Reconditioning Post Injury: Part 1 Musculoskeletal Injuries: Mechanisms and Causes
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1 Bond University From the SelectedWorks of Rob Marc Orr December 17, 2012 Reconditioning Post Injury: Part 1 Musculoskeletal Injuries: Mechanisms and Causes Rob Marc Orr, Bond University Available at:
2 Reconditioning Post Injury: Part 1 Musculoskeletal Injuries: Mechanisms and Causes Rob Orr (Bond University)
3 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Why? Understand how IOT optimise reconditioning and prevention How force is transferred Look at tissue properties Panjabi s stability and control principle Causes of MSI
4 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Force Transfer From muscle to bone
5 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Properties of tissues
6 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Properties of tissues Nordin, M., & Frankel, V. H. (2001). Basic biomechanics of the musculoskeletal system. Lippincott Williams & Wilkins.
7 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Stability Control System Passive System Active System Panjabi MM. The stabilizing system of the spine. Part 1, function, dysfunction and enhancement. Journal of Spinal Disorders 1992; 5 (4):
8 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Stability in action Control System Passive System Active System
9 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 1: Faulty Control Excessive Load Ligamentous damage Skeletal damage Control System Excessive Load Muscle damage Tendon damage Passive System Active System Delayed / Slow Commands Neurological injury? Faulty Joint Position Sense? Fatigue?
10 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 1: Faulty Control Control System Passive System Active System Faulty Commands Poor motor patterns (Global vs local / technique)
11 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 1: Faulty Control Excessive Load Ligamentous damage Skeletal damage Control System Excessive Load Muscle damage Tendon damage Passive System Active System Faulty Commands Poor motor patterns (Global vs local)
12 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 2: Weak muscles Excessive Load Ligamentous damage Skeletal damage Control System Excessive Load Muscle damage Tendon damage Passive System Active System Muscles too weak to overcome force General weakness Weakness through specific ROM (inner/outer ROM Strong muscle but external force too great Previous injury
13 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 2: Weak muscles Excessive Load Ligamentous damage Skeletal damage Control System Excessive Load Muscle damage Tendon damage Passive System Active System Muscles too weak to overcome force FATIGUE
14 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 3: Osseoligamentous System Dysfunction Control System Excessive Load Ligamentous damage Skeletal damage Excessive Load Muscle damage Tendon damage Passive System Active System Pain Muscle spasm increases load to muscle and bone Alters movement mechanics (up/down Kinetic chain)
15 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Scenario 3: Osseoligamentous System Dysfunction Control System Excessive Load Ligamentous damage Skeletal damage Excessive Load Muscle damage Tendon damage Passive System Active System Dysfunction in movement Joints don t work properly increasing muscle work or loading other joints
16 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI Intrinsic Factors Previous Injury Muscle weakness Poor biomechanics Poor fitness Extrinsic Factors Clothing Equipment Work Environment
17 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI 1. Forceful exertions Acceleration Force (F=MxA)
18 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI 1. Forceful exertions Acceleration Force (F=MxA) Awkward movement / positions
19 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 2. Work posture Passive Kinetic Known Causes of MSI
20 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI 3. Repetitions and Duration Volume Intensity
21 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 4. Vibration Known Causes of MSI Low frequency continuous vibration
22 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 5. Work area Physical space Known Causes of MSI
23 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 5. Work area Physical space Known Causes of MSI Occupational demands
24 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI 5. Work area Physical space Occupational demands Environmental
25 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 6. Tools Passive Active Known Causes of MSI
26 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes Known Causes of MSI 7. Position and Nature of Load Position (COG)
27 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 7. Position and Nature of Load Position (COG) Known Causes of MSI Nature ( Live vs Dead / Size)
28 Reconditioning post injury: PT 1 MSI: Mechanisms and Causes 8. Load handling No Lift policies Known Causes of MSI
29 Reconditioning Post Injury: Part 2 Musculoskeletal Injuries: Types & reconditioning programs Rob Orr (Bond University)
30 Why? Need to know what the injury is Pathological factors will influence rate of tissue healing Lack of pain and normal functional movement is not an indication that the injury and its cause have been resolved.
