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1 Concpts For Advancd Prformanc Robrt Mangin, M.Ed., PT, ATC National Dirctor Sports Rsidncy Program NovaCar Rhabilitation Associat Athltic Dirctor of Sports Mdicin Univrsity of Cincinnati Dpartmnt of Athltics Adjunct Clinical Instructor of Orthopdics Univrsity of Cincinnati Dpartmnt of Orthopdic Surgry Objctiv Masurs Th End All Advancs in Rhabilitation Th commonly hld blif is that rstoration of masurabl structural and biomchanical paramtrs to a joint indicats rstoration of normal function. INTRODUCTION: Emrging clinical and basic scinc findings indicat a much gratr dgr of undrlying biological complxity in th joint. Evidnc suggsts that rstoration of idntifiabl structural abnormalitis alon is not sufficint to rstor a joint to its full pr-injury lvl of physiologic function. 3 Biomchanical studis Clinical studis Rhabilitation Stags Acut: immdiat intrvntion, pain, motion, arly muscl loss Intrmdiat: motion rstoration, low rsistanc program, cor training Advancd: prformanc training Goal of this talk Evaluation, dtrmin rturn to play Factor 1: Motion Associatd With Mchanism of Injury Rotation is a critical motion rlatd to injury and includs both tibial rotation and valgus rotation. Advancd rhabilitation rcrats and controls ths mchanisms on th patint as positions chang. A critical factor is prparation as th body altrs its position during prformanc Majority of injuris ar noncontact, and occur du to poor body control Rotational concpts involv Uppr and Lowr Limb 1

2 Scondary Mchanisms of Injury Hyprxtnsion High load dmand on cruciats, not protctd by clos chain Valgus / Varus load application rarly rsults in sufficint forc unlss accompanid by a scondary load. Factor 2 Gnral Concpt Form vs. Function Basball Soccr Chrladrs Vollyball Football Hocky Sport vs. Physiology vs. Mchanics Playr = W tach Playrs a comprhnsiv program of strngthning, agility, spd, and nduranc Factor 2: Advanc Rconditioning Training Rturn to Activity Advanc Training must considr th patint goals and activity lvl: Ths ar complx intrvntions that failur may rsult in salvag surgry Functional Progrssion SKILL PHYSICAL FITNESS TACTILE SENSING PSYCHOLOGY FACTORS Factor 2: Comprhnsiv Approach Advanc Training must considr th patint goals and activity lvl: Ths ar complx intrvntions that failur may rsult in salvag surgry Functional Progrssion SKILL PHYSICAL FITNESS TACTILE SENSING PSYCHOLOGY FACTORS Concpt 1 Tchnical Skill Rhabilitation tachs idal body movmnt Quality rptitions, rplicating protctiv movmnt Ag dpndnt Injury dpndnt Playr = larns a systmatic form of slf control Concpt 2 Tactil Snsing: Prparation for a Rspons Dsign program to corrlat with xrcis dmands Follows th scintific basis of xrcis physiology Tach athlt a rflx rspons to xtrnal stimulation 2

3 Concpt 3 Physical Fitnss and R-Conditioning Exrcis Physiology % Scinc/50% Art Injury vs. Prformanc Tst and Masurs Prformanc: Functional Scrns NFL Combin Spcific Bnch 225 Shuttl Yard sprint Additional lnmts Pull ups Body fat Concpt 4 Psychological Qualitis Functional Progrssion Factor 3: Lowr Limb Dynamic Stabilization Th mntal aspct of rhabilitation has bn shown to influnc spd and fficincy Effctiv Componnts Plyomtrics Tchniqu analysis Strngth training Cor Stability Inffctiv Componnts Lack landing/cutting training Balanc training only Rsistanc training only Rhab on th fild Evryon Maks a Big Dal of Clos Chain Training So What, Only If It s s Functional Pain: rducd antrior displacmnt by KT Bynnon and Johnson, Human modl, CKC activitis rducd strss on graft Markoff: cadavric masurmnt dcrasd shar, sam as Grood Brac for Protction No protction in hyprxtnsion or with rotation Advancd Training Exrciss For Lowr Extrmity Training Comprhnsiv rhabilitation of th lowr xtrmity complx rquirs all availabl tchniqus, th dpndnt variabl among patints is th ability to follow up in a controlld mannr. Th program must not only account for ffctivnss but also b practical and asily implmntd in a hom or school stting. 3

