Week 3 - Achieving Rehabilitation Outcomes PDF

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice  EHR520 – Week 3 Achieving Rehabilitation Outcomes Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Achieving Rehabilitation Outcomes FLEXIBILITY AND RANGE OF MOTION Definitions Flexibility – The musculotendinous unit’s ability to elongate with application of a stretching force Range of Motion (ROM) – The amount of mobility of a joint that is determined by the soft-tissue and bony structures in the area If a patient has impaired flexibility then they will also have a reduced ROM Injury results in some degree of lost ROM (due to pain, swelling, muscle spasm, shortening of connective tissue due to inactivity and/or loss of neuromuscular control) Week 3 - Achieving Rehabilitation Outcomes 4 Connective Tissue - Composition Connective tissue is composed of cells and extracellular matrix The extracellular matrix consist of: Collagen – Tensile strength and stiffness Elastin – Elongation Reticulin – Tissue repair Ground substance – Gel that reduces friction and supplies nutrients Loose CT (Areolar) – Irregular arrangement with loose cross-links Dense CT Regular Dense CT – Fibres arranged in parallel to resist high levels of strain (eg. tendons) Irregular Dense CT – Fibres not arranged in parallel, which allows for resistance to multiple directions of force (eg. joint capsule) Week 3 - Achieving Rehabilitation Outcomes 5 Effects of Immobilisation on Connective Tissue Connective tissue is continually turned over and has a tendency to shorten with time Immobilisation results in a loss of ROM in all tissues, with increased collagen cross-links, a loss of ground substance and fibrosis Muscle Immobilisation decreases fibre size, as well as myofibril and capillary numbers. It increases fibrous and fatty tissue within muscle and atrophy occurs within two weeks Articular Cartilage Impact depends upon duration, position and weight bearing activity, but prolonged immobilisation can result in irreversible damage The flexibility of ligaments, joint capsules, fascia and tendons all reduce with immobilisation. It is therefore important to minimise the duration of immobilisation and maintain some movement and loading where possible Week 3 - Achieving Rehabilitation Outcomes 6 Effects of Re-Mobilisation on Connective Tissue Early re-mobilisation – Prevents cross-links and increases fluid content in the extracellular matrix. There is improved collagen strengthen through re- alignment of fibres One week of immobilisation can have long-term negative effects and four weeks of immobilisation can result in permanent changes Muscle – Movement speeds up healing of the haematoma, increases tensile strength and improves myofibril regeneration and alignment Joints – Controlled motion and loading (WB) limits cartilage degeneration and facilitates repair Bone – Progressive overloading in a controlled manner increases density Week 3 - Achieving Rehabilitation Outcomes 7 Neuromuscular Influences on ROM Muscle Spindles Sensitive to tension in muscles – respond to changes in muscle length and the rate of change Will trigger a muscle contraction if the muscle is being overstretched to protect the joint/s Golgi Tendon Organs Located at the proximal and distal muscle-tendon junctions Sensitive to muscle contraction During a slow stretch the golgi tendon organs will fire to inhibit muscle contraction Week 3 - Achieving Rehabilitation Outcomes 8 Neuromuscular Influences on ROM Week 3 - Achieving Rehabilitation Outcomes 9 Determining Normal ROM Normal joint ROM varies between joints, patients, sports, positions and occupations, but there are guidelines (see table) Certain athletes require more ROM for certain joints (eg. more GHJ ER for baseball pitchers) Compare the ROM of the injured joint to norms and the contralateral side Week 3 - Achieving Rehabilitation Outcomes 10 Measuring ROM Goniometer is a commonly used tool (Residential School) Correct and consistent placement and measurement is needed for accurate results Position the fulcrum (pivot point) of the goniometer over the joint axis or rotation (know your bony landmarks) Record any pain, quality of movement and ROM (degrees) Inclinometers and electrogoniometers can also be used (phone apps) Eyeballing joint ROM is a really important skill (Residential School) Week 3 - Achieving Rehabilitation Outcomes 11 Measuring ROM Week 3 - Achieving Rehabilitation Outcomes 12 Stretching Techniques Stretching can be active, passive or a combination of both Evidence suggests that significant time spent stretching is required to change muscle length (increase