The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education…
Following any type of surgery, significant weakness of the primary and secondary musculature is common. For example, quadriceps weakness has been documented during the immediate post-operative phase following surgery (Snyder-Mackler et al), as well as years following rehabilitation (Rosenberg et al). Additionally, patients who undergo Total Knee Arthroplasty (TKA) exhibit similar findings. According to Mizner et al and Stevens et al, quadriceps strength drops 50-60% of pre-operative levels one month following TKA, despite the initiation of rehabilitation within 48 hours of surgery. Following this trend, Rokito et al found external rotation deficits following rotator cuff repair of 79% and 90% at six months and one year, respectively. Considering the severity and chronicity of these strength deficits, more effective interventions are warranted to restore strength and improve long-term outcomes. One particular modality that has been shown to improve these deficits is neuromuscular electrical stimulation (NMES).
Kim et al recently published a systematic review investigating the utility of NMES following ACL reconstruction to improve quadriceps function and strength. In this review, which involved 8 randomized controlled trials (RCTs), it was demonstrated that NMES in conjunction with exercise, compared to exercise alone or in combination with electromyographic bio-feedback, results in greater quadriceps strength recovery. As discussed in a previous article, return to sport is the ultimate goal for most patients and quadriceps femoris strength is of the utmost importance. Schmitt et al conducted a cross-sectional study to determine the impact of quadriceps weakness on return to sport functional testing. Those patients who presented with a quadriceps index (quadriceps strength involved/uninvolved) of < 85% performed inferiorly when compared to those with a quadriceps index of > 90%. Additionally, quadriceps weakness predicted performance on single-leg hop testing regardless of graft type, presence of meniscus injury, knee pain, and knee symptoms. Similarly, Fitzgerald et al not only measured increased quadriceps strength, but also length of time until progression to agility/plyometric training. This randomized controlled trial found that those in the NMES group met the criteria for progression in a greater proportion than those in the control group. At 16 weeks, 85.7% (18/21) of patients receiving NMES achieved progression to agility training, whereas only 68% (15/22) of those in the control group achieved similar results.
In addition to ACL rehabilitation, those undergoing total knee arthroplasty enjoyed similar benefits. Stevens-Lapsley et al conducted a prospective, longitudinal, randomized controlled trial investigating the effects of NMES on patients following TKA. Patients were randomized into a group receiving standardized rehabilitation or to a group receiving the same rehabilitation in addition to NMES, which was initiated 48 hours following surgery. In both the short-term (3.5 weeks) and long-term (52 weeks), patients in the NMES group demonstrated superior quadriceps strength, hamstring strength, and functional performance (Timed “Up & Go” Test, the Stair-Climbing Test, and the Six-Minute Walk Test). Additionally, Walls et al investigated the pre-operative utility of this modality. Those individuals who received NMES achieved significant increases in quadriceps strength from weeks 6-12, whereas the control group did not achieve the same feat. Lastly, in a case report published by Petterson et al, a cyclist presenting 12 months following bilateral TKA displayed significant impairments with regards to quadriceps strength and volitional muscular contraction. Following six weeks of NMES and volitional therapeutic exercise, this patient achieved a 25% improvement in left quadriceps femoris maximal volitional force output and his central activation ratio (CAR) also improved from 0.83 to 0.97 as quantified by the burst superimposition technique. Furthermore, strength gains continued after the end of treatment as his quadriceps strength index was 94% of his right leg at 12 months following treatment.
While the majority of research pertaining to the efficacy of NMES has been done in the lower extremity, this is not the only region where its benefits can be found. As previously stated, muscular deficits frequently accompany patients following rotator cuff repair. To this end, Reinold et al investigated the ability of NMES to affect maximum voluntary contraction of the infraspinatus muscle. In comparison to trials without NMES, peak force production was significantly greater with an average force of 3.75 kg in comparison to just 3.08 kg. This increase was present regardless of patient age, size of the tear, intensity of the current, or the number of days following surgery. While this preliminary study does not give credence to the effect during a full course of rehabilitation, it does speak to the ability of NMES to increase the ability of this musculature to contract safely and more efficiently following surgery. Further research will define the effectiveness of this intervention following rotator cuff pathology, however this study lends hopeful possibilities.
