I was performing an initial evaluation on a complex patient. Her history included a lateral ankle reconstruction five years ago with recurrent ankle instability and an ACL reconstruction 10 years prior. Over the past couple of years her knee and ankle instability worsened so much that she couldn’t play basketball at home with her kids. She opted to have both her ankle and ACL reconstructed again.
At the time of her evaluation, I had recently changed my approach to goal setting and discharge criteria. I was taught in PT school to be sure to get the patient’s goals (in this case, to be able to play basketball). But what I wasn’t doing was clearly describing and getting the patient to “sign off” on the goals that I had for her (for both return to sport and discharge…and those may be different). So I went through my discharge checklist with her. Since she was no stranger to rehab, most of the first part of the checklist made sense (normal range of motion, good strength, etc).
But when I got to the Y Balance Test she asked, “What is that?”
YES! An opportunity to talk about my favorite subject! I started to describe it verbally but decided it would be best if I just stood up and showed her. As I was doing the posterolateral reach, she stopped me. “I have never been able to do that after my previous surgeries! Do you really think I will actually be able to do that?”
“Yes, you will able to that and more! I will have utterly failed you if you can’t do this by the end rehab.”
This interaction taught me 4 important lessons:
1. Clearly articulate discharge criteria on the first day
Think of it this way, if a mother brings her teenage daughter in after ACL reconstruction, both are highly motivated to avoid a future occurrence of this type of physical and emotional pain, not to mention the financial burden. Unfortunately, much like pregnancy and childbirth (from what I have heard!), the passage of time dulls the memory of the pain encountered. Signing off on clear, objective return to play and discharge criteria at the start, minimizes the negotiating when they “feel and look ready to play.”
2. Avoid the perception of “Bait and Switch”
If the discharge criteria is not articulated clearly up front, it can feel a bit like you just want to keep the patient around for your financial gain. The surgeon told her she would be back to sports in 4-6 months. When that time rolls around, questions naturally crop up about going back to sport. If you begin defining the criteria at this point, it feels as if you just moved the finish line on her and this is incredibly frustrating. If I talk about the return to sport criteria early, it also gives me the opportunity to discuss the 4-6 month time frame that was introduced by the surgeon. I clarify that it means no earlier than 4-6 months and discuss the importance of passing all of the return to play criteria on the checklist.
3. People are highly motivated if they know they are going to be tested
Do you remember when you were given reading assignments in college? Did you do the reading? Even with the best intentions and interest in completing the assignment, more urgent tasks commonly take priority. I only did the reading if I knew that there would be a specific quiz over it. Patients are very similar. A well placed return to sport and discharge checklist can tap into a patient’s motivation. Objective physical testing criteria encourages compliance and accountability all around.
4. We can give hope
Patients sometimes lack perspective regarding recovery goals and we need to provide specifics regarding their realistic potential. Can you imagine a patient not being able to perform the posterolateral reach of the Y Balance Test after an ACL reconstruction? Obviously this patient didn’t know it was possible (or that she should be able to do it). We may take our knowledge about recovery for granted. Many patients carry fears about the future or think their pain and disability is permanent. Conveying clear expectations for the recovery of function can not only boost compliance for the effort required, but also bolsters the hope patients can have for returning to the activities that matter to them.
How do you think using a return to sport and discharge checklist early in rehabilitation could impact the people in our care?
03 Feb 2016
While I am confident my return to play checklist is a comprehensive, evidence-based way of ensuring an athlete’s durability, I think it was lacking an important element.
Recently, I was working with a patient who had an ACL reconstruction 6 months prior. She had finished physical therapy elsewhere, but the family wanted to be sure she was ready to return to sport. Her surgeon sent her to me for testing to be sure she was ready. My immediate question was, why isn’t this already being done as part of her rehabilitation process at the other facility? But that is for another post…..
