Ep 196: Taking care of strength business in ACL rehabilitation, with Olivia Barbosa

[00:00:05] [SPEAKER_00]: Insights, the podcast that aims to help you translate quality research to quality practice.

[00:00:12] [SPEAKER_00]: I'm Clara Durn, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy.

[00:00:17] [SPEAKER_00]: It's great to have you listening today.

[00:00:22] [SPEAKER_00]: I think we can all agree that strength is a core focus of many sports injury rehabilitation programs,

[00:00:29] [SPEAKER_00]: and it's usually a prominent discharge criterion too.

[00:00:32] [SPEAKER_00]: The years we've used the limb symmetry index, where one compares the injured limb to the uningid limb as a benchmark for recovery.

[00:00:40] [SPEAKER_00]: But you all know that there are limits to the limb symmetry index, not least that the strength of the uningid limb can change.

[00:00:47] [SPEAKER_00]: My guest today has an important message to share.

[00:00:50] [SPEAKER_00]: Beware the moving target of strength in the uningid limb when measuring and monitoring strength after ACL reconstruction.

[00:00:58] [SPEAKER_00]: Olivia Barbosa is a sports physiotherapist with over a decade of experience in soccer and rugby.

[00:01:04] [SPEAKER_00]: She currently works at the Asperger Orthopedic and Sports Medicine Hospital, where she contributes to the concussion and the ACL clinical teams

[00:01:12] [SPEAKER_00]: and does research focused on muscle activation and strength recovery in ACL rehabilitation.

[00:01:19] [SPEAKER_00]: Olivia Barbosa, welcome to JOSPT Insights.

[00:01:22] [SPEAKER_01]: Thank you very, very much, Claire.

[00:01:24] [SPEAKER_00]: Thanks for saying yes to jumping on the podcast Olivia.

[00:01:27] [SPEAKER_00]: Today we're talking about what is really a core skill set for sports rehabilitation specialists.

[00:01:33] [SPEAKER_00]: I'm talking about monitoring and progressing strength.

[00:01:38] [SPEAKER_00]: Let's start with why it's so important to monitor strength during rehabilitation for.

[00:01:43] [SPEAKER_00]: Let's say in ACL injury we're going to talk about quads and hamstring strength.

[00:01:46] [SPEAKER_00]: So we can really talk about any sort of lower limb injury.

[00:01:51] [SPEAKER_00]: Maybe let's keep us focused on the ACL because I know that's one of your clinical specialties.

[00:01:57] [SPEAKER_01]: So we know that with ACL patients that they have this residual knee muscle strength deficits,

[00:02:04] [SPEAKER_01]: they can persist for over two years and of course this can negatively influence performance.

[00:02:10] [SPEAKER_01]: And also it hasn't suggested of one of the reasons that can be related to injury rates.

[00:02:20] [SPEAKER_01]: Historically ACL rehabilitation has been shifting from a time-based criteria to performance based criteria.

[00:02:27] [SPEAKER_01]: And strength has been one of these performance based criteria that is being mostly used.

[00:02:33] [SPEAKER_01]: We initially had a benchmark of 80% of lymphedemistry index that started to move on to 90% of LSI.

[00:02:44] [SPEAKER_01]: And now, nowadays we can even expect that some athletes should reach 100% or 110%.

[00:02:52] [SPEAKER_01]: So that's quite a lot and we can see that sports have been increasingly demanding.

[00:02:58] [SPEAKER_01]: And also our discharge criteria has been increasingly demanding and stringent for these patients.

[00:03:07] [SPEAKER_01]: We are expecting our athletes to be faster and stronger.

[00:03:10] [SPEAKER_01]: And so this is the importance of monitoring their strength during rehabilitation.

[00:03:16] [SPEAKER_00]: Absolutely, and I refer to strength as or measuring a monitoring strength as a core skill set.

[00:03:21] [SPEAKER_00]: And it really is for exactly the reasons that you talk about.

[00:03:26] [SPEAKER_00]: And yet as a profession, a rehabilitation profession, when we're talking amongst ourselves,

[00:03:31] [SPEAKER_00]: it's almost like we think about the performance measuring and some of the wearables and some of the technology

[00:03:38] [SPEAKER_00]: and we think about those sorts of skills but some of these really core fundamental skills.

[00:03:42] [SPEAKER_00]: We almost neglect or at least we don't talk about how to do them well, which is why I'm so glad that you're here today.

[00:03:48] [SPEAKER_00]: What are the typical ways that you see people measuring and monitoring strength in clinical practice, Olivia?

