EHR 520 weeks 1 - 4

Ethical and Legal Standards - Personal Response and Needs

• Everyone responds differently to an injury and rehabilitation program due to individual physiological and biochemical differences.
• Non-physical variables that influence a patient's recovery include outside support, psychological makeup, and external pressures.
• A rehabilitation program should be designed based on each patient's individual responses.

Components of a Rehabilitation Program: Principles, Objectives, and Goals

Principles

• Seven principles of rehabilitation:
  • Avoid aggravation
  • Timing
  • Compliance
  • Individualisation
  • Specific sequencing
  • Intensity
  • Total patient

Avoid Aggravation

• Therapeutic exercises can exacerbate an injury if not administered correctly.

Timing

• Rehabilitation programs should begin as soon as possible to prevent prolonged rest and delayed recovery.
• Rest is sometimes necessary, but excessive rest can be detrimental to recovery.

Compliance

• Patient compliance is crucial for a successful rehabilitation program.
• Patients are more likely to comply with a program they understand and have a stake in.

Individualisation

• Each person responds differently to an injury and rehabilitation program.
• Providing personalized instructions and reinforcement can enhance compliance and progress.

Qualities of Professionalism

Being a Professional

• Professionals should participate in their profession's society or association (e.g., ESSA for Exercise and Sports Science Australia).
• Members' active participation is essential for the society or association's needs.

Ethical and Legal Standards

Rehabilitation

• Rehabilitation aims to help individuals achieve maximal function, well-being, and independence.

Consent

• Healthcare professionals must respect patients' autonomy and right to consent or refuse treatment.

Touch

• Touch is an integral part of an AEP's duties, but it should always be purposeful and respectful of the patient's boundaries.
• Patients should be informed about the purpose and nature of touch.

Problems and Goals

Problems

• A list of problems to be addressed in the treatment program should be created, prioritizing the most significant issues.

Goals

• Goals should be objective and measurable whenever possible.
• The ultimate goal of therapeutic exercise is the return of the patient to their optimal level of activity.

Evidence-Based Practice

• AEPs should base their rehabilitation techniques and applications on three factors: empirical evidence, clinical experience, and patient goals and needs.

Outcomes-Based Practice

• Outcomes-based practice involves assessing treatment effectiveness based on clinician, patient, or stakeholder perspectives.
• Outcomes tools, such as questionnaires, can be used to evaluate treatment outcomes.

Phases of Rehabilitation and Therapeutic Exercise

• During the rehabilitation process, the damaged tissue is easily damaged by forces applied to it, and any new bleeding can restart the inflammation process, adding to the healing time.
• Exercise applied to the damaged tissues during this time can exacerbate the injury, resulting in additional tissue damage.
• Phase 2: Active Phase, pain and oedema are under control, with a focus on mobility, joint range of motion, and tissue flexibility.
• In Phase 2, exercises are mostly passive with some gentle active exercises, and strength is developed through isometric and light isotonic exercises.

Ligament Sprains, Tendons, and Muscle Strains

• Ligament sprains can occur due to macrotrauma or repetitive microtrauma.
• Tendons are prone to ruptures and tendinopathy.
• Muscle strains occur due to overstretch, being forced to contract against too great a resistance, and can damage the muscle, tendon, musculotendinous junction, or tendon-bone interface.
• Precipitating factors for muscle strains include lack of flexibility, inadequate warm-up, insufficient strength/endurance, and poor coordination.

Muscle Tissue and Regeneration

• Muscle tissue contains unique structures called satellite cells that enable it to regenerate.
• Satellite cells are muscle stem cells that fuse with adjacent myofibres to repair and regenerate muscle tissue.
• Satellite cells restore and replace muscle cells routinely damaged during activity.
• Larger injuries, such as ruptures or severe lacerations, heal with scar tissue.

Muscle Strains and Grades

• Muscle strains can be classified into three grades:
  • Grade I: Some fibres are stretched or torn, with tenderness and pain on active ROM.
  • Grade II: A number of fibres are torn, and active contraction is painful, with a palpable divot and swelling.
  • Grade III: Complete rupture with immense immediate pain.