Neuromuscular electrical stimulation should play an integral role in your practice regardless of setting. Patients presenting with strength deficits and impairments will benefit from NMES when combined with volitional exercise. Meryl Gersh, PT, PhD goes into great detail with regards to electrode placement, optimal dosage, and indication criteria in her course “Applying Electrical Stimulation in Your Physical Therapy Practice”. Increasing your patients’ volitional muscular contraction is of the utmost importance when it comes to fostering improved long term outcomes and NMES in conjunction with their current program should yield enhanced results.
Over at ACL Prevention, Trent Nessler, DPT has posted several fantastic posts centered around using movement analysis in the treatment of orthopedic conditions (“Does Movement Assessment Really Tell You Anything?“, “Does Injury Prevention = Improved Performance?“, “Does endurance play a role in lower kinetic chain injury prevention?“).
Evidence-Based Practice has been an important topic leading up to and following the AAOMPT Annual Conference in Cincinnati, Ohio. Selena Horner at Evidence in Motion and Harrison Vaughn at In Touch PT both give their opinion on the current state of this theoretical model (“AAOMPT and Evidence Based Practice” and “Evidence-Based Practice: Survey Results“).
Mike Reinold has continued to provide excellent content at his website starting with his views on Glenohumeral Internal Rotation Deficit (GIRD). As he points out, GIRD is not as simple as previously assumed and, at times, these deficits are not detrimental to the athlete or his/her performance. The take away from this article is simple, “assess, don’t assume”.
Finally, over at Ortho Chat, my fellow classmate TJ Moore posted several fantastic interviews with some of the leaders in our field. The first of which is a discussion with Keelan Enseki regarding the treatment of Sports Hernia. Shortly following, Chad Cook joined him to discuss the current state of Randomized Controlled Trials in the physical therapy literature. And finally, Tom Tisdale discussed the current best practice with regards to treatment, diagnosis, and prevention of Ulnar Collateral Ligament Pathology. Definitely worth checking out.
1. Engquist M, et al. Surgery Versus Nonsurgical Treatment of Cervical Radiculopathy: A Prospective, Randomized Study Comparing Surgery Plus Physiotherapy With Physiotherapy Alone With a 2-Year Follow-up. Spine. 2013; 38(20): 1715–1722.
2. Ericsson YB, et al. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. British Journal of Sports Medicine. 2013; 47(15): 980-985.
3. Farrokhi S, et al. A Biomechanical Perspective on Physical Therapy Management of Knee Osteoarthritis. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(9): 600–619.
4. Gagnier JJ, et al. Interventions Designed to Prevent Anterior Cruciate Ligament Injuries in Adolescents and Adults: A Systematic Review and Meta-analysis. American Journal of Sports Medicine. 2013;41(8):1952–1962.
5. Kuhn JE, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. Journal of Shoulder & Elbow Surgery. 2013; 22(10): 1371-1379.
6. Manske RC, et al. Current Concepts in Shoulder Examination of the Overhead Athlete. International Journal of Sports Physical Therapy. 2013; 8(5): 554–578.
7. Martin RL, et al. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(9): A1–A40.
8. Peters J, et al. Proximal Exercises are Effective in Treating Patellofemoral Pain Syndrome: A Systematic Review. International Journal of Sports Physical Therapy. 2013; 8(5): 689–700.
9. Rio E, Moseley L, Purdam C, et al. The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Med. 2013.
10. Shaarani SR, et al. Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. 2013; 41(9): 2117–2127.
Research Review: Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction
In my first in a series of ‘Research Review’ articles for MedBridge Education, I will review a recent study that appeared in The American Journal of Sports Medicine. Shaarani et al investigated the utility of a Prehabilitation program for patients scheduled to undergo anterior cruciate ligament reconstruction (ACLR). Considering the variable rate of return to sport following ACLR (43-93%), urgency exists for improving rehabilitation following ACL injury.
