Figure 10: Plyometric Exercises
Note . From Western Schools, © 2018.
Psychological considerations during the rehabilitation process Psychological readiness to return to sport after an injury does not always correspond with physical readiness (Podlog & Eklund 2007). Although fear of movement and pain catastrophizing are not associated with knee function in the early rehabilitation phase (Flanigan, Everhart, et al., 2015), after an ACL injury patients may avoid intense physical activities that are associated with previ - ously experienced pain or injurious situations because of the ex- pectancy of having a relapse of pain or reinjury (Everhart, Best, Flanigan et al., 2013; Hartigan et al., 2013). Athletes with poor adherence to rehabilitation also have worse recovery after ACL re- construction (te Wierike, van der Sluis, van den Akker-Scheek, Elf- erink-Gemser, & Visscher, 2013). Additionally, patients with lower motivation are less compliant with home exercises and put forth less effort during rehabilitation (Flanigan, Everhart, et al., 2015). This study found that positive emotions increased and negative emotions decreased as rehabilitation progressed and upon return to sport, however, psychological distress significantly increased when competition was resumed as compared to rehabilitation (Everhart, Best, & Flanigan et al., 2013; Hartigan et al., 2013). Patients and athletes who exhibit characteristics of psychological distress may need strategies and techniques to adequately ad- dress these issues if they aim to return directly back to the same sport or activity in which they were injured. In addition, some may have low personal coping skills to deal with psychological aspects of the injury (Herring et al., 2006). Patients who exhibit pain catastrophizing or kinesiophobia behaviors may benefit from cognitive-behavioral therapy (Nicholas et al., 2012), desensitiza- tion therapy augmented with physical therapy (George, Wittmer, Fillingim, & Robinson, 2010), or a referral to sports psychologist (Podlog, Dimmock, & Miller, 2011). In patients with anxiety or de- pression, educating the athlete and identifying inaccurate infor- mation about the injury and rehabilitation process may reduce the emotional stress associated with the injury (Prouty et al., 2006). This approach may include adequately counseling the athlete about the recovery process and the challenges of rehabilitation. Additionally, networking with peers who have successfully recov- ered from ACL injury and reconstruction may provide the needed social support to be successful (Parent & Fortin, 2017; Podlog et al., 2011). Patients with low self-efficacy (belief in your ability to succeed in specific circumstances), low self-motivation (doing what needs to be done), or low optimism (hopefulness of the fu- ture or successful outcome) may benefit from motivation commu- nication or in-person interviewing, such as in a face-to-face meet- ing where the therapist questions and consults with the patient (Mertens, Goossens, Verbunt, Köke, & Smeets, 2013; Scherzer et al., 2001; Skolasky, Riley, Maggard, Bedi, & Wegener, 2013). Goal- setting and positive self-talk are effective strategies to help pa- tients combat motivation or optimism issues, which may enhance their ability to successfully return to sports and continue lifelong activity participation (Mertens et al., 2013; Skolasky, Riley, Mag- gard, Bedi, & Wegener, 2013).
Plyometric exercise is typically implemented in later phases of ACL rehabilitation to prepare athletes for return to their desired activity levels. Plyometric exercises may be initiated for patients who can tolerate moderate loading during strengthening exer- cises and perform functional movements in a proper pattern (Chmielewski et al., 2006). Plyometric exercises are initiated at low levels of intensity and then progress to higher intensity levels when patients are confident with the task and have tolerated pre- vious intensity levels well. Progressing through the levels of diffi- culty of plyometric exercises is guided by the absence of adverse responses such as joint pain or joint swelling, as shown in Table 3 (Chmielewski et al., 2006). When performing exercises that re- quire single-legged landing, patients are instructed to land while maintaining proper knee alignment over their toes, with a soft landing to avoid further joint damage (Palmieri-Smith & Thomas, 2009). Plyometric exercises are incorporated into reinjury preven- tion programs to improve the neuromuscular and biomechanical characteristics of injured athletes (Myer et al., 2006). In addition, plyometric training has been found to significantly minimize the incidence of injury in female athletes when augmented with dy- namic stabilization training (Mandelbaum et al., 2005; Myer, Ford,
Palumbo, & Hewett, 2005). Table 3: Soreness Rules
Timing of Soreness Encountered During Training Soreness encountered during warm-up Soreness encountered during exercise Soreness encountered one day after exercise (not muscle soreness)
Presence of Soreness Soreness goes away.
Action Plan
Patient continues at the same intensity level.
Soreness continues.
Patient takes off 2 days and drops off the training intensity 1 level. Patient takes 1 day off, continues at the same intensity level (does not advance to next volume or intensity level). Patient either advances to the next volume
Soreness continues.
Soreness not encountered
No soreness.
or intensity level or follows training
progression prescribed by healthcare provider.
Note . Reprinted with permission. © 2013, Zakariya Nawasreh.
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