CHAPTER 8 PRINCIPLE OF REHABILITATION.pptx

injury

1. CHAPTER 8 Principle of Injury Rehabilitation Edited by Mohd Faridz Haji Ahmad (PhD)

2. INTRODUCTION Student should be able to understand the concept of injury rehabilitation in sport. Student should be able to identify the objective of rehabilitation. Student should be able to identify the component of rehabilitation. Student should be able to monitor the progress of rehab program and return to sport.

3. CONCEPT OF INJURY REHABILITATION IN SPORT Sports rehabilitation begins as soon as possible after the initial treatment of an acute injury. Treatment techniques are frequently used in acute to subacute presentations, and focused on pain relief before the rehabilitation phase begins. Rehabilitation focuses on return to sports participation, and aims to return the sports person to their pre-injury level of performance. Once the athlete has successfully returned to sport, rehabilitation can adopt a preventive approach. Promote the healing process by assisting the progression through the stages of healing resulting in healed tissue that is able to withstand forces it will eventually be expected to cope with. Maintain strength & cardiovascular fitness to minimize the detraining effects suffered & thus promoting return to sport as quickly as possible.

4. Restoration of function. Return to athletic competition. In order to achieve the goals of rehabilitation program, you must have: a) short term goal plan b) long-term goal plan – return to play GOALS OF REHABILITATION PROGRAM Provide immediate first aid & care. Reduce / minimize pain. Re-establish neuromuscular control. Restore full range of motion. Restore increase strength, endurance & power. Improve postural stability & balance. Maintain cardiorespiratory fitness. Incorporate into a functional progression.

5. Prevent deconditioning. Rehabilitate the injured body part in a safe, efficient & effective manner. OBJECTIVES OF THE REHABILITATION PROGRAM

6. [1] PREVENT DECONDITIONING Providing exercises for the cardiovascular system, the uninvolved areas of the injured extremity or segment, and the uninvolved extremities. Some of deleterious effects of bed rest on CV function occur rapidly. Immobilization results in considerable bone, joint, & soft tissue changes. Inactivity results in atrophy & reduction in breaking strength of bone. Bed rest has reportedly been found to decrease strength by 1.0%-1.5% per day. Develop exercises that challenge the uninjured parts while not harming the injured area, but it is important for you to design programs with the objective of maintaining current conditioning levels as much as possible.

7. [2] REHABILITATE THE INJURED PARTIN A SAFE, EFFICIENT & EFFECTIVE MANNER. Requires good knowledge of the injury, the healing process and methods of rehabilitation. Complete rehabilitation of an injured athlete requires not only recovery of the injured tissue, but also recovery from the secondary effects the injury induced on other parts of the body.

8. COMPONENTS OF PROGRESSIVE REHABILITATION PROGRAM

9. KEY TO SUCCESSFULL REHABILITATION PROGRAM [1] Explanation The rehabilitation should be explained to the patient with realistic, approximate time frames. Important to set a short-term goals and long- term goals. [2] Provide precise prescription The therapist must emphasize the correct exercise technique and carefully apply principles for progression and limitation of exercise and activity.

10. KEY TO SUCCESSFULL REHABILITATION PROGRAM [3] Make the most of the available facilities If facilities such as a gymnasium, pool or biofeedback devices available, the program must take advantage of the facilities. [4] Begin as soon as possible The rehabilitation program should start as early as possible following injury or surgery.

11. PRINCIPLES OF REHABILITATION Seven (7) principles of rehabilitation ( ATC IS IT ): A void aggravation T iming C ompliance I ndividualization S pecific sequencing I ntensity T otal patient

12. Avoid aggravation Important not to aggravate the injury during the rehabilitation process. Rehabilitation program, if administered incorrectly or without good judgment, has the potential to exacerbate the injury, that is, make it worse. The primary concern of the rehabilitation program is to advance the injured individual gradually and steadily and to keep setbacks to a minimum. It is should be designed to be safe, effective, efficient in guarded manner. PRINCIPLES OF REHABILITATION