Randomized Controlled Trial (RCT).
20 patients with a rupture of the ACL were recruited from 2 orthopedic centers between December 2010 and December 2011. Following randomization, 11 patients were assigned to the intervention group while 9 were placed in the control group. No significant differences existed between groups for age, height, weight, body mass index, and Tegner activity level before/after injury.
Inclusion Criteria: Males between the ages of 18 and 45 years old with an isolated ACL tear. All patients had a positive anterior drawer, Lachman, and pivot-shift test.
Exclusion Criteria: Associated fractures, meniscal repair, collateral ligament injury requiring repair/reconstruction, comorbidities that would be contraindicated from high physical exertion, and living outside the Greater Dublin area for practical reasons related to exercise supervision and exercise gym usage.
Outcome Measures: Single-leg hop test, peak torque of the quadriceps and hamstring, muscle cross-sectional area (CSA), Modified Cincinnati Knee Rating System (mCKRS), and Tegner activity level.
Randomization: From a pool of 437 patients, 56 were eligible following inclusion/exclusion criteria. There were, however, 14 non-responders and 19 subjects who refused to participate. Randomization was determined following outpatient consultation. Opaque envelopes were used to randomly assign individuals to their group.
Interventions: The Prehabilitation Group (PG) was enrolled in a 6-week exercise program, which consisted of supervised resistance and balance training. This program was comprised of 4 exercise sessions per week, which included 2 supervised gym sessions and 2 supervised home sessions. The primary focus was lower limb strengthening with a quadriceps emphasis, as well as proprioceptive training. Each exercise consisted of 3 sets of 12 repetitions and the weights were increased weekly by 10-15%. During the last gym session, the weights were reduced to the previous week’s value to prevent preoperative fatigue and to favor the muscular response to endurance and gaining mass. In contrast, the Control Group (CG) was not given a pre-operative exercise program; however these patients were not discouraged from exercise or taking part in normal activity of daily living before surgery. Postoperatively, both groups received standardized physical therapy sessions, which included increasing range of motion (ROM) and weight-bearing while improving symmetry and gait pattern.
Immediately following the 6-week Prehabilitation program, the intervention group showed several significant improvements prior to surgery. These benefits included the following: significantly improved single-leg hop testing; increased quadriceps and vastus medialis CSA, and improved mCKRS. At 12 weeks post-operative, the rate of decline in the single leg hop test was less and the mCKRS was significantly improved in the exercise group compared with the CG, however no changes existed between groups in CSA. Of particular importance was that on average patients in the PG returned to sport in 34.2 weeks versus 42.5 weeks in the CG though this did not reach statistical significance (P=0.055).
The most important limitations of this study were the small sample size (n = 20) and lack of a long-term follow-up in comparison to the typical rehabilitation length. It is therefore difficult to extrapolate these short-term benefits to long-term outcomes. Additionally, single-leg hop and peak quadriceps torque testing were observed by an individual who was not blinded to the treatment groups. Finally, in terms of the study design itself, utilizing a sham exercise program would have eliminated the potential attention bias.
This pilot study supports implementing a prehabilitation program following ACL injury in preparation for surgical intervention. As previously stated, the percentage of patients who are able to return to sport following ACLR is broad and relatively unimpressive. The benefits of prehabilitation demonstrated during this initial investigation could have a profound impact on return to sport following ACLR. The improvement in single-leg hop testing is particularly encouraging, as it has been documented to be a problematic area with regards to athletes following ACLR. Both Myers et al and Xergia et al found significant asymmetries in single-leg hop testing between individuals who had undergone ACLR and uninjured control subjects. Following rehabilitation, athletes need to have the proprioceptive ability and confidence to perform single-leg stopping, cutting, and jumping activities without hesitation. Coinciding with these measures, this study did show a shorter timeframe for return to sport in athletes who completed a course of prehabilitation. Despite not reaching statistical significance, an average decrease of over 8 weeks is clinically meaningful to any sports medicine practitioner, athlete, or coach.
