Posted on 10/19/2017 by NovaCare Rehabilitation and Select Physical Therapy
Play It SafeOne of the most devastating injuries in sports today is the anterior cruciate ligament (ACL) injury. We sat down with Trent Nessler, P.T., MPT, DPT, national director of sports medicine innovation, to ask him a few questions regarding ACL injuries and his exclusive evidenced-based ACL Play it Safe Program.
What are three measures that can be taken to prevent ACL injury?
If you were going to break it down into three measures, these would be:
Education – Almost 80 percent of ACL injuries are non-contact in orientation. This means there is no contact with another player or structure, but typically result from a rapid change in direction or jumping motion. There are certain movement patterns that put an athlete at greater risk for these non-contact injuries. Using a baseline movement screening process is critical to identifying those at risk. The results should further guide training that can be implemented throughout the season to reduce the athlete’s risk of injury.
It is also imperative for athletes, coaches and parents to understand that when you address movements that are associated with non-contact ACL injuries, they see a significant impact on their on-field athletic performance. The knee abduction that occurs not only puts excessive stress on the ACL and structures of the knee, but also results in a significant loss of kinetic energy transfer from the lower limb, hips to the core. This loss of energy has a direct impact on vertical jump, sprint speed, explosive power and pitching velocities.
Movement Assessments – There are many movement assessments on the market today. Although some have become the standard of practice in our industry, the fact that we are still depending on the eyeball to score the majority of these assessments introduces a tremendous amount of subjectivity into the equation. Three-dimensional technology, complete with cameras and wearable sensors, however, are removing the subjectivity from the equation and allowing for improved reliability.
Training – Many good injury prevention programs out there have been shown to reduce injury rates in athletes. However, the challenge is the adoption of these programs as a standard part of an athletic program or season has been very low. Why is that? If the program takes too long, then teams, coaches and athlete are less likely to do it. Knowing that these programs improve movement and movement efficiency, we should be promoting the impact on sports performance versus injury prevention. Approaching a coach or athlete with an effective and proven 20-minute program that helps to improve their sprint speed and vertical jump will cause the adoption rate to become much higher.
Technology is an ever-changing industry, and ACL injuries are a prevalent occurrence. How do the two go together and benefit patients?
One of the most exciting trends we are seeing today is the adoption of 3D wearable sensor technologies. These can and are having a huge impact on ACL injuries. The technology inside a 3D wearable sensor is what’s called an inertial measurement unit (IMU). An IMU detects and records motion, rotation and acceleration data. We now use these for movement assessments in our athletes to detect degree of knee abduction and the speed at which it occurs within a very high degree of accuracy. In addition, this becomes a much more efficient and reliable way to measure movement that puts athletes at risk for injury and performance issues. This is a huge step in ACL prevention! For the first time ever, we are collecting movement data with technology and combining it with demographic data for every athlete assessed.
Aside from use of IMUs in assessment, it can be used in training. We are in the process of leveraging this same technology to track movement during single limb training. This will not only give the athlete immediate feedback on how they are moving, but will identify those athletes at risk during their training. This information could be used to refer them to a provider for a more extensive movement assessment and treatment. This would expand the scope of ability to identify athletes at risk beyond just those who have a physical or who see a health care provider.
You developed a nationally recognized non-operative ACL program – the ACL Play it Safe Program – to decrease the likelihood of injury and enhance athletic performance. What sets this program apart from others and how can folks learn more about it?
Trent ACL 2As a result of numerous researchers’ hard work and the influence of great mentors, the development of the ACL Play it Safe Program was made possible. The things that set this program apart are:
The ACL Play It Safe program is specifically designed to improve performance on the movements that are assessed with the ViPerform Athletic Movement Index (AMI). So, athletes can be assigned to the level of the program based on an assessment.
The program has four distinct levels of progression; level one for athletes who don’t move very well, all the way up to level IV for athletes who move efficiently.