31 Injury Classifications by Mechanism Traumatic EG: Ankle sprain/ Muscle strain / Fracture Causes: Extrinsic / Intrinsic Overuse EG: PFPS, RC Impingement, Compartment Syndromes Causes: Extrinsic / Intrinsic Recurrent Recurrent injuries are those that continue to re occur Causes: Faulty Mechanics / Insufficient healing recovery / Lack of re strengthening / Faulty sensory information Joint position sense / Loss of ROM
32 Types of Injury Hard Tissue / Bony (Osseous) Fractures / Joint Displacement Arthritis / Joint Degeneration Soft Tissue Muscle Strains / Ligament Sprains Tendonitis / Tendo alegias (Lateral Epicondylitis / Lateral Epicondylealgia) Contusions / Hematomas Bursitis Neural Tissue Neuropraxias / Direct injury to the CNS / PNS
33 Fractures
34 Fractures MOI include: Direct impact Indirect impact (FOOSH) Overuse (Stress Fracture)
35 Fractures
36 Fractures Healing may be impaired by: Local Factors Movement Interposition of soft tissue in fracture gap Infection Poor blood supply Poor nutrition Age Poor general health Poly pharamcy (steroids)
37 Fractures Predictors of Fracture Healing Spiral fracture in UL (children) 3/52 Spiral fracture UL (adult) 6/52 Spiral fracture LL 2x as long to unite 12/52 Transverse fracture takes twice as long again Fractured femur add 25%
38 Joint Displacement
39 Joint Displacement Types Subluxation displacement of part of a joint Dislocation complete displacement of the joint MOI includes: A direct force (Eg Knee in the shoulder) An indirect force (FOOSH or ABD& ER) Overuse (Supraspinatus weakness/instability) Common Sites Glenohumeral Joint Acromioclavicular Patella Fingers
40 Muscle Strains
41 Muscle Strains MOI Indirect injury caused to muscle by excessive stretch Occurs where highest proportion of FT II fibres, examples include: Rectus Femoris Biceps Femoris Medial Gastrocnemius Muscle moved in eccentric manner
42 Muscle Strains Grades Mild / First Degree Strain Weakness mild or absent Moderate / Second Degree Strain Notable loss of muscle fibers Weakness Severe / Third Degree Strain Reduced muscle function Complete rupture Myofascial separation complete
43 Muscle Strains Long Term Sequelae Partial tear predisposes to complete tear Fibrosis Fatty replacement Very rarely ossification
44 Ligament sprains
45 Ligament sprains MOI = explosive movement with forces that cause a joint to move beyond its normal ROM and design Tackled to the side of the knee Slip and Fall
46 Ligament sprains Grades Mild / First Degree Sprain Pain reproduced by stretching the ligament Local tenderness Minor swelling / bleeding Strapping may help
47 Ligament sprains Grades Moderate / Second Degree Sprain Major swelling with some bleeding Increased dysfunction and instability
48 Reconditioning post injury: PT 1 MSI: types & mechanisms
49 Ligament sprains Grades Severe / Third Degree Sprain Complete rupture Immediate pain and loss of function Joint unstable Conservative approach (splint for 6 weeks) or Surgery
50 Reconditioning post injury: PT 1 MSI: types & mechanisms
51 Ligament sprains Common Sites Ankle ATFL, CFL Knee MCL, LCL, ACL, PCL
52 Tendonitis
53 Tendonitis MOI (Overuse) Acute or Chronic
54 Tendonitis Grade 1 2 Pain after activity only Pain at the start of the activity that disappears Pain Returns after the activity Does not restrict activity
55 Tendonitis Grade 3 4 Pain at the start of the activity that continues during and after the activity Restriction of activity Pain during everyday activities Progressing and getting worse
56 Tendonitis Common Sites Shoulder Rotator Cuff (supraspinatus) Long Head of Biceps Elbow Lateral Epicondyle Tennis Elbow (Although may be more than just a tendonitis) Medial Epicondle Golfers elbow Brachilias Rope Climbing, Chin Ups
57 Tendonitis Common Sites Knee Quads tendon Hamstring tendon Adductor tendon Ankle Achilles Tendon
58 Stages of Recovery Stages of soft tissue response to injury (Brukner P, Khan K: Clinical Sports Medicine, 3rd edn. New York: McGraw-Hill, 2007.)
59 Stages of Recovery The Repair Stage General Tissue Healing Rates Muscle 6 Weeks Tendons 3 6 Weeks Ligaments 12 Weeks Bones/Joints 6 12 Weeks
60 Considerations when developing a recon / rehab program Input versus Output
61 Input versus Output
62 Considerations when developing a recon / rehab program Quality of intake
63 Considerations when developing a recon / rehab program Cardio Vascular What is the amount of moderate physical activity recommended by ACSM to maintain body weight?
64 Considerations when developing a recon / rehab program Logistics
65 Considerations when developing a recon / rehab program Medication
66 Considerations when developing a recon / rehab program The training high
67 Considerations when developing a recon / rehab program What am I going to do today?
68 Considerations when developing a recon / rehab program What caused the injury?
69 Patient Mobility
70 The Programming Approach Rehabilitation specific considerations : MOI and other injuries Chronic or Acute injury Conservative vs Surgical treatment Surgery PWB, NWB, FWB Constraints (Braces, slings, crutches) Employment and Role Stage of Rehabilitation (post Sx, RTW)
71 Indirect Programming Considerations Other areas under load Indirect loading (Pushing through the heels of the feet during a Seated Shoulder Press) Available ROM (Knee ROM available and the Lat Pulldown) Limb Position and Swelling (Limb in a lowered position)
72 The Rehabilitation Exercise Programming Process Review the Referral Review limitations Aim of program Assess the Patient Subjective (Painful activities, Latency of exercise effects?) Objective (Girths, Strength, CV) Patient Goals From referring practitioner From patient
73 The Rehabilitation Exercise Programming Process 2 Develop the Program Exercises Loading parameters (Sets, Reps, Rest etc) Implement Program D.E.P. Process Supervision Reassess after 1st session Latency / Swelling Heat / Stiffness Pain
74 The Rehabilitation Exercise Programming Process 3 Adjust program as required Additional liaison with practitioner as required Adjustments will need to be reassessed Reassess Reports Progression Completion of Rx??
75 When training a WII police officer Consider the mechanism of injury Consider the potential causes (rehab/prehab) Consider the tissue (load deformation and recovery) Consider the nature of the injury Consider the wider impacts Develop and continually reassess and monitor the program
76 Reconditioning Post Injury Rob Orr (Bond University)
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