1

Use and Misuse of Rehabilitation Modalities

Walter R. Frontera, MD, PhD - Professor and Chair

Department of Physical Medicine and RehabilitationHarvard Medical School / Spaulding Rehabilitation Hospital

Boston, Massachusetts, USA

REHABILITATION

The restoration of structure and function

Overloading

Pain

Inflammation

Tissue injury

Continued activity

Rest

Benefits of mobilization/immobilization

Mobilization Immobilization

Increases tensile strength Accelerates formation of granulation tissue matrix

Improves orientation of regenerating muscle fibers

Limits size of scar

Stimulates resorption of connective tissue scar

Improves penetration of fibers through connective tissue

Improves recapillarization

Decreases atrophy of muscles

Interventions

Massage

RICE (rest, ice, compression, elevation)

Pain management

TENS

Pharmacological interventions

Analgesia

Anti-inflammatory agents

Exercise

Static (isometric)

Electrical stimulation

2

Massage and muscle and skin blood flow

Hinds et al. MSSE 36:1308-1313, 2004

Physiological effects of cold

reduction in cellular metabolism

reduces cell death

reduction in blood flow

analgesia

increases time of muscular relaxation

decreases recovery time

Cryotherapy duration to decrease thigh 1 cm sub-adipose intramuscular temperature 7 degrees C

8

23

38

59

0

10

20

30

40

50

60

70

0-10 11-20 21-30 31-40

Tim

e (m

in)

Anterior thigh skinfold (mm)

From: Otte et al., Arch PM&R 83:1501, 2002

Intramuscular temperature change across groups at 20 minutes of cryotherapy

-7

-5.23-3.97

-1.79

-10-9-8-7-6-5-4-3-2-10

0-10 11-20 21-30 31-40

Tem

pera

ture

(deg

C)

Anterior thigh skinfold (mm)

From: Otte et al., Arch PM&R 83:1501, 2002

Rx d/c after 8 minutes

The role of ice in soft tissue injuries

Evidence-based review of 45 textbooks and 160 references

Significant cooling within 10 min of ice to a depth of 2 cm in those with less than 1 cm of fat; 20-30 min required for athletes with more than 2 cm of fat

Ice packs more effective than gel packs or chemical cold packs

A wet towel (used as barrier) is the most effective conductor

TENS after arthroscopic surgery of the knee

119 119 119103 112

119 114 124130

0

20

40

60

80

100

120

140

160

control placebo tens

Rom

(deg

rees

)

From: Jensen et al., AJSM 13:27, 1985

3

Pharmacologic agents - NSAID’s

Brand name Unit dose (mg) Dosing scheduleAspirin Aspirin 325 Q 4 h

Celecoxib Celebrex 100 BID Ibuprofen Motrin 800 QID

Indomethacin Indocin 25-50 TID Naproxen Naprosyn 500 BID Piroxicam Feldene 20 QD Rofecoxib Vioxx 25 QD Sulindac Clinoril 200 BID

Effect of COX-2 inhibitor on ligament healing

(load to failure) in the rat

0

10

20

30

40

50

60

COX-2 injured (R) Reg Diet Injured (R)COX-2 Uninjured (L) Reg. Diet Uninjured (L)

Loa

d (N

/kg)

From: Elder et al., AJSM 29:801, 2001.

NSAID’s (Naproxen Sodium) after eccentric exercise in healthy middle-aged men

39 3740

27

0

10

20

30

40

50

naproxen placebo

before 3 days afterkg

From: Baldwin et al., J. Gerontol. 55A:M510, 2001

FSR (%/h) of mixed skeletal muscle protein before & after the eccentric exercise bout

0

0.05

0.1

0.15

ACET IBU PLA

pre post

FSR

(%/h

)

Modified from: Trappe et al. AJP-Endocrinol Metab. 282: E551-E556, 2002.

ACET, acetaminophen group (n=4); IBU, ibuprofen group (n=7); PLA, placebo group (n=6); *P<0.05 from pre-exercise

*

Improper use of corticosteroid injections

acute trauma

intratendinous injections

infection

multiple injections (more than 3)

injection immediately before competition

frequent intra-articular injections

From: Leadbetter (1990)

Proper use of corticosteroid injections

6-week pre-injection trial of rest, adjusted level of play, & conditioning

discrete, palpable site of complaintperitendinous or inflammatory target tissue (avoid tendon)

limit of 3 injections, spaced weeks apart

rest (protection) for 2-6 weeks after injection

avoidance of contributing mechanical cause

From: Leadbetter (1990)

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Physiological & therapeutic effects of heat

increases tissue

metabolism

increases blood flow

analgesia

muscular relaxation

help in stretching of

tissue

Effect of ultrasound on tendon strength

0

10

20

30

40

50

60

70

Right tendons

treated control

Ten

sile

Str

engt

h (N

)

From: Enwemeka AJPM&R, 1999.

