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.

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?

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.

Now that you have defined your why, addressed your culture, and understand test selection, let’s get into the nitty gritty of testing a large group for systematic injury prevention. To jumpstart your efforts, I have created this calculator to help you estimate how many people you can test in a given time period. You can adjust the test selection, the number of testers, and your testing timeframe. This will initiate a good thought process for our next posts on the mechanics of testing. 

The calculator is free for subscribers of philplisky.com. Join Us to download your FREE calculator and newsletter.

Your feedback and suggestions for improving the calculator are welcome, so please post below.

Bottom Line Up Front: The individual tests selected for an injury prevention system are important and should certainly possess basic psychometric properties (reliability, predictive and discriminant validity, etc.). However, it is important to use a systematic approach for injury risk factor identification and management to ensure that a comprehensive and effective plan is provided for each individual under your care.

What to Test

Which tests should be used in an injury prevention system? It boils down to identifying and managing the known risk factors for injury. What are the most common neuromuscular risk factors for injury? They can be summed up in three categories:

  • Pain
  • Previous injury
  • Abnormal motor control (due to abnormalities in ROM, stability, coordination, balance, etc.)

Let’s look at how a successful injury prevention program, the FIFA 11+ , addresses these risk factors.  There is good research showing that the FIFA 11+ successfully reduces injury rates. The researchers who developed the FIFA 11+ program address many of the neuromuscular factors related to injury, including core and leg strength, balance, and plyometrics/agility. Thus, a soccer player who has poor core strength gets a little dose of core strengthening to address his deficit (plus the other stuff he may or may not need). This a program that I highly recommend, particularly if the alternative is doing nothing. But the problem with this ‘one size fits all’ approach is that it doesn’t test any of the factors it is attempting to mitigate. There are no feedback loops and ironically, it is inefficient because of its efficiency of quickly addressing many factors in a warm up session. It gives everyone a small dose of the same thing.

Let’s consider a school that has identified children who are not reading at their grade level. A program is implemented requiring all students to spend 30 additional minutes per day performing phonics and reading. Sure, a program has been implemented to address the problem, but what about the kids with dyslexia, vision problems, or those who struggle with the alphabet? Much like the FIFA 11+, this program will help those who are ripe for it, but will not affect those who have risk factors which exclude them from benefiting. Again, the research is clear, group programs work for those athletes that they work for….but not everyone.

With regard to injury in soccer, which tests would you perform to identify all the different root causes of all the different potential injuries? This is the current dilemma in injury prevention research.

What is the solution? Systematic injury reduction requires a level of individualization. Let’s consider the Lehr et al study.  Prior to the season, athletes were given a questionnaire, Functional Movement Screen and Y Balance Test.  The move2perform algorithm was used, which looks at the interplay of several risk factors. For example, having pain on a test trumps movement and Y Balance Test scores. Individuals with pain land in the highest risk category.  If someone has a previous injury AND motor control dysfunction, as identified by the Y Balance Test or Functional Movement Screen, they are in the second highest category. If they have no previous injury or discernible motor control dysfunction, they are in the lowest level risk category. For someone in the lowest risk category, I would proceed to higher demand screening for power, energy storing, and postural integrity under load (Fundamental Capacity Screen). However, the path would be different for those in the other risk categories.

One of the biggest mistakes I see when choosing screens is honing in on the predictive validity of a test in isolation and trying to find a single, best screen. In reality, musculoskeletal injury is multifactorial and incredibly complex.  While the screen(s) you choose should be reliable, modifiable, have discriminant validity (i.e., distinguish between those with and without the disorder), and be predictive of the outcome desired outcome (e.g. injury prediction, performance improvement, identifying the barriers to skill development), it is vital to recognize that having a system that directs to multiple intervention paths is crucial. I cannot foresee a day when one screen or test will be sufficient to predict musculoskeletal injury.

An injury prevention system must be based on principles and procedures using an organized, algorithmic approach that is rooted in research. Using the Functional Movement System for injury prevention considers the interplay of the tests being used, the hierarchy of how the tests are administered and how the results are addressed.  Further, it contains vital feedback loops and gives individualized action steps based on the results. As test results change, so do the action steps.

A comprehensive injury prevention system protects you from selecting isolated tests designed to identify only a certain risk factor or from attempting to manage risk factors with an injury prevention program for individuals who will not benefit.

What risk factors do we look at in our injury prevention system?

