How can functional testing help make return to play decisions?

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1 International classification of functioning, disability and health (ICF) How can functional testing help make return to play decisions? Håvard Moksnes Sport physiotherapist, PhD World Health Organization, 2001 Rehabilitation algorithm Exercise progression model Blanchard & Glasgow, 2014 Functional tests International classification of functioning, disability and health Definition Assessor observed of tasks classified as activities using the ICF model World Health Organization 2001, Dobson et al 2012 World Health Organization 2001, Dobson et al

2 Assessment of function Aim: Capture the overall impact of an injury on limb function I. Patient-reported outcome II. III. Physical performance tests Clinical outcome Hegedus 2015, Bagiella et al 2009, Bent et al 2009 I. Patient-reported outcome Questionnaires II. Performance-based outcome Hop tests and agility tests Muscle strength measurements III. Clinical outcome Range of motion, joint effusion and laxity measuremen I. Patient-reported outcome Questionnaires II. Performance-based outcome Hop tests and agility tests Muscle strength measurements III. Clinical outcome Range of motion, joint effusion and laxity measuremen I. Patient-reported outcome Questionnaires II. Performance-based outcome Hop tests and agility tests Muscle strength measurements III. Clinical outcome Range of motion, joint effusion and laxity measurements Assessment of function Aim: Capture the overall impact of an injury on limb function I. Patient-reported outcome II. III. Physical performance tests Clinical outcome Hegedus 2015, Bagiella et al 2009, Bent et al

3 Functional tests Different tests depending on purpose Clinical case Post-injury impairment assessments Outcome of treatments Pre-operative assessments Rehabilitation milestones Return to play decisions Dear Håvard, I am conserned about my son because he has become very inactive. He has abandoned football and is mainy hanging around with his friends playing videogames. He is now 14 years old and it is 3 years since his ACL rupture. Could you please have a look at his knee? Best regards NN Rehabilitation milestone 1 Rehabilitation milestone 2 Adequate loading, alignment and terminal knee extension = initiate running Exercise progression model Assessment of impairments Aim: Capture the overall impact of an injury on limb function I. Patient-reported outcome II. III. Physical performance tests Clinical outcome Blanchard & Glasgow, 2014 Hegedus 2015, Bagiella et al 2009, Bent et al

4 Clinical assessment Ankle mobility testing Stroke test Zero = No wave produced with downward stroke Trace = Small wave of fluid on the medial side of the knee 1+ = Larger bulge of fluid on the medial side of the knee 2+ = Effusion completely fills the medial knee sulcus with downward stroke or returns to the medial side of the knee without downward stroke 3+ = Inability to move the effusion out of the medial aspect of the knee Lachman test Pivot shift test Medial and lateral stability Jointline palpation Active knee extension lag test Logerstedt et al 2010 Askling H-test Test validity and reliability Validity «The extent to which a measurement actually the phenomenon it is intended to measure» Reliability «The ability of a measurement to provide accurate and consistent measurements during repeated of the same phenomenon» Andresen 2000, Clark 2001 Askling et al 2010 Agility tests Agility T-Test and several other tests Benchmark required! Psychological factors Psychological readiness Low fear of new injury Trust in knee & good knee function Sheppard J & Young W, 2006; Munro A & Herrington L, 2011 Ardern et al

5 Psychological factors Psychological readiness Low fear of new injury Trust in knee & good knee function «You are not a patient anymore! now you have to become an athlete again»...and honesty Return to play test batteries Noyes FR et al AJSM, 1991 Return to play test batteries LSI > 90% = RTS?? A piece in the puzzle! the muscle function tests that are commonly used are not demanding enough or not sensitive enough to identify differences between injured and non-injured sides» Thomeé et al KSSTA

6 What does the literature tell us? Residual quadriceps impairments affect movement strategies but not Return to sport rates.. What does the literature tell us? Residual quadriceps impairments affect movement strategies but not Return to sport rates.. However, it might affect the risk of reinjury? Palmieri-Smith et al 2015; Grindem et al 2012 Palmieri-Smith et al 2015; Grindem et al 2012 Delaware-Oslo ACL Cohort Study Prospective 2 yr follow-up of 106 ACL-R Re-injuries: Pass RTP quadriceps; 5.9% vs 32.7% Level I; 4.3 x re-injury risk RTP < 9 months; 39.5% vs 19.4% Risk of re-injury 51% per month Grindem et al 2016 Muscle strength test ASPETAR ACL cohort 158 professional athletes 4 x increased risk of re-injury if failed criteria Isokinetic strength test 3 single leg hop tests On-field sports-specific rehabilitation Running t test Quadriceps Max effort with increasing load until failure Highest watt registered Kyritis et al

