Interventions REHABILITATION. The restoration of structure and function. Benefits of mobilization/immobilization. Overloading.

Transcription

1 Use and Misuse of Rehabilitation Modalities Walter R. Frontera, MD, PhD - Professor and Chair REHABILITATION The restoration of structure and function Department of Physical Medicine and Rehabilitation Harvard Medical School / Spaulding Rehabilitation Hospital Boston, Massachusetts, USA Benefits of mobilization/immobilization Inflammation Overloading Tissue injury Pain Rest Continued activity Mobilization Increases tensile strength Improves orientation of regenerating muscle fibers Stimulates resorption of connective tissue scar Improves recapillarization Decreases atrophy of muscles Immobilization Accelerates formation of granulation tissue matrix Limits size of scar Improves penetration of fibers through connective tissue Interventions Massage RICE (rest, ice, compression, elevation) Pain management TENS Pharmacological interventions Analgesia Anti-inflammatory agents Exercise Static (isometric) Electrical stimulation 1

2 Massage and muscle and skin blood flow Hinds et al. MSSE 36: , 24 Physiological effects of cold reduction in cellular metabolism reduces cell death reduction in blood flow analgesia increases time of muscular relaxation decreases recovery time Time (min) Cryotherapy duration to decrease thigh 1 cm sub-adipose intramuscular temperature 7 degrees C From: Otte et al., Arch PM&R 83:151, 22 Anterior thigh skinfold (mm) 59 Temperature (deg C) Intramuscular temperature change across groups at 2 minutes of cryotherapy Rx d/c after 8 minutes Anterior thigh skinfold (mm) From: Otte et al., Arch PM&R 83:151, 22 The role of ice in soft tissue injuries TENS after arthroscopic surgery of the knee Evidence-based review of 45 textbooks and 16 references 16 Significant cooling within 1 min of ice to a depth of 2 cm in those with less than 1 cm of fat; 2-3 min required for athletes with more than 2 cm of fat Ice packs more effective than gel packs or chemical cold packs Rom (degrees) A wet towel (used as barrier) is the most effective conductor control placebo tens From: Jensen et al., AJSM 13:27,

3 Pharmacologic agents - NSAID s Effect of COX-2 inhibitor on ligament healing (load to failure) in the rat Brand name Unit dose (mg) Dosing schedule Aspirin Aspirin 325 Q 4 h Celecoxib Celebrex 1 BID Ibuprofen Motrin 8 QID Indomethacin Indocin 25-5 TID Naproxen Naprosyn 5 BID Piroxicam Feldene 2 QD Rofecoxib Vioxx 25 QD Sulindac Clinoril 2 BID Load (N/kg) COX-2 injured (R) COX-2 Uninjured (L) Reg Diet Injured (R) Reg. Diet Uninjured (L) From: Elder et al., AJSM 29:81, 21. NSAID s (Naproxen Sodium) after eccentric exercise in healthy middle-aged men FSR (%/h) of mixed skeletal muscle protein before & after the eccentric exercise bout kg before 3 days after.15 pre post * FSR (%/h) ACET IBU PLA naproxen placebo ACET, acetaminophen group (n=4); IBU, ibuprofen group (n=7); PLA, placebo group (n=6); *P<.5 from pre-exercise From: Baldwin et al., J. Gerontol. 55A:M51, 21 Modified from: Trappe et al. AJP-Endocrinol Metab. 282: E551-E556, 22. Improper use of corticosteroid injections Proper use of corticosteroid injections acute trauma intratendinous injections infection multiple injections (more than 3) injection immediately before competition frequent intra-articular injections 6-week pre-injection trial of rest, adjusted level of play, & conditioning discrete, palpable site of complaint peritendinous or inflammatory target tissue (avoid tendon) limit of 3 injections, spaced weeks apart rest (protection) for 2-6 weeks after injection avoidance of contributing mechanical cause From: Leadbetter (199) From: Leadbetter (199) 3

