2014 advanced training [read-only] - memorial...
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Robert Mangine, M.Ed., PT, ATC
National Director Sports Residency Program
NovaCare Rehabilitation
Associate Athletic Director of Sports Medicine
University of Cincinnati
Department of Athletics
Adjunct Clinical Instructor of Orthopedics
University of Cincinnati
Department of Orthopedic Surgery
Concepts For Advanced PerformanceConcepts For Advanced Performance
manginre@ucmail.uc.edu
Objective Measures Objective Measures ““The End AllThe End All””
•The commonly held belief is that restoration of “measurable” structural and biomechanical parameters to a joint indicates restoration of normal function.
INTRODUCTION:
! Emerging clinical and basic science findings indicate a much
greater degree of underlying biological complexity in the joint.
�Evidence suggests that restoration of identifiable structural
abnormalities alone is not sufficient to restore a joint to its full
pre-injury level of physiologic function.
Advances in RehabilitationAdvances in Rehabilitation
33•• Biomechanical studiesBiomechanical studies
•• Clinical studiesClinical studies
Rehabilitation StagesRehabilitation Stages
Acute: immediate intervention, pain,
motion, early muscle loss
Intermediate: motion restoration, low
resistance program, core training
Advanced: performance training
Goal of this talk
Evaluation, determine return to play
Factor 1: Motion Associated Factor 1: Motion Associated
With Mechanism of InjuryWith Mechanism of Injury
Rotation is a critical motion related to injury and includes both tibial rotation and valgusrotation. Advanced rehabilitation recreates and controls these mechanisms on the patient as positions change.
A critical factor is preparation as the body alters its position during performance
Majority of injuries are non-contact, and occur due to poor body control
Rotational concepts involve
Upper and Lower
Limb
2
Secondary Mechanisms of Secondary Mechanisms of
InjuryInjury
Hyperextension
High load demand on
cruciates, not
protected by close
chain
Valgus / Varus
load application
rarely results in
sufficient force
unless accompanied
by a secondary load.
Factor 2 General ConceptFactor 2 General Concept
Form vs. FunctionForm vs. Function
Baseball
Soccer
Cheerleaders
Volleyball
Football
Hockey
Sport vs. Physiology vs. Mechanics
Player = We teach Players a comprehensive
program of strengthening, agility, speed, and endurance
Factor 2:Factor 2:
Advance Reconditioning TrainingAdvance Reconditioning Training
Return to ActivityReturn to Activity
� Advance Training must consider the patient goals and activity level:
� These are complex interventions that failure may result in salvage surgery
– Functional Progression
� SKILL
� PHYSICAL FITNESS
� TACTILE SENSING
� PSYCHOLOGY FACTORS
Factor 2:Factor 2:
Comprehensive ApproachComprehensive Approach
� Advance Training must consider the patient goals and activity level:
� These are complex interventions that failure may result in salvage surgery
– Functional Progression
� SKILL
� PHYSICAL FITNESS
� TACTILE SENSING
� PSYCHOLOGY FACTORS
Concept 1Concept 1
Technical SkillTechnical Skill
Rehabilitation teaches
ideal body movement
Quality repetitions,
replicating protective
movement
Age dependent
Injury dependent
Player = learns a systematic
form of self control
Concept 2 Tactile Sensing:Concept 2 Tactile Sensing:
Preparation for a ResponsePreparation for a Response
Design program to correlate with exercise demands
Follows the scientific basis of exercise physiology
Teach athlete a reflex response to external stimulation
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Concept 3 Concept 3
Physical Fitness and RePhysical Fitness and Re--ConditioningConditioning
Exercise Physiology 101
50% Science/50% Art
Injury vs. Performance
Test and MeasuresTest and MeasuresPerformance: Functional
Screens
NFL Combine – Specific
Bench 225
Shuttle 20
40 Yard sprint
Additional elenemts
Pull ups
Body fat
Concept 4 Psychological Concept 4 Psychological
Qualities Functional ProgressionQualities Functional Progression
The mental aspect of
rehabilitation has
been shown to
influence speed and
efficiency
Rehab on the field
Factor 3: Lower Limb Dynamic Factor 3: Lower Limb Dynamic
StabilizationStabilization
Effective
Components
Plyometrics
Technique analysis
Strength training
Core Stability
Ineffective
Components
Lack landing/cutting
training
Balance training only
Resistance training
only
Everyone Makes a Big Deal of Everyone Makes a Big Deal of
Close Chain TrainingClose Chain Training
So What, Only If ItSo What, Only If It’’s Functionals Functional
Paine: reduced anterior displacement by KT-1000
Beynnon and Johnson, Human model, CKC activities reduced stress on graft
Markoff: cadaveric measurement decreased shear, same as Grood
No protection in hyperextensionNo protection in hyperextension
or with rotationor with rotation
Brace for Protection
Advanced TrainingAdvanced Training
Exercises For Lower Extremity Exercises For Lower Extremity
TrainingTraining
Comprehensive rehabilitation of the
lower extremity complex requires all
available techniques, the dependent
variable among patients is the ability to
follow up in a controlled manner. The
program must not only account for
effectiveness but also be practical and
easily implemented in a home or school
setting.
