Preparing your patients for the game of life and sport: Bridging the gap between physical therapy and performance

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2 Preparing your patients for the game of life and sport: Bridging the gap between physical therapy and performance By: Dr. Arianne Missimer, PT, DPT, RD, RKC, CICS, CSCS, T.P.I. MP 3, K Vest 2 Owner CORE Fitness Clinic Director Kinetic Physical Therapy

3 My Mission To restore sustainable and optimal health in individuals through proper nutrition, performance enhancement, and rehabilitation and bridge the gap between performance and physical therapy. Nutrition Physical Therapy Performance

4 Special Thanks Gray Cook Lee Burton Mike Boyle Greg Rose Gary Gray Dr. Ed Thomas Athletes Performance Mike Clark Michol Dalcourt Thomas Myers Shirley Sarhman Vladmir Janda Pavel Kolar Stuart McGill Dr. Mark Cheng Craig Leibenson Charlie Weingroff NSCA!!

5 Objectives Defining the GAP Discuss pain s effect on movement Identify movement indicators as a means of a common language Bridging the Gap Integrate quality, movement based training Treat the WHOLE person Form a Rehabilitation to Performance Continuum Form a multidisciplinary team

6 What is the GAP? Isolated vs. integrated Pain free vs. functional Movement based approach vs. impairment based Fitness/Performance vs. rehabilitation Injury prevention vs. treatment of injuries Common language Global, comprehensive, movement based approach Insurance

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9 Movement Specialists. Need to understand : Effect of injury and pain Kinetic linking Force production Regional interdependence Need to have a: Movement based approach Common language

10 Why do people sustain non contact injuries? 2 17 Predictors of Injury: Previous Injury Ekstrand et al 2006, Murphy et al 2003 Asymmetries Baumhauer et al 2001, Myer et al 2008, Nadler et al 2001, Plisky et al 2006, Rauh et al 2007, Soderman et al 2001

11 What happens if we only get our patients pain free? 1 Impairment focused?!? Normalize Enhance performance Pain distorts motor control High threshold strategies

12 Movement changes after injury!!! Decreased proprioceptive input Movement patterns are lost due to: imbalances asymmetrical movement improper training incomplete recovery from injury

13 We first need to understand movement Nervous Musculoskeletal Kinetic Chain Image adapted from Integrative Health

14 Fascial System 18 Muscles are discrete, while fascia is continuous. Tom Myers Three dimensional matrix Dynamic structural support

15 Anatomy Trains 18 Superficial Back Line Superficial Front Line Lateral Line Spiral Line Arm Lines Functional Lines Deep Front Line Adapted from Anatomy Trains by Tom Myers

16 Nervous System Sensory Integrative Motor Communication Network 19 Sense changes in either the internal or external environment Analyzeand interpret the sensory information to allow for proper decision making, producing the appropriate response Neuromuscular response to the sensory info

17 Reflexes 20 Primitive: Involuntary response to specific stimuli Postural: Allow adaptation of posture to changes in environment Locomotor: MOVEMENT Compression and distraction

18 Neurodevelopment Fundamental activities of the human body revolve around simple and basic patterns of human movements Developmental sequence that starts at infancy and develops through childhood (rolling crawling walking)

19 Mobility? Motor Milestones

20 Motor Milestones 20 Newborns move their head with their eyes 3 5 months Move their eyes I of their head Lift their head up with control Weight bear on their arms to see toys Initiate rolling (Postural reflex)

21 Motor Milestones 6 8 months : Sit upright without support Crawling (Locomotor reflex)

22 Motor Milestones to 12 months: develop the S curve months: Stand briefly alone without support with high guard Deadlifting 21 months 24 months: Deep squat to play Stand on one foot with support briefly

23 Neurodevelopment planning initiation of motor Children learn to balance themselves through feel Gravity begins to pull their ribs down, and their limber frames begin to develop stability Motor Planning

24 Motor Planning Motor plans are developed around your physical limitations Sound movement BEFORE performance enhancement Pain distorts motor control

25 Motor Learning Cognitive phase Associative phase Autonomous phase Cognitive Associative Autonomous

26 Mobility and Stability Mobility: freedom of movement; moving through a non restricted, pain free ROM Stability/motor control: ability to maintain posture and/or control motion Coordination, sequencing, and timing Static and dynamic Central Nervous System (CNS) organizes functional patterns M bilit d St bilit /M t C t l

27 Adapted from Mike Boyle Adapted from Mike Boyle

28 Functional Performance Pyramid Skill Adapted from Gray Cook 2004 Performance Movement

29 We know what FUNCTIONAL is, so what is DYSFUNCTIONAL? Poor movement competency=compensation Poor durability Microtrauma Weakest link Inefficiency

30 As to the methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble. Ralph Waldo Emerson

31 Establish a Movement Baseline If you could predict if you were 2 3x more likely to get injured, wouldn t want to know? How can we determine effectiveness of our treatment plans and training programs if we have nothing objectively measure? Screen foundational movements for a proactive approach to injury prevention

32 Movement Indicators 1 Functional Movement System: Selective Functional Movement Assessment: Evaluation Functional Movement Screen: Checks risk Y Balance Test: Measures ability Skill Performance MOVEMENT Adapted from Gray Cook 2004

33 Functional Movement Screen 1 Reliable and reproducible screen Identifies Physical imbalances, limitations, and weaknesses Potential cause and effect relationships of deficits and microtrauma/ chronic injuries Improves fundamental movement patterns with simple corrective exercises Great communication tool!!

