Athletics rehabilitation

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1 19 th July, ISBS2016 Applied Sessions Athletics rehabilitation Integrative Approaches for Successful Rehabilitation This session will be led by an orthopedic surgeon and an athletic trainer who are very closely working with athletic population in Korea. The session will first provide insights with regard to updated surgical procedures and post operation healing process for the knee injuries. The session will also address on the return to sports criteria after rehabilitation and what the integrated rehabilitation model is comprised of. Organizer Dr. Ki-Kwang Lee He received his Ph.D. in Sports Biomechanics from Oregon State University. He is currently a professor at Kookmin University, Seoul, Korea. His research interests include the application of biomechanics to physical education and sports medicine, information and communication technology for sports industry, and footwear biomechanics. He served as a national R&D program director for sports industry in ministry of culture, sports, and tourism. Speakers Dr. Jin Goo Kim: Orthopedic rehabilitation after ACL reconstruction(tentative) Jin Goo Kim, MD., PhD, is a professor of Department of Orthopedic surgery and the Chief of Sports Medical Center at Kunkuk University Medical Center in Seoul, Korea. He has conducted research in sports medicine, arthroscopy, and knee orthopedics. He served as a editorial board for the American journal of sports medicine and Korean knee society and medical consultant of Korea Ladies Professional Golf Association.

2 19 th July, ISBS2016 Applied Sessions Dr. Junggi Hong: Neurological Considerations in Sports Rehabilitation Dr. Hong is the Chair of Sports Health and Rehabilitation Department at Kookmin University. He received his Ph.D in Exercise Science (Motor Control based Athletic Training) from Oregon State University. His primary research interest is to examine neuromuscualr mechanisms of sports injury and to investigate whether sports injuries could be prevented with various types of sports performance training.

3 INTEGRATIVE APPROACHES FOR SUCCESSFUL REHABILITATION Ki-Kwang Lee Sports Biomechanics Lab., Kookmin University, Seoul, Korea Currently it is common that sport biomechanists and orthopedic surgeons work together for sports injury prevention and rehabilitation training in Korea. Functional training is the latest issue in not sports injury prevention but rehabilitation at the moment. It works on the premise that the body is designed to work by performing patterns of movement which engages muscles in natural way rather than in one plane of movement. Understanding how each of the body's joints or systems works independently is essential to see whether that section has the capacity to function as part of the whole. A biomechanical screen will provide this information and is used as a precursor to functional screening and training. Once each joint or system has the capacity to function correctly, functional training using combinations of joints and systems, then becomes more likely and the movements are pure not compensatory. Dr. Junggi Hong is the most active scholar and practitioner in the performance training and sports medicine for athletes in Korea. He contributes athletic rehabilitation and injury prevention field in Korea through co-work with many athletic trainers in various professional sports teams and physicians in sports medical centers in Korea. Allowing a patient to return to sport and unrestricted physical activity after ACL injury and reconstruction is one of the most challenging and difficult decisions an orthopaedic surgeon has to make. Indeed, many factors have to be taken into account before it can be considered safe for a patients to load a reconstructed knee. Dr. Jin Koo Kim is the best physician for athlete s ACL reconstruction and researcher in sports medicine, especially at evaluating return to sport. As a director of ports medical center at Kunkuk general hospital, he works with many trainers who graduated sports science major from the athletes ACL reconstruction to successful return to sports through evidence based rehabilitation training. While currently they are using one-legged hop test, muscle co-contraction test, Carioca test, and isokinetic muscle strength test to evaluate rehabilitation progress and to make decision the return to sports, they also are doing many research for application of information and communication technology, such as various sensor technology and virtual reality system to athletic rehabilitation training and evaluation the return to sport.

