23 May 2013

Injury Prevention Programs for Groups

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Myklebust G, Skjølberg A, Bahr R. ACL injury incidence in female handball 10 years after the Norwegian ACL prevention study: important lessons learned. Br J Sports Med. 2013 May;47(8):476-9

After implementing ACL prevention programs in handball teams for over 10 years, the authors sought to answer the question of what made the injury prevention programs successful. They came to 3 main conclusions for successful programs:

  1. “must have coach as a “partner” in the process.”
  2. The prevention program was efficient
  3. The message “we delivered to coaches in seminars, through pamphlets, interviews and on our website, was no longer ‘may reduce injury risk’, but ‘will reduce injury risk by at least 50%’. This ‘specific’ information meets one of the Heath Brothers’ criteria for ‘sticky’ messages—messages that have influence.”

Finally, the authors concluded:

“Risk factor studies are necessary to identify the individual’s needs for special training and optimise the selection of preventive exercises. In the meantime, we suggest that team sports include prevention exercises in their warm-up, tailor the exercise  programme to the specific sport and focus on coach education as a key factor”

 

Here are a few of the studies demonstrating using the Y Balance Test as a predictive tool

Injury Prediction

Plisky PJ, Rauh MJ, Kaminski TW, Underwood, FB. Star Excursion Balance Test predicts lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911-9

  • “Players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P<.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P<.05).”
  • TAKE HOME MESSAGE: This was the first study demonstrating the Star Excursion Balance Test’s predictive ability. If you athletes have an asymmetry or low composite score, they may be at great risk of injury. Thus, one should consider using the SEBT for return to sport testing and in the pre-participation physical.

Gribble PA, Hertel J, Plisky PJ. Using the Star Excursion Balance Test to Assess Dynamic Postural Control Deficits and Outcomes in Lower Extremity Injury – A Literature and Systematic Review. J Athl Train. 2012;47(3):339-57.

  • “The Star Excursion Balance Test is a reliable measure and a valid dynamic test to predict risk of lower extremity injury, to identify dynamic balance deficits in patients with lower extremity conditions, and to be responsive to training programs in healthy participants and those with lower extremity conditions.”
  • TAKE HOME MESSAGE: The Star Excursion & Y Balance Test should be used for return to sport testing, pre-participation physicals, and annual musculoskeletal exams.

Functional Movement Screen Injury Prediction Studies

O’Connor FG, Deuster PA, Davis J, Pappas CG, Knapik JJ. Functional movement screening: predicting injuries in officer candidates. Med Sci Sports Exerc. 2011 Dec;43(12):2224-30.

“Both Long Cycle and Short Cycle cohorts demonstrated higher injury risk among candidates who had scores ≤14 compared with those with scores >14 (LC: risk ratio (RR) = 1.65, 95% confidence interval = 1.05-2.59, P = 0.03; SC: RR = 1.91, 95% confidence interval = 1.21-3.01, P < 0.01). Overall, 79.8% of persons with scores ≤14 were in the group with fitness scores <280 (/300), whereas only 6.6% of candidates in the group with fitness scores ≥280 had scores ≤14.”

Take Home: Functional Movement Screen score is associated with injury risk in Marine officer candidates regardless of the length of the basic training session.

 

Kiesel K, Plisky PJ, Voight ML. Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen? N Am J Sports Phys Ther. 2007 Aug;2(3):147-58.

“The results of this study suggest fundamental movement (as measured by the FMS™) is an identifiable risk factor for injury in professional football players. The findings of this study suggest professional football players with dysfunctional fundamental movement patterns as measured by the FMS(™) are more likely to suffer an injury than those scoring higher on the FMS™.”

Take Home: Performance on a basic test of fundamental movement patterns is helpful in predicting injuries in professional football players.

 

Chorba RS, Chorba DJ, Bouillon LE, Overmyer CA, Landis  JA. Use of functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports  Phys Ther. 2010;5:47-54.

“A score of 14 or less on the FMS™ tool resulted in a 4-fold increase in risk of lower extremity injury in female collegiate athletes participating in fall and winter sports. The screening tool was able to predict injury in female athletes without a history of major musculoskeletal injury such as ACLR.”

Take Home: It is interesting to note that athletes with history ACL reconstruction were included in the study. This may indicate that the Functional Movement Screen may be able to pick up some of the motor control changes that occur after injury that place athletes at increased risk.

Asymmetries are common in the human body and can lead to a wild goose chase in musculoskeletal assessment.  But how do we know which asymmetries are important and will lead to injury? Well, let’s look at some common misconceptions as well as the research.

