3/16/2010

POST-REHABILITATION EXERCISE
POST- Course Outline
FOR PERSONAL TRAINERS
 Scope of practice
 Concepts of injury (pathology, histology,
physiology, physics)
 Upper Quadrant – shoulder, elbow, wrist
 Lower Quadrant – hip, knee, ankle
 Spine
 Medical Communications and Post-Rehab
Dean Somerset, BSc. Kinesiology, CEP, CSCS, MEPD Fitness
Rehabilitation & Medical Fitness Coordinator, World Health

Course Objectives
Course Objectives
 Develop safe & effective exercise programs  Administer & interpret results of fitness
for improving cardiovascular, neurologic, assessments, use parameters set by licensed
metabolic and musculoskeletal health in HCP to give effective exercise programs
clients not requiring medical supervision  Understand common mechanisms of
 Learn related anatomy/physiology associated injuries and prevention
with specific MSK injuries & medical  Communicate with HCPs & insurance
conditions, their response to exercise carriers, knowledge of FOIP &
confidentiality

1
 3/16/2010

Course Requirements Textbook

 Complete classroom and practical material
 “The Clinical Orthopedic Assessment
 Complete written exam (75 multiple choice Guide – 2nd edition.” by Loudon, Swift
questions, 25 short answer questions, 1 of 4 case & Bell, 2008
study questions)
 Best text to accompany material
 Complete and provide documentation of 10 hours covered within this course
job shadowing in a HCP setting (physiotherapist,
 ONLY IF DIRECTLY REFERENCED
chiropractor, GP, surgeon, naturopathic doctor)
will information be on the exam (ie.
 Completion gains the designation of “Post- See table 2.X)
Rehabilitation Specialist”, a IFH in-house
certification, soon to be valid across Canada
(expected 2011)

Why Post-
Post-Rehab?? What Makes a Post-
Post-Rehab Trainer?
• Able to show •Image
you know presented to
your stuff those you work
with

Perceived Perceived
Competency Professionalism

Work
Referral within
Networks Scope of
Practice
• Physios, • Use your
chiropractors, knowledge,
MDs, etc. refer when
necessary

2

Competency & Professionalism
Knowledge base
Image and Obligation
Practical Experience
Certifications/recognition
Scope of Practice
 The PRS does NOT have the ability to work with a
clientele that exhibits any/all of the following symptoms:
 Not received medical clearance
 Have a condition that requires medication, currently not
under a prescription(ex: hypertension, diabetes, etc.)
 Burning, sharp or radiating pain; numbness; sudden loss of
strength/function in the area; open wounds; chest pain or
shortness of breath; localized swelling; or night pain
 No longer receiving treatment from a primary source of
care, but still symptomatic of their condition
 Undiagnosed pain
3/16/2010
Scope Of Practice
 The Post-Rehabilitation Specialist can work with a
clientele that meets the following criteria:
 Received medical clearance, or clearance from a HCP
(physio, chiro, OT, other registered rehabilitation
specialist) to begin a fitness program
 Injury/condition has stabilized enough to allow them to
begin a fitness program with minimal impact to their
activities of daily living, or an increased risk of relapse
 Still undergoing periodic treatments as a maintenance
or preventative measure for their injury/condition, and
are receiving feedback on their progress from their
HCP
Scope of Practice
The PRS is able to provide the following:
 Fitness programming progressions for MSK injuries and
medical conditions, based on HCP recommendations
 Screening to identify potential risk factors
 Exercise programs to improve clients’ overall level of health
& wellness
 Assessment of physical capabilities, postural alignment, and
functional strength/ROM of a client
 Develop specific programs focusing on RT and/or cardio
conditioning that meets precautions of their injury/condition
 Guidance with weight reduction, lean muscle gain
3
 3/16/2010