[00:03:56] [SPEAKER_01]: So specifically for ACL rehabilitation, the gold standard that is described in the literature is as a kinetic testing.

[00:04:04] [SPEAKER_01]: And there has been a recommendation that we use concentric mode at a speed of 60 degrees per second for fiber petitions.

[00:04:12] [SPEAKER_01]: Of course, the advantage of using is a kinetic testing is that we have a set of metrics that we can analyze and we're in we can be more specific.

[00:04:22] [SPEAKER_01]: Then when we prescribe exercises to our patients, so we can address these.

[00:04:28] [SPEAKER_01]: But of course not all clinicians will have access to ISO kinetic machines probably the majority of the clinicians won't have.

[00:04:36] [SPEAKER_01]: So using a belt stabilized handheld dynamic, the normal meter for example has shown a high diagnostic accuracy in identifying for the substring is the metrics after ACL reconstruction.

[00:04:52] [SPEAKER_01]: So it's much cheaper equipment to use and you can be also reliable to measure strength.

[00:04:58] [SPEAKER_01]: Can you give us an idea of what that setup looks like?

[00:05:01] [SPEAKER_01]: Yeah, so usually we will have to use a belt, so the dynamic will have to be fixed to anywhere where you can push only against the belt.

[00:05:13] [SPEAKER_01]: So if you're not really holding the dynamic meter and we can that that is a metric testing at 60 degrees of flexion.

[00:05:24] [SPEAKER_01]: So you can standardize the way you are measuring the strength.

[00:05:27] [SPEAKER_01]: And why 60 degrees, Olivia?

[00:05:30] [SPEAKER_01]: Because usually is the round that angle that the patients can produce the highest force for the quarter steps.

[00:05:37] [SPEAKER_00]: Now you mentioned the limb symmetry index a little while ago, you talked about we started off with an 80% limb symmetry index was the goal then it went to 90% and now we're even aiming for 100%.

[00:05:49] [SPEAKER_00]: The limb symmetry index has been getting a bit of a bad rap recently.

[00:05:54] [SPEAKER_00]: We walk us through what are the pros and then maybe some of the cons of using the limb symmetry index to monitor progression of strength.

[00:06:03] [SPEAKER_01]: So we have to acknowledge that LSI will use an involved link as a reference.

[00:06:11] [SPEAKER_01]: And we have been having some studies showing that during rehabilitation after ACL specifically that there were no changes in an involved strength.

[00:06:22] [SPEAKER_01]: Other studies also found that both the predictive strength of the an involved limb will be lower compared to match healthy controls.

[00:06:32] [SPEAKER_01]: So this leads to LSI being an insufficient metric to ensure that we attain adequate strength in the involvement.

[00:06:43] [SPEAKER_01]: And also even we can overestimate the recovery of the involvement of the involvement.

[00:06:48] [SPEAKER_01]: This is what the literature tells us, but anecdotally what we were seeing in our clinical practice was that some of our patients were having complete, it's complete opposite.

[00:07:02] [SPEAKER_01]: We were having patients that were achieving huge amounts of strength.

[00:07:07] [SPEAKER_01]: And this was an issue towards the end of the rehab because we had a huge gap to close between the involvement and the an involved link.

[00:07:18] [SPEAKER_01]: So we found ourselves trying to change and moving chasing and moving target that it was really hard to attain.

[00:07:27] [SPEAKER_01]: So one of the limitations of the LSI as a metric is that ideally we also consider the absolute values of the LSI because we are looking at the involvement compared to other involved.

[00:07:43] [SPEAKER_01]: But it still can be an useful metric because when you look at the deficit, you can have a quick understanding of how far the involvement is from the an involved limb strength.

[00:07:56] [SPEAKER_00]: So Olivia what you're saying is that these athletes you were doing such a good job as a rehab clinician these athletes were recovering strength so well in their.

[00:08:05] [SPEAKER_00]: Operated limb in the in the limb that it had the ICL reconstruction and then the uninvolved limb was was deteriorating or just wasn't improving as much.

[00:08:14] [SPEAKER_01]: It was the other way so we were improving so much the ending volume.

[00:08:19] [SPEAKER_01]: And then when we use the LSI as a discharge criteria, it was really hard to discharge the patients basically because the ending volume wouldn't reach the same amount.

[00:08:29] [SPEAKER_01]: The end volume wasn't reaching the same amount of the ending volume.

[00:08:33] [SPEAKER_00]: You're setting the benchmark too high to high yeah got it got it okay now you mentioned the analysis that you've recently done and we've recently published in JOSPT will link to the paper in the show notes for people who are interested to read it.

