November 2005

Solving the Athletic Patient Puzzle

By Stephen Clark, PT, DPT, OCS, MBA

In order to be successful in sports rehab, therapists must adjust their methods

Is there really a difference between rehabbing a competitive athlete and a sedentary patient? Do weekend warriors and professional and Olympic athletes really require a different approach than your average worker or orthopedic patient? The answer is a resounding "Yes," and to become a successful athletic physical therapist and sports medicine specialist, you must understand what makes the athletic patient different from the rest.

Reducing a patient's activity level is sometimes challenging, but try telling a weekend warrior or professional athlete that they need to rest and you had better have track shoes on ready to catch them as they run out of your clinic. The last thing a competitive athlete wants to hear is that they cannot participate in their sport. Sometimes they will lie, cheat, and steal just to keep playing. A good sports medicine physical therapist or athletic trainer sympathizes with this behavior and tries every possible way to keep the athlete playing. Part of it is a negotiation between you and the patient, eg, "In order to allow your back to recover, I'll let you throw the ball but absolutely no swinging the bat." If an athlete knows you are working with them, they are more likely to follow your program. However, it cannot just stop with good negotiation techniques. Athletic therapists must have additional tools to make a difference for this demanding patient group. For an athletic patient to maintain their highest possible level of participation while injured, the athletic therapist must understand and master the Irritability Threshold Matrix (ITM).

IRRITABILITY THRESHOLD MATRIX
The Irritability Threshold Matrix is a tool used by the athletic physical therapist or athletic trainer during rehabilitation to allow the athlete to continue to participate in their sport at their highest possible level while simultaneously maximizing their recovery potential. In order for an athlete to recover and become less symptomatic, the therapist and the athlete must work together to keep the specifically injured tissue under the irritability threshold (Chart 3). The irritability threshold is a variable point in time during the athletic rehab continuum when a subjective reproduction of symptoms occurs and/or the objective assessment of impairments is measured indicating that the injured tissue is unable to meet the demands necessary for requested athletic activities. A patient develops athletic dysfunction when they cross over the irritability threshold. A careful and continuous assessment of symptoms and impairments will determine if an athlete is recovering (under the irritability threshold) or regressing (over the irritability threshold). Obvious reproductions of symptoms and impairments can include increased pain, edema, palpable tenderness, lost range of motion, and weakness. Frequently, and more difficult to determine, are episodes of irritability, which result in a decrease in sport performance, accelerated fatigue, uncharacteristic weakness, and/or compensatory movement pattern. It takes frequent and close communication with the athletic patient to know what a normal performance should be in order to decide whether the athlete has crossed over the irritability threshold or simply performed poorly.

CONTROLLING THE IRRITABILITY THRESHOLD
There are five irritability factors with many possible combinations that contribute to the irritability of a tissue that need to be understood and controlled. If the therapist correctly identifies the causative factors and the athlete modifies those activities that correlate with crossing over the irritability threshold, the athlete and therapist should anticipate a successful rehabilitation (Chart 1). Sport activities or treatment techniques that exceed the irritability threshold will perpetuate the inflammatory cycle, create athletic dysfunction, and prolong rehabilitation. All five factors can contribute to recovery in various proportions and at different stages throughout the rehab process. Reproduction of symptoms or the development or exacerbation of impairments during or up to 24 hours after treatment or sport activity should be interpreted as crossing above the irritability threshold. One or all of the time, force, and position factors must be corrected until the injured tissue is not provoked.

AGGREGATE FORCES
The aggregate force through a tissue has to do with the repetitions, sets, and load being applied and transferred through the target tissue. You must apply the appropriate force during a treatment in order to stimulate the healing response but avoid going over the irritability threshold. The literature can tell you how to strengthen a fast twitch muscle fiber or when a nerve achieves chemical neuromuscular fatigue, but only the therapist can interpret all the necessary information to determine how the athlete is progressing.

POSITION
Even if you have the proper aggregate force with optimal timing, the proper alignment must be maintained or you risk crossing the irritability threshold. During treatment, the athletic therapist must pay close attention to proper sport-specific alignment to ensure maximum potential and minimal irritability. Athletes often perform at the extreme limits of anatomical and structural ability. Therefore, the athlete must be trained into full anatomical positions as well. The athletic therapist must place sport-specific torque at the end of range of motion in order for the athlete to be prepared for their return to sport. Most patients do not require such attention, nor do they request it, but an athlete must be completely restored prior to discharge and return to full competition.

REHAB MILESTONES
Athletic patients are willing and actually prefer to set goals ranging anywhere from a one degree improvement in range of motion to the exact day they will be back playing. This group of patients loves to "be in control" of their rehab. If the patient does not think you have a complete and logical plan of care that will fully and safely return them to their sport within the shortest period of time, they might just go off on their own. Athletes need to feel like they are training, so if they are not playing their sport, then they are actively participating in their rehab. The Athletic Rehabilitation Continuum (Chart 2) shows the relationships of the athletic rehabilitation process to guide the athletic physical therapist and establish a partnership with the patient. Often, goals for the athletic patient group include "time off" and "rest."

