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Prehabilitation & Improved
Performance for Athletes (P.I.P.A.)
Tina NguyenMay 2, 2011
KSN 501
Table of Contents Introduction
Prehabilitation
Other ACL Prevention Programs
P.I.P.A. Program
Program Overview
Program Component Details
Recommendations
Introduction~200,000 ACL injuries occur each year in the
U.S.
70% non-contact: cutting, jumping
ACL Injury Mechanism 1. Anterior Tibial Shear 2. “Knee Valgus Collapse”
Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes. Journal of Strength & Conditioning Research, 25(1), 271-285.Thomas, A.C., McLean, S.G., Palmieri-Smith, R.M. (2010). Quadriceps and hamstrings fatigue alters hip and knee mechanics. Journal of Applied Biomechanics, 2, 159-170.
Prehabilitation Why?
Secondary injury Financial (surgery/rehab) Psychosocial Costs
Benefits Drawbacks
Less time Lack of high-intense loads
Cost effective Increase time demands
Improve compliance Unable to change warm-up for variability
Increase fatigue Monotony
Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes . Journal of Strength & Conditioning Research, 25(1), 271-285.
Program Comparison
Program Components
Time/Duration
Feedback
Research
KLIPCenter for Orthopaedic and Biomechanics Research, Boise State University
PlyometricsAgility
20 minutes3x/week7 weeks
InstructionsVideotapeHandouts
Irmischer et al, 2004Pfeiffer et al, 2006
PEPSanta Monica Orthopaedic and Sports Medicine Research Foundation
Warm-UpStretchStrengthPlyometricsAgility
15-20 mins3x/week
InstructionsVideotape
Pollard et al, 2006Mandelbaum et al, 2005
WIPPSportsMetrics, Cincinnati Sports Medicine and Orthopaedic Center
Warm-UpPlyometricsStrengthFlexibilityAgility
20 mins3x/week6 weeks
InstructionsVideotape
Barber-Westin et al, 2010Barendrecht et al, 2011
P.I.P.A. ProgramActive Warm-Up
Jog
Walking Calf Raise
High Knee Walk
High Knee Cradle
Heel to Glute Stretch
Jog
Strength/EccentricSingle-Leg Split Squat
Single-Leg Dead Lift
Squat Jumps
Single Leg Hops
Plyometrics
Single-Leg Lateral Bound
Forward Bound
Squat Jumps over cone
Single-Leg Jumps over coneSingle-Leg Lateral Jumps over cone
Agility
Diagonal Quick Steps
Diagonal RunShuffle (*add unanticipation)
T Drill
~20 minutes 3 X/ week7-weeks Pre-SeasonBrophy et al. , 2010
Holcomb et al., 2007
Brophy, R.H., Silvers, H.J., Mandelbaum, B.R. Anterior cruciate ligament injuries: Etiology and prevention. Sports Med Arthrosc 18: 2-11, 2010.Holcom, W.R., Rubley, M.D., Lee, H.J., Guadagnoli, M.A. Effect of hamstring-emphasized resistance training on hamstring:quadriceps strength ratios. Journal of Strength & Conditioning Research 21: 41-47, 2007.
P.I.P.A. Overview Purpose: To reduce the incidence of ACL injuries through
neuromuscular training, which reduces the risk factors associated with the injury
Population: Female athletes that require jump landing, change of direction, and decceleration
Females are 2-8 times more likely to suffer an ACL injury than males
Females: Greater hip adduction & internal rotation (knee valgus) knee flexion time activation in hip musculature in response to sudden
loading Quad dominant Smaller intercondylar notch
Thomas, A.C., McLean, S.G., Palmieri-Smith, R.M. Quadriceps and hamstrings fatigue alters hip and knee mechanics. Journal of Applied Biomechanics 2: 159-170, 2010.
