Return to Competition Strategies for the

Transcription

1 Bill Knowles, ATC, CSCS Return to Competition Strategies for the Joint Compromised Athlete Planned Performance Reconditioning

2 Ultimately, injury is an opportunity to become a better football playing athlete and potentially a better football player

3 In high performance sports STRIVE FOR and potentially a better football player

4 Evidence Based Medicine (science) in conjunction with Experience Based Evidence (art)

5 RETURN TO COMPETITION STATEGIES RtC

6 RETURN CONTINUE TO COMPETE STRATEGIES SUCESSFULLY returning for another season and another and another

7 JOINT COMPROMISED ATHLETE J C A L C A LOAD COMPROMISED ATHLETE

8 LOAD COMPROMISED ATHLETE L C A Once an LCA. Always an LCA! RtC strategy continuously

9 L C A it aint over till it s over

10 ATHLETE SUSTAINABILITY PROGRAM A S P

11 LCA RtC ASP

12 RtC REHAB - [post-injury, post-op] RECONDITIONING (Athletic Development) RETURN TO TRAINING (skills, technical) RETURN TO PLAY RETURN TO COMPETITION

13 RECONDITIONING re-establishing and/or improving an athlete s overall physical qualities after injury or surgery.

14 RECONDITIONING Continue fitness and strength training; thereby reducing the amount of deconditioning

15 TRAINING AROUND THE INJURY

16 It s about the athlete, not the specific injury WRONG FOCUS RIGHT FOCUS Athlete Athlete Injured Body Part Injured Body Part

17 What is training around the injury????? FIRST - It s about how you approach working with an injured athlete.

18 What is training around the injury????? SECOND It s about PREPARING THE ATHLETE FOR A RETURN TO COMPETITION while also addressing the specific injury

19 What is training around the injury????? THIRD - It s about recognizing that injury causes a disruption in normal or trained movement patterns fix this!

20 PAST 2 YEARS - RESEARCH Science catching up to the art (experience) in some ways

21 Bill s paradigm for injury Athlete Injury L C A Arthrogenic Muscle Inhibition Athlete Sustainability Program RtC Strategies Brain Plasticity The Talent Code Mylin

22 New paradigm for knee injuries ACL injury leads to early onset osteoarthritis OA now presenting in year olds

23 Rupturing the ACL leads to OA in 5-20 yrs after injury Ages the knee approx 30 yrs

24 Quad weakness is a consequence of ACL injury and any knee joint injury including patella femoral pain

25 Quad weakness is considered to result from.. Arthrogenic Muscle Inhibition AMI

26 Arthrogenic Muscle Inhibition Caused by a change in the discharge of sensory receptors from the damaged knee joint Describes the inability to completely contract a muscle despite no structural damage to the muscle or innervating nerve

27 A M I Can delay or even prevent effective strengthening during RtC Stategies Magnitude of strength gain limited

28 A M I Bi-lateral situation Quad activation deficits as high as 7-26% in unaffected limb Anterior knee pain = higher deficit than ligament injuries

29 A M I TIME SCALE Most severe in the first few days post injury or operation before reducing somewhat. Plateau s in the medium term (6 months) Slowly declining in long term (18-33 months)

30 Arthrogenic Muscle Inhibition Severity of injury = increase severity of AMI May also increase the AMI severity of the uninjured limb

31 A M I CAUSES Pain, Swelling, Inflammation Poor Joint Control, Joint Degeneration

32 A M I AFFECTS: Affects Type II, High Threshold, Fast Twitch muscles Does not affect Type I, Low Threshold, Slow Twitch muscles

33 A M I Treatment approaches to combat AMI: TENS Cryotherapy Edema reduction NMES

34 A M I COMPEX: early, often, SMASH IT! High intensity COMPEX can get to the Type II, HT Co-contracted position. NOT straight leg! or FES Functional Electrical Stimulation

