Thanks so much Kyle, again I'd like to thank the Academy for Sports Physical Therapy as well as AOSSM for inviting me to be part of this really exciting session. And again, it's a great opportunity for us to do these exchange lectures and I appreciate the opportunity to contribute. I have nothing to disclose. So my objectives for today are really just to discuss some emerging technologies and techniques that we're seeing in sports physical therapy. With that, we'll talk about some current evidence linking these emerging techniques to future outcomes. But in many cases, we're still looking to develop more stronger evidence in these areas. So we'll review some possibilities for us as we look forward. So if I would have done this talk five or ten years ago, we probably would have talked a lot about different treatments like dry needling or BFR. But today's theme is really going to move forward to emerging technologies because there's a lot of technologies which have been developed not only in the last few years but over probably the last decade that we're seeing utilized in many different arenas, especially in athletics and sports and performance. But now we're starting to utilize them more in sports physical therapy. So we're excited to see the integration of these technologies and I'll talk about a few of them today. So the four areas that I'll speak of, one are advances in quantitative movement analysis. Next we'll talk a little bit about telehealth, telemonitoring, and wearables in rehabilitation. We'll speak briefly about the use of virtual reality. And then finally, just quickly talk about the recent focus on neuroplasticity and musculoskeletal rehab. So we'll start out with quantitative motion analysis. And it's important for us, and again, as was mentioned, I'm an ACL researcher. So I'll lean on my ACL work a bit to demonstrate why there's a need here. But certainly there's generalizability across all patients with musculoskeletal injuries. And so we know that this is really valuable for us at the time of return to sport as well as throughout the episode of care. So why is this an important topic? Well, currently we know that our current criteria to return athletes to sport are really not well defined. And they don't give us a good indication of who will be successful and who will fail once they return to sport. Movement is a key variable in return to sport decision making. As a physical therapist, our mantra is we're movement system specialists. And so certainly we want to find the most objective way for us to measure and assess movement to determine if folks are ready to safely move back to their sports. Finally, we need to really look for a clinically feasible but objective movement assessment. And we'll speak a little bit about why that's been a little bit of a challenge for us as professionals to define something that is both clinically feasible and giving us valuable information. And as a result of all of this, many of our patients are failing to safely return to sport. And I'll lean on, again, the ACL literature to demonstrate that. So in a study we published in 2014, we were looking at the incidence of second ACL injuries after folks had ACL reconstruction and returned to sport. We looked at young patients between 10 and 25 years old. And what we found in the two years after they returned to sport following an ACL reconstruction, almost 30% suffered a second ACL injury. And our young athletes were six times more likely to suffer a second ACL injury than someone who had never previously suffered an injury. And there's been several studies, systematic reviews and other studies, which have demonstrated very similar results in young athletes. So what criteria are we currently using? So if we look over the last 20 years in the literature, it's sad to say we've seen very little movement in what we use as a professional organization. So in 2004, there was a systematic review that demonstrated that only about a third of studies used objective isokinetic strength testing. Two-thirds used functional hop testing. But at that point, over 10 to 15% of those studies reported no objective testing to make a determination about return to sport. In 2007, Sue Barber Weston et al. published a much larger systematic review of over 264 articles. And what they noted was that 40% of the studies in the literature had no objective criteria at all to make a decision about return to sport. And only 13% actually reported objective criteria. And in 2018, in a scoping review that was published by Bruguier et al., what they looked at was all the studies that were published from 1986 to current. And what this graph demonstrates is the proportion of studies which use these different type of measures to make decisions about return to sport. And what you'll appreciate, from about 1990 to present, there's very little change in the type of measures we're using to make decisions about return to sport. So it begs the question, what is missing? And I'll argue that we need to more objectively assess our movement. So in data that we presented in 2018 here at AOSSM, we looked at the current return to sport criteria in these young patients, again our 10 to 25-year-old patients. And what we noticed was the current criteria to make decisions about return to sport. They didn't identify differences in who went on to suffer a second ACL injury and not. So basically we looked at the top six criteria at that point in time which were used to make decisions about return to sport, which included quad strength, four hop tests, and one patient reported outcome measure. And we looked at the percentage of those patients, over 150 patients, that actually met the criteria that we would say are ready to return to sport, which is greater than 90% limb symmetry or greater than 90 out of 100 on your patient reported outcome score. And at that point in time, 26% of patients who had been released to return to sport actually passed those criteria. And then we beg the question, well, what if we elevated the criteria a little bit and made it 95% instead of 90? Because some would argue that those tests probably are not strong enough to make a decision of who will be successful. And only 9% passed it. So again, many of our patients are not passing that. And here's the sad truth beyond that, as we look at the differences in those two cohorts, the group that actually passed all six return to sport measures and the group that failed to pass one of those, there was no difference in the proportion of those patients that went on to suffer a second ACL injury. So essentially, the criteria that we were using, they're not giving us good information about who goes on to suffer a second ACL injury. So again, if we look globally at what criteria we're using today to make decisions about return to sport, strength, functional performance, and patient report outcomes, we're starting to look at that. But I'd argue we're not looking objectively at quality of movement. So again, how do we quantify that movement? And there's a spectrum of ways that