Active Warm-Up
blood flow to working muscles
core temperature
muscle stiffness
Active = progression
Activation of one muscle while contracting another
Active Warm-UpJog
Walking Calf Raise
High Knee Walk
High Knee Cradle
Heel to Glute Stretch
Jog
Strength/Eccentric Single-Leg (SL) exercises - glute/hamstring activation
Hamstrings – tibia internal and external rotation Hams-to-Quad Ratio
Decrease hip adduction (P= .015) Decrease knee abduction (P= .038) Decrease ankle eversion (P= .020) Increase knee flexion (P= .005)
Myer, et al., 2006
Leg Dominance (Myer et al., 2006) Glute Activation
Medius – hip abduction; Maximus – hip external rotation “Eccentric load of hamstrings was more effective in increasing
hamstring-to-quadriceps strength ratios than traditional concentric exercises in multiple studies.” (Kaminski et al., 1998)
Strength/Eccentric
Single-Leg Split Squat
Single-Leg Dead Lift
Squat Jumps
Single Leg Hops
Bien, D.P., (2011). Rational and implementation of anterior cruciate ligament injury prevention warm-up programs in female athletes . Journal of Strength & Conditioning Research, 25(1), 271-285.Herman, D.C., Onate, J.A., Weinhold, P.S., Guskiewicz, K.M., Garrett, W.E., Yu, B., Padua, D.A. The effects of feedback with and without strength training on lower extremity biomechanics. The American Journal of Sports Medicine 37(7): 1301-1308, 2009.Kaminski, TW, Wabbersen, CV, and Murphy, RM. Concentric versus enhanced eccentric hamstring strength training: Clinical implications . J Athl Train 33: 216–221, 1998.Myer, G.D., Ford, K.R., Brent Jensen, L., Hewett, T.E. The effects of a plyometric versus dynamic stabilization and balance training on power balance, and landing force in female athletes. Journal of Strength & Conditioning Research 20(2): :345-353, 2006.
Strength/Eccentric cont.
Blackburn & Padua, 2009: Trunk flexion = GRF (F1.38 = 41.607, P< .001)
Shimokochi et al, 2009 (At peak knee extensor, mean ± SD): Sagittal-plane ankle internal moment, Nm/kg 0.2 ± 2.1 Peak knee-extensor moment, Nm/kg -3.8 ± 2.1 Sagittal-plane hip internal moment, Nm/kg 0.8 ± 2.7 Anterior-posterior center of pressure, m -0.026 ±
0.046
Strength/Eccentric
Single-Leg Split Squat
Single-Leg Dead Lift
Squat Jumps
Single Leg Hops
Blackburn, T.J., Padua, D.A. Sagittal-plane trunk position, landing forces, and quadriceps electromyographic activity. Journal of Athletic Training 44(2): 174-179, 2009.Shimokochi, Y., Lee, S.Y., Shultz, S.J., Schmitz, R.J. The relationships among sagittal-plane lower extremity moments: Implications for landing strategy in anterior cruciate ligament injury prevention. Journal of Athletic Training 44:91): 33-38, 2009.
• Squat Jumps• Technique
Emphasis• Posterior Kinetic
Chain• Core Stability
Training
Plyometrics
Purpose: Introduction to acceleration/speed Power development in flexor musculature Static to progressive (forward/lateral) movement
Effects: GRF deep knee flexion
SL Forward/Lateral Jumps Over Cone – Coronal plane knee control Side to side imbalances (multiplane knee load)
Shimokochi & Shultz, 2008: multiplane loadings are primary mechanism
Plyometrics
Single-Leg Lateral Bound
Forward Bound
Squat Jumps over cone
Single-Leg Jumps over cone
Single-Leg Lateral Jumps over cone
Myer, G.D., Ford, K.R., Brent Jensen, L., Hewett, T.E. The effects of a plyometric versus dynamic stabilization and balance training on power balance, and landing force in female athletes. Journal of Strength & Conditioning Research 20(2): :345-353, 2006.Lephart, S.M., Abt, J.P., Ferris, C.M., Sell, T.C., Nagai, T., Myers, J.B., Irrgang, J.J. Neuromuscular and biomechanical characteristic changes in high school athletes: A plyometric versus basic resistance program. Biomechanical Journal of Sports Medicine 39: 932-938, 2005.Shimokochi, Y. & Shultz, S.J. Mechanicms of noncontact anterior cruciate ligament injury. Journal of Athletic Training 43(4): 396-408, 2008.