[00:08:49] [SPEAKER_00]: I think that's the perfect segue to talk specifically about this analysis because it was a large data set lots of strength data and that's the beauty of the clinical practice environment where you're working is that you are.

[00:09:02] [SPEAKER_00]: You have this very large pool of athletes.

[00:09:04] [SPEAKER_00]: This analysis was of course in hamstring strength over 600 male athletes and it's important that we mentioned these are male athletes only so some of the results may not quite apply to female athletes.

[00:09:17] [SPEAKER_00]: Let's start with how did you measure strength in your study and then we'll get into what you found.

[00:09:23] [SPEAKER_01]: We follow the goal standard that is describing the literature we use the isokinetic testing at 60 degrees per second and we use fiber petitions with maximum construction.

[00:09:33] [SPEAKER_01]: We decided to collect this data initially mainly for two two different reasons first we wanted to see how the quadriceps and hamstrings would progress throughout rehabilitation and.

[00:09:46] [SPEAKER_01]: The second objective was to determine how that strength at different time points would compare to preoperative levels so we ended up with 65 male professional and recreational athletes.

[00:10:01] [SPEAKER_01]: And what we found was that activity level has an effect on strength or so we can see that professional athletes display a higher level of strength compared to recreational which would be expected right also we saw that activity level can affect progression of strength, especially in the beginning of rehab.

[00:10:24] [SPEAKER_01]: We found that an involved limb strength of quadriceps and hamstrings will gradually increase after ACL reconstruction in both the sub-categories of activity level.

[00:10:37] [SPEAKER_01]: And specifically for quadriceps strength professional athletes will exceed the pre-op values by three months and recreational athletes will exceed pre-op values by six months to let a little bit longer to increase the strength.

[00:10:55] [SPEAKER_01]: For hamstrings for the hamstrings strength we saw that both groups will surpass their pre-op values by four and a half months.

[00:11:05] [SPEAKER_01]: And we also noticed that most strength gains were attained between one and a half months and four and a half months and that after six months they started to plateau.

[00:11:17] [SPEAKER_00]: That's really interesting and I want to get a little bit of information about how often these athletes are training with you.

[00:11:26] [SPEAKER_00]: Is your clinical practice environment at Aspatar similar to someone who's listening to us today who might work in solo private practice and may only see these athletes once a week.

[00:11:37] [SPEAKER_01]: So we can say that in Aspatar we are privileged that for athletes, for example, we can see them every day.

[00:11:45] [SPEAKER_01]: We see them on a daily basis for professional athletes.

[00:11:49] [SPEAKER_01]: For the recreational athletes we also see them quite often. You can be two to three times a week.

[00:11:57] [SPEAKER_01]: So it's quite an intensive rehabilitation program.

[00:12:00] [SPEAKER_00]: And as a clinician, Olivia, what's your suspicion there? Are you getting better results because you're saying people more often?

[00:12:08] [SPEAKER_01]: I think if we have motivated patients that they go to the gym and they can do we also have those kind of patients where we give a home exercise program and they hit the gym by themselves.

[00:12:20] [SPEAKER_01]: They are motivated, they come once a week and they do their testing every six weeks and they still have good results.

[00:12:27] [SPEAKER_01]: So I think it depends on the patient, it depends on their motivation to follow through with rehabilitation.

[00:12:35] [SPEAKER_00]: The other interesting thing to me is that you said some athletes are hitting their pre-op values as early as one and a half months after their Ascel Reconstruction.

[00:12:44] [SPEAKER_00]: And that suggests to me one of two things, maybe their pre-op values were pretty low or they are doing some pretty high level strength training quite early after Ascel Reconstruction.

[00:12:57] [SPEAKER_00]: How do you think about that as a clinician?

[00:12:59] [SPEAKER_01]: We have to consider that after an Ascel injury there can be some deconditioning physical deconditioning due to activity modification.

[00:13:10] [SPEAKER_01]: So athletes are training less frequently and that can lead to a critical increase in strength.

[00:13:18] [SPEAKER_01]: Also with the Ascel injury, there can be a potential out through a neural drive, especially of the 40th semester.

[00:13:27] [SPEAKER_01]: And it has been described not only for the involved limb but also for the uninvolved leg.

[00:13:32] [SPEAKER_01]: So this is why when we use pre-operative data, we have to consider this aspect and be cautious on how to use those values because most likely the patient will be weaker after injury.

[00:13:48] [SPEAKER_00]: Which is the perfect segue to me asking you, what have you changed in your rehab practice as a sports physiotherapist?