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Types of FlexibilityTypes of Flexibility
Static Stretching:
Inhibition of tension receptors in our
muscles. When done properly, static
stretching slightly lessens the
sensitivity of tension receptors,
which allows the muscle to relax and
to be stretched to greater length.
Typically held for 10-30 seconds.
KICKERS, they tend to do their
own thing
Types of FlexibilityTypes of Flexibility
Dynamic Flexibility:
Actively moving a body part
through a range of motion
with momentum to help
improve neuromuscular
control, speed, and power
development.
Research on Dynamic Research on Dynamic --vv-- StaticStatic
Dynamic -v- Static Stretching Warm-up: The
Effect on Power and Agility Performance
Danny J. McMillan, Josef H. Moore, Brian S. Hatler, and Dean C.
Taylor
Results/Conclusion: Tested in T-Shuttle (agility), underhand
MB toss (upper body power), and 5 step jump (lower body power).
All 3 trials showed dynamic significantly better
than static or no warm up.
Research on Dynamic Research on Dynamic --vv-- Static Static
Static and Dynamic Acute Stretching Effect on
Gymnasts Speed in Vaulting
Pediatric Exercise Science, 15, 383-91. Siatras, T.,
Papadopoulos, G., Mameletzi, D., Gerodimos, V., &
Kellis, S. (2003).
Conclusion: Gymnasts running speed during
vaulting decreased after warm up with
static stretching compared with warm-up
alone or warm-up with dynamic stretch.
Dynamic Warm UpDynamic Warm Up Advanced Training StrengthAdvanced Training Strength
Olympic Lifts
Posterior Chain
Dead Lift
Stiff leg single leg dead lift
Single arm high pulls
Control weight overhead, serves multiple
purposes and balance functions
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Key to SuccessKey to Success
Pick it up off the floor
The Body
One Piece
Rarely Isolate muscle complex
Put it
overhead
Technique
critical
Strength ConceptStrength Concept
Emphasize Posterior Chain
Key to injury Prevention
( Hamstring, Gluteals, Spinal mm)
1. Dead lifts
2. Reverse Hypers
3. Glut/Ham
4. Low intensity
Bryan Mann, Development of the Posterior Chain, 2002
Insert Stacy Andrews
Glut Ham machine
Posterior Chain EmphasisPosterior Chain Emphasis
Step 1, Early
Step 2 Late
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Advanced Training Advanced Training
Limb Control ConceptLimb Control Concept
� Core Training Series
� Total Lower Extremity Training
� Functional PNF patterns
�Double leg bounding low level Plyometrics
� Single limb position 20% of training time +++++++
�Single Limb with external stimulation
Use 3 to 4 exercises and keep sets and reps low,
Provide proper warm up
Advanced Training Advanced Training
Core EmphasisCore Emphasis
The Effect of Core Proprioception on Knee Injuries: Zazulak BT, Hewett TE, et al AJSM, vol 35 2007
Impaired core propriceptionmeasured by active repositioning of the trunk, predicted knee injuries in female but not males. 3.3 fold increase in injury
Each degree of error in repositioning
resulted in 3.3 fold increase in odds
ration of ligament/meniscal injury of
the knee
Trunk ControlTrunk Control
Trunk displacement greater in athletes who suffered
knee ligament and ACL injuries
Lateral displacement was the strongest predictor of
injury
Dynamic Core EmphasisDynamic Core Emphasis
Functional Options
Strength Training as Total Body Strength Training as Total Body
Movement and Functional PositionMovement and Functional Position
Train
movement not
MUSCLE
Lateral Core MovementLateral Core Movement
Lateral Trunk Movement
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Advanced TrainingAdvanced Training
Strength EmphasisStrength EmphasisHigh resistance leg Press
Limited Knee extension
Full ROM Hamstring
Hip work, Inner/Outer thigh
Squats partial vs. full
Periodization program alter 8
week cycles
Eccentric emphasis, single leg
High load after healing period
Patella monitored
Advance TrainingAdvance Training
Neurological Neurological ““ContributionsContributions””
Rich Interplay (Afferent to Efferent) enables Rich Interplay (Afferent to Efferent) enables combination of Active & Passive Elements to combination of Active & Passive Elements to provide provide ““Harmony of motion & functionHarmony of motion & function””
Active - Muscular Stiffening of Joints (Eccentric is absorbing energy), key to middle of range
Passive - Non Contractile Soft Tissues, key to End Range
Affected by Magnitude of stretch, velocity of stretch, and time
Time between stretch stimulus and shortening response must be short
Mechanoreceptor AnatomyMechanoreceptor Anatomy
4 Types Receptors1:Ruffini corpuscles (type
I: pressure)
2:Pacini corpuscles (type II: velocity)
3:Golgi-Mazzoni
(type III: pressure)
4:Free nerve endings (type IV: pain)
Nerve supply of the human knee and its functional importance*Nerve supply of the human knee and its functional importance*
John C. Kennedy,John C. Kennedy,†† MD et al.MD et al.