Shaarani SR, O’Hare C, Quinn A, Moyna N, Moran R, O’Byrne JM. Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. 2013; 41(9): 2117–2127.
Biomechanical and neuromuscular factors receive considerable attention in discussing Return to Sport Following ACL Reconstruction. Psychological considerations, however, despite playing an integral role in returning an injured athlete to their respective sport, often go underappreciated. The purpose of this piece is therefore to briefly review the literature related to the psychology of ACL injury and surgery, and to discuss how the rehabilitation professional can enhance their understanding of the psychological domain to foster improved outcomes in working with this population of athletes.
Once a patient has successfully met all return to sport criteria, the next step naturally involves returning to sport. While some patients seamlessly return to their pre-injury status, others struggle with simply returning to their sport. One needs to look no further than the case of Derrek Rose, star of the Chicago Bulls and MVP of the NBA in 2011, to appreciate the challenge in returning an athlete to sport. After sustaining an ACL tear and subsequently undergoing surgery, he was sidelined for approximately 16 months. In contrast to this situation, Adrian Peterson, defied all odds by returning to the starting lineup nine months following his surgery. While both of these athletes undoubtedly worked hard throughout the rehabilitation process, other factors may account for the difference in time in returning to their respective sports.
According to a recent systematic review conducted by Te Wierike et al.,fear of re-injury was the leading cause of failure for athletes with an ACL injury and subsequent reconstruction to return to sport. Along these same lines, Ardern et al conducted a systematic review with meta-analysis of return to sport outcomes of nearly 5,000 patients following ACL reconstruction. This study demonstrated that only 63% of patients returned to their pre-injury level of competition. Again, fear of re-injury was the most common reason cited for a reduction in or cessation of sports participation. In agreement with the aforementioned studies, a case-control investigation conducted by Ardern et al, found that significant independent contributions for returning to pre-injury level one year post-operatively were explained by psychological factors. These included subjective readiness to return to sport, fear of re-injury, and sport locus of control. This study also determined that factors influencing athletes’ prospective judgment of their ability to return to sport predicted returning to their pre-injury level.
A cross-sectional study performed by Chmielewski et al found that fear of movement/re-injury levels appear to decrease during ACL reconstruction rehabilitation and are associated with function in the timeframe when patients return to sports. Therefore, being psychologically prepared for return to sport is critical when considering each patient’s readiness. In addition to this study, Ardern et al conducted a systematic review looking into the psychological factors involved in returning athletes to sport following injury. This review of 11 studies and nearly 1,000 patients determined that the three central elements of return to sport were from the self-determination theory, which includes: autonomy (urge to be causal agents of one’s own life and act in harmony with one’s integrated self); competence (seek to control the outcome and experience mastery); and relatedness (universal want to interact). This same study found that positive psychological responses including motivation, confidence, and low fear were associated with an increased likelihood of returning to one’s pre-injury level status in a more timely manner. Naturally, return to sport elicits a certain level of fear and anxiety for all athletes, though individuals who possess these internal motivating factors enjoy improved post-operative outcomes.
Considering this information, the question becomes how can clinicians identify those patients who may be at a psychological disadvantage during the rehabilitation process? According to Chmielewski et al, a patient’s psychosocial profile can be positively altered in the short-term following ACL reconstruction. This means that clinicians must take the time to accurately identify those individuals who may be at risk of poor outcomes due to fear of re-injury or fear avoidance beliefs. This can be accomplished through the use of the Tampa Scale for Kinesiophobia (TSK-11), the Fear Avoidance Beliefs Questionnaire (FABQ), and/or the more specific Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Recently, Lentz et al determined that individuals with a lower TSK-11 score were more likely to return to their pre-injury level of competition following ACL reconstruction. While the other two outcome measures have greater scientific backing at this point, the newer I-PRRS has just begun the process of validation. In 2009, Glazer et al published a validation study to support the scale’s utility. The I-PRRS scores were found to be lowest after injury, increased before release to practice, increased again before returning to competition, and had no change after competition. This demonstrates the general progression of psychological preparedness and thus the validity needed to make this a useful measure for clinicians when determining an athlete’s readiness for return to sport.