[00:13:56] [SPEAKER_00]: Because of the results that you were seeing in these data.

[00:13:59] [SPEAKER_01]: So one of the things that we got from this data was having normative values for our recreation athletes.

[00:14:07] [SPEAKER_01]: We already had reference values for our professional athletes because we are lucky enough to have our local athletes doing their pre-season screening at Asceler.

[00:14:18] [SPEAKER_01]: But we didn't have those reference values for recreational athletes.

[00:14:22] [SPEAKER_01]: And this is helpful for us because we can set more realistic objectives for them.

[00:14:29] [SPEAKER_00]: How do you get the pre-op values from recreational athletes who you're not seeing all of the time?

[00:14:35] [SPEAKER_00]: How does that work in practice?

[00:14:36] [SPEAKER_00]: Because we often talk about this, I think, I can remember teaching when I'm teaching about Asceler rehab.

[00:14:42] [SPEAKER_00]: What is talk about?

[00:14:43] [SPEAKER_00]: I'll get a pre-op value, a pre-op test of strength value if you can.

[00:14:48] [SPEAKER_00]: And for some people that's possible and for others you just don't say the athlete in time.

[00:14:53] [SPEAKER_00]: So how does it work in your practice environment, Olivia?

[00:14:57] [SPEAKER_01]: We're still trying to get the strength values before the surgery.

[00:15:02] [SPEAKER_01]: So if we get the athlete right after injury, which a lot of the times we do because we are a specialized hospital in Qatar.

[00:15:10] [SPEAKER_01]: So a lot of the patients that come directly to the hospital and oftentimes we are able to assess them right after injury

[00:15:19] [SPEAKER_01]: or at least, we try to assess them before the surgery.

[00:15:23] [SPEAKER_00]: How would you suggest people who are listening to us today, Olivia?

[00:15:26] [SPEAKER_00]: Think about their approach to strength testing during rehabilitation, given all of the data that you've collected, all of your clinical experience?

[00:15:35] [SPEAKER_00]: What sort of tips and ideas would you like to pass on to our listeners today?

[00:15:40] [SPEAKER_01]: So I think the first thing that is important is that assessment is performed in a consistent matter.

[00:15:46] [SPEAKER_01]: So whatever tests you are doing, do the same test in the same way and ideally we'll do them within the same time frame.

[00:15:56] [SPEAKER_01]: And consistent testing is a good opportunity to reflect on your own practice at each cycle that you set within the rehabilitation process.

[00:16:05] [SPEAKER_01]: So you can think to yourself, are you giving the appropriate exercise to target the deficits of your patients?

[00:16:12] [SPEAKER_01]: Or are you loading your patient enough to elicit adaptation and to reach the outcomes that you are setting for the following assessment point?

[00:16:22] [SPEAKER_01]: And we can use this smaller goals to reach the bigger goal.

[00:16:26] [SPEAKER_01]: That's why it's so useful to manipulate your patients.

[00:16:30] [SPEAKER_01]: Because the patient comes out of ACL surgery, for example, which is such a long period of rehab for nine months to a year even.

[00:16:39] [SPEAKER_01]: And it can be quite overwhelming to think about that final and point of rehab.

[00:16:44] [SPEAKER_01]: So having this consistent measurement through rehab can give them smaller goals that they can achieve at each cycle until the following assessment point.

[00:16:56] [SPEAKER_00]: Yeah, I think that's really important. It's helping keep the athletes motivation and interest going especially for a long rehab like ACL as you say.

[00:17:06] [SPEAKER_00]: And also it's helpful for you as a clinician.

[00:17:09] [SPEAKER_00]: I think to keep your motivation and interest going as well.

[00:17:12] [SPEAKER_00]: I'm making sure that you are checking in with what you're prescribing and checking in to see is this actually doing what I was expecting it to do?

[00:17:21] [SPEAKER_00]: Exactly.

[00:17:21] [SPEAKER_00]: Now we talked a little bit at the start about how your study is including only male athletes.

[00:17:30] [SPEAKER_00]: Let's talk a little bit about sex differences in strength and get your sense as a clinician of how these results might apply to female athletes with whom people listening to us today might be working.

[00:17:43] [SPEAKER_01]: One of the messages that we want to pass through with this paper is that the end of the limb wheeling please if you work on it.

[00:17:53] [SPEAKER_01]: So regardless if you're male or female, if you're targeting the deficit, the strength deficits in your patients, they will improve.

