How would you respond if someone asked, “How much would you bet that your patient or client is ready to go back to sport, work, or daily activity without increased risk of injury?”  We may never be completely confident and it won’t be a sure bet.  But, how do you determine a patient’s readiness?  If previous injury is a risk factor for future injury, are we actually sending people back at their optimal level?  We had the same questions.

In the last post I discussed the research regarding how managing the number of risk factors someone has may be the key to optimizing our outcomes with rehabilitation and performance. Start by reading that post or watching that video first because we are now going to discuss those risk factors when it comes to rehabilitation and discharge.

Military Power, Performance, and Prevention TrialTo recap, we tested 1466 soldiers to identify the most robust risk factors for injury. The risk factors were important, but even more so the number of those risk factors when looking at the relationship to future injury.  The more risk factors someone had, the more likely to get injured. Thus, our goal in performance or rehabilitation should always be to test and determine the risk factors in order to work on reducing them.

Time and time again, previous injury, length of time loss, and perceived recovery come out as risk factors. So what can we do after someone gets hurt to reduce this? 

Here is what we did in the second major study. We wanted to see what soldiers looked like after an injury when they were cleared for full duty. Secondly, we prospectively followed these folks out for a year to see if the same risk factors predicted re-injury and if the cut points remained the same. We added some additional tests like the Selective Functional Movement Assessment (SFMA) top tier movements, weighted shuttle run, 75% bodyweight carry, etc.

We presented on our preliminary answers to the first question at Combined Sections Meeting of the APTA in Denver in February. Here are two of the research questions we asked:

What percent of those cleared for full duty had pain with the simple movements in the Top Tier SFMA?

The SFMA is a movement based diagnostic system and provides healthcare professionals with an efficient and systematic tool to reach a comprehensive movement diagnosis. 

The entry point into the system is the Top Tier tests — 7 basic movement patterns graded as Functional and Non-painful (FN), Functional Painful (FP), Dysfunctional Non-painful (DN), and Dysfunctional Painful (DP). If a Top Tier test does not pass the FN grade, then that specific movement must go to a breakout pattern to find the true cause of dysfunction. 

We found that 44% had pain on the top tier Selective Functional Movement Assessment!!!!!!! Let that sink in for just a moment…44% of soldiers had pain with a basic movement like touching their toes or squatting……after they had been released as “good to go” from their injury.

 

What percent of those cleared for full duty had 5 or more risk factors?

Remember, having 5 or more risk factors substantially increased your likelihood of getting injured (see previous post).

70% of those cleared for duty had 5 or more risk factors (to be fair, they already possessed 2 of  the risk factors of profile time and previous injury). Compare that to the 40% who had 5 or more risk factors in the previous study and had an injury in the last 5 years. On the other hand,  those who had not sustained an injury in the past 5 years, only 7% had 5 or more risk factors.

To summarize, we found 70% of those cleared for duty, who were classified as ready, still had 5 or more risk factors for injury.  That difference cannot be ignored.

Now, what should we do with these findings?

We may be managing the local problem (knee, back, etc.) in rehabilitation, but we may not be managing risk factors. We need to think about rehabilitation differently. Certainly, let’s continue to get people out of pain, but let’s look at creating a standard operating procedure for testing and mitigating risk factors as part of our rehabilitation plan.

  1. TEST RISK FACTORS

First, let’s test for the risk factors. Which ones should we test and what should they be? Right now, until we have the results of this most recent study analyzed we should be testing:

Risk Factors From Survey Data

    • Age > 26
    • Sex: Female
    • Prior Injury
    • Perceived Recovery
    • Length of Profile
    • Army Run ≥ 15.3 min

Risk Factors From Physical Testing

    • DF Asymmetry ≥ 4.5°
    • YBT-LQ: Anterior Reach ≤ 72% Limb Length
    • YBT-UQ: Superolateral Reach ≤ 80.1% Limb Length
    • YBT-UQ: Inferolateral Reach Asymmetry ≥ 7.75
    • Pain present with Movement

For example, after an ankle sprain we may fix the person’s dorsiflexion range of motion and restore their ankle strength and lower extremity balance, but if they have hip pain with a squat below 90 degrees, that is a risk factor we need to fix even if wasn’t related to the original injury. 

2. USE/CHANGE DISCHARGE CRITERIA

Let’s continue rehabilitation until that person has reduced their number of risk factors rather than only rehabilitating the primary problem. This should go a long way to reducing musculoskeletal pain being one of the most costly diagnoses for our health care system and one of the greatest factors impacting our military readiness.

