Performance Physical Therapy for the Tactical Athlete Case

Performance Physical Therapy for the Tactical Athlete, Case Report Lawrence Waters, SPT, Eric Shamus, DPT, Ph. D, Stephen Black, PT, DSc Department of Rehabilitation Sciences, Florida Gulf Coast University, Fort Myers, FL Clinical Impression Introduction EXOS Accelerated Return to Duty (ARD) Program. • 4 -weeks of intensive interventions aimed at maximizing athletic performance for members of the Special Operations Community. • Holistic approach to rehabilitation provided by Physical Therapists, Registered Dieticians, Sports Performance Coaches, and Massage Therapists. • Rehab Sessions ranged from 45 -60 min. daily utilizing the EXOS performance physical therapy system to Learn, Design, Deliver, and Refine. • Two-phase physical therapy program • Phase 1: Eliminate Dysfunction and Pain found with the EXOS Movement Assessment. • Phase 2: Bridge the Gap from Rehab to Performance with the EXOS Global Movement Themes (GMT) (Figures 1 and 2. ) Figure 1. EXOS Global Movement Theme Ex. Progression 1 High Split (HS) Ex. 2 3 Single Undulate Leg HS and Stance SLS (SLS) Ex. Adapted from Wilkins T. 4 Low Split (LS) Ex 5 Undulate SLS and LS 6 Undulate HS, LS and SLS 7 Plyo HS, SLS, LS Ex. Patient History/Systems Review 39 -year-old Caucasian male HPI: • 4 -weeks post Left Quadricep Tendon Repair. PSH: • Left Sub Chondroplasty 2019 • Left Lat. Patellar Release 2012 PMH: • Chronic Left Knee Pain. • Bilateral GH Labral Tears • L 5 Spondylolisthesis • Polytrauma from Blast Injuries • Depression • Sleep Disturbances • Chronic Headaches Examination Patient is a good candidate for ARD due to complex presentation, PMH, including the reports of depression, sleep disturbances, and a stressful work environment. Successful intervention will be improved outcome measures (Table 1. ) and increased ability to train and conduct missions. Intervention Generally each exercise was limited to 1 set of 6 -8 reps per side. If the patient failed to achieve the movement a verbal cue was given with demonstration. If the set was successful a progressive exercise was selected based on Figure 3. to provide as many novel exercises as possible each session. Week 1: Focus: Build ROM for med. and lat. hip rotation. Increase knee flexion. • Manual therapy: Increase tissue extensibility, restore joint dynamics for hip rotation • Exercise: Prone and supine isometric holds at end range progressed to side sitting/quadruped controlled articular rotations (CAR) Week 2: Focus: Improve motor control for trunk rotation • Exercise: Side lying kettlebell arm bar w/ trunk rotation progressed to side sit with trunk rotation. Additional progression to quadruped and kneeling trunk rotation exercises Week 3: Focus: Resolve dysfunction found in assessment. Develop positions for EXOS GMT (Figure 2. ) • Exercise: Star Pattern Exercise for combined hip flexion internal rotation and ipsilateral trunk rotation. Neutral standing to High Split transition Week 4: Focus: Build into the EXOS Global Movement Theme Progressions (Figures 1 and 2. ) • Exercise: High Split Lifts and Chops, Single Leg Stance Lifts and Chops, High Split to Single Leg Stance with Vasso Strap Figure 2. EXOS GMT Positions Non-Weight Bearing Quadruped/ Side Sitting Kneeling Full Weight Bearing Adapted from Wilkins T. External Cue Against Load Incr Neutral Against Load easi ng Com plex ity Outcomes Table 1. Selected Outcome Measures Test Administered Initial Scores Lower Extremity Functional Scale (LEFS) 49/80 Modified Oswestry Disability Index (M-ODI) 18% Disability of the Arm Shoulder and Hand (DASH) 11. 4% Functional Movement Screen (FMS) 3/21 Exit Scores 55/80 5% 6. 8% 13/21 • Observations at discharge: Significant improvement to gait Independent during weight room sessions • Acuity of surgery and the 4 weeks ARD cycle meant the patient was not prepared for a full return to duty. • The patient returned to a military rehabilitation program to continue progressing while he applied for another cycle of the ARD program. Clinical Implications • Through the EXOS GMT the patient increased participation in both field and weight room group training sessions. • Providing a systematic approach to transition between rehab performance training allows entry level physical therapists to successfully rehabilitate operators. The EXOS performance physical therapy model should be considered when looking for extra curricular education. Ligament Testing: Negative Sensation Testing: Negative Range of Motion: Left Knee: Full Ext. 60 Degrees Flx. Strength Testing: Deferred • EXOS Movement Assessment: Significant tissue extensibility and joint dynamic impairments limiting hip and trunk rotation. Complexity of External Cue Neutral Exercise • The ARD program is a rehab system that provides our warfighters with a diverse staff of professionals dedicated to performance • Observation: Significant antalgic gait with decreased left stance phase • Local Tissue Assessment: Scar tissue moderately adherent Significant edema Significant tone in left distal quadriceps • • Figure 3. EXOS Exercise Progression Matrix High Split Single Leg Stance Low Split Adapted from Wilkins T. References: See Handout with Reference List • There are numerous stake holders in return to duty decisions. The decision must balance their competing interests to reach an outcome that is acceptable to all.

