“Strength without agility is a mere mass.” – Fernando Pessoa
Every ACL injury takes a different route to recovery. Some return to their activities of daily living, some to recreational sports, and some jumpstart their sports career. All this with evidence-based rehabilitation!
But why is it that some have to compromise on their dream to resume elite-level sports and settle for less?
What do the current numbers say?
Recent statistics show that the incidence of ACL injuries in team sports is not decreasing. (3)(4)(5)
As for the non-athletes, current ACL rehabilitation protocols might be adequate due to lesser demands for day-to-day activities.
Yet a recent study of ACL injuries in the English Premier League over the past 15 years reported that ACL injury prevalence has remained essentially unchanged over this period. (6) An extensive research database on the incidence of ACL injuries still shows some drawbacks. The point of concern is that there is a six times greater ACL injury incidence during competition as compared with training.
Why is there a discrepancy between training and actual field play?
We’re missing something!
Adopting a more holistic approach that shifts the viewpoint from purely physical affections may be a good start. A vital component of a rehab program is Agility training that helps to bridge the gap between training and return to function.
‘Agility’ is a word that has been explored over the years to find its true meaning. It goes beyond “rapid change in position of the body”!
Have we deciphered the true meaning of Agility?
An important point to note is that there is a difference between the change in direction (COD) ability and agility. Agility comprises a decision-making process and the following action in response to a stimulus. For example, carrying out a COD in response to an opponent’s movement. While agility is a reaction, COD is a pre-planned movement. (6)
The difference between the two may seem trivial but is extremely important when evaluating performance and injury risk. This surely is one link towards bridging the gap.
As important as it is to perform the right movement at the right time, in the right way, it is also crucial to be in the right state of mind.
Dr. Maithili Bhuptani, a Sports Psychologist talks about Emotional Agility & how an ACL injury has devastating effects on an athlete’s mind.
Components of Emotional Agility By Susan David
Showing up when you’re finding things really difficult- very relevant to the rehab process because any athlete who has undergone an injury finds it very difficult to just show up for their rehab sessions, just be there for their process. Focus on the positive emotions like “how can I get better”
Stepping out – detaching from your emotions and your thoughts and seeing the thoughts for the way they are.
Walking the ‘why is this happening to me’ and taking the long view of life. Doing what is more necessary.
Moving on– moving on from the why, the anger, the grief, and actually moving on to the rehabilitation.
Targeting Emotional Agility post ACL injury
There are many steps and processes from getting injured to fully recovering. The middle steps are what form the concept of emotional agility.
Language of the physiotherapist matters. How to not disregard emotions- if athletes remain angry or keeps regret they will not be able to do the rehabilitation with a 100% positive attitude towards healing and recovery.
Accepting what they are feeling.
Cognitive resources– not wasting energy and thoughts on unproductive thoughts like “I’ll never get better” and instead redirecting them to recovery.
The ability to quickly identify relevant cues (perception), make decisions, and maneuver into position (action), is characteristic of some of the world’s best team sport athletes. It is this ability that distinguishes them from their lesser-skilled counterparts. (7)
However, the effect of superior decision-making skills is not restricted to performance enhancement; decision-making ability may also be a contributing factor to the injury. (8)
Read that again!
The relevance of agility, from the perception of the situation to the execution of the movement, is particularly high when considering anterior cruciate ligament (ACL) injuries.
Do the existing agility tests precisely test all these components?
Recent research studies mention changes in the assessment of COD and Agility performance.
Changes in the assessment of COD performance:(9)
So far, the focus merely lies on the time taken to complete the test (linear speed) but is it giving us the information we need about COD?
The focus should be on testing how the COD is performed, along with the entry velocity and exit velocity.
Avoid focusing on confounding factors like linear speed capabilities. Hader et Al have shown that minimum speed reached during the COD was the strongest predictor of performance outcome which was quantified as the total time taken to complete the COD test. Such an analysis could allow for more complex and specific COD tests.’
To explain this with an example: A T-test can be focused to evaluate each specific COD allowing for a potentially more valid assessment of COD.
Recent research also proposes the use of a novel term called ‘COD deficit’. It can be calculated with any COD test when you have a linear sprint that is of equal distance to that covered in the COD test.
