Therapeutic Modalities and Injury Rehabilitation

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Therapeutic Modalities and Injury Rehabilitation

• Unit 7

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Therapeutic Modalities

• Create optimum environment for injury healing
• Reducing pain and discomfort
• Many different modalities to choose from

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Selection of Specific Treatment is dependant on

• Injury site, type and severity
• Modality indication and contraindication
• Physician prescription
• Athlete willingness to accept treatment

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More is not better

• Misuse or overuse of a modality can
• Aggravate the condition
• Delay the athletes return to play

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Legal Concerns

• Must be administered in accordance with local
  regulations
• Documentations of all treatments

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Types of Modalities

• Cryotherapy
• Ice packs, ice massage, whirlpool, immersion,
  sprays
• Thermotherapy
• Moist heat packs, whirlpool, paraffin,
  ultrasound, phonophoresis
• Contrast
• Electrotherapy
• Iontophoresis
• Mechanical
• Massage, manipulation

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Cryotherapy

• Cold application
• 15-20 minutes every 11/2 waking hours- along with
  rest, compression, and elevation
• Reduces many adverse conditions related to
  inflammatory phase

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Physical and Physiological Effects of Cold

• PHYSICAL
• Conduction- when a cold object is applied to a
  warmer object, heat is abstracted
• The longer cold exposure is the deeper the
  cooling is.
• Tissue that has previously been cooled takes
  longer to return to normal temperature than
  tissue that has been heated
• Dept of cold penetration can reach up to 5 cm

• PHYSIOLOGICAL
• Decrease in tissue temp
• Decrease in blood flow
• Vasoconstriction
• Decrease in muscle spasms
• Decrease in pain perception
• Decrease muscle fatigue
• Decrease metabolic rate
• Decrease waste products in area that act as
  muscle irritant
• Increase collagen inelasticity and joint
  stiffness
• Increase capillary permeability

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Special Considerations

• Indications
• Acute sprains, strains, contusions, spasms,
  inflammation
• Contraindications
• Circulatory disturbances, hypersensitivity,
  prolonged application over superficial nerves
• Allergic
• React with hives, joint pain and swelling
• Continued on next slide

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Special Considerations Cont

• Raynauds Phenomenon
• Condition that causes vasospasm of digital
  arteries lasting min-hours
• Can lead to tissue death
• Ice should never be applied for longer than
  20-30 minutes
• Hunting Response
• Occurs when cold is applied for longer than 30
  minutes intermittently
• Vasodilation occurs for 4-6 minutes
• Reaction against tissue damage from too much cold

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Stages of Cryotherapy

• 0-3 minutes after initiation feel cold sensation
• 2-7 minutes after initiation feel mild burning,
  aching
• 5-12 minutes after initiation feel numbness,
  anesthesia

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Cryotherapeutic Methods

• Ice Packs
• Flaked or crushed ice in a towel or plastic bag
• Apply for 15-20 minutes combined with RICE
• Ice Massage
• Paper cup filled with frozen water to from an ice
  cylinder
• Rub or massage directly over area until skin
  becomes bright pink- usually for 7-10 min
• Cold Water Immersion
• Whirlpool, bucket or container filled with
  mixture of water and ice- temp- 55-65 degrees F
• Immersion for 10-20 minutes- great for hands,
  feet and ankles
• Vapocoolant Sprays
• cold spray of chemicals sprayed of surface of
  skin to freeze it
• Treat myofascial pain and trigger point, usually
  combined with stretching. Effects are superficial
  and temporary

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Thermotherapy

• Used of sub-acute injuries
• Used to increase blood flow
• Promotes healing in the injured area
• Vasodilation occurs to shunt cooler blood to
  warmed area
• Do not use until active inflammatory process is
  over/ no signs of swelling

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Conduction

• Occurs when heat is transferred from a warmer
  object to a cooler one
• Heat should never exceed 116 degrees F
• Examples are moist heat packs, paraffin baths,
  and electric heating pads

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Physical Principles of Heat

• Conduction
• Convection
• Radiation
• Conversion

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Convection

• Refers to the transference of heat through the
  movement of fluids or gases
• Factors that influence convection heating are
  temperature, speed of movement and the
  conductivity of the part
• Example whirlpool bath