These outcome measures may give us the ability to more accurately identify those individuals at risk for suboptimal outcomes. Regardless of baseline mentality, however, recovery from injury demands a psychologically driven process. This Biopsychosocial Model is composed of 4 distinct processes (Wiese-Bjornstal et al). The first of which is Cognition, which includes the thoughts an athlete experiences following injury. Within this category lies the athlete’s internal Health Locus of Control (HLOC), which is the capacity that the athlete believes they control the events in their life. Nyland et al found that athletes with a high internal HLOC were more satisfied with their knee function in addition to their ability to perform ADLs, and participate in sport following ACL reconstruction. The second category is the patient’s Affect. This concerns the way an athlete feels following injury. As most clinicians appreciate, injuries can lead to substantial psychological changes, sometimes verging on depression. Studies have shown, however, that there are positive psychological changes as rehabilitation progresses, with fewer negative emotions and more positive feelings about returning to sport. In light of this information, the fear of re-injury has significant impact on the rehabilitation process and can lead to sub-optimal outcomes, potentially preventing return to athletics. The Behavior of the patient throughout the rehabilitation process can also be an influential factor. The two most important behaviors for patients following ACL reconstruction are avoidance coping and rehabilitation adherence. Avoidance coping can be broken into behavioral avoidance coping (the conscience decision to remove oneself from a threatening environment) and cognitive avoidance coping (the responses aimed at denying or minimizing the seriousness of a crisis). While these avoidance techniques may be beneficial in the recovery process, poor adherence to physical therapy has been shown to be detrimental to recovery. Brewer et al found that patients who had a higher score for adherence experienced fewer knee symptoms compared to those who demonstrated poor adherence to their physical therapy program. The final cornerstone to the Biopsychosocial Model is the Outcome. A deficiency or inadequacy in any combination of the three previous categories can negatively impact a patient’s post-rehabilitation outcome. As was shown by Lentz et al, return to pre-injury level of sports participation is multi-factorial and those who did return had less knee joint effusion, fewer episodes of knee instability, lower knee pain intensity, higher quadriceps peak torque-body weight ratio, higher IKDC scores, and lower TSK-11 scores.
Finally, considering this model and the personality traits associated with successful outcomes, what can clinicians do to foster improved outcomes following ACL injury and/or surgery? Regardless of whether or not reconstruction is performed following ACL injury, several psychological interventions have been proven beneficial for athletes during their rehabilitation (relaxation, imagery, training of self-efficacy, and modeling). Cupal and Brewer conducted a randomized controlled trial comparing the outcomes of patients who received relaxation and guided imagery training in conjunction with a typical post-operative protocol to those who only completed the protocol. In the end, the experimental group had greater knee strength, less re-injury anxiety, and less pain compared with the placebo and control group. In order to improve patients’ self-efficacy through modeling, Maddison et al gave their intervention group two separate videos to aid the ability of their athletes’ to cope throughout the rehab process. This study showed that patients, who watched the videos, perceived less pain and had more self-efficacy than those who did not receive this intervention. It should also be noted that athletes often benefit from discussing their injury (i.e. how it happened and how it has affected their life). Additionally, Mankad et al found that athletes who wrote about their injury in the form of written disclosure statements had a reduction of stress and total mood disturbances.
Returning an athlete to sport requires the use of a specific criterion-based protocol, functional sport-specific testing, and proper psychological management of stressors and emotions associated with the injury. Successful rehabilitation of an athlete back to their sport involves careful consideration of all of these aspects. Considerable attention has been paid to the pathoanatomical, biomechanical, and neuromuscular aspects though sports medicine professionals often neglect the psychological impact. As the recognition and implementation of psychologically-driven interventions increases, positive outcomes with regards to return to sport should follow.
