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.

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

I was performing an initial evaluation on a complex patient. Her history included a lateral ankle reconstruction five years ago with recurrent ankle instability and an ACL reconstruction 10 years prior.  Over the past couple of years her knee and ankle instability worsened so much that she couldn’t play basketball at home with her kids. She opted to have both her ankle and ACL reconstructed again.

Picture by Elvis Kennedy Double Rainbow in Door County

Picture by Elvis Kennedy – Double Rainbow in Door County

At the time of her evaluation, I had recently changed my approach to goal setting and discharge criteria. I was taught in PT school to be sure to get the patient’s goals (in this case, to be able to play basketball). But what I wasn’t doing was clearly describing and getting the patient to “sign off” on the goals that I had for her (for both return to sport and discharge…and those may be different). So I went through my discharge checklist with her. Since she was no stranger to rehab, most of the first part  of the checklist made sense (normal range of motion, good strength, etc).

But when I got to the Y Balance Test she asked, “What is that?”

YES! An opportunity to talk about my favorite subject! I started to describe it verbally but decided it would be best if I just stood up and showed her. As I was doing the posterolateral reach, she stopped me. “I have never been able to do that after my previous surgeries! Do you really think I will actually be able to do that?”

“Yes, you will able to that and more! I will have utterly failed you if you can’t do this by the end rehab.”

This interaction taught me 4 important lessons:

1.  Clearly articulate discharge criteria on the first day
Think of it this way, if a mother brings her teenage daughter in after ACL reconstruction, both are highly motivated to avoid a future occurrence of this type of physical and emotional pain, not to mention the financial burden. Unfortunately, much like pregnancy and childbirth (from what I have heard!), the passage of time dulls the memory of the pain encountered. Signing off on clear, objective return to play and discharge criteria at the start, minimizes the negotiating when they “feel and look ready to play.”

2.  Avoid the perception of “Bait and Switch”
If the discharge criteria is not articulated clearly up front, it can feel a bit like you just want to keep the patient around for your financial gain. The surgeon told her she would be back to sports in 4-6 months. When that time rolls around, questions naturally crop up about going back to sport. If you begin defining the criteria at this point, it feels as if you just moved the finish line on her and this is incredibly frustrating. If I talk about the return to sport criteria early, it also gives me the opportunity to discuss the 4-6 month time frame that was introduced by the surgeon. I clarify that it means no earlier than 4-6 months and discuss the importance of  passing all of the return to play criteria on the checklist.

3.  People are highly motivated if they know they are going to be tested
Do you remember when you were given reading assignments in college? Did you do the reading? Even with the best intentions and interest in completing the assignment,  more urgent tasks commonly take priority. I only did the reading if I knew that there would be a specific quiz over it. Patients are very similar. A well placed return to sport and discharge checklist can tap into a patient’s motivation.  Objective physical testing criteria encourages compliance and accountability all around.

4.  We can give hope
Patients sometimes lack perspective regarding recovery goals and we need to provide specifics regarding their realistic potential.  Can you imagine a patient not being able to perform the posterolateral reach of the Y Balance Test after an ACL reconstruction? Obviously this patient didn’t know it was possible (or that she should be able to do it). We may take our knowledge about recovery for granted. Many patients carry fears about the future or think their pain and disability is permanent.  Conveying clear expectations for the recovery of function can not only boost compliance for the effort required, but also bolsters the hope patients can have for returning to the activities that matter to them.

How do you think using a return to sport and discharge checklist early in rehabilitation could impact the people in our care?

 

While I am confident my return to play checklist is a comprehensive, evidence-based way of ensuring an athlete’s durability, I think it was lacking an important element.

Recently, I was working with a patient who had an ACL reconstruction 6 months prior. She had finished physical therapy elsewhere, but the family wanted to be sure she was ready to return to sport. Her surgeon sent her to me for testing to be sure she was ready. My immediate question was, why isn’t this already being done as part of her rehabilitation process at the other facility? But that is for another post…..