Scope of Practice Scope Of Practice

The PRS is not able to provide the following:
 Diagnosis for an injury or condition, medical
treatment or recommendations, or the administration
of therapeutic substances (medications, supplements,
ice/heat)
 Nutritional advice beyond the scope of the Canada
Food Guide
 Fitness programming that is contraindicated by the
medical or primary source of care
 Counseling/therapeutic services for clients with
suspected psychological impairments/dysfunctions
 Services for Post-Rehab clients who have not been
given medical clearance to exercise
 Hippocratic oath – “above all, do no harm”
 Keep the concept of patient wellness as the defining
criteria guiding their training
 Differential diagnosis – list of potential causes,
systematically eliminating from most to least
severe
 Consult with expert necessary
 Authorization to release – Freedom of Information
Protection act (FOIP), professionals can’t give out
patient information without them knowing about it
 Signed consent, otherwise HCP won’t talk to you

Scope of Practice Concepts of Injury

 Hippocratic oath – don’t know what to
do, don’t do anything
 Differential diagnosis – refer if
undiagnosed pain, new/worsening
sympotms, or no improvement in 4
weeks
 Scope of practice – know it, stay within it
 Authorization of Release – Privacy laws

4
 3/16/2010

Concepts of Injury Concepts of Injury

Types of Force
Application

Inflammation Proliferation Remodelling

• Immediate, • Removal of • Contraction

SHEAR ROTATIONAL essential debris, laying of scar,
IMPINGEMENT systemic maturation
down new
reaction tissues of collagen

BENDING DISTRACTION

Concepts of Injury - Inflammation Concepts of Injury - Inflammation

 Initial response to injury, bodies attempt to stabilize
injury by rushing chemical compounds & specified
cells into area.
 Important and necessary step in healing, but often
over inflamed – feedback loop with negative effects
 Platelets release blood factors to stop bleeding, as well
as bind to frayed collagen fibres around injury site
 Bind fibrin & collagen to form a lattice-like net to stop
bleeding & provide tensile strength to area

5
 3/16/2010

“Therapeutic Exercise for Musculoskeletal Injuries.” - Houglum

Concepts of Injury - Inflammation Concepts of Injury - Inflammation
Injury
 Body tries to remove debris (debridement) from Blood Vessel Disruption
area (dead/damaged cells, foreign matter, blood Vasoconstriction
factors) with neutrophils & macrophages – first 48
Vasodilation
hours Exposed Collagen
 Chemical reactions cause continued debridement Influx of
endings
Blood
to allow for proper healing, and the stimulation of Serum
Platelets
Fibrin Plug
Proteins Clotting
new tissue development and growth Factors Release of
Bind to exposed Phospholipid
 Results in localized redness, edema, pain, increased collagen release Fibrinogen Fibronectin
temperature, reduced/loss of function Growth
Stimulated clotting Factors Cell migration
promotion
mechanism
into wound

Concepts of Injury - inflammation Concepts of Injury - Inflammation

 Tensile strength of tissue is very low at this point
(fibrin connective lattice, vs. Dense mature collagen)
 Lasts about 5 days, if inflammation is managed
properly
 Type III collagen makes few cross-links, low strength
 Goal of phase is to control inflammation, maintain
mobility and functional capabilities
 Controlling swelling is IMPERATIVE, as even small
amounts of excessive fluid will shut down
associated muscles (withdrawal reflex) via neural
inhibition

6

Concepts of Injury - Proliferation
 Characterized by three stages:
◦ Epithelialization
◦ Granulation
◦ Collagen Synthesis
 Fibroblasts cause angiogenesis, increased extracellular
collagen formation, and epithelial cell mitosis
characterize this stage
 Epithelial cell formation breaks down fibrin networks
and restores lymphatic flow through area
 Development of new matrix (granulation) with
collagen, reticulin and elastin increases tensile strength
with some give
Concepts of Injury - Proliferation
 Goal of stage is to regain proprioception, range
of motion, and functional circulation through the
injured area
 Tensile strength of the area is increasing, but still
susceptible to re-aggravation if strained
excessively
 Collagen fibres are still immature and brittle,
minimal cross-links
3/16/2010
Concepts of Injury - Proliferation
 Scar tissue formation is thick and swollen
(keloid) due to increased fluid in the scar area,
increased angiogenesis
 Increased density of type III collagen, increased
number of cross-links between fibres
 Wound (distance between injured tissues) begins
to contract, and fills with more dense connective
tissue, matrix and blood vessels
 Stage lasts up to about 21 days after injury
Concepts of Injury - Remodelling
 Wound continues to contract and
become more granular
 Increased maturation of collagen
fibres (conversion to type 1 collagen)
and cross-link formation increases
tensile strength of the area
 Reformation of cross-links and re-
alignment with normal uninjured
tissues allows the scar to increase it’s
strength beyond haphazardly laid
down collagen
7
 3/16/2010

