Monday, November 17, 2014

Sports Medicine Expert Series - Part II

 As stated in our blog last week, I was recently asked to participate in a Sports Medicine Expert Series.  This series was put together by Howard Luks, MD – Chief of Sports Medicine at University Orthopedics, Professor of Orthopedic Surgery at New York Medical College and nationally recognized expert in the area of ACL reconstruction.  This series was developed to provide five professional opinions from some of the top orthopedic sport medicine physicians in the country and from some of the national leaders in the area of physical therapy and athletic training. 

Again, not that I would consider myself an expert at anything, but to be included amongst such a prestigious group is truly humbling and an honor.  Included in here is a reprint of each my responses to questions posed to the group throughout the series.

Why is physical therapy important after surgery (a very common patient question)? What are stages and areas of concentration within each post op phase?

Physical therapy is critical for the patient to achieve their optimal outcome.  Most patients (>95%) do not know what to do following an ACLR and therefore need the guidance of a skilled physical therapist to aid them in achieving optimal outcomes.  Working with the right skilled therapist will help the patient achieve their maximum potential and significantly reduce their risk of re-injury when they return to sport.  That said, there are several phases of rehabilitation, all which have well published goals/objectives.  Included here are a few additions for the first five stages for the athletic ACL population.
  • Phase I-II (0-4 weeks)
    • Goals are several fold including inflammation reduction, gain TKE (terminal knee extension) and restore normal gait pattern (way we walk).
    • All the goals are important but as little as 5 degree extension lag will alter gait.  So there is a lot of focus on restoration of TKE and normalizing gait pattern (stride length, TKE at heel strike and cadence).
    • Due to the impact on lower extremity kinematics, core training is started right away as well as some form of cardiovascular training
    • Low level proprioceptive retraining and SL activities are started as indicated per protocol or when cleared by physician.  This aids in building limb awareness which many times is lacking well before the injury itself.
  • Phase III (4-6 weeks)
    • Goals include control swelling, maintain TKE, increase knee flexion and progressive strengthening.
    • All goals are important but a significant portion of athletes continue with a lateral shift with bilateral squats and decreased confidence in the involved limb 12-14 weeks post op or even when they return to sport.  This is a major risk factor so starting to train early aids in reducing.  So neuromuscular retraining is started at this point.  This includes correction of lateral shift in squatting motion (body weight only and only in range can be performed without pain) and closed kinetic chain single limb activities.
    • Neuromuscular retraining is KEY with all exercises.  Ensuring proper kinematics with lowest level of exercises to higher level.  Prevention of adduction in the frontal plane is constantly emphasized with any exercise.
    • Use pain and swelling as a guide.
  •  Phase IV (6-10 weeks)
    • Goals include control swelling, maintain TKE, increase knee flexion and progressive strengthening/proprioception.
    • All goals are important but including hip proprioception and closed kinetic chain strengthening for the gluteus medius is key.  Manual proprioceptive retraining for the core and while in single limb CKC exercises is key to progression to the next step.
  • Phase V (10-12 weeks)
    • Goals include control swelling, progressive strengthening/proprioception and prep for running in next phase.
    • All goals are important but ground reaction forces transmitted through the limb with running = ~2.6x body weight.  Therefore maintaining stability in single limb performance and preventing adduction in the frontal plane is key.  Progressed from low level of plyometric activity to higher.   More aggressive manual techniques include more manual proprioceptive retraining including full body work and single limb work.

How do deal with the emotional/psychological component of the recovery?

Data from both the NCAA and the NATA indicates that athletes who suffer an ACL injury tend to experience more depression, have a fear of re-injury, have decreased sport satisfaction, have a higher academic test failure rate and lower GPA as a result of their injury.  This would suggest that there is a psychological impact their injury may have on them as well as the physical impact.  All too often, it is the one component that clinician’s often miss, the psychological component.  For many, it is an uncomfortable aspect of care to address.  It is too touchy feely.  Yet, how can you possibly address the “whole” athlete if you don’t address?

How do you deal with?    According to the studies, the most significant psychological factors contributing to inability to return to pre-injury levels were: psychological readiness, fear of re-injury, sport locus control (sense their outcome determined by internal or external factors) and the athlete’s pre-operative estimate of the number of months it would take to return to sport.  This highlights some very key take aways which we can address. 