34 Corrective Algorithm Corrective Algorithms ASLR SM RS TSP ILL HS DS Mobility Stability Top 3 Asymmetries within the algorithm Pain? Stop, begin SFMA or refer.

35 Application/Benefits <14 predicts risk for injury Standardizes movement Establishes appropriate goals Corrective strategies Prior to discharge Pre participation Communication and common language

36 Preparing your patients/clients for the game of life and sport Screen, test, assess Posture and breathing Neuromuscular activation Corrective exercise Movement preparation Performance Recovery Re screen, test, assess

37 You can teach a student a lesson for a day; but if you can teach him to learn by creating curiosity, he will continue the learning process as long as he lives. -- Clay P. Bedford

38 Computer Man

39 Posture Foundation for all movement Good posture=good habit=positive well being Ideal alignment=optimal movement Maintaining or restoring precise movement of specific segments is the key to preventing or correcting musculoskeletal pain. Sahrmann

40 Posture Pillar Strength: Athletes Performance Foundation for kinetic linking Dynamic coordination of stability Production or transfer of force from LE to UE via the pillar Proper stance for optimal movement Safely and effectively dissipate forces that move through the body

41 Breathing Movement dysfunction is evident when breathing and postural control are compromised Cornerstone of optimal health and well being Optimal motor program First movement What s normal??? breaths/minute (adult) 20,0000 breaths/day!!!

42 Breathing Poor Breathing Increased sympathetic activity Increased neural drive to global muscles Inhibits local muscles Adopts a high threshold strategy Proper Breathing: Increased parasympathetic activity Improves recruitment patterns of the core for improved postural control Optimizes respiratory function Decreases risk of injuries, particularly upper quarter Harmony, timing, sequencing, rhythm, coordination

43 Breathing

44 Mobility Mobility first??? Quality stability is driven by quality proprioception If limitations in mobility exist, quality proprioception is not possible Gain mobility, then train stability

45 Self Myofascial Release 19 Improves flexibility, function, performance Reduces injuries Apply deep pressure into myofascial restrictions to influence kinetic chain Autogenic inhibition of muscle spindle Search and Destroy!

46 Stability/Motor Control Stability does not equal strength Example: Tubing Shoulder ER Stability is reflex driven Neuromuscular and postural control Sequencing and timing Static before dynamic

47 High Threshold Strategy Inner Respiration Continence Segmental stability Outer Postural stability Resists external load Movement production Energy transfer

48 Neuromuscular Activation Core activation Activity dependent Problem specific

49 Corrective Exercise Progressions and regressions following the neuromotor developmental sequence Removing the dysfunctional pattern will improve stability/motor control Don t correct the movement, correct the primitive things that came before that Eliminate counterproductive activities

50 Rolling Patterns

51 Corrective Exercise Practice makes perfect, right? Do a few things really well! Highest quality of motion with every repetition within a ROM that you can exhibit highest neural control Otherwise, the info is INEFFICIENT!

52 Corrective Strategies Soft Tissue Mobilization Active Isolated Stretching PNF Movement patterning Movement preparation Active rest Can correct in 2 3 weeks Accountability: Homework!

53 Proper Execution Perception Verbal cueing??? RNT Self limiting positions Quality vs. quantity Reps????

54 Movement Preparation 32 20% greater speed and power output Increases core temperature Increases heart rate Increases blood flow to the muscles Actively lengthens muscles Activates nervous system Prepares for the demands of the sport/activity

55 Mindful Movement Dancers, acrobats, martial artists Indian clubs, kettlebells Precision and fluidity Breathing Control BRAIN TRAINING BE PRESENT!

56 Performance Functional training =core training=movement based training Primal movements Optimal loading the myofascial system in all 3 planes Life and sport Skill requirements What about PERFORMANCE rotation? Movement

57 Any questions? VS. Image adapted from factory.com Image adapted from

58 Recovery Mindset Sleep Nutrition Active rest Soft tissue mobilization

59 For your patients/clients Educate and empower! Posture/CORE 101 Self soft tissue mobilization Neuromuscular Activation Corrective Exercise Movement Preparation Optimal Performance Program Regeneration/Recovery Teach sustainability Encourage Rehabilitation to Performance Continuum

60 Performance Team Rehabilitation to Performance Continuum Rehabilitation Return to activity/sport Multidisciplinary approach Performance specialist/cscs Registered dietitian Physical therapists/chiro s Mental health Sports professionals/coaches Physician

61 Rehabilitation to Performance Continuum Ethical responsibility to screen before D/C Communication, understand each other s role, and collaborate Develop a common language Goal: work together for the best interest of our patient/clients

62 Rehabilitation to Performance Age/Diagnosis Precautions Functional Movement Screen Score: Corrective Strategies Sport/Activity Specific Returned to full capacity : YES /NO Continuum

