PowerPoint 1 Flashcards
1
Q
rehabilitation
A
restoration, following disease, illness, or injury, of the ability to function in a normal or near-normal manner
2
Q
the rehabilitation team
A
athletic trainer & ATS athlete/patient physician coaches strength and conditioning coaches patient's family
3
Q
the sports medicine approach to rehab
A
- more aggressive because of the competitive nature of sports
- seasons are relatively short in duration
- goals are to return to play (RTP) as soon but as safely as possible
4
Q
objectives of rehab
A
prevent de-conditioning
rehabilitate injury
5
Q
objectives of rehab: prevent de-conditioning
A
minimize the impact of lost training/competition time and help athlete be ready to return ASAP
6
Q
objectives of rehab: rehabilitate injury
A
restore back to greatest extend possible
7
Q
goals of rehab
A
- utilize appropriate long-term and short-term goals to motivate patient and track progress
- be SMART in your goal setting
8
Q
the evaluation process
A
observation
assessment
plan
9
Q
any rehabilitation plan is only…..
A
as good as the accuracy of the diagnosis
10
Q
good diagnosis begins with…..
A
accurate history (subjective)
11
Q
evaluation: observation
A
inspection
R/A/R/ROM (flexibility, mobility, strength)
special tests (proprioception, neuro - sensory motor reflex)
12
Q
evaluation: assessment
A
contributing factors complete base the rehab plan on the evaluation include problem list (everything abnormal) include STG & LTG here or in P
13
Q
evaluation: plan
A
usse time-specific objectives
functional tx goals
14
Q
after the evaluation & intervention
A
modalities as an adjunct
re-evaluate the patient
15
Q
rehabilitation of special populations
A
hospital patient pediatric patient social factors industrial patient adolescent athlete
16
Q
special populations: social factors
A
home
support system
work
transportation
17
Q
special populations: industrial patient
A
cumulative trauma disorders (CTD)
workmen’s comp issues
18
Q
adolescent athlete
A
epiphyseal plates
other developmental conditions (OSD, SCGE etc)
19
Q
it is impossible to accelerate the process, however…..
A
we can create an environemtn that we maximize the body’s ability to heal
20
Q
early motion has been shown to …….
A
maximize these efforts by decreasing swelling, maintaining muscle tone, minimizing bone and connective tissue weakness
21
Q
immobilization is detrimental to…..
A
the healing process and may result in permanent impairment
22
Q
connective tissue
A
composed of collagen, elastin, reticulin, and ground substance
23
Q
connective tissue: quantities of these substances vary….
A
according to the structure and determine characteristics of structure
24
Q
connective tissue: collagen
A
group of proteins that provide strength & rigidity
major component of endomysium
breaks down with age
25
four main types of collagen connective tissue
I: skin, tendon, bone (scar tissue0
II: cartilage
III: granulation tissue
IV: Cell membranes
26
elastin connective tissue
elastic portin that provides extensibility or return to shape after deformation
27
elastin connective tissue is found in
skin, arteries, ligaments, cartilage, & bladder
28
reticulin connective tissue
- structurally similar to Type III collagen (granulation tissue)
- weaker, less orderly than collagen
- important during healing as an intermediate tissue
29
ground substance connective tissue
- areolar (loose) versus dense connective tissue
30
ground substance: connective-tissue continuum, function depends upon organization
parallel: strength
randon: movement
dense irregular: strength in multiple directions
31
mechanical properties of connective tissue, all occur simultaneously within connective tissue
elasticity
visoelasticity
plasticity
32
elasticity
return to normal length after elongation
33
viscoelasticity
resists deformation, but not completely
34
plasticity
permanent deformation
35
physical properties of connective tissue
force deformation
| creep
36
physical properties of connective tissue: force deformation
amount of force applied to maintain change of length/deformation and is time dependent
37
physical properties of connective tissue: creep
low level of force over time causes plastic deformation
influence of heat, time
fatigue failure, stress fracture
38
muscle spindle fibers (MSFs)
sensitive to stretch and activate muscle in response to lengthening and the rate of change in the muscle's length
39
muscle spindle fibers: two types of intrafusal fibers
- nuclear bag fibers: sensitive to stretch and velocity of stretch
- nuclear chain fibers: sensitive to stretch only
40
Golgi Tendon Organs (GTOs)
- long, delicate tubular capsules, located at the distal and proximal muscle-tendon junctions, that contain a cluster of nerve fibers
- less sensitive to stretch than muscle spindle
- very sensitive to muscle contraction
- perform autogenic inhibition of muscle when stimulated
- simultaneous activitation of antagonistic muscle
41
effects of muscel spindle and GTO
- both function as protective mechanisms
- if stretch is applied too quickly, muscle contracts due to MSF activiation
- when stretch is applied slowly, muscle relaxes due to inhibition mediated by GTO
- contraction of antagonist inhibits agonist contraction
42
inflammation: the reaction to injury
- body's natural & necessary response to injury
- may become problematic with repeated injury or microtrauma
care must be taken during the inflammatory phase, to not allow excessive activity
43
inflammation: may become problematic with repeated injury or microtrauma
cumulative effect causes increased pathology to the joint and/or surrounding structures
44
inflammation; care must be taken during the inflammatory phae, to not allow excessive activity
gentle ROM, isometrics, posture are all that should be allowed
RICE
45
reaction to injury: inflammatory response is the same, regardless of the .....