In the next post, we will discuss another study from our research that may help us get buy in for patients and athletes on reducing risk factors. Because, quite frankly, very few people care about risk factors. Spoiler alert, people do care about performance and possessing risk factors has an influence on performance!

 

Rhon DI, Teyhen DS, Kiesel K, Greenlee TA, Shaffer SW, Goffar SL, Plisky PJ. Does Recency of Musculoskeletal Injury Strengthen Association between Past Injury History and Future Injury Risk? Podium, APTA CSM Annual Conference, Denver, CO. February 2020

Rhon DI, Teyhen DS, Kiesel K, Greenlee TA, Shaffer SW, Goffar SL, Plisky PJ. Selective Functional Movement Assessment in Soldiers Cleared for Unrestricted Full Duty after Musculoskeletal Injury Podium, APTA CSM Annual Conference, Denver, CO. February 2020

 

Military Power, Performance, and Prevention Trial

How can we keep people healthy and participating in the activity they love? How do we ensure that those going back to sport or going back to work are ready, and how do we make sure they don’t reinjure?  These questions have fascinated me for much of my professional career.  Whether this has been through pre-participation physicals or return to sport/work testing, it has been my personal quest to make our current system better.

Part of the problem with researching this area is that injury risk is multifaceted and most research looks at a single variable in isolation.  It is difficult to determine injury risk in complex human beings in unpredictable environments.  That is why I am so excited to talk about the latest injury risk factor study that was published. I am excited because it is a major study from a research line that we have been working on for the past 10 years. 

So, if we all accept that injury risk is multifactorial and that multiple factors interplay to increase someone’s injury risk, then we need to be able to investigate as many of those factors as we can simultaneously. But studies that examine multiple risk factors are extremely hard to do and require large numbers of subjects with extensive follow up. 

Just doing a single factor (balance) prospective cohort study in high school basketball players across 8 high schools almost caused me to quit research altogether! The amount of time it takes to design the research, get IRB approval, get each institution’s approval, subjects’ consent, and then testing for days/weeks is massive; and you haven’t even started following the people for a year.  

But the biggest hurdle is testing enough subjects and then performing long enough follow up to have an adequately powered study to test MP3 Research Teammultiple risk factors. Most studies are limited by this.  It’s the main reason there are so few studies that look at the multiple variables of injury risk, and it is one of the reasons I am so excited about the research this team was able to accomplish.   

The group includes some of the most amazing people that I have worked with. There are so many people to name so please see the author list, the acknowledgements section, and beyond that there are even so many more who helped make this possible. So here is the background…

It all started when researchers from Army Baylor (Drs. Teyhen and Shafer) came to Evansville and saw how we were categorizing large numbers of athletes based on risk factors using our research and Move2Perform algorithm. That is where this 10-year journey began.

This core team of 5 PhDs and me scoured the literature for as many risk factors for military injury as possible. The only criteria was that the risk factor needed to be tested in a field expedient and reliable manner. We really cast a wide net. 

Here are the factors that we included:

86 Survey QuestionsSurvey Station

Demographic (e.g. age, sex, education, income, smoking)

Military Specific Job (e.g. deployment, load carriage)

Fitness level (e.g. overall, running, military specific)

Current & prior injuries (e.g. number, body areas, SANE (% recovered from previous injuries))

Biopsychosocial (e.g. satisfaction, depression, anxiety, catastrophizing, fear of pain)

 

Physical Factors

Hop TestingArch Height Index (AHI)

Half Kneeling Ankle Dorsiflexion (DF)

Functional Movement Screen (FMS)

Lower Quarter Y-Balance Test (YBT-LQ)

Upper Quarter Y-Balance Test (YBT-UQ) 

Triple and 6-meter hop tests

Pain with Any Tests

 

Population

We tested 1466 soldiers and then followed them for a year tracking their injuries. We separately analyzed 211 special forces (Army Rangers) and published that risk factor study here. So we were left with 966 combat, combat service, and combat service support members. 

What is interesting to me is that when people think of a military study, they think of those directly in combat (front line soldiers). Our study included those folks but also included all of the combat service and combat service support personnel — everyone from mechanics to cooks to office workers. It really represents the average population more than you would think.

We followed this group of soldiers for a year and tracked injury using direct monthly follow up with the soldiers, medical record review, and profile data. We analyzed these data to identify the most robust combination of risk factors for injury. We can break the factors into two groups: 6 factors that you can just ask the person and the other 6 require physical testing. The logistic regression identified the following risk factors:

Risk Factors From Survey Data

  • Age > 26
  • Sex: Female
  • Prior Injury
  • Perceived Recovery
  • Length of Profile
  • Army Run ≥ 15.3 min

 

Risk Factors From Physical Testing

  • DF Asymmetry ≥ 4.5°
  • YBT-LQ: Anterior Reach ≤ 72% Limb Length
  • YBT-UQ: Superolateral Reach ≤ 80.1% Limb Length
  • YBT-UQ: Inferolateral Reach Asymmetry ≥ 7.75
  • Pain present with Movement

While it is interesting that each of these factors is predictive of injury, what is more important is that the number of risk factors you possess dramatically increased your risk for injury. Look at this table, the greater number of risk factors, the greater risk of injury.