7 Muscle strength test Traditional hop tests Calf endurance # of reps Work Max displacement Noyes FR et al AJSM, 1991 Traditional hop tests Single hop for distance (cm) Triple hop for distance (cm) Crossover hop for distance (cm) 6-m timed hop (sec) Single-legged hop tests (Noyes 1991) After ACL injury Leg symmetry index of the single hop for distance test can significantly predict self-reported knee function after 1 year of non-operative treatment in ACL injured adult individuals Individuals with SH test LSI > 88% have a 89% probability of having IKDC 2000 scores within normal ranges at a 1 year follow-up Noyes FR et al AJSM, 1991 Grindem et al AJSM 2011 Single-legged hop tests (Noyes 1991) After ACL reconstruction Hop tests using MuscleLab Single-legged hop tests conducted after ACL reconstruction can predict the likelihood of successful and unsuccessful outcome 1 year after ACL-R Individuals with >88% LSI for the triple x-over test at 6 months post-operative positive prognosis Individuals with <88% LSI for the 6m-timed hop test at 6 months post-operative negative prognosis Preoperative hop tests are not able to predict postoperative outcomes Logerstedt et al AJSM 2012 Squat jump on one Counter movement jump (CMJ) on one Hopping x 25 Sidehop 30 sec Hop height Evaluate quality of landing Silbernagel et al 2006, 2008 &

8 Single leg CMJ Pre-injury 18,2 Single leg CMJ Pre-injury 18,2 25 National team Avg: 19,8 25 National team Avg: 19, ,51 16, ,51 16,25 16,34 16,79 8 months 10 Injured Non-injured 10 Injured Non-injured Single leg CMJ Pre-injury 18,2 Hopping test 25 National team Avg: 19,8 Squat jump on one ,51 20,21 16,25 16,34 16,79 14,51 8 months 10 months Counter movement jump (CMJ) on one Hopping x 25 Sidehop 30 sec 10 Injured Non-injured Average hop height Jump coefficient (contact/flight time) Evaluate flow and quality Silbernagel et al 2006, 2008 & 2012 Hopping; jump coefficient Pre-injury 0,77 Hop tests using MuscleLab 1,4 1,2 1 0,8 0,6 0,4 1,32 1,12 0,97 1,13 1,08 0,9 National team Avg: 0,83 8 months 10 months Squat jump on one Counter movement jump (CMJ) on one Hopping x 25 0,2 Sidehop 30 sec 0 Injured Non-injured Number of jumps Augustsson et al

9 Sidehop 30 seconds Pre-injury 61 Clinical case Injured Non-injured National team Avg: 64 8 months 10 months Dear Håvard, I am conserned about my son because he has become very inactive. He has abandoned football and is mainy hanging around with his friends playing videogames. He is now 14 years old and it is 3 years since his ACL rupture. Could you please have a look at his knee? Best regards NN Patient-reported outcome KOS-ADLS: 100 VAS: 87 IKDC 2000: 97 KOOS: 100, 100, 100, 100, 94 Performance-based outcome 4 hop tests Single hop 93% Triple hop 103% Crossover hop 102% 6 m timed hop 101% Isokinetic strength tests Quadriceps 109% Hamstrings 93% International classification of functioning, disability and health Clinical outcome KT1000: 7 mm side-to-side difference Postive Lachmans test Positive Pivot shift test No giving way episodes World Health Organization,

10 International classification of functioning, disability and health Exercise progression model R T P Blanchard & Glasgow, 2014 World Health Organization, 2001 Take home messages Progression through rehabilitation is guided by functional testing Functional tests are important pieces of the return to play puzzle Movement quality is as important as quantity IOC DIPLOMA IN SPORTS PHYSICAL THERAPIES A 2-year online education programme Richard Budgett Roald Bahr Mario Bizzini Marco Cardinale Tom Clanton Ben Clarsen Jill Cook Ann Cools Nicol van Dijk Lars Engebretsen Anna Frohm Phil Glasgow Marie-Elaine Grant Robert Granter Roger Hawkes Gwen Jull Gino Kerkhoffs Karim Khan Alex Kountouris Rob LaPrade David Martin Romain Meeusen Winne Meeuwisse Håvard Moksnes Margo Mountjoy Inigo Mujika Grethe Myklebust Peter O Sullivan Kieran O Sullivan Nicola Phillips Noel Pollock Craig Purdam Michael P Reiman Martin Schwellnus Kevin Singer Dominique Sprumont Kristian Thorborg Evert Verhagen Peter Van de Vliet Stuart Warden Rod Whiteley Rich Willy Fiona Wilson Erik Witvrouw Barbara Wondrasch Summary Functional tests are important pieces of the rehabilitation puzzle A graded progression through sport specific training is imperative in decision-making The Oslo Sports Trauma Research Center has been established at the Norwegian School of Sport Sciences through generous grants from the Royal Norwegian Ministry of Culture, the South-Eastern Norway Regional Health Authority, the International Olympic Committee, the Norwegian Olympic Committee & Confederation of Sport, and Norsk Tipping AS Movement quality is as important as quantity 10