location and nature of the injurious agent, and consists of chemical, metabolis, permeability, and vascular changes, followed by some form of repair 9primary & secondary injury)
46
soft tissue healing
inflammation (0-7 days)
repair/regeneration (4-21 days)
remodeling/maturation (up to 2 years)
47
fracture healing
acute (0-7 days)
repair/regeneration (8-12 weeks)
remodeling (up to 2 years)
48
peripheral nervous tissue healing
wallerian degeneration (3-5 days) in distal axon
remyelination may start 8 days after injury
regeneration occurs at 2-4 mm/day
49
muscle tissue healing
inflammation (7 days)
repair/regneration (4-21 days)
remodeling/maturation (up to 2 years)
50
reaction to injury: secondary ischemic death problematic not simply because of loss of cells
- increased hematoma
- histamine, bradykini, leukotrienes & prostaglandins increase vascular permeability and allow fluid and cells to escape into the interstitial spaces
- net result: increase edema
51
response of joint structures to injury (synovial)
synovial membrane proliferates synoviocytes, increases vascularity and graudal fibrosis
52
continued irritation of synovial membrane may lead to a chronic synovitis
chronic synovitis causes cell dealth (synoviocytes)
WBCs ingest lysosomes and proteolytic enzymes
WBCs die releasing what was ingested
enzymes cause further damage to the joint structures
53
management of chronic synovitis
conservative (NSAIDs & steroidal anti-inflammatories, rest, aspiration, cold)
synovectomy
54
cartilage injury usually leads to
synovitis (activity mediated effusion)
55
response to joint structures to injury
- loss of proteoglycan in articular cartilage results in physical changes
- collagen fibers become more susceptible to mechanical damage
- synovial fluid viscosity goes down (hyaluronic acid influences viscosity directly)
56
hemarthrosis can result in irreversible damage to the joint
- can cause articular cartilage damage
- irreversible decrease of PG synthesis
- slower return to normal rates of synthesis
57
joint capsule reacts to inflammation similar to synovial tissue
- can become fibrotic/scarred
| - chronic swelling may lead to permanent stretch of the capsule and ligaments
58
effects of immobilization on connective tissue: general changes is soft tissue
- ground substance is reduced, leading to increased collagen cross-links, reducing mobility
- the fiber meshwork contracts so that the tissue becomes dense, hard, and less supple
- with injury, new collagen formation encourages new/excessive cross-link formation, restricting movement of collagen tissue
- wound contraction reduces range of motion
59
effects of immobilization on connective tissue
- with edema and immobilization, fibrosis increases as a result of increased tissue fluid protein and deficient local metabolism
- normal collagen replacement and reorganization occur, producing a dense meshwork
- collagen fibers bind to other strucutres and limit tissue mobility
- without stress, structure becomes weaker secondary to decrease in collagen mass
- end result is loss of range of motion
60
effects of immobilization on muscle
decreased muscle fiber size
reduced number of myofibrils
reduced oxidative capacity
increase in fibrous and fatty tissue in the muscle
61
effects of immobilization on muscle: decreased muscle fiber size
atrophy is primarily from decreased cross-sectional area and not loss of fibers (sarcopenia), as seen in elderly
62
effects of immobilization on muscle (numbers)
- 6 weeks of elbow cast immobilization resulted in greater than 40% decrease in muscle strength
- quads cross-sectional areaa can decrease 21%-26% duirng 4-6 weeks of immobilization in non-pathological subjects
- trainiing before immobilization dramatically decreases the amount of atrophy during immobilization
- reduced intramuscular capillary density
- atrophy can be seen in two weeks
- with prolonged immobilization, the normal neural feedback system of movement is lost
63
effects of immobilization on muscle ( histological changes)
decreased ATP, ADP, CP
| fewer mitochondria
64
effects of immobilization muscle: fiber type & atrophy
- both type I and type II fibers atrophy during immobilization
- the contractile ability of type I seems to be more adversely affected than the Type II
- exercise with decreased intensity and increased frequency will be more beneficial to the patient (also beneficial for healing)
65
more effects of immobilization: muscle
- immobilization results in changes to myotendinous junction
- 50% decrease of collagen and muscle cells
- therefore, a dramatic increase in activity after immobilization may lead to tendopathy or even ruptue at the myotendinous junction
66