All of the platforms are in and it’s time to vote for your AAOMPT Student SIG Leadership team! If you are a Student SIG member, you will receive an e-mail with instructions for the vote. The voting process will end Monday, October 14th. Good luck to all of the candidates!
John Snyder, SPT, CSCS
University of Pittsburgh
AAOMPT Student SIG – Membership Chair
We want you to join the Student Special Interest Group of AAOMPT!
2013 AAOMPT student special interest leadership elections are under way! If interested in applying for a leadership position please send an e-mail to Cody Mansfield, SPT (firstname.lastname@example.org) or myself (email@example.com) with the information below by October 4th, 2013*:
Physical Therapy Program:
Year in program:
Position Applying for:
200 word platform describing your qualifications and interest in manual therapy:
*Once platforms are collected, members of the AAOMPT student sig will vote. Election date is TBD (likely mid to late October). Newly elected members will start in November. All leadership positions are available: President, Vice President, Secretary, Treasurer, Web Administrator, Social Committee Chair, Member at Large, Employment Chair, and Fundraising Chair. Refer to link for specific leadership role responsibilities.
In my previous post, I discussed the current research and concepts with regards to Return to Sport following Anterior Cruciate Ligament Reconstruction (ACLR)… Now it is time to discuss how we, as clinicians, can help to prevent these injuries altogether.
A recent Systematic Review and Meta-analysis of 14 studies and 27,000 participants conducted by Gagnier et al found that neuromuscular and educational interventions appear to reduce the incidence rate of ACL injuries by approximately 50%. Within this systematic review, 109 ACL injuries were prevented; that means 109 athletes will not have to face the unfortunately low return to sport and high re-injury rate associated with ACLR. The first ACL prevention program was published in 1999 by Hewett et al and focused on flexibility, plyometrics, weight training, and emphasized maintaining adequate frontal, transverse, and sagittal plane mechanics throughout each exercise/movement. During this study of 1,263 athletes, there were five non-contact ACL injuries in the untrained female group, one in the untrained male group, and none in the trained female group. This study determined that female athletes who do not undergo neuromuscular training have a 3.6x increased likelihood of sustaining a non-contact ACL injury. Since this initial study, several additional randomized controlled trials have also shown the benefits of injury prevention programs on the incidence of ACL injury (Mandelbaum et al, Gilchrist et al, Olsen et al, Caraffa et al, Myklebust et al, and Petersen et al).
In addition to these randomized controlled trials, there have also been several systematic reviews detailing the benefit of neuromuscular training in the prevention of serious knee injury. The first of which was a meta-analysis conducted in 2006 by Hewett et al of 6 studies investigating prevention programs for female athletes. This analysis found that 4 out of 6 neuromuscular intervention programs significantly reduced knee injury incidence, and 3 out of 6 significantly reduced anterior cruciate ligament injury incidence. Overall, the meta-analysis of these 6 studies demonstrates a significant effect of neuromuscular training programs on anterior cruciate ligament injury incidence in female athletes. Later in 2010, Yoo et al found that the odds ratio of injury prevention was 0.40 with the implementation of a prevention program. Yoo and colleagues also determined through meta-analysis that pre- and in-season neuromuscular training with an emphasis on plyometrics and strengthening exercises was effective at preventing ACL injury in female athletes, especially in those under 18 years of age. Finally, in 2012, Sadoghi et al found an overall risk reduction following the implementation of a prevention program of 52% for female athletes and 85% for male athletes. This coupled with the overall reduction of 50% stated by Gagnier et al shows more than enough reason to suggest the need for widespread usage of injury prevention programs amongst all athletes.