Concepts of Injury - Remodelling Concepts of Injury - Remodelling

 Water content of area is reduced, allowing more
cross-link formations and an increased scar
contraction
 Main goals of this stage are to increase strength,
range of motion, proprioception and restore
normal function to area
 Training can include increased loading (weight
training to fatigue/failure, low intensity plyometrics)
 Can take up to 2 years to complete

Concepts of Injury Concepts of Injury – Repetitive Strain

Adaptive
Phases
HYPERTROPHY

http://www.medicalive.net/319_wound_healing_process DEPENDENT ON
HOMEOSTASIS
RELATIVE RISK

TIME,
ATROPHY

MAGNITUDE,
DEATH

DEATH
INJURY

AND DIRECTION
OF FORCE
APPLICATION

VOLUME OF FORCE APPLICATION

Mueller & Malluf. Phys Ther,Vol. 82, No. 4, April 2002, pp. 383-403

8
 3/16/2010

Concepts of Injury – Repetitive Strain Concepts of Injury – Repetitive Strain

 Based on Physical Stress Theory (referenced previously):

 Low magnitude force application over an extended

period of time can result in injury
 Injury results in inflammation, making tissue less
tolerant to stress, therefore more likely to re-injure
 Re-application of stress prior to relieving acute
inflammation results in further injury or prevention
of regeneration
Mueller & Malluf., 2002

Concepts of Injury – Repetitive Strain Concepts of Injury – Repetitive Strain

 Also called overuse injuries, cumulative trauma  Accumulation of “micro traumas”
conditions to area reduce strength and
 Damaged tissue exposed to more trauma before resilience of tissues, leading to
degeneration and reduced
full recovery from previous trauma
function
 Common in endurance activities, postural
 Depending on severity, may
dysfunctions, occupational settings, racket sports
require immobilization,
 Much more involved therapy than acute injuries, Patellar tendonitis, polarized light
therapeutic modalities, or simply
microscopy
but will be able to function at a higher level rest to reduce inflammation and
 Main impact is on activity that causes RSI promote healing

9
 3/16/2010

Concepts of Injury – Repetitive Strain Concepts of Injury - Function

Functional
 Inflammation creates  As tissues heal, reduced Threshold

swelling in area, reducing impulse on pain

the contractility of receptors

STRENGTH
TENSILE
No more pain
surrounding tissues  Makes individual think
 Reduced strength and they can return to
function of surrounding activity
tissues pre-disposes the  Pain cessation typically TIME
area to a reduced stability at around 80% of tensile
and greater risk of re-injury strength

Concepts of Injury - Function Concepts of Injury - Function

 Tensile strength of tissues is still not optimal, Loading Capacity of Injured Tissues
increasing for >1 year after injury
Resisted,
 Susceptibility to re-injury dependent on Active, non-
amount of scar tissue, recovery modalities Passive,
terminal terminal
used (active vs passive therapies), age of terminal into
Active, terminal
patient, tissue strength prior to injury, activity
non-
requirements (ankle vs wrist) terminal
Passive,
 Neural re-innervation requires absence of non-
swelling terminal

10
 3/16/2010

Concepts of Injury - Function Concepts of Injury - Function

Tissue Healing Chronology
Tissue Type Inflammation Proliferation Remodeling
Ligament > 72 hours Day 2 – week 6 + 12 months Clinical
ROM, mobility Strength
Tendons > 72 hours Day 2- week 4 + 12 months modalities
Muscle1 > 120 hours Day 3- day 18 6wks – 6 mo
Cartilage First 48 hours Up to 1 month Up to 6
months
Bone2 > 72 hours Up to 1 month 12 weeks
 1. specialized satellite cells regenerate muscle fibres, thus Activity specific Agility Proprioception
faster healing
 2. constantly undergoes remodelling,, can heal faster than
other tissues if isolated.

