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.  

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.


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. 

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