Timid rehabilitation protocols can lead to a “false positive” when it comes time to assess an athlete’s readiness to return-to-play, whether that is on a field or in everyday life. Rehab specialists’ risk aversion in the clinic can backfire by increasing the risk of re-injury upon return-to-play.
Low expectations, outdated protocols and an exaggerated sense of caution can derail an athlete’s return from injury, weeks or months after they were formally cleared to resume training and competition. Or, to put it more simply, “Patients are babied too often.”
Bo Selvig is the Clinic Director at Lone Peak Performance and Fitness. A physical therapist himself, Selvig has seen in school and with personal experience the gap between the conventional wisdom and practice of rehabilitation and what patients really need to return to full health and full activity with minimal risk of re-injury.
With a heavy year around caseload of ACL injuries and reconstructions, Selvig has been able to advance his treatment with this specific population. He is currently seeing eight patients with ACL injuries. They include two competitive teenage ski racers, a world-class teenage snowboarder and five recreational adult skiers. Selvig looks to the etiology of ACL injury to guide his rehab programs from day one. Hyperextension at the knee can be a major factor, but opposing transverse plane motion at the femur and tibia and lack of frontal and transverse plane control at the hip also play major a role.
Rehab specialists often overlook these latter components. Putting the knee into a loaded valgus position, especially in the early post surgical phase is almost forbidden by conventional protocols and what is taught in school. The idea of a closed-chain, loaded, rotational movement goes against much of the established practice and education in the field. But as Selvig points out, even minor movements in these areas in early stages of rehab can have major effects later in the rehab process. An injury that occurs in three planes should be rehabbed in three planes – not doing so would be going against the fundamentals of human movement.
To that end, Selvig introduces tri-planar movement days after surgery. A patient will perform small 3-dimensional hand reaches and tri-planar weight shifts during their initial post-op visits. They are loading in functional positions from day one and they do everything in weight-bearing positions.
“If I could, I would get rid of all of the treatment tables in our clinic. I find therapists rely too heavily on table intervention and not enough on progressive loaded exercise. It is frustrating to hear that therapists are still doing straight leg raises or clam shells days or even weeks after surgery. Granted, there may be an appropriate time for this, but I feel that for the majority it is unproductive.”
Within a few weeks he includes single-leg squats, split squats and sport-specific loading in multiple planes. He looks for quality of movement and compensations to ensure that he is adequately loading the knee in a tri-planar fashion – with a large focus of neuromuscular control in the transverse and frontal planes. All of this is in addition to the standard sagittal plane work.
So why do so many PTs and Sports Med docs fight heavy lifting protocols during RTP periods? https://t.co/lSE9hZxCGR
— dpfaff (@PfaffSC) November 15, 2017
Four-to-six weeks post-op Selvig introduces the 1080 Quantum to begin isokinetic movement and to quantify his patients’ progress. Patients perform this part of their rehab wearing a vest or harness connected to the 1080 Quantum. Selvig has them perform weight shifts and small functional positioning, and changes their position relative to the machine to load them in various planes. He cues them to initiate movement at the pelvis to assess adduction/abduction and internal/external rotation. He also pays attention to how the foot is reacting and moving. “Much of my focus is geared towards the hip and the foot. The knee is literally stuck in the middle and only does what the foot allows and what the hip can control.”
Selvig increases gross neuromuscular recruitment by adding vibration to the movements on the 1080 Quantum. Simply rotating the hips toward and away from the machine under vibration and load provides a more effective stimulus than the movement alone, with significantly greater benefit to long-term stability and control than avoiding such movements altogether.
With a high population of downhill skiers and snowboarders who spend nearly their entire sport-time in a state of eccentric loading and frequently go into a valgus knee position, this is a particularly important stage. If athletes do not have full proprioceptive input and lack fundamental eccentric control they will not be able to progress to the next stage of rehab and further increase their chance of injury. Selvig finds that this often underemphasized early stage is crucial in developing strength and neuromuscular control in a timely manner. But he is quick to point out this is not specific to skiers, athletes in general or ACL rehabilitation. All patients – regardless of injury or activity demands – must be able to move and control all three planes if they are to complete a full recovery and avoid risk of re-injury.