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Radiation

• The process whereby heat energy is transmitted
  through empty space
• Heat is transferred from one object through space
  to another object
• Examples Infrared heating and ultraviolet
  therapies

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Conversion

• Refers to the generation of heat from another
  energy form such as sound, electricity and
  chemical agents
• Examples Ultrasound therapy, diathermy,
  chemical agents- balms

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Physiological Effects of Heat

• Bodys response to heat depends on
• Type of heat energy, duration, intensity, tissue
  type
• Decrease muscle spasm
• Decrease pain perception
• Increased blood flow
• Increase metabolic rate
• Decreased joint stiffness
• Increase range of motion
• Increasing the extensibility of collagen tissue
• Increased general relaxation

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Special Considerations

• Reasonably safe- as long as heat is at safe
  intensity and application is not for too long
• Contraindications
• An area of loss of loss of sensation
• Immediately after an injury
• An area where there is decreased arterial
  circulation
• Eyes and genitals
• Abdomen during pregnancy
• To a malignancy
• Monitor heat when applied to elderly patients or
  infant

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Thermotherapy Methods

• Moist Heat Packs
• Whirlpool Bath
• Contrast Bath
• Paraffin Bath
• Ultrasound Therapy
• Phonophoresis

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Moist Heat Packs

• Commercial Packs- Hydrocollator Packs
• Silicate gel in a cotton pad immersed in 170
  degrees of hot water
• Apply 15-20 minutes
• Layers of towels are used between packs and the
  skin to avoid burning. As packs cool remove
  towels
• Deep tissues are not significantly heated
• Inhibited by subcutaneous fat acts as insulator
• Patient should be in comfortable position
• Patients should not lie on the hot pack because
  heat can not dissipate out

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Whirlpool Bath

• Tank with a turbine motor which regulates the
  movement of water and air
• Cold- 55 degrees F, Neutral- 92-96 degrees F,
  Warm- 96-98 degree F and Hot 98-104 degrees F
• Convection and Conduction are occurring
• Reduces swelling, muscle spasm and pain and
  active movement is also assisted

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Whirlpool Continued

• Treatment time should not exceed 20 minutes
• Whirlpool unit/tank must be kept clean
• Frequent water changes and daily cleaning
  essential
• Open wounds and abrasions should be handled
  cautiously so that contamination or spreading of
  the infection is prevented

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Contrast Baths

• One unit holding hot water at 105-110 degrees F
  ( for example a whirlpool)
• One unit holding cold water at 50-65 degrees F
  ( for example a bucket can be used)
• The goal to alternating hot and cold is to
  increase local circulation to the treated limb
• Vasodilation from hot water and Vasoconstriction
  from the cold water accomplishes this

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Contrast Baths Continued

• The limb is first placed in the warm water for 5
  minutes
• Then is alternated to the cold water for 1 minute
• Hot to cold is 1 cycle, after first cycle use 4
  minutes in hot and 1 minute in cold
• Repeat 4/1 cycle for up to 30 minutes

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Paraffin Baths

• Paraffin and mineral oil that is kept at 125-130
  degrees F in a controlled unit
• Provide superficial heat to angular, bony areas
  of the body (hands, feet, wrists)
• Allows the part to remain elevated
• Sustains heat which increases circulation and
  decreases pain in affected area
• Before treatment clean and dry area to be treated
  thoroughly

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Paraffin Bath Continued

• Dip the affected part into the paraffin bath and
  quickly pull it out
• Allow the accumulated wax to dry and form a solid
  covering
• This process of dipping and withdrawing is
  repeated until the wax coating is 1/4 to 1/2 inch
  thick

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Ultrasound Therapy

• Ultrasound uses high frequency sound waves
• Sound energy causes molecules in the tissues to
  vibrate, thus producing heat and mechanical
  energy
• 1mHz is the frequency used when heating is needed
  for deep tissue
• 3mHz is the frequency used when heating is
  needed for areas with minimal soft tissue
  coverage
• Nerve tissue is twice as sensitive to ultrasound
  than muscles

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Ultrasound Therapy

• Thermal and mechanical effects of ultrasound
  increase circulation and promote healing
• Ultrasound raises tissue temperature 7-8 degrees
  F up to 2 inches below the skins surface
• Little or no change in skin temperature
• Also provides a micro massaging action on cells