During her testing I found:
- painful and dysfunctional squatting pattern (hips shifting away from surgical knee)
- dysfunctional trunk stability push up
- painful posterior rocking clearing test
- Y Balance Test Lower Quarter composite score below peer referenced risk cut point
- decreased broad jump distance
- 20% single leg hop asymmetry (I did not continue with triple hop due to safety concerns)
- Substantial Deficit Move2Perform category
Was she ready or not? Clearly she was not. Had the family not insisted on additional formal testing, she would have become another re-tear statistic. After 3 months of additional rehab with intermittent visits (1x per week for the first 3 weeks, then once every two weeks, then once a month) the testing was repeated. She performed much better, but was still lacking a bit of distance with broad jump and triple hop (although symmetrical) . What I noticed in her rehabilitation sessions was that she would have decreased knee control as the session progressed.
While I knew that fatigue amplifies motor control deficits, I never formally included testing under fatigue conditions as part of my return to sport criteria. I had only used fatigue in the past to “prove” that someone was not ready or if I noticed that their mechanics tended to decline with fatigue. However, there is enough research on the effect of fatigue on a previously injured person’s motor control that it is worth considering it as part of the criteria.
Researchers have found on the Y Balance Test Lower Quarter that a fatigue protocol decreases reach distances (Sarshin 2012). Even the original Star Excursion Balance Test research found that in people with chronic ankle instability the test results when fatigued compared to the un-fatigued condition are much worse on the involved side. The uninvolved side does decrease but not nearly as much as the involved side.
Basically, fatigue amplifies the motor control deficits that are found in the injured limb. Another example of this in the literature is Augustsson et al who found a similar decrease in performance with functional hop testing after fatigue in patients post ACL reconstruction. They found while most passed hop testing with about 90% limb symmetry index under normal conditions , when fatigued the study showed two thirds of the subjects LSI dropped below 90% (see this post to see why 90% may not be enough).
Fatigue can be accomplished in multiple ways. For example, you can use cycle ergometry followed by lunges or intense sport specific drills to fatigue someone before testing. Researchers have found that the more intense the fatiguing activity, the greater the decrease in motor control as measured by the Y Balance Test. A BORG scale of over 15 can be used to help ensure the activity is intense enough. Activities should be either sustained anaerobic activity or high intensity intervals to best produce the fatigue. Remember, when interpreting the results of testing, we are more concerned about amplified left/right asymmetry in unilateral activities like the Y Balance Test or single leg triple hop, rather than just a decrease in overall performance. For example, the Y Balance Test Anterior Reach Asymmetry changing from 3cm to 6cm is more significant than if the Y Balance Test Composite Reach decreases from 102% to 95%.
I think testing with fatigue on board is an important condition to add to return to sport criteria. I recommend getting your baselines in an un-fatigued situation, but in order to confirm that rehabilitation has normalized the motor control changes that occur after injury and to be certain that the player is indeed ready to return to sport, go ahead and fatigue them and see if there is a side-to-side difference. This is supported by research and certainly an evidence-based way to go about return to sport and discharge testing.
I would love to hear your thoughts!
Do you do return to sport testing under fatigue conditions?
If so, what fatigue protocol do you use?
12 Jul 2015
Please help guard your kids from their next ACL tear. Please.
As a father of 4 boys, protecting their health and wellbeing is of utmost importance to me. My wife and I believe sports participation offers our children physical, emotional, and leadership benefits. Unfortunately, sports injuries are costly both physically and emotionally. It seems that injuries are just part of the package. Or are they?
These injuries can be reduced. That’s right, we know how to predict and prevent ACL tears and all of the subsequent misery. We know how to prevent ankle sprains and other maladies. The real problem is that we just can’t get parents and health care providers to take action.
Numerous researchers, myself included, have dedicated their lives to injury prediction and prevention. So, what do we know? By combining multiple, easy to perform movement tests and other evidence-based risk factors, we were able to develop an injury risk algorithm that categorizes an athlete’s injury risk. We put the algorithm into a novel software application called Move2Perform, making injury risk prediction available to fitness and health care professionals globally.