With all of this readily available evidence, surely these programs are being utilized by coaches at all levels, right? Unfortunately, according to a survey of female soccer coaches conducted by Joy et al, only 19.8% of coaches implement an Injury Prevention Program (IPP). Of these coaches who chose to implement an IPP, they did so for injury prevention (93%) as well as performance enhancement (36%). Performance enhancement is what will drive athletes, coaches, and parents toward IPPs – with the added benefit of a decreased likelihood of a catastrophic season-ending injury. Thankfully, the literature is in favor of IPPs with regards to performance enhancement as well. In 2005, Myer et al conducted a study investigating the performance enhancing effects of their injury prevention program. They found significant improvements in 1-Repitition Maximum Bench Press and Squat, Single-Leg Hop Distance, Vertical Jump, and speed in the 9.1 meter dash. This study also showed an overall decreased knee valgus and varus torque during functional movement as an added benefit. While injury prevention is the end goal, performance enhancement is what will bring clients through your doors and will make coaches change their philosophy. It is up to physical therapists, athletic trainers, strength & conditioning coaches, and physicians to bring this information to coaches and players alike. We have the evidence to support the effectiveness of these programs, but we need to take the time to educate those who will benefit most.
All this being said, what makes a successful program? While specific areas of training have not been adequately differentiated in terms of effectiveness, there is a general consensus as to what aspects should be included. These areas include a dynamic warm-up, restoration of proximal stability, proprioceptive training, plyometric training, neuromuscular re-education, strength training, and education. One area cannot be proven more effective than another, however certain qualities of a program have been deemed indicative of an effective program. The first and likely most important quality is patient/client compliance. Wingfield et al recently conducted a cluster randomized controlled trial to evaluate the effectiveness of a neuromuscular warm-up program in preventing acute knee injury in adolescent female soccer players. Not surprisingly, they found that athletes who performed ≥ 1 exercise session per week had a lower rate of ACL injury, severe knee injury, and of any acute knee injury compared to the control group. Additionally, in a systematic review conducted by Sugimoto et al, it was found that incidence rates of ACL injury were lower in studies with high rates of compliance with neuromuscular training than in studies with low compliance rates. So, this begs the question of, “How do we make our athletes compliant?” In my opinion, we must provide a solid, systematic evaluative and progressive program addressing each individual athlete’s deficiencies.
There are several Injury Prevention Programs available from the simple (FIFA 11+, Santa Monica Prevent Injury and Enhance Performance Program, ect.) to the more advanced systematic programs implemented by trained fitness and healthcare professionals. Of the programs available, there are two that appear to encompass all aspects of injury prevention that therapists and/or strength & conditioning coaches should consider implementing. The first of which is the Dynamic Movement Assessment (DMA) developed by Trent Nessler, DPT. The DMA consists of a thorough functional assessment backed-up by the use of video feedback to provide visual input to both athletes and clinicians alike. This allows for detailed understanding of where these faulty movement patterns are stemming from and how these deficits should be corrected. The second program is seemingly simpler, albeit a much more researched program in the Functional Movement Screen (FMS)/Selective Functional Movement Assessment (SFMA). These systems are comprised of several tests that provide the ability to ‘screen’ athletes for the poor movement patterns often associated with increased likelihood of injury. Regardless of the specific system, the key to any successful program is selecting a solid classification system to identify those at risk and implement exercise programs to improve their specific movement patterns and/or deficient muscular performance.
Check out a new blog created and managed by my fellow University of Pittsburgh DPT classmate, TJ Moore, SPT, ATC named ‘Ortho Chat’! This website offers video chats regarding various aspects of orthopedic and sports physical therapy… and there are many more to come!
Below are a few video samples, one of which includes a guest appearance by my former Clinical Instructor and hip pathology expert Keelan Enseki, PT, MS, ATC, OCS, SCS, CSCS…
Sports Hernia/Athletic Pubalgia discussion with Keelan Enseki
Randomized Controlled Trials with Chad Cook
First Four weeks of ACL rehab
Clinical decision making is integral to becoming an effective clinician, regardless of profession. One tool that we, as physical therapists, have is the clinical prediction rule (CPR), which is the best combination of medical signs, symptoms, and/or other findings in predicting the probability of a specific disease or outcome. There have been many CPRs developed over the years (some better than others), but I thought it was necessary to provide these CPRs with their accompanying statistical significance to my readers. These CPRs may help in determining what physical examination tests to choose and/or what interventions to utilize based on your patient’s clinical presentation.
