Incorporating Functional Performance Testing into Clinical Practice EATA 58th Annual Meeting and Clinical Symposium Ph

1. Incorporating Functional Performance Testing into Clinical Practice EATA 58th Annual Meeting and Clinical SymposiumPhiladelphia, PA January 10, 2006 Thomas W. Kaminski, PhD, ATC, FACSM Associate Professor Director of Athletic Training Education

2. Learning �All of life should be a learning experience, not just for the trivial reasons but because by continuing the learning process, we are challenging our brain and therefore building brain circuitry� Arnold Scheibel

3. Workshop Objectives Background and Relevance Mechanics and Physiology Specific Performance Tests Reliability and Validity Concerns Take Home Message

4. What is Function? Function � from Latin �functio� meaning to perform, the special action or physiologic property of an organ or other part of the body (Stedman�s) What constitutes lower extremity �function�? Speed Agility Hopping Jumping Landing Balance Proprioception Stability Strength Muscle Reaction Time Joint Laxity Kicking Subjective considerations

5. Ultimate Rehabilitation Goal Return the athlete/patient to the highest functional level in the most efficient manner!

6. Functional Performance Testing Can assist the clinician in making return to play decisions �These tests are designed to simulate, in a controlled manner, the stresses produced and imposed on the LE during athletic participation� � Drouin and Riemann - ATT 2004 The outcome measure is a summary variable that represents a patient�s sensorimotor function, muscle strength and power, flexibility, pain, and confidence

7. Why Do Clinicians Find These Tests Useful? Quantitative measure utilized to define function Simulates real-life forces Indirectly assesses the extent to which pain inhibits the task execution Indirectly quantifies muscular strength Indirectly assesses the ability of a limb to absorb force Assesses the ability of muscles to dynamically stabilize joints Quantitatively assesses progress within rehab Qualitatively assess compensation or asymmetry via clinical observation Provides psychological reassurance to the athlete

8. Return to Play Criteria Acute signs/symptoms of the LE injury have resolved, no pain or edema is evident Athlete has full ROM normal strength muscle endurance CV endurance appropriate proprioception agility & coordination

9. Return to Play Criteria 3) Athlete is able to perform any and all sport specific activities at least as well as they could before the injury 4) Athlete has full confidence in abilities to perform without doubt/hesitation or with any modification to performance

10. Are You Still Awake?

11. Concept of Functional Testing �Involves having the athlete/patient perform certain tasks appropriate to the stage in the rehabilitation process in order to isolate and address specific deficits� � Mullin 2000 � ATT Function is �quantified� using maximal performance of an activity � Harter 1996 - JSR Purposes: Determine risk of injury due to limb asymmetry Provide an objective measure of progress Measure the ability of the individual to tolerate forces Should be correlated with functional ability!

12. Concept of Functional Testing �Single most important activity that an athlete has to accomplish successfully prior to a return to play is change of direction, specifically the cutting mechanism� Chu 1995 � Clin Sports Med Two types of cutting techniques: Andrews et al. 1977 - Am J Sports Med Sidestep Cut � planting the foot opposite to the direction of intended movement Crossover Cut � planting the foot on the same side of the new direction then crossing the opposite leg in front to provide acceleration in the new direction

13. Concepts of Functional Rehabilitation Begins on the day of injury and continues until pain-free gait & activities are achieved! Four Aspects of Functional Rehabilitation: ROM Strengthening Proprioception Activity-Specific Training

14. Example Rehabilitation Template - Post Ankle Sprain ROM Achilles tendon stretching Strengthening Isometric/manual exercises Dynamic exercises (cuff weights, surgical tubing, resistive bands) Toe raises, heel walks, toe walks Isokinetic training

15. Example Rehabilitation Template - Post Ankle Sprain 3. Proprioceptive and Balance Training Wobble boards Progress from NWB to WB, different stances, EO vs. EC, different surfaces Important to vary speed and intensity 4. Return to Activity-Specific Training Pain-free walking Progress to 50% walk + 50% jog Progress to running, running backward, pattern running Sport specific maneuvers

