Week 13 - Total Body Considerations and Implications of Surgery and Medications.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 13 Total Body Considerations and Implications of Surgery and Medications Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Total Body Considerations and Implications of Surgery and Medications AQUATIC THERAPEUTIC EXERCISE Principles of Water and Hydrodynamics Specific gravity = relative density = density of an object relative to water Archimedes’ Principle of Buoyancy: Body in water experiences an upward thrust equal to displaced water Centre of Buoyancy: CoG of the water an object displaces Floating equilibrium occurs when centre of buoyancy and body’s CoG are in vertical alignment Week 13 - Total Body Considerations and Implications of Surgery and Medications 4 Hydrostatic Pressure Pascal’s Law: The pressure from a fluid is exerted equally on all surfaces of an immersed object at any given depth; the more deeply the object is immersed the greater the pressure Week 13 - Total Body Considerations and Implications of Surgery and Medications 5 Weight Bearing in Water The deeper a body is submerged in water, the less weight is going through the legs Week 13 - Total Body Considerations and Implications of Surgery and Medications 6 Indications for Hydrotherapy Indications Pain Oedema Muscle spasm Loss of ROM Weakness Limited endurance or restricted weight‐bearing due to injury Maintenance of CRF Week 13 - Total Body Considerations and Implications of Surgery and Medications 7 Advantages of Hydrotherapy Advantages Can partially WB in water due to reduced effect of gravity – the deeper the body in the water the less WB Warmth – reduced muscle spasm and pain cycle Increased ROM and pain‐free ROM Useful in re‐training normal gait pattern – muscle tone and activation Week 13 - Total Body Considerations and Implications of Surgery and Medications 8 Hydrotherapy – Precautions and Contraindications Precautions Fear of water Medications (e.g. those that affect BP and heart rate) Susceptible to ear infections Allergies Diabetes CVD or suffer seizure Contraindications Contagious illness Open wounds Advanced kidney disease Faecal incontinence Week 13 - Total Body Considerations and Implications of Surgery and Medications 9 Hydrotherapy – Principles and Guidelines Include a warm-up and cooldown The warmer the water the shorter the warm-up needs to be Begin with ROM & flexibility, progress to strength & endurance, add coordination & agility before functional/performance‐specific exercises Maintain hydration – they will sweat Adjust resistance by manipulating variables: Longer lever arm = greater resistance Faster movements = greater resistance Larger or broader objects = greater resistance Cardiorespiratory training – deep water running, treading water, swimming Week 13 - Total Body Considerations and Implications of Surgery and Medications 10 Spinal Exercises in Shallow Water Week 13 - Total Body Considerations and Implications of Surgery and Medications 11 Spinal Exercises in Deep Water Week 13 - Total Body Considerations and Implications of Surgery and Medications 12 Total Body Considerations and Implications of Surgery and Medications THERAPEUTIC EXERCISE EQUIPMENT Therapeutic Exercise Equipment Large variety of Equipment Uses Price Equipment selection determined by Budget Client needs Clinician preferences Week 13 - Total Body Considerations and Implications of Surgery and Medications 14 Range of Motion Equipment Goniometers for objective measurement Stabilising equipment for stretching Straps and belts to support or apply stretch force Straps, sticks/dowel, and ropes to aid in active stretching Week 13 - Total Body Considerations and Implications of Surgery and Medications 15 Resistive Applications Manual resistance Body weight resistance Rubber tubing and bands Free weights Isotonic machines Week 13 - Total Body Considerations and Implications of Surgery and Medications 16 Swiss Balls Offer a new and different method of training for the client Can be used to develop flexibility, strength, endurance, balance & coordination Both open‐kinetic and closed‐kinetic chain exercises Progress from body weight exercises by adding resistance from cuff weights, resistance bands, free weights and cable machine exercises Week 13 - Total Body Considerations and Implications of Surgery and Medications 17 Foam Rollers Kinaesthetic awareness, balance, proprioception, flexibility & strength Rolling + stretching = greater flexibility improvements than either one in isolation Efficacious as a warm‐up tool and for reducing both the severity and duration of DOMS post‐exercise Can initiate the relaxation response, reducing pain Week 13 - Total Body Considerations and Implications of Surgery and Medications 18 Aquatic Equipment Assistive equipment Used to help position a client in the water (supine, prone, vertical) Flotation