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Implementation Strategies for ACL Injury
Prevention:
Practical Applications
Lindsay J. DiStefano, PhD, ATC
Associate Professor
Department of Kinesiology
University of Connecticut
1
What is in Injury Prevention
Program/Preventive Training Program?
• Exercise-based program
• Multi-faceted program consists of:
– Plyometric
– Balance
– Agility
– Flexibility
– Strengthening (Steffen, 2008; Gilchrist, 2008; LaBella, 2011; Walden, 2012)
2
Dynamic Warm-up/Injury Prevention Program
P-1
P-2
Acceleration Action Jog Recovery Dynamic activity
~8 meters ~4 meters
3
Need for High Movement Quality
4
Need for High Movement Quality
5
Need for High Movement Quality
6
How Can We Promote COMPLIANCE?
DO AN INJURY
PREVENTION PROGRAM
Routine
Cue
Positive reinforcement
Ready to perform
Desire for reward
Perform PTP
Initiation of training
Adapted from Padua, 2014
Injury Prevention
Modify Risk Factors Early
Create Habits
Fundamental Movement Skills
9
2015 Basketball Dynamic Warm-Up
“EO BASKETBALL!”
Key Points: Land softly, get low, bend your knees
Exercise Description
Elephant to Flamingo § Right foot forward with heel on ground and
knee straight § Squat down on left leg and lean forward
swinging arms down right leg to pull toes up § Step up onto right leg, pull left foot to left
buttock to stretch left quad. Repeat with opposite leg.
§ Stand on left foot, Raise right knee up § Rotate right knee and hip out § Two step shuffle diagonally.
§ Repeat on left side § Repeat by “closing” the gates bring knees
inward.
Good position Bad position
Cues
Open / Close the Gate
Butt Kicks
§ Lunge forward onto right foot § Keep your torso straight and drive your
hips towards the ground
§ Rotate arms across chest to stretch back § Repeat with opposite leg
AHHHHH Lunge
Side Lunge
Elephant:
Sit back like you’re
sitting in a chair!
Flamingo:
Bend your stance
leg!
Rotate your hips to get a good
stretch!
Keep knees at 90 degrees and
your knee
behind your
toes!
Court Set-up
Exercise
Progressive Run
Recovery
Jog back
to Start
§ Lunge sideways onto right leg § Sit back and stretch inside of leg § Repeat on opposite side
Sit back!
Keep your
knee behind
your toes!
§ Step forward and balance on one leg § Raise your other leg straight ahead
while keeping your knee straight.
Keep your kicking leg
straight!
Kick Walks
Elevator Jumps
§ Squat down, jump up for max height, repeat 9 times
Get low! Land softly! Sit back!
PEDIATRIC ACL INJURY PREVENTION PROGRAM “EO BASKETBALL!”
Exercise Description Cues
§ Explode diagonally to the right 3 steps § Land on outside foot (right), plant, and cut
in opposite direction.
! Cuts
EXPLODE off the cut
Land softly!
§ Lay right side-lying with elbow stacked
under shoulder, feet together. Lift hips off
ground, keeping body in a straight line.
§ Bend bottom knee to 90 degrees if needed.
§ Hold Side Plank for 20 seconds.
§ Carioca facing one direction to half court.
§ Transition into a left side-lying plank and
hold for 20 seconds.
§ Carioca back to baseline facing other
direction.
Hips too low
Hips too high
Hips too low
Hips too high
Common Errors
T Shuffle
Balance Hops § Hands on hips § Hop forward from left foot onto right
foot
§ Land low – bend at knees, hips, ankles § Balance on stance leg for 5 seconds
§ Repeat on opposite leg.
Hold your
balance for 5
seconds!
Arrow Sequence
§ Hands on hips § Hop sideways from right foot to left foot
§ Land low, land softly
§ Balance for 5 counts
§ Repeat on opposite leg
Lateral Hops Hold your
balance for 5
seconds!
§ Skip for maximal height § Land softly § Repeat and sprint to 20 yard
line
Leaps
§ Sprint to half court § Side shuffle to sideline
§ Side shuffle back
§ Sprint to end baseline
10
AT
Coach
Captain Athletic Director
Coach
Team MD
Captain Coach
11
Are they ready for change?
Knowledge
Perceptions
Risk
Benefits
Self-efficacy
Social norm
Implementation Barriers
Time
Personnel
Environment
Organization
Identify barriers & solutions
Session Duration & Frequency
Time of Day
Total Duration
Support Personnel
Individuals to Train
Goals & Metrics
Current Behaviors
Equipment Location
12 Padua, 2014
Goals & Metrics
• What matters to them?