Pain with movement
Previous Injury
Y Balance Test Composite risk cut score based on gender, sport, and competition level
Y Balance Test Asymmetry
Functional Movement Screen 0’s and 1’s

Remember, these are used to identify AND manage the most common risk factors for future injury of pain, previous injury, and abnormal motor control.

In upcoming posts we will discuss how to physically accomplish getting these risk factors tested and what to do with the results.

 

25 Mar 2017

Evaluate and Strategize

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You are on the road to implementing an injury prevention system.  You have defined your why, addressed your culture, and adjusted your mindset.  The next step is to look at your current reality and define the path to your goal.

What is your current reality?

Most teams I consult with are currently collecting data that they are not even using and asking me what screens they should add. How about dealing with the information you are already collecting? Figure out how to use the data you are collecting or stop collecting it!

Here are a few questions to evaluate your current state:

What is your historical injury rate?
What measurements are you currently taking?
What are you doing with the information once you get it?
Are you re-testing?
What is working with your program? Do you have data to back up that assertion?
What isn’t working with your program? Do you have data to back up that assertion ?
What are you doing because of tradition?

Once you have answered these questions, you should have a good handle on where you are. Now you need to develop a strategy.

Developing a Strategy

Identify what to stop doing

This is the hardest part. It is easy to add screens, tests, assessments and data points. From the questions above, what data (screens/tests) did you identify that you are either not acting on, not retesting, or you found that the measure is not giving you the intended information.  Again, either use it or stop collecting it! Last week we looked at a common limiting belief about time constraints.  Here is an opportunity to create some time!

Dream Big (how will we accomplish our why)

When we are starting a project, we use the phrase, “start with ideal.” Given unlimited time, money, and staffing, what would you accomplish and what is the ultimate outcome? Forming an ideal and keeping it in mind at all times throughout the process helps you see the possibilities, not the barriers. Go back to your why statement for the guiding principles for your decisions.

Now determine your goals

Define the specific goals of your injury prevention system. How will you know when you have achieved success? I highly recommend that  they are written in the SMART format (Specific, Measurable, Actionable, Realistic (to a degree) and have a Timeframe. For example,

We will have a player readiness rate of 98% average in the 2017 season.

Now that your start and endpoints are clear (where are you now and where you want to go), you are ready to get into the nuts and bolts of implementing your injury prevention system. Comment below with some things you will eliminate as well as your goals for this year. In the next post, I will get into the specifics of accomplishing those.

 

Wanted: Extraordinary Attributes

I am blessed to work with professionals of the highest caliber in the world in rehabilitation and performance. This is most evident to me in our Sports Physical Therapy Residency team. What sets these sports residents apart? After obtaining a Doctorate in Physical Therapy, these PTs apply for a rigorous, 15 month sports physical therapy training program that requires 50-60 hours each week.  Less than 10% of all doctoral students apply for a any type of residency program, and less than 1% of all PTs pursue a residency.  Among the applicants to our program, only three are accepted. To say that I get to work with the best of the best of the best is an understatement. It strikes me, though, that while all of the graduates are remarkable, some stand out as extraordinary in their brilliance and success.

Over the past 10 years, I have worked diligently to identify the traits that separate the brilliantly successful from the rest. Finally, this year with the help of several books and countless discussions with our team, we were able to identify and articulate those traits. There were three essential books which aided us in expressing the expectations representative of our residency culture: Mindset, The Ideal Team Player, and Grit.

These are the characteristics of our sports residency team members:

Our residency program expects and seeks to nurture individuals who are positive, humble, hungry, people-smart, and have grit, all with a growth mindset.

One of our Residency faculty recently posted on the topic of a “growth mindset.”  Reading it will give you a flavor of how deeply these values are entrenched in our program.

If your team members don’t know your vision (your why), your efforts are much less likely to  succeed. Also of importance is that they know how team members are to accomplish the vision. The tactical steps about “how” things are supposed to get done come to mind for most. But, I care most about our team being aligned with our vision and possessing the character traits to carry out that vision. In my experience, this helps the end product take care of itself with the perk of eliminating micromanaging. The vision is simply accomplished by having specific goals in conjunction with continual communication and accountability.

Many people have experienced working alongside a team member who is not displaying the desired character traits.  In The Ideal Team Player, Lencioni describes the requisite traits as virtues and offers solutions when they are not exhibited. If you cannot successfully “rehabilitate” a team member, liberate them from their current position. In this case, kindness is essential. And in this case, being kind means relieving the team member from their current position. When an individual is held back by your culture, you are doing them a disservice by allowing them to persist in a culture that does not match them. Let me be more clear, I have seen numerous teams that were unable to successfully implement a systematic approach to injury prevention because of one person. One person can also cause many outstanding people to leave an organization. Most of the time, this person is merely “tolerated” for who they are. In order for a team to be successful, this cannot occur.