flexibility) – at least 4 minutes per day, per muscle Prolonged static stretching can result in increased muscle length (creep phenomenon), but it is boring! Dynamic and PNF stretching is typically used later in the rehabilitation program PNF stretching requires some skill from both the patient and clinician Week 3 - Achieving Rehabilitation Outcomes 13 Exercise Progression and Considerations The choice of stretch depends upon: Tissues involved Stage of healing Patient’s motivation Time and facilities available Week 3 - Achieving Rehabilitation Outcomes 14 Exercise Progression and Considerations 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 – can begin to use PNF stretching Vertebral column stretches Avoid referring pain – consider intensity of the stretch and body position Two joint muscles should be stretched over both joints Week 3 - Achieving Rehabilitation Outcomes 15 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 If tightened soft tissue is providing joint stability Week 3 - Achieving Rehabilitation Outcomes 16 Indications, Contraindications and Precautions Precautions Patient education – no pain, just mild discomfort due to the tension being applied No new swelling should occur Stretch slowly to the point of resistance and release slowly A stretched muscle should always be relaxed If a stretch is too hard then this will cause muscle contraction, making the stretch painful and ineffective Week 3 - Achieving Rehabilitation Outcomes 17 Achieving Rehabilitation Outcomes MUSCLE STRENGTH AND ENDURANCE Neuromuscular Physiology Receptor input from the periphery to the CNS via afferent nerves is interpreted by either the spinal cord, brainstem or cerebral cortex A response (impulse) is sent along efferent nerves to motor units within muscle. This causes the motor unit to fire, triggering all of the muscle fibres it innervates to contract (all-or-none principle) The strength of contraction depends upon the number of motor units recruited. More motor units (and therefore muscle fibres) results in a greater strength of contraction Week 3 - Achieving Rehabilitation Outcomes 19 Muscle Structure and Function Motor units: nerve (motor neuron) & muscle fibres Sarcomeres contain actin & myosin which slide over one another when a motor unit is stimulated (action potential) Muscles move joints & continually maintain posture against gravity Joint movement: one end of muscle remains stable while other end moves e.g. raising a glass to your mouth Heavier object = greater force required by both the stabilising & moving muscles Week 3 - Achieving Rehabilitation Outcomes 20 Muscle Strength, Power, Endurance and Recovery Strength: Max force a muscle (or group) can exert – MMT grading scale 1 to 3min rest between sets Power: Strength over a distance for a specific amount of time – important in falls prevention, speed of contraction important 3 to 5min rest between sets Endurance: Continually produce force over period of time 30sec rest between sets Week 3 - Achieving Rehabilitation Outcomes 21 Types of Muscle Activity Isometric muscle activity (no change in muscle length) Advantages: low jt. stress so can be used early in rehab; can be used for weak muscles that can’t overcome gravity Disadvantages: strength gains limited to ±10-15 deg. of the angle used in the ex; Valsalva manoeuvre is a risk Contract 66% - 100% max effort for 6 secs Isotonic – concentric (muscle shortens); eccentric (muscle lengthens) Optimal strength gains: combination of concentric & eccentric DOMS greater from eccentric contractions Isokinetic (speed is controlled throughout movement but amount of resistance varies throughout ROM) Machines for isokinetic training and testing Week 3 - Achieving Rehabilitation Outcomes 22 Types of Muscle Activity Week 3 - Achieving Rehabilitation Outcomes 23 Open and Closed Kinetic Chain Activity Kinetic chain: A series of segments linked by moveable joints Open KC: Distal segment can move freely in space Closed KC: Distal segment is fixed (or relatively fixed) Open KC ex’s involve faster movements e.g. throwing a ball; closed KC ex’s place less shear stress on a jt. & provide greater jt. stability (muscle co-contraction) Open KC ex’s can target specific muscles e.g. muscle strains & tendon injuries Functional activities involve both OKC & CKC movements therefore important to include both in overall rehab program Week 3 - Achieving Rehabilitation Outcomes 24 Manual Muscle Testing (MMT) Assesses a muscle’s ability to move jt. through normal ROM Graded 0 to 5 Eliminate gravity if muscle not strong enough to overcome it (i.e. work across gravity) Quality of