Concepts of Injury - Function Concepts of Injury - Function

 Clinical modalities
 Possibly post-surgical if required
 Goal of reducing and controlling inflammation,
increasing regeneration of tissues and increasing
tensile strength in a controlled manner
 Increasing wound strength while decreasing
wound size as much as possible
 Re-aligning scar tissue to promote function,
flexibility and strength of surrounding tissues
 ROM, Mobility
 Immobilized tissues will atrophy and shrink, goal
is to maintain ROM through healing
 Uses passive mobilization first, then to active and
eventually resisted mobilization
 Tensile strength of area is still reduced, so
primarily performed in clinical settings
 Still in proliferation phase

11

Concepts of Injury - Function
 Strength
 Initial resistance training and TENS stimulation
used to regain contractile capabilities of
surrounding muscles
 Increase in vascularisation, nutrient uptake,
hypertrophy, and contractile protein remodelling
 Combination of eccentric, concentric, and
isometric modalities
 Bridging proliferation and regeneration phases
Concepts of Injury - Function
 Agility
 Application of force in different directions, with
force attenuation requirements
 Use of low-intensity plyometric activities
 Beginning to regain confidence in capabilities to
perform more intense activities. Can begin to
ease into previous activities, but in a very slow
and to-pain-tolerance manner.
 Tensile strength is still less than optimal
3/16/2010
Concepts of Injury - Function
 Proprioception
 Regaining neurofeedback into areas to increase
balance, force delivery capability, motor control
 Initial modalities will involve non-weight bearing,
into partial weight bearing, to full weight bearing
 Still working on building flexibility and strength,
but with more advanced tolerances
 Primarily regeneration phase
 MINIMUM STANDARDS FOR DISCHARGE!!
Concepts of Injury - Function
 Sport-Specific
 Return to previous activities, minor restrictions
depending on injury
 Strengthening of tissues will continue, but may
never reach pre-injury state (scar tissue tensile
strength, elasticity/contractility)
 Maintenance usage of therapeutic modalities to
prevent re-injury
 resolution
12
 3/16/2010

Osteoarthitis
Osteoarthritis
 Chronic disease primarily in synovial joints due to
degeneration, previous trauma, or genetic
susceptibility
 Changes to articulating structure include erosion
of cartilage, exposure of subchondral bone, and
increased friction in joint
 Synovial fluid changes can include increased
enzyme activity and protein concentration

Osteoarthritis
 Outer edges of joint develop
osteophytes and increase bone density Examples of
and size, where mid-joint bone
becomes scarred from friction Osteoarthritis
(sclerotic)
 Decreased concentration of hyaluronic
acid (fluid forming compound) as well
as reduction in synovial fluid output
 Reduced fluid increases friction,
pressure, and scarring of joint surface

