THE ASPETAR WAY

– Written by Enda King, Qatar

In Aspetar, our Mission is to assist all athletes achieve their maximum performance and full potential. We aim to give each athlete the individualised support they need based on their injury, their goals and their lifestyle to optimise outcomes as efficiently as possible. The Aspetar Way is our approach to ensure these aims are achieved with consistency and repeatability to the highest level throughout our team for every athlete:

THE ASPETAR WAY (Figure 1)

1. Individualised Approach.
2. Assessment Guided Rehabilitation.
3. Multidisciplinary Team (MDT) Contribution.
4. Address multiple physical qualities concurrently.
5. Focus on motor learning and development rather than training.

INDIVIDUALISED APPROACH

Although ACL injury is unfortunately frequent in many sports involving landing, pivoting and contact, the journey after injury is a very unique experience for every athlete. While injury to the ACL is a consistent theme with all, there are a variety of ways each athlete may deviate from the time of injury: 

1. Level of trauma to other structures in the knee
2. Disuse and deconditioning post injury and post surgery
3. Graft type used (patellar, hamstring, quadriceps)
4. Post operative precautions
5. Athlete motivation and goals
6. Demands of sports they are returning to
7. Previous training history
8. Response to training stimulus
9. Social Support (Work/Family/Financial Commitments and Constraints)

Our approach is also individualised to that athlete’s injury history to ensure we use the time afforded by ACL rehabilitation to target all deficits relating to previous injury not only those related to the current knee injury. Our approach is to modify our exercise selection, programming, periodisation and support to fit these individual differences while helping all to achieve their common goal as effectively and efficiently as possible.

ASSESSMENT GUIDED REHABILITATION

Before starting on any journey it is essential to have clarity about what the end of the process should look like and the steps required to get there. While many rehabilitation processes know where to begin the journey, and commence with clear direction, they often lose their way or fail to complete the journey, ultimately compromising the athlete’s outcomes.

The end of the rehabilitation journey for most athletes, the clinicians, and various stakeholders that are supporting them is:

1. To return to their pre-injury sport
2. To do so with the absence of symptoms (pain or instability) in the knee
3. To minimise the risk of subsequent injury to either knee
4. To return to their preinjury levels of performance (or higher)

While there are many biopsychosocial factors contributing to achieving those goals, from a rehabilitation point of view the focus is to restore pre-injury level of physical function while concurrently addressing any modifiable risk factors for subsequent injury to either knee or barriers to athletic performance. Once the athlete is “fully rehabilitated” further training is part of maintaining and developing athletic performance, reducing injury risk and maintaining long term health.

Key to this process, our 3D biomechanics assessment lab provides neutral objective review of our athlete’s progress at every step along the way to guide the rehabilitation journey to completion in a timely fashion. It sets out the tests, variables and thresholds within those variables that are required to be achieved prior to the completion of rehabilitation. It also provides periodic detailed feedback to the rehabilitation team on where the athlete is at in each test and variable, what the priorities are for the next block of rehabilitation and the expected progress to be made between testing sessions. It focuses not only on the recovery of knee function but highlights deficits throughout the kinetic chain relating to the initial injury and surgery, and previous injury history, that can be targeted and developed concurrently.

This approach has a number of positive influences on the process for the athlete and the rehabilitation team:

ATHLETE

1. Improves goal setting and motivation – the athlete can clearly see what are the important components that need to be targeted and how the exercises that have been selected are specific to their individual needs
2. Sets priorities – while the athlete wants to progress as quickly as possible it helps them understand how each component of rehabilitation builds upon the next and where specific deficits need to be address prior to progression
3. Reflection – it empowers the athlete to reflect on the previous rehabilitation block, what has gone well and what could go better and helps them understand that there is not always a direct correlation between effort and progress.

REHABILITATION TEAM

1. Consistency of Care – having clear KPI to achieve at each stage of the rehabilitation process and prior to discharge ensures that the rehabilitation team are always working in a cohesive manner towards consistent outcomes for each athlete and has consistent standards across all athletes.
2. Learning and Development – the constant objective feedback and goal setting from the assessment lab provides valuable feedback to the rehabilitation team on the effectiveness of their exercise selection, coaching and periodisation and over time leads to improvement in performance across the team
3. Innovation – having detailed biomechanical feedback on each athlete as well as clear KPI to achieve between each testing block leads to constant innovation of rehabilitation processes as the team strive to achieve the prescribed targets as efficiently as possible.