Introduction EXOS Accelerated Return to Duty (ARD) Program. Figure 1. EXOS Global Movement Theme Exercise. Progression 1 2 3 4 5 6 • 4 -weeks of intensive interventions aimed at High Split Single Leg Undulating Low Split Undulating maximizing athletic performance for members (HS) Stance (SLS) HS and (LS) SLS and LS HS, LS and of the Special Operations Community. Exercises SLS Exercises Adapted from Wilkins T. • Holistic approach to rehabilitation provided by Physical Therapists, Registered Dieticians, Sports Performance Coaches, and Massage Therapists. 7 Plyometric HS, SLS, LS Exercises • Rehab Sessions ranged from 45 -60 min. daily utilizing the EXOS performance physical therapy system to Learn, Design, Deliver, and Refine. • Two-phase physical therapy program • Phase 1: Eliminate Dysfunction and Pain found with the EXOS Movement Assessment. • Phase 2: Bridge the Gap from Rehab to Performance with the EXOS Global Movement Themes (GMT) (Figures 1 and 2. ) Figure 2. EXOS GMT Positions High Split Adapted from Wilkins T. Single Leg Stance Low Split

Patient History and Systems Review 39 -year-old Caucasian male HPI: • 4 -weeks post Left Quadricep Tendon Repair. PSH: • Left Knee Sub Chondroplasty 2019 • Left Lat. Patellar Release 2012 PMH: • Chronic Left Knee Pain. • Bilateral GH Labral Tears • L 5 Spondylolisthesis • Polytrauma from Blast Injuries • Depression • Sleep Disturbances • Chronic Headaches

Examination and Clinical Impression Examination Findings • Observation: Significant antalgic gait with decreased left stance phase • Local Tissue Assessment: Scar tissue moderately adherent Table 1. Selected Outcome Measures Significant edema Significant tone in left distal quadriceps Test Administered • Ligament Testing: Negative • Sensation Testing: Negative • Range of Motion: Left Knee: Full Ext. 60 Degrees Flx. • Strength Testing: Deferred Lower Extremity Functional Scale (LEFS) Initial Exit Scores 49/80 55/80 Modified Oswestry Disability Index (M-ODI) 18% 5% Disability of the Arm Shoulder and Hand (DASH) 11. 4% 6. 8% Functional Movement Screen (FMS) 3/21 13/21 • EXOS Movement Assessment: Significant tissue extensibility and joint dynamic impairments limiting hip and trunk rotation. Clinical Impression Good candidate for ARD due to complex presentation, PMH, and the reports of depression, sleep disturbances, and a stressful work environment. Successful intervention will be improved outcome measures (Table 1. ) and increased ability to train and conduct missions.

Intervention Generally each exercise was limited to 1 set of 6 -8 reps per side. If the patient failed to achieve the movement a verbal cue was given with demonstration. If the set was successful a progressive exercise was selected based on Figure 3. to provide as many novel exercises as possible each session. Figure 2. EXOS GMT Positions High Split Single Leg Stance Low Split Adapted from Wilkins T. Week 1: Focus: Build ROM for med. and lat. hip rotation. Increase knee flexion. • Manual therapy: Increase tissue extensibility, restore joint dynamics for hip rotation • Exercise: Prone and supine isometric holds at end range progressed to side sitting/quadruped controlled articular rotations (CAR) Figure 3. EXOS Exercise Progression Matrix Week 2: External Neutral Focus: Improve motor control for trunk rotation Complexity Cue Against • Exercise: Side lying kettlebell arm bar w/ trunk rotation progressed to of Exercise Against Load side sit with trunk rotation. Additional progression to quadruped Load and kneeling trunk rotation exercises Non-Weight Week 3: Incr Bearing easi n Focus: Resolve dysfunction found in assessment. Develop positions for g Quadruped/ C omp EXOS GMT (Figure 2. ) Side Sitting lexi t • Exercise: Star Pattern Exercise for combined hip flexion internal y Kneeling rotation and ipsilateral trunk rotation. Neutral standing to High Split Full Weight transition Bearing Adapted from Wilkins T. Week 4: Focus: Build into the EXOS Global Movement Theme Progressions (Figures 1 and 2. ) • Exercise: High Split Lifts and Chops, Single Leg Stance Lifts and Chops, High Split to Single Leg Stance with Vasso Strap

Outcomes and Clinical Implications Outcomes • Observations at discharge: Significant improvement to gait Independent during weight room sessions • Acuity of surgery and the 4 weeks ARD cycle meant the patient was not prepared for a full return to duty. • The patient returned to a military rehabilitation program to continue progressing while he applied for another cycle of the ARD program. Table 1. Selected Outcome Measures Test Administered Lower Extremity Functional Scale (LEFS) Initial Exit Scores 49/80 55/80 Modified Oswestry Disability Index (M-ODI) 18% 5% Disability of the Arm Shoulder and Hand (DASH) 11. 4% 6. 8% Functional Movement Screen (FMS) 3/21 13/21 Clinical Implications • The ARD program is a rehab system that provides our warfighters with a diverse staff of professionals dedicated to performance • Through the EXOS GMT the patient increased participation in both field and weight room group training sessions. • Providing a systematic approach to bridging the gap between rehabilitation and high levels of performance allows entry level physical therapists to successfully rehabilitate operators. The EXOS performance physical therapy model should be considered when looking for extra curricular education. • There are numerous stake holders in return to duty decisions. The decision must balance their competing interests to reach an outcome that is acceptable to all.

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