Monday, May 27, 2019

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

Throughout this entire series, we have talked about how do we know if an athlete is ready for return to play?  Last week, we looked at some specific testing that we can use that will give us some very objective data on the athlete's status and whether or not they are ready to return to play.  But as we found out from King et al Am J Sport Med 2019, as much as we would like to think we are changing movement with our protocols, the reality is, we are not as good as we think we are.  Considering this, it is not only important to "measure movement" but also to know how to positively impact the movements we measure. 

So, we know what the movements are but how do we change them?  That is the intention of our discussion today.  To determine what the movements are telling us and how we can use this information to create exercise program which address.  Before we do that, we must first talk about 7 key concepts that we feel must be considered when creating programs designed to improve movement.
  • Repetitions to Substitution - repetitions to substitution simply means only performing the number of reps the athlete can perform while maintaining correct technique.  We know that it takes 3,000 to 30,000 repetitions to change a motor plan in the primary motor cortex.  By using this approach, you continue to train the proper motor plan and prevent re-training the default faulty motor program you are trying to prevent.  When applying this technique, this does not mean that you discontinue the exercise once proper technique is not able to be maintained.  You can simply decrease the intensity or difficulty of the exercise so you can continue to reinforce the new motor plan and continue to build endurance.  An example of this is performing single leg squats where the contralateral limb is not in contact with the ground.  Once the athlete is no longer able to do the exercise without maintaining proper hip or knee position, we would then regress the exercise to a single squat with the contralateral limb in contact with the ground.  This way we continue to push the strength, endurance and proper motor plan with a less intense form of the exercise.
  • Rapid Neuromuscular Response (RNMR) - in sports, most of the movements we do are explosive and/or require rapid response by the system to create stability for rapid change in direction.  These kind of movements require a rapid neuromuscular response to provide stability in order to allow maximal transfer of kinetic energy across the system and to avoid excessive stress/strain to the structures and tissues along the chain.   RNMR is not trained in open kinetic chain exercises or isolation with traditional closed kinetic chain exercises.  However, training RNMR can be accomplished in a lot of ways.  This would include:
    • Perturbations - There are a lot of forms of perturbations.  These can be done in a more static fashion - performing single leg squats followed by holding in position while providing perturbations in a direction that requires resisting adduction and internal rotation.  This can be progressed to doing perturbations throughout the squatting motion.  Using the spiral technique and the end of the CLX band, we can provide multidirectional pulls in internal rotation and adduction throughout the squatting motion.  This can also be done in a more dynamic explosive fashion.  While performing squat jumps and that athlete can be perturbated while in the air before landing.  This can also be done in both anticipated fashion and unanticipated fashion. Done on every rep (anticipated) or varying number of reps (unanticipated).  *It should be noted - perturbations are not meant to break the athlete.  They are meant to get a rapid response from the system to create stability.  So if you are pushing so hard that the athlete is not able to stabilize and prevent the movement, we are then training a motor plan to do just that...break*
    • Visual Motor Training - visual motor training is another great way to build rapid neuromuscular response.  With this type of training, the athlete is typically responding to some type of visual cuing that is requiring a motor response.  In the video below, the athlete is using the Quick Board.  This is a device where the athlete must respond to visual cue on an Ipad and touch the corresponding sensor on the foot plate.  
  • Whole kinetic chain stability - as described, whole kinetic chain stability is just that, stability of the entire lower kinetic chain from the foot to the spine.  All too often we focus on one component of the kinetic chain (foot or knee) while ignoring the other components (hip or spine).  For example, if the athlete is performing a single leg squat, they may be maintaining frontal plane stability of the knee but not controlling the hips.  If this is not corrected, then we are teaching the athlete to control frontal plane stability of the knee at the expense of lack of transverse and sagittal plane stability at the hip. So in our effort to reduce risk for injury at the knee, we could potentially be increasing their risk for hip injury.  As pictured here, the athlete is controlling frontal plane motion of the knee but has both sagittal and transverse plane motion at the hip.  If we allow this to occur in training then this is the motor plan we are training for when it matters the most, when the athlete is in play or fatigued.
  • Fatigue state training - fatigue state training should be an essential part of the training regime.  There is a lot of controversy on whether or not fatigue adds to ACL risk.  Is this true or is it that we simply have not figured out how to measure this correctly in the research?  What we do know from the studies is fatigue does add to increase in forefoot pressures and decrease activity in runners (Weist et al Am J Sport Med) and to an increase in frontal plane motion of the knee (Brazen et al Clin J Sport Med) during explosive activities.  That said, there is enough evidence that we should be including this as a part of our training.  This can be accomplished in a lot of ways.  We utilize this technique as a part of our prevention programs where the exercises are done at the conclusion of practice when the athlete is tired.  From a specificity standpoint, the carry over from this kind of training to improved movement in a fatigued state (later in the game) is much better.  This means they are not only moving better and reducing risk but also moving better which means performing at a higher level.  However, when incorporating fatigue state training, it is imperative that there is a focus on technique.  If we allow the athlete to train with poor technique in a fatigued state then this will be the pattern they revert to when they are fatigued.  
  • Include Plyometrics Exercises and do them first - plyometrics are great exercises and great way to develop explosive power and rapid neuromuscular responses.  These should ONLY be included when the athlete has demonstrated the ability to maintain stability of the entire lower kinetic chain during single leg closed kinetic chain activities.  As with all exercises and especially plyos, it is imperative that technique is maintained throughout.  With high explosive exercises such as plyos, there is often greater recruitment of the entire kinetic chain (core to feet).  As such, each component is being trained for their part in creating this rapid form of stability.  If poor technique is allowed, then each link along the chain is laying down a faulty motor pattern that will be reverted to when explosive power is needed.  Therefore, we recommend, due to the higher intensity of this training, the need for whole kinetic chain stability and propensity for reverting to faulty movement patterns, that once plyos are included in the routine that they are done at the beginning of a training session versus at the end.   As basic as it sounds, that it is not so basic.  Perfect example is the video below.  This athlete was doing plyos as a part of her rehabilitation and was being evaluated for RTPlay.  Sadly, this is the technique she did for 2 weeks in physical therapy under the direction of a PT.  
  • Don't Ignore the Core - all too often we hear about the core this, the core that, the core, core, core.  We know from our previous blogs that core stability does have a direct impact on lower extremity injuries, ACL injuries, and athletic performance.  Yet, when it comes to rehab, it is often thrown in as an after thought or not included at all.  When including core, it should include some isolation but should also be included in full kinetic chain training as well as integrated with RNMR.  
  • Demonstration - we have found that a large percentage of athletes are visual learners.  As such, providing them with verbal instructions, although good, gets a better result of the desired technique, when we demonstrate desired motion and the motion we want them to avoid.  
Being mindful of these 7 key concepts will go a long way in creating permanent changes in the motor plans that athletes revert to in athletic play and which will reduce injury risk and improve athletic performance.  Next week, we will discuss how each individual movement can 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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