Improved shock absorption (~20%)(Lephart et al, 2005)
Agility Addresses change of direction and deceleration
Focus: driving off back foot, lower extremity mechanics
Agility
Diagonal Quick Steps
Diagonal RunShuffle (*add unanticipation)T Drill
Shuffle (*add unanticipated directional change) Simulates sport
movement Sell et al, 2006:
Unanticipation vs. Planned
Sell, T.C., Ferris, C.M., Abt, J.P., Yung-Shen, T., Myers, J.B., Fu, H.F., Lephart, S.M. The effect of direction and reaction on the neuromuscular and biomechanical characeristics of the knee during tasks that simulate the noncontact anterior cruciate ligament injury mechanism. The American Journal of Sports Medicine 34(1): 43-54, 2006.
Agility cont.
Imwalle et al, 2009: Hip and knee internal rotation (p = 0.008) increased during 90° cut
vs the 45° cut Mean hip flexion (p < 0.001) was also greater in 90° cut
T Drill: incorporates multiplane movements and most concepts from previous components
Imwalle, L.E., Myer, G.D., Ford, K.R., Hewett, T.E. Relationship between hip and knee kinematics in athletic women during cutting maneuvers: A possible link to noncontact anterior cruciate ligament injury and prevention. Journal of Strength & Conditioning Research 23(8): 2223-2230, 2009.
P.I.P.A. Summary Emphasize Technique
Induce Fatigue Affects muscle spindles & Golgi tendon organs decreased
proprioceptive feedback to CNS & decreased neuromuscular control (Fischer, 2006)
Chappell et al 2005: 21% peak proximal tibial anterior shear force Females had greater knee extensor moments (P = .001) 96% knee valgus moment/ 43% knee varus moments for females 14% knee flexion angle
Provide Feedback Herman et al, 2009:
Feedback showed significant improvements in kinetic and kinematic variables
Chappell, J.D., Herman, D.C., Knight, B.S>, Kirkendall, D.T., Garrett, W.E>, Yu, B. Effect of fatigue on knee kinetics and kinematics in stop-jump tasks. The American Journal of Sports Medicine 33(7): 1022-1029, 2005.Fischer, D.V. Neuromuscular training to prevent anterior cruciate ligament injury in the female athlete. Strength & Conditioning Journal 28(5): 44-54, 2006.Herman, D.C., Onate, J.A., Weinhold, P.S., Guskiewicz, K.M., Garrett, W.E., Yu, B., Padua, D.A. The effects of feedback with and without strength trainfing on lower extremity biomechanics. The American Journal of Sports Medicine 37(7): 1301-1308, 2009
Future Recommendations
Optimal Duration
Unanticipated changes of direction
Young age population
Implicit learning (Benjaminse & Otten, 2010)
References Barber-Westin, S.D., Smith, S.T., Campbell, T., Noyes, F.R. The drop-jump video screening test: retention of
improvement in neuromuscular control in female volleyball players. Journal of Strength and Conditioning Research 24(11): 3055-3062, 2010.
Barendrecht, M., Lezeman, H.C.A., Duysens, J., Smits-Engelsman, B.C.M. Neuromuscular training improves knee kinematics, in particular in valgus aligned adolescent team handball players of both sexes. Journal of Strength and Conditioning Research 25(3): 575-584, 2011.
Benjaminse, A., Otten, E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Trauatol Arthrosc 19(4): 622-627, 2010.
Dienst, M., Schneider, G., Altmeyer, K., Voelkering, K., Georg, T., Kramann, B., Kohn, D. Correlation of intercondylar notch cross sections of the ACL size: A high resolution MR tomographic in vivo analysis. Arch Orthop Trauma Surg 127: 253-260, 2007.
Irmischer, B.S., Harris, C., Pfeiffer, R.P., DeBeliso, M.A., Adams, K.J., Shea, K.G. Effects of a knee ligament injury prevention exercise program on impact forces in women. Journal of Strength & Conditioning Research 18(4): 703-707, 2004.
Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., Thomas, S.D., Griffin, L.Y., Kirkendall, D.T., Garrett, W. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. The American Journal of Sports Medicine 33(7): 1003-1010, 2005.
Pfieffer, R.P., Shea, K.G., Roberts, D., Grandstrand, S., Bond, L. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. The Journal of Bone and Joint Surgery 88-A8: 1769-1774, 2006.
Pollard, C.D., Sigward, S.M., Ota, S., Langford, K., Powers, C.M. The influence of in-season injury prevention training on lower-extremity kinematics during landing in female soccer players. The clinical Journal of Sport Medicine 16(3): 223-227, 2006.