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Take your rehab to a higher

level by using digital video andaccompanying software to

analyze movement, progress,

and outcomes.

One Frame

at aTime

Successful rehabil i ta-tion today is based onoutcomes. How quickly doyou get your athletes backon the field? How effec-

tively can you react to the individualsubtleties of each athlete? How well canyou assess and treat the entire athlete,and not just the injury?

Its no longer good enough simply toknow anatomy and traditional treat-ment protocols. We need to understandhow to analyze and adapt our approach

based on each athlete and each rehabworkout they do. We need to know howto navigate the exercise choices that

By Larry Jaffe

& Gray Cook

gettyimages

Larry Jaffe, PT, MS, SCS, ATC, a video

analysis expert, practices at Memorial

Hospital West in Pembroke Pines, Fla.,

where he is developing a Pediatric and

Adolescent Sports Medicine Program.

Gray Cook, MSPT, OCS, CSCS, creator

of the Functional Movement Screen,

practices at Orthopedic and Sports

Physical Therapy in Danville, Va. He can

be reached at:

www.functionalmovement.com.

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produce the greatest benefits and get in-jured athletes back to play as efficientlyand effectively as possible.

One major key to accomplishing thisis to maintain the highest level of ob-jectivity during assessment and cor-rective exercises. In order to assesswhether an athlete is completing exer-

cises in a functional manner, we haveto see the nuances of their movements.We also have to ensure the movementsare consistently correct and fundamen-tally sound.

Another key is communicating withathletes. They need to know immedi-ately when their movements are off, sothat incorrect movement patterns dontbecome habitual. They also have to bequickly convinced of the need to alterwhat they are doing wrong.

This makes rehab a more dynamic

process, but also a more difficult one.How can you continually assess andanalyze? And how can you providefeedback to the athlete that is meaning-ful and consistent? We have found thatusing digital video and computer soft-ware during the rehab process is part ofthe answer to both these questions.Assessment & treAtment

In our practices, rehabilitating an ath-lete always starts with a full-body func-tional assessment in conjunction withan orthopedic assessment of the inju-ry. We dont just want to treat the in-jured anatomy, we want to understandall the limitations the athlete is experi-encing. We also want to understand anycompensation the athlete has acquiredwhile living and moving around an in-jured segment. The compensation canoften be a potentially greater problemthan the original injury, if not managedeffectively. As weve discussed in previ-ous articles in this magazine, we use theFunctional Movement Screen (FMS) toassist us in our assessment, which helpsreveal where any underlying problems

lie by applying the standardized move-ment format.

More recently, we have used digitalvideo cameras and software to take theFMS to a higher level of objectivity. Byfilming our athletes and using Dart-fish software, which can analyze andbreak down athletic movement, as wellas measure angles and view the interac-tion of body segments. This allows for amore specific and objective evaluation.

Using video also allows us to docu-ment the athletes starting point and

their progress. As we re-assess through-out the rehab process, we can scientifi-cally compare their movements fromweek one to week two, week four, andweek eight. We can see the effectivenessof therapeutic choices. We can decide ifand when we need to alter our approach.For example, as an athlete performs a

straight leg raise, we can compare thedegree of an extension lag or the con-trol of the hip raising and lowering theleg as they progress through rehab.

Another benefit of training with vid-eo is the ability to observe movement inareas that are hard to see in a mirror.For example, after an athlete has anytype of shoulder surgery, they tend tohave difficulty controlling their scapu-la. By setting up a camera behind theathlete, they are able to see what theirscapula is doing during an activity such

as shoulder abduction.During the latter stages of rehab, thevideo helps us determine when an ath-letes more complicated and function-al movement patterns have returnedto pre-injury levels. For instance, if wehave a baseball pitcher making a come-back from elbow surgery, we want tosee his elbow rising higher than hisshoulder during the pitching motion.Often, it is hard to pinpoint the exactlocation of the elbow because the ac-tion happens so fast. With digital video,we can slow things down and see pre-cisely where the elbow is relative to theshoulder. This way, we can be assuredof a functional outcome to the rehab,and the athlete can be more confidentas they return to play.

