Can End Stage Rehab be Assessed Truly Scientifically?
Last month I was invited to present at the annual Football Medical Association (FMA) conference by my old boss Dr Bryan English. I was given the somewhat provocative title of ‘Can end stage rehab be assessed truly scientifically?’ and I am going to share a summary of it here.
My emphasis throughout was that the scientific assessment of rehabilitation is just one piece of a very complex puzzle and that it cannot be the sole determinant of Return to Training or Playing, but can help add objectivity to decision making.
Rehabilitation is an important process because there is a 4x greater risk of reinjury compared to the original injury (Fuller et al, 2007) and specifically in football a 5x greater risk of reinjury has been associated with knee and ankle sprains (Arnason et al, 2004). Despite this risk one survey found 35% of experienced team clinicians would ‘clear’ an athlete to participate even if the risk of an acute injury was increased (Schultz et al, 2013). In my opinion this may be down to the complexity associated with end stage rehabilitation. The same research group that conducted the survey had previously published a decision making Return to Play (RTP) Model (Creighton et al, 2010) aiming to help clarify the process and decreased controversy. It splits the decision into three main steps with 19 factors however, each of these have their own level of controversy and complexity.
Furthermore what are we actually aiming for in the end stage? One of the suggestions in that paper was ‘full return without restriction’ but is that always realistic or necessary? I presented GPS IMA data that could be used to assess the restriction in high intensity changes of direction in a player two years post Achilles tendon rupture – would no restriction ever be possible from this severity of injury?
I discussed the importance of your end stage philosophy as a department, which followed on nicely from the excellent, earlier presentation by the Middlesbrough FC team, Chris Moseley and Adam Kerr, on their philosophy. At what point does the player get passed between physio and conditioner? Who is responsible for the rehabilitation? How do you define RTT/RTP? How does the Coach expect the player to be when returning to training – can you use training as part of the end stage or should they be 100%? What are the differences between the 1 on 1 rehab environment and the 20+ man unpredictable, reactive training environment and what you can therefore achieve within them?
I like the following quote from Joyce and Lewindon’s High Performance Training for Sports (2014) to summarise:
‘Although we cannot perfectly guarantee that an injury will not recur when the player steps out onto the pitch, there are a number of factors that, if taken into consideration when determining return to competition, can help determine whether the risk of playing is acceptable.’
So now we understand the context of data in rehabilitation, what can we assess scientifically?
- We can track progress in physical capacity both bilaterally and unilaterally, for example using jump testing. However, caution must be exercised if comparing against the uninjured side – we do not work in a symmetrical sport and a recent publication from cricket demonstrated pain was associated with symmetry rather than asymmetry (Gray et al, 2015).
- We can use technology to assess movement during function in detail. I presented accelerometry data during a straight line running clip of a player returning from a Grade II deltoid ligament injury that highlighted the difference in force the player was putting through the foot strikes on the injured side compared to the non-injured side.
- We can objectify the demands of training and games for each individual player; for me one of the greatest advantages from the upsurge in Sport Science in football over the past few years. By understanding these individual demands you can create targets or exit criteria for the end stage. (Whilst always considering the complexity of injury and the other pieces of the rehabilitation puzzle of course!!)
- We can align the objective feedback during rehabilitation with these targets or criteria. I demonstrated how colour coding a GPS report can help to align the data with exit criteria.
- Finally, we can continue to assess throughout the reintegration from rehabilitation to training. I used an example that highlighted a jump in load (rolling one and three weekly load) for a player returning to training, which may have contributed to a reinjury.
Many thanks to the FMA and Dr Bryan English for the invitation to speak. You can read more about the Football Medical Association here: http://www.footballmedic.co.uk/
Arnason A, Sigurdsson SB, Gudmundsson A, et al. (2004) Risk factors for injuries in football. Am J Sports Med 32: 5S-16S.
Creighton DW, Shrier I, Shultz R, et al. (2010) Return-to-Play in Sport: A Decision-based Model. Clin J Sport Med 20: 379-385.
Fuller CW, Bahr R, Dick RW, et al. (2007) A framework for recording recurrences, reinjuries, and exacerbation in injury surveillance. Clin J Sport Med 17: 197-200.
Gray J, Aginsky KD, Derman W, et al. (2015) Symmetry, not asymmetry, of abdominal muscle morphology is associated with low back pain in cricket fast bowlers. J Sci Med Sport 23: pii: S1440-2440(15)00091-2. doi: 10.1016/j.jsams.2015.04.009. [Epub ahead of print]
Joyce, D; Lewindon, D., editors; 2014. High-performance Training for Sports. Champaign, IL: Human Kinetics, .
Shultz R, Bido J, Shrier I, et al. (2013) Team Clinician Variability in Return-to-Play Decisions. Clin J Sport Med 23: 456-461.
Really interesting article! RTP is a complex subject.
What do you think about the use/addition of EMG to asses neuromuscular activity of the player during the rehabilitation process? I came to find this Finnish company (www.myontec.fi) who design short pants embedded with textile electrodes and thought this could a plus for the rehab process. What do you think?
Thank you for your comment. I haven’t had any direct experience with using EMG myself within rehabilitation but I have read a little about it. My colleague has done a bit of work in the past with the EMG shorts. I think it is an interesting area with great potential although not within limitations, especially in terms of measuring the activity of the deep muscles. Here are a couple of papers on using EMG to understand neuromuscular activity during different exercises.
Zebis, M.K., Skotte, J., Andersen, C.H., Mortensen, P., Petersen, M.H., Viskaer, T.C., et al. (2012) Kettlebell swing targets semitendinosus and supine leg curl targets biceps femoris: an EMG study with rehabilitation implications. Br J Sports Med. Epub ahead of print.
Serner, A., Jakobsen, M.D., Andersen, L.L., Holmich, P., Sundstrup, E., & Thorborg, K. (2013). EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. Br J Sports Med, 3:1-8.
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