The implications of the findings can’t be underestimated. Regardless of whether you are doing a wellness or pre-season physical or discharging someone from rehab, you need to check the number of risk factors present and do everything you can do reduce that number. These risk factors may or may not be related to the original injury. But we need to check them as part of our standard operating procedure for discharge and pre-participation.

If you have any questions about the study, don’t hesitate to email me here. In the next video, I will talk about our next study and some of the preliminary results we presented at CSM this year.

 

Studies Resulting from the MP3 Trial

  1. Developing predictive models for return to work using the Military Power, Performance and Prevention (MP3) musculoskeletal injury risk algorithm: a study protocol for an injury risk assessment programme.
  2. Automation to improve efficiency of field expedient injury prediction screening.
  3. Normative data and the influence of age and gender on power, balance, flexibility, and functional movement in healthy service members.
  4. Association of Physical Inactivity, Weight, Smoking, and Prior Injury on Physical Performance in a Military Setting.
  5. Application of Athletic Movement Tests that Predict Injury Risk in a Military Population: Development of Normative Data.
  6. Incidence of Musculoskeletal Injury in US Army Unit Types: A Prospective Cohort Study.
  7. What Risk Factors Are Associated With Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study.
  8. Identification of Risk Factors Prospectively Associated With Musculoskeletal Injury in a Warrior Athlete Population.

PT Board Specialty Exam Prep Guide – Sports (SCS) – Orthopaedic (OCS)

Updated 2/1/2020

Figuring out which resources to use to prepare for the PT board specialty exam can be a daunting process. But with the right study plan and a few key resources, you can ace the test!

There is one thing that you need to know about preparing: You have to use multiple sources in order to be prepared for the board specialty exam. For example, if you completed a residency program that used much of the material from Evidence in Motion, then I recommend using the Medbridge Specialty Exam Prep Course (they have SCS, OCS, GCS, NCS, PCS). But if your residency is like ours, we use a lot of the prep material from Medbridge, so you can certainly use the Medbridge Study Guides and practice exams, but I would recommend using another program as well (e.g. Evidence in Motion (they have OCS, SCS, GCS, and NCS) or The SPTS Sports Certified Specialist Examination Preparatory Course (2020)

If you didn’t do a residency program, I would recommend doing both (e.g. Medbridge and Evidence in Motion). Those two resources will really give you a comprehensive way to be certain to learn the material.

If you are looking for additional ways to study and additional practice exams (although MedBridge has 4 practice exams), below is list of resources to aid your studying for the Board Certified Specialist Examination:

Medbridge

My favorite part of the Medbridge SCS prep is the study guides. These guides are amazing and are incredibly comprehensive. They were developed by Jenna Gourlay, and I have had multiple exam takers tell me using these guides helped them tremendously. Here is how I recommend using them:

  1. Complete a section of the blank study guide without using resources. This will give you a good indication of your current knowledge level on the topic area
  2. Go back to your resources to complete the areas you left blank
  3. Make flash cards and take notes on the areas that you don’t feel as confident in. I can’t emphasize enough how important it is to HANDWRITE notes. The learning research on this is unequivocal.

Also, there are over 500 SCS and OCS practice questions. That is such a helpful way to gauge your knowledge as well as study in a different way. One thing to note with any practice test, I wouldn’t use your score to be predictive of what your performance will be on the exam. They are intended to identify areas of weakness and provide practice, not perfectly replicate the board specialty exam.

Optim OCS Prep Course

This course contains:

  • online lectures covering each body region
  • Practice examination with 200+ questions
  • Examination will be graded and participants will receive specific feedback on areas of improvement
  • Weekly newsletters with pertinent tips and advice
  • Research breakdowns of top journal articles
  • Online question and answer sessions with OCS clinicians
  • Access to 100+ OCS study sheets and infographics

Evidence in Motion SCS Test Prep Course
While I haven’t used this course personally, I know many people who have that found it extremely valuable. Like I said, I recommend this course to our residency graduates as it gives them a different perspective.