Video also gives us the ability toreview a performance many times.During live observation, we cannotpossibly see everything that goes on asthe body progresses through the rapidand complex movements produced dur-ing exercise. But by viewing a work-out multiple times, slowing it down, or

freezing one frame, we can zero in onparticular areas.

Lets say a volleyball player is havingback pain. We may look at her spikingmotion during practice and not see any-thing wrong. But with video, we canwatch specific areas of her body, frameby frame, to find the cause of the pain.Maybe limited hip motion is the culprit.Maybe there is a problem with how herknees absorb her landing. Maybe hershoulder is rotating in a deficient way.The video lets us look at each area in

isolation.Video assessment can also reveal how

movement is changed by the addition oftape, braces, or splints. It is sometimesdifficult to convince athletes to wear abrace or tape during practice and com-petition. By filming them with andwithout the brace, you can show them

how it is effective.Conversely, the video can help us

wean an athlete off a brace. We com-pare movement patterns with and with-out the brace, and when there is nosignificant difference between the two,the athlete can see that they no longerrequire the additional support.

CommuniCAtion

None of this analysis will do any good,however, if the athlete is not convincedhis or her movement has problems or

inefficiencies that need to be addressed.This is the second area where the videoand software play a critical role. Vid-eo-assisted visual feedback can helpathletes see what is wrong with theirmovement, or help show them how totake things theyre doing right to thenext level.

Video feedback allows athletes toanalyze, interpret, and evaluate theirown performance. Most athletes un-derstand what they are asked to doduring a training session, but manyhave difficulty feeling what theyshould be doing. When athletes cansee their performance as an observer,not a participant, they can understandin a more meaningful way what theyare doing well and what they need tocorrect.

Typically after reviewing their per-formance on the video, I ask them whatthey think, instead of telling them whatI think. I ask, What did you see? Whatwas good? What do you need to cor-rect? This gives them more ownershipand buy-in, which leads to better out-

comes in the long run and gives themgreater motivation to improve.

Weve also found that when an ath-lete trains with multiple camerasaround them and a monitor directly infront of them, they concentrate moreon utilizing proper form. For exam-ple, during the inline lunge, did theirknee track medially during the con-centric phase of the lunge? If an ath-lete can answer that question on theirown, theyre more likely to correct themovement. After a couple sessions in

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front of the cameras, athletes learnwhat proper movement feels like, andtheir sound technique carries over tosport-specific drills.

Ultimately, athletes become betterat correcting themselves through thisprocess. They are more excited aboutrefining the quality of each movement

they produce. They cant wait to get thefeedback from the video!

How to use it

A video feedback system can be as sim-ple as one camera placed in one spot inthe room. Or it can be as sophisticatedas several cameras at different angleswith large computer monitors and soft-ware to analyze everything.

If you can only afford one camera, setit up where it can capture the athlete atthe most critical angle. Also make sureit is far enough away so that it can filmthe complete activity. After the athletehas finished the prescribed exercises,review the video with him or her. To-gether, you can discuss what went welland what needs improvement.

With a computer monitor and soft-ware, you can do much more. Once thevideo is loaded onto the computer, theDartfish software allows the instructorto view clips at several speeds, draw lineson or highlight certain parts of clips,and even share the analyzed clips via theInternet. Dartfish also gives the instruc-

tor the ability to compare multiple clips,either from the same athlete or from dif-ferent people (for instance, a rehabbingathlete and a healthy athlete).

In our clinic, we typically use twocameras, placed at the front and side ofthe athlete. We try not to change the lo-cation of the cameras, so we can easilycompare the athletes video with otherrecordings. The Dartfish software al-lows us to zoom in and manipulate theposition of the athlete. Sometimes weeven place a camera directly overhead,

for a view that wed never see otherwise.