we can look at it. Those that is the most objective and probably the most expensive, and those that is probably the cheapest, but many would question how objective and how reliable that is. So we're going to talk a little bit about this continuum of motion capture from a 3D motion capture all the way down to our visual inspection. So if we start out with 3D motion, all of us would argue that it's the gold standard. It's the most reliable and valid method to assess movement. And several studies have looked at 3D assessment in healthy populations and have identified folks that they predicted that would go on to have an ACL injury, a primary ACL injury. So we see that the 3D motion gives us very good data. In 2010, we did a similar study looking at, again, the patients who had followed, who were returning to sport after ACL reconstruction, and we identified four measures that predicted who would go on to suffer that second ACL injury. These four measures are here, and interestingly to note, three out of those four measures are measurements of movement. One is net internal rotation moment, a second is knee valgus, a third is side-to-side differences in sagittal knee moment, and then the fourth is balance or postural stability. So when you bring those four measures together, it created a very predictive model of who would go on to suffer a second ACL injury with very high sensitivity and specificity. Interestingly, when we looked at just one of those motion variables, it in itself still had very good sensitivity and specificity. So the take-home point is, we really think that motion is something we should assess to make a determination of someone's readiness to return to sport. But despite the fact that we published that 12 years ago, we still haven't done a good job implementing that. And I think some of the emerging technologies are going to give us, as clinicians, an opportunity to do a better job of assessing movement moving forward. So if we had to summarize 3D motion, we would all agree it's reliable, it's validated, it's been associated with future injury. But the reason probably we don't use it is it's very expensive, and there's limited feasibility and generalizability as a result. So if we go down a step to 2D motion analysis, and let's think about some of the advantages. Because when we talk about 2D motion analysis, we start to talk about maybe something that's a little more generalizable to many of our clinics and on our athletic fields. It's relatively cost-effective. There could be, as I mentioned, generalizability. And we may be able to complete the evaluation in a very timely manner. So our patient comes in, we do the assessment, and we have good data to act on it. And really, it may be good enough. So there's been many studies over the last 10 years, 10 which I've listed here, which have demonstrated reliability in 2D measures, all of which have looked at different types of movements, but have demonstrated high inter- and inter-rater reliability. Similarly, there's been five studies which have been published, again, over the last 10 years, looking at validity. So comparing 3D measures to some of these 2D measures and demonstrating good validity. So again, we're starting to get some momentum behind some of these 2D measures. Again, when we look at a healthy population, there was three studies that are listed here that looked at 2D assessments of motion and noted that there was a demonstration of increased ACL injury risk with some measures which were assessed in 2D. Again, looking at knee valgus with certain measures such as dropped vertical jumps or single limb landing. And then one study at the bottom looked at not just one joint measurement, but looked more holistically at the movement of the individual with two dimensions and also demonstrated a predictive model of lower extremity injury. But to date, no one's looked at two-dimensional motion and looked at second injury or re-injury risk. So when we talk about utilizing this in our clinic with our patients after they've had surgery or after they've had injury, that's one thing that we still need to look at. We've started down that path. We published a study in 2021 looking at some 2D measures and seeing if we could predict from these 2D measures who would go on to have a second ACL injury. And again, we reported this in 2021. And what we did was we took very simple 2D measures. There's many different, there's a lot of different freeware available that you can measure angles as you see here. And we looked at individual angles such as knee valgus or lateral trunk lean. And we looked at some of the combined measures as that last study mentioned. And we looked at, if we looked at them individually or some of these angles collectively, are we able to determine who's at high risk for future injury? And what our data suggested that with this type of technology, we looked at folks who were very rigid and had deficits in motion or failed to have what we consider normal movement. We identified some folks who had wildly excessive motions, which we would say is high risk. And we're starting to identify really that sweet spot, like what's the appropriate amount of motion that we might accept and think is low risk. So again, we're starting to get some pilot data about how to utilize 2D measures again to determine risk of future injury. Just a few others, there's other technologies which we've experimented with, again, some nice systems that are commercially available, not only to look at very objectively taking the video, but also looking at taking angle measurements as well. So again, different options which are available in 2D. So the question is, is 2D good enough? So we think from this data, which I've just presented, it's reliable. It may be valid when we compare to 3D. We may be able to start to link to outcomes in healthy populations. We're starting to see some emerging evidence linking 2D motion to outcomes after ACL reconstruction. And actually, the AOSSM and AIRCAST funded a study in our lab to really take this a step further and hopefully we'll have some great data to present next year, really starting to look at, can we utilize 2D to accurately predict second ACL injury? But really, the ideal methods to best assess movement, we're still working on it. So clinical implementation, it's not just for ACL patients, so I just want to make sure we note that. So I talk a lot about ACL because that's my research, but not just for return to support decision making, but as a therapist, assessing their movement throughout the rehab episode is critical. And if we can utilize this technology to really accurately assess how folks are moving, we can change our rehab interventions on the fly to try to get better interventions on that at the end as well. So in summary, to summarize some of the 2D motion, certainly movement assessment is a key factor. There's probably clinically feasible ways to do it. The best method, still a work in progress. And really, there still may be better options to come. So I'll close the door on 2D