16. Making Comparisons Normative values Pre-injury baseline values Functional levels of other team members Limb symmetry scores (Ipsilateral Limb/Contralateral Limb) (100) = Limb Symmetry Percentage 85% or better goal is the recognized standard Agonist/Antagonist muscle group ratios H:Q --- E:I ---ER:IR ratios Error scores 20 sec. time frame --- compared to contralateral limb Timed performance comparisons

17. Screening Criteria Can the injured area tolerate the forces inherent in a functional performance task? Criteria to consider: General health status (PAR-Q) Full ROM Absence of pain, effusion, and crepitus Symmetrical gait Appropriate strength Limb Symmetry Index LSI (%) = injured limb score ? uninjured limb score x 100 Execution of 1 RM squat @ 150-200% of BW Single leg stance ?45 sec. with eyes open and closed

18. Physical Activity Readiness Questionnaire (aka PAR-Q)

19. Skill-Related Fitness Element - Speed Relates to the ability to perform movement within a short period of time. Energy comes from anaerobic pathways: ATP-CP system (< 5 sec.) Glycolysis (< 45 sec.) Principal fuel ? CHO (glycogen)

20. Lower Extremity Functional Testing Sprint Tests Set distance (40 yd, 100 yd, 100 meters) Time the distance Infrared Timing Devices Mean of 3 - 5 trials Compare pre vs. post

21. The 40 Yard Dash The 40-yard dash was created as a tool for measuring the speed of football players. The Dallas Cowboys of the 1960's are credited as the first team to use the test to evaluate the overall speed of players. Emphasizing speed and quickness with athletes like "Bullet" Bob Hayes (1968 Tokyo Olympics gold medallist in the100 meters) the Cowboys became a dominant organization. The Cowboys figured no player would run any further than 40-yards on any given play and thus by default the 40 became the measuring stick of the modern day athlete. Today, most organizations�including the NFL scouting combine�use electronic timing which is powered by lasers. Over time, the 40-yard dash has developed a cult following among coaches, scouts and fans.

22. NFL Combine � 40 -Yard Dash Normative Values

23. Lower Extremity Functional Testing The Wingate Anaerobic Test Maximal Anaerobic Power � ability to exercise for a short time at high power levels Requires pedaling or arm cranking on a bicycle ergometer for 30 seconds @ maximal speed Power is determined by counting pedal revolutions Watts = kp x rpm

24. Wingate Anaerobic Test � Peak Power Norms (Young Adults)

25. Lower Extremity Functional Testing Anaerobic Power Line Drill for Basketball �Suicides� or �Death Warmed Over� drills 300-yard Shuttle Run Timed trials Performed with someone of equal capacity Course completed in two separate trials (5� rest between) Average of 2 trials

26. Skill-Related Fitness Element - Agility Relates to the ability to rapidly change the position of the entire body in space, with speed and accuracy Combines balance, speed, strength, and coordination 10-yard agility ladders are a common tool used to improve agility

27. Lower Extremity Functional Testing SEMO Agility Drill Timed test Most complete the course in 10-15 sec. Average of 3 to 5 trials Normative Values: ?range from 12.19 to 14.50 sec. ?range from 10.72 to 13.80 sec.

28. Lower Extremity Functional Testing Illinois Agility Run Test 10 (l) x 5 (w) meter course 4 cones mark start, turning points and finish Middle cones are spaced at 3.3 meters Begin face down at start Object to move as quickly as possible through the course

29. Lower Extremity Functional Testing Agility Tests Other various agility patterns exist �Figure of 8� Box or cone configurations Zigzag runs 90? lunge �W�-sprint course Carioca 40� distance for time

30. Lower Extremity Functional Testing Co-Contraction Semicircular Test Originally designed to provide a dynamic pivot shift in the ACLD knee Can be modified and used in ankle rehab Athlete/patient completes 5 repetitions in shortest time 3 lengths R to L 2 lengths L to R Average of 3 trials Tubing is stretched to 48� (4�) beyond recoil length

31. Skill-Related Fitness Element - Power Relates to the rate at which one can perform work (strength over time) or (force x distance ? time) Combines muscular endurance and muscle strength The ability to engage and produce force early in the activation pattern (rate of force production) is becoming an important feature of the acute functional ability of muscle

32. A Closer Look @ Power

33. Lower Extremity Functional Testing Vertical Jump Tests Use the appropriate test to match the sport Ex. VB = step & jump vs. FB = run and jump for distance Reach distance subtracted from jump distance Examples: Vertical jump Step and jump One foot vs. two foot takeoff Standing vs. squat start

34. Lower Extremity Functional Testing Vertical Jump Mats Athlete wears waist belt attached to measuring tape that is grounded to the mat. Other systems use computers to measure amount of time and distance traveled.