63 Rehabilitation to Performance Continuum Yes/No Comments CORE 101 Correctives Neuromuscular Activation Movement Preparation Strength Power, Speed, Agility Energy System Regeneration/Recovery Yes Yes Yes Yes Yes No No Yes Rehabilitation Return to Activity/Sport

64 Key Points Pain and injury alter movement Understand movement Functional Performance Pyramid Dysfunction = poor durability Establish a movement baseline Whole patterning is the rule Sport and life are movements! Establish a performance team Rehab to Performance Continuum

65 Questions?

66 References 1. Cook G. Movement. Functional Movement Systems. Aptos, CA: On Target Publications; Ekstrand J et al. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. British Journal of Sports Medicine. 2006: 40; Murphy D et al. Risk factors for lower extremity injury: a review of the literature. British Journal of Sports Medicine. 2003: 37; Baumhauer J. et al. Ankle ligament injury risk factors: a prospective study of college athletes. Journal of Orthopedic Medicine. 2001: 19; Myer, G. et al. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinics in Sports Medicine. 2008: 7; Myer G. et al. Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament regiment. Journal of Strength and Conditioning Research. 2008: 22; Nadler et al. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil 2001; 80: Plisky P et al. Star excursion balance test as a predictor of lower extremity injury in high 9. school basketball players. Journal of Orthopaedic & Sports Physical Therapy. 2006: 36;

67 References 9. Rauh M. et al. Quadriceps angle and risk of injury among high school cross country runners. Journal of Orthopedic & Sports Physical Therapy. 2007: 37; Soderman, K. et al. Risk factors for leg injuries in female soccer players: a prospective investigation during one out door season. Sports Medicine. 2001:9; McGuine T et al. Balance as a predictor of ankle injuries in high school basketball players. Clinical Journal of Sport Medicine. 2000: 10; Tojian, T. and McKeag, D. Single leg balance test to identify risk of ankle sprains. British Journal of Sports Medicine. 2000: 40; Wang, H. et al. Risk factor analysis of high school basketball player ankle injuries: a prospective controlled cohort study evaluating postural sway, ankle strength, and flexibility. Archives of Physical and Medical Rehabilitation. 2006: 87; Hewett, T. et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in females athletes: a prospective study. American Journal of Sports Medicine. 2005: 33; Zazulak, B. et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical epidemiologic study. The American Journal of Sports Medicine. 2007: 35;

68 References 16. McHugh M, et al. Risk factors for noncontact ankle sprains in high school athletes: The role of hip strength and balance ability. American Journal of Sports Medicine. 2006: 34; McHugh M et al. Oversized young athletes: a weighty concern. Journal of Sports Medicine. 2010: 44; Myers TW. Anatomy Trains. Myofascial Meridians Manual for Movement Therapists. Second Edition. Edinburgh, CA: Elsevier; Clark, M., Luceh, S., Rodney, C., Cappuccio, R., Humphrey, R., Kraus, S., Titchenal, A., & Robinson, P. (2004). Optimum performance training for health & fitness professional. (2 nd ed.). USA: National Academy of Sports Medicine. 20. Cambell S.K. (2006). Physical Therapy for Children. (3 rd ed.). St. Louis, Missouri: Saunders Elsevier. 21. Gray, GW. Wynn Marketing Inc; Adrian, MI: Lower Extremity Functional Profile. 22. Kiesel K, Plisky PJ, Voight ML. Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen? N Am J Sports Phys Ther August; 2(3):

69 References 23. Hertel J, Miller SJ, Denegar CR. Intratester and intertester reliability during the Star Excursion Balance Tests. J Sport Rehabil. 2000;9: Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12): Kinzey SJ, Armstrong CW. The reliability of the star excursion test in assessing dynamic balance. J Orthop Sports Phys Ther. 1998;27(5): Chaiwanichsiri D., Lorprayoon E., Noomanoch L. Star excursion balance training: effects on ankle functional stability after ankle sprain. J Med Assoc Thai. Sep 2005;88 Suppl 4:S Olmsted LC, Carcia CR, Hertel J, Shultz S. Efficacy of the Star Excursion Balance Tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37(4): Hertel J, Braham RA, Hale SA, Olmsted LC. Simplifying the Star Excursion Balance Test: analyses of subjects with and without ankle instability. J Orthop Sports Phys Ther. 2006;36: Earl JE, Hertel J. Lower extremity muscle activation during the Star Excursion Balance Tests. J Sport Rehabil. 2001;10:

70 References 30. Gribble PA, Hertel J. Considerations for normalizing measures of the Star Excursion Balance Test. Measurement in Physical Education and Exercise Science. 2003;7(2): Sahrmann S A. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MS: Mosby; Camhi, J. (2012). Lower quarter functional restoration workshop manual. Phoenix, AZ: Athletes Performance. DOI: Cook, G Athletic body in balance. Optimal movement skills and conditioning for performance. Champaigne, IL: Human Kinetics 35. Bear M, Connors B, Paradiso M. 2007Neuroscience. Exploring the Brain. Baltimore, MD: Lippincott Williams & Wilkins