[00:18:02] [SPEAKER_01]: Of course we cannot extrapolate these data to female athletes and we initially we wanted to include females because we have some female athletes in Qatar,

[00:18:12] [SPEAKER_01]: but they represented only 4% of our population.

[00:18:15] [SPEAKER_00]: Olivia, let's talk a little bit about progressing rehab.

[00:18:19] [SPEAKER_00]: You mentioned you also mentioned discharge criteria and I'd like to get to discharge criteria too.

[00:18:24] [SPEAKER_00]: So these strength measures, what do they mean or how do you approach progressing rehabilitation based on what you're measuring?

[00:18:33] [SPEAKER_00]: And I'm conscious that we're talking here primarily about the uninvolved or the non-operated limb.

[00:18:39] [SPEAKER_00]: So how do you then translate that into your thinking about rehab and designing and monitoring the progressions in your rehab program?

[00:18:47] [SPEAKER_01]: If we talk about discharge criteria, we cannot say that we have in the literature there is not a set of values that we can say that.

[00:18:54] [SPEAKER_01]: Okay if the athlete reaches this certain amount of strength, they're going to be injured less.

[00:18:59] [SPEAKER_01]: So the best thing we can do is try to get the athletes to reach their pre-ingered level as much as possible.

[00:19:08] [SPEAKER_01]: If you're working with professional athletes, it's likely that you will have their pre-ingered levels of strength, so usually measured at pre-season.

[00:19:17] [SPEAKER_01]: But if you don't, then okay you can use their pre-up levels if you see them at pre-up and that could be for example the first goal to achieve.

[00:19:30] [SPEAKER_01]: Later it's always good to have some reference values from the literature and try to reach those goals in terms of normative data.

[00:19:41] [SPEAKER_01]: It's good to be aware that some studies, they have mixed populations and it was also one of the reasons why we wanted to represent the recreational athlete separately from the professionals because activity level has an effect on the magnitude of strength they will display during rehabilitation.

[00:20:01] [SPEAKER_01]: So one of the ways that you can overcome that when you use reference values is try to categorize your own patients with a technical activities scale.

[00:20:11] [SPEAKER_01]: For example, and that can be helpful in finding the appropriate amount of strength in terms of reference values in the literature.

[00:20:20] [SPEAKER_00]: Can you run us through the technical activity scale Olivia for those who are unfamiliar with the technique?

[00:20:26] [SPEAKER_01]: Yes, the technique is a scale that is a score that goes from 0 to 10.

[00:20:32] [SPEAKER_01]: It categorizes the athletes between competitive and recreational and also pivoting non-perverting and subventory.

[00:20:39] [SPEAKER_00]: Olivia, it's been really wonderful hearing how you take these very clinical data and apply them to your practice and also how you build in, I guess evidence-based practices what we're talking about and contributing to research.

[00:20:54] [SPEAKER_00]: Leading research in this case, you're the lead author on this paper.

[00:20:57] [SPEAKER_00]: In a recent J was pity in sites episode we were talking with end-to-king one of your colleagues about how do you manage research and clinical practice as a full-time clinician?

[00:21:10] [SPEAKER_00]: I would love to hear a little bit from you about how that has worked for you.

[00:21:14] [SPEAKER_00]: How is it as a clinician did you get into research and how do you think about applying research in your practice?

[00:21:20] [SPEAKER_01]: Yes, so it's not easy but working with more with the ACL patients and seeing that there are still some gaps in the literature that we can help fill in.

[00:21:33] [SPEAKER_01]: That was a good motivation to do some research on the side outside the clinical hours.

[00:21:40] [SPEAKER_01]: We are so lucky at Aspera to have our movement analysis lab and having the support from the staff there, especially rule-ash is really supportive in terms of ACL research and that may make things easier.

[00:21:56] [SPEAKER_00]: Some of our listeners will know Dr. Rulukwatsafakis work in ACL, she led the recent Aspera ACL clinical practice guidelines.

[00:22:05] [SPEAKER_00]: Lots of wonderful, clinically relevant work coming from Aspera that can help all of us around the world do better for the patients and the athletes with whom we're working.

[00:22:15] [SPEAKER_00]: Olivia, it's been a joy hearing from you today and getting your insights as a specialist sports physiotherapist and someone who's on the ground everyday working in this area.

[00:22:27] [SPEAKER_00]: So I want to say thank you so much for joining me on Joe's PT insights.

[00:22:32] [SPEAKER_01]: Thank you for having me.

[00:22:37] [SPEAKER_00]: Thanks for listening to this episode of Joe's PT Insights.

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