Monday, May 20, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part IIX

Over the course of the last 8 weeks, we have looked at a lot of research and asking the question, how do we know when is the right time to return to play following ACLR.  Although I don't think that answer is clear, I do think it has provided us some clear direction on what we should be doing and how we should be assessing people for return to play.  Based on all the research we have reviewed and 20+ years of sports medicine clinical practice, several things have become clear.

  1. We need to test stability during single limb performance - this means controlling both magnitude of motion and speed at which that motion occurs. 
  2. We must stop relying on subjective measures and leverage technology to provide us more objective measures
  3. Measurement of limb symmetry index (LSI) is important and should be a measure of biomechanical factors versus just ability to perform
  4. We need to incorporate all segments of the lower kinetic chain that contribute to single limb stability  
  5. We need to incorporate some form of on the field testing to measure LSI in explosive activities 
Based on the research we have developed a sequence of tests (Athletic Movement Index or AMI) that has been guided by the research and which leverages the latest in 3D wearable sensor technology (DorsaVi).  The ViPerform AMI uses the DorsaVi sensor to track movement within 3% of a Vicon system during a sequence of core, bilateral and single limb tests.  Throughout this series of tests, the athlete is does not rest and goes from one test to the next.  For the single limb tests, all single limb test (SL Squat, SL Hop, SL Hop Plant, ankle lunge) are performed on the right first to completion then the sequence is repeated on the left.

Core Tests: The core tests consist of the plank and the side plank tests.  During this sequence of tests, the athlete performs the test for a set period of time.  In this example, the sensor measures the athlete's ability to maintain stability in flexion/extension and rotation for a set period of time.  The athlete is scored based on their ability to maintain this stability.

Squat Test: In this test the athlete performs a bilateral squat for a set number of repetitions.  Throughout the test, the athlete is measured on their ability to squat without a lateral shift (shifting their hips to the right or left throughout the motion) as well as measurement of their trunk flexion/extension throughout the squatting motion.

Single limb tests:  The single limb tests consist of the single leg squat, single leg hop and the single leg hop plant.  During the single leg squat, the athlete is measured on their ability to control magnitude and speed of frontal plane motion of the knee during the test.  The athlete is also scored on the whether or not they squat low enough as well as their ability to maintain balance during the course of the test.

Single leg Hop and Hop Plant - during these two tests the same factors are measured and assessed.  The only difference is that single leg hop is an explosive vertical hop on one leg and the hop plant is an explosive hop in the following sequence; forward, backward, lateral and medial.

The entire test takes ~15 minutes and a report is automatically generated at the conclusion of the test.  In most rehab scenarios, portions of the test are performed as the athlete progresses throughout rehab and as the protocol allows.  For example, an athlete who is being released to do plyometrics, we will progress them to plyos when they are able to control the frontal plane motion and speed of motion during a single leg squat.  This same philosophy is applied when progressed to sport specific training and for return to play.

For those athletes being assessed for return to play, we will perform the entire sequence of movements of the ViPerform AMI and add the acceleration deceleration test.  This on field assessment allows us to measure an athlete's limb symmetry during max acceleration and deceleration.

By being able to accurate capture the athlete's biomechanics during an athletic movement assessment and combine that with on the field assessment, we can clearly see where we need to work on from a rehabilitation/performance standpoint as well as make a more informed decision on return to play.

The best part of doing this in this fashion, with the use of technology and linking this to a master data base, is we are now able to collect over 1,000 data points for every assessment that is performed.  Since completing over 11,500 assessments since starting, we can now determine if any athlete falls within normative values or are they 1 or 2 standard deviations beyond norms.

Next week, we will discuss how data to drive what we do clinically.  It is where the rubber meets the road.   If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @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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