movement, pain, full ROM or restricted Compare strength to uninjured side Contraindications Inflammation is present Acute pain is present Week 3 - Achieving Rehabilitation Outcomes 25 MMT of Hip Extension Week 3 - Achieving Rehabilitation Outcomes 26 MMT of Knee Extension Week 3 - Achieving Rehabilitation Outcomes 27 Neurological Testing Indicated when suspected nerve involvement Back injury, client c/o loss of strength, paraesthesia, or numbness 1. Sensory (dermatomes) 2. Motor (myotomes) 3. Reflex (deep tendon, superficial, & pathological reflexes) Assesses the integrity of spinal nerve roots and peripheral nerves Nerve root damage: Abnormal motor and sensory function over large area Peripheral nerve damage: abnormal motor and sensory function over a localised area Week 3 - Achieving Rehabilitation Outcomes 28 Dermatome Testing Dermatomes: Areas of the skin innervated by a specific nerve root Ax: Compare injured to uninjured side using touch discrimination Alter the pressure of touch Sharp vs. blunt objects Hot vs. cold Can the client accurately detect the changes in sensations with each test? Week 3 - Achieving Rehabilitation Outcomes 29 Dermatome Testing VIDEOS: Dermatomes lower limb (Physiotutors): https://www.youtube.com/watch?v=SzAyUsA25MQ Dermatomes upper limb (Physiotutors): https://www.youtube.com/watch?v=VlPpdRTGH-o Week 3 - Achieving Rehabilitation Outcomes 30 Dermatome Testing Week 3 - Achieving Rehabilitation Outcomes 31 Myotome Testing Myotomes: Muscles that are innervated by a specific nerve root Can assess upper and lower limbs using isometric contractions against manual (therapist) resistance Grade using the MMT 0-5 scale VIDEOS: Myotomes of the lower limb (Physiotutors): https://www.youtube.com/watch?v=ptO9ZvsUPDg Myotomes of the upper limb (Physiotutors): https://www.youtube.com/watch?v=kPuQPqBMGj0 Quizlet Myotome Poem: https://quizlet.com/79513813/myotome-poem-flash- cards/ Week 3 - Achieving Rehabilitation Outcomes 32 Myotome Testing Week 3 - Achieving Rehabilitation Outcomes 33 Reflex Testing Deep tendon reflexes: Use reflex hammer to apply quick-stretch to tendon to illicit a reflex (muscle-jerk) response Deep tendon reflex grading scheme Week 3 - Achieving Rehabilitation Outcomes 34 Reflex Testing VIDEOS: Lower limb deep tendon reflexes (Physiotutors): https://www.youtube.com/watch?v=kFkRa17hlVc Upper limb deep tendon reflexes (Physiotutors): https://www.youtube.com/watch?v=FZsexSwddc0 Week 3 - Achieving Rehabilitation Outcomes 35 Gradations of Muscle Activity Passive ROM: No work from muscle, movement provided by therapist, when muscle or soft tissue too weak to withstand strain Active Assisted ROM: Some active movement from pt. with assistance from therapist e.g. early healing phase Active ROM: Pt. can move segment through ROM without any extra resistance applied Resisted ROM: Strengthening ex’s with additional resistance (e.g. weights, resistance bands etc.) Week 3 - Achieving Rehabilitation Outcomes 36 Strengthening Principles Begin strength training during proliferation phase after flexibility has been introduced Justify every exercise – how does it relate to the pt.’s goals & the injury Isometric first (if needed) then isotonic, single-plane ex’s before multi-plane ex’s Functional ex’s before performance-specific movements Specific Adaptations to Imposed Demands (SAID) Type of contractions Speed of contractions No. of reps & load (strength vs. endurance) Directions of movements, ex’s should reflect pt.’s activities Week 3 - Achieving Rehabilitation Outcomes 37 Achieving Rehabilitation Outcomes THE ABC’S OF PROPRIOCEPTION Introduction and Rationale Agility, balance and coordination are based on strength & flexibility Proprioception: The body’s ability to determine the position of a joint in space and time, to interpret the information and respond consciously or subconsciously through posture or movement Proprioceptors: Afferent nerves that receive and send impulses from stimuli within skin, muscle, joints, and tendons to the central nervous system (CNS) Tension of a muscle, position of a body part, pressure & vibration Week 3 - Achieving Rehabilitation Outcomes 39 Neurophysiology of Proprioception Cutaneous receptors: Skin tension & fingertip pressure/touch – may be enhanced by compression when injured (e.g. compression sleeves, tape) Muscle spindles: Respond to stretch & detect rate of stretch, cause agonist muscle contraction GTOs: Detect tension & cause muscle relaxation when high tension might cause damage Muscle spindles & GTOs work together for smooth joint motion Joint receptors: Detect joint position at end‐ROM, similar to