From the Evidence in Motion Website:

  • Interact with other “SCS-preppers” in an exclusive online forum.
  • Weekly summaries of the most “need to know” info for the SCS Exam with quizzes.
  • Pre-course exam, quizzes and post-course exam with over 350 SCS-style review questions.
  • Citations and full text are provided for all quiz and pre-course exam questions.

Physical Therapy OCS Exam Review
While I haven’t used this guide, it does offer 25 free practice questions which is worth doing even if you don’t purchase the guide. These practice questions are pretty robust, and if indicative of the entire product, it should be a great resource.

PT Ortho & Sports Questions Volume II: Pass the Test Without Breaking the Bank, PT Ortho Questions: Pass the test without breaking the bank, and PT Sports Questions: Get an Edge Over the Competition

I just reviewed these for the first time and I really like them! It is great to have access to that many questions. Each question has an explanation of why the answer is correct and links to the citing course (a great way to dive into areas that you feel less confident).

The SPTS Sports Certified Specialist Examination Preparatory Course (2020)

“Edited by Robert Manske, PT,DPT, MEd, SCS, ATC, CSCS and John DeWitt, PT, DPT, SCS, AT, this home study course has been developed by the leaders in sports physical therapy to help physical therapists confidently sit for the SCS examination.”

This is a brand new preparation course from the Sports Section. Looking forward to getting feedback on it!

OCSexamprep.com

I particularly like the OCS Pop Quizes  from OCSexamprep.com. It is a great way to quickly review when you don’t have a lot of dedicated time.

Specialist Certification: Cardiovascular & Pulmonary

From Angie Nottingham Henning “The acute care section/CVP section has a drop box with files, study guide, suggested courses, and suggested textbooks for study for the CCS.”

Cardiovascular & Pulmonary Candidate Guide (.pdf)

Helpful links:

American Board of Physical Therapy Specialties (ABPTS) SCS Candidate Guide. 
Current Concepts of Orthopaedic Physical Therapy 4th Ed

This is a must read for those taking the SCS. The other specialty guides can be found here.

If there any resources that I missed (or if you have more insight/feedback on the resources), please email me or comment below so we can make this page as robust as possible for future exam takers. I would even love to add more in-depth information in the other specialty areas.

For the best deal or cheapest price on Medbridge CEUs (Over 45% off or $175 discount) use the promo code PLISKY. For PTs, if  you use promotional code PLISKY you get your MedBridge CEUs for $200 (a $175 discount). This is 47% off the normal price. For students, receive  76% off using promo code PLISKYstudent at checkout — $275 Off

 

 

 

 

 

03 Dec 2019

CEU Update #2

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As promised, just wanted to give a quick update on the CEU progress:

Melody completed 2 MedBridge Courses this weekend (the app works perfectly in the car)! She really enjoyed John Synder’s courses on the hip:

The Athlete’s Hip: Screening & Evaluation of Posterolateral Hip Pain

The Athlete’s Hip: Treatment of Hip Pathology

She said she thought the courses were really well done, evidence-based, and John was interesting to listen to. How are you doing on your CEUs?

I need to get on my CEUs…..once the semester is done!

Because I had a few people ask why I didn’t post the discount code for MedBridge earlier (because they paid full price), I have put it below.

 

Medbridge Promo Code: The Medbridge Promo Code “PLISKY” will give full access to MedBridge CEU courses for $95 for SLPs and $200 for PTs, OTs, ATCs, and nurses.

I can’t believe I already messed up.

In September, I posted about how this year was going to be different. I wasn’t going to wait until the last minute to get my PT and NATABOC CEUs done. So much so that I posted publicly and said I was going to share my progress in order to help my accountability. Suddenly it is November and I haven’t done anything. To be fair, we did unexpectedly buy a house, but that is just an excuse. So in order to keep my promise, I am going to walk you through what I have done so far to hopefully keep everyone motivated.

No photo description available.

 

My first step was to get organized. MedBridge makes this easier through their tracker tab.

I started by entering my CPR certification and 2019 Combined Sections Meeting attendance.

Once I did this, I had an idea of how many CEUs I needed. 

Now it is time to select courses. Since my wife and I were traveling this past weekend, we used the Medbridge app to watch. Watching through the app was seemless. Our first course was 

A Clinical Application of Easing Pain via Neuroplasticity

This was a great course that included the latest information on the neuroscience of pain. If you haven’t done his other courses, I highly recommend them!!!

The Neuroscience of Sprains, Strains, Pain and Sports Performance

Teaching People About Pain

A Clinical Application of Easing Pain via Neuroplasticity

 

****************************************************************************************

For the best deal on Medbridge CEUs (Over 45% off or $175 discount) use the promo code PLISKY. For PTs, if  you use promotional code PLISKY you get your MedBridge CEUs for $200 (a $175 discount). This is 47% off the normal price. For students, receive  76% off using promo code PLISKYstudent at checkout — $275 Off

Coupon Code Good through 12/31/2020 ($175 off) — Updated

MedBridge Promo Code: PLISKY

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Does the Functional Movement Screen Predict Injury?