During her testing  I found:Return to Sport Fatigue

  • painful and dysfunctional squatting pattern (hips shifting away from surgical knee)
  • dysfunctional trunk stability push up
  • painful posterior rocking clearing test
  • Y Balance Test Lower Quarter composite score below peer referenced risk cut point
  • decreased broad jump distance
  • 20% single leg hop asymmetry (I did not continue with triple hop due to safety concerns)
  • Substantial Deficit Move2Perform category

 

Was she ready or not? Clearly she was not. Had the family not insisted on additional formal testing, she would have become another re-tear statistic. After 3 months of additional rehab with intermittent visits (1x per week for the first 3 weeks, then once every two weeks, then once a month) the testing was repeated.  She performed much better, but was still lacking a bit of distance with broad jump and triple hop (although symmetrical) . What I noticed in her rehabilitation sessions was that she would have decreased knee control as the session progressed.

While I knew that fatigue amplifies motor control deficits, I never formally included testing under fatigue conditions as part of my return to sport criteria. I had only used fatigue in the past to “prove” that someone was not ready or if I noticed that their mechanics tended to decline with fatigue. However, there is enough research on the effect of fatigue on a previously injured person’s motor control that it is worth considering it as part of the criteria.

Researchers have found on the Y Balance Test Lower Quarter that a fatigue protocol decreases reach distances (Sarshin 2012).  Even the original Star Excursion Balance Test research found that in people with chronic ankle instability the test results when fatigued compared to the un-fatigued condition are much worse on the involved side. The uninvolved side does decrease but not nearly as much as the involved side.

Basically, fatigue amplifies the motor control deficits that are found in the injured limb.  Another example of this in the literature is Augustsson et al who found a similar decrease in performance with functional hop testing after fatigue in patients post ACL reconstruction.  They found while most passed hop testing with about 90% limb symmetry index under normal conditions , when fatigued the study showed two thirds of the subjects LSI dropped below 90% (see this post to see why 90% may not be enough).

Fatigue can be accomplished in multiple ways. For example, you can use cycle ergometry followed by lunges or intense sport specific drills to fatigue someone before testing. Researchers have found that the more intense the fatiguing activity, the greater the decrease in motor control as measured by the Y Balance Test. A BORG scale of over 15 can be used to help ensure the activity is intense enough.  Activities should be either sustained anaerobic activity or high intensity intervals to best produce the fatigue. Remember, when interpreting the results of testing, we are more concerned about amplified left/right asymmetry in unilateral activities like the Y Balance Test or single leg triple hop, rather than just a decrease in overall performance. For example,  the Y Balance Test Anterior Reach Asymmetry changing from 3cm to 6cm is more significant than if the Y Balance Test Composite Reach decreases from 102% to 95%.

 

I think testing with fatigue on board is an important condition to add to return to sport criteria.  I recommend getting your baselines in an un-fatigued situation, but in order to  confirm that rehabilitation has normalized the motor control changes that occur after injury and to be certain that the player is indeed ready to return to sport, go ahead and fatigue them and see if there is a side-to-side difference. This is supported by research and certainly an evidence-based way to go about return to sport and discharge testing.

Click Here for the Return to Play and Discharge Checklist

 

I would love to hear your thoughts!

Do you do return to sport testing under fatigue conditions?

If so, what fatigue protocol do you use?

Comment below.

 

 

 

12 Jul 2015

A Call to Parents

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Please help guard your kids from their next ACL tear. Please.

As a father of 4 boys, protecting their health and wellbeing is of utmost importance to me. My wife and I believe sports participation offers our children physical, emotional, and leadership benefits. Unfortunately, sports injuries are costly both physically and emotionally.  It Injury preventionseems that injuries are just part of the package.  Or are they?