If you are ever curious as to what patients tend to respond favorably to spinal manipulation or if you cannot quite remember what symptoms tend to coincide with carpal tunnel syndrome, you can find the answers in OMPT’s new ‘Clinical Prediction Rules‘ section. In the top right corner of this webpage, you can find ‘Clinical Decision Making’, click on this tab and you will be taken to the menu leading you to 19 of the most relevant CPRs to physical therapists. Or, you can CLICK HERE
Harrison Vaughan, PT, DPT at In Touch PT delves into some current evidence and clinical reasoning related to mechanical traction for patients presenting with neck pain (“What is Your Clinical Reasoning Behind Using Cervical Traction?“). As he states, the current CPR is unvalidated and likely leaves out many patients who could potentially benefit from this intervention.
Once again, Mike Reinold, PT, DPT, SCS, ATC, CSCS has provided several great posts over the past few months. One post of particular note titled, “Are We Putting Our Kids at Risk for Youth Baseball Injuries?“, discusses the importance of understanding what young overhead athletes can and cannot tolerate. Additionally, a guest post written by Peter Nelson lays out the recent research and principles related to groin injuries in ice hockey players.
The Manual Therapist has again provided great content, one great post was a guest article written by Andrew M. Ball, PT, DPT, PhD, OCS, CMTPT titled, “DPT vs Experience“. Which is most important? Well, neither is and the sooner our profession realizes this, the better. An entry-level graduate will not have the tools or clinical reasoning skills that an experienced clinician has, regardless of educational level. However, I believe current DPT graduates are starting at and performing at a higher level than their predecessors. Both aspects are important in becoming an ‘expert clinician’ and in my opinion, you cannot have one without the other.
Over at The Sports Physio, several informative articles have been published over the past few months. The first two of note have to do with the assessment and treatment of sacroilliac joint disorders (“What is the best way to reliably assess the Sacroiliac Joint?” and “What is the best way to treat a painful Sacroiliac Joint?“). While I cannot say I 100% agree with his conclusions, I do agree that palpating for ‘rotations’ or ‘fixations’ in this region should be phased out of clinicians’ clinical reasoning schemes. While we likely do not fix ‘malalignments’, manual treatments in this region often provide pain relief based on a more neurophysiological course of action than anything in the neighborhood of biomechanical. Next up, a great review of everything postrolateral corner was written by Richard Norris (“The Postero-Lateral Corner, the “Dark side of the Knee”“). Definitely worth a read.
Finally, over at the AAOMPT Student SIG’s Blog, Scot Morrison posted a fantastic review of the current state of pain science and the importance of implementing this information in our assessment/treatment of patients (“Pain Series: A look at the role of movement in relation to pain“). This article provides a great resource for those that need a better understanding of modern pain science and, more specifically, the neuromatrix theory initially proposed by Ronald Melzach back in 1989. Obviously, much has changed since then with regards to the neuromatrix theory and pain science in general and this is where this article provides great information for any reader.
Ardern CL, et al. Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery. American Journal of Sports Medicine. 2013;41(7):1549–1558.
Bialosky JE, et al. Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):457–465.
Cleland JA, et al. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients Status Post Inversion Ankle Sprain: A Multi-Center Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):443–456.
Cynn HS, et al. Musculoskeletal Predictors of Movement Quality for the Forward Step Down Test in Asymptomatic Women. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):504–510.
de Oliveira RF, et al. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Physical Therapy. 2013;93(6):748–756.
Donaldson M, et al. The Role of Patients’ Expectation of Appropriate Initial Manual Therapy Treatment in Outcomes for Patients with Low Back Pain. Journal of Manipulative and Physiological Therapeutics. 2013;36(5):276–283.
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