A study by Lehr et al validated this algorithm in collegiate athletes. Lehr’s study demonstrated that athletes who were categorized by the Move2Perform software as being in the highest two risk categories were 3.5 times more likely to get hurt than their peers. Interestingly, no athletes who were in the optimal (lowest risk for injury) group were injured — apparently being “protected” from injury.
A similar algorithm has been developed for the U.S. military. Our ability to test and categorize many people quickly led a team of researchers to replicate the injury prediction in sports for the U. S. Military. The result was a 5 year research project called the MP3 study—Improving Military Power, Performance, through Prevention – which developed an injury predication algorithm for our service members. In addition, these sports and military algorithms are now being applied in the occupational setting.
But what can I do as a parent?
There are several steps parents can take to decrease their child’s risk of injury. Begin by embracing prevention. Like vehicles, bodies require preventative maintenance. Youth does not insulate your child from injury. A comprehensive movement “check up,” annually at minimum, is essential for musculoskeletal health.
In addition, here are 6 suggestions you can implement as a parent to help protect your child from injury (I will expand on each of these in subsequent posts):
1) Don’t have your child specialize in one sport too early or play too often. Using the guideline of no more hours per week in sports practice or competition then their age can solve a lot of problems
2) Find a provider using the best evidence available for your child’s movement screening
3) Be sure research-validated testing is performed pre-season and between sport seasons
4) Ensure that the risk factors identified during testing are corrected and verify that they have been corrected with re-testing
6) If your child does get injured, insist on standardized, evidence-based return to sport testing prior to being released from medical care. Being pain-free and “feeling great at practice” is not sufficient.
I realize it is hard to make injury prevention measures a priority between all of the practices and games, but identifying and correcting faulty movement patterns is essential to musculoskeletal health. We schedule maintenance for our cars to avoid inconvenient breakdowns. We see the dentist twice a year for precisely the same reason. It’s time we embrace the wonderful truth about injury prevention—injuries can be predicted and prevented.
You want to be a better communicator, but can’t make it to speakers school. In other posts, I have written about other things you can do to become a better speaker. In this post, I have compiled my favorite resources to improve your communication and public speaking skills. I prefer to “read” (listen to) these books through Audible, as I can listen when I am walking/running or driving.
In my opinion, this is the best overview of many different resources and research by far. If I could only read one book on communication, this would be it. It is an extremely easy to digest, action-oriented book that gives an explanation of the research and a lot of practical examples.
With any communication, whether it is a note to a physician, a talk I’m going to give, or complex problem solving, I always “Start with Why.” If you want to get a taste of what the book is like, check out his TED talk. It could change your perception of communication forever.
Chip & Dan Heath
My favorite example from this book is the question, “Why do we tend to remember the meaningless details or urban legends, yet completely forget what we hear in presentations at work or a continuing education course?” The authors do an excellent job of lining out what makes ideas “sticky.”
Chip & Dan Heath
Another great one from the Heath brothers! This is a must read for public speakers as well as anyone who is dealing with behavior change (e.g. getting patients to do their home exercise programs or trying to change cultural norms in your organization). Remember, behavior change is our ultimate goal with communication.
I really enjoyed the The Dynamic Communicator DVD series from Ken Davis and Michael Hyatt. I don’t think the DVDs are available any more but they have a live conference as well as a book. It is a clean, systematic approach to getting your message across that utilizes much of the current research on the public speaking.
Don’t wait until the “perfect time” to improve you communication – do something TODAY! Whether you are aware of it or not, you are speaking publicly to your audience every day. Make the most of it!
What are your favorite communication improvement resources? Share them below so we can all benefit
15 Sep 2014
I have found a secret when it comes to great communication.
What is it? ……….I am glad you asked! But first, I want you to think about this question for a moment– what is the purpose of communication? Write it down or at least come up with your answer before continuing……
If your answer involves anything to do with “getting your point across” or “having the other person understand what you are saying,” you are missing a major component of communication. Ultimately, communication has one goal – to get the other person to change his behavior in the way that you want him to. That’s right, the goal of most communication is behavior change.