4 Typs of Flxibility Typs of Flxibility Static Strtching: Inhibition of tnsion rcptors in our muscls. Whn don proprly, static strtching slightly lssns th snsitivity of tnsion rcptors, which allows th muscl to rlax and to b strtchd to gratr lngth. Typically hld for sconds. Dynamic Flxibility: Activly moving a body part through a rang of motion with momntum to hlp improv nuromuscular control, spd, and powr dvlopmnt. KICKERS, thy tnd to do thir own thing Rsarch on Dynamic -v- Static Rsarch on Dynamic -v- Static Dynamic -v- Static Strtching Warm-up: Th Effct on Powr and Agility Prformanc Danny J. McMillan, Josf H. Moor, Brian S. Hatlr, and Dan C. Taylor Rsults/Conclusion: Tstd in T-Shuttl (agility), undrhand MB toss (uppr body powr), and 5 stp jump (lowr body powr). All 3 trials showd dynamic significantly bttr than static or no warm up. Static and Dynamic Acut Strtching Effct on Gymnasts Spd in Vaulting Pdiatric Exrcis Scinc, 15, Siatras, T., Papadopoulos, G., Mamltzi, D., Grodimos, V., & Kllis, S. (2003). Conclusion: Gymnasts running spd during vaulting dcrasd aftr warm up with static strtching compard with warm-up alon or warm-up with dynamic strtch. Dynamic Warm Up Advancd Training Strngth Olympic Lifts Postrior Chain Dad Lift Stiff lg singl lg dad lift Singl arm high pulls Control wight ovrhad, srvs multipl purposs and balanc functions 4

5 Ky to Succss Pick it up off th floor Th Body On Pic Rarly Isolat muscl complx Strngth Concpt Put it ovrhad Tchniqu critical Emphasiz Postrior Chain Ky to injury Prvntion ( Hamstring, Glutals, Spinal mm) 1. Dad lifts 2. Rvrs Hyprs 3. Glut/Ham 4. Low intnsity Bryan Mann, Dvlopmnt of th Postrior Chain, 2002 Postrior Chain Emphasis Stp 1, Early Insrt Stacy Andrws Glut Ham machin Stp 2 Lat 5

6 Advancd Training Limb Control Concpt Cor Training Sris Total Lowr Extrmity Training Functional PNF pattrns Doubl lg bounding low lvl Plyomtrics Singl limb position 20% of training tim Singl Limb with xtrnal stimulation Us 3 to 4 xrciss and kp sts and rps low, Provid propr warm up Advancd Training Cor Emphasis Th Effct of Cor Propriocption on Kn Injuris: Zazulak BT, Hwtt TE, t al AJSM, vol Impaird cor propricption masurd by activ rpositioning of th trunk, prdictd kn injuris in fmal but not mals. 3.3 fold incras in injury Each dgr of rror in rpositioning rsultd in 3.3 fold incras in odds ration of ligamnt/mniscal injury of th kn Trunk Control Trunk displacmnt gratr in athlts who suffrd kn ligamnt and ACL injuris Latral displacmnt was th strongst prdictor of injury Dynamic Cor Emphasis Functional Options Strngth Training as Total Body Movmnt and Functional Position Latral Cor Movmnt Train movmnt not MUSCLE Latral Trunk Movmnt 6