effects of immobilization of connective tissue: articular cartilag
- changes dependent on position of immobilization, duration of immobilization, and weight-bearing status of joint
- reduced proteoglycan concentration
- less matrix organization
- necrosis of areas of constant pressure
- increased fibrofatty tissue within the joint that becomes scar tissue
- irreversible damge occurs with continued immobilization
67
effects of immobilization of connective tissue: periarticular connective tissue
- this is soft tissue surroundign the joint, such as ligaments, the joint capsule, fascia, tendons, and synovial membranes
- connective tissue becomes thick and fibrotic
- reduced GAG and water in ground substance decrease extracellular matrix
- diminished tissue mobility secondary to changes in ground substances, increased collagen cross-links, and continued collagen processing
- clinical result is decreased range of motion
68
effects of immobilization on articular cartilage
- articular cartilage undergose structural, biochemical, and physiological changes during immobilization
- decrease in glycosaminoglycans (GAGs) decreases ability to resist compressive force
- joint motion is key to diffusion rate of synovial fluid whihc maximizes articualr cartilage nutrition
- weight-bearing w/o ROM can cause severe articular cartilage damage
- intermittent joint loading is important
69
effects of immobilization on articular cartilage: articular cartilage undergoes structural, biochemical, and physiological changes during immobilization
ribrillation, fraying, cyst formation, varying degrees of chondrocyte degeneration, atrophy, sclerosis, and cartilage resorption
70
effects of immobilization on ligaments
- ligaments undergo same structural changes during immobilization that other tissues undergo
- some unique changes, however, because of the bone-ligament interface
- ligament does not necessarily atrophy
- immobilization leads to decrease collagen leading to decreased tensile strength of the ligament
- ligaments respond positively to stress
71
effects of immobilization on ligaments: ligament does not necessarily atrophy
there is a resorption of tissue at the bone-ligament junction
72
effects of immobilization on ligaments: ligaments respond positively to stress
important not to "over-stress" the ligament during rehabilitation
73
effects of remobilization of muscle
- principle of overload
- quadriceps is more predisposed to atrophy than hamstring
- EMS is a valuable tool to help minimize atrophy
- biofeedback another good tool
74
effects of remobilization of muscle: Quadriceps is more predisposed to atrophy than hamstrings
- BTB grafts seem to weaken quads more than hamstring graft weakens hamstring muscles
- research suffests that quad strength is slower to return with BTB than with ham graft
75
effects of remobilization on articular cartilage
- return to normal structure and function is much longer than immobilization period required to inhibit structure and function
- remobilization must consist of controlled stresses
76
effects of remobilization on articular cartilage: signs of damage due to rehab include
effusion/edema, erythema, pain, or inability to complete task correctly
77
early treatment
- helps prevent synovitis, damaged joint capsule, and damge to the articular cartilage
- it also allows return of normal joint kinematics
- AROM & PROM, compression, massage, and electric stimulation work well to help reduce swelling
- ice is important for tissue health
- reduction of post-traumatic joint effusion is paramount in the early rehabilitation process and is important in the restoration of joint kinematics
- prolonged effusion, if left unchecked, can result in reactive synoviutis, damage of the joint capsule, and degradation of articular cartilage
78
Quadriceps shutdown
- decreased activity of the quadriceps due to increased fluid volume within the knee joint
- small volumes (20-30 ml) have been shown to result in 60% decrease in quad function
79
quadriceps shutdown: decreased activitly of the quadriceps due to increased fluid volume within the knee joint
will lead to atrophy and weakening
80
quadriceps shutdown: small volumes (20 - 30 ml) have been shown to result in 60% decrease in quad function
- 50 - 60 ml for vastus lateralis and rectus
| - VMO is most sensitive to small volumes
81
effects of remobilization on connective tissue
- enhanced recovery
- prevents abnormal collagen corss-link formation
- increases fluid content in the extracellular matrix of connective tissue
82
effects of remobilization on connective tissue: positive impact on most structures
- effects on muscle fibers
- effects on articular cartilage
- effects on periarticular connective tissue
83
arthrofibrosis