Common Misconceptions of the Functional Movement Screen

The purpose of the Functional Movement Screen is to:

  1. Set a movement baseline
  2. Identify major problems with basic movement patterns
    What are major problems? In order of priority, they are:

    1. Pain with movement (scored as a 0 on the Functional Movement Screen)
    2. Inability to perform a simple movement pattern even when allowed a compensation (scored as a 1)
    3. Major asymmetry with movement

We also need to remember that the Functional Movement Screen is PART of a system that includes a rehabilitation assessment (Selective Functional Movement Assessment) if there is pain or injury, as well as testing (Y Balance Test Upper and Lower Quarter).

Misconception #1: The Functional Movement Screen isn’t really a screen because it’s not sensitive

Let’s start with an analogy from the athletic pre-participation physical: Cardiovascular Screening

In order to reduce sudden cardiac death in athletes, current guidelines recommend that an athlete undergo 12 tests including: targeted questions of personal and family history, heart murmur, femoral pulses to exclude aortic coarctation, physical stigmata of Marfan’s syndrome, and brachial artery blood pressure (standard blood pressure reading).1 This screening protocol has a low sensitivity for detecting conditions related to sudden cardiac death, so there has been extensive discussion in the literature about adding 12 lead EKG to the screening protocol. The use of 12 lead EKG is under great debate because of its high false positive rate (between 15 and 40%), the associated medical costs, and the lack of qualified personnel to interpret the results. What’s interesting about this is that even with the addition of EKG, every cardiac condition predisposing young athletes to sudden cardiac death is not identified; “specifically, anomalous coronary arteries, premature atherosclerotic coronary artery disease, and aortic root dilatation will go largely undetected.”1 So based on this, let’s ask some questions:

Considering there are 12 components to the cardiovascular screen above, let’s consider one that everyone is likely familiar with: blood pressure.

Is blood pressure a good screen?

Our immediate question should be: “For what purpose?”

Screening for sudden cardiac death in athletes? Not by itself.

You need to use multiple factors, and even still, you might not catch everything. However, if it’s positive by itself, it warrants further investigation and/or treatment.

Identifying someone in a hypertensive crisis? Yes

Identifying someone with high blood pressure? Yes

 

Now let’s take this same line of thinking and apply it to the Functional Movement Screen:

Is the Functional Movement Screen a good screen?

Our immediate question should be: “For what purpose?”

Screening an athlete for risk of injury? Not always by itself.

It’s best to use multiple factors (see how this has been researched below). If it’s positive by itself, it warrants further investigation and/or treatment, particularly if pain is present.

Identifying someone who has pain during 7 basic movements? Yes

Identifying a person who is unable to perform 7 basic movement patterns? Yes

Bottom Line: Similar to blood pressure, the Functional Movement Screen is good at what it’s designed to do — identify those who are unable to perform basic movement patterns and identify people who have pain with those movements. From an injury risk perspective, just like blood pressure, it’s much better when combined with the results of multiple tests and risk factors.

This brings us to another common misconception:

Misconception #2: The Functional Movement Screen is designed to be diagnostic

Keeping with our cardiovascular screening analogy, if someone has high blood pressure, you don’t know why and what you do about it depends on the results. The table below categorizes the results, and then the action plan is based on the category.

Action plan based on the category

  1. 200/120 – Hypertensive Crisis: This is clearly a medical emergency – no brainer, go to the hospital and get treatment immediately.
  2. 145/95 – Hypertension: Depending on your medical history (have you had a heart attack or stroke in the past?) and your current circumstances, further testing and some form of treatment is required.
  3. 130/85 – Pre-hypertensive: This is a warning sign – you may not require medical intervention, but you should be actively working with your physician, modifying your lifestyle, and re-testing regularly.
  4. 110/70 – Normal: Keep up the good work. You still need regular monitoring of your blood pressure.

* adapted from American Heart Association Guidelines

Using a similar construct of analyzing multiple risk factors to identify someone who is at risk of sudden cardiac death, Lehr et al used an injury prediction algorithm to categorize injury risk.

