid the foundation or ground work of how we are conducting all our studies.  In this blog, we would like to highlight one of those for you as well as our results.  This study is done at the Division I level and involves female volleyball players.  As with most female sports that involve jumping, knee injuries are fairly common among this population.  So we wanted to see, if we implemented our assessment and intervention, would this have an impact on the team's injury rates and athletic performance.

Methods:
This study included 23 female volleyball players ranging in age from 19 years old to 22 years old.  All the athletes were scholarshiped athletes and were sophomores to seniors in their academic career.   Each athlete went through a baseline movement assessment (ViPerform AMI) at the conclusion of the season which consisting of 7 core movements.  Prior to performing this test, demographic information from each athlete was obtained.  This included name, age, weight, previous orthopedic history, previous ACL history and concussion history.  The ViPerform AMI movements consisted of:

  • 1 minute plank
  • 20 squats
  • 1 minute sideplank (right then left)
  • 10 single leg squats
  • 10 single leg hops
  • 10 single leg hop plants
  • Ankle lunge test

Prior to performing each test, the athlete was fit with 3D wearable sensors (provided by DorsaVi).  For the first three tests, the sensors were placed at T10 and L5/S1.  For the single limb tests, the sensors were placed on the right and left shin.  Each athlete performed each test while data was captured from the sensors.

At the conclusion of testing all athletes, the 3D data and video was reviewed with the team athletic trainer and strength coach.  The evaluator then assigned each athlete to level I - level IV of the ACL Play It Safe Program based on a predetermined set of criteria for each level assignment.  The ACL Play It Safe Program consists of 2 distinct routines - a pre-practice routine (performed as a warmup) and a post-practice routine (fatigue state training).  This was performed in the off season and as a part of their strength and conditioning program and carried through to their in-season competition.  The ACL Play It Safe exercises consist of:

  • Pre-Practice Routine
    • Dynamic Lunge
    • Sumo Squat
    • High Knee
  • Post-Practice Routine
    • Single Leg Hop
    • Single Leg Toss
    • Single Leg Lumbar Hip Disassociation (LHD)
    • Glut Med Series
    • Plank
    • Side Plank

Each athlete is provided instructions in the exercises, provided the ACL Play It Safe App (consisting of videos of each exercise) as well as the ACL Play It Safe Kit (consisting of TheraBand CLX, TheraBand padded cuffs, stability trainer and drawstring backpack).  The pre exercises are performed just prior to training or practice and the post exercises are performed immediately after practice or training.  The entire program takes ~20 minutes.  The exercises were performed under the direction of the team strength coach and done three times per week.  Each athlete performed these exercises throughout the season and compliance was tracked via the strength coaches attendance log.

Results/Discussion:
The team strength coach tracked 100% compliance with the programming as assigned to each athlete.

Hypothesis I - If an athlete performs the ACL Play It Safe program, they will show improved results on the ViPerform AMI test with retesting.  The range of improvement on the test ranged from 32-54 point improvement with the average improvement of 41 points.  Running a statistical analysis via an independent t-test, clinical significance is noted at P<.05.  The independent t-test was P=.001 showing a high correlation with performing the exercises to improvement on the test.  Restated, if an athlete performs the exercises they are assigned to based on their individual results on the ViPerform AMI, there is a high probability they will have >12% improvement on the overall battery of tests.

Hypothesis II - If an athlete performs the ACL Play It Safe program based on their individual movement results, this will result in a reduction on injuries and improvement in athletic performance.  All recordable injuries were documented through the team's athletic training electronic medical record.  For the purposes of this study and with a lack of a control group, this seasons data was compared with the previous 5 years of injury data collected for the volleyball team.  When comparing days on the disabled list and recorded non-contact musculoskeletal injuries, there was >70% reduction in total days on the DL and an 80% reduction in non-contact lower kinetic chain injuries.

In addition, there was a average 30# increase in clean and jerk, a 1.18 inch improvement in vertical jump from stance, and .944 increase in vertical jump from approach.  The team also recorded their best season performance in 5 years with ability to compete in the Quarterfinals of their division.

It should be acknowledged that we identify and recognize several flaws with this study.  One is uncontrolled variables.  Without a "true" control group, all we could do is compare results to the previous 5 years of performance and injury data.  This introduces a lot of variables that are not controlled.  However, aside from this assessment and training, there were no other fundamental changes to the program.  There was significant reductions in injury rates, substantial health care cost savings and improvements in performance.  Whether there are controlled variables or not, the school and athletic department felt there was a significant return on investment.