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Pulsed and Continuous Waves

• Pulsed
• Non thermal effect
• The flow of sound waves are interrupted, thus
  less energy is produced
• Best used on
• Sub acute injuries
• Wound healing
• Over bony areas

• Continuous
• Thermal effects
• Sound waves are continuous
• Increase circulation
• Non thermal effects
• At a low intensity
• Acute injuries

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Indications for Ultrasound

• Post acute soft tissue trauma
• Bursitis
• Tendonitis
• Fascitis

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Contraindications for Ultrasound

• Acute inflammatory conditions with continuous
  mode
• Over areas with limited vascularity or sensation
• Over eyes, ear, heart, reproductive organs,
  endocrine glands, CNS or open epiphysis (growth
  plates!!!)

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More info on Ultrasound

• There must be a coupling medium
• Acoustic energy can not travel through air, is
  reflected by skin
• Lotion, gel, water applied to the skin
• Transducer (sound head) should be kept moving at
  all times
• Small circles or longitudinal strokes at speed
  1-2 inches per second

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More info on Ultrasound

• Treatment is 5 minutes for an area 3-4 times of
  the sound head
• Intensity
• Determined by the stage of injury and depth of
  target tissue
• Underwater application
• Good for bony areas like hand, wrist and feet
• Hold sound head 1 inch from body part and move in
  circular or longitudinal patterns

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Phonophoresis

• Method of driving molecules through the skin by
  ion transfer by the mechanical vibration of the
  ultrasound
• Designed to move an entire molecule of medication
  into injured tissues
• Hydrocortisone and and anesthetic are used with
  success
• Massage medication into the skin over area, then
  spread the coupling agent, then ultrasound
• Lower intensity for a longer duration
• Tendonitis, bursitis and painful trigger points

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Electrotherapy

• Purpose
• Control pain
• Exercise muscle tissue to decrease atrophy
• Encourage circulation
• Increase tissue temperature
• Encourage breakdown of adhesions
• Reeducate muscles

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Physical Principles of Electrotherapy

• Electricity is a form of energy that displays the
  following factors on tissue
• Magnetic
• Chemical
• Mechanical
• Thermal Effects

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Electrotherapy Currents

• Produce waveforms
• Waveforms refer to the shape, direction,
  amplitude and duration of electric current
• Direct Current
• Flows in one direction
• Electrons move from a negative to a positive pole
• Feel tingling, followed by a feeling of warmth
• Chemical reactions, increase blood flow, muscle
  reeducation, decrease swelling, spasm and pain
• Alternating current
• AC
• The flow of electrons reverse in direction once
  each cycle

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Special Considerations for Electrotherapy

• Contraindications
• Pacemakers
• Pregnancy
• When muscle contractions are not wanted
• Nonunited fractures
• Areas of active bleeding
• Near malignancies

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Electrotherapy Methods

• Moist electrode pads are placed on the skin
• Small pad is the active pad which brings the
  current to the body
• Larger pad is where the electrons leave the body
• Closer the pads are the shallower and more
  isolated the muscle contraction
• The farther apart the pads are, the deeper and
  more generalized the contraction
• Active exercise can be used at same time
• Ice packs, cold water immersion and ultrasound
  can all be combined with electrotherapy

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Iontophoresis

• Process which chemical ions are transported
  through the intact skin by an electrical current
• Polarity of the electrode used depends on the
  polarity of the ion introduced
• The most common used medication for iontophoresis
  are hydrocortisone and salicylates
• The patient should not experience discomfort or a
  burning sensation
• Treatment times are 10-20 minutes, once a day

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Mechanical/Manual Therapy

• Therapy where the direct use of the providers
  hands are being used
• Used in conjunction with or as supplement to to
  other methods
• Massage
• One of the oldest modalities used
• Manipulation
• Joint mobilization

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Massage

• Therapeutic and Physiological Effects
• Stimulating Cell metabolism
• Increasing venous flow and lymphatic drainage
• Increase circulation and nutrition
• Stretches superficial scar tissue
• Relaxes muscle Tissue

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Contraindications to Massage

