Monday, June 18, 2018

Assessing Risk - Is it possible Part VI

Last week, we discussed, according to the research, what we need to assess as well as the importance of video.  We now know that video is an important component of an assessment as well as helping an athlete correct faulty movement patterns. 

In addition, providing video feedback, we also need to look at additional factors that result in compensatory strategies that were identified in the Wren et al study.  Hartigan et al J Ortho Sport Phy Ther 2013 looked at Kinesiophobia (fear of movement) prevalence in ACLR athletes.  What the authors found was that a lot of athletes scored high on the Tampa Scale for Kinesiophobia following ACLR.  This is a research based valid measure of fear of movement in athletes.  Whether it is the chicken before the egg or egg before the chicken, what we do know is that athletes high high Kinesiophobia move differently.  They are more hesitant to move to the involved side, tend to shift their weight away from the involved side and have less control of the limb in single limb activities.  So is it the subconscious awareness of the movement or lack of stability that creates the fear or is it the fear that creates the lack of stability.   Sadly there are a lot of athletes that are discharged from PT who still demonstrate a lot of kinesiophobia.

The answer is not real clear.  What we do know is that you can train them out of it.  Before I knew what kinesiophobia was, the young athlete pictured here presented to my office for a return to play (RTPlay) assessment.  During his history he stated:

  1. I am not confident moving to that side
  2. That side does not feel the same
  3. I don't feel like I am as strong on that side
  4. I am nervous cutting to that side.
These are all classic signs of kinesiophobia.  But what we found during the exam was this same athlete demonstrated one of the largest lateral shifts I have seen (>3 inches away from the operative side) during a squat.  In addition, his single limb test demonstrated a lack of control of valgus in loading and landing as well as a significant variance in vertical hop on the involved versus the non-involved.  So was it his lack of stability and motion causing the kinesiophobia or the kinesiophobia causing the motion.  Most likely it is a combination of the two but both which can be addressed.

What we know is that this starts with providing the athlete with Sport Locus of Control in the visit #1.  Ardern et al Am J Sports Med 2013 showed that athletes who have had an ACLR have relinquished this sport locus of control to the health care provider.  So what the heck is that and why does it matter?    As an athlete, who is in control of your destiny as an athlete?  Who controls how hard you work?  Who determines how hard you practice?  Who determines how much you effort you put out on the field.  Ultimately, who determines you success in sports?  The answer in most cases is you, the athlete.  You are in control of your destiny.  You have the sport locus of control.  You are in control of your destiny in sports.

Following an injury or ACLR, the athlete, many times for the first time, reliquish this sport locus of control to the health care provider.  So suddenly someone else tells them what they can do at the gym, when they get off crutches, when they can start doing drills, practice with or without a brace and when they can get back to sport.  In other words, someone else has the Sport Locus of Control.  This lack of control can lead to depression and can add to kinesiophobia.  So, it is vital that we give that control to the patient in visit 1.  I am often heard saying, I am simply a coach and an educator, I will coach you along the process and educate you why we do what we do but at the END OF THE DAY IT IS UP TO YOU!  In that one sentence, I am passing the sport locus of control over to the athlete.

In addition to passing the sport locus of control onto the athlete, we must also think through how we can impact kinesiophobia starting immediately in the first visit.  What we have found that works very well is:

  1. Educate the athlete why you do what you do - they are much more likely to do if they know why.
  2. Pair with other ACLRs who are later in the process.  This will create conversations and they will see how far along they will be in 3 weeks, 2 months, 4 months - it is encouraging.
  3. Start full weight bearing as soon as possible.  This will help to normalize gait, aid in reducing qua atrophy and reduce risk for lack of TKE with gait.
  4. Start single leg activities as soon as possible.  This is NOT balance but things like single leg squats, single leg hops, etc.  This will build confidence.  
  5. Push quality over quantity.  We know it is the magnitude and speed of valgus that cause injury.  Make sure they control that throughout the range of motion prior to proceeding.  
  6. Make them work hard.  Push them hard but safely.  People are often amazed at what they can achieve.  
Take a look at this still taken from an Olympic athlete that had been dealing with an injury.  She was reporting loss of confidence on this side as well as loss of explosive power.  Despite months of rehab and working with sprint coaches, and strength coaches, these movements remained.  By providing her visual feedback (via video), educating her on, giving her the control training her hard to prevent, not only is she able to run pain free but also is performing at a higher level.

Too touchy for you?  Me to.  Next week we will talk about specific training to control dynamic valgus.  Please make sure to check out our new website at where our goal is to help you help others.  #ViPerformAMI

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 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. 

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