FQ4: How is injury rehabilitation managed?

Question 1

rehabilitation procedures - progressive mobilisation

in general + hamstring tear

Answer 1

• gradual increase in joint ROM/movement
• Injury + RICER can lead to joint stiffness/tightness - (muscle not used for extended period)
• required because of this tightening of muscles + stiffening of the joint
• slowly stretches the muscles allowing for a gradual increase in ROM at joint → gradual progression helps increase movement in ligaments around joint
• necessary to enhance RO movement available at (ham)
• Should begin as early as possible = to help prevent scar tissue + reduce recovery time
• (ham) tear causes severe damage to muscle + connective tissues e.g. tendons + ligaments, leading to scar tissue formation + immobilisation
• Important that slow increase in ROM is pain-free (slight discomfort is ok) → involves both passive (done first) + active movement
• A + P techniques can be introduced soon after injury to prevent muscle inactivity e.g. of A+P exercise for (ham) = flexion + extension of knee by athlete + physiotherapist
• important athlete = ready to undertake this phase by ensuring movements are slow, circulation to area is increased beforehand +
  movement remains pain-free
• utilises dynamic, static + PNF stretching = NOT ballistic = can further damage (no stretching of (ham) in inital acute period)
• Often begins w/ static –> PNF stretches (added contraction during rehab stimulates greater healing of muscle) → dynamic used through rehab w/ slow passive movements at beginning + active + faster movements at end
• However, progression + stretching for mobilisation = individualised for each case + specific injury acquired e.g. hamstring tear
• Key stage = as prevents muscle stiffness

Question 2

rehabilitation procedures - graduated exercise (stretching, conditioning, total body fitness)
- Shoulder dislocation (SD)

Answer 2

• Refers to the gradual increase in ROM, intensity, + activities = ensure athlete’s recovery is as pain-free as possible
• ensure exercise intensity + activities progress w/ healing + do not cause further injury
  Involves three stages:
  Stretching
• ensures that injury heals w/o scarring (scarring = shortens muscle + makes it prone to further injury)
• Static stretching = least intense = also least gain
• PNF = most beneficial form during rehab → Gains in ROM are large = helps prevent joint stiffness + promotes recovery
• Dynamic = used towards end = requires more control
• For SD: beneficial = reduces muscle tension, increases circulation + deltoid muscle + tendon length + improves ROM at injured site
• Stretching = form of PNF + static stretches at initial stage, ensuring correct technique + no pain
  Conditioning
• strengthening muscles to their pre-injury levels
• specific to injury + athlete involved
• Muscles = need to be strengthened again as the reversibility effect would have caused atrophy in unused muscles
• SA: vital as inactivity leads to muscle atrophy = imperative strength in muscle is regained + is slowly overloaded w/ further resistance to initiate further strength gains
• e.g. suitable resistance exercises for SD: anterior deltoid raises w/ low resistance or rotator cuff exercises
• Graduated conditioning of muscles begins w/ the strengthening of the muscles + developing muscular endurance
• Exercises begin at low intensities + PO = used to ensure intensity slowly increases as muscular strength + endurance rise
  Total Body Fitness
• regaining level of mental + physical fitness reached by athlete before injury
• reversibility effect causes a loss of TBF
• refers to both health + skill related components
• helps ensure complete recovery in each component = no weakness when athlete returns to play
• Must involve all principles of training particularly PO
• essential to restore TBF not just recuperation of SA
• choice of TBF exercises = depend on type + severity
• In case of a SD e.g. light resistance training through use of elastic bands + low intensity swimming

Question 3

rehabilitation procedures - training

- (ham)

Answer 3

• involves participating specific training to restore athlete to full capacity
• Although athlete may have returned to full fitness, strength + condition = still not
  fit enough to return to comp
• Training during rehab = slow down + limit loss of fitness → train w/ non-injured side or limbs
• Once athlete = completed rehab = still require training before can return to play → lack of engagement in their sport means sport-specific components of fitness, e.g coordination + agility have not recovered
• Regained through training + comp simulation
• Training after rehab aims to: develop sport-specific fitness components/skills, increase confidence + ensure a safe return to play
• Once athlete is pain free + performing at pre-injured levels, perf should be assessed to determine readiness to return to full comp
• must undertake training to ensure speed, agility + muscle coordination are restored to full capacity.
  e.g. AFL player = (ham)
  = may return to lower grades before re-entering senior
  team
• has been found will ensure physiological readiness to return to full comp