7 Advancd Training Strngth Emphasis High rsistanc lg Prss Limitd Kn xtnsion Full ROM Hamstring Hip work, Innr/Outr thigh Squats partial vs. full Priodization program altr 8 wk cycls Eccntric mphasis, singl lg High load aftr haling priod Patlla monitord Advanc Training Nurological Contributions Rich Intrplay (Affrnt to Effrnt) nabls combination of Activ & Passiv Elmnts to provid Harmony of motion & function Activ - Muscular Stiffning of Joints (Eccntric is absorbing nrgy), ky to middl of rang Passiv - Non Contractil Soft Tissus, ky to End Rang Affctd by Magnitud of strtch, vlocity of strtch, and tim Tim btwn strtch stimulus and shortning rspons must b short Mchanorcptor Anatomy 4 Typs Rcptors 1:Ruffini corpuscls (typ I: prssur) 2:Pacini corpuscls (typ II: vlocity) 3:Golgi-Mazzoni (typ III: prssur) 4:Fr nrv ndings (typ IV: pain) Nrv supply of th human kn and its functional importanc* John C. Knndy, MD t al. Th Amrican Journal of Sports Mdicin, Vol. 10, No.6 Nurological Golgi Tndon Organs (GTO) On of two systms that monitor muscl stiffnss, th Muscl Spindl is th othr Prsnt in Tndon as a strtch rcptor in lowr bundl to nrv ratio thn first thorizd Rsponds to strtch on Tndon Rspons slowr thn muscl Advancd Training Clinic to th Fild Succssful Rhabilitation transition clinic simulation to fild activity 1:Training tchniqu 2:Start to push functional conditioning 3: Mntally push athlt 4: Intgrat strngth and position coach 7

8 Plyomtric Warm up Program Trunk rotations Trunk sid bnds Trunk PNF pattrns Band Kicks Doubl lg bounding Jump Rop Spd laddr Us 3 to 4 xrciss and kp sts and rps low, this is warm up Plyomtric Intrmdiat Advanc Training Spd of th GAME/Spd of INJURY Cross ovr hops Latral cup or con hops Forward and latral bag hops Latral bag and ball toss Latral hop and 2 dirction tubing Rciprocal raction: must incorporat acclration and dclration manuvr into program Powr and nduranc timing: incorporation of closd chain xrciss to facilitat impact loading Comprssiv Loading: Incorporation of closd chain xrcis to facilitat landing mchanics Enhancs nurological fdback Plyomtric Advancd Advancd Training Clinic to th Fild Dot drills Continu trunk program Highr lvl box drills Rsistanc front hop Rotational position landing Succssful Rhabilitation transition clinic simulation to fild activity 1:Training tchniqu 2:Start to push functional conditioning 3: Mntally push athlt 4: Intgrat strngth and position coach 8

9 Plyomtric Intrmdiat Cross ovr hops Latral cup or con hops Forward and latral bag hops Latral bag and ball toss Latral hop and 2 dirction tubing Advancd Training Sssion AGILITY AND QUICKNESS PROGRAM Station 1 Dummy Exrciss A) Straight Lin Bags B) Crossing Bags Station 2 Dot Drills - Hl on ach dot (start) - 5 drills: 6 tims ach - 1st day - 80 sc. or lss - 1st Mon lin & big skilld Station 3 A) Plyoboxs up/down 10" sid to sid 18" Partnr Latral Con Hop Station 4 A) Plyoball Toss Chst Pass B) Plyoball Sit-Ups Factor 9 Fatigu Biomchanical Altrations Incras antrior shar forc Dcrasd propriocption Dcrasd nuromuscular function Lat onst of lowr xtrmity muscl activation Significant diffrnc in th kn valgusvarus momnt Arobic Rconditioning Functional arobic rconditioning Simulat Fatigu Fatigu Fatigu FORM - FORM Carry it for TIME and DISTANCE 9