What do we do when we communicate? Let’s say we’re trying to get a co-worker to embrace the Functional Movement System or get a coach or player to engage in injury prevention. What happens? Typically, we are so excited and passionate about our topic that we end up sounding much like a pushy sales person. (When talking about injury prevention and the annual musculoskeletal exam, I get like a Labrador Retriever puppy who wants to play fetch — including the slobber!) We say too much! This tends to cause people to shut down.
If that is the case, then what is a key pre-requisite for behavior change — the person has to be ready and willing to change. Re-read the title, tweet or facebook post that got you here. Why did you click on it?
Many times, people will not be ready for change or even know that they should change. We tend to think that means we need to bombard the person with information so he can make a decision. This is precisely the wrong thing to do.
The secret to great communication is to provide a morsel of intriguing information and wait for the person to ask a question. If he asks a question, that means that he is engaged and ready for the information and depending on the information you provide, for a subsequent behavior change. When you are speaking to a large group, you shouldn’t expect the question to be voiced out loud, but write your talk so that it answers the natural questions the audience member will be thinking.
Keep your goal of a specific behavior change in mind and craft your words carefully to arouse curiosity. Put your intriguing facts on the line and wait. Remember, you need to give them time to process the information. A long pause works really well and builds anticipation for what you are going to say next. Hook them with the most compelling information you can muster, in as few words as possible. Ready your audience for their first step in the direction you would like them to go, without leaving any slobber on their sleeves.
Last week, someone commented to me “I heard you speak in 2009, you are so much better!” I was really grateful for that compliment. I have been working hard on being a better speaker for the past several years. I frequently get asked, “how do you become a better speaker?” So I thought I would write a series on it.
One of the turning points in my speaking career was attending speakers training with Thomas Plummer and Greg Rose. Speakers’ school commences with “Welcome to Hell”, the opening line from Greg Rose. He goes on to say, “After a talk, when you ask your friends and colleagues how you did, they will tell you you that you did great…….we are not your friends.”
And with that warm introduction, speakers’ school begins. First, you are filmed and evaluated on how you walk into a room or on to stage. Key message here – head up, good posture and what you are currently doing is neither (even if you think you are).
Then, your wardrobe is critiqued…..how was I supposed to know that pleats and cuffs were for fat old men? After critiquing what you are currently wearing, they take a picture of you to see which color shirts look best on you with your complexion and hair color. As far as appearance goes, here are a few general guidelines (particularly for men):
- Bright color, non-patterned shirt
- Dark colored pants
- Professionally cut hair
- Large watch so you can see time
- Clean, polished shoes
- Fashionable belt (no, not the one you won at the rodeo)
These seem like small things, but they add up for a lot of unspoken credibility.
You then read a children’s book outloud and your voice, inflection, and speed are critiqued. This is something that you can do on your own. Play it back. Can you understand yourself and do you find yourself interesting — not your topic, but your voice? Could you imagine if people read books to their children in the same manner that they give a talk in front of people – but I guess that monotone, non-dramatic voice would be good for getting the kids to sleep!
Then comes the real test – a 5 minute talk that is filmed in high definition – no notes, no power point. It is then played back while you sit at the front of the class. You get to critique yourself first. Then, the class critiques you. Then, two guys in the back (Greg and Thom) who can only be described as the Simon Cowells of public speaking give you “feedback.” No holds barred!
As if that is not bad enough, you “get” to give your talk again implementing the feedback you received. Each time you make a mistake such as the common “um” or “ya know”, you have to stop and start over. Evidently the phrase I said over and over again was “you guys”. If it takes multiple attempts for you to get rid of your filler phrase, the class gets to throw things at you every time you say it – most of the objects are Nerf, but let me tell you, a Nerf soccer ball hurled at your face from the side (only seen at the last second before it hits you) can be quite the jolting experience.