For example, the time taken to run a 10-m linear sprint would be subtracted from the time to complete a COD test (which covers 10 m) to calculate the COD deficit.
This measure has been recently assessed and needs further research.
Changes in the assessment of Agility performance(9)(10)
There is no single test that can assess the COD or agility performance given the diverse nature of movements in our daily lives or sport. It is of utmost importance to know “what are you testing?” and “why”!
Agility training programs usually comprise a planned outline of tasks to be performed with predictable movements and a controlled environment. Sprinting a distance between point A and B to and fro doesn’t catch the patient off-guard.
But this is not the case with actual daily life situations or in a sports field. Running to catch a taxi or dodging an opponent’s move in soccer will come with a bunch of surprises like an unexpected obstacle or a defending player!
In a true sense, agility training should prepare the patients to face every kind of challenge that comes in the way.
Various studies have studied the effects of COD training and COD speed on sports performance but very few have studied the effect of agility training. It is an interesting point to note that current agility training protocols miss out on addressing the decision-making and perceptual components.
As a solution to this, a recent study analyzes two training strategies:
Evasion drills: A simple example in basketball is a 1 versus 1 activity, where an attacker attempts to evade a defender as he or she drives to the basket. The players swap partners so they are required to observe a variety of kinematic cues, and they also swap attacking and defending roles.
Small-sided games (SSGs): This involves games that use a reduced number of players and field/court area with modified rules. The proposed benefits of SSG are the potential to simultaneously develop various fitness components, skills, and tactics as well as being time efficient. To maximize the agility demands of SSGs, rules need to be adopted that encourage evasive skills such as limiting the number of passes or directly rewarding evasive actions via the scoring system.
A few tips to keep in mind while designing agility drills:(11)
Know the “why”: Drills will differ for a young non-athlete and an elite-level athlete.
Make a gradual progression from Closed agility drills to Open agility drills as per the demands of the patient’s goals.
Addition of auditory cues to increase complexity: Use of words “switch”, “stop”, “go”.
Addition of visual cues by the trainer: spreading arms out to show change of direction or lifting them to indicate start/stop.
Both auditory and visual cues may be combined to continue challenging even the most advanced-level athletes. For example, combining an auditory cue with a ball toss or varying the cues, such as calling out a number that corresponds to a specific cone or pointing at a designated cone, can further challenge perceptual skills and reactive abilities.
The use of SSGs and Evasion drills will ensure true transfer of training in elite-level athletes.
This is about physical agility. It is equally important to target mental/emotional agility as well. Dr. Maithili shares insights about how a sports psychologist plays a crucial role in retraining this aspect.
When and how does a sports psychologist come into the picture?
On-field.
Very few clinical sessions.
Prefer working in their natural habitat.
Notions and stigmas of visiting hospitals or seeing doctors.
Consults are very casual and informal.
Pop in a rehab session with a physiotherapist and hangs around start chatting.
Cognitive Behavioural therapy requires them to go back home do some thinking.
Thought processing journaling is homework-based.
Break down the injury rehab process into different phases and set different goals for different phases.
Mental imagery for different rehab phases.
Different goal-setting exercises. Different criteria are set up for different phases.
Before rehab during and post-rehab is like a diet plan.
It becomes like a periodized plan so it’s easy for the athlete to follow. It is much more fun & doesn’t seem like a session.
Although lower body strengthening, core strengthening, and balance training are all important aspects of ACL prevention, these do not replicate positions or situations that many athletes will be involved in during their sports. In comparison, agility exercises contain more dynamic and sport-specific movements than balance training and strength training, making them an essential part of an ACL injury prevention program.
