Monday, December 10, 2018

Improving Movement When It Matters - Part I

Over the course of the last month we have been discussing LSI and what it means.  Although it provides us good information, how do we use this knowledge to create exercises that aid in improving LSI.  The idea is not only to provide the strength and endurance that is needed but also to develop the motor patterns in the higher centers that are needed to and which will aid in having maximal carry over to sport.  If we do that, does that really create movement patterns that will carry over to sport?  This is the golden nugget that everyone is looking for.

Throughout this series we are going to dive into some of the philosophy, physiology, neurology and research behind why we do what we do.  During the course of this series we are going to discuss:

  • Kinesiophobia - what is it and how does this limit return to sport
  • Your impact on psychological movement
  • Why Single limb training aids in maximizing return to sport and athletic performance
  • What is the roll of fatigued state training and why this is important
  • Movement at the hips and how this leads to increased risk and altered performance

Kinesiophobia was first described in the literature in the early 2000s but has recently gotten a resurgence with the publication of some land mark studies.  Kineisiophobia is simply the fear of moving.  In physical therapy, you often see this in patients who have suffered a fall.  They develop a fear of falling and thus a fear of moving because they are afraid of falling.  This results in significant alterations in their gate, moving from piece of furniture to furniture and a shuffling type of gait pattern.  This same fear of movement is also quite prevalent in some athletes following an Anterior Cruciate Ligament Reconstruction.  In the initial phases of rehab they may be fearful of walking with full range of motion (so may end up limiting their terminal knee extension), may be afraid of walking without a brace on or putting weight on their involved leg. 

As we progress through the phases of rehab, this can become more profound and psychologically impactful.  Hartigan et al JOSPT 2013 showed that those with higher levels of Kinesiophobia are not only more likely to have a delayed return to sport but also more likely to reinjure upon their return to sport.  Cozzi et al JSR 2015 showed that those with a higher degree of Kinesiophobia may actually result because of a self perceived level of knee function.  Meaning that the athlete subconsciously knows the function or dysfunction of their knee and sense the risk.  Some studies are now correlating the outcome measures for Kinesiophobia (Tampa Scale of Kinesiophobia) to knee outcome measures (IKDC or Marx Scale) and seeing a strong correlation with.  But, what has yet to be determined is the correlation of Kinesiophobia and movement.  One would suspect that those with significant pathological movement of the knee would have greater kinesiophobia than those who have less.

So what is the treatment for kinesiophobia?  Unfortunately there is not a lot in the literature about how to treat kinesiophobia in the athlete.  There is a fair amount out there about how to treat this in the elderly patient and the low back patient but not in the athlete.  Looking at what literature there is, there is some common themes.
  • Education - educate the athlete about their injury, expected progression of rehabilitation and how importance of restoration of early function
  • Graded exposure to therapy techniques to increase confidence
  • Graded exposure to activity
Although this relates to the elderly patient and low back patient, it also has a lot of application to our athletes.
  • Educate the athlete on their injury, the importance of progression of rehab, importance of incorporating single limb activities early in the rehab process, their role in the rehabilitation process and how this aids in faster/safer return to sport
  • Early introduction to single limb activities.  Myers et al AJSM 2012 showed that single limb testing is one of the best indicators of risk with return to sport.  As such, the earlier single limb training is incorporated into rehabilitation the more confidence the athlete will have in that limbs performance over time
  • Incorporating aggressive single limb training in later phases of rehabilitation.  Kristineslund et al AJSM 2013 showed that single limb performance is a better indicator of how the limb will function in sport.  Considering, this should indicate the importance of pushing more aggressive types of single limb training.  Not only does this help from a strength and endurance perspective but will also improve the athlete's confidence in that limb with sport related activity.

It goes with out saying, this is a criterion based methodology.  All too often I see athletes training (many times under the supervision of a therapist) single limb exercises with dysfunctional or pathological movements.  Remember, the movement that you train is the movement you will get on the field.  If you train bad movement, you can't expect the athlete to have good movement on the field.  So what is meant by criterion based methodology is that the athlete is only progressed once they are able to do the previous level of single limb exercise with proper form.  If they are unable to perform without maintaining good position of the knee and hips, then they should not be progressed up to the next level.

Taking this approach is the first step in building the athlete's confidence in their limb, decreases their kinesiophobia and improves their chances with return to sport.

Next week will continue along a similar line of discussion with talking about your impact on psychological movement.  If you enjoy this blog, please share with your colleagues and follow us on instagram @ bjjpt_acl_guy and twitter at @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 has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

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