10 w k 1 w k 2 w k 3 w k 4 Exampl of Running Program Basktball Sprint Program 1) run 20 yrds in 4 sc. 20 2) rpat 15 tims 1) run 40 yrds in 6.5 sc. 40 2) rpat 10 tims 1) run 60 yrds in 9 sc. 60 2) rpat 8 tims 1) run 20 yrds in 4 sc. 20 2). rpat 20 tims 1) run 40 yrds in 6.5 sc. 40 2). rpat 15 tims 1) run 60 yrds in 9 sc. 2). rpat 8 tims 1) run 20 yrds backward & uphill. BWK 2) rpat 15 tims 1) run 20 yrds backward & uphill. 2) rpat 20 tims BWK 1) run 20 yrds in 4 sc. 20 2). rpat 20 tims 1) run 40 yrds in 6.5 sc. 40 2). rpat 20 tims 1) run 60 yrds in 9 sc. 60 2). rpat 10 tims 1) run 20 yrds backward & uphill. BWK 2) rpat 20 tims 1) run 20 yrds in 4 sc. 20 2). rpat 25 tims 1) run 40 yrds in 6.5 sc. 40 2). rpat 20 tims 1) run 60 yrds in 9 sc. 60 2). rpat 10 tims 60 1) run 20 yrds backward & uphill. 2) rpat 20 tims BWK Arobic Rconditioning Rtro Initiation of rtro training can occur by Stairmastr Band Training Tradmill Progrss to inclin Aquatic Rturn to Play Assssmnt Rturn to Play Assssmnt Arthromtry tsting Subjctiv Examination (I.. pain) Baslin Masurmnts Muscl valuation Joint Arthromtr Functional Hop Tsting Sports-Spcific Tsting KT-1000 valuation high lvl rliability Dvlopd as a masuring tool to aid clinical manual xam Usr dpndnt No on gold standard, must pic togthr rsults and us xprtis Rturn to Play Assssmnt Objctiv Muscl Evaluation Functional Tsting Critical to Rturn to Play Tripl Hop Distanc Many choics ar availabl: MMT grading systm clinician dpndnt Hand-Hld Dynomomtr Isokintics dpndnt on vlocity of tst Singl Lg Hop Tim Hop Cross Ovr Hop 10

11 Rturn to Play Assssmnt Rturn to Play Critria Cornrback Assssmnt Mdical Claranc Rturn to Play Normal bas masurmnts KT 1000 < 3 mm Balanc tsts <20% Isokintic tsting <10% Functional Hop tsts <15% Rturn to Play Position Spcific Conclusion and Outcom Diffrncs xist btwn th basball throwr and th quartrback in trms of frquncy and typ ( pitchs vs. passs and numbr of typ of pitchs) Th Quartrback is xposd by his position at th tim of rlas to traumatic impact Contact from a antrior or postrior blow rsults in high skltal forcs with th arm in a vulnrabl angl Clar undrstanding of normal anatomy and biomchanics Rstoration of normal movmnt pattrns Slction of appropriat xrcis to rstor normal function THANK YOU Rfrncs Knndy JC, Alxandr IJ, Hays KC. Nrv supply of th human kn and its functional importanc. AJSM.1982; 10: Mangin RE, Krmchk TE. Evaluation basd protocol of th antrior cruciat ligamnt. J Sport Rhabil.1997; 6; Barbr SD, Noys FR, Mangin RE, McClosky JW, Hartman W. Quantitativ assssmnt in normal an antrior cruciat dficint kns. CORR. 1990; 255: Noys FR, Barbr SD, Mangin RE. Abnormal lowr limb symmtry dtrmind by functional hop tst aftr antrior cruciat ligamnt ruptur. AJSM. 1991; 19: Wilk t al. Th rlationship btwn subjctiv kn scors, isokintic tsting, and functional tsting in th ACL rconstructd kn. JOSPT. 1994; 20:

12 Factor 1 Functional Rturn Concpts Rhabilitation starts Immdiatly aftr th injury w nd a aggrssiv plan that starts in th acut phas Propr acut intrvntion spds rturn Initial ligamnt injury occurs with Compnsation with activitis of daily living Sports, Work Rlatd Function, or activitis of daily living R-injury Mniscus tar Arthritis Rhabilitation is Prformanc Training Tchnical Skill Ambulation pattrns Sports spcific movmnts Occupational spcific Tactical Sns Propriocption Kinsthtic awarnss Physical Fitnss Strngth Powr Spd and nduranc Psychological Qualitis Tactical Sns Factor 3: Lowr Limb Dynamic Stabilization Basic Concpts Advancd functional training is a intgratd approach of th nuromuscular systm Incorporat functional dmands on th body basd on physiologically accptd concpts Dsignd to improv prformanc and prvntion of rpat injury. Control kn and ankl mobility to avoid unwarrantd motions Rturn nuromuscular systm function to load dmand 12