The American Journal of Sports Medicine, Vol. 10, No.6The American Journal of Sports Medicine, Vol. 10, No.6
Neurological Golgi Tendon OrgansNeurological Golgi Tendon Organs
(GTO)(GTO)
One of two systems that monitor muscle
stiffness, the Muscle Spindle is the
other
Present in Tendon as a stretch receptor
in lower bundle to nerve ratio then first
theorized
Responds to stretch on Tendon
Response slower then muscle
Advanced Training Advanced Training
Clinic to the FieldClinic to the Field
Successful Rehabilitation
transition clinic simulation to
field activity
1:Training technique
2:Start to push functional
conditioning
3: Mentally push athlete
4: Integrate strength and
position coach
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Plyometric Warm up ProgramPlyometric Warm up Program
Trunk rotations
Trunk side bends
Trunk PNF patterns
Band Kicks
Double leg bounding
Jump Rope
Speed ladder
Use 3 to 4 exercises and keep sets and reps low,
this is warm up
Plyometric IntermediatePlyometric Intermediate
Cross over hops
Lateral cup or cone hops
Forward and lateral bag
hops
Lateral bag and ball toss
Lateral hop and 2
direction tubing
Advance TrainingAdvance Training
Speed of the GAME/Speed of INJURYSpeed of the GAME/Speed of INJURY
Reciprocal reaction: must
incorporate acceleration and
deceleration maneuver into
program
Power and endurance timing:
incorporation of closed chain
exercises to facilitate impact
loading
Compressive Loading: Incorporation
of closed chain exercise to
facilitate landing mechanics
Enhances neurological feedback
Plyometric AdvancedPlyometric Advanced
Dot drills
Continue trunk
program
Higher level box drills
Resistance front hop
Rotational position
landing
Advanced Training Advanced Training
Clinic to the FieldClinic to the Field
Successful Rehabilitation
transition clinic simulation to
field activity
1:Training technique
2:Start to push functional
conditioning
3: Mentally push athlete
4: Integrate strength and
position coach
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Plyometric IntermediatePlyometric Intermediate
Cross over hops
Lateral cup or cone
hops
Forward and lateral
bag hops
Lateral bag and ball
toss
Lateral hop and 2
direction tubing
Station 1
Dummy Exercises
A) Straight Line Bags
B) Crossing Bags
AGILITY AND QUICKNESS PROGRAM
Station 2
Dot Drills
- Heel on each dot (start)
- 5 drills: 6 times each
- 1st day - 80 sec. or less
- 1st Mon- 65 - line & big
-60 - skilled
Station 3
A) Plyoboxes
up/down
side to side
� � � � � � � � � �
Partner Lateral Cone Hop
� � � � � � � � � �
Station 4
A) Plyoball Toss
Chest Pass
B) Plyoball Sit-Ups
10"
18"
Advanced Training Session
Factor 9 FatigueFactor 9 Fatigue
Biomechanical Alterations
Increase anterior shear force
Decreased proprioception
Decreased neuromuscular function
Late onset of lower extremity muscle
activation
Significant difference in the knee valgus-
varus moment
Aerobic ReconditioningAerobic Reconditioning
Functional aerobic
reconditioning
Simulate
Fatigue
Fatigue
Fatigue
FORM - FORM
Carry it for TIME and Carry it for TIME and
DISTANCEDISTANCE
10
1) run 20 yrds in 4 sec.2) repeat 15 times
1) run 40 yrds in 6.5 sec.2) repeat 10 times
1) run 60 yrds in 9 sec. 2) repeat 8 times
1) run 20 yrds backward & uphill. 2) repeat 15 times
w
e
e
k
1
w
e
e
k
2
w
e
e
k
3
w
e
e
k
4
1) run 20 yrds in 4 sec.2). repeat 20 times
1) run 40 yrds in 6.5 sec.2). repeat 15 times
1) run 60 yrds in 9 sec. 2). repeat 8 times
1) run 20 yrds backward & uphill. 2) repeat 20 times
1) run 20 yrds in 4 sec.2). repeat 20 times
1) run 40 yrds in 6.5 sec.2). repeat 20 times
1) run 60 yrds in 9 sec. 2). repeat 10 times
1) run 20 yrds backward & uphill. 2) repeat 20 times
1) run 20 yrds in 4 sec.2). repeat 25 times
1) run 40 yrds in 6.5 sec.2). repeat 20 times
1) run 60 yrds in 9 sec. 2). repeat 10 times
1) run 20 yrds backward & uphill. 2) repeat 20 times
20
40
60
BWK
20
40
60
BWK
BWK
60
40
20
60
40
20
BWK
Example of Running Program
Basketball Sprint Program
Aerobic Reconditioning RetroAerobic Reconditioning Retro
Initiation of retro
training can occur by
Stairmaster
Band Training
Treadmill
Progress to incline
Aquatic
Return to Play AssessmentReturn to Play Assessment
Subjective
Examination (I.e.