35 SEEING THINGS DIFFERENTLY This is NOT just a joint problem or a lower extremity issue

36 it s a brain injury

37 ACL Deficiency Causes Brain Plasticity A Functional MRI Study Eleni Kapreli, et al Univ. Athens, Greece

38 Brain Plasticity Purpose: Whether chronic ACL causes plastic changes in brain activation patterns Plasticity = change in cortical properties = based off peripheral information

39 Results: fmri Brain Plasticity the rupture of the ACL influences the ascending afferent and descending efferent pathways causing reorganization of CNS function

40 Brain Plasticity Conclusion: ACL deficiency can cause reorganization of the CNS regarded as a neurophysiologic dysfunction, not a simple peripheral musculoskeletal injury

41 Brain Plasticity Knee bone is connected to the head bone

42 Key Message: Brain Plasticity Rehab focus on CNS re-education, rather than on peripheral neuromuscular function Visual and sensory information Nike Strobe Glasses, Montreal Vision Training, etc Reduce preparatory time for mov t execution (don t take mov t quality for granted!)

43 The TALENT CODE

44 The TALENT CODE Myelin the Deep practice cell

45 The TALENT CODE Myelin Mov t = precisely timed electrical signals through a chain of nerve fibers. Myelin wraps the nerve fibers to increase signal speed, strength and accuracy.

46 The TALENT CODE Myelin the Deep practice cell Myelin can regulate velocity speeding or slowing signals to hit synapses at the optimal time

47 Myelin the Deep practice cell The TALENT CODE It s not how fast you can do it its how slow you can do it correctly T. Martinez Am. football coach

48 Myelin the Deep practice cell The TALENT CODE Myelin wraps it doesn t unwrap - that why habits are hard to break How to diminish the skills of a superstar talent? - practice keeps myelin healthy

49 The TALENT CODE Deep Practice To avoid mistakes you must learn to feel them immediately Deep concentration, very fatiguing

50 The TALENT CODE Master Coaches - Teachers (Physio s, S&C, Fitness) - Careful, deliberate cultivators of myelin through deep knowledge of the subject matter

51 Practice does not make perfect Practice makes permanent!

52 isport PROGRAM Post Injury Return to Competition Strategies for the Load Compromised Athlete LCA RtC-S

53 Primary Objectives Athletic Development Gambetta

54 Goals Do no harm To prepare a completely adaptable athlete to return to competition ADAPTED OR ADAPTABLE? Gambetta

55 Goals To prepare the athlete to be fully able to thrive (not just survive) when they return to the competitive environment Gambetta

56 Philosophy for lower extremity rehab It is not a race to get them back it is a process to get them better It s not about an earlier return to competition; it s about a longer preparation period. Gambetta

57 Managing the JCA / LCA

58 Athlete MEDICAL SUPERVISION Sports Med Physician Sports Ortho Surgeon REHAB RECONDITIONING (Fitness, Physio) ATHLETIC DEVELOPMENT (Coach, Fitness, Physio) INJURY REDUCTION PROGRAMS

59 Prepare the athlete, not the injury CORRECT FOCUS Fitness Injury

60 Remember: JUST BECAUSE THE BIOLOGY OF THE INJURY HAS HEALED THE ATHLETE MAY NOT BE PREPARED!

61 RETURN TO COMPETITION STAGES

62 RtC REHAB - [post-injury, post-op] RECONDITIONING (Athletic Development) RETURN TO TRAINING (skills, technical) RETURN TO PLAY RETURN TO COMPETITION

63 RtC REHABILITATION Post-injury, Post-op Key Concerns: Inflammation Swelling --> ROM Pain Reduce or slow down the effects of AMI Must Consider COMPEX Game Ready Cryotherapy Pool / ROM / Movement Quality Training

64 Envelope of Healing Trauma Induced Inflammation pain/swelling Upper Limit Elite Athlete Zone Homeostatic Loading No swelling, pain, inflam, full ROM

65 The concept of musculoskeletal function includes the capacity not only to generate, transmit, absorb, and dissipate loads.but also to maintain tissue homeostasis while doing so. (Dye et al.) [Applies to Rehab/Reconditioning and Athletic Development]

66 Factors Contributing to Function of the Knee Joint after Injury or Reconstruction of the ACL Dye, Woyts, Fu, Fithian, Gillquist JBJS, 1999 Goal of Therapy: maximization of the load transference capacity of the knee joint as safely and predictably as possible.

