Monday, July 1, 2019

NFL ACL Epidemic - Will the 2019/20 Season Be Any Different? - Part III

Last week, we looked at the study by King et al Am J Sports Med 2019.  This was an interesting
study that looked at athletes who had an ACLR and rehab following.  From what we read last week, the results are not quite what we would expect or, as a clinician, hope to see.  For more specifics on the study, please refer to last week's blog.

This study has a lot of application to all levels of athletes and especially to the professional football player.  Aside from the results themselves and more importantly, what can we learn from this?  If we can gleam some key points from this study and apply what we are learning, may be, just may be, our athletes will go back to sport moving better, get injured less on return to play and perform at a higher level.

So what does this meant to us?

  1. Need to be assessing motion throughout the rehab process - as clinicians, we want to think the intervention strategies we are doing are going to change movement.  Unfortunately, this study shows that this may not be the case.  So how do we know.  We need to assess motion throughout the rehab process.  This should include:
    1. Sequential testing - a progressive series of movements that move from easy to more complex
    2. Comprehensive - a series of movements that test all the kinetic chain components that contribute to pathokinematics 
    3. Movement specific - a series of movements that assesses or evaluates movement patterns identified in the research that have been shown to be associated with risk
    4.  Includes closed kinetic chain testing of LSI - includes a series of movements that are closed kinetic chain and single limb in nature.  Should also include enough tests or reps that sensitivity can be created to capture small changes in movement.  
    5. Differential diagnostic in nature - A series of movements that allows the practioner to identify where the chain is falling apart and create targeted interventions to address.
    6. Should be done at various stages throughout the rehab process - time between testing should be 4-6 weeks to allow for neuromuscular and hypertrophy changes significant enough to impact closed kinetic chain full body weight testing 
  2. Visual interpretation alone is not good enough - visual observation alone is NOT enough.  Wren et al J Ortho Sport Phy Ther 2018 showed that someone can pass a functional test (single leg hop for distance for example) and still have horrible biomechanics.  Therefore the athlete's ability to perform the task alone is not enough.  One common complaint is that to get a "truly accurate measure of motion" takes too long.  To truly get reliable and valid measure of motion requires expensive equipment and a lot of time.  Ten years ago, that would have been the case.  Today, not so much.  With some of the IMUs (inertial measurement units) on the market, you can get a very accurate measure of movement in a progressive series of movements in 15 minutes.  Some might say and do say that is too long!  I would simply say, how important is it to you?  Is it worth 15 minutes to make sure you they are moving better, that our programs are truly impacting risk factors and improving movement and that are accurately preparing them to return to sport safer, stronger and better than what we have previously done?  Just a word of caution - there are other markerless technologies out there (Kinect based) that take less time but the technology is much less accurate (20-25% error rate).  In movement, that kind of error rate is the difference between injury and not.
  3. Allows to create better exercises and see effectiveness of - assessing movement throughout
    the rehab process allows us to be much more targeted and effective with our interventions.  By doing this, we can then see much sooner in the rehab process if we are truly impacting the movements we know that puts athletes at risk.  
  4. Means better rehab, better outcomes and better/safer return to play - assessing movement throughout rehab provides much more effective rehab.  At the conclusion of rehab, what we see is the athlete is moving better, their patient reported outcomes are scoring higher, there is less incidence of kinesiophobia (as measured via TSK-11) and (although we don't know yet) we would suspect that reinjury rates are less.
  5. Addressing root cause - assessing movement in a comprehensive, sequential manner allows us to get determine a root cause or root link in the chain which is contributing the the pathokinematic movement patterns we are seeing.

Across the board, high school to collegiate to professional, if we get better of assessing movement and DO IT throughout the rehab process, we should see an impact on injury rates.  But how does this impact NFL players.  If we can do this in rehab, why can't we do this in physicals. 

The major push back on this is typically time that it takes.  With a roster of 90 to 100 athletes and taking 15 minutes per athlete, most teams will say this takes to much time.  My question would be, how important is it to you.  Having done large groups of athletes (400-600) athletes, we know, if well coordinated can be done efficiently enough that you could assess over 110 athletes in a day.  End of the day, we can do more efficient, less comprehensive assessments, like we do today but we can't expect anything to change.  Insanity = doing the same thing over and over and expecting a different result.  Let's stop the insanity and start truly assessing movement today!

We hope you enjoyed the start of this series.  If you did, 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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