pain)
Baseline
Measurements
Muscle evaluation
Joint Arthrometer
Functional Hop
Testing
Sports-Specific
Testing
No one gold standard, must piece
together results and use expertise
Return to Play AssessmentReturn to Play AssessmentArthrometryArthrometry testingtesting
KT-1000 evaluation high
level reliability
Developed as a
measuring tool to aide
clinical manual exam
User dependent
Return to Play AssessmentReturn to Play AssessmentObjective Muscle EvaluationObjective Muscle Evaluation
Many choices are
available:
MMT grading system
clinician dependent
Hand-Held
Dynomometer
Isokinetics dependent
on velocity of test
Functional Testing Critical to Functional Testing Critical to
Return to PlayReturn to Play
Single Leg Hop
Cross Over Hop
Time Hop
Triple Hop
Distance
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Return to Play AssessmentReturn to Play Assessment
Medical Clearance ≠ Return to Play
Cornerback Assessment
Return to Play CriteriaReturn to Play Criteria
Normal base
measurements
KT 1000 < 3 mm
Balance tests <20%
Isokinetic testing <10%
Functional Hop tests
<15%
Return to PlayReturn to Play
Position SpecificPosition Specific
Differences exist between the baseball thrower and the quarterback in terms of frequency and type
( pitches vs. passes and
number of type of pitches)
The Quarterback is exposed by his position at the time of release to traumatic impact
Contact from a anterior or posterior blow results in high skeletal forces with the arm in a vulnerable angle
Conclusion and OutcomeConclusion and Outcome
Clear understanding of normal anatomy and biomechanics
Restoration of normal movement patterns
Selection of appropriate exercise to restore normal function
THANK YOUTHANK YOU ReferencesReferences
Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance.
AJSM.1982; 10: 329 - 335
Mangine RE, Kremchek TE. Evaluation based protocol of the anterior cruciate ligament. J Sport Rehabil.1997; 6; 157-181.
Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment in normal an
anterior cruciate deficient knees. CORR. 1990; 255: 204-214
Noyes FR, Barber SD , Mangien RE. Abnormal lower limb symmetry determined by functional hop test after anterior cruciate ligament rupture. AJSM. 1991; 19: 513-518
Wilk et al. The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL reconstructed knee. JOSPT. 1994; 20: 60-73
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Factor 1 Functional Return ConceptsFactor 1 Functional Return Concepts
Rehabilitation starts
Immediately after the
injury we need a
aggressive plan that
starts in the acute
phase
Proper acute
intervention speeds
return
Initial ligament injury occurs withInitial ligament injury occurs with
Sports, Work Related Function,
or activities of daily living
Compensation
with activities
of daily living Re-injury
Meniscus tear
Arthritis
Rehabilitation is Performance Rehabilitation is Performance
TrainingTraining
Technical Skill
Ambulation patterns
Sports specific movements
Occupational specific
Tactical Sense
Proprioception
Kinesthetic awareness
Physical Fitness
Strength
Power
Speed and endurance
Psychological QualitiesTactical Sense
Factor 3: Lower Limb Dynamic Factor 3: Lower Limb Dynamic
StabilizationStabilizationBasic ConceptsBasic Concepts
Advanced functional training is a integrated approach of the neuromuscular system
Incorporate functional demands on the body based on physiologically accepted concepts
Designed to improve performance and prevention of repeat injury.
Control knee and ankle mobility to avoid unwarranted motions
Return neuromuscular system function to load demand
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