If you have survived all of this, and take the time to implement all of the feedback, you will be a better communicator. I promise. If you are not up for speakers’ school quite yet or can’t get to one, there are some simple steps you can take to improve your public speaking. Start by doing an audio recording of yourself reading a children’s book and then video yourself giving a 5 minute talk…..you will be better for it.
I will be doing an entire series on communication as it is so important, not just for public speaking, but for achieving buy in for what you want to accomplish — performing a home exercise program, implementing group injury prevention testing, or for your colleagues to join you on your quest for excellence.
Misconception #1: The Functional Movement Screen isn’t really a screen because it’s not sensitive
Misconception #2: The Functional Movement Screen is designed to be diagnostic
Misconception #3: The Functional Movement Screen results relate to how the person will perform under load or in competition
To read the entire post CLICK HERE
Disclosure: I teach an online Return to Sport Testing course for MedBridge. To find out why I recommend MedBridge CLICK HERE
Using two different statistical techniques, the authors performed a factor analysis to determine if the individual tests of the Functional Movement Screen are independent of each other or sum together into one construct. Basically, they looked at whether the total score of the FMS is useful to reveal the whole picture of an individual’s movement or if the individual score on each test needs to be considered.
Here is what they found:
“Results do not offer support for validity of the FMS sum score as a unidimensional construct.”
The individual test results give different information than the total FMS score. In other words, a score of 1 on the push up is not measuring the same movement construct as a score of 1 on the squat.
Another quote from the study:
“When using FMS results to communicate with patients and to direct rehabilitative needs, the sports medicine professional should focus more on the individual movement scores rather than the composite score”
This is definitely the case, as a person can have a composite score of 16 and score a 1,3 on the Active Straight Leg Raise and a zero on the squat. Even though the person has a high composite score, he still has pain and substantial fundamental movement deficits that must be addressed.
Bottom Line: While the Functional Movement Screen composite score was initially used in injury prediction research, the score on the individual tests is more important. In my opinion (supported by the research), you should not have any 0’s (pain) or 1’s (can’t perform a simple movement pattern) on any individual test. But guess what, if you have at least 2’s on all 7 tests, you already have a minimum of a 14.
Remember, the Functional Movement Screen is a filter, what are you trying to catch? I am primarily interested in catching pain with movement as well as the inability to perform a simple movement.
Ben Kazman J, Galecki J, Lisman P, Deuster PA, Oʼconnor FG. Factor Structure of the Functional Movement Screen in Marine Officer Candidates. J Strength Cond Res. 2014;28(3):672-8.
26 Apr 2014
Recently, I tested a player in professional sports who had the following Y Balance Test and Functional Movement Screen scores.
If you will notice, his Y Balance Test Lower Quarter scores were great – symmetrical and above the risk cut point for his gender, sport, and competition level. But his Functional Movement Screen was riddled with fundamental movement pattern deficits and asymmetries. This a classic example of why both tests are necessary for a more complete profile of the athlete’s motor control of body weight.
In an unpublished analysis of 1490 athletes/active individuals, we found 677 (45%) passed the Y Balance Test Lower Quarter and of those 677 that passed, 243 (35%) failed the FMS. So, if you only use the Y Balance Test Lower Quarter, you will miss about 16% of the athletes who are at risk of injury.
However, consider another athlete on the same team:
As you can see with this player, his FMS score was good (no zero’s or one’s). While he may possess movement competence as demonstrated by the Functional Movement Screen, he has deficits in his motor control capacity as measured by the Y Balance Test Lower Quarter. But with an anterior reach asymmetry and a composite score below his peers (other professional baseball players), he is at risk of injury. His dynamic left/right imbalance and decreased performance at his limit of stability is a substantial risk factor for injury.
If we go back to the analysis of the 1490 athletes/active individuals, we found that 535 (35%) passed FMS and of those 535 that passed, 253 (47%) failed the Y Balance Test Lower Quarter. If you just use the FMS, you will miss about 17% of the total number of athletes who are at risk injury.