This program has a pre-practice routine that takes five minutes and a post-practice routine that takes 15 minutes. The post-practice routine is a fatigue-based training routine. This is where fatigue from practice is carried over in the post-practice routine. From a training specificity standpoint, we find that training in a fatigued state has better carry over to later in the game when performance issues are likely to arise and injuries rates increase.
Each athlete is given a kit that has standardized equipment in it. This prevents them from using different types of equipment or variations in resistance from training session to training session, allowing for more consistency in the progression.
The program offers a video instruction of each exercise that can be accessed on the complimentary ACL Play It Safe app. This ensures there is no error or change in interpretation of the exercise from athletic trainer to coach to athlete.
So far, this program has been implemented with more than 3,000 athletes across the country. We are using this as a part of their rehabilitation and return-to-play. When implemented correctly and with the ViPerform AMI, we are seeing an average of 58.2 percent reduction in lower extremity injuries from the spine to the foot and ankle.
For more information on this program, folks can email me directly at [email protected] I look forward to hearing from you!
Posted on 10/6/2017 by Melissa Bloom, P.T., DPT, NCS
Cooler temperatures, students returning to school and the start of another football season are all the telltale signs of fall. And with football back, reports of concussion will inevitably follow. While advancements continue to be made in regards to concussion prevention and treatment, the long-term effects of head trauma, specifically chronic trauma encephalopathy (CTE), remains a huge concern.
You may have previously heard of CTE from the movie “Concussion,” or even from recent media reports. CTE is a tough topic for me. My trouble with the conversation is that there are a lot of unknowns and uncertainties. With the potential for serious injuries, there is the chance for panic and decisions made on emotions versus science. Moreover, ignoring the conversation leads to misinformation. So, it’s time we talk about CTE; what is it and what it means for the future of football.
What is CTE?
CTE is a progressive neurodegenerative disease associated with repetitive head trauma. CTE involves cellular pathological changes similar, but different, to Alzheimer’s disease. The buildup of Tau protein in the brain causes cell death, atrophy and abnormal functioning. CTE can currently only be diagnosed after death by examining the brain under a microscope.
Symptoms can be physical, involving gait abnormalities and slowness of speech, or psychiatric and behavioral, including personality changes, depression and aggression. Various cognitive and processing deficits are also common with CTE, including difficulty thinking, concentrating and remembering.
One consistent scientific challenge is understanding the extent to which age-related changes, psychiatric or mental illness, alcohol or drug use, coexisting dementia or other unknown factors play a role in developing CTE. Currently, this is largely unknown and has not been accounted for in research. CTE is more common in contact sports, but other factors in these athletes may also lead to the disease.
Recent Study and Media Interviews
Earlier this year, the Journal of American Medical Association released an article on CTE. The study looked at participation in American football along with multiple physical and psychosocial variables, and they compared these factors to diagnosis of CTE. Results of this study travelled across the media quickly, with the overall conclusion that players of American football may be at increased risk for CTE. Of the 202 individuals in the study, they found 177 were diagnosed with CTE. The researchers further concluded that 99 percent of subjects who played in the National Football League (NFL) were diagnosed with CTE. What a headline.
Not to downplay the severity of CTE and valid concerns that exist about it, but I want to discuss some limitations about what we can take from these results. First, they conducted their study with football players whose brains were donated for research of CTE, creating a significant selection bias. It was known that their brains would be studied regarding a possible connection with CTE and their participation in contact sports. Individuals and their families who participated (i.e., donated their brain) may have noticed symptoms consistent with CTE prior to death, which led to their participation.
What trends did they find?
Beyond the expected motor, cognitive and psychological involvement known to accompany CTE, there were other notable trends. Substance abuse was noted in 67 percent of those diagnosed with mild CTE, and 49 percent in those diagnosed with severe CTE.
The presence of co-morbid neurodegenerative diseases was also common, including Alzheimer’s, Lewy Body Dementia (LBD) and other motor neuron diseases. In fact, more than 19 percent of the subjects with CTE presented with LBD alone. The current study was not designed to determine the impact these factors had on the development of CTE.