4 Physiological & therapeutic effects of heat Effect of ultrasound on tendon strength increases tissue metabolism increases blood flow analgesia muscular relaxation help in stretching of tissue Tensile Strength (N) Right tendons * treated control (P<.25) From: Enwemeka AJPM&R, Results of VAS score before & after hyperthermia (434MHz) Physiological capacities hyperthermia ultrasound Flexibility (joint range of motion) 7 6 Muscle strength (maximal force) Muscle (local) endurance 2 1 manual pressure before mannual pressure after isometric contraction before isometric contraction after Cardio-respiratory endurance (aerobic power or capacity) From: Giombini et al. IJSM 23:27, 22 Elements of an exercise prescription type of exercise frequency (sessions/week) duration (per session; # of sets & repetitions) intensity 4

5 Components of contractures in immobilized knee joints over time Flexibility training - prescription combined arthrogenic myogenic 7 degrees Type: static, proprioceptive neuromuscular facilitation (PNF; contract-relax or contract-relax agonist contract) Frequency: 2-3 times / day Duration: 3-6 seconds per stretch; 4-5 times each Intensity: pulling sensation but no pain weeks From: Tradel and Uhthoff. Arch PM&R 81:6-13, 2. Joint Damage Muscle weakness Reflex inhibition Immobilization Muscle wasting Muscle weakness (Nm) after knee ACL injuries (injured side) T 2 relaxation time for the supraspinatus muscle immediately after three exercises MVC MVC + electrical stimulation control isolated ACL ACL + joint damage pre-exercise post-exercise empty can full can horizontal abduction From: Urbach and Awiszus, IJSM 23: , 22. From: Takeda et al. AJSM 3:374, 22. 5

6 Shoulder muscle activity during rehabilitation exercises (% increase in MRI signal intensity) SIR SLA MP 81 5 deltoid supraspinatus subscapularis infraspinatus SIR=supraspinatus exercise in internal rotation; SLA=side-lying abduction; MP=military press. From: Horrigan et al, MSSE 31:1361, Strength training - prescription Type: free weights, pulleys, elastic tubing, special devices (variable resistance, velocity specific, etc.) Frequency: 3-4 days per week (alternate days) Duration: 3-4 sets; 8-1 repetitions/set; 1-3 minutes of rest between sets for each muscle group Intensity: 6-8% 1RM; 6-1RM Strength training: general principles Individualization Specificity type of muscle contraction range of motion velocity of movement muscle group task sport energy metabolism Progressive overload Variation (periodization) Strength training: acute program variables Choice of exercise (isolated, multijoint, concentric, eccentric) Order of exercise (larger first; sports oriented goal) Number of sets and volume (load x reps x sets); high volume for hypertrophy Rest periods between sets and exercise (sports and metabolic specificity) Resistance (loads < 6RM are more effective for strength/power; loads > 2RM are more effective to develop endurance) Open kinetic chain exercises Closed kinetic chain exercises Closed and open kinetic chain sport actions 6

7 Endurance training - prescription Risk of re-injury 12 months after ankle sprain & rehabilitation including balance training Type: walking, jogging, running, swimming, rowing, dancing, cycling, x country skiing; sports specific control trained Frequency: almost every day of the week; sports specific (running vs. archery) Duration: 3 minutes; sports specific metabolic demands number Intensity: moderate to vigorous; 7-85% max HR; sports specific at anaerobic threshold 5 From: Holmes et al. SJMSS 9:14-19, Return to training & competition after injury an early return results in re-injury objective evidence of recovery absence of inflammation complete joint range of motion recovery of muscle strength tested balance, coordination Sports-specific skills Maximum speed Jumping Kicking the ball 7

8 Prevention of injury Simultaneous Processes maintenance conditioning program modification of training errors improvements of technique equipment check-up biological healing physical rehabilitation psychological recovery use of orthotic devices (ankle sprains) Absence of evidence does not mean evidence of absence 8