67 Program Design Stages Reconditioning - [Athletic Development] Return to Training (skills, technical) Return to Play Return to Competition

68 Develop a plan

69 Criteria based progressions Not protocol driven There are no RtC Protocols that are scientific based for Elite Level only methods

70 RtC THE GOAL IS A LONGER PREPARATION PERIOD NOT A FASTER RETURN TO COMPETITION!

71 RtC PREPARATION MEANS. Achieving the highest level of training within the shortest period of time while respecting the biology of healing

72 AND THEN STAYING THERE FOR AS LONG AS YOU CAN [ = stress sustainability ]

73 Injury should not significantly interfere with LTAD: Long Term Athletic Development

74 LONG TERM ATHLETIC DEVELOPMENT LTAD Long Term Injured Athlete Planned Performance Reconditioning

75 LONG TERM ATHLETIC DEVELOPMENT LTAD / / LT IA PP R

76 LTAD / / LT IA PP R = opportunity ALL DEPARTMENTS WORKING TOGETHER ALL THE TIME

77 COMMON PROBLEM: 0 Post-op Time Table REHAB Physio based Strength and Conditioning Sport Specificity (running) Low Intensity Strength/Agility Med Intensity High Intensity Return to Team Training Return to Competition Non Injured Athlete High Intensity Athletic Development, Sport Skills, Competition

78 Better Option: 0 Post-op Time Table RECONDITIONING REHAB (Physio) ATHLETIC DEVELOPMENT S&C. Sports Science, Coaches, Physios Low Intensity Strength/Agility Med Intensity High Intensity Skill Development: (technical coaches involved) Team Train Non- Contact/Contac t R T C Non Injured Athlete High Intensity Athletic Development, Sport Skills, Competition

79 KEY POINTS IN THE isport PROGRAM

80 Performance Paradigm FORCE REDUCTION PROPRIOCEPTION FORCE PRODUCTION Gray, Gary 1994 PERFORMANCE PARADIGM DESCRIPTIONS FORCE REDUCTION Deceleration Pronation Eccentric Absorbing Loading STABALIZATION Proprioception Proprioception Proprioception Proprioception Proprioception FORCE PRODUCTION Acceleration Supination Concentric Propelling Unloading

81 Return To Running Return to MDSA (Multi-Directional Speed and Agility) (Keep it relative to functional strength during all stages of Reconditioning)

82 Reconditioning Return to Skill Training (Keep it relative to functional ability)

83 Research References A Neuromuscular Mechanism of Posttramatic Osteaoarthritis Associated with ACL Injury: Riann M. Palmiero-Smith, et al, Exercise and Sports Science Review, ACSM, July 2009, Vol 37, Number 3: Quadriceps Activation Following Knee Injuries: A Systematic Review: Joseph M. Hart, et al, Journal of Athletic Training, 2010:45(1): Quadriceps Arthrogenic Muscle Inhibition: Neural Mechanisms and Treatment Perspectives: David Andrew Rice, et al, 2009, Published by Elseiver Inc. doi: /j.semarthrit

84 Research References Anterior Cruciate Ligament Deficiency causes Brain Plasticity Eleni Kapreli, et al, AJSM, 2009 Vol 37, No.12 Concentric and Impact Forces of Single-Leg Jumps in an Aquatic Environment versus on Land N. Travis Triplett, et al, Medicine & Science in Sports & Exercise, 2009, DOI: /MSS.0b013e3181a252b7 Effects of Cryotherapy on Arthrogenic Muscle Inhibition Using an Experimental Model of Knee Swelling. David Rice, et al, 2009 American College of Rheumatology, Vol. 61, No.1 Jan 15, 2009 pp78-83.