Even the authors note that caution must be used in interpreting the high frequency of CTE in their sample. Their results do not allow for estimates of prevalence, due to the lack of comparison groups. Additionally, the sample population was not representative of the overall population of former players of American football. The majority of players only play youth or high school levels, but most individuals in this study played at the college or pro level.
Evidence supports an association between long-term cognitive, neurobehavioral and psychiatric problems with participation in contact sports, such as football, boxing, soccer, etc. While it seems plausible there is a connection between CTE and repetitive impacts seen with American football, it is currently not possible to determine the causality or risk factors with any certainty. We need to proceed cautiously and collect additional research. However, concussion screenings and efforts to minimize concussion can improve the current health of players even if the long-term effects are unknown.
There is an inherent risk with contact sports for concussive and sub-concussive impacts. The challenge now is evaluating the risk given uncertain long-term consequences and the many scientific questions we don't have answered. For now, let’s continue to play smart, wear protective gear, get baseline tested for concussion and, should a concussion occur, thoroughly go through the rehabilitation process for safe return-to-play and activity.
Melissa Bloom By: Melissa Bloom, P.T., DPT, NCS. Melissa is a physical therapist with Physiotherapy Associates in Atlanta, GA. Melissa is a board certified neurology specialist. She specializes in vestibular rehabilitation and concussion management and teaches nationally on both topics.
Physio, NovaCare Rehabilitation and Select Physical Therapy are part of the Select Medical Outpatient Division family of brands.
Posted on 9/13/2017 by Andrew Piraino, P.T., DPT, OCS, CSCS
Low back pain is common. It’s so common that about 80 percent of adults will at one point experience this condition. It ranks among one of the top reasons to see a physician and costs the United States more than $100 billion dollars every year.
When faced with an episode of low back pain, it’s easy to go into crisis mode. You may be routed through various specialists and receive various imaging tests, such as X-rays and MRI. These tests can reveal scary findings, such as “herniated discs,” but don’t panic.
First, many of these findings are normal. Researchers have found that in adults without low back pain, two of out three have an abnormality at one disc or more. This makes imaging of limited use, unless something like a fracture is present that needs surgical management. Physicians agree; the American Academy of Family Physicians recommends against any imaging for low back pain for the first six weeks unless serious signs are present, such as trauma.
Often, you may be referred for physical therapy. You may have some familiarity with various exercises and hands-on treatment provided by therapists. But why is physical therapy unique, and what exactly does it do?
Physical therapists today are doctoral-level trained specialists in human movement, completing four years of undergraduate education, three years of doctoral training and often further residency or fellowship training in addition to board certification. Poor movements and postures can cause low back pain and, therefore, physical therapists are optimally equipped to address the cause of the problem rather than treating the symptoms. Just like the song lyrics to ‘Dem Bones,’ each area of the body affects another, which is what physical therapists are trained to observe and address.
For example, take a truck driver who has worsening low back pain with sitting in his truck and bending (pictured below). While a massage at his back area makes him better temporarily, his pain always returns several days later. A physical therapist may look at this driver and find he has tight hamstrings (the muscles on the back of the thigh). Every time he straightens his right leg to reach his pedal, his tight hamstrings pull his back into a bent position (Figure B). And so, all day long, as he drives, his back is bent over and over while he operates the gas and brake pedals. Try sitting up straight and then straightening your knee. You may find it’s hard to do!
Low Back Pain
A - Driver at rest.
B - Driver's hamstring pulls on his pelvis and bends his back whenever he tries to use the pedal.
C - Driver after physical therapy treatment to improve his hamstring flexibility... no more dysfunction!
While physical therapy may provide hands-on treatment to alleviate pain, it would also include exercise to decrease stiffness of his hamstrings, which would allow him to move without causing his back to compensate every time (Figure C). Therefore, our truck driver is able to sit and drive all day without pain. Rather than seeking symptom relief, he now knows what caused the pain, and the exercises and positioning to prevent it from returning.