Two to four months after surgery, Selvig transitions from low speed, low load and vibration on the 1080 Quantum to increasing the load and varying the speed of movement. He establishes their baseline force, power, speed and acceleration on the affected and non-affected side with tri-planar squats, lunges, jumps and sport- / function-specific movements. He typically begins with concentric movements starting at 1 m/s and eccentric movements at 2.5-3 m/s. As patients progress, he maintains this eccentric-to-concentric speed ratio of 2.5-3x. Speed and load vary based on how the athlete is performing, with Selvig making adjustments constantly throughout the treatment session. “One of the real benefits of the 1080 Quantum is that I can literally change the speed limit or load at the push of a button. There is nothing else out there like it.”
At this stage of recovery the data output from the 1080 Quantum takes on an important role for both Selvig and the patient. It contributes objective, real-time data to help progress treatment, rather than Selvig relying solely on subjective input. The data also provides the patient with real-time cueing – a bit of extra motivation – to increase their performance through a given movement. A July study in the Journal of Strength and Conditioning Research validated this effect in resistance training, and Selvig – like many other performance specialists – has seen similar effects on his own.
Global strength and hypertrophy is a significant focus during this stage, and the volume of sets and repetitions reflects this. An exercise may be performed for 3-4 sets of 12-15 repetitions at the appropriate speed and load. Selvig also incorporates supersets, sets to fatigue and neuromuscular training during each session, explaining “Each session is different. I go into a session with a general idea of what I would like to accomplish but ultimately the athlete’s body dictates what we do and how we do it.”
The final stage emphasizes maximal power and force production and absolute tri-planar neuromuscular control. He manipulates the speed of the movement more than the load, aiming for lower concentric speeds and higher eccentric speeds to produce maximal force and power during both phases of a muscular contraction. The 1080 Quantum again allows him to overcome conventional caution by safely loading the athletes in functional positions without a potentially dangerous load on their back.
The rate of re-tears in the first year after surgery can be 10-15 times higher than in the non-injured population. The rate drops to 5-10 times higher in the second year. Selvig believes periodic “check-ins” post-return-to-play can alert coaches and rehab specialists to an increased potential for re-injury. Many of the same variables from his rehabilitation stages – decrease in eccentric force production or control, reduced tri-planar movement, disparity in force production between affected and non-affected leg – could signal the need for specific training, or additional recovery periods in the training or competition season.
Recent technologies allow Bo Selvig to quantify his methods, and validate his perspective on the shortcomings of traditional rehabilitation and return-to-play protocols. Referring to a recent patient, he said:
“I recently had an individual with multiple complex fractures of his scapula after a mountain bike injury. He opted not to undergo surgery. After the fracture had healed and a few months of rehabilitation, his MD decided to clear him for complete return-to-sport with no solid objective foundation.
“Testing on the 1080 Quantum revealed there was still a 30% deficit in strength in various functional positions (not your typical manual muscle testing). This objective data allowed us to continue with intervention, get the patient close to pre-injury levels and significantly reduce the risk of him re-injuring himself.”
Referring to another patient he encountered, “He came to us about four months post ACL reconstruction for a strength assessment on the 1080 Quantum. Testing revealed that he was strong in the sagittal plane but lacked significant strength and motor control in the frontal and transverse planes. This is a classic case of these important areas being underemphasized or even overlooked early on in the rehab process. Unfortunately he was unable to continue treatment with us, but hopefully he and his therapist will be able to utilize these findings throughout the rest of his rehabilitation.”
Stepping out of the ingrained constraints of risk aversion is not limited to rehab specialists and practices with the latest equipment. A provider only needs the will and confidence to think independently – not the machines – to progress a patient through rehab and return them with full confidence to doing what they love.
Basing much of his practice on progressive rehabilitation and training, Selvig encourages providers to step outside of the traditional protocols and interventions. Seeking answers beyond conventional acceptance will provide better care and outcomes, and create more room for the profession and the professionals in it to grow.