Monday, February 19, 2018

Innovations in Sports Science - Athletic Telemedicine

Last week, we started off discussing the innovations in sports medicine.  This particular discussion is going to be around the evolution of how we interact with our athletes.  Any of us that work in sports medicine know that the sooner an athlete can be assessed by a health care professional and get access to the medical referral process (when needed) that the better the long term outcome and the faster the athlete is able to return to sport.  There are numerous studies indicating that high school athletes having immediate access to a certified athletic trainer helps to reduce injuries, has a better long term outcome and has a substantial impact on the total health care cost.

A huge part of this impact outlined above is due to the ability to have minor musculoskeletal injuries evaluated by a health care professional who understands musculoskeletal injuries, who can aid in early intervention and aid in navigating the health care process for those that require further intervention.  Despite the fact that this is common knowledge in the respective health care fields and in the industry, not all athletes have this level of access.  But what if athletes could have this level of access.  How could that be done?

Telemedicine is defined as the remote diagnosis and treatment of patients by means of telecommunications technology.  This is a relatively new approach in health care with new telemedicine companies and platforms popping up all over the US.  But what if this same type of approach were applied to athletes.  This is where Health Roster comes into play.  Healthy Roster (HR) initially positioned itself as an athletic training electronic medical record that is HIPAA compliant.  HR is both a web-based interface which also provides an app that is available for the clinician as well as the athlete.

How this is being used in sports medicine is not only as a athletic training electronic medical record but also as an athletic telemedicine tool.  How this works as a telemedicine tool.

With this tool, a sports medicine provider can offer this to their clients or community.   An athletic trainer or physical therapist has an account and offers the service to a client, sports organization, school or club.  The club then offers this to their athletes.  If an athlete get injured, then they download the free app and enter a code that is provided by the sports medicine provider.  Once the athlete has entered the code and their information, the app will notify the athletic trainer, physical therapist or other qualified health care provider immediately.  Once notified, the health care provider can then contact the athlete immediately through the app via a phone contact or Facetime.

By using Facetime, the health care provider can provide a limited assessment of the athlete immediately.  If treatment is appropriate, they can give this immediately to the athlete and document all this within HR.  This allows both the health care provider a record of the information and the athlete something to go back to for instructions that they may not remember.  If a referral is required, this can also be done immediately through the app to the affiliated physician.

By leveraging this as an athletic telemedicine tool, the athlete, school or organization can be provided with a health care professional and expertise despite limited resources.  For the health care provider, they can now provide a level of service what was not previously able to do with limited bandwidth and resources.  Although telemedicine does not and will not replace a quality face to face interaction with your health care professional, it does provide a valuable alternative when no other resource is available.   

Stay tuned as we continue this discussion next week.

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.  He is the founder | developer of the ViPerform AMI, 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 is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, February 12, 2018

Innovations in Sports Science

Over the course of the last couple of years, I have been blessed to be asked a lot to present at sports medicine conferences on the use of technology in sports medicine.  When I first started practice back in 1997, I never would have imagined that this would become an area I had so much passion about or that it would be the main focus of my job or career as a physical therapist.  But it has and is becoming such a critical part of what we do in the treatment of the injured athlete, prevention of injuries and improvement in athletic performance.  During a recent presentation, I came to the realization that this might be something worth sharing with wider audience and hence, why I decided to do this blog series.

Before I begin, one thing we all need to keep in mind when it comes to technology is that most of the time this is being presented to us, it is being presented by a technology company and by IT people.  These are not clinicians.  Sometimes we forget this when we are presented with technologies that are so cool and have the potential to really alter the way we look at things.  Somethings to keep in mind:

