Monday, February 4, 2019

Improving Movement When It Matters - Part IVB

Last week, we reviewed some of the literature as it relates to fatigue.  The take home from all this was the question, should we include this philosophy in our assessment and in our training.  As a review and from the previously reported studies, we know that fatigue:
  1. Decreases force attenuation
  2. Increases shear stresses at the knee by
    1. Increasing valgus stresses
    2. Increasing tibial rotational stresses
    3. Increasing foot pronation
    4. Increasing facet pressures
  3. There is a larger impact in female athletes than male athletes
Considering the above, what we should take away from this is that we should include some form of fatigue methodology into our movement assessment.  When considering this, there is really two ways to go about this. 
  1. A standardized fatigue protocol prior to movement assessment
  2. Employ a movement assessment that brings in a fatigue component
When considering a fatigue protocol, we should look to the literature to guide us on what we should use.  To do a fatigue protocol, it must be efficient, cost effective and something you could do in the clinic without the need of purchasing expensive equipment.  in 2012, in the J of Athl Train, Quammen et al looked at two different fatigue protocols, the SLOW-FP and the FAST-FP (slow linear oxidative fatigue protocol and the functional agility short term fatigue protocol).  The SLOW-FP is the one we traditionally think of that is a treadmill based protocol and the FAST-FP we will describe shortly.  The authors had 15 female soccer players perform both protocols and looked at kinematic and kinetic measures taken via Viacom.  The measures for both protocols were compared to pre-fatigued state measures.  What the authors found was that the FAST-FP had a greater impact on kinematic and kinetic measures known to put athletes at risk.

The take home from this was that by implementing the FAST-FP, we now have an efficient, cost effective protocol that can be implemented in the clinic as a part of a movement assessment designed to assess an athletes movement in a fatigued state. What we have found is that use of the FAST-FP prior to testing will often reveal movement patterns that were previously not seen in our higher end athletes.  To perform the FAST-FP, all you need is three cones, a 31 cm step and agility ladder.  The athlete performs the FAST-FP in the following sequence:

  1. 31 cm step up for 30 seconds at 220 bts/min
  2. L drill (Pictured here)
  3. 5 counter jumps at 80% max
  4. 5 yard agility latter
    1. Set 1&3 in forward direction
    2. Set 2&4 in lateral direction
Each of the exercises in this sequence is performed immediately after the other with the athlete jogging from one to the next.  The entire sequence takes a total of 4 1/2 to 5 minutes.  Immediately after this fatigue protocol, the athlete then moves into the movement assessment so that the fatigue that is created in the FAST-FP is carried over into the movement assessment.  This is a very aggressive form of testing and we only recommend performing this type of assessment with your higher end Division I athletes and above. 

With this level of testing there are some clear guidelines that should be followed.  Prior to implementation with post op patients, the following should be met:
  1. >24 weeks post op if ACL
  2. Full pain free ROM
  3. <1+ effusion with stroke test
  4. >70% symmetrical quad strength
  5. Cleared for plyometrics
  6. Cleared for lateral/diagonal movement
In addition, contraindications to this level of testing (unless medically cleared) are:
  1. Cardiac history
  2. Cardiac arrhythmia
  3. High blood pressure
  4. Asthma
  5. Sickle Cell Anemia
 Finally, during this level of testing, you should be following the athletes ratings of perceived exertion.  Most athletes (high level) will find this an 8/10 on this scale.  Our elite (Olympic) to pro-athletes typically rate this 7/10 on this scale. 

In absence of the FAST-FP, is there a way to include this philosophy in our movement assessment.  Next week, we will continue this discussion as we look at that question in more detail.  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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