Assessment guided rehabilitation removes all bias and offers clarity of where the athlete is at during each phase of rehabilitation. Progress is measured, not on time from surgery, but on the development of the key competencies between each testing block. As outlined above, athletes have a variety of different knee pathologies and procedures, previous injury histories, individual responses to training stimulus and time required for progression. Regular assessment provides a neutral objective review that the KPI of each stage of rehabilitation are being achieved and assures that the program for the subsequent training block is specific to the needs of the athlete at that time. 

MULTIDISCIPLINARY TEAM (MDT) CONTRIBUTION

Within Aspetar, and within our rehabilitation team, we have a multidisciplinary approach to the care of each athlete, dependant on their stage of rehabilitation, to ensure they achieve their goals. The Aspetar team is uniquely positioned to guide the injured athlete through every step of the process from injury on the field, through to diagnosis, surgery, rehabilitation, reconditioning and back to the team environment. While every facility is different in terms of the size and breath of their MDT and the expertise that they have, it is important that the signpost for their involvement in the process and their roles and responsibilities are clearly defined to ensure continuity of care throughout (see table 1). As part of the process it is also important, where permitted, to engage other key stakeholders, including sports coaches, agents, and when appropriate family members, in the information exchange. Their involvement facilitates their understanding of the rehabilitation process and allows them to contribute their expertise, drawing from their knowledge of the athlete and the sport. This collaborative effort ensures a seamless transition to restoring the athlete to peak performance throughout the rehabilitation process and beyond.

ADDRESS MULTIPLE PHYSICAL QUALITIES CONCURRENTLY

There are a number of physical components which are all inter-related that need to be addressed throughout the rehabilitation process (see table 2). It is key that the early components are addressed in a timely and effective manner so as not to inhibit and delay progress in subsequent qualities and thus delay the rehabilitation process and achievement of the necessary KPI for progression. For example, early effective management of pain and swelling (clinical) facilitates strategies to redevelop quadriceps activation which in turn facilitates the redevelopment of double and single leg squat patterns. These patterns can then be loaded appropriately to elicit strength adaptations which can be expressed at speed during explosive jumping and landing which provide the foundation for change of direction mechanics that can then be challenged during sports specific drills. This requires co-ordinated planning, systems and communication across the team to ensure efficient and successful transitions through each phase.

Where possible it is important to introduce the simplest or lowest level of each component/exercise in the earlier phases so that that athlete is already familiar with the exercise, understands how their current work greatly influences where they need to go next, and creates confidence that each component of the process is working towards the end goal (common mistakes in this process are highlighted in table 2). This pathway is supported by the role that nutrition, sleep, psychology play across all of these phases to ensure that athlete is giving their body the best chance to adapt appropriately to the training stimulus. Central to the approach is developing all aspects of the athlete’s physical capacity, hence the early emphasis placed on conditioning which is initiated in the weeks just after surgery and progressed in modality and intensity throughout the rehabilitation process to ensure that the transition back to sport and peak performance is as seamless as possible.

FOCUS ON MOTOR LEARNING AND DEVELOPMENT RATHER THAN TRAINING

The efficiency that the rehabilitation KPI can be achieved ultimately influences the transitions through rehabilitation and swiftness at which at athlete can return to their chosen sport. On occasion athletes can feel they have followed the training plan and worked their hardest only to have an aggravation of knee symptoms or ongoing and persistent deficits in certain physical qualities between testing sessions. This commonly occurs if the rehabilitation program is not addressing their individual deficits or if the athlete’s focus during these sessions is on getting through the program (i.e. training – how many sets and reps have I done?) rather than on the quality of the execution of each exercise (i.e. practicing – am I moving/executing better than I was previously?).