  • This is a tech company trying to sell you technology.  They are not clinicians so we must critically analyze what we are looking at by applying some of the foundational science and some common sense.  They will not offer up the error rate their technology has nor the fact that most of that has been programmed out so that you, the user, never realize it.
  • As a non-clinician, you should question:
    • Ease of implementation into your clinical practice.  How easy is it to implement into your patient flow and does it have the efficiency to allow for use in everyday busy sports medicine practice.
    • Validity of the clinical measure - Does this technology truly measure what it states.  If you have an IMU embedded into clothing, does this truly measure joint motion.  Or do the materials move around on the skin and give you false readings.  Are the angles that you place on 2D video accurate or are they truly 15+ degrees off a Viacom system?  Does the Kinect based measurements truly provide accurate joint movement or is this 20%+ off of true motion?
    • Billing - do they really know how you can bill for this technology.  THIS SHOULD BE THOROUGHLY INVESTIGATED.  There are several technologies that tell you how you can bill that DOES NOT fall within ethical or legal billing compliance.  In addition, if you are billing only 4 units during a patient visit and if you are billing 97530 (Ther Act) does this add any additional revenue to your business?  Or, is this adding an expense on top of what your existing net revenue per visit is?
    • Is it truly HIPAA Compliant - there are a lot out there that DO NOT understand the level of security that must be put in place to protect patient information.  At the end of the day, it is the clinician that is held responsible for this.  For the athlete is entrusting you with this information.  
Now that we have that bases, there are several innovations that I would like to speak to in sports medicine.  These are not all technologies but innovations that we can use to assess, treat and help our athletes avoid injuries and perform better.  These would fall in the area of:

  • Innovations in exercise - here we will discuss some of the innovations in theraband technology and integration of apps for training.
  • Innovations in recovery - this section we will discuss some of the advances in recovery science and certain products that are being utilized to help in the recovery process.
  • Innovations in assessment - here we will discuss the use of 3D wearable technology and how this is being leveraged not just to assess athletes but also to provide mass data.  This amount of data allows for mining of trends we never knew existed.
  • Innovations in athletic telehealth - how telemedicine is allow us to have interactions with athletes much early in the process and speed their road to recovery.
During this series, I will discuss a series of different products I have come across and some which I use.  This is by no means meant to be an endorsement but rather sharing of my experience with.  Each product should be thoroughly evaluated by those interested prior to purchase or use.



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.  He is the founder | developer of the ViPerform AMI, 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 is also a competitive athlete in Brazilian Jiu Jitsu. 



Monday, February 5, 2018

Does Sport Specialization Increase Risk For Injury - Part II

Last week we looked at a study by McGuine et al Am J Sport Med 2017.  In this study, the authors showed that if an athlete specializes in a sport that they are more likely to suffer a lower extremity injury than athletes who do not specialize.  As a parent or coach, we may push our young athlete to specialize in sport thinking that this is going to help them perform better in the sport and increase their likelihood of succeeding in that sport.  What that means is different for everyone.  It may mean that they just perform better or that they make the varsity team or that they will improve the likelihood that they will get a college scholarship.  At the same time, many of us do not realize we are actually putting them at great risk for injury.  According to Rugg et al Am J Sport Med 2014, if an athlete suffers a knee or ACL injury prior to a division I career, they are 8 times more likely to suffer a knee injury or ACL injury during their Division I career.  This pure fact is preventing some university's from recruiting athletes with a previous knee history.  So, instead of helping our athlete, we may actually be jeopardizing their chances for a athletic scholarship.

What if I told you that athletes that specialize actually do not play better than athletes that play multiple sports.  Sound counter intuitive doesn't it?

Reference Article:
Rugg C, Kadoor A, Feeley B, Pandya N.  The effects of playing multiple high school sports on national basketball association players’ propensity for injury and athletic performance. Am J Sport Med.  Published online before print. 2018.
Purpose:
The purpose of this study was to determine if National Basketball Association (NBA) players who play multiple sports as adolescence are less likely to get injured.  In addition, do these multisport athletes have higher participation rates in terms of games played and career length over their single sport athlete counterparts.

Methods:
First round draft picks from 2008-2015 in the NBA were included in this study.  From publically available records from the internet, the following data for each athlete was obtained:

  • Participation in high school sports
  • Major injuries sustained in the NBA
  • Percentage of games played in the NBA
  • Whether the athlete was sill active in the NBA

Athletes who participated in sports in addition to basketball during high school were defined as mulitsport athletes and were compared with athletes who participated only in basketball in high school.  Breakdown of the multisport and single sport athlete data is represented below.