Wild Goose Chase

Common Misconceptions About Asymmetries

1.  If someone performs well at their sport with an asymmetry, the asymmetry doesn’t matter.

Who ever said that asymmetry IS related to performance? Asymmetry is related to injury risk, not necessarily performance. While I am concerned about performance, I am more concerned about keeping them in the sport and participating without being encumbered by injury.

 2. Asymmetries are only important if they cause pain.

I am mostly concerned with asymmetries that cause movement inefficiency or are related to injury risk. To me,  asymmetrical fundamental movement patterns will lead to injury or inefficiency (i.e. energy expenditure that is unnecessary for performance of the activity).

3. There is no research that indicates asymmetry increases risk of injury

Those who have an anterior reach distance asymmetry on the Y Balance Test (Star Excursion Balance Test) are at increased risk of injury in high school basketball and multiple collegiate sports (Plisky 2006, Lehr 2013)

Those who have an asymmetry on the Functional Movement Screen (Kiesel 2013 in press) are at increased risk of injury in professional football

Strength and flexibility asymmetries:

        • Athletes experienced more lower extremity injuries if they had knee flexor and hip extensor strength asymmetries (Knapick 1991Nadler 2001)
        • Eccentric hamstring strength asymmetries were at greater risk of sustaining a hamstring muscle strain. (Fousekis 2011)
        • Hamstring/quad ratio asymmetry (Soderman 2001)
        • Ankle strength asymmetry (Baumhauer 1995)

Asymmetrical landing patterns predict second ACL tear in previously reconstructed athletes (Paterno 2010)

Bottom Line: I really don’t put much stock into isolated bony asymmetries (e.g. torsions, misalignments, etc.), but I do feel that modifiable movement asymmetries that are related to risk of future injury are extremely important. Further, the literature is replete with studies that indicate asymmetries exist after pathology (Gribble 2013, Hewett 2013).  Since previous injury is the most robust risk factor for future injury, we owe it to our athletes to normalize these modifiable risk factors.

What do you think?

 

Balance Test - Post-Lat

In athletes with chronic ankle instability, 2 studies report that fatigue decreases the reach distance on both sides(Gribble 2004, Gribble 2007). However, the unstable side is affected to a greater degree. So, performing a fatigue protocol prior to testing for return to sport might be a good idea. It will amplify those remaining neuromuscular control deficits. But remember, it will also decrease the composite score as well, so the results might not be as comparable to the age, gender, and sport specific injury risk cut points. But, I wouldn’t want anyone’s composite score so close to the risk cut point that fatigue tips them over the edge. Another

You should also consider fatigue with pre-participation physicals. Many places use the Y Balance Test not only for risk identification, but also as a baseline measure for return to sport after musculoskeletal injury or concussion. So if the athletes have a heavy workout prior to testing, their scores may be a little lower. I think that may be important to note, but would not cause me to postpone testing.

What do you think?

What research is there to support using the Upper Quarter Y Balance Test for return to sport testing?

Just like other return to sport tests, there is very little in the literature (really nothing). As far as the Upper Quarter Y Balance Test, there are 2 research studies (Gorman et al 2012, Westrick et al 2012). Both studies found the Y Balance Test – Upper Quarter to be reliable. In addition, both studies found there was no difference in YBT-UQ performance between dominant and non-dominant limbs. This indicates that YBT-UQ performance may serve as a good measure in return to sport testing when rehabilitating shoulder and arm injuries. Westrick et al state:

“Similarity on the UQYBT between dominant and non-dominant limbs indicates that performance on this test using a noninjured UE may serve as a reasonable measure for “normal” when testing an injured UE.”

Y-Balance Test - Medial

Y-Balance Test - Infero Lat

Y-Balance Test - Sup Lat

We are also finding right/left symmetry on the YBT-UQ in professional and collegiate baseball players (including pitchers). So, I think if overhead athletes and healthy adults demonstrate symmetry on the YBT-UQ, that patients should demonstrate symmetry before return to sport/activity (or at least before discharge).

Other tests to consider are the Closed Kinetic Chain Upper Extremity Stability Test and the One Armed Hop test. But remember, these measure power (versus dynamic control near limit of stability) in a very limited dynamic range compared to the Y Balance Test. The YBT-UQ uniquely requires stability at the person’s limit of stability in a one-arm push up position unlike planks, side bridges, trunk flexor/extensor endurance tests and the CKCUEST. Westrick et al report:

“There was a significant fair to moderate association between performance on the UQYBT and the CKCUEST, LTET, and push-ups. These results suggest the tests are interrelated but do not necessarily assess equal components of UE CKC ability.”

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