• Acute injuries
• Hemorrhaging
• Infection
• Thromboses
• Nerve damage
• Skin Disease
• Possibility of Calcification

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Massage Methods

• Effleurage
• Superficial or deep stroking with the heels and
  palms of the hand
• Petrissage
• Kneading, hold soft tissue between the thumb and
  forefinger and alternately roll, lift, twist to
  loosen tissue
• Tapotement
• Cupping, hacking, pincing and percussive movements

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Massage Methods

• Vibration
• Trembling, forward and backward movement, rapid
  shaking of tissue by hand or machine
• Friction
• Pressure across muscle or tendons. Fingers and
  thumbs move in circular patterns, stretching
  underlying tissue

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Massage

• Use lubricants
• Oil, lanolin, lotion, powder
• Stroke toward the heart
• Increases venous return to reduce swelling
• Proper positioning
• Injured part made easily accessible, comfortable
  and relaxed
• Be confident

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Manipulation/Manual Therapy

• Mobilization of joints and soft tissue to allow
  proper functioning of a body part
• All movement is passive on part of the athlete
• Based on the concepts of joint play
• Gliding and rolling of one joint surface on
  another
• At no time should a provider attempt manipulation
  without education and practice

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Rehabilitation

• Unit 7

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Definition

• Restoration to a functional level for daily
  living
• Return to an appropriate level of competitive
  fitness

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Individualized and Influenced by

• Severity of injury
• Stage of tissue healing
• Type of Treatment (surgery, protocol)
• Strength of the muscles of the limb
• Pain on motion of the joint
• Joint swelling
• Sport specific demands

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Rules of Rehabilitation

• Create an environment for optimal healing
• Do no harm
• Be as aggressive as you can without doing harm
• If it hurts, dont do it

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Goals of Rehabilitation

• Vigorous, intense BUT controlled exercise
  allowing return to competition
• Ensuring injured part is as optimally conditioned
  as possible
• Restoration of function to the greatest possible
  degree in the shortest possible time
• Goals must be realistic and reachable

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Realistic and Reachable Goals

• Increase range of motion
• Increase strength
• Increase joint mobility
• Increase endurance
• Encourage relaxation
• Enhance coordination and skill
• Improve joint stability
• Prevent re-injury

• Decrease pain
• Improve function
• Minimize atrophy and deconditioning
• Improve technique, posture and mechanics
• Decrease inflammation and swelling
• Improve motor control

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Equipment

• Specialized equipment is very useful
• This will not guarantee results if program is
  inadequate, if athlete is not motivated or there
  is poor supervision
• Possible to use little or no equipment
• As long as the program is carefully and
  knowledgeably designed for athletes needs and if
  athlete is adequately motivated and supervised

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Psychology of Rehabilitation

• Rehab is 75 psychological and 25 physical
• Rapport with athlete is critical (motivation and
  communication)
• Help athlete deal with fear, anger, depression,
  self-doubt, and motivation
• Use a variety of exercise to achieve the same
  results and avoid boredom
• Involve injured athlete with the team as much as
  possible- meetings, functions and practice

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Components of a rehab program

• Program must be progressive increase amount of
  work performed at each session
• Use correct form to maximize results and prevent
  injury
• Strength
• Speed
• Endurance
• Flexibility
• Proprioception
• Sport Specific Skills- functional

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Common Mistakes in Rehab

• Look for the culprit not the victim
• Focusing on one single muscle group
• Not moving on until injured limb is equal or
  superior to the uninjured side
• Proprioception is often forgotten
• Postural defects, anatomical malalignment and
  biomechanical imbalances are neglected
• Sports specific skills are not incorporated
• SAID principle not incorporated

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Types of Exercise

• Isometric
• Isotonic
• Isokinetic
• Plyometrics
• Manual Resistance
• Concentric/Eccentric Contraction
• Open / Closed Chain

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ISOMETRIC EXERCISE

• Does not result in any movement of the joint
• Often performed against a fixed resistance
• Least effective form of strength improvement
• Static exercise since there is no movement
• Examples Wall press, stationary press