Results:
237 NBA athletes were included in this study of which 36 (15%) were multisport athletes and 201 (85%) were single sport athletes in high school.  The multisport cohort played in statistically significantly greater percentage of total games (78.4% vs. 72.8%) with a p value of .001 (remember p <.05 is statically significant).  Multisport athletes were less likely to sustain a major injury during their career (25% vs. 43%) with a p value of .03.  A greater percentage of multisport athletes were active in the league at the time of the data collection, indicating increased longevity in the NBA (94% vs. 81%) with a p value of .03.

What does this mean?  Simply stated that this appears to show that multisport athletes played more games per season, had longer NBA careers and were injured less.  Although this is a good sample size and over 7 year period, the number of multisport athletes is still relatively low.  Was this 15% purely representative of those freakish athletes that were just super talented and could play any sport no matter what?  That is hard to say.  Or is it that as a result of them playing multiple sports they are freakish athletes?  More likely, it is a combination of the two.

One thing we do know for sure is that multisport athletes due get injured less than single sport athletes.  We also know that by playing multiple sports, the training effect is much greater.  Those athletes who play multiple sports have a better kinesthetic awareness, better neuromuscular control, better agility and overall better athleticism.  Just like cross training, better prepares you physically rather than just doing one form of training, so does playing multiple sports.  That is why you see so many athletes today adding cross training to their routines.  In the off season, they are not playing their main sport, but rather biking, lifting weights, swimming.  We know this adds to recovery and helps to strength areas of weakness that may not be addressed during normal seasonal performnce of our sport.  Anecdotally, we have seen this in the clinic and now we are starting to see this represented in the research.  Just because we do not have a plethora of studies showing us this, it does make sense both from a physiological, neurological and psychological perspective.

So, the next time you have an athlete or parent thinking about playing a single sport, keep this in mind.  Single sport athletes get injured more and may not perform as good as multisport athletes.

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. #ViPerformAMI #ACLPlayItSafe #ResearchThatWorks


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.  He is the founder | developer of the ViPerform AMI, 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 is also a competitive athlete in Brazilian Jiu Jitsu. 

Monday, January 29, 2018

Does Sport Specialization Increase Risk for Injury?

Sports has a lot of positive impacts on kids.  Studies show that kids that participate in sports have an improved quality of life, are less likely to smoke, to be truant and more likely to get better grades and stay in school.  Under the right coach and with the right team, this can also provide a lot of positive influences to kids in a time and age where they really need this.  With over 7.8 million kids participating in interscholastic sports each year, sports injuries are  going to happen.  Our goal is always to minimize those that we can.

Obviously with the focus of our discussions through the history of this blog, we tend to focus a lot on lower extremity injuries and specifically knee injuries.  Why is that?  Ingram et al AM J Sport Med 2008 showed that the most commonly reported athletic injury between the ages of 15 and 25 is an injury to the knee.  Further, Fernandez et al Acad Emerg Med 2007 showed that lower extremity injuries accont for 60-75% of all injuries in high school athlete populations.  Rechel et al J Trauma 2011 showed that 50-60% of all athletic injuries requiring surgery where injuries to the knee.  If you include the low back injuries in these numbers, then you encompass >75% of athletic injuries that occur and hence why our focus primarily on the lower kinetic chain.

Over the course of the last several years, we have discussed various strategies on how we can help reduce these injury rates, especially in our younger athletes.  I have been blessed throughout my career to work along side some of the industries best in the field of sports medicine.  As such, it has led to some amazing learning opportunities.  Two of the pioneers in this area,  from an educational perspective, innovation perspective and research perspective, is Kevin Wilk, DPT, FAPTA (with Champion Sports Medicine - Alabama) and Dr. James Andrews (Andrews Institute - Florida).  Both of these sports medicine legends have and continue to be a huge influence on who I am professionally and what we do.  Dr. Andrews is the founding member of the American Orthopaedic Society for Sports Medicine's STOP Campaign.  STOP (link on the right hand of this blog) stands for Sports Trauma and Overuse Prevention and is a national campaign to help educate and prevent youth sports injuries.