13. Timing The rehabilitation program should begin as soon as possible—that is, as soon as it can occur without causing aggravation. The sooner patients can begin the rehabilitation program, the sooner they can return to full activity. Following injury, rest is sometimes necessary, but too much rest can actually be detrimental to recovery. PRINCIPLES OF REHABILITATION

14. Compliance Without a compliant patient, the rehabilitation program will not be successful. To ensure compliance, it is important to inform the patient of the content of the program and the expected course of rehabilitation. Patients are more compliant when they are better aware of the program they will be following, the work they will have to do, and the components of the rehabilitation process. PRINCIPLES OF REHABILITATION

15. Individualisation It is first necessary to recognize that each person is different. Each person responds differently to an injury and to the subsequent rehabilitation program. Expecting a patient to progress in the same way as the last patient you had with a similar injury will be frustrating for both you and the patient. It is also important to realize that even though an injury may seem the same in type and severity as another, undetectable differences can change an individual’s response to it. Individual physiological and chemical differences profoundly affect a patient’s specific responses to an injury. PRINCIPLES OF REHABILITATION

16. Specific sequencing A rehabilitation program should follow a specific sequence of events. This specific sequence is determined by the body’s physiological healing response. PRINCIPLES OF REHABILITATION

17. Intensity The intensity level of the rehabilitation program must challenge the patient and the injured area but at the same time must not cause aggravation. Knowing when to increase intensity without overtaxing the injury requires observation of the patient’s response and consideration of the healing process. PRINCIPLES OF REHABILITATION

18. Total patient You must consider the total patient in the rehabilitation process. It is important for the unaffected areas of the body to stay finely tuned. This means keeping the cardiovascular system at a preinjury level and maintaining range of motion, strength, coordination, and muscle endurance of the uninjured limbs and joints. The whole body must be the focus of the rehabilitation program, not just the injured area. Remember that the total patient must be ready for return to normal activity or competition; providing the patient with a program to keep the uninvolved areas in peak condition, rather than just rehabilitating the injured area, will help you better prepare the patient physically and psychologically for when the injured area is completely rehabilitated. PRINCIPLES OF REHABILITATION

19. STAGES OF REHABILITATION PROGRAM Return to sport

20. STAGES OF REHABILITATION PROGRAM Management

21. To improve soft tissue extensibility and joint ROM (flexibility and mobilization exercises should begin as early as possible). Consideration of pathophysiology of tissue healing to minimize immediate inflammation and initially restricting excessive force to the injured area. Frequent, gentle ROM exercise (active/passive) can be done within the limits of pain. Heat, ice or electrotherapeutic modalities may be useful adjuncts before or after the rehabilitation exercise. Muscle conditioning begins as early as possible within a safe, pain-free range. INITIAL STAGE

22. Can begin when the athlete: is able to perform daily activities. has good ROM and reasonable strength which correspond to part-way through the repair phase of tissue healing. INTERMEDIATE STAGE

23. Flexibility exercises for the injured part and adjacent areas should be performed regularly to reduce cross-linkages in scar collagen. Soft tissue therapy and variety stretching techniques should be used. Joints restricted in ROM should be mobilized. Strengthening exercises are progressed according to the SAID principle and FITT principle . During late intermediate stage, power will be developed by increasing the speed of resisted exercises. INTERMEDIATE STAGE

24. SAID principle S pecific A daptations to I mposed D emands Ability of the body to adapt to stress & overload imposed on it. Critical to consider during rehabilitation. Indications of having applied too much stress: Pain, swelling, loss or plateau in strength or range of motion. As healing progresses exercise intensity should increase. FITT principle F requency I ntensity T ime T ype INTERMEDIATE STAGE ( con’t )

25. Can begin when the athlete: has gained adequate strength and endurance. full flexibility and range of motion. activities of daily living will produce little or no symptoms or signs. proprioceptive, agility and functional exercises are performed without adverse effect and athlete able to tolerate a reasonable volume of work. entering the remodeling/maturation phase in the healing tissue process. ADVANCE STAGE