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ISOTONIC EXERCISE

• The joint is moved through a range of motion
  against the resistance of a fixed weight
• The resistance is fixed and the speed is variable
• Dynamic movement since movement takes place
• Greatest strength gain takes place in the initial
  movement as the muscle attempts to overcome
  resistance / Least strength gain is at the mid
  point
• Examples Bench press, arm curls, squat, heel
  raises

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ISOKINETIC EXERCISE

• Exercise where there is variable resistance and
  where the speed of the motion is set
• Resistance accommodates to match the force
  applied
• Dynamic contraction since there is maintenance of
  a constant velocity
• Advantage- visual readouts are possible which
  helps evaluate progress and acts as a powerful
  psychological stimulus for the athlete
• Disadvantage- Cost of isokinetic machines

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PLYOMETRICS

• A variety of exercises that utilize explosive
  movements to increase athletic POWER
• Maximize the stretch reflex
• Examples Power jumps, leaps, bounds, throwing a
  weighted object- medicine ball
• Should be performed 2-3 days a week to allow full
  recovery from fatigue
• Strength should first be attained to provide
  stability- current injury is a contraindication

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Stretch Reflex

• The muscle is fully stretched immediately
  preceding the shortening of it
• An eccentric contraction occurs immediately
  before the concentric contraction
• The greater the stretch put on the muscle from
  its resting length immediately before the
  contraction the greater the load the muscle can
  lift or overcome
• Rate is more important than magnitude

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MANUAL RESISTANCE

• A provider adjusts the speed of movement and
  resistance to that best suited to the athletes
  needs
• Will vary according to the stage of
  rehabilitation and the state of fatigue

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Concentric Exercise

• Concentric exercises are related to positive work
  
• The muscle shortens as the weight is lifted
• Example
• The up phase of a biceps curl
• The biceps is the muscle working concentrically

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ECCENTRIC EXERCISE

• Eccentric exercise is related to negative work
• Muscle lengthens or is forcibly stretched while
  the weight is lowered
• Greater strength gains
• More stressful work for muscles resulting in
  muscle soreness
• Example
• Lowering a dumb bell during a biceps curl
• The biceps is the muscle that is working
  eccentrically

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Open Chain Exercise

• Exercise when distal segment is not fixed and is
  freely moving in space
• Functional for upper extremity
• Examples
• Leg extension
• Leg flexion
• Abduction/Adduction exercise machines
• Functional activities such as throwing, jumping

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Closed Chain Exercise

• Exercise where distal segment is fixed
• Functional for lower extremity
• Examples
• Standing leg press with sport cord
• Lunges
• Baps board
• Slide board
• Therapy Balls

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Phases of Rehabilitation

• There are three phases
• Phase 1- Acute
• First 48-72 hours
• Phase 2- Sub-acute
• 72 hours to about 2 weeks after injury
• Phase 3- Intermediate
• Last up to 6 months

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Phase 1- Acute

• First 48-72 hours
• Symptoms- redness, heat, swelling, pain,
  inflammation, loss of function
• Short Term Goals
• Decrease pain, swelling and inflammation
• Increase Range of Motion and Control Pain
• Maintain Cardiovascular conditioning

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Phase 1-Acute continued

• Emphasis of cardiovascular fitness
• Isometric contractions if immobilized
• Exercise the opposite unaffected limb may provide
  cross over reaction
• Muscle stimulation
• RICE used to control swelling

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Phase 2- Sub acute

• 72 hours to about 2 weeks
• Inflammation is decreasing and tissue is being
  repaired
• Begins as soon as pain and swelling are
  controlled and complete immobilization is no
  longer necessary
• Warm up the area prior to attempt exercise and
  ROM will allow tissue to respond more effectively
• Ice injured area after working it to prevent
  secondary swelling and effusion

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Phase 2- Sub Acute continued

• Short Term Goals
• Reach full range of motion
• Increase muscle strength, power and endurance to
  all muscle groups
• Maintain cardiovascular endurance to pre-injury
  strength
• Begin proprioception training

• Amount of time needed for tissue repair is based
  on several factors
• Degree of injury
• Location of injury
• Age
• Nutritional status
• Medical problems
• Medications
• Use of corticosteroids

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Phase 3- Intermediate

• Lasts up to 6 months
• Tissue is repairing, changing and remodeling to
  restore function
• Prepare for Specific Functional Exercises
• Including open and closed chain exercises