- excessive formation of scar tissue around a joint after injury or surgery
- usually within the joint capsule, synovium, or intra-articular spaces
- most commonly affects the knee joint
- characterized by a lack of flexion as well as extension
- prolonged immobilization for any injury puts the joint at risk for arthrofibrosis
84
arthrofibrosis: induced primarily by immobilization
- results in significant decrease in GAGs, water loss, abnormal cross-link formation, and joint restriction
- scar tissue forms within the joint spaces and recesses further limiting ROM
85
arthrofibrosis: often a complication of ACLR
delaying surgery until the hemarthrosis and synovitis have resulved, ROM restored, quad control; decreases risk of arthrofibrosis
86
effects of remobilization on ligaments
- bone-ligament junction recovers much slower than mid-substance of ligament
- endurance type activities seems to increase ACL strength and stiffness the best
- immobilization not only weakens the injuryed ligament but also non-injured ligament
- it can take > 1 year for ligament to return to pre-injury levels
87
effects of remobilization on bone
premanent bone loss can occur after 12 weeks of immobilization
88
effects of remobilization on bone: this can be prevented with exercise
isometric or isotonic
89
benefits of identifying "injury prone" atheltes early:
- identification
- intervention
- prevention
- sport selection/sport avoidance
90
risk factors: early research in the 70's-90's personality traits
- introverts vs. extroverts
- internal vs. external locus of control
- self-concept
- anxiety
- aggressiveness
- dominance
91
bottom line to be determined from trait studies
- no two athletes are alike
- impossible to group by gender, sport, or other factor
- even still, clinician should not overlook the importance of the influence that the patient's personality will have on healing outcomes, rates, etc
92
more contemporary life stress model says that the psychological response to injury varies and is most dependent upon a number of factors, with personality being just one
- personaltiy
- coping strategies and resources (include prior injury/history)
- nature and magnitude of outside stressors
- intervention
93
risk factorsL negative stressors
```
death
injury
illness
breakupo
loss of sport
previous injury
academics
daily hassles/finances
```
94
risk factors: stress (in its various forms) has a high correlation with athletic injurys
- seems to hold true across sports, experience levels, and genders
- seems to hold true for eustress or distress (signigicant life changes, relationships, "the madden curse")
95
risk factors: negative influences of stress
- compromises in motor coordination and timing
- delayed reaction time
- concentration problems
- increased muscular tension
- increased respiration, heart rate, BP
96
risk factors: other factors
- narrow internal focus
- fatigue
- social support networks
97
injury occurence
- emotional responses can and do impact healing & recovery
| - more recent work has suggested that copign is far less predictable and stepwise
98
initial thoughts of coping: KLubler-Ross stages of grief
- denial (not me)
- anger (why me)
- bargaining (if me, then...)
- depression (why)
- acceptance (okay. now what?)
99
injury occurence: gender differences
females tend ot be less irritable and move toward positive thoughts patterns sooner than male counterparts
100
injury occurrence: social support system
develop approach to ensure that athletes are invested in your system and recognize that they are valuable contributors
101
recovery: malingerers
often times atheltes discover that others treat them with more attention and respect in an injured state than a healthy one
102
recovery: adherence
- may be mandated
| - can be nurtured/improved
103
adherence to rehab
- self-motivation
- explain the process
- develop rapport
- task involvement
104
adherence to rehab: self-motivation
prevalent belief that "you either have it or you don't"
- activating the support network
- often in the absence of a qualified professional, the AT is teh best qualified to help
105
adherence to rehab: taks involvement
- believe in clinician
- believe in plan
- see opportunities to return
106
adherence to rehab: activating the support network
teammates
friends
relationships
teachers
107
adherence to rehab: often in the absence of a qualified professional, the AT is the best qualified to help
- goal setting
- visualization/imagery
- self-talk
108
other issues to consider during rehab
- chronic pain
- RTP
- career-ending/altering injuries
- refer prn
- don't be overwhelmed
- at the end of the day, their pain is not your pain and you can't help them best unless you are at yiour best!