ligament receptors CNS requires input from sensory, motor & joint receptors to accurately detect joint & limb position Week 3 - Achieving Rehabilitation Outcomes 40 Neurophysiology of Proprioception Week 3 - Achieving Rehabilitation Outcomes 41 Central Nervous System Proprioceptor Sites Motor response depends on whether the impulse is received by the spinal cord, brain stem or cerebral cortex Spinal cord: Quickest response ‘spinal reflex’, protects joint from excessive stress by contracting muscles to stabilise the joint (e.g. sudden change of direction/position) Brain stem: Primary proprioceptive centre that also receives input from eyes & vestibular centres (ears) to maintain balance & posture Cerebral cortex: Highest level - provides conscious control. Responsible for learning correct movement patterns until they become automatic Balance, agility & coordination are all interrelated – all involve proprioceptors Week 3 - Achieving Rehabilitation Outcomes 42 Central Nervous System Proprioceptor Sites Week 3 - Achieving Rehabilitation Outcomes 43 Feedforward and Feedback Proprioception Feedforward proprioception Muscles are pre‐activated in anticipation of movements/loads based on prior experience This is a fast pathway e.g. stretch‐reflex phenomenon (jumping, running) Feedback proprioception Reflex pathways continually adjust ongoing muscle activity for motor task performance Slower pathway e.g. maintaining posture, walking Proprioception training should be: Performed accurately / precisely Performed with high repetitions Progressively overloaded Week 3 - Achieving Rehabilitation Outcomes 44 Balance The body’s ability to maintain equilibrium by controlling COG over BOS Involves vestibular, oculomotor & proprioceptive systems Necessary for both static & dynamic activities – strength & CNS input Sensory input Vestibular system of inner ear Oculomotor system using vision Proprioceptive system using input from muscles, tendons, joints & skin Tests: Romberg’s; SLS test; Standing Stork; Four Square Step Test; Berg Balance Scale; Functional Reach (ESSA Manual & rehabmeasures.org) Progress from stable to unstable surface & from static to dynamic movements Week 3 - Achieving Rehabilitation Outcomes 45 Coordination Coordination: How a smooth pattern of activity/movement is produced through a combination of muscles working together with appropriate intensity and timing Components include the perception of activity, feedback from proprioceptors, performance adjustments and repetition Progress from static & simple ex’s to dynamic & complex ex’s Accuracy is critical – Stop when pt. becomes fatigued & loses coordination Week 3 - Achieving Rehabilitation Outcomes 46 Agility Agility: The ability to control the direction of the body or its parts during rapid movement Requires first the development of flexibility, strength & power, followed by balance and coordination Characterised by rapid changes of direction & sudden stopping/starting (e.g. sports, recovering from a trip/stumble to prevent a fall) Start with simple & slow movements, progressing to complex & fast ex’s Ex’s should resemble the pt.’s activities & can be broken down into smaller parts Week 3 - Achieving Rehabilitation Outcomes 47 Therapeutic Exercise for Proprioception Introduce balance, coordination & agility ex’s (in that order) after developing some flexibility & strength Gradually increase the complexity & intensity of ex’s, building up to movements that resemble the pt.’s activities Lower‐body ex’s: standing balance, progress from eyes open to closed, stable to unstable surfaces Consider using compression to enhance proprioception & joint stability Upper‐body ex’s: Same principles, progress from single‐ to multi‐planar movements, add resistance/WB ex’s before activity‐specific movements (e.g. throwing, catching, using sports equipment) Week 3 - Achieving Rehabilitation Outcomes 48 Achieving Rehabilitation Outcomes PLYOMETRICS Plyometric Production Plyometrics or “stretch-shortening activity” The lengthening of muscle/tendon followed by rapid shortening E.g. Achilles tendon during running, jumping, bounding Faster stretch-reflex (i.e. elastic energy) = greater force produced (i.e. kinetic energy) Mechanoreceptors (muscle spindles & golgi tendon organs) send degree & rate of stretch information to the CNS for processing The CNS responds by contracting the muscle Greater the degree and/or rate of stretch = greater the contractile force produced Plyometric training improves muscle synchronisation, strength through a full ROM and neuromuscular coordination = greater power output Week 3 - Achieving Rehabilitation