So what I'm going to tell you today is that yes, wearables can guide decision-making. I'm going to tell you how we're using it right now, if this works. Next slide. Disclosure. Next slide. So I have no conflicts related to this wearable technology. Next slide. I also have no conflicts related to name, image, and likeness, and I don't... You can go back a slide. I don't know if you can see that. There you go. All right. Up one more slide. In Birmingham, we're hosting right now, I'm sure you guys are all aware of the International World Games, right? This is the year after the Olympics event for all of the sports that are internationally sanctioned by the IOC, but do not play in the Olympics. So we have 100 countries, 3,500 athletes, 25 venues we're covering, all my fellows and Jeff Dugas, my partner, are all covering these events right now, and I covered a bunch before I came down here. We have things like powerlifting, and karate, and lacrosse, and bowling. Next slide. We also have some weird things like parkour. We have floorball, and we have something called canopy, where it's essentially trick skydiving. They come out of a helicopter at 5,000 feet, and they try to drag their feet through some water as they hit the ground, and they have a lot of face plants. So it's a very aggressive sport, but that's why a lot of my partners aren't here this week. Next slide. So what we're talking about is return to playing athletes. I think every player, every family, every coach, every athletic trainer has these questions. After an ACL, when can you start a running program, a cutting program, jumping? When do we get back to practice, and when do we play again? No matter whether you're recreational, collegiate, or high school, or professional, everybody's got the same question. Next. We have some gold standard tests that everybody's kind of shown in these talks previously, and hundreds of publications are out there looking at best criteria to return to play. The problem is most of these are based on side to side difference. So you're comparing injured leg to uninjured leg. And ultimately, several studies have shown that the uninjured leg after an ACL is not actually uninjured. It loses up to 30% of quad strength just because of time off, pain, disuse, all those other things that happen after injury, and probably some neural connections as well. So we're using an uninjured leg that actually has some loss of function. Next. So how do we determine safe return to play? So those of you that know this guy, know that he thinks that every ACL, regardless of concurrent pathology, should be back at four months. So if you let him return, he makes the decision, everybody's back at four months, it's easy. Everybody's back at four months, straightforward. Next slide. So this is the traditional things that we've used over the years. I think all of you guys have probably used it as well. Subjective derating scales, ligaments assessment, strength testing, hop testing, and functional testing. Next. The IKDC is a great follow-up tool for ACLs, but not really great at telling you when they can play again. Next. The KT2000 we used to use when I first got to Birmingham in 1999 on every ACL. Next. And it would give these nice reports that showed that you went from six millimeters of laxity down to one millimeter of laxity. But again, that doesn't tell you they can play. Next. I think strength testing has been a big bonus for most of us. The KT, excuse me, the Biodex testing, where you can get some peak torque to body weight numbers for both quad and hamstring. Next. You can also get side-to-side comparison, but again, you're comparing against a potentially non-normal uninjured leg. Next. This is what I call in West Alabama the poor man's Biodex. This is a single-leg leg press. So all the high school kids in Livingston, Alabama and West Alabama where they don't have Biodex machines, you know, I get them to do a single-leg leg press and compare the two sides. And whenever they're within 10%, that's a pretty good indicator that maybe their strength is back. Next. A single-leg hop test has been shown by Sue Barber-Weston and Frank Noyes and others to be a really good show of function, and I think that's something we still use clinically today. Next. And then functional testing, such as the functional movement screen in 2014 described by Kiesel, has been a big part of return to play also in the physical therapy world. And I think it has some validity and certainly shows a patient's activity level and functional ability. Next. And as you've seen on the previous papers, you know, Y balance test has been shown in ACL surgery and also now in hip surgery to maybe have an important indication of a return to function. Next. So, ultimately, what is the best control to determine normal return to function? Is it the contralateral leg? Next. I'd say no, because the contralateral leg is not always normal. Sometimes it grows during rehab, too, so you're returning, you're comparing an injured recovering leg to a leg that's grown in strength 30% during the rehab process. Next. So, I think the best control is their pre-injury function. The problem is, in most cases, we don't know their pre-injury function very closely. Next. And that's where wearable technology comes in. Next. So, wearables are common in everyday use, you know, we have iPhones and Fitbits and all kinds of crazy things now where you can check your own EKG and you can diagnose your own atrial fibrillation standing here at the podium. We have a variety of GPS methods collecting data employed by a lot of professional mini college teams and, you know, it's amazing that the iPhone just had its 15th birthday party. June the 29th, 2007 was the introduction of the iPhone. Think about how far