35. Vertical Jump Data � How Do You Compare?

36. Lower Extremity Functional Testing Reactive Neuromuscular Training (Plyometrics) Explosive power = strength x speed Stretch-shortening principles (precede a CON muscle action with an ECC muscle action) Dr. Donald Chu � �Jumping into Plyometrics�

37. Skill-Related Fitness Element � Balance Relates to the maintenance of equilibrium while stationary or moving Primary control mechanisms involve: Proprioception and Peripheral Control Central Processing of Anticipatory Postural Adjustments The muscles, as the termination of the final pathway of the SM system, particularly contribute to the maintenance of body balance

38. Lower Extremity Functional Testing Balance Tests Numerous variations of the Romberg test are available Valid and reliable Scoring may include time or use of the Balance Error Scoring System (BESS) Can be performed on a variety of surfaces

39. The BESS

40. Lower Extremity Functional Testing Balance Tests Star Excursion Balance Test (SEBT) Reliable (Kinzey & Armstrong 1998 � JOSPT, Hertel et al. 2000 � JSR) A test of dynamic stability (strength, hip, knee, & ankle ROM, proprioception, NM control) as an alternative to those involving a quiet stance Goal is to reach as far as possible with one leg in each of 8 directions while balancing on the contralateral leg Three reaches in each direction are averaged Posteromedial reach is highly representative of all 8 components! (Hertel 2004)

41. Components of the SEBT

42. SEBT Simplified Posteromedial reach direction was most highly correlated with computed factor in both groups (R2>0.9)

43. SEBT Scoring Can average the 3 trials Reach distance is normalized for limb length Reach Distance/Limb Length x 100 A composite reach distance = sum of the 3 reach directions (normalized)

44. Values for Comparison

45. Skill-Related Fitness Element � Reaction Time Relates to the time elapsed between stimulation and the beginning of the reaction to it. Hick's Law - reaction time increases proportionally to the number of possible responses until a point at which the response time remains constant despite the increases in possible responses. Anticipation is a strategy used by athletes to reduce the time they take to respond to a stimulus.

46. FASTEX Consists of 8 deformable force platforms with piezoelectric sensors The shock impulses are then transformed in quantifiable variables (time, speed, force, etc�)

47. Health-Related Fitness Element � Cardiorespiratory Endurance Ability to continue or persist in strenuous tasks involving large muscle groups for extended periods of time Most important of the health-related physical fitness components Gold standard measure is VO2 max (oxygen uptake during maximal exercise)

48. Lower Extremity Functional Testing Field Tests of Cardiorespiratory Endurance 1-mile run time YMCA 3-minute step test (see diagram) 12� step Metronome set @ 96 beats/min Record time to recover to resting heart rate

49. YMCA 3-Minute Step Test

50. Health-Related Fitness Element � Musculoskeletal Fitness Comprised of three components: Flexibility � functional capacity of the joints to move through a full ROM Muscular Strength � the maximal one-effort force that can be exerted against a resistance Muscular Endurance � the ability of the muscles to apply a submaximal force repeatedly or to sustain a muscular contraction for a certain period of time.

51. WOW!

52. Hopping Tests Background: Sensitive enough to evaluate functional abilities � Worrell et al. 1994 � JSR Involve strength, cutting, balance, landing, etc.. Performed on a single leg or two legs

53. Hopping Tests: Implementation Strategies Explicit directions need to be given on how to complete the task Upper extremity movements? Position of the hands? Shoes on or off? Single best trial or the average? Average of the trials ? most reliable! How much rest? 10-15 sec between trials 5 minutes between different tasks Practice trials? 3-4 (50%, 75%, 100% effort)

54. Single Leg Hop Goal: To hop as far forward as possible on 1 leg Equipment: Tape measure secured to floor Directions: Patient stands on test leg with heels on the zero mark. Hop as far forward as possible, landing on the test leg. Measurement: Horizontal distance measured from heel at starting point to heel on landing Average of 3 jumps normalized as a % of the persons total height

