Sma 2015 hamstring symposium

PowerPoint-Prsentation

Nicol van DykRehabilitation DepartmentAspetar Sports Medicine and Orthopaedic Hospital

Criteria based progressionRehabilitation ProtocolforHamstring Strain Injury

Thank you David and Tony for the invitation to be part of this symposium today. Its wonderful to be here, and thoroughly impressed by the researchers yesterday. Some wonderful work to aspire to. I will be giving you the run down of our criteria for progression in our rehab protocol.1

AcknowledgmentConcurrent study with large RCT Main contributorsPatrice MuxartPhilipp JacobsenAnne van der MadeArnlaug WangensteenRod Whiteley

3

Outline of this presentation Criteria based progression algorhythmClinical predictors for RTS Re-injury risk


Case presentation24yr old professional1st HSI 1 day agoLeft HS Grade II BF(MRI confirmed)

Now lets imagine we have this scenario. Harry is a 24yr old football player with What else would you like to know? What would you measure at the initial assessment, and perhaps one week later? How long do you think it would take for him to return to sport? 10d? 20d? 40d?Hold on to that thought and Ill show you what weve come up with.6

Rehabilitation ProtocolOptions:Time basedCriteria based

7

OverviewWhat we didCRITERIA BASED PROGRESSIONAssessment protocolTreatment protocolHSI Grade I & IIWhat we measure and whyClinical reasoning for progression n>150RTS ~23 days (15-31) 6% recurrence

The article on thi 8

Passive movementMassage no painMassage - discomfortActive range of motionEccentric outer rangeSlow runConcentric through rangeFast runEccentric inner rangeIsometric inner rangeDirection changeOuter range ballisticStretchingTrunk controlCardio (bike)Isometric outer rangeTreatment Protocol

So we pooled together all the possible treatment modalities we could think we would use to treat HSI.Then we arranged them from easiest to hardestAnd it seemed like these exercises/treatments grouped themselves in 3 main stagesPassive (soft tissue)Passive movementActive movementStretchingStrengthening Eccentric & ConcentricRunning ProgressionFunctional

9

Cardio (bike)Massage - discomfortEccentric outer rangeSlow runConcentric through rangeFast runEccentric inner rangeIsometric inner rangeDirection changeOuter range ballisticStretchingTrunk controlIsometric outer range2 Run > 70%ROM SLR & HS > 75%3 100% runningPainless direction changePassive movementMassage no painActive range of motion1Painless single leg squatPainless bike 2XBW, 5 minsFull knee Ext supine

So we pooled together all the possible treatment modalities we could think we would use to treat HSI.Then we arranged them from easiest to hardestAnd it seemed like these exercises/treatments grouped themselves in 3 main stagesPassive (soft tissue)Passive movementActive movementStretchingStrengthening Eccentric & ConcentricRunning ProgressionFunctional

10

PhysioOn-fieldStage 1Stage 2Stage 3Stage 4Stage 5Stage 6Pain free single leg squatPain free bike 150W, 5 minsRun > 70%ROM SLR & HS > 75%100% runningPain free direction changeLight Football Training SessionIn-between Football Training SessionHeavy Football Training Session

The actual program ended up being 6 stages11

Additionally we measure daily a number of features, all of which our regression equations showed to be useful. The strongest predictors are highlighted, and our clinical decisions (progress, ISQ, regress) are based on these features12

Principles (after experience)Reassess and compare:Same or better Push Harder!Worse Too Much!

13

Daily monitoring of strength has been extremely useful to document the players recovery and later in rehabilitation the response to training14

The problem is the solution

Sports-specific replication of running:VolumeIntensityMechanics

GaitWalkJogRunTriple extensionLate swing (A drill)Direction change

4 laps =8 sprints X 3 sets~ 700m11s 3.1 s10% 100%3 reps12s 9s60% 100%

16

PhysioOn-fieldStage 1Stage 2Stage 3Stage 4Stage 5Stage 6Painless single leg squatPainless bike 150W, 5 minsRun > 70%ROM SLR & HS > 75%100% runningPainless direction changeLight Football Training SessionIn-between Football Training SessionHeavy Football Training Session

The constraints of a randomized controlled trial forced us to include a lot of on-field work in the clinic (running progression in particular) bear this in mind.Here are our 6 stages and the criteria to progress between them17

Criteria based progression algorhythmClinical predictors for RTS Re-injury riskOutline of this presentation

When can I play again?