26. Athletes are prepared for return to sport by progressing through a sequence of functional activities required for the sport. Muscle conditioning should be sport-specific. The exercise techniques, skills, volumes and intensity should be as specific as possible to the sport. Athlete will continue: Strength: with high load, low repetition. Muscular Endurance: with low load, high repetitions. Power: enhanced with the use of fast-speed isotonic exercises and functional plyometric exercises. Attention must be devoted to the athlete’s biomechanics and psychological well-being. The athlete is usually participating in between 70% and 90% of normal training load by the later part of the advanced stage. Regaining the necessary muscle conditioning, flexibility and function to facilitate return to sport, an important component at this stage of the rehabilitation program is to restore the athlete’s confidence. ADVANCE STAGE

27. The following criteria should be used when determining whether an athlete is ready to return to full sporting activity: Time constraints for soft tissue healing have been observed. Pain-free full range of movement. No persistent swelling. Adequate strength & endurance. Good flexibility. Good proprioception & balance. Adequate cardiovascular fitness. Skill level necessary for successful performance. No persistent biomechanical abnormality. Athlete psychologically ready. Coach satisfied with training form. RETURNING TO SPORT

28. Relative contraindications to return to sport: Persistent recurrent swelling Joint instability Loss of joint range of motion Lack of full muscle strength It is vital to emphasize to the athlete that rehabilitation does not stop when he/she returns to sport because collagen maturation and remodeling may continue up to 12 months post injury. An athlete should not be considered completely rehabilitated until he/she has completed a full season of sport successfully following injury. RETURNING TO SPORT

29. Continually monitor the patient’s progress. A number of parameters should be monitored: Pain Tenderness ROM Swelling Heat Redness Ability to perform exercises and functional activities. (If adverse effects occur, the program should be either reduced or continued at the same level) MONITORING OF REHABILITATION PROGRAM

30. An exercise training program ideally is designed to meet individual health and physical fitness goals . EXERCISE PRESCRIPTION

31. Essential part of the rehabilitation program is recovery. Allowing tissues to adapt to the stress of exercise. Eg :- A runner with Achilles tendinopathy may initially run every third day, then every second day, then two out of every three days and ultimately six or seven days per week ** On non-running days, the athlete should maintain fitness by swimming or cycling as well as performing other rehabilitation program, for example, muscle strengthening.** FREQUENCY

32. INTENSITY Intensity Category Objective Measures Subjective Measures Sedentary < 1.6 METs < 20% HRR < 20% 1RM RPE < 8 (Scale 6 -20) Modified RPE < 1 (Scale 0 - 10) Light 1.6 < 3 METs 20 < 40% HRR 20 < 40% 1RM RPE 8-10 (Scale 6 -20) Modified RPE 1-2 (Scale 0 - 10) Moderate 3 < 6 METs 40 < 60% HRR 40 < 60% 1RM RPE 11-13 (Scale 6 -20) Modified RPE 3-4 (Scale 0 - 10) Vigorous 6 < 9 METs 60 < 85% HRR 60 < 85% 1RM RPE 14-16 (Scale 6 -20) Modified RPE 5-6 (Scale 0 - 10) High >9 METs >85% HRR >85% 1RM RPE >16 (Scale 6 -20) Modified RPE >7 (Scale 0 - 10)

33. Activities that is directly stressing the injured area , time spent should be increased very gradually. Advisable to slowly increase the amount of time spent performing a particular activity. TIME (DURATION) TYPE (MODE) Early stages: Activities that do not directly stress the injured area. However, these exercises may still result in some mobilization/strengthening of the injured area. Later stage: Activities specifically involving the injured area. Aerobic and resistance training Interval vs. Continuous Unilateral vs. Bilateral UB vs. LB vs. Total body

34. Avoid strenuous exercises during acute flare-ups and periods of inflammation. Progression in duration of activity should be emphasized over increased intensity. Adequate warm-up and cool-down periods of 5 to 10 mins are critical for minimizing pain. Inform individuals some discomfort during or immediately after exercise may be expected. However, if joint pain persists for 2 hours after exercise and exceeds the level of pain before exercise, the duration and/or intensity of exercise should be reduced in future sessions. Appropriate shoes that provide shock absorption and stability are particularly important. SPECIAL CONSIDERATION