The following components (risk factors) with various weightings and interactions were included in the algorithm:

  • Previous Injury
  • Y Balance Test Composite risk cut score based on gender, sport, and competition level
  • Y Balance Test Asymmetry
  • Functional Movement Screen Total Score
  • Functional Movement Screen Asymmetry
  • Pain with testing

Here are the results of that study (Lehr 2013)

*=significant p < 0.05     †= Moderate & Substantial Risk Categories Combined

A couple things to note: When multiple risk factors are used in combination, the injury prediction results become more robust. Those in the high-risk categories were nearly 3.5 times more likely to get injured and no one in the normal group was injured (high sensitivity = 1.0).

To be clear, someone in the normal category would have a Y Balance Test Composite above the risk cut score based on gender, sport, and competition level; no Y Balance Test Asymmetry; Functional Movement Screen Total Score above 14; no Functional Movement Screen Asymmetry, and no pain with testing.

So, we recommend the intervention be matched to the category (similar to how blood pressure is managed):

  1. Substantial Deficit: There is pain with testing (injury) or substantial dysfunction. This requires one on one evaluation (Selective Functional Movement Assessment) and intervention with a health-care provider. Re-testing to ensure lower category is key.
  2. Moderate Deficit: Depending on your medical history (have you had an injury/surgery recently or multiple injuries?) and your current circumstances, you need one on one intervention with either a strength and conditioning or medical professional. Re-testing to ensure lower category is key.
  3. Slight Deficit:This is a warning sign, you may not require one on one intervention, but you should be actively working with your medical and strength and conditioning professional, modifying your training, and re-testing regularly.
  4. Optimal: Keep up the good work. Continue with evidence-based group injury prevention programs. You still need regular monitoring of your risk factors.
    **note** researchers have found that being in this category may be a protective factor for injury, so striving for this category is a worthwhile goal.

Misconception #3: The Functional Movement Screen results relate to how the person will perform under load or in competition

Remember, the goal of the Functional Movement Screen is not to measure sport performance. So the research studies that are trying to see if it relates to performance really don’t make much sense to me. Physical and sport performance is also highly variable, so it’s difficult to compare athletes of different skill. One study did look at the relationship of the Functional Movement Screen score and the potential for performance improvement in elite track and field athletes. That does make some sense – if you have a quality foundation, you are able to build better performance on that.

Further, I also believe that if someone does indeed pass the Functional Movement Screen and Y Balance Test, that he/she can still be at risk of injury because of poor landing mechanics, strength, endurance, poor agility, or power. But if he/she has passed, at least I can know that he/she possesses the basic motor control to improve those higher-level performance measures. I would recommend testing the building block of performance through the Fundamental Capacity Screen.

Summary

I think many of the misconceptions about the Functional Movement Screen relate to using a tool to perform something it was never designed to do. The FMS was not designed to:

  • Be a comprehensive screening protocol for injury risk
  • Determine a medical diagnosis or precisely pinpoint where the problem is
  • Be used as a performance metric

References

  1. Asif IM1, Rao AL, Drezner JA. Sudden cardiac death in young athletes: what is the role of screening? Curr Opin Cardiol. 2013; 28(1):55-62.
  2. Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2014;63(4):878-85.
  3. Lehr ME, Plisky PJ, Kiesel KB, Butler RJ, Fink M, Underwood FB. Field Expedient Screening and Injury Risk Algorithm Categories as Predictors of Non-Contact Lower Extremity Injury. Scan J Med Sci Sport. 2013 Aug;23(4):e225-32

It is pretty well accepted that being able to stand on one leg under control is foundational for sport performance. As a matter of fact, it is essential for the most basic human performance — walking and not falling. In every sport, baseball in particular, a controlled weight shift is essential.  When you ask any hitting or pitching coach what happens when a player cannot maintain balance in a swing or in the pitching motion, there is a resounding agreement that the results are disastrous. It is particularly obvious with young players whose skill (or lack of skill) can’t mask their poor balance.

So, I guess then the next question is how should we test balance? You can most fundamentally test it by standing on one leg under control with eyes open and closed. This is a simple and quick way to determine if someone has even the most basic balance competence. Measure the number of seconds that he stands under control. A minimum eyes open time would be 10 seconds (with >30 seconds being average — but that is just standing on one leg without touching down with no respect for control or quality). For eyes closed, 8 seconds appears to be the average (again just standing on one leg without control).  If the player can do this, he has the most basic balance competence.

From research and clinical experience, basic balance competence (standing still on one leg) is enough to build basic life activities on, but not a solid enough foundation to develop sport skill. So, how should we ensure our athletes have the balance required for sport?

Deficits in performance of any system, whether it is the heart or an air conditioner, is best determined by a stress test. By challenging the system beyond basic competence (by walking for the heart or through normal weather conditions in the case of the air conditioner), we rarely uncover flaws unless they are HUGE. So how do we “stress test” balance?

