Monday, December 12, 2016

Challenging the Status Quo - Part V

Throughout the course of this series, we have been questioning the status quo.  This has obviously resonated with a lot of folks as we have had a 400% increase in visits to our blog.  This is great and I am humbled that people want to hear what we have to say.  At the same time, I think we all want to learn more about movement and to do that, we have to challenge the status quo and truly look to push to innovate in the area of technology and movement science.  In this series we have specifically addressed the following:
  1. Movement is very complex and very hard for the majority of people to see and assess
  2. The standard of practice is often 5-10 years behind the literature and clinical advancements
  3. There is a strong correlation to improvements in movement efficiency and to mitigating risk of injury and improving athletic performance
  4. We need to recognize where the flaws are in the current ways we assess movement are so that we can become better at what we do
  5. Sometimes movement is just movement and we try to over complicate it
Last week we had somewhat of a controversial discussion about one of the gold standards in movement assessment, the FMS.  During this discussion we simply highlighted what some of the current research shows about the validity and reliability of this particular test.  It was intended to be a simple discussion of what current research shows us and why that might be the case.  In addition to the discussion, last week's blog leads us right into this week's discussion, which is the standard of practice or care, in my opinion, tends to be the standard of the lazy and status quo. 

Throughout my career, I have been blessed to teach and interact with clinicians from all over the US and abroad.  I often find that there are groups that encounter who are truly inspiring to me.  Super smart, engaged and hungry for more information.  As a therapist, these types of groups (highly educated, versed in the literature, practicing on the cutting edge and highly engaged) can be intimidating.  These are the level of individuals who will challenge you, question you, back their points of view with research.  You truly must be versed in the literature.  At the same time, these are also the groups that I learn the most from and that consistently inspire me to do what I do.  This weekend, I had one such encounter with the opportunity to teach to a group in St. Louis.  Teaching to groups like this encourages me and gives me hope for our respective profession.  But frankly, that represents only 10% of our respective professions.  

In the world of movement assessment, I feel that we tend to be the standard of lazy and status quo. Why do you say that?  If we are doing movement assessment aren't we practicing a higher standard of practice?  Aren't we doing more than 99% of the respective professions?  Are we?  Let's talk about that.  Are we using the gold standard and thinking this is the answer?  Are we using this despite the fact that the literature does not support.  More importantly, that the top risk factors for injury are not even assessed with?  Are we relying solely on 2D technology for movement assessment?  If so, are we keeping abreast of what the research shows us and updating what we do based on?  From what I see, we are not!  Honestly, it goes back to basics.

We talked about the standard of practice so let's take a look at 2D analysis.  There has been numerous conferences I have attended where there is a presentation by someone doing movement assessment using 2D technology. This is great technology and is HUGE in helping our understanding of movement and in educating our patients about movement.  The impact to patient care has been awesome and I applaud those that are using it! However, throughout these presentations there is never any acknowledgement of the limitations this type of technology has.  I have seen clinicians show 5-10 degrees of improvement in pronation at the foot and ankle during gait based on their 2D assessment.  For the audience, we take that for granted that this is accurate.  But is it really?  When performing movement assessment with 2D technology we HAVE to know the limitations.  For example:
  1. Camera angle - a slight pitch of the camera off to the right or left can make it appear as if there is a valgus at the knee that is not there.
  2. Camera tilt - a slight tilt of the camera can make it appear there is movement at the knee, pelvis and foot that is not truly there.
  3. Angles on 2D - unless you are palpating and putting markers on the body and drawing angles from that, then your angles on 2D have an accuracy of +/- 10-15 degrees.  
  4. Tracking on 2D - this is done on pixels (color) and relies on contrast in colors.  If you don't have contrasting colors on the subject to the background, then the tracking becomes much less accurate.
  5. Measuring internal rotation - although we may to be able to visually see internal rotation on video, you can't accurately measure this on 2D video.  This is a 3 dimensional movement that can't be accurately measured on 2D.
  6. Measuring valgus from lateral view - This is a motion that occurs in the frontal plane and must be measured from an anterior or posterior view (anterior preferred).  To try to quantify this frontal plane motion from a lateral view is impossible.  
Some of the biggest mistakes I see.

  1. No standardized placement of cameras.  If you don't control your variables then you never know if the impact you are seeing is the result of camera position or true training impact.  This should include:
    • Height of the camera is same
    • Distance from the subject is same
    • Ensure the camera is straight on with the patient
    • Ensuring the camera is plumb and level 
  2. Frames per second too slow to capture movement - this should be at 120 fps at a minimum.  90 fps will work in most cases but 120 gives a much clearer picture.
  3. Measurement of angles - measurements of angles in 2D is not accurate unless you place markers on bony landmarks.
  4. Measuring valgus or knee position from lateral view during cone hops - frontal plane motion is one of the greatest risk factors and to attempt to measure that from a lateral view is not accurate.
If we are going to assess movement, we need to completely standardize all aspects of the movement capture. If you are using 2D, addressing the above is critical.  Most who do 2D and who read this will think they do.  But do you?  I see a lot of presentations and return to sport calls being made by 2D and when looking at the reports, you can clearly see a lot of this is not being controlled.  It is not a criticism of the individual provider but more a question on whether or not we are doing something that is in the best interest of our athlete.  Make sure what we do is accurate and the only way to do that is take the time to control the above.

If we are making return to play decisions, from a movement perspective, there are several things that I would want to assess.
  1. What is the magnitude of frontal plane motion during single leg activities
  2. What is the speed of the frontal plane motion during single leg activities 
    • Should be <20 degrees per second in single leg squat
    • Should be <100 degrees per second in single leg hop
  3. What is the limb symmetry index during single leg activities 
  4. What is the limb symmetry during functional activities - sprinting
Sadly you very rarely see these assessed.  Can you assess these in a efficient, reliable and affordable way?  Absolutely.  With advances in 3D technology, we now have the ability to look at movement like never before.

We hope you enjoyed this discussion and we will close out this discussion next week.  I would like to take a moment to thank those who have been inspirational to me.  Thank you Todd Ellenbecker, Kevin Wilk, Sam Runfola, Elizabeth Darling,Thiago Lopes, Fabio Machado, Justin Sampley, Lesley Parrish, Carl DeRosa and my lovely wife and children.

Dr. Nessler is a practicing physical therapist with over 17 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 >3000 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. 

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