There are many strategies we incorporate to address this challenge throughout the rehabilitation process:

Create an optimal motor learning environment

It is important that the rehabilitation team incorporate motor learning principles into their rehabilitation process and create an optimal motor learning environment for that athlete:

1. Self Organisation – rather then tell the athlete how to execute a movement (e.g. lunge and squeeze your gluteals and keep your knee out) provide them with a movement task to solve and allow their motor system to self organise to execute to ensure the greatest improvement within and between sessions (i.e. lunge with front foot on a bosu or side decline board without falling) (Image 1)
2. Constraints – rather than tell the athlete not to sway their trunk during hopping or change of direction drills – ask them to hold a stick/wooden dowel over their head which will lock the arms and constrain the trunk forcing the lower limbs to form an alternative (more efficient) motor strategy. (Image 2)
3. External Focus – instead of internalising their focus on a specific body part (e.g. lock out your knee as you jump) provide an external focus to drive the movement strategy you are looking for (jump to touch the basketball rim) 
4. Variability – while executing the same exercise use a variety of equipment you have available during the same task to improve the motor learning and retention of the desired pattern (e.g.  hip lock drill for running – banded, hydrobag, trampoline, visual distraction goggles) (Images 3-5).

Focus on Quality vs Quantity – its not what you do but the way that you do it!

There is regular feedback on the quality of execution of each exercise in the program as much as the number of sets and repetitions. This helps the athlete avoid:

1. Rushing through the exercises to complete the prescribed dosage but without the quality to achieve the technical changes and motor patterns
2. Not recognising the exercise is no longer technically challenging (i.e. landing exercise) or is not intense enough (leg press for a 10RM but athlete could do 4-5  more repetitions at the prescribed weight) this not achieving the desired adaptation
3. Not listening to their body during the exercise execution for example either aggravating their anterior knee during a quadriceps strengthening exercise or feeling the load/strain in their lumbar spine instead of their hamstrings during a deadlift or bridge exercise for example..

Optimal use of Technology – did I do what I set out to do the way I set out to do it?

Technology has an increasingly important role to play in optimising training during both athletic development and rehabilitation. We incorporate technology throughout the process in a number of different ways to enhance the athlete focus on practice and development of each physical quality:

1. Assessment guided rehabilitation - as outlined previously the state of the art biomechanical assessment lab has over 40 infrared cameras and 10 force plates which can provide kinetic and kinematic outcomes throughout the kinetic chain across a range of performance and sports specific tests to track and feedback progress in improvement in motor control and performance throughout the process to the athlete and rehabilitation team
2. Muscle Recruitment – using EMG sensors for biofeedback to optimise motor redevelopment of muscle activation and patterning and gamify the process to improve buy in and compliance (Image 6).
3. Strength/Explosiveness – incorporating velocity based training tools into strength and explosiveness training motivates the athletes maximum effort, ensures they are training at the desired intensity (velocity) and allows the monitoring of fatigue during and between sessions (Image 7).
4. Landing Mechanics – the use force plates can provide real time feedback on asymmetries in landing mechanics as well as feedback on the quality of the landing on both limbs. This encourages the athlete to self organise their landing strategy with being told how to do so maximising motor learning with a session and carry over between sessions (Image 8).
5. Virtual Reality – the use of VR headsets can provide a variety of neurocognitive stimulus during simple exercises such as balance or during virtual sports specific drills during early rehabilitation when the knee is still recovering challenging the athlete long in advance of their return to the field (Image 9).
6. Training Progression – the use of bespoke programming software to allow the athlete to see all their planned rehabilitation sessions and dates in advance, accurately record the training stimulus every session, monitor wellness and fatigue levels across the training block and chart progressive over load. All of these components improve compliance and motivation and maximise the training adaptation.

Even the “best” rehabilitation programs are diminished if their execution is not appropriate to achieve the desired training stimulus and adaptation. To minimise such issues, measure their effort and focus on how they have progressed not on how often or how hard they have trained.

SUMMARY

During ACL rehabilitation, our processes should match the goals of each individual athlete, provide clarity on the key physical outcomes we want to achieve, and track their progress throughout. Physiotherapists are required to utilise their entire rehabilitation skillset to develop all the relevant qualities concurrently giving us the best chance of supporting each athlete to achieve their maximum performance and full potential after injury while being supporting each member of the MDT in completing their roles and responsibilities. Furthermore, systems can be reviewed and refined on an annual basis to further enhance our standard of care as our clinical practice, technology and research evolve over time. 

This is the Aspetar ACL Way – what is your way?

Enda King P.T., Ph.D.

Head of Elite Performance and Development

Aspetar Orthopedic and Sports Medicine Hospital

Doha,Qatar

Contact: enda.king@aspetar.com

Header image by Kate Tann