According to Dr. James Andrews, the nation's leading expert in sports related injuries, one of the leading causes of preventable sports related injuries is early sports specialization.  Why is that?  It use to be when I played sports, it was a seasonal thing.  You played your sport during the spring or fall and then when the season was over you either played another sport or you did something else.  Today however, sports are all year round.  Where a soccer player may start their season with the school, then once that is over, the athlete then move on to play with their club or travel team resulting in the athlete sometimes playing the same sport all year long.  Parents unknowingly think this will help them become a better athlete.  Give them a competitive edge.  Yet the reality is, they are also increasing their risk for injury.  Is this true?  What does the research tell us?

Reference Article
McGuine T, Post E, Hetzel S, Brooks A, Trigsted S, Bell D.  A prospective study on the effect of sport specialization on lower extremity injury rates in high school athletes.  Am J Sports Med. 45:2706-2712. 2017.

In this prospective study, the authors set out to determine if sport specialization was associated with increase risk for lower extremity injuries in high school athletes.

Methods:  Participants in this study where interscholastic athletes in grades 9 through 12th.  Athletes were recruited from 29 Wisconsin high schools during the 2015-2016 school year.  Participants completed a questionnaire identifying their sport and history of lower extremity injuries.  Sports specialization of low, moderate or high was determined using a previously published 3-point sale.  Athletic trainers reported all lower extremity injuries that occurred during the school year.  Statistical analysis was performed on the data.

Results: A total of 1544 athletes participated in the study, 780 females and 764 males.  A break down of the subject by sport is in the table below.  Mean age was 16.1 y/o +/- 1.1 years.  These athletes completed 2843 athletic seasons and participated in 167,349 athletic exposures.


235 participants (15.2%) sustained a total of 276 lower extremity injuries that caused them to miss a median of 7.0 days.  Injuries occurred most often to the ankle (34.4%), knee (25%) and upper leg (12.7%).  Injuries included ligament sprains (40.9%), muscle/tendon strains (25.4%) and tendinitis/tenosynovitis (19.6%).  Statistical significance is determined by a P value <.05.  The incidence for lower extremity injury for those that had moderate sport specialization was p = .03 and for those that had high sport specialization was p = .02.

What this indicates is that the more the athlete specializes in a single sport versus multiple sports, the higher the likelihood for them to suffer a lower extremity injury.  Next week we will look at one additional study and why sport specialization may be leading to an increase in risk.

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. #ViPerformAMI #ACLPlayItSafe #ResearchThatWorks


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.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 

Monday, January 22, 2018

Make 2018 Be The Year Of Change - Part V

In our last blog, we highlighted a current research project with Division I football 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 our assessment and our intervention but more the approach and methodology.  Time and time again, it works.  We just have to do it.  So, how about you and I, work hand in hand and make 2018 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!  #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.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 







Monday, January 15, 2018

Make 2018 Be The Year Of Change - Part IV

In our last blog, we highlighted a current research project with Division I volleyball players.  As a note, as with all our research projects we have two major goals in mind:

  • Perform quality research that can aid to the body of evidence on movement assessment and injury prevention
  • Critically evaluate our processes for inefficiencies so we can constantly improve the process.  

The majority of testing we have done in mass physicals up to this point was with smaller teams (Volleyball, Basketball, Soccer).  The number of athletes was much less and this allowed us to become much more proficient with our testing and not rushed.  It allowed us to work out the kinks in the process.  We knew, in order for us to expand this to football and to an entire athletic program, we had to have this process down like a well oiled machine.  We knew a Division I football team could have up to 110 players and a Division I athletic program may have 500+ athletes.  When we first started this, we could do a volleyball team or basketball team in about 4 hours.  Now, through this process, we can efficiently process 104 athletes per day.

So, in this next project, we wanted to see if we would get similar results with Division I football players.  Why football?  According to industry data, Division I football teams spend a majority of their health care dollars on non-contact injuries to the lower kinetic chain.  Although the dollar amounts have been removed, this chart shows 28% of the dollars spent are for non-contact knee injuries and 51% of the dollars spent are injuries from the ankle to the hip.  When you include the lumbar spine in these numbers, you are looking at almost 70% of the health care spend.