cuffs, pull buoys, vests and belts, kickboards and water dumbbells Resistive equipment In addition to the above we can use flippers, boots, gloves, paddles & bells Week 13 - Total Body Considerations and Implications of Surgery and Medications 19 Plyometric Equipment Hurdles Boxes Agility ladders Cones Sticks Medicine balls Trampolines Week 13 - Total Body Considerations and Implications of Surgery and Medications 20 Total Body Considerations and Implications of Surgery and Medications TOTAL BODY CONSIDERATIONS Geriatric Physiological Considerations Body changes with age: Muscle (sarcopenia – decrease in size & number of muscle fibres) Bone (osteopaenia & osteoporosis – particularly post‐menopause) Neurology (reduced proprioception – balance, coordination, agility) Rehabilitation considerations: Cardiovascular system (see table 15.3 for target heart rates for various ages) Neuromuscular system (slower adaptations to exercise) Week 13 - Total Body Considerations and Implications of Surgery and Medications 22 Osteoporosis Loss of bone density classified as either osteopaenia or osteoporosis No signs & symptoms until a fracture occurs 1 in 2 women and 1 in 8 men are likely to suffer an osteoporotic fracture in their lifetime 4 out of 5 people with osteoporosis don’t know they have it even though they’re at a greatly increased risk of fracture WHO Osteopaenia: BMD >1 standard deviation below young‐ normal values Osteoporosis: BMD >2.5 standard deviations below young‐normal values Expressed as a T-score Week 13 - Total Body Considerations and Implications of Surgery and Medications 23 Osteoporosis Common risk factors: Female Age 50+yrs Family Hx of osteoporosis Low BMI Premature menopause Prolonged premenopausal amenorrhoea Low testosterone in men Lack of WB PA (particularly in adolescence and early adulthood) Chronic smoking/excessive alcohol Low calcium Chronic use of medications (particularly corticosteroids) Week 13 - Total Body Considerations and Implications of Surgery and Medications 24 Osteoporosis Common health issues: Compression or wedge fractures of vertebra Several can accumulate without obvious symptoms Severe kyphosis can result (Dowager’s hump) Hip fractures: Fracture NOF: Approximately 25% over 50yrs will die in first year following hip fracture Common to lose function & independence Week 13 - Total Body Considerations and Implications of Surgery and Medications 25 Osteoporosis – Recommendations for Exercise Programming Increasing BMD is only part of the aim of exercising in this population: Muscle strength, posture & balance also minimise risk of falling & therefore fractures Well balanced program focusing on aerobic & strength training recommended More vigorous, impact‐oriented activities reserved for those not yet classified as severely osteoporotic Specific exercises to focus on: Improving balance & muscle strength FWB exercises where appropriate Week 13 - Total Body Considerations and Implications of Surgery and Medications 26 Osteoporosis – Recommendations for Exercise Programming Avoid: Trunk flexion & rotation, particularly in combination Regular flexion exercises (e.g. sit‐ups, crunches) can cause new vertebral fractures FWB exercises if severe osteoporosis, multiple vertebral fractures or back pain that limits participation: recommend to change to water‐based exercise Week 13 - Total Body Considerations and Implications of Surgery and Medications 27 Total Body Considerations and Implications of Surgery and Medications IMPLICATIONS OF SURGERY Surgery Most MSK injuries resolve without the need for surgical intervention When surgery is needed, a well‐planned individualised pre‐ and post‐operative rehabilitation plan is required Significantly contributes to overall surgical success and functional restoration Exercise rehabilitation, plus: Use of crutches, mobility instructions (e.g. in/out of bed, chairs, on/off toilet, precautions & contraindications to certain movements, guidance around immobilisation & the use of supportive equipment) Acute traumatic soft tissue injuries may require surgical repair: Muscle or tendon ruptures Cartilage or ligament lesions Major joint dysfunction resulting from: Rheumatoid arthritis (RA) or osteoarthritis (OA) Bony procedures Fractures, articular surface repair Week 13 - Total Body Considerations and Implications of Surgery and Medications 29 Indications for Surgery 1. Severe pain due to trauma to soft tissue or deterioration of articular surfaces 2. Chronic joint swelling 3. Marked limitation of active or passive joint motion 4. Gross instability of a joint or bony segment that leads to limitation of function 5. Joint deformity and abnormal joint alignment 6. Overall decrease or loss of function needed to maintain independence in daily activities and personal care Week 13 - Total Body Considerations and Implications of Surgery and Medications 30 Complications of Surgery 