Outcomes 50 Pre-Plyometric Considerations Strength Adequate strength needed to minimise injury risk and maximise power output (P=Fxd/T) Flexibility More flexibility = greater lengthening and elastic energy storage; also greater force dissipation over time (e.g. landing) Proprioception Good agility, balance and coordination to handle rapid and forceful movements in a controlled manner Progression Simple to complex Low-load to high-load Few reps to high-reps Week 3 - Achieving Rehabilitation Outcomes 51 Plyometric Program Design Builds upon the strength, flexibility and proprioception training to develop speed, coordination, efficiency and power Specificity – Progress from general to sport-specific plyometric exercises Intensity – Manipulate jump height, apply weight, distance of jumps/throws, weight of objects, speed of movements Volume – Number of foot contacts (lower body) and number of sets/reps (upper body) Recovery – Between sets: 45-60s / W:R ratio of 1:5 to 1:10 for power development; 10-15s for endurance; circuit training with minimal rest for aerobic conditioning Between sessions: At least 48 hours, maybe longer (e.g. 72 hours if high-load session) Week 3 - Achieving Rehabilitation Outcomes 52 Plyometric Program Considerations Age – Lower loads for pre-pubescent boys and girls due to their stage of growth and development (typically between 8-13 years). Also be cautious if prescribing plyometrics to older adults who may be deconditioned. Body Weight – Heavier weight places greater forces through the body which increases injury risk. Adjust volume and intensity accordingly. Surface – Some ‘give’ is best (e.g. synthetic running track, grass oval/field) Technique – Land on midfoot (not ball of foot or heel), maintain upright torso, sequential movement pattern between legs, torso and arms. Goals – Need to be specific to the demands on the sport/activity and level of performance (e.g. elite vs. recreational) Movement patterns? Reps per game/match? Rest? Surfaces? Playing positions? Re-assess/test regularly Week 3 - Achieving Rehabilitation Outcomes 53 Plyometric Precautions and Contraindications Precautions Timing – Perform plyometrics early during each session after a thorough warm- up (avoid performing when fatigued) DOMS – normal response, educate the client, wait until soreness has dissipated before commencing next plyometric session Contraindications Acute inflammation Recent surgery Joint instability Week 3 - Achieving Rehabilitation Outcomes 54 Lower-Extremity Plyometrics Jumps in place a) Two-foot ankle hop b) Hip-twist ankle hop Standing jumps a) Standing long jump b) Standing long jump over obstacle c) Standing long jump with sprint Multiple jumps and hops a) Single-leg hops b) Stadium hops Week 3 - Achieving Rehabilitation Outcomes 55 Lower-Extremity Plyometrics Bounding a) Skipping b) Single-leg bounding Box jumps a) Front box jump b) Pyramiding box hops Depth jumps a) Depth jump b) Single-leg depth jump Week 3 - Achieving Rehabilitation Outcomes 56 Upper-Extremity Plyometrics Ensure no trunk-related injuries are present Throw/catch with partner, against wall or rebound trampoline Chest pass Overhead pass Single-arm throw/catch Side-to-side rotational throws with medicine ball Medicine ball slams Backward overhead throws Basketball dribbling in different patterns Progress from simple to complex, straight to diagonal/rotational, heavier balls, higher resistance tubing and faster speeds Week 3 - Achieving Rehabilitation Outcomes 57 Achieving Rehabilitation Outcomes FUNCTIONAL AND PERFORMANCE-SPECIFIC DEVELOPMENT Definitions, Foundations and Goals Functional exercises: Dynamic, multi‐planar movements that may or may not use equipment that the patient uses in their job/sport to prepare them for performance‐specific training Performance‐Specific: Exercises that directly mimic the demands of the activity (e.g. job, sport) including the equipment Return to Play/Work: You need to assess the healing status of injury; test functional performance; psychological readiness to return Goals of exercise rehab programs: 1. Achieve full or normal levels of flexibility, strength, endurance and coordination; 2. Achieve full or normal speed, power, control and agility; 3. Restore the patient’s skills and self‐confidence to perform as they were prior to injury Week 3 - Achieving Rehabilitation Outcomes 59 Basic Functional Activities & Performance-Specific Exercises 1. Provide clear instructions and feedback to the client 2. Check for their understanding of what they need to do and why 3. Start with slow and precise movements with no added weight 4. Increase task