Tissue Engineering and Advances in Investigation

• Tissue Engineering is an interdisciplinary and multidisciplinary field that aims to develop biological substitutes to restore, maintain or improve tissue function.
• Substances used in tissue engineering include the body's cells, plastic, polymers, and proteins.
• Polymers can be synthetic, inorganic materials or biopolymers from plants, animals, and smaller animal and plant forms.
• Biopolymers are used to build scaffolds that create an environment conducive to new tissue formation.
• Cells from the body are inserted into these scaffolds, which produce interactions with other cells and ultimately form new tissue.

Role of Therapeutic Exercise in Healing

• Exercise can enhance recovery, but only if applied appropriately at each specific stage of healing.
• Signs of too much stress include increased pain, increased oedema, and decreased function.
• You need to consider the healing phases and timing for each injury.

Examination and Assessment

• Subjective examination involves a systematic, yet flexible approach to information gathering, establishing a level of comfort and trust with the client.
• Information to gather includes general demographics, occupation, history of injury, client's report of pain, onset and pattern of symptoms, past medical history, and previous and current rehab/treatment.
• Objective examination involves assessing the extent of the injury, how it affects the patient's function and quality of life, and determining the objective examination process.

End-Feel of Movement, ROM, and Muscle Strength

• End-Feel is the nature of the resistance felt at end-ROM, which can be capsular, bony, or soft.
• ROM can be normal, hypermobile, or hypomobile, and may vary in athletes.
• Muscle strength is tested using manual muscle testing, which assesses contractile tissue, including muscle, tendon, and nerve.

Special Tests, Neurological Tests, Touch/Palpation, and Functional Testing

• Special tests help distinguish muscle, ligament, tendon, joint surface, and nerve injuries.
• Neurological testing includes examination of sensory, motor, and reflex parameters.
• Touch/palpation is used to assess skin temperature, tone, and oedema, as well as fascia, muscles, ligaments, and tendons for tenderness, trigger points, and crepitus.
• Functional testing determines painful activities, the injured part's ability to perform an activity, and quality of movement.

Individualisation of Rehabilitation and Exercise Continuum

• Each client will progress at different rates and respond differently to rehab.
• Re-assess continually, including outcome measures.
• Challenge the client, but do not over-stress and aggravate the injury.
• Regularly discuss progression with the client in relation to their short- and long-term goals.
• In situations of long-term injury and chronic pain, ideally progress to self-management.

Effects of Immobilisation on Connective Tissue

• Immobilisation results in a loss of ROM in all tissues, with increased collagen cross-links, a loss of ground substance, and fibrosis
• In muscles, immobilisation decreases fibre size, myofibril and capillary numbers, increases fibrous and fatty tissue within muscle, and leads to atrophy within two weeks
• In articular cartilage, prolonged immobilisation can result in irreversible damage
• The flexibility of ligaments, joint capsules, fascia, and tendons all reduce with immobilisation

Effects of Re-Mobilisation on Connective Tissue

• Early re-mobilisation prevents cross-links and increases fluid content in the extracellular matrix
• Dynamic and PNF stretching is typically used later in the rehabilitation program
• PNF stretching requires some skill from both the patient and clinician

Exercise Progression and Considerations

• The choice of stretch depends upon tissues involved, stage of healing, patient motivation, time, and facilities available
• First week: stretching within the pain-free ROM
• Re-modelling phase: light intensity prolonged stretches and short-duration active and passive stretches
• 3-4 months post-injury: scar tissue is stronger, and PNF stretching can begin

Indications, Contraindications, and Precautions

• Indications: decreased ROM due to scar tissue adhesions, adaptive shortening of soft tissue due to immobilisation/movement restriction
• Contraindications: fracture, bony block, infection, acute inflammation, sharp pain, tightened soft tissue providing joint stability
• Precautions: patient education, no new swelling, stretch slowly to the point of resistance and release slowly, stretched muscle should be relaxed