1. Postoperative infection or poor wound healing 2. Postoperative vascular disorders, such as thrombophlebitis and pulmonary embolism 3. Delayed healing of soft tissue or bone 4. Adhesions and contractures of soft tissue and joints 5. Loosening of prosthetic implants leading to instability and pain 6. Biomechanical breakdown of implants 7. Increased pulmonary secretions and risk of pneumonia and atelectasis Week 13 - Total Body Considerations and Implications of Surgery and Medications 31 Post-Operative Goals and Guidelines for Exercise 1. Impairments / Problems Postoperative pain because of disruption of soft tissue Postoperative oedema Postoperative circulatory and pulmonary complications Joint stiffness or limitation of motion because of injury to soft tissue and necessary postoperative immobilisation Muscle atrophy because of immobilisation Loss of strength for functional activities Limitation of weight bearing Potential loss of strength and mobility in un‐operated joints Week 13 - Total Body Considerations and Implications of Surgery and Medications 32 Post-Operative Goals and Guidelines for Exercise 2. General Postoperative Treatment Goals and Plan of Care During the Maximum Protection Phase Week 13 - Total Body Considerations and Implications of Surgery and Medications 33 Post-Operative Goals and Guidelines for Exercise 2. General Postoperative Treatment Goals and Plan of Care During the Maximum Protection Phase Week 13 - Total Body Considerations and Implications of Surgery and Medications 34 Post-Operative Goals and Guidelines for Exercise 3. General Postoperative Treatment Goals and Plan of Care During the Controlled Motion / Protection Phase Week 13 - Total Body Considerations and Implications of Surgery and Medications 35 Post-Operative Goals and Guidelines for Exercise 4. General Postoperative Treatment Goals and Plan of Care During the Minimum Protection / Return to Function Phase Follow the goals and plan of care for normal final stage of rehabilitation / chronic treatment plan Progression of exercise is more gradual due to more severe injury requiring surgery Return to a full functional activity level may take more time Adapt or avoid certain recreational or occupational activities that could cause re‐injury Week 13 - Total Body Considerations and Implications of Surgery and Medications 36 Post-Operative Goals and Guidelines for Exercise 5. General Postoperative Precautions Avoid specific joint motions or weight bearing consistent with the surgical procedure. Progress exercise gradually during the early postoperative period. Soft tissues disturbed during surgery will be inflamed. Allow adequate time for healing to occur. Avoid vigorous / high intensity stretching or resistance exercise to muscles or tendons that have been incised and reattached during surgery for at least 6 weeks to ensure adequate healing and stability. Continually note the level of swelling, pain, and wound drainage. If a marked increase is noted report immediately and discontinue exercise to that area until further notice. Modify or avoid any recreational, occupational or ADLs that could contribute to eventual failure of the surgical repair or reconstruction Week 13 - Total Body Considerations and Implications of Surgery and Medications 37 Total Body Considerations and Implications of Surgery and Medications MEDICATIONS Medications Common medications in the musculoskeletal injury include: Paracetamol NSAIDs (Ibuprofen, Diclofenac, Meloxicam, Celecoxib) Anticonvulsants (Gabapentin, Pregabalin) TCAs (Amitriptyline) Opioids (Codeine, Oxycodone, Tramadol, Tapentadol, Morphine) Corticosteroids (Prednisone, Prednisolone, Methylprednisolone, Bethamethasone) Medicinal marijuana Week 13 - Total Body Considerations and Implications of Surgery and Medications 39 Medication Considerations Common medications in the musculoskeletal injury include: Paracetamol NSAIDs (Ibuprofen, Diclofenac, Meloxicam, Celecoxib) – Interactions with many anti-hypertensive medications – can increase blood pressure. Need to check blood pressure if concurrently prescribed Anticonvulsants (Gabapentin, Pregabalin) – Low level addictiveness. – Can cause drowsiness TCAs (Amitriptyline) – Low level addictiveness – Can cause drowsiness Week 13 - Total Body Considerations and Implications of Surgery and Medications 40 Medication Considerations Common medications in the musculoskeletal injury include: Opioids (Codeine, Oxycodone, Tramadol, Tapentadol, Morphine) – Susceptible to dependence – Can cause drowsiness / sedation – Can cause hallucinations Corticosteroids (Prednisone, Prednisolone, Methylprednisolone, Betamethasone) – Can cause hypertension – Can cause insomnia – Can cause osteopaenia / osteoporosis and diabetes (prolonged use) Medicinal marijuana – Possible hallucinations (depending on THC component) Week 13 - Total Body Considerations and Implications of Surgery and Medications 41