By having someone stand on one leg and reach with the other leg as far as he can, he gets to his “limit of stability”. This is the maximum distance someone can reach without “falling” or touching down. It is at this limit of stability that performance deficits and asymmetries are magnified (just like your under performing air conditioner on a 102 degree, 98% humidity Evansville day). This is where the Y Balance Test (YBT) comes in. It is designed to reliably stress test balance. But it does not just stress test balance in one plane of movement, it does it in 3 planes so that the multitude of balance requirements are covered.

I think it is important that we discuss what balance at the limit of stability requires. In order to be able to stand on one leg and reach, you have to have numerous other systems working properly and in concert.

Let’s look at a few:

1) Strength at foot/ankle, knee, hip

2) Range of motion at foot/ankle, knee, hip, spine, shoulders

3) Stability at all of the above joints

4) Proprioception — knowing where your body parts are in space

5) Vestibular (inner ear) function

6) Coordination

7) Confidence/lack of fear avoidance

The list actually can go on and on. What is great about stress testing balance through the YBT is that if anything in the above list is substantially dysfunctional, it will show up in the test. Further, if a few things in the list have slight deficit, those deficits combine to produce a measurable dysfunction.

Ok, so now that we know we should be stress testing balance what should we be looking for in the Y Balance Test?

1) Symmetry

While actual structural symmetry in humans rarely occurs (e.g. many of our bones are shorter or longer on one side and may have torsion), movement symmetry is important since all running is performed on a symmetrical base. Even seemingly asymmetrical balance movement (like pitching) requires equivalent stability on both the stance and lead leg. I am not aware of any research in any sport that indicates having asymmetrical balance is advantageous or has injury risk reduction associated with it. There is even research that demonstrates that baseball players who have had a UCL tear have significantly decreased balance compared to health controls.

So for the Y Balance Test Lower Quarter, we look for less than a 4cm asymmetry in the anterior (forward) direction and less than 6cm asymmetry in the posterior (backward/crossing behind) directions.

 

2) Overall Performance

Rarely is it ever a good thing to be in the bottom ⅓ of your peer group on anything, let alone something that might identify you as having a poor performance base or being at greater risk of getting hurt. But in addition to that, there is research that says if you perform in the bottom ⅓ of your group (according to age/competition level, gender, and sport (see below)), you are more likely to lose time due to an injury. In addition, clinically when we see someone (particularly pitchers) with poor balance and good mobility (ASLR and Shoulder Mobility of 3,3) and they are competing a high levels, collegiate or pro, they are the classic big engine with no breaks.

 

Hopefully it makes sense why balance should be stress tested in all of our athletes. But it’s not just our athletes, balance should be stress tested in the elderly as well as the general population.  While our single leg stance measurement is a convenient representation of static balance, the YBT is able to quantify the dynamic balance necessary for daily living. Our ability to be both effective and efficient, whether in sport or in life, relies on our ability to demonstrate acceptable and symmetrical balance at the limits of our stability.

How do you test balance in your athletes?

August 20, 2019

The goal of this page is to provide a comprehensive guide for the best online CEU for physical therapists, certified athletic trainers, students and all other health care professionals including the best deal and promo codes for MedBridge. I will update this page with new courses and requirements on a regular basis.

No matter how hard I try, I end up scrambling to get CEUs for all my difference certifications and licenses. The list seems to be never ending PT, ATC, CSCS. But even worse, each of the licenses has different CEU category requirements.

What is the Best MedBridge Promo Code?

Promo code PLISKY will get you the best deal on MedBridge continuing education.

Physical Therapy – Receive $175 off (over 45% savings) off using promo code PLISKY

Athletic Training – Use discount code PLISKY for 45% off NATABOC CEUs including EBP CEU category

Speech Language Pathologist (SLP — Hundreds of SLP CEUs — Only $95/year (60% savings)

Occupational Therapy – Get $175 off using coupon code PLISKY

Students – There is no better deal than what students get $275 off using promo code PLISKYstudent  at checkout. That is over 86% off!

What are the Best PT and NATABOC CEU Courses?

Here are some of my favorite courses:

Of course, I think some of the courses I did were pretty good 🙂

For NATABOC CEU EBP (clinical) and EBP (foundation)

Susan Yeargin’s courses on heat illness are essential for anyone (ATC or PT) for the best evidence on managing heat illness:

Body Temperature Assessment for Exertional Heat Stroke

Lenny Macrina’s courses on the shoulder are outstanding and evidence-based.