Thus, it is important to use both the Functional Movement Screen and Y Balance Test for a more complete profile of the athlete as well as the most robust injury risk prediction (see Lehr et al 2013). Or at a minimum, establish basic motor control competency with the Functional Movement Screen first, then move on to the Y Balance Test.
What do you think?
14 Mar 2014
In previous posts, I discussed why we would consider testing an athlete in an open-kinetic chain sport with a closed-kinetic chain test. Then, I discussed the hierarchy of testing and began with the Functional Movement Screen Trunk Stability Push Up and the Upper Quarter Y Balance test as basic tests of movement competency, motor control competency, and motor control capacity. Now we will examine another test that looks at capacity – the Closed Kinetic Chain Upper Extremity Stability Test.
The Closed Kinetic Chain Upper Extremity Stability Test is reliable and has some discriminant and predictive validity.1-3 The test is performed in a pushup position with the hands placed 36 inches apart on strips of athletic tape. The person reaches with alternating hands across the body to touch the piece of tape under the opposing hand. The number of cross-body touches performed in 15 seconds is recorded. The test can be modified by performing the test in the kneeling position.
It has also been suggested that the number of touches can also be divided by height to normalize the number of touches to each person. While this does give some normalization, the test is still not body relative since everyone has hands placed 36 inches apart (think about how hard that position would be for 5 foot tall gymnast compared to a 7 foot tall basketball player). In addition, a power score can be calculated by “multiplying the average number of touches with 68% of the patient’s body weight in kilograms, which is the weight of the arms, head, and trunk. That score is then divided by 15, which is the duration of the test in seconds. The power score reflects the amount of work performed in a unit of time.”
It appears that the CKCUEST does have some discriminant validity. In a recent study, researchers found that those with shoulder impingement performed substantially worse on the test compared to activity level matched controls.3 They also found the MDC to range between 2 and 4. What is interesting is that 15-25% of the “healthy” subjects reported shoulder pain after performing the test. This again speaks to the importance of having a hierarchy of testing (and maybe the number of people that consider having shoulder pain as normal).3 There is one prospective study that examines the predictive validity of the CKCUEST in collegiate football players.4 Researchers did a battery of strength, ROM, shoulder endurance, and CKCUEST at the beginning of the season on 26 players. The authors found that scoring less than 21 touches increased the likelihood of a shoulder injury during the season (5/6 of the injured players scored below 20 touches).4 While this test requires upper quarter stability, it is more of a speed/agility/power test as its measurement is touches per unit of time/height/bodyweight. I think the real value of the test lies in what one of the original authors describes as its ability to identify patients who were
“unwilling or unable to perform or developed pain during the test were not able to participate in their sport pain-free in the glenohumeral complex.”1
Bottom Line: Given the number of healthy people that have pain with the test and its potential predictive validity, it may have a place in the testing continuum to identify those with unreported pain/problems once lower level testing is complete (shoulder mobility, impingement clearing test, trunk stability push up, etc.). In addition, it can be used as one factor to determine that a person has the capacity to accept weight through one limb which is an important demonstration of stability and strength particularly after rehabilitation. Remember, this assumes all lower level testing has been passed.
1. Goldbeck TG, Davies J. Test-Retest Reliability of the Closed Kinetic Chain Upper Extremity Stability Test: A Clinical Field Test. J of Sport Rehabil. 2000;9(1):35-46.
2. Roush JR, Kitamura J, Waits MC. Reference Values for the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) for Collegiate Baseball Players. NAJSPT. Aug 2007;2(3):159-163.
3. Tucci HT, Martins J, Sposito Gde C, Camarini PM, de Oliveira AS. Closed Kinetic Chain Upper Extremity Stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC musculoskeletal disorders. 2014;15:1.
4. Pontillo M. Spinelli BA SB. Prediction of In-Season Shoulder Injury From Preseason Testing in Division I Collegiate Football Players. Sports Health. 2014.