Monday, February 11, 2019

Improving Movement When It Matters - Part IVC

Over the last couple of weeks, we have been looking at the impact that fatigue has on human movement.  We know from the literature that athletes are at greater risk of injury later in the game.  This is due to the impact that fatigue has on response time, muscular strength and proprioception to name a few.  As such, assessing fatigued state movement should be a standard of practice however, few, if any, movement assessments incorporate this concept.

It is one thing to consider this conceptually, but another to put this in practice.  If you were to put this in practice, what kind of results can you get?  Although there is not much in the literature on, what we know through our own research is this can have a huge impact on your outcomes.  This is one of the things we have been evaluating for the last 8+ years.  Although our research is not published, all of it is IRB approved and is developed under the process of "Proper Discovery".  This simply means that in each study, we take what we learn and apply that for process improvement and re-evaluate what kind of impact this has.  It is the purest form of applying research to clinical practice and is what we do every day in the clinic.

Before discussing what we see, we should reiterate 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
This type of testing is also contraindicated and requires medical clearance with those with a history of:
  1. Cardiac History
  2. Arrhythmia
  3. High blood pressure
  4. Asthma
  5. Sickle Cell Anemia
In our study with Division I & II female soccer players, we performed movement assessments on 102 players under 2 separate conditions.  Athletes were then categorized, based on their overall scores as:
  1. Low risk
  2. Minimal risk
  3. Moderate risk
  4. High risk
Based on the risk rating, athletes were then assigned to one of four intervention groups.  Level I for those at high risk and level IV for those at low risk.  The team then performed these exercises all season long.  Throughout the season, we tracked injury rates, days on the DL, average days on the DL and health care claim submissions.

Scenario I: All athletes performed a movement assessment consisting of:
  1. Full squat test
  2. Step up test
  3. Single leg squat test
  4. Single leg hop test
  5. Plank test
  6. Bilateral side plank test
Each athlete was scored on each test and based on their overall score provided a risk rating.

Scenario II: All athletes performed the functional agility short term fatigue protocol (FAST-FP) and then performed the movement assessment as described above.  Each athlete was scored on each test and based on their overall score provided a risk rating.

When looking at the data, this is what we found:
  • Non-fatigued state
    • Average RPE 6/10
    • 25% of athletes categorized as "at risk"
    • 2% of the athletes categorized as "high risk"
    • Average score on core was 7.5 for all subjects
  • Fatigued state
    • Average RPE 8.5/10
    • 5% of athletes categorized as "at risk"
    • 36% of athletes categorized as "high risk"
    • Average score on core was 4.5 for all subjects
Although there is still a lot of questions about the data and some variables that were not controlled or assessed, athletes in this study were assigned to the intervention group based on their fatigue state data.  For our intervention group (N=42), we had the following results:
  • 100% reduction of non-contact ACL injuries Y1&Y2
  • 60% reduction in the number of days on the DL
  • 58.2% reduction in the number of non-contact LKC injuries (foot, ankle, knee, hip and low back)
  • $200K reduction in claim submissions over a 2 year period

Keeping in mind this was only an N=42, the reduction in ACL injuries is not statistically significant.  But the number of days on the DL, the overall reduction rate in LKC injuries and the cost savings is.  From a research perspective, we should have compared intervention based on fatigued data and non-fatigued data.  However, based on the fatigue state data and wanting to do the best thing for our athletes, we chose to only do based on fatigued state data.  Although this is a criticism from a research perspective, from a clinical perspective it was the right thing to do and in the end, helped a lot of kids.

Next week, we will discuss how we apply this concept of fatigue to our movement assessment in the absence of a pre-fatigue protocol.   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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