These injuries can be reduced. That’s right, we know how to predict and prevent ACL tears and all of the subsequent misery. We know how to prevent ankle sprains and other maladies.  The real problem is that we just can’t get parents and health care providers to take action.

Numerous researchers, myself included, have dedicated their lives to injury prediction and prevention. So, what do we know? By combining multiple, easy to perform movement tests and other evidence-based risk factors, we were able to develop an injury risk algorithm that categorizes an athlete’s injury risk. We put the algorithm into a novel software application called Move2Perform, making injury risk prediction available to fitness and health care professionals globally.

A study by Lehr et al validated this algorithm in collegiate athletes.  Lehr’s study demonstrated that athletes who were categorized by the Move2Perform software as being in the highest two risk categories were 3.5 times more likely to get hurt than their peers. Interestingly, no athletes who were in the optimal (lowest risk for injury) group were injured — apparently being “protected” from injury.

A similar algorithm has been developed for the U.S. military. Our ability to test and categorize many people quickly led a team of researchers to replicate the injury prediction in sports for the U. S. Military.  The result was a 5 year research project called the MP3 study—Improving Military Power, Performance, through Prevention – which developed an injury predication algorithm for our service members.  In addition, these sports and military algorithms are now being applied in the occupational setting.

But what can I do as a parent?

There are several steps parents can take to decrease their child’s risk of injury.  Begin by embracing prevention.  Like vehicles, bodies require preventative maintenance.  Youth does not insulate your child from injury.  A comprehensive movement “check up,” annually at minimum, is essential for musculoskeletal health.

In addition, here are 6 suggestions you can implement as a parent to help protect your child from injury (I will expand on each of these in subsequent posts):

1)      Don’t have your child specialize in one sport too early or play too often. Using the guideline of no more hours per week in sports practice or competition then their age can solve a lot of problems

2)      Find a provider using the best evidence available for your child’s movement screening

3)      Be sure research-validated testing is performed pre-season and between sport seasons

4)      Ensure that the risk factors identified during testing are corrected and verify that they have been corrected with re-testing

5)      Once screening and testing are clear, have your child perform one of the many validated prevention programs (FIFA 11+, SportsMetrics, Santa Monica PEP)

6)      If your child does get injured, insist on standardized, evidence-based return to sport testing prior to being released from medical care. Being pain-free and “feeling great at practice” is not sufficient.

I realize it is hard to make injury prevention measures a priority between all of the practices and games, but identifying and correcting faulty movement patterns is essential to musculoskeletal health.  We schedule maintenance for our cars to avoid inconvenient breakdowns.  We see the dentist twice a year for precisely the same reason.  It’s time we embrace the wonderful truth about injury prevention—injuries can be predicted and prevented.

 

 

I wrote a post for Medbridge on the Common misconceptions of the Functional Movement Screen. Here are the 3 misconceptions I covered:Trunk Stability Push Up

 

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

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

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

 

To read the entire post CLICK HERE

Disclosure: I teach an online Return to Sport Testing course for MedBridge. To find out why I recommend MedBridge CLICK HERE

 

 

  • The Selective Functional Movement Assessment top tier testing reliability was examined in two ways:
    Click for larger view

    Click for larger view

    categorizing each of the 7 patterns into pattern into 4 categories (FN, FP, DN, DP) or by the criteria checklist (the criteria by which each movement is determined to be functional or not). Both methods demonstrated good to excellent reliability in raters who have experience with the grading (i.e. greater than 25 hours experience with the SFMA). Raters with only 8 hours experience had poor reliability. This speaks to the importance of training AND practice in clinically assessing movement (Juneau et al and Glaws et al)

 

  • An individualized corrective program based on movement deficits identified by screening improved collegiate softball players Move2Perform injury risk category. In addition, the FMS and YBT scores improved with significant difference from baseline to final testing in both screens. With regard to overall injury-risk category, there was a 31.2% reduction from high-risk to low-risk categories with this individualized injury-prevention program. The researchers suggested further risk reduction may have occurred if all of the players in the highest risk category (substantial risk) received one on one interventions (Erion et al)