Achieving Rehabilitation Outcomes - Muscle Strength and Endurance

• Neuromuscular physiology: receptor input from the periphery to the CNS, response sent along efferent nerves to motor units within muscle
• Motor units: nerve (motor neuron) and muscle fibres
• Sarcomeres contain actin and myosin which slide over one another when a motor unit is stimulated

Muscle Structure and Function

• Muscles move joints and continually maintain posture against gravity
• Joint movement: one end of muscle remains stable while the other end moves

Muscle Strength, Power, Endurance, and Recovery

• Strength: max force a muscle (or group) can exert
• Power: strength over a distance for a specific amount of time
• Endurance: continually produce force over a period of time

Types of Muscle Activity

• Isometric muscle activity (no change in muscle length): advantages: low joint stress, can be used early in rehab; disadvantages: strength gains limited, becomes fatigued and loses coordination

Agility

• Agility: the ability to control the direction of the body or its parts during rapid movement
• Requires the development of flexibility, strength, and power, followed by balance and coordination

Therapeutic Exercise for Proprioception

• Introduce balance, coordination, and agility exercises (in that order) after developing some flexibility and strength
• Gradually increase the complexity and intensity of exercises, building up to movements that resemble the patient's activities

Plyometric Production

• Plyometrics or “stretch-shortening activity”: the lengthening of muscle/tendon followed by rapid shortening
• Faster stretch-reflex (i.e., elastic energy) = greater force produced
• Performance-specific exercises: walking, jogging, running, jumping, bounding

Upper-Extremity Functional and Performance-Specific Progression

• Progress from non-weight-bearing to partial-weight-bearing to full-weight-bearing positions using a combination of closed- and open-kinetic chain exercises
• Check technique and control: look for scapula positioning and movement
• Build up to full kinetic chain exercises – fingers, hand, wrist, elbow, and shoulder

Returning The Patient To Full Participation

• 1. No acute signs or symptoms of the injury are present and no pain or oedema
• 2. Can demonstrate full ROM, normal strength, endurance, and CR fitness
• 3. Can perform the skills at least as well as they could before the injury
• 4. Has confidence in their ability to return to full activities without hesitation

Posture and Body Mechanics

• Posture is defined as the relative arrangement of the body's parts, with good posture being the state of muscular and skeletal balance that protects the body's supporting structures against injury or progressive deformity.
• Good posture allows for efficient muscle function, optimal positions for thoracic and abdominal organs, and involves perception of balance, space, gravity, self-image, and kinaesthetic awareness.
• The Alexander Technique aims to reduce muscle tension, increase awareness, and improve movement quality through self-examination, breathing, balance, and coordination.
• Body awareness programs, such as Pilates, focus on relaxation, concentration, control, breathing, and postural alignment to build strength and balance the body.

Ambulation and Ambulation Aids

• Normal gait cycle requires specific joint range of motion (ROM) and muscle activity.
• Clinical gait analysis involves assessing areas of tightness, pain, or weakness, and observing gait patterns, including stride rate, step length, limping, and favouring one side.
• Pathological gait patterns include Trendelenburg gait, quadriceps gait, restricted knee motion, ankle lurch gait, shortened step length, and antalgic gait.
• Ambulation aids provide external support for mobility and can affect pain perception.

Chronic Pain

• Chronic pain is the brain's interpretation of nociceptive input and is characterized as maladaptive, dominated by cognitive and emotional dimensions, and not correlated with structural or anatomical damage.
• Chronic pain involves peripheral sensitization, where nerve endings become more sensitive, and central sensitization, where the brain dedicates a greater area to nociceptive information.
• Neurotags, including past experience, mood, attention, knowledge, and cues, can contribute to chronic pain.
• Behavioural components, such as fear, anxiety, and avoidance, can also play a role in chronic pain.

Red vs. Yellow Flags

• Red flags indicate potentially serious pathology, while yellow flags suggest an increased risk of progression to long-term pain and disability.

Treatment

• Exercise intervention can facilitate neuroplasticity and reduce pain through the release of BDNF.
• Discussing the neurophysiology of pain with patients can be more productive than discussing anatomy and structure.