Question 4

rehabilitation procedures - use of heat and cold

- SD

Answer 4

HEAT:
- Not to be used after initial treatment of injury (within first 48 hrs)
- Increases blood flow to injured area (delivers nutrients + white blood cells, while removing waste)
- increases flexibility (increases elasticity of fibres), tissue repair (by increasing blood flow)
- Decreases joint stiffness (increases fluid to joint)
- Can use a heat pack, hydrotherapy, UV lights, infrared heating etc
COLD:
- Used immediately after injury and/or treatment
- Decreases: blood flow, inflammation, pain
0 Can use cryotherapy, ice baths, ice packs, cold water, ice massage etc
- SA: use of cold = vital in initial treatment of a SA
- while use of heat is helpful prior to commencing the PM phase.
Cold therapies = use of ice + ice baths to minimise swelling + pain at SA site immediately post-injury + for up to 48 hrs post injury
- Heat = used to increase circulation, tissue healing + relax injured muscle
- Heat can be applied superficially via heat packs after first 48 hrs post-injury
- Research shows = use of H+C is a key component of rehab process of SA as it assists + speeds healing of injured site

Question 5

Return to play - Indicators of readiness to play (pain-free, degree of mobility)

Answer 5

• e.g. ankle injury = need to meet specific standard of function before return
• reduce chance of re-injury to ankle (or any injury)
  PAIN FREE (PF):
• When PF - indicates nearly ready to return to play
• need to ensure PF for all movement
• particularly movement specific to their sport
• eg netball player should be able to run, jump + change directions w/o any pain in ankle
• Need to be PF completing drills, mini games, + during actual comp simulations → not just fitness activities e.g. agility runs
• Athlete who is not yet PF has a higher chance of re-injury if return to play
  DEGREE OF MOBILITY
• refers to amount of movement around injured area
• E.g. if athlete has (ham) then = need to have restored their mobility or RO movement at both hip + knee of injured (ham)
• Movement = smooth + show confidence in (ham) through both speed + power
• need to ensure DOM or ROM at e.g. ankle is at least same as or, preferably, better than it was before injury
• e.g. netball player
  should have full ROM of their ankle e.g. able to write alphabet w/ their foot
• Ways to measure improvements to injured area: elasticity, strength, mobility, pain-free, balance

Question 6

Return to play - monitoring progress (pre-test and post-test)

• would talk about how tests indicate readiness to return to play - through indicators e.g. pain-free + degree of mobility

Answer 6

• To monitor progress, compare results from a pre-test (taken before injury) to a post-test (taken after injury)
• All athletes RTP should undertake + pass comprehensive skill + physical related tests
• tests should include a demonstration of pain-free full ROM e.g. injured shoulder in football should be able to complete a
  circumduction test free of any musculoskeletal pain
• if athlete experiences any
  discomfort or pain = would indicate not ready to RTP
• need to check DOM e.g. soccer player = torn ligament should undergo various physical skills e.g. agility + mobility tests (eg Illinois Agility Test) = ensure can
  successfully bear full weight + complete full pre-injury duties
• Establishes a loss of fitness comps eg. speed + agility
• Pretesting: results from regular testing before injury has occured → elite athletes often complete regular tests on physical fitness
• Post testing: after rehab of injury
• If results are similar to that of pre-test than rehab can stop provided on indicators of readiness to return to play are present
• These tests should focus on all components/ incorporate sport specific movement patterns/ be injury specific
• E.g. sprained ankle: agility testing = vital when monitoring progress → changing direction, differing speeds, differing forces → however, if athlete was a swimmer, agility testing = not as applicable as for a netball player
• eg. injured knee = an agility test would be suitable, Illinois test, whereas a grip strength or power test would not

Question 7

Return to play - monitoring progress (pre-test and post-test) = other examples from a practice response