(P<0.025)

*

Results of VAS score before & afterhyperthermia (434MHz)

0

1

2

3

4

5

6

7

manual pressurebefore

mannual pressureafter

isometriccontraction before

isometriccontraction after

hyperthermia ultrasound

From: Giombini et al. IJSM 23:2007, 2002

Physiological capacities

Flexibility (joint range of motion)

Muscle strength (maximal force)

Muscle (local) endurance

Cardio-respiratory endurance (aerobic power or capacity)

Elements of an exercise prescription

type of exercise

frequency (sessions/week)

duration (per session; # of sets & repetitions)

intensity

5

Components of contractures in immobilized knee joints over time

0

10

20

30

40

50

60

70

2 4 8 12 16 20 24 28 32

combined arthrogenic myogenic

degrees

From: Tradel and Uhthoff. Arch PM&R 81:6-13, 2000.

weeks

Flexibility training - prescription

Type: static, proprioceptive neuromuscular facilitation (PNF; contract-relax or contract-relax agonist contract)

Frequency: 2-3 times / day

Duration: 30-60 seconds per stretch; 4-5 times each

Intensity: pulling sensation but no pain

Joint Damage

Muscle weakness

Muscle wasting

Reflexinhibition Immobilization

Muscle weakness (Nm) after knee ACL injuries (injured side)

142.3156.9

97.4115.6

75.4

108.4

020406080

100120140160180

control isolated ACL ACL + joint damage

MVC MVC + electrical stimulation

From: Urbach and Awiszus, IJSM 23:231-236, 2002.

T2 relaxation time for the supraspinatus muscle immediately after three exercises

30

40.5

30.5

41

30.232.7

05

1015202530354045

empty can full can horizontal abduction

pre-exercise post-exercise

From: Takeda et al. AJSM 30:374, 2002.

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Shoulder muscle activity during rehabilitation exercises (% increase in MRI signal intensity)

59

84

64 63

81

50

10

32

0

42

74

36

0

20

40

60

80

100

deltoid supraspinatus subscapularis infraspinatus

SIR SLA MP

SIR=supraspinatus exercise in internal rotation; SLA=side-lying abduction; MP=military press. From: Horrigan et al, MSSE 31:1361, 1999.

Strength training - prescription

Type: free weights, pulleys, elastic tubing, special devices (variable resistance, velocity specific, etc.)

Frequency: 3-4 days per week (alternate days)

Duration: 3-4 sets; 8-10 repetitions/set; 1-3 minutes of rest between sets for each muscle group

Intensity: 60-80% 1RM; 6-10RM

Strength training: general principles

IndividualizationSpecificity

type of muscle contractionrange of motionvelocity of movementmuscle grouptasksportenergy metabolism

Progressive overloadVariation (periodization)

Strength training: acute program variables

Choice of exercise (isolated, multijoint, concentric, eccentric)

Order of exercise (larger first; sports oriented goal)

Number of sets and volume (load x reps x sets); high volume for hypertrophy

Rest periods between sets and exercise (sports and metabolic specificity)

Resistance (loads < 6RM are more effective for strength/power; loads > 20RM are more effective to develop endurance)

Open kinetic chain exercises

Closed kinetic chain exercises

Closed and open kinetic chain sport actions

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Endurance training - prescription

Type: walking, jogging, running, swimming, rowing, dancing, cycling, x country skiing; sports specific

Frequency: almost every day of the week; sports specific (running vs. archery)

Duration: 30 minutes; sports specific metabolic demands

Intensity: moderate to vigorous; 70-85% max HR; sports specific at anaerobic threshold

Risk of re-injury 12 months after ankle sprain & rehabilitation including balance training

29

7

0

5

10

15

20

25

30

35

40

num

ber

control trained

From: Holmes et al. SJMSS 9:104-109, 1999.

Return to training & competition after injury

an early return results in re-injury

objective evidence of recovery

absence of inflammation

complete joint range of motion

recovery of muscle strength

tested balance, coordination

Sports-specific skills

Maximum speedJumpingKicking the ball

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Prevention of injury

maintenance conditioning program

modification of training errors

improvements of technique

equipment check-up

use of orthotic devices (ankle sprains)

Simultaneous Processes

biological healing

physical rehabilitation

psychological recovery

“Absence of evidence does not mean evidence of absence”