Sadly the results are not much better in professional football.  According to data provided by the NFL for the 2014/2015 football season, 50.4% of the injuries to football players were in the lower limb.  If you include the lumbar spine, hip and foot/ankle, this represents >70% of the injuries in NFL players.  In addition, of the 202 ACL injuries in the NFL since the 2013 season, over 73% of those are non-contact in orientation.  Aside from the cost, in a recent study by Mai et al - Am J Sport Med 2017, the authors showed NFL Players who have an ACL injury:

  •   They have decreased performance for up to 2 years post ACLR
  • The shorten their professional career by average of 2 years
So, obviously identifying those at risk in football is critical.  So in this project, as a part of pre-season physicals we screened the football team.  


Methods:
This study included 220 male football players ranging in age from 19 years old to 22 years old from 2015 to 2017.  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) as a part of their preseason physicals 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).  The program was performed during the season with the pre-practice routine done prior to practice and the post practice routine being done at the conclusion  of practice.

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

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.  Injury data was tracked through the team's athletic training EMR over the 2015/16 and 2016/17 football season.

Results/Discussion:

Hypothesis I - If a Division I football 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 days on the disabled list there was >60% reduction in total days on the disabled list and the 2 years with intervention had the lowest recordable injuries in 5 years.

By region,  injury rates decreased by:

  • Knee 72%
  • Lumbar spine 65%
  • Lower leg 53%
  • Ankle 48.5%
  • Foot 7%
In addition to the above results, there was also a 44% reduction in concussions during this time period.  We don't know what the correlation is but it is something we are tracking and seeing more and more.  There are a couple of theories with this.
  • Teams are using the ViPerform AMI as baseline movement assessment and using this baseline data for making comparisons for return to play decisions after a lower kinetic chain injury and concussion.  Could this have some impact on reducing reinjury rates (concussion)?
  • The ACL Play It Safe Program is single limb training intensive.  Does this single limb training have an impact on agility which is allowing athletes to avoid concussive blows?
  • The ACL Play It Safe Program is fatigue state training.  Is this fatigue state training having an impact on performance and avoidance later in the game when concussions are more likely to occur?
We do not have the answer to this but we are tracking this trend and and seeing it repeated in several of our studies.  So although we don't understand the correlation, we should remain aware of the impact and use the information to our advantage.  


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 performance and injury data.  This introduces a lot of variables that are not controlled.  Why do we do this?  Frankly, we have no choice.  The schools we do our research with are schools that work with us because we provide a service.  It would be hard to ever tell a team that we are going to implement this program with half the team and not the other half.  If we were to do that, most schools would not allow us to do.  Therefore it is an all or none deal.

Considering this and the flaws, aside from this assessment and training, there were no other fundamental changes to the program.  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.  They see the results both injury wise, performance wise and cost wise.  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.

Before we close this out, we must give a huge shout out to Lesley Parrish, DPT at Champion Sports Medicine at Troy University.  Without Lesley, neither one of these studies would have been possible.  She is the PI on both of these studies has been leading the way in injury prevention in college athletics.  Thank you Lesley.  Stay tuned next week as we start to discuss the impact of this type of program implementation with Division II soccer.  #ViPerformAMI #ACLPlayItSafe

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries.


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.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu. 








Monday, January 8, 2018

Make 2018 Be 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.

Before we close this out, we must give a huge shout out to Lesley Parrish, DPT at Champion Sports Medicine at Troy University.  Without Lesley, this study would not have been possible.  She is the PI on this study has been leading the way in injury prevention in college athletics.  Thank you Lesley.    #ViPerformAMI #ACLPlayItSafe

Help us ring in 2018 right by spreading the word and helping to prevent athletic injuries. 


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.  He is the developer of an athletic biomechanical analysis, is an author of a college textbook on this subject  and has performed >5000 athletic movement assessments.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Chairman of Medical Services for the International Obstacle Racing Federation and associate editor of the International Journal of Athletic Therapy and Training.   He is also a competitive athlete in Jiu Jitsu.