4 ORTHOPEDIC REHABILITATION AND CRITERIA TO RETURN TO SPORTS AFTER ACL RECONSTRUCTION Jin Goo Kim Department of Orthopedic Surgery, Sports Medical Center, Kunkuk University Medical Center, Seoul, Korea INTRODUCTION: The goal of anterior cruciate ligament (ACL) reconstruction is for athletes to return to their previous level of athletic ability, which has been an indicator of treatment success for many surgeons. In many cases, an ACL injury results in a premature end to a career in sports. However, ongoing advances in graft selection, anatomical graft placement, and fixations have allowed athletes to more consistently return to sports (RTS) after surgery. The combined use of strong fixation and an appropriate rehabilitation program should restore the knee function and normally allow RTS. However, the ability to make RTS is determined by many factors, including postoperative knee function, proprioception and muscle strength, associated meniscal, cartilage, or ligament injury, social factors, and psychological issues, such as fear of re-injury and motivation. And Returning to previous level of sports more determined by differences in rehabilitation than by surgical procedure, fixation method, or type of graft. CURRENT ADVANCES IN SPORTS MEDICINE: (1) Knee stability Large difference in AP translation (i.e. KT-2000) between the reconstructed knee and non-injured knee do not correlate with subjective scores of knee function.. Despite increased AP translation can control the knee and do not utilize the available translation space during activity. Some patients continue to participate in sports despite a torn ACL. But rotational stability is very important. Rotational stability is a prime factor that warrants a patient to return to sports. (2) Static laxity system Static laxity testing system (Anterior drawer test, Lachmann test, KT-2000 arthrometer) can`t represent the functional status. (3) Muscle action 19-44% quadriceps muscle strength deficit 6 months after ACL-R. Hamstring muscle have less than 10% deficit. Some studies specified exact limits of muscle strength for allowing the patient to return to sports. Acceptable deficiency in isokinetic muscle strength is < 15%. Although theoretically, both quadriceps and gastrocnemius contraction results in increased ACL strain, Quadriceps muscle strength correlates with good outcome after ACL-R. Hamstring contraction decreases ACL strain. However, no correlation could be found between hamstring strength and functional tests. (4) Functional performance tests Functional performance tests (e.g. co-contraction, Carioca, shuttle run tests) have been validated as useful assessment tools after ACL-R. (5) Proprioception and Neuromuscular control of the Knee 2 Different control system to maintain the system s homeostasis Feedback controls : stimulation of a corrective response within the corresponding system after sensory detection. Feedforward controls: anticipatroy actions occurring before the sensory detection of a homeostatic disruption.

5 REHABILITATION PROTOCOL AFTER ACL RECONSTRUCTION OF KONKUK UNIVERSITY MEDICAL CENTER (KUMC): Phase Duration Traditional goal Our goal Phase 1 0~2weeks ROM Active extension Full weight bearing Phase 2 3~4weeks Weight bearing Quadriceps activation Strength Phase 3 6~12weeks Strength Proprioception & Neuromuscular control Phase 4 3~6months Functional Functional Phase 5 6months Return to sports Return to sports EVALUATION METHODS IN KUMC: (1) One-legged hop for distance The one-legged hop test was performed three times for each leg. The longest distances for the involved and the uninvolved limb were used. This test was designed to test the concentric and eccentric strength and neuromuscular coordination of the extremity. (2) Co-contraction test The co-contraction test was performed by securing a heavy Velcrobelt around the subject's waist and attaching it to a heavy 48-inchlength of rubber tubing with an outer diameter of one inch. The tubing was anchored to a metal loop secured to a wall 60 in.above the floor. A semicircle was painted on the floor with a radius of 96 in. with the metal loop at the center. The subject stood facing the wall with the toes of his/her feet on the semicircle, which stretched the tubing 48 in. beyond its recoil length. The cocontraction test required each subject to complete 5 wall-to-wall traverses of the 180 semicircle with tension applied to the overstretched rubber tubing. The subjects began the test on the right side of the semicircle, moving in a sidestep or shuffle fashion, completing the five lengths (three lengths right-to-left, two length left-to-right) in the minimum amount of time possible. This test was designed to reproduce the rotational forces at the knee necessitating control of tibial translation by the thigh musculature. (3) Carioca test The carioca test required the subjects to move laterally with a crossover step. The test was performed over two lengths of a distance of 40 ft. The subjects began moving from left to right, then reversed direction retracing the first 40-foot path, thus moving a total of 80 ft in the minimum amount of time possible. This test was used to reproduce the pivot shift phenomenon in the ACL deficient knee. (4) Isokinetic muscle strength Isokinetic muscle strength was measured using a Biodex System III Dynamometer (Biodex Medical Systems, Shirley, New York). Isokinetic muscular strength test were performed both at the common angles and at deeper knee flexion angles, classified as 0 to 90 (standard isokinetic muscle strength test in the sitting position)and 60 to 120