Answer 7

• other methods of helping to determine athlete is ready to RTP in terms of skill + physical tests, specifically strength + flexibility testing
• Strength testing: involves comparison b/w injured + uninjured limb = to ensure
  athlete has recovered full mobility + strength to prevent recurrence of injury or a secondary injury
• also ensures optimal perf upon RTP
• to perform these tests athlete must perform exercises related to sport eg kicking a football w/ both inured + uninjured leg.
• If athlete can demonstrate have 90-95% of strength + ROM returned to injured limb = deemed fit to play under this strength + flexibility testing protocol
• A no. of generic skills tests can be utilised to compare athlete pre to post injury
• e.g. using vertical jump to test for muscular power in a basketball player in pre-season = provide a guide + comparable statistics to judge readiness to RTP for activities related to jump shots + slam dunk
• Game-specific skill tests = trad method for assessing if athlete = fit enough to RTP by putting them through a series of game-specific drills (like running, pivoting,
  passing, throwing)
• Athletes should be assessed by qualified staff that they can complete these specific game-related skills to an acceptable level = capable of being competitive upon RTP

Question 8

Return to play - psychological readiness

Answer 8

• If not psychologically ready = shouldn’t return → can lead to re-injury / further damage
• Athletes returning from major injuries (esp long term e.g. knee reconstruction) can = fear, anxious → can impact their well being + readiness to RTP
• If an athlete is not confident in their bodies ability to manage comp they will shield the injured side to protect it → causes poor technique + can lead to injury somewhere else
• Lack of confidence = diminish their perf
• E.g. rugby league = hold back from tackle (hesitation) = further injury
• Overconfidence: want to return (motivated, competitive) = return before physically ready by hiding pain when testing (hide/ shield from profs) = more likely to re-injure
• Sometimes a Psychological Readiness to Return to Sport Scale is used = asks athletes to rate confidence about their injury, skill level + pain
• Trainers can help their athlete’s psychologically prepare by using various psychological strategies + providing frequent positive feedback during training

Question 9

Return to play - Specific warm-up procedures

Answer 9

• Warm up given in addition to normal warm ups
• Specific warm up procedures help to protect against re-injury by ensuring area has an adequate blood supply (target injury to ensure is properly warmed up) + prepared for rigour of full comp
• E.g. hamstring strain = result in more dynamic stretching, + strength based activities around hip + knee
• Agility runs may be added to prepare hamstring for application + absorption of forces
• May include massage (increases blood flow, warms the muscles + increases flexibility)
• Most important aspect: warm up targets injured area + replicates comp demands

Question 10

Return to play - Return to play policies and procedures

Answer 10

• Sports each have specific RTP policies + procedures (many are similar)
• Need to be followed by coaches + athletes to promote player safety + wellbeing
• Many developed in conjunction w/ academic organisations e.g sports medicine Aus
• NRL, AFL, FIFA use the SMA position statement - concussion to guide their policies on procedures for concussion injuries
• Are also specific to sport, as some sports = more dangerous than others + require a more strict policy for RTP than other sports
• Many protocols for RTP involve: a medical clearance, scans being completed + reviewed (x-ray, MRI etc), fitness + skills tests, other prof clearance (physio, exercise physiologist etc)
• Each sport is dif therefore require dif policies
• Eg Soccer vs boxing being knocked out
• Boxing: banned for 28 days first week + 3 months second time
• Soccer: player cannot return to match that day but once cleared can return to normal activities
• Greater chance of reinjury in boxing for a player being knocked out or concussion
  Swimming vs soccer: Sprained wrist: swimming = relies on wrist to create force → therefore, complete rehab + medical checks required as can lead to further injury
• Soccer: hands can’t be used → less chance of reinjury = no procedure

Question 11

Return to play - Return to play policies and procedures

- specifically for ethical considerations

Answer 11

pressure to play
- e.g. if fullback injured + team at risk of not making final series –> pressure from fans, team etc to play
- Policies e.g. an independent medical clearance are now in place in most prof sports to remove pressure from player + coach to decide when to RTP
- club coach + medical staff have a duty of care towards player’s wellbeing + health
- Hence, club officials must ensure player safety is paramount to all
selection decisions regarding injured players RTP
- e.g. may feel internal pressure to return e.g. lose place in team
- team physio = monitor player’s progress using results from pre + post testing.
- By making comparisons of fitness results in regards to indicators of readiness (ie
level of strength of the ankle joint, range of movement, pain-free sprinting action), an
independent assessment can be determined.
- These procedures ultimately remove
decision + pressure from player + prioritise player making a full recovery from injury as most sig factor