Advanced Rehab for the Baseball Pitcher to Improve ROM & Strength

Biomechanics of the Shoulder

The Shoulder: Traumatic and Post Operative Injuries

Shoulder Instability: Anterior, Posterior, and Multidirectional

Shoulder Fractures, Little League Shoulder, and Sprengel Deformity

The Shoulder: Overuse Injuries in Athletes

The neuroscience of pain is essential for any rehabilitation provider and the following courses are the best in my opinion:

Teaching People About Pain

What is Medbridge NATABOC CEU provider number?

Medbridge’s provider number to enter for your NATABOC CEU is P8441

 

PLISKY — Best MedBridge Promo Code

08 Jul 2019

Be Careful Which Gauges You Watch

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I am a numbers and information guy. The more information I can analyze the better. I particularly like

numbers when I can use them to track my progress. As some of you have read, this year I overhauled how I went about goal setting. My big goal for the year was being able to complete our backyard Ninja Warrior course. So I started by getting some baseline data of movement and capacity via my FMS, YBT, and FCS. This allowed me to know what fundamental building blocks needed to be in place for me to achieve my goal.

I went about addressing those problems, but not in the typical way. I went about addressing them through permanent lifestyle change — if I didn’t feel I could sustain it forever, I wasn’t going to start it. This entailed kettlebell training 2 times per week, MAF running (tons more coming on this in the next few weeks), and walking 2-4 times per week (I LOVE to walk).

So here are the results of the past 3 months:

  1. Weight exactly the same (I want to be about 10 pounds lighter)
  2. VO2 Max (actual chart above) steadily getting worse
  3. Backyard Ninja Warrior course still unable to complete

Not the best right? Maybe I should change my training methods? Maybe I should go back to the way I was working on goals in the past? Hold on, not so fast:

  1. I have stuck to and enjoyed my work outs
  2. I have had nearly zero low back pain (those of you who know me well know I can get a wicked lateral shift and pretty substantial pain)
  3. I was able to go to a Ninja Warrior gym with the boys and complete way more obstacles, including some short warped walls (the bigger ones are now on my radar)
  4. I feel great!

If I were watching the gauges society and sports science would have me watch, I would have been disappointed. But by having my goals tied to my highest values and making permanent lifestyle changes, I am achieving the goals that are most important to me.

By the way, I do think my weight (and more importantly body fat %) and VO2 max are going to improve to record levels ultimately. I just needed to clear the land and finish the foundation first. Doing the foundational things first makes the progress seem slow and ugly at times, but I know it will pay off

If you would like to hear more from me, join me at Functional Movement, Professional Rebellion, MedBridge, ProRehab & University of Evansville Sport Residency Program, or University of Evansville DPT Program.

Testing One Team Case Scenario

The head coach of the men’s soccer team has requested your consultation to assist with implementing an injury prevention system in preparation for the upcoming season. The soccer team has been plagued with time loss injuries to key players, resulting in several disappointing seasons. The coach recognizes that in order to be successful and competitive in the conference, his best players need to be healthy and on the field.

Let’s run through the major areas of preparation for a successful testing day.


Time Allocation: Test Selection, Staffing & Equipment
Your resources include 5 people, 1 Y Balance Test Kit and 2 FMS kits and you have approximately two hours to test 25 athletes.  Since this is your first time testing, I would recommend that you perform the Functional Movement Screen and Y Balance Test Lower Quarter to get the most information with the least amount of testing. The testing calculator reveals that with 5 novice staff (4 testers and 1 coordinator), you should be able to test 25 players in under 2 hours.  

Station Setup

 

 

 

 

 

 

 

 

 

Testing Flow

Plan to arrive early to arrange your equipment according to the stations in the table.  Begin your set up with at least 6 Y Balance practice stations made with athletic tape in order for the athletes to perform the necessary warm-up repetitions in preparation for the YBT. Take a few minutes to review the test criteria with the testers.

The team will arrive at the designed testing time and begin by watching the 2 minute YBT instructional video. (The video is available for download in your online Y Balance Test Certification Course.) The team can watch this video as a group and then fill out the injury and health history questionnaires. Following the video, the athletes will be directed to the YBT practice stations where they will perform 6 “warm-ups” in each reach direction on both legs.

Following the YBT warm up, the athletes proceed to any open FMS or YBT stations with their testing forms. Since this is your first testing session, you should collect the forms once testing is complete and enter the results into the Move2Perform software afterwards. This will allow time for you to review the individual/group scores and formulate a plan prior to meeting with the athletes and coaches.

If you would like more information or different testing scenarios, you can get the free ebook here.

In upcoming posts, common pitfalls in testing, methods for follow up, and overcoming common barriers will be discussed.


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About Phil

Phil Plisky

I want to change peoples lives through dialogue about creating an ideal career, injury prevention research, and return to activity testing.

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Copyright © 2013 Phil Plisky.