CAse study

Heres a closer look at how we usedigital video in a rehab situation: Theathlete is a 20-year-old female NCAADivision I soccer player who has beencleared to play, but has a history of in-juries that continue to bother her. Thathistory includes repeated right anklesprains, a severe left hamstring strain,and occasional lower-back pain.

We start by asking her to complete

the FMS. Test results are as follows:Overhead deep squat: score of 2 (best

is 3), which indicates the movement isperformed with a compensation. Thereis demonstrated decreased mobility inthe right hip and ankle.

Hurdle step: score of 2 for the right,1 for the left (a 1 indicates the athlete

is unable to perform the movement).When raising her right leg, she dis-played an inability to balance and alaterally flexed spine to the left. Whenraising her left leg, she made contactwith the hurdle and lost her balance.

Inline lunge: 2 for both right and leftlegs. She displayed a mobility deficiencyin the right lower leg and a stability is-sue during the left leg stance.

Straight leg raise: 2 for both the rightand left legs. She demonstrated ad-equate hamstring flexibility, but had

poor hip mobility (tight hip flexors onthe contralateral side) and weak lower-abdominal stability.

When reviewing the FMS, the athletewas surprised that she scored so lowsince she was able to participate in pre-season workouts and scrimmages. Sheactually felt she had completed the testbetter than other players on her teamwho scored higher than her. It was notuntil we reviewed the video and allowedher to help rescore her own test that shewas able to recognize and acknowl-edge her poor technique. We explainedthat we were not simply testing her ath-leticism with the FMS (she proved herathleticism on the field)we were dem-onstrating that by moving poorly withbasic functional movements, many un-derlying compensations were present,which were robbing her of movementefficiency.

With the help of the Dartfish vid-eo analysis software, we could slowdown each test and look at her tech-nique throughout the entire movement.As seen in Frame One (at left), during

the hurdle step the athlete was unableto raise her right leg straight over thebarrier without losing some balance.Dartfish provided tracking of the move-ment: The green line is the PVC pipe(dowel) the patient is to hold parallel tothe ground. The purple line is perpen-dicular to the f loor, and the blue line isthe athletes midline.

In Frame Two, the athlete is perform-ing a deep squat. The purple line tracksher spine, and the green angle showsher loss of motion compared to if her

Frame Two: Deep Squat

Frame One: Hurdle Step

Frame Three: Inline Lunge


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body was parallel to the floor.Frame Three shows an inline lunge.

The blue line is perpendicular to thefloor. The orange cross is trackingthe patella during the lunge. And thezoomed-in image reveals the movementof the athletes patella during the lunge.

Once the athlete was aware of the

compensation, we used a two-cam-era setup to show her a frontal and lat-eral view of herself completing the testmovements. We reviewed the test witha module of the software that allows forinstant replay at several different speeds.

We then used the In The Actionmodule of the Dartfish software to seehow her body compensates while sheperforms the exercises. Once she sawwhere her movement was deviating fromthe norm, she better understood whereand how she needed to improve. She

went through a regimen of correctiveexercises, and once she had developedgreater mobility in her hip, she trainedin front of the cameras to ensure that shewas maintaining proper form.

For this athlete, we used the video tohelp assess deficiencies, develop a train-ing protocol, and teach her to self-cor-rect her motions. It made the processmore efficient and effectiveand willhelp her avoid future injury.

Questions & Answers

Video with software analysis can be aneffective tool for the evaluation and re-habilitation of the injured athlete. Sincethis tool can enhance the quality andquantity of information, it can, how-ever, provide as many questions as an-swers. The purpose is not to randomlyrecord all movement looking for prob-lems. The key is to choose movementsand movement patterns that are mostrepresentative of the basic problem ateach stage of rehabilitation.

The clinician can use this movementas a baseline and then begin treatment

and prescribe exercises to improve thechosen movement or movement pat-tern. This process can be repeatedthroughout rehabilitation until resto-ration of functional movement is dem-onstrated and the athlete is returnedto their chosen sport. n

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