This is a simple example, but it appreciates the entire body’s contribution to movement and pain, rather than focusing on the area of pain alone. Hopefully this demystifies what physical therapists do, and how they work to optimize each person’s movement and prevent their painful condition from returning!
If you are experiencing low back pain, please call one of our conveniently located centers in your area to experience the power of physical therapy today! For more information and to watch a brief informational video, please click here.
Andrew PirainoBy: Andrew Piraino, P.T., DPT, OCS, CSCS, treats at Select Physical Therapy in Pasadena, TX and is involved with our orthopaedic physical therapy residencies at the market and national level. He completed doctorate and residency training at the University of Southern California in 2012 and 2013, respectively, and is board certified in orthopaedics. Andrew specializes in orthopaedic movement dysfunction across the lifespan, from young, recreational athletes to adults with complex multi-system involvement.
Posted on 8/23/2017 by Colleen Boucher, P.T., DPT
Wearing proper clothing, getting the right amount of sleep and practicing proper stretching techniques are vital to an athlete’s success. But, just as is important is eating the right foods. A proper diet will allow athletes to remain active, maximize function and minimize risk for injury. Eating the right foods will also address factors that may limit performance such as fatigue, which can cause deterioration in skill or concentration during an event.
Using guidelines from the American College of Sports Medicine, we believe practicing these tips will help athletes remain active in their favorite sport. What and when you eat prior to physical activity makes a big difference in the way you perform and recover.
Eat three to four hours before your workout and make sure you’re eating food that not only contains adequate amounts of proteins and carbohydrates, but also provides sustainable energy, speeds recovery time and boosts performance. Early fatigue caused by malnutrition can result in improper mechanics, creating predisposition to injury.
Athletes should eat a diet that gets the bulk of its calories from carbohydrates, an athlete’s main fuel. Eating foods such as breads, cereals, pasta, fruit and vegetables will help to achieve maximum carbohydrate storage.
Re-fueling after exercise is just as important. Eating protein, carbohydrates and a small amount of fat after activity prevents the breakdown of muscles and can lead to better next-day performance. While protein doesn’t provide energy, it is needed to maintain muscles. Focus on incorporating foods with high-quality protein, such as fish, poultry, nuts, beans, eggs and milk.
Practicing proper hydration is equally important in reaching your optimal level of success. Athletes, especially those participating in high-intensity sports, should drink fluids early and often. An easy way to ensure you’re properly hydrated is focusing on the color of your urine. A pale yellow means you’re getting enough fluids, while a bright yellow or dark color means you need to drink more. We encourage athletes to:
Drink 17 to 20 ounces of water two to three hours prior practice.
Drink 7 to 10 ounces every 10 to 20 minutes during activity.
Drink 7 to 10 ounces of water after practice for every two pounds of body weight lost.
Drinking the right liquids is also a key factor in an athlete’s diet. Milk is preferred by many athletes as it provides a good balance of protein and carbohydrates. Sports drinks are great for replenishing electrolytes, which are lost when you sweat. If you’re losing a lot of fluid as you sweat, it’s a good idea to dilute sports drinks with equal amounts of water to ensure you’re getting the right balance of fluid and electrolytes. If possible, drink chilled fluids, which are more easily absorbed than room-temperature liquids and can help to cool your body.
Finally, avoid extreme diets as they increase the risk of micro-nutrient deficiencies. Vitamin and mineral supplements aren’t necessary if your diet includes a variety of nutrient-dense foods. Often, these supplements require supervision and monitoring for safety and effectiveness.
By: Colleen Boucher, P.T., DPT, center manager from NovaCare Rehabilitation’s Sicklerville, NJ center. Colleen has been a part of the NovaCare team since 2001 and enjoys treating all types of patients. She has a strong interest in vestibular rehabilitation and concussion management.