Monday, June 8, 2015

To Change Movement - We Must 1st Change - Part II

 Last week we were discussing the latest research related to injury risk and impact of psychology with return to sport.  Specifically, we were discussing Ardern et al paper from 2013 where the authors looked at the psychological factors influencing return to sport.  We concluded that discussion talking about how the therapist, athletic trainer or performance coach influences the sport locus of control. 
Another factor touched on in this article was fear.  So, another key take away is the rehab provider’s ability to build the patient’s confidence during the course of rehabilitation.  Most fear full body weight support on the involved limb and 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 (within protocol and MD clearance) 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.  We must also be willing to take them to the next step!  Physical therapist are notorious for stopping rehab within the clinic walls.  For athletes, if they are ever to return to the field and to the same level of performance, we must be willing to progress them to that step.  That means taking them on the field and have a sound and systemic approach to more aggressive agility work.  Pushing with in the physiological parameters of healing to push the psychological parameters of the athlete.
Sounds basic right?  Unfortunately it is not.  Let’s look at the following scenario.  The following picture demonstrates an athlete who was being evaluated for returned to sport.  The athlete was psychologically ready to return but further investigation of his program showed he was not doing a lot of aggressive single limb exercises nor progressed to any type of agility work.  When assessing his single limb performance, there was a clear variance in symmetry between the right side and the left side on multiple single limb closed kinetic chain tests.  So, although this athlete was psychologically prepared now, would he be when he returned to the field?  Knowing the level of play this athlete was at and how so many of these athletes are intimately aware of their bodies, one might conclude that when he started some aggressive sprinting and agility work, he would sense this mass variation.  Would this not play into his psychology during play and impact his performance? 
Consider for a moment an RGIII or GSP.  Phenomenal athletes and very physical specimens in their respective sport.  Even though they were “ready” to return to sport, you could see notable asymmetries in single limb performance in both and as a casual observer, you could see hesitation with movement to the involved side.  Most would say, in both cases, that these athletes also had some deep (maybe subconscious) fear of moving to that side and it dramatically impacted their performance. 
So, let’s go back to what we said at the beginning of this series. We have to get better at preventing injuries.  Despite the last 15 years of biomechanical research related to non-contact injuries and risk factors, we simply are not that much better at preventing them.  In 2014, Dodwell et al showed, despite all we have learned, there has been a dramatic increase in pediatric ACL injuries over the last 20 years.  Similar results were demonstrated by Mall et al in 2014 when looking across multiple age groups.  So is it that we are simply getting better at diagnosing these problems or is it that there is truly an increase.  We don’t know the answer to that question but based on what we do know, we can make some assumptions.  In 2015, Jaynathi et al showed that early specialization significantly increased the risk for serious overuse injuries in youth athletics.  Considering the plethora of research available, today, we still assess and treat the way we did 10+ years ago.  In some instances, we may assess movement but we do it in such a rudimentary way that it does not assess for the what the research suggest are risk factors.  Based on the most current research, it might suggest that we consider the following when assessing risk:
  • Age/Gender
  • Sport/Single sport or multiple
  • Previous knee/ACL injury
  • History of concussion
  • BMI
  • Movement
  • Gmed/Gmax strength relative to % body weight
  • Limb symmetry
  • Impact of fatigue

This is obviously not an all inclusive list but is a list that is based on the most current research.  All of these factors we can test and ironically, if movement/symmetry is improved, there is also a huge impact to athletic performance.  Some coaches will say that they get this and know this intuitively.  They are the exception.  To truly and profoundly impact injury rates, we have to come up with a better, more reliable, more sensitive and efficient way that this can be done for the masses.   
After doing this for over 17 years, there is a couple of things that are apparent to me.  One is that everyone moves different but there is always an opportunity to optimize that for performance improvement and reduced injury risk.  Second is that I learn something new everyday.  If you are closed minded and believe you have it figured out, you will NEVER know more than what you know today!  I simply am not that smart and every athlete I see and every coach, athletic trainer and physical therapist I meet teaches me something new.  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.  #MovingToChangeMovement and help us spread the passion.
Trent Nessler, PT, MPT, DPT:  Physical Therapist | Author | Educator |Innovator in Movement Science and Technology.  Dr. Nessler is a physical therapist and owner of Athletic Therapy Services.  He serves as a practicing clinician and movement change consultant for practices and organizations looking to develop injury prevention initiatives and strategies.  He has been researching and developing movement assessments and technologies for >10 years is the author of the textbook Dynamic Movement Assessment: Enhance Performance and Prevent Injury, and associate editor for International Journal of Athletic Therapy & Training.  You can contact him directly at

No comments:

Post a Comment