complexity once they master basic movements 5. Increase task intensity as the patient’s confidence improves 6. Repetition is key Lower body examples: side shuffles, cariocas, hops, backward running, slide board exercises, broken‐down sport skills Upper body examples: juggling, theraband movements, throwing, dribbling a ball, broken‐down sport skills For functional ex’s: Add multi‐joint and multi‐planar movements For sport‐ or performance‐specific ex’s: Add in work or sport‐specific skills Week 3 - Achieving Rehabilitation Outcomes 60 Progression from Functional Exercises to Performance- Specific Development Gradually increase the physical and neurological demands of the training Force and intensity: Add weight or resistance Speed: Increase rate of movements while maintaining good technique Distance: Add distance to running, jumping, hitting or throwing Complexity: Increase repetitive multi‐directional movements or combine skills (e.g. throw/catch on unstable surface) Support: Reduce base of support by narrowing stance or jumping on 1 leg vs. 2 Progress the type of exercise: (e.g. from running on treadmill to overground running) Week 3 - Achieving Rehabilitation Outcomes 61 Precautions Patient must complete a thorough warm‐up Correct any errors in technique and break the skill down if needed e.g. Sit‐to‐stand on chair before performing squat Provide clear instructions and demonstrations for each exercise Make sure they understand how to perform the exercise and why they’re doing it – must be relevant to their goals If any additional pain or swelling occurs during or in the 24‐hours after a session, regress the exercise(s) Take a biopsychosocial approach – challenge the client but don’t push them. Psychologically they might not be ready to progress Week 3 - Achieving Rehabilitation Outcomes 62 Final Evaluation Required to be passed before the all‐clear is given to return to work or sport Should be objective in nature Evaluation should include all relevant skills for the job/sport Tests matched to job or sport demands Can use previously developed tests and create your own – work with employer/coach as appropriate Tests must be repeatable Include details of testing conditions, instructions and requirements Week 3 - Achieving Rehabilitation Outcomes 63 Lower-Extremity Functional and Performance-Specific Progression Functional exercises can begin relatively early for some patients Treadmill: Cariocas, backwards and sideways walking Body weight or weighted: lunges, step‐ups, step‐downs etc. Plyometric and agility exercises Performance‐specific exercises Walking, jogging, running – increasing speed, distance, flat to hilly, change of direction (agility) Tests Should accurately reflect the demands of the client’s job or sport Running for distance/time, jump tests for height/distance, agility tests Test at beginning of functional training and again prior to return to play/work Goals should be related to performance of these tests Week 3 - Achieving Rehabilitation Outcomes 64 Upper-Extremity Functional and Performance-Specific Progression Progress from non‐WB (e.g.TB/light weights) to partial‐WB (e.g. Swiss ball) to full‐WB (e.g. push‐up) positions using a combination of closed‐ and open‐kinetic chain exercises Check technique and control: Look for scapula positioning and movement (regress if needed) Build up to full kinetic chain exercises – fingers, hand, wrist, elbow & shoulder Testing: Same principles as for lower body (accurate, objective, repeatable) e.g. Throwing/striking/swimming speed; throwing or hitting distance and/or accuracy; lifting and carrying capacity; ability to use and control equipment etc. Week 3 - Achieving Rehabilitation Outcomes 65 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; they’ve achieved adequate levels of proprioception, agility and coordination for their job or sport; 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. Week 3 - Achieving Rehabilitation Outcomes 66 Maintaining Cardiorespiratory Fitness During Rehabilitation MSK injuries often result in a reduction in overall PA, leading to a reduction in CR fitness Aim is to use aerobic activities – large muscle groups and rhythmical movements to stimulate a significant CR response If LL injury: Arm ergometry or swimming If UL injury: Walking, steps, stationary cycling If spinal injury: Avoid high spinal loading/bracing (e.g. stationary cycling, treadmill walking with hand rails, some swimming strokes if tolerable) Continuous vs. interval training Calculate target intensities and monitor throughout – avoid aggravating existing injury Week 3 - Achieving Rehabilitation Outcomes 67