6 (prone position isokinetic muscle strength test), respectively. To evaluate the standard isokinetic muscle strength in the sitting position, the patients were seated on the Biodex testing device with the chest, pelvis, and thigh immobilized with straps. After the range of motion of the knee joint in flexion and extension was measured, the flexion angle of the knee joint was adjusted to 0 to 90. To measure the isokinetic muscle strength in the prone position, the knee joint was aligned with the axis of rotation, and the angle was adjusted to 60 to 120. After the patient had warmed up and became familiar with the procedure, the measurements were repeated 4 times with an angular velocity of 60 /s. First, the contralateral side was measured, and then the side treated with ACL reconstruction was examined. The peak torque (the maximum value during the 4 repetitions) of flexor muscles was assessed, and the values of both knees were compared. The flexor deficit in the isokinetic test was calculated as follows: (involved knee strength/uninvolved knee strength) 100. CONCLUSION: 1. Lack of objective criteria to reliably determine how and when to progress a patient through end stage rehabilitation. 2. Rotational stability is a prime factor that warrants a patient to return to sports. 3. Obtaining neuromuscular control and rotational stability is of utmost importance at end stage rehabilitation. 4. Our algorithm identifies postsurgical deficits and addresses them by team approach through out the return-to-sports phase.

7 A MISSING LINK FOR AN EFFECTIVE REHABILITATION Junggi Hong Department of Health and Sport RehabilitatIon, Kookmin University, Seoul, South Korea KEY WORDS: neuromuscular control, muscle imbalance, athletic training An increase in quantity and improvement in quality of sports rehabilitation related research has contributed to establishing an effective rehabilitation strategy and protocols for common sports injuries. There used to be variations in rehabilitation protocols for sports injuries among allied health professionals but with the effort to implement evidence-based medicine in athletic training field, now there seems to be a consensus on how sports injuries should be both acutely and chronically treated and how rehabilitation process should progress. The common rehabilitation protocols recommended by literature include patient education, pain management during and after inflammatory process, range of motion exercises, muscle strengthening, neuromuscular control training, functional training, and sport specific training or active daily life related exercises. For instance, the shoulder specific rehabilitation protocols are implemented based upon this literature and experts knowledge based models and some of the detail strategies in the rehabilitation protocols include performing limited range of motion exercises before full range of motion exercises, shoulder adduction exercises before abduction exercises, using stable surface before unstable surface, performing closed chain exercises before open chain exercises, using barbells before dumbbells, isometric exercises before regular speed exercises for muscle strengthening, and traction before approximation. These theoretically sound rehabilitation protocols have helped many athletes recover from injury and return to sports but it is not without limitations. Although these steps are consequentially implemented and each phase of rehabilitation process is carefully monitored if the allied health professionals such as athletic trainers and sports physiotherapists overlook some of the adaptations occurred not only in musculoskeletal system but also in the central nervous system, the efficacy of rehabilitation process could be compromised. Kinematic factors such as joint angle, muscle activation, peak moment and force are definitely important to monitor athletes progress and determine the efficacy of a treatment and rehabilitation. In order to improve these kinematic variables, biomechanical and kinesiological approaches have been applied. Joint mobilizations for range of motion limitation and consequential strengthening exercises from isometric to eccentric mode for muscle imbalance restoration are commonly implemented in the rehabilitation settings. However, neurological and neuromuscular alterations or deficits caused by the primary injury tend to be overlooked and seldom addressed by the most of athletic trainers and physiotherapists. Neurological deafferentation by injuries is already well documented and it is a contributing factor for causing muscle imbalance and movement dysfunction. Not only receiving no neural input from the central nervous system but also altered muscle recruitment pattern caused by joint mechanoreceptors and muscle receptors could cause prolonged joint dysfunction and pain. Delayed joint function restoration and chronic pain delays rehabilitation process. In this presentation, neurological mechanisms of how injury can cause altered muscle activation and recruitment patterns, which could be negatively affecting rehabilitation process, will be discussed. Also some of the strategies for effectively addressing aforementioned limitations during the rehabilitation process will be introduced. REFERENCES: Azevedo, D. C., Pires, T. L., Andrade, F. S., & McDonnell, M. K. (2008). Influence of scapular position on the pressure pain threshold of the upper trapezius muscle region. European Journal of pain, 12(2),

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