55. Single Leg Triple Hop Goal: To hop as far forward as possible 3 consecutive times Equipment: Tape measure secured to floor Directions: Patient stands on test leg with heels on the zero mark. Hop 3 consecutive times on the same foot. On the final hop, hop for maximal distance and hold landing foot stable for 1 sec. Measurement: Horizontal distance measured from heel at starting point to heel after 3rd hop

56. Single Leg Triple Crossover Hop Goal: To hop as far forward as possible 3 consecutive times across a 15 cm interval marked on the floor Equipment: Two 8 m strips of tape 15 cm apart secured to the floor Directions: Patient stands on test leg with heels on the zero mark. Hop 3 consecutive times on the same foot, crossing over the tape strip with each hop. On the final hop, hop for maximal distance and hold landing foot stable for 1 sec. Measurement: Horizontal distance measured from heel at starting point to heel at final landing

57. Single Leg 6 m Hop for Time Goal: To hop a 6 m distance as quickly as possible. Equipment: Stopwatch and 6 m tape measure Directions: Stand on one leg, crouch with arms at sides, then hop forward for 6 m as quickly as possible. Measurement: Time to the nearest 0.01 sec.

58. Single Leg Vertical Jump Goal: To jump as high as possible and land on one leg Equipment: Wall and chalk Directions: Patient standing reach is recorded. Jump on one leg, touch the wall with chalked fingertips, and land on same leg. Measurement: Maximum height jumped minus patient�s standing reach height.

59. Hopping Tests: Interpretation of Results

60. Hopping Tests: Validity Issues Very little evidence to suggest strong correlations with proprioception, muscle strength & power, joint laxity and self-assessment measures of function Hop tests provide additional information independent of these other measures of function. Hop test scores are a summary variable that reflect the net outcome of the sensorimotor components contributing to performance.

61. Functional Octagonal Hop Test A novel test that will utilize agility, speed, jumping, landing, cutting, strength, and balance ability Performed on a wooden surface using one foot

62. Lower Extremity Functional Testing ICC measurements taken on 13 subjects indicates good (0.60) to excellent (0.81) reliability Non-dominant foot more reliable than dominant Familiarization trials are the key to improving the reliability of this task

63. Functional Hop Test

64. Ouch That Has Got To HURT!

65. Combined Functional Assessment Protocols

66. Carolina Functional Performance Index (CFPI) Developed to evaluate LE functional performance CFPI index was determined based on the results of two tests: Carioca test Co-contraction test Prediction equations: (x1 = co-contraction score in seconds & x2 = carioca score in seconds) Males: 1.09 (x1) + 1.415 (x2) + 8.305 = CFPI Females: 1.26 (x1) + 1.303 (x2) + 8.158 = CFPI ?CFPI = 31.551 ? CFPI = 36.402

67. Functional Fatigue Protocol Subjects perform a series of running, jumping, and cutting activities until a deficits of 50% from baseline is achieved Six stations set-up on a gymnasium floor: SEMO Agility Drill Plyometric Box Jumps Two-legged Hop Test Side-to-Side Bounding Hops Mini-Tramp Balance Co-contraction Drill

68. Functional Fatigue Protocol

69. Functional Fatigue Protocol

70. Functional Fatigue Protocol

71. Where Do We Go From Here? As clinicians become more comfortable with the various functional performance tests available to them, it is hoped that they will incorporate them into their clinical practice. There are a variety of resources available to obtain normative data for comparison

72. Take Home Message Functional Performance Testing should be incorporated into the clinical setting: Determine performance deficits Used to classify stability status As a measure of RTP status Make bilateral comparisons Most tests are reliable and easy to use

73. Helpful References Drouin JM, Riemann BL. Lower extremity functional performance testing, Part 1-3. Athletic Therapy Today; 9 (2,3,4), 2004. Clark NC. Functional performance testing following knee ligament injury. Physical Therapy in Sport; 2: 91-105, 2001. http://www.brianmac.demon.co.uk/

74. Today�s lecture can be viewed at the following URL address:http://www.udel.edu/HNES/AT/Site/lectures.html

75. Thank You