To ensure that you are assembling the best possible team, begin by articulating what characteristics are most desirable for your team. If one of my consulting clients has questions about getting change within your organization, I first ask:

  1. What is your vision (your why)?
  2. If I were to ask your staff (and sometimes I do) what the vision is, would they know?
  3. What are the characteristics of your team and your team players?

Those questions have to be answered before we get into the “what” of implementing an injury prevention system. In future posts, I will be discussing the nuts and bolts of systematic injury prevention, but I can’t emphasize enough that the greatest need for most organizations is not the specifics of the system, but the foundational vision and culture to execute the details.

Share what you think the characteristics of an ideal team player are below.

24 Feb 2017

Shaping Culture to Get Buy In

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Why I think the Cubs won the World Series

In a word, culture. From any vantage point, they exude a culture with a common vision, an emphasis on continuous improvement with attention to detail, respect on all levels, and fun.  I have frequently seen teams win national championships within a couple years of implementing the Functional Movement System. Why is that? Am I biased and naive enough to think that teams who have players who perform better on the overhead deep squat are destined for a title victory?  By no means!  I think it is the result of being purposeful in building a culture that repeatedly does the simple, little things well. This type of success has roots in embracing a culture of communication and accountability. How does this start?

In her book, Grit: The Power of Passion and Perseverance, Angela Duckworth spends a day with the Seattle Seahawks to try to understand their culture after back to back Super Bowl appearances. The first thing she notes is Head Coach Pete Carroll’s emphasis on “Starting with Why.” (See my previous post on creating your Why.)

Check out this video: Sam Ramsden, Head Athletic Trainer, Seattle Seahawks

“Once you have done the work to create that clear vision, it is the discipline and effort to maintain that vision that can make it all come true.” Pete Carroll.

An article on Seahawks.com illuminates the importance of both the culture and a compelling vision (why statement) for your screening efforts. Take a look at how they describe implementing the Functional Movement System.

“The reasons the Seahawks are incorporating these tests to launch their offseason program starts at the top with general manager John Schneider and coach Pete Carroll.
This is a vision that John and Pete have for this organization,” said Ramsden, who was the Seahawks’ head trainer for eight years and an associate trainer for five years before stepping into his new role. “They’ve put me into a position to try to bring it to life.”

But once that is developed, how do you create the culture you want that accomplishes the vision?

1. Talk about your vision — constantly.

Every team member should be able to articulate the vision. Decisions are made in accord with the vision. Motivation is drawn from the vision. Team members are held accountable to the vision. This mission must be communicated daily. Every question is an opportunity to respond in terms that underscore and propel you toward the mission.  

2. The devil is in the details.

“It is not one thing, it is a million things. It’s a million details.  

It is countless small things, each is doable.” Pete Carroll

Accountability is key. There is truth in the adage, “What gets measured, gets done.” Everyone wants to know what winning looks like in their particular job. In the realm of injury prevention and performance enhancement, baseline screening and re-testing is key. The reports that are shared from re-testing foster communication – communication about progress toward the vision. This helps continue the culture change and is a catalyst for buy in.

3. Communicate to foster buy in.

Accountability is important, but without a supportive culture it can lead to individualism as well as the temptation to  “cook the books”. If I am going to be held accountable for improving someone’s movement screen score, I might be tempted to fudge that score in order to look better. This is where vulnerability and mutual support are crucial. Everyone “has each other’s back” has to be the attitude. An emphasis must be made on helping one another identify and removing resistance to implementation along the way.  A  ‘no blame’ policy assists in navigating through hurdles. When communication or accountability breaks down for any portion of the organization, even if a single person fails to act in the direction of the vision, it could thwart the efforts of the whole group.

So why do teams tend to win after implementing the Functional Movement System? I believe it is the result of  their commitment to communication and accountability, and a willingness to start with the little things to pursue a common vision. This communication,  accountability, and adherence to the vision permeates the culture and spills over into every area. It makes sense that teams that have created a culture embodying these values would be inclined to adopt a comprehensive  system for injury prevention.  In my next post, we will continue to talk about developing your culture with your team members.

Post below about how have you seen doing the little things right over and over again can lead to outrageous success in large goals?


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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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