Keep an eye out for this paper as it was just accepted to the Journal of Kinesiology in Sport and will be coming out in print in 2020.  If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on Instagram @ bjjpt_acl_guy and twitter @acl_prevention so we can continue to share some of the latest news.  If you happen to be at APTA Combined Sections this year, please come by and see us Thursday where we will be presenting on RTSport Following ACLR.  Train hard and stay well.   


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie. 

Monday, January 6, 2020

Make 2020 The Year Of Change - Part II

Last week we started the discussion around some current research projects we have going on around the US.  In this series we are going to highlight three specific studies we have going on at the Division I level.  All of these studies are IRB approved.  Why Division I?  There are several reasons for this:
  • Access - with many of our relationships, this allows us access to this level of athlete.  With that, we can include our baseline movement testing as a part of their pre-season physicals fairly easily. 
  • Maturity - Division I athletes who are there on scholarship take their sport very seriously.  As such they are much more likely to put forth a solid effort needed during the assessment.
  • Tracking - at this level we can track injury rates through the athletic trainers EMR (electronic medical record) as well as claim submissions.  This allows us to track injuries but also track costs associated with.
  • Compliance - athletes at this level tend to be more compliant with the recommendations we give.
Secondly, we have a very standardized process we go through with all the athletes.  We first put each athlete through a standardized sequence of movements and based on the results, we then assign them to a standardized sequence of movement specific exercises.

For the movement assessment, each athlete is fit with a 3D sensors (provided by DorsaVi).  These sensors have an IMU (inertial measurement unit) inside that has an accelerometer, gyrometer and magnitometer.  This measures motion, rotation and acceleration data during any movement.  With these sensors, we are able to measure motion or stability within 3% of a Viacom system for spinal motion and knee motion.  

During the test, the athlete will perform three core tests, one bilateral test and 4 single limb tests.  During the core tests, the sensors will measure the athletes ability to maintain stability of the core within 10 degrees of flexion and extension and rotation.  During the bilateral tests, the sensor will provide the degree of lumbar flexion and lateral shift (how much the hips move during the motion).  In the single limb tests, the sensors provide us with the magnitude of frontal plane motion (varus and valgus) and the speed of frontal plane motion.  At the conclusion of the test, the system will provide with an automated report of all this data.  

As cumbersome and time consuming as this may sound, this process takes ~16 minutes per athlete.  In one of our largest data captures, we collected movement data on 400 athletes over a 4 day period and were assessing 109 athletes per day.  So, from an efficiency standpoint, this is a very efficient process.  

The movement test itself is exhausting.  It consists of 83 repetitions and 3 one minute timed tests.  It is an athletic exam and therefore we feel must be athletically demanding.  All of the single limb tests are first performed on the right side then the left side.  This allows to build up fatigue on one side through the completion of the tests followed by the contralateral side.  

Once the report is generated, we then assign each athlete to one of four levels on the ACL Play It Safe Program.  This is a program that we designed specifically to improve performance on the tests that we are testing.  We hypothesized that if we improved performance on the tests we were assessing that we would see an impact on injury rates and athletic performance.  And that is exactly what we are seeing.  

Next week we will get into some of the specific results and studies.  But I want all to realize, this is not just for Division I athletes.  This is for any and all athletes.  The ACL Play It Safe Program will not only reduce injury risk for all lower kinetic chain injuries but we are showing that it also improves vertical jump and sprint speed.  Best of all, it is free.  Simply download the app on IOS or Android and get a video of each exercise included as a part of the program.  Download it today and start impacting your athlete's performance.  

Stay tuned next week as we start to discuss the first of the two studies.  #ViPerformAMI #ACLPlayItSafe  Help us ring in 2020 right by spreading the word and helping to prevent athletic injuries. If you enjoy this blog, please share with your colleagues, athletes and training partners and please be sure to follow us on Instagram @ bjjpt_acl_guy and twitter @acl_prevention so we can continue to share some of the latest news.  If you happen to be at APTA Combined Sections this year, please come by and see us Thursday where we will be presenting on RTSport Following ACLR.  Train hard and stay well.   


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI,  ViPerform AMI RTPlay, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent also a Brazilian Jiu Jitsu purple belt and complete BJJ/MMA junkie.