Refrences
Robert A. Donatelli, Kenji Carp, Chapter 12 – Evaluation of the Trunk and Hip CORE, Editor(s): Robert Donatelli, Sports-Specific Rehabilitation, Churchill Livingstone, 2007, Pages 193-221, ISBN 9780443066429, https://doi.org/10.1016/B978-044306642-9.50015-0. (https://www.sciencedirect.com/science/article/pii/B9780443066429500150)
Young, Warren PhD1; Farrow, Damian PhD2 The Importance of a Sport-Specific Stimulus for Training Agility, Strength and Conditioning Journal: April 2013 – Volume 35 – Issue 2 – p 39-43 doi: 10.1519/SSC.0b013e31828b6654
Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567-1573. doi:10.1177/0363546514530088
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804-808. doi:10.1136/bjsports-2016-096031
Agility Training: A Potential Model for the Reduction and Rehabilitation of Anterior Cruciate Ligament Injury Paul, Darren J.; Akenhead, Richard Strength and Conditioning Journal. 40(1):98-105, February 2018. doi: 10.1519/SSC.0000000000000361
Walde ́ n M, Ha ̈ gglund M, Magnusson H, and Ekstrand J. ACL injuries in men’s professional football: A 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med 50: 744–750, 2016.
Abernethy B. Anticipation in squash: Differences in advance cue utilization between expert and novice players. J Sport Sci 8: 17–34, 2008.
Gabbett TJ, Ullah S, Jenkins D, and Abernethy B. Skill qualities as risk factors for contact injury in professional rugby league players. J Sports Sci 30: 1421– 1427, 2012.
Nimphius, Sophia PhD1,2; Callaghan, Samuel J. BSc (Honours)1; Bezodis, Neil E. PhD3; Lockie, Robert G. PhD4 Change of Direction and Agility Tests: Challenging Our Current Measures of Performance, Strength and Conditioning Journal: February 2018 – Volume 40 – Issue 1 – p 26-38 doi: 10.1519/SSC.0000000000000309
Spiteri, Tania PhD1; McIntyre, Fleur PhD1; Specos, Christina MSc2; Myszka, Shawn MS3 Cognitive Training for Agility: The Integration Between Perception and Action, Strength and Conditioning Journal: February 2018 – Volume 40 – Issue 1 – p 39-46 doi: 10.1519/SSC.0000000000000310
Young, Warren PhD1; Farrow, Damian PhD2 The Importance of a Sport-Specific Stimulus for Training Agility, Strength and Conditioning Journal: April 2013 – Volume 35 – Issue 2 – p 39-43 doi: 10.1519/SSC.0b013e31828b6654
Meierbachtol A, Obermeier M, Yungtum W, Bottoms J, Paur E, Nelson BJ, Tompkins M, Russell HC, Chmielewski TL. Injury-Related Fears During the Return-to-Sport Phase of ACL Reconstruction Rehabilitation. Orthop J Sports Med. 2020 Mar 26;8(3):2325967120909385. doi: 10.1177/2325967120909385. PMID: 32258182; PMCID: PMC7099672.
Mann DTY, Williams AM, Ward P, and Janelle CM. Perceptual-cognitive expertise in sport: A meta-analysis. J Sport Exerc Psychol 29: 457–478, 2007.
Lloyd, Rhodri S. PhD, CSCS*D1; Read, Paul MSc, CSCS2; Oliver, Jon L. PhD1; Meyers, Robert W. MSc1; Nimphius, Sophia PhD, CSCS*D3; Jeffreys, Ian PhD, CSCS*D, FNSCA, RSCC*D4 Considerations for the Development of Agility During Childhood and Adolescence, Strength and Conditioning Journal: June 2013 – Volume 35 – Issue 3 – p 2-11 doi: 10.1519/SSC.0b013e31827ab08c
Dawes, Jay MS, CSCS, NSCA-CPT,*D Creating Open Agility Drills, Strength and Conditioning Journal: October 2008 – Volume 30 – Issue 5 – p 54-55 doi: 10.1519/SSC.0b013e318189660a
Marques, J.B., Paul, D.J., Graham-Smith, P. et al. Change of Direction Assessment Following Anterior Cruciate Ligament Reconstruction: A Review of Current Practice and Considerations to Enhance Practical Application. Sports Med 50, 55–72 (2020). https://doi.org/10.1007/s40279-019-01189-4
Share this article
Related Posts
Women’s Health Rehab: Piles
Pediatrics: Physiotherapists’ Ignored Treasure
Study Abroad: Unexplored Courses for Physios
Talk like you mean it: Effective Geriatric Communication
Blood Flow Restriction Technique: Is it new for the Gain World?
