Monday, November 12, 2018

Limb Symmetry Index - What is it and Is it important - part III


Last week, as we continued our discussion on Limb Symmetry Index (LSI), we looked at the Wellsandt et al 2017 study which provided some insight as to how we might assess LSI in Anterior Cruciate Ligament Reconstructed (ACLR) athletes.  Traditionally this was done by comparison of the involved limb to the uninvolved limb at the same time (same time post op ACLR).  However, this study indicates that a more sensitive measure may be comparing the involved side post operatively to the non-involved side pre-operatively.  Measuring in this fashion would prevent any of the degradation that might occur to the uninvolved side as the result of lower level of activity due to surgery on the involved side.  In other words, it would prevent the detraining effects on the uninvolved side from influencing the LSI measure.

For the purposes of this study as well as in most instances, LSI is a common measure used to determine whether an athlete is ready for return to play.  However, there appears to be a lot of inconsistency in what is measured for return to play, specifically following ACLR.  So what types of measures should be used to determine LSI? So Melick et al Br J Sports Med 2016 performed a systematic review of the literature to determine what we should be assessing, according to the literature, when we are looking to return an athlete to play following an ACLR. 


Methods:
The authors of this study did a systematic review of studies published from 1990 to 2015.  Ninety studies were included that addressed 1 of 9 predetermined clinical topics.

1.     Preoperative predictors for postoperative outcomes
2.     Effectiveness of physical therapy
3.     Open and closed kinetic chain quadriceps exercises
4.     Strength and neuromuscular training
5.     Electrostimulation and electromyographic feedback
6.     Cryotherapy
7.     Measures of functional performance
8.     Return to play
9.     Risk for reinjury

Results: Rehabilitation after ACLR should include a prehabilitation phase and 3 criterion based posteroperative phases:

1.     Impairment based
2.     Sport specific training
3.     Return to play

A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one stage to the next.  Post-operative rehabilitation should continue 9-12 months.  To assess readiness to return to play and the risk of reinjury, a test battery including strength tests, hop tests, and measurement of quality should be used.

Discussion: This study brings up a lot of good information but also brings to the forefront some important questions.  First, as a sports physical therapist, the blaring question is around the 9-12 months of rehabilitation.  Although I could not agree more and studies are pretty clear that athletes should not return to play for 12 months, how do we get insurance to pay for this?  With changes in health care and insurance reimbursement, the majority of insurance companies limit your care to 4-5 months post operatively.  None will pay for rehabilitation that includes return to play.  This despite the fact that reinjury rates are so high, osteoarthritis rates are so high and the majority of athletes who have will return to play whether or not they get the appropriate course of care.  Considering, I think we must be more creative in our plan of care and more inclusive of collaborative partners in the entire continuum of care for our athletes.  By early inclusion of our athletic trainers and strength coaches in the process not only allows us to have a more well-rounded approach to the athlete, it is also in the best interest of the athlete’s long term joint health and overall health to have this approach.  At the same time, we must include innovative ways to continue the athlete’s progression without our immediate and constant direction.  Programs like the ACL Play It Safe program provide us structured ways to progress an athlete through the process in addition to what our athletic training and strength coach counterparts would do. 

 Another point this brings up is what tests should we use to return an athlete to play?  When reviewing the literature, there does not appear to be a lot of consistency in how this is assessed.  Some studies look at variance in quadriceps strength, some in single leg hop distance, single leg triple hop distance, LESS test, timed hop, agility drills, the list is endless.  So what is right?  

 Next week, we will start to look at this question in a little more depth.  So make sure to stay tuned.  If you enjoy this blog, please share and follow us on instagram @ bjjpt_acl_guy and on twitter @ ACL_prevention.  #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, 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.