 

  • A high percentage of athletes after ACL reconstruction cleared by the surgeon to return to sport did not pass even basic injury prediction tests including the Functional Movement Screen and Y Balance Test Lower Quarter. The authors stated, “progressive standardized tests of neuromuscular function may be beneficial to add to the interdisciplinary decision making process when returning patients safely to their prior level of sports participation” (Butler et al)

 

References

Erion A, Alm A, Hudson C, Matsel K. Athlete-Specific Corrective Exercises Improve Functional Movement Tests and Injury Risk Categories in a Collegiate Softball Team. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53-4.

Juneau CM ,Hewett T, , Glaws K, Becker L, Di Stasi S. Inter- and Intra-rater Reliability of the Selective Functional Movement Assessment in a Healthy Population. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.

Glaws K, Juneau CM, Becker L, Di Stasi S, Hewett T. Intra- and Inter-rater Reliability of the Standard Scoring of the Seven Fundamental Movements of the Selective Functional Movement Assessment (SFMA) in Healthy Adults. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1): A53.

Butler RJ, Mayer S, MD,  Garrett W, Taylor D, Moorman C, Toth A,  Queen R. Functional testing differences in ACL reconstruction patients cleared vs. not cleared to return to sports using clinical examination. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1) A34

While there has been a lot of great information presented, here are a few pearls from the first day:

2014-02-04 13.03.39

  • Not surprisingly, wrestlers perform better than baseball players on the Upper Quarter Y Balance Test.  Just like the Lower Quarter Y Balance Test, norms and risk cut points need to be gender, age, sport/activity specific. Want more info in need for population specific norms CLICK HERE

 

  • Shoulder flexion ROM limitation may be a risk factor for injury in professional baseball pitchers. This was not presented as formal research, but was briefly mentioned as an upcoming publication during the morning throwing athlete session. I am intrigued.

 

  • Asymmetrical Lower Quarter Y Balance Test at 12 weeks status post ACL reconstruction identifies those who won’t pass hop testing at time of return to sport. This is important as it can identify early those who may need different rehab strategies before higher level (e.g. plyometric) activity can be performed

 

References

Garrison C, Wolf G, Bothwell J, Conway J, Thigpen C.  Single Leg Squat Symmetry at 3 months is related to Single Leg Functional Performance at Time of Return to Sports Following Anterior Cruciate Ligament Reconstruction. Platform Presentation. J Orthop Sports Phys Ther. 2014;44(1):A50-51.

 

Myers HS, Poletti M, Butler R. Functional Performance on the Upper-Quarter Y Balance Test Differs Between Throwing Athletes and Wrestlers. Poster presentation. J Orthop Sports Phys Ther. 2014;44(1):170.

In a previous post, I discussed the importance of closed kinetic chain testing in a baseball player. A quote from one of the original reliability studies on the Closed Kinetic Chain Upper Extremity Stability Test (Goldbeck & Davies 2000) provides additional support for the need for closed kinetic chain testing:

“Typically, in clinical practice, a measurement or test is performed to evaluate the status of a particular parameter, and then, based on the test results, appropriate intervention strategies are applied to improve the deficit. Clinicians must ask themselves why closed kinetic chain upper extremity exercises are being integrated into treatment programs when no testing has been performed to demonstrate any deficits in those areas”

So, if you are doing rehabilitation in the closed-kinetic chain, you need to test in the closed kinetic chain as well: trunk stability push up, Upper Quarter Y Balance Test, plank, CKCUEST, and one-arm hop test.

Goldbeck TG, Davies GJ. Test-retest reliability of the closed kinetic chain upper extremity stability test: a clinical field test.  J Sport Rehabil. 2000;9:35-45.

Trunk Stability Push UpY-Balance Test - Infero Lat


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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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