Athletes need to be involved in their rehab. It is called "buy in," and if you can get an athlete to buy in to your particular rehab program, they will become actively involved and follow your rehab plan. A partnership with an athletic patient is most important because the athlete knows better than anyone what they must do to optimize their own abilities. It is not just enough to understand how an individual athlete can throw a fast ball exceeding 90 mph. An athletic physical therapist must understand, teach, and treat the subtle differences between athletes who can throw at 90+ mph. In order to help the therapist and the athlete communicate, I divide the rehabilitation process into three stages.

Author Stephen Clark (right) helps a patient attempt a Phase IV, closed chain, dynamic, plyometric upper extremity exercise by alternating his arms at variable speeds and durations.

THE POWER OF THREE
Sometimes the easiest explanation can make a big difference in helping the patient understand the rehab process. Explain to the patient that their rehab will consist of three stages of an undetermined time. The closer they follow your program, the faster they will progress to the next stage and eventually back to their sport. The total duration of rehab can be as little as three treatments or as long as 6 months; the stages are not time dependent. Rather, they serve as key milestones in a person's recovery and serve the purpose of indicating progressions for treatment strategies. Each case is different, but a general rule of thumb applies to all patients that enter the clinic: I call it the Power of Three.

Stage 1
The first third consists of anti-inflammatory or tissue healing treatments using mostly manual skills and modalities to create a healing environment for the injured tissue. Phase I and II exercises are low load, controlled speed, limited duration and frequency, and performed in a supported, controlled, and isolated manner. The therapist and patient must take care to avoid going above the irritability threshold by controlling all or most of the causative factors.

Stage 2
The second third consists of a continuation of manual therapy techniques, a decrease in the use of modalities, and a change to Phase III therapeutic exercise. Phase III exercises are multi-jointed, complex movement patterns with a medium load, speed, duration, and intensity. Aggressive manual therapy for tissue remodeling and neuromuscular integration is appropriate. Patients and therapists have a tendency to progress too quickly through this stage. This leads to an increased incidence of exacerbation and creates only a partial foundation for the most demanding stage ahead.

Stage 3
The final third consists of a discontinuation of modalities and limited manual therapy. Fully loaded Phase IV and V athletic functional exercises are performed with increased speed designed to simulate sport-specific conditions and prepare the athlete for competition. These exercises consist of significant aggregate force and speed and should be performed only by those patients who are preparing for a competitive return to sport.

Chart 3. The Irritability Threshold Matrix is a tool used by the athletic physical therapist during rehabilitation to allow athletes to participate in their sport at the highest possible level while simultaneously maximizing recovery potential.

KNOW THE SPORT
To be a successful sports medicine physical therapist, you must understand the specific mechanics of the athlete's sport. Physical therapists are experts at breaking down the kinetic and kinematic movement chain.

If you know the sport, you are way ahead of the game—baseball, soccer, football, basketball, volleyball, and swimming should be readily known by the therapist. The therapist needs to know the names of the positions, time of the game, and basic rules so they can "walk the talk" with the athlete. However, if the therapist is unfamiliar with the sport, there are a number of fast track ideas the therapist can use to quickly learn about it. The first is to ask the athlete to "show me" the movement that hurts.

It sounds simple, but all athletes love to show you their "move" whether it is the strength required for drawing the bow for an Olympic archer, the lower extremity movement required to initiate a plie in second position, or the arm angle to make a curve ball "fall off the table." The second is to gather information about the particular sport from TV, the Internet, magazines, books, friends, or any other appropriate source.

The third is to actually attend a game with the patient even if they are not playing. You will be surprised at how much information you can learn in a short period of time. Remember you do not need to play the particular sport to be a successful athletic physical therapist, but you had better be able to know what you are talking about and be able to explain it to the athlete.

TIS THE SEASON
It used to be easy to remember the exact season for a particular sport. One season followed another, and an athlete was usually in the off season, preseason, or mid season. Now, particularly youth and high school athletes are playing their sport year round for school, clubs, and camps. The athletic physical therapist must understand each patient's individual schedule and season. Rehab goals and training will be different based on the timing of the athlete's season. Are you trying to get the athlete healthy for a regular season game or would you rather have the athlete sit out this game to play in the play-offs? A lot of the time, when an athlete is reaching the end of their competitive season, the athletic therapist is more likely to be trying to get the athlete to participate at their highest possible level and keeping them competitive. If the athlete is injured during a club sport or less competitive season, the therapist has more time to rehab the athlete.

INTEGRATE COACHES AND TEAM ATHLETIC TRAINERS
After all you have done with the athletic patient, you still cannot simulate team drills, contact, equipment, and game situations. There comes a time when the athlete must work in combination with their athletic physical therapist and the team position coaches and trainers. This is where knowing the sport helps. The therapist understands what the athlete is safely capable of doing and allows a reintegration back into the sport while still under the supervision of the medical team and direct instruction from the coaches. The therapist, athletic trainer, and coaches are all available to discuss the athlete's safe and successful return back to their sport.

Stephen Clark, PT, DPT, OCS, MBA, is the CEO of Athletic Physical Therapy, Westlake Village, Calif.

LOOKING FOR EXPERT ADVICE? Experts here are available to answer all your questions! Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER Interactive Media  Archives  · December 2008  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article