– Warm-up, performance, sport-specificity
• Educate
Organization
13
Academic
• Classes (10) & Exams missed (2)
• Test failure rate (36%)
• GPA (0.3)
Individual
• Player efficiency rating (NBA)
• Power rating & Durability (NFL)
Team
• Team ranking (r = .93)
• Games won (r = .88)
• Points scored (r = .89)
• Point differential (r = .82)
• Total points over season (r = .93)
Performance
Cost
Disability
Must develop systematic processes to prevent
musculoskeletal injury and optimize performance
Number of games missed due to injury is
predictive of the number of team wins
during a season
NBA Seasons 2001 - 2011
Impact of Injury in
Sports
14 Padua, 2014
15
16
Acute Performance Changes
• Power (Yamaguchi, 2005)
• Strength (Yamaguchi,
2007)
• Sprint time (Goodwin,
2002; Fletcher, 2007; Faigenbaum, 2006)
• Vertical jump (Faigenbaum, 2006; Thompsen, 2007)
• Agility tasks (McMillan,
2006)
17
Performance Changes over Time
• Vertical jump (Chappell,
2008; DiStefano, 2012; Kilding,
2008; Hewett, 1996; Noyes,
2005)
• Hop distance (Herrington, 2010; Barber-
Westin, 2010)
• Hop speed (Chappell,
2008)
• Sprint speed (Kilding,
2008; Barber-Westin, 2010)
18
Organizational Goals
Peck, 2013 19
Organizational “ideas”:
Sport Specificity • Majority of programs are generic
– Tested in soccer or handball
– Do not include true “sport-specific” activities
• Sport-specificity
– Makes it relatable
– Perceived effectiveness
– Options for increasing difficulty
– Not boring
– Fun!
20
21
Current Behaviors “Relative Advantage” Organization
Where?
When?
How?
-Individual?
-Team-based?
Relative Advantage
22
Current Activities Revised Activities Hip Gates Hip Gates
Quad Pulls Quad Pulls
Butt Kicks Butt Kicks
Hamstring Sits Hamstring Sits
Hamstring Kicks Front Hamstring Kicks Front
Hamstring Kicks Across Hamstring Kicks Across
Walking Lunges Walking Lunges
High Knees High Knees
Side Lunges Side Lunges
Side Shuffle Side Shuffle
Carioca Carioca
Power Skips Power Skips
Forward Hops to Balance Forward Hops to Balance
Missing: Add:
Core Exercises Plank Series
Additional Balance Side Hop to Balance
Plyometrics Squat Jumps
Implementation Barriers
Time
Personnel
Environment
Organization
Identify barriers & solutions
Session Duration & Frequency
Time of Day
Total Duration
Support Personnel
Individuals to Train
Goals & Metrics
Current Behaviors
Equipment Location
23
Barrier: Time
• More is better
• Minimum
• Organizational constraints
• Total dosage
– 10 min/day
– 3 days/week
– 6 weeks
– 10x3x6=180 min 24
Time
CT Coaches Survey
0 50 100 150
5
10
15
20
30
Number of Respondents
IPP
Du
rati
on
Minutes Willing to Perform an IPP
No
Yes
88%
79%
26%
20%
25
50%
Martinez, 2014
Retention of ACL IPP
0
1
2
3
4
5
6
7
8
Pre-test Post-test Retention-test
LE
SS
Time
Extended
Traditional
*P<0.05 Padua, 2012 26
Implementation Barriers
Time
Personnel
Environment
Organization
Identify barriers & solutions
Session Duration & Frequency
Time of Day
Total Duration
Support Personnel
Individuals to Train
Goals & Metrics
Current Behaviors
Equipment Location
28
Implementation Barriers
Time
Personnel
Environment
Organization
Identify barriers & solutions
Session Duration & Frequency
Time of Day
Total Duration
Support Personnel
Individuals to Train
Goals & Metrics
Current Behaviors
Equipment Location
29
Who will implement?
• Athletic Trainer
• Coach
• Athletes
• Strength & Conditioning staff
• Parent
• Teacher
30
Steps for “Training”
Establish:
• Knowledge of effectiveness
• Alignment with goals of “trainer” & organization
• Knowledge of program
• Self-efficacy
• Feedback
• Maintenance
31
32
To
tal
LE
SS
Sc
ore
P r e P o s t
3
4
5
6
7
8
9
E x p e r ie n c e d
N o v ic e
*
To
tal
LE
SS
Sc
ore
P r e P o s t
3
4
5
6
7
8
9
E x p e r ie n c e d
N o v ic e
*
To
tal
LE
SS
Sc
ore
P r e P o s t
3
4
5
6
7
8
9
E x p e r ie n c e d
N o v ic e
*
To
ta
l L
ES
S S
co
re
P re P o s t
3
4
5
6
7
8
9
E x p e r ie n c e d
N o v ice*
Pryor, 2015
1) Establish administrative support
2) Develop an interdisciplinary team
3) ID barriers & solutions
4) Develop a scalable PTP
5) Train the trainers & users
6) Fidelity control
7) Maintenance/exit
Summary
Key Points
• Identify implementation barriers & develop solutions prior to developing a PTP
• Establish high-level of self-efficacy, not just knowledge
• Regular, targeted feedback on implementation fidelity
• Goal-oriented exit strategy
• Maintenance support plan
33 Padua et al., 2014
Acknowledgements
R01-AR050461
R03-AR057489
P60-AR064166
Pilot Research Award
W81XWH-11-2-0176 CDMRP Peer Reviewed
Medical Research Program
34