·        The psychological state of the provider has a direct and profound impact on the patient.  Do you smile, do you engage the patient, do you project positivity?  YOUR projection influences the patient. 
·        As a provider, our role is as an educator and coach, with emphasis in this case on coach.  Coaching is not passive.  It is methodical in approach, motivational, inspirational and purposefully driven to the end goal all while also being empathetic to the athlete.  If done right, it also gives the athlete the sport locus control. 
·        Make sure they know they have an active role in the process and it takes hard work, but at the end of the day, they can and will control their destiny.
·        Build the patient’s confidence during the course of rehabilitation.  Most fear full body weight support on the involved limb, single limb landing and cutting on the involved side.  There are a lot of ways to minimize this fear, one of which is getting them to do single leg activities early (as mentioned in previous post) and often.  Building the confidence in the limb as soon as possible so that they can see putting weight on the leg will not result in re-injury. 
·        Make them work it.  Making an athlete work hard and pushing them physically will build mental toughness and confidence.  All too often, we are afraid to push patients.  If done within the parameters of the healing process and within protocol, it can and will result in huge physiological and psychological improvements.  But it must be based on sound principles. 
·        Consult with the referring physician and provide the athlete with realistic estimate of time it takes to return to sport.  Obviously the greatest influence on pre-operative belief and estimate is the orthopedic surgeon.  Most will set that expectation for the athlete pre-operatively.  Unfortunately and all too often, the rehab provider may report something different to the patient.  This can result in a significant and negative impact on the patient’s psychological status.  Two conflicting estimates of return to sport can create an instant internal conflict for the patient.  Who do I trust?  Who do I believe?  This can seriously impact their motivation and sport locus control.  As a rehab provider, this should be avoided at all costs.

What are your return to sports criteria following a "routine" ACLR?

Return to sport is one of the hottest debated topics in sports physical therapy.  When is the right time?  If we get it wrong, we increase the athlete’s risk of re-injury.  We already know from the research that 20% re-tear in 2 years (Brophy et al, AJSM 2012) and only 43% return to the same level of performance (McCullough et al, AJSM 2012) following ACLR.  So how can we optimize their potential? 

We know from the research that certain movements place athletes at risk (Frank et al AJSM 2013).  We also know that asymmetry in single limb performance (Myer et al AJSM 2012 & Grindem et al 2011) places an athlete at greater risk.  So how do we quantify this in a meaningful way that is objective and sensitive?  In interest of full transparency and full disclosure, I am the CEO and Founder of the company that developed the technology (3D-DMA™) I will mention below.  Prevention of injury and assisting in making return to sport calls is what we as a company have been called to do and have devoted the last 12 years to accomplish.  Our goal was to develop an objective way to measure movement that is efficient and cost effective so we can make more informed decisions with return to sport & reduce risk for future injury and improve athletic performance.

Assuming that the patient has progressed through all phases of rehab and has been deemed appropriate for testing to return to sport, we have a specific protocol we put patients through (3D-DMA™).  This system removes subjectivity out of this process by using advanced 3D gaming technology (Kinect v2) in combination with a series of movements performed in a progressively more challenging sequence (DMA™).  This provides us with an accurate measure of movement on multiple tests and clear measure of bilateral performance as well as single limb symmetry on three separate tests.  Using this standardized approach allows us to see how the athlete is moving overall as well get accurate measure symmetry between the involved and uninvolved in both movement and power output.  Using this information in combination to what they are doing in rehab and the physician’s examination allows us to make a much more informed decision or recommendation for return to sport.

We hope that you found this blog insightful and useful.  As we stated previously, stay tuned and if you like what you see, SHARE THE PASSION!  It is the biggest compliment you can give.  Follow us on Twitter @ACL_prevention and tweet about it.  #DMAOnTheMove and help us spread the passion and #movementonmovement #PT #ATC #ACLChat.
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Trent Nessler, PT, MPT, DPT:  CEO/Founder ACL, LLC | Author | Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and CEO/Founder of ACL, LLC.  He is the researcher and developer the Dynamic Movement Assessment™, Fatigue Dynamic Movement Assessment™, 3D-DMA™, author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training. For more information, please see our website at www.aclprogram.com