Question 12

Return to play - Return to play policies and procedures (specific rugby league + union example)

Answer 12

• In recent times, sports such as rugby league + union have introduced policies that address player safety in regards to head injuries.
• nature of these sports = becoming more powerful as size + strength of players increases.
• Hence head injuries in the form of concussion are occurring more regularly
• Policy changes by game administrators now require ref to stop play + remove injured player using a free head injury interchange
• A SCAT or COG test is conducted by a club doctor who assesses for signs of
  dizziness, memory loss or blackouts.
• These procedures = vital for long-term health of
  rugby players.
• Repeated head knocks can lead to irreversible brain damage
• Clubs are now very conscious of long-term litigation concerns if continue to play athletes who have repetitive concussion injuries.
• therefore evident that player welfare is now a major consideration in decisions made by club administrators as to when to return a player to field from any form of concussive head injury

Question 13

Return to play - ethical considerations, eg pressure to participate

Answer 13

• All athletes feel pressure to participate in comps
• growing professionalism of sport + its huge popularity in our society = placed high exp + pressure on sports stars to RTP from injury, often before returned to full fitness + are match ready
• is also a pressure felt across amateur + junior sports
• Can be internal + external
  External Pressure
• Placed upon athlete eg coach, teammates, fans, sponsors, media, ranking
• Coaches see players as a commodity + seek to get from their athletes what they are costing the club
• have a neg effect = cause an athlete to RTP prematurely, increasing risk of re-injury
• is unethical (more interested in money/winning/reputation) = lead to greater injury = destroy an athlete’s career
• Unethical for coaches + other staff to place external pressures upon athlete to RTP before ready
  Internal Pressure
• Stems from within athlete → self expectation, motivation, may consider themselves as indispensable, feelings of guilt = letting teammates/ fans down
• Pressure can cause them to RTP early, or lie to medical staff about symptoms
• Pressure from within may help athlete focus more on
  recovery + better adhere to programs + prof advice
• e.g. high profile players, who = crucial to success of team, = often feel obliged to RTP well before injury is fully recovered - e.g. rugby league halfback =
  suffered from a knee injury may be forced onto sidelines for a no. of weeks.
• If team = danger of being eliminated from final series = pressure on that player from
  fans, media + sponsors will be intense
• athlete may return prematurely, risking further injury + ultimately leading to a longer period of time needed out of the game to recover

Question 14

Return to play - ethical considerations, eg use of painkillers

Answer 14

• Pain exists to tell athlete when a particular movement causes further damage to body = indicator that injury is occurring or has occurred
• Painkillers = drugs used to mask pain associated w/ injury
• use can be warranted short-term for minor injuries
• Ongoing use of painkillers may lead to increased healing time or re-injury
• UOP for more serious injuries may lead to increased/ irreparable damage
• use of painkillers masks the natural indication to stop placing pressure on injury → can lead to greater injury, not being able to modify movements accordingly
• Often used in high pressure matches or when is a long break after comp = likely to risk further injury + continue to compete because know have 3-6 months to recover afterwards
• Greater pressure during an indiv sport than in a team sport → substitution can be made in a team sport - need to pull out as an indiv = guarantees the loss
• Some painkillers e.g. paracetamol might be taken to address headaches or soreness around bruises.
• Prescription painkillers by way of injection = ethical concern
• Painkilling injections desensitise injured tissue, prolonging healing process + set an env for further/ permanent damage w/o athletes knowledge
• e.g. Codeine/methadone to cover level 2 (ham) can lead to a ruptured (ham) - can cause further + long term injury
• may RTP following a painkilling injection + suffer a complete rupture of muscle
• decision to use painkillers rests w/ the indiv in consultation w/ the team doctor, trainer + coach
• Athlete’s + their medical team need to weigh up risks + rewards of use of painkillers during comp
• danger = exacerbating injury + making it worse
• e.g. cricket fast bowler may suffer from a bruised heel from repetitive pounding of bowling excessive overs in a test match –> desire/ pressure to return = use pain killing injections to manage pain of injury + allow player to participate = numb injured site –> bruised heel = more serious damage in form of stress fractures if not treated appropriately