motion and talk about a few of those other things I wanted to mention. So one is telemonitoring, telehealth, and wearables. There was a great presentation yesterday by Lyle Kane, or two days ago by Lyle Kane, that talked a little bit about the use of some of these wearables in large, healthy populations, like football teams and things like that. And I think that's great, and I think as a rehab professional, we're starting to tap in to the utilization of some of that data into our patient populations. So I want to look through a few lenses as we talk about this, one being the advantages of some of these opportunities for activity tracking, adherence in our patients, motivation for our patients, and then finally, how we can improve technique and feedback. So activity tracking. So there is many, many, many different activities. We all have them on our watches, on our rings, and everything else that tells us how physically active we are. And as a healthy population, it's beneficial for us to track this information. And from a rehab profession, we see benefits as well, especially as we're starting to transition folks back to activity after an injury, or back to sport after we've released them. It helps us better objectively identify how active they're being, and can we progressively return them to activity. It helps us with this mindset of progressive load management, because we can objectively assess how active they are to make sure we're ramping them back up to activity appropriately. Well, what about adherence? I think that's probably every therapist's nightmare, is are our patients doing their exercises at home? Is the home exercise program getting done? And I think for many of us, we are concerned that it doesn't. But this does give us objective information about how adherent are our patients. And much of the technology that's being developed can provide dashboards, not just to the patient, but also to us as therapists, about completion of exercises, and what I'll talk about in a minute, is accuracy and quality of exercise as well. So again, there's potential to really increase the accuracy of the exercise dose. And again, for us, dosage is really a key factor in rehab as we move forward. It's not just do you get therapy or not, it's what's the appropriate dose of physical therapy that's provided, and is it coming and getting us to the best outcome for our patients? What about technical improvement? And this is really a great thing for us to think about, because, and there's two types of system. One is a visual-based system, where you get visual feedback, and a lot of us have seen this in our kids with different types of gaming systems. But also with use of IMUs. And so both of these types of technology give us visual feedback at the time of exercise, and they have give us the opportunity to report the quality of the exercise that's executed. So if they're going home and doing exercise, and they can bring us information back, are you doing it like I coached you to do it, or like we worked on doing, or are you struggling? And do we need to really work on that as well? So there's definitely potential to improve this quality of the home exercise program or the quality of intervention as well. So the wearables do provide a lot of opportunity for us moving forward in rehab. So two more quick slides. One is about virtual reality and sports PT. Again, so virtual reality, again, I work in the Cincinnati Children's Hospital. My patients are generally 6 to 26, and they love games. And so getting a system that brings gaming to them and gets them involved in activity really has the opportunity to improve motivation as well. And you can see this one picture on the left, you see them using a commercial system. Again, kids love to come into the clinic and do some of the virtual reality as part of their rehab. But the system on the right, you see, again, a more high-tech system, but similarly, another type of virtual reality environment, which challenges the patient in a different way. And beyond just motivation, there is data that's starting to be presented that suggests that the use of virtual reality challenges our patients at a higher level. This one study that was published in Sports Health several years ago reported that patients getting motion analysis done in a scenario where they're in a very comfortable environment, and then doing the same type of motion where there's a virtual reality that's challenging them and bringing them more to the playing field, we see very different results in their movements, suggesting that the level we bring them to in a very controlled clinic, as far as their ability to move comfortably, probably is not enough. We need to challenge them in their own environment, which we've always said for years. But it's hard for us as clinicians to bring them onto a field when we're bound to a clinic. So if we can bring the field into our clinic, it's new technology that helps us move forward. And one last comment is on neuroplasticity and ACL injury. And I'll start by saying this really isn't new. For many years, we've talked about how musculoskeletal injury results in central changes. We see changes in our brain, changes in neural activation. But in the last 10 years, there's really been a lot more literature that's been published. And one by Dustin Grooms, which was published in 2017, which really kicked off a lot of this work. And it's really started to talk about the differences in functional MRI findings regarding neural activation after musculoskeletal injuries. And just because I'm just going to talk about this for a minute, we could probably talk for a day about it. But what has really motivated the profession in physical therapists to do is think about different interventions to not just focus distally and to think about how we can challenge our patients in different ways to hopefully address some of these neural activation changes that we see at the time of injury. Some of those things being visual perturbation training with things such as stroboscopic glasses, virtual reality, as I just mentioned, and dual task activities with some neurocognitive challenges. So all of these are new interventions, which we're seeing being used in clinics. And I think, especially in this area, research will really lead us the way to determine what's the most efficacious in some of these new interventions as we move forward. So to summarize, the great news is rehabilitation is evolving. We're seeing lots of us in the physical therapy world and others really trying to leverage some of this evolving technology to get the best outcomes for our patients. So with this new and evolving technology, hopefully we can expand opportunities for novel interventions, but most importantly, we must continue to really work to continue to confirm the efficacy and utility of these interventions, again, in the spirit of getting the best outcomes for our patients. Thank you very much.

emerging technologies

sports physical therapy

quantitative movement analysis

telemonitoring

virtual reality