Well, this is the question we are always asked, and usually its not only the player, but also the coach and the team management. How do we answer this question? Now I have already shown you our average time to return to sport was 23 days. Now how much play would you accept around that time prediction? 6 months? 3 months? 1 month? 2 weeks? 1 week? Less?If I say our average return to sport was around 23 days, how much 19

StudyNInterventionControlPEDro scoreEffectCibulka (1986)20SI manipulationNo5/10=Kronberg & Lew (1989)28SLUMP stretchingNormal stretching3/10+Malliaropoulos (2004)80Intensive stretchingNormal stretching4/10+Sherry & Best (2004)24Core stability + agilityStretching+ strength7/10+Silder et al. (2013)31Core stability + agilityRunning + eccentric5/10=Askling et al. (2013)75Lengthening exercisesConventional6/10+Askling et al. (2014)656/10+Cochrane (2012)Stretching(daily)Intensive stretching(4x daily)=323

PEDro score is 21

Return to Sport (RTS) after HSISimilar Grading Similar sporting requirements

1 - >50 weeks reported

In the literature, that is actually there is also a relatively broad answer. Now, do actually know why we measure certain things? Do we know if what we measure are important? This is exactly what we wanted to answer, and it is this question that we would like to focus on today:What do we measure, what measurements do we have to focus on?22

Treatment Outcomes

n:90Days to 1st treatmentDays to dischargeDays of treatmentMean3.2623.1919.93Min0117Max85551SD1.488.408.24

So remember this guy? How long did you think he would take to get back? Now if we had to say to him on day 1, we would say this based on the 90 subjects we have included.23

Regression Analysis

I am not sure how many stats junkies we have here today (I myself have to admit are fast becoming one), but I am not going to go into the statistical model too much. I do want to just explain it briefly.24

Best subsetsAdjusted R2Overfitting

Regression Analysis

R-squared or the coefficient of determinination is used to denote how well data fit a specific model. In other words, does what I predict will happen actually happen? The VARIANCE is of course when it doesnt work out exactly as predicted, and we often express how much of this variance we can explain also. In our case, we used a best subsets approach (which means we tried to determine which variables should be included by doing scatter plots of each one and depending on the kurtosis of the data, mean, medians and various measures of variance). But then we definitely overfitted the data. So as you can see here, we came up with a too good to be true scenario. So this is the one limitation to this analysis.25

Initial Exam 50.3% variance explained ( 23 days)

MRI parameters 8.6% variance explained ( 40 days)

Initial Exam & MRI 3% extra variance explained

ResultsXXX

So we looked at 3 different scenarios, and this is what we could explain.26

ResultsWeek 1 Exam 97% variance explained ( 5 days)`

What does this mean for us clinically? 28

Outer Range P with strength test

Max P @ injuryDelay start of treatmentPeak Torque HS CON 60/s Playing footballSingle leg BridgeWeek 1 Mid Range StrengthInner range strength injured legOuter Range strength %Pain free walkingRegression Equation Week 1

So this seems to be the indicators that we need to pay attention too. Now from that initial slide where we had all of them, these are the ones to pay attention to. Now, on the basis of 90 patients, I wont tell you to discount 100 years of clinical experience, and at this stage we are still considering that. Although I would suggest that these are the ones we need to pay more attention to.29


Predictors of Recurrence?6/90 (6%)

Take home messageStart treatment earlyLength of pain (palpation)Max P at the time of injuryStrength Mid Range(outer if you can)Length of pain(palpation)Single leg bridgeHamstring strength (compared to other side) and PStrength Outer Range

INITIAL EXAMWEEK 1 EXAM

Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and timeto return to pre-injury level. Br J Sports Med 2006; 40(1):40-44.Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinicalexamination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc 2010; 18(12):1798-1803.Opar, DA, Piatkowski, T, Williams, MD, Shield, AJ. A Novel Device Using the Nordic Hamstring Exercise toAsess EccentricReurink G, Goudswaard GJ, Oomen HG, et al. Reliability of the Active and Passive Knee Extension Test inAcute Hamstring Injuries. Am J Sports Med Published Online First: 4 June 2013.doi:10.1177/0363546513490650Pincivero, Lephart, & Karunakara, 1997Schneider-Kolsky ME, Hoving JL, Warren P, Connell DA. A comparison between clinical assessment andmagnetic resonance imaging of acute hamstring injuries. Am J Sports Med 2006; 34(6):1008-1015.Thorborg K, Bandholm T, Holmich P. Hip- and knee-strength assessments using a hand-helddynamometer with external belt-fixation are inter-tester reliable. Knee Surg Sports Traumatol Arthrosc2013; 21(3):550-555.Tol et al 2014Whiteley et al (2012)_ Correlation of isokinetic and novel hand-held dynamometry measures of kneeflexion and extension strength testing JSAMS

References

Health & Medicine

Sma 2015 hamstring symposium