it's gone over the last 15 years. Next. So, GPS systems are available already in many, many college and pro sports and they're usually used by the strength and conditioning coaches, not the medical staff. They use them to look at physical fitness, explosiveness, max speed, things that they're trying to acquire in workouts, not from a team physician standpoint. And most team physicians don't even know that their teams have these, honestly. Next. So, we can measure and track a lot of variables. Total distance and max velocity. Next. You can see tracked over time. Next. We can do player load and explosiveness. Next. We can look at what's called inertial movement analysis. So, this kind of interesting chart shows acceleration at the top, deceleration at the bottom, high speed cutting to the right on the right side and high speed cutting to the left on the left side. And so, you can follow their true function on the field using this. Next. And then you can look at side to side balance. You know, there's some kids that cut really hard off the right leg and low to the right leg and some kids are really off the left leg and if you know that pre-injury and they come back and they cut really hard off the uninjured leg, is it because they're not recovered or is it because they've always done that? Well, if you know, have pre-injury data, you may know that information. Next. So, we started doing this in 2013. We're nine years into data collection now. We have 85 patients that wear the devices both in practice and games. Next. This is what it looks like. There's a little thing that fits in the back of their shoulder pads. It's funny when I walk out on the field at a game behind the players, you know, they're always these big, strong, Hulk guys and they've got this little green blinker going on behind them. When the new fellows come into town, I always tell them that they're cyborgs. That green means they're on. So, if you see a green beeper, you might not want to get close to that kid. Next. Each one has their own little device that goes on them for every practice and if they're not wearing shoulder pads, it goes in their shirt. Next. So, this is the data collection we have every day. And on each of these variables, we have 300 to 400 data points per player per day. Next. We also have some new technology in the weight room that has what they call smart bars or smart activated tools where they can look at acceleration of the weight bar, look at explosiveness, not just how much weight you can press. Next. And they're starting to go to new systems that instead of using free weights, actually use resistance. So, you can get 3D momentum and different muscle activation patterns. And this is kind of the science of weight room that's coming along that's going to change over the next 10 years. Next. So, what have we seen so far? So, Norman Waldrop, my foot and ankle partner and I have put this in, it should be published soon, looking at our ACL database. We had the GPS data normalized over 10 metrics for all of our players starting in 2013. For the specifically ACL injured players, their average return to play at the University of Alabama after passing traditional testing, hop tests, isokinetic biotech testing, all that, was 5.4 months. But only 60% actually returned to 90% threshold on GPS data. And it actually took them more like 10 months to get back to their 90% criteria when you look at GPS inertial movement data. And the last thing to come back after an ACL is acceleration. Next. There are some limitations. GPS data is only good for outdoors. We can't use satellite testing inside. So there are some radio frequency systems that we use now in basketball and indoor sports. You can't really look at mechanics, so if a guy lands or cuts awkwardly, you really can't assess that like you can with video analysis. Sometimes TMI, you know, anybody under 40 knows TMI means too much information. So you're overloaded with about 200,000 data points per week, and it's hard to know what to collect, what to catalog, how do we measure it, you know, how do we report it. When do they call me and say, hey, this guy's got a problem? Next. So how do we track progress currently in Tuscaloosa? We do a weekly rehab dashboard, and this is what it looks like. Next. So this is a sophomore running back. He tore his ACL last season. He's nine months out now. Next. We know his pre-injury data. So the top part is the strength data in the weight room in watts of power for different lifts. The bottom is his catapult data, acceleration. Next. And now we know his current data. So this is his last test, which was the end of June, and we know that he's 90% overall back to his current function. He's about 92% in strength and 89% in function. Next. So in conclusion, if your players do well like Kenny and Drake did, next, you might get yourself on the front cover of Sports Illustrated like Norman Waldrop did after fixing his ankle the year before. Next. So my criteria, I still use the same kind of basic systems I grew up using, a subjective knee rating evaluation, ligamentous exam. I don't use the KT-2000. I usually do a manual max test myself. Strength testing using the Biodex, hop test, and functional testing. Once they pass that, that means they can get on the field. Not for full play, but they get on the field. At that point, next, at that point, we start using the wearable technology, and that's when we see that they get to their pre-injury 90% GPS data. That confirms that the athlete has truly returned to pre-injury function and gives me a lot more confidence in allowing these elite players back to play. Next. Thank you. Hopefully you're going for number seven this year.

wearables

decision-making

return to play

ACL injury

wearable technology