13

Osteoarthritis
 Pain is always present, and made worse with
activities requiring involved site
 Pain is worse following periods of inactivity (early
morning, plane rides, end of work day in office)
due to reduction in synovial fluid production
 Most often affects 55+ years, but signs of OA can
be present as young as 45 years
 Women effected more than men & show greater
deleterious effects from OA
Osteoarthritis
 Low-impact exercise and weight reduction are
always recommended for OA, as it reduces
loading on affected joint, and increases production
of synovial fluid
 Muscles around a damaged joint may lose neural
tone, resulting in atrophy, reduced proprioception,
and decreased vascular activity. Exercise helps to
regain and maintain these factors
 Cannot be reversed, but can reduce damage and
help control symptoms
3/16/2010
Osteoarthritis
 May present with visible joint
deformation (osteophyte), warm
to the touch (inflammation),
swelling, limited ROM, altered gait
mechanics and possibly crepitus
(joint noise)
 Primary causes are idiopathic (no
known cause), where secondary
causes include obesity, repetitive
strain, trauma, infection, genetics,
gout (crystal deposits)
Osteoarthritis
 Many advanced cases require joint replacement
surgeries to improve quality of life and functional
capability (many discussed later)
 Typically only done once pain is unbearable and
function is impeded significantly, replacements have
somewhat short lifespan and their own problems
 Replacements cause immediate pain relief,
increased range of motion, and overall
improvements to functional capacity
14
 3/16/2010

Osteoarthritis Sprains
 Ligamental injuries, caused when fibres are stretched
beyond their normal limits.
 Rated in degrees based on involved structures, as well
 http://video.about.com/arthritis/Osteoarthritis.htm
as extent of damage within the ligament
◦ 1st degree – mild tearing and over-stretched fibres
◦ 2nd degree – partial thickness tear of ligament, accompanied
by pain, swelling, and loss of function to effected area
◦ 3rd degree – complete rupture of ligament, requires surgery
◦ 4th degree – avulsion fracture, rupture with ligamental
attachments dislodging bone segments

Sprains
 Damaged ligaments will
produce pain, swelling,
bleeding into the periphery,
reduced strength/function of
area
 Ligaments with partial-
thickness tears will be able to
regenerate on their own, while
full-thickness tears will require
surgery
Sprains
 Cause reduced stability in effected joint,
reduced strength in associated muscles,
decreased confidence in functional capabilities
until joint is finished healing
 Healing time is primarily determined by blood
flow to area and level of vascularization
 Bracing/taping is often required to increase
stability and prevent further injury while
healing

15
 3/16/2010

Fractures Fractures
 Breaking of bone, result from excessive pressure or rapid
change in force application beyond bone’s capabilities
 Fractures in youth can be troublesome if they involve
epiphyseal (growth) plate
 Fx’d growth plate lead to premature calcification, and
cessation of bone growth

Salter-Harris Classification

Fractures Fractures
 Can be either open or closed, depending on
whether skin is broken
 Typically require surgical intervention
 May require screwing bone segments together, use
of a plate or rod to provide structural support
during healing, or external bracing
 Typically will be isolated in a cast to prevent
movement of end segments that would open the
callus

16
 3/16/2010

Fractures Fractures
5 distinct phases of fracture healing:
1. Fracture occurs, inflammation runs its’
course
2. Formation of granulation tissue at bone ends
3. Replacement of granulation tissue with callus
4. Replacement of callus with lamellar bone
5. Remodelling of bone to normal contours

Exercise Risk Analysis

Tensile Strength
BONE, 7-12 WEEKS Variable √ Description √ Description
T
E
MUSCLE, 7-12 Starting Position Stable Unstable
DAYS
N Range of Motion Narrow or limited ROM Full ROM
S
I Weight Bearing Non or partial weight Full weight bearing
L bearing
E
LIGAMENTS & TENDONS, Impact Loading Non-impact Rapid, explosive
S 40-50 WEEKS
T Control Full control, no external Non-control, high
R stimuli external stimuli
E
N Required skills Minimal/none Coordination,
G CARTILLAGE proprioception, high
T level
H
Rating Safest Safe Balanced Risk/Safety Risky
TIME Riskiest

17
 3/16/2010

Instructions to Clients BREAK

 Goals of Program – targets to shoot for
 Program design characteristics
 Exercises – names, techniques, quality over quantity
 Dose – Frequency, Intensity, Duration, sets, reps, rest
 DOMS – it’s not a bad thing, it will happen and needs
to happen. Recognize good pain from bad pain
 Criteria to meet before exercising again – return to
painless state, no swelling, completed homework
End of Section 1
 Progressions – 10% rule, millimetres not inches

18