van den Akker-Scheek, Elferink-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 address 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), desensitization 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 depression, educating the athlete and identifying inaccurate information 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 recovered 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 future or successful outcome) may benefit from motivation communication or in-person interviewing, such as in a face-to- face meeting 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 patients 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, Maggard, Bedi, & Wegener, 2013).
Table 3: Soreness Rules Timing of Soreness Encountered During Training
Presence of Soreness Soreness goes away.
Action Plan
Soreness encountered during warm-up Soreness encountered during exercise Soreness encountered one day after exercise (not muscle soreness)
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. 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 previously experienced pain or injurious situations because of the expectancy 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 reconstruction (te Wierike, van der Sluis,
PROGRESSION
Patients may progress through the rehabilitation process at different rates, depending on individual characteristics, the number and severity of impairments, and concomitant pathologies. The development and implementation of rehabilitation should reflect a criteria-based approach based on scientific research of tissue-healing constraints, knee complex biomechanics, neuromuscular physiology, and activity-specific tasks. Thus, systematic progression should be criteria-based and time-based, and not solely on fixed timetables. Soreness rules ACL rehabilitation programs should use effusion grades and soreness rules to monitor the therapeutic exercise progression of patients following ACL injury and reconstruction. The use of soreness rules depends on the timing of adverse effects experienced during performance of the exercises. (See Table 3.) When an adverse response is encountered, the recovery period will be prolonged until the impairment has completely resolved. In addition, the intensity of the next exercise session should be reduced to a lower level to avoid recurrence of soreness Running, agility, and return-to-sport training After ACL injury or ACL reconstruction, patients may develop cardiovascular deconditioning because of the lack of aerobic training. Patients with an ACL-deficient or an ACL-reconstructed knee who wish to return to sport or recreational activities are
Before returning to participation in high-demand activity levels, patients should demonstrate pain-free performance of loading activities and tolerate these activities without experiencing adverse joint reactivity such as joint pain, joint effusion, or muscle soreness. These adverse responses, sometimes experienced by patients progressing to a higher level of therapeutic exercise, can cause muscle inhibition, joint deterioration, and an increase in the number of treatment sessions required to achieve rehabilitation goals (Chmielewski et al., 2006). or effusion. If joint pain or joint swelling are experienced after exercising, but the symptoms resolve before the next rehabilitation visit or after the next warm- up, then the program should not be progressed but rather maintained at the same level and monitored for reoccurrence of symptoms. Chmielewski and colleagues (2006) suggest that a patient should tolerate two to three sessions at a specific intensity without any adverse responses before the intensity of the program is progressed.
encouraged to initiate a gradual running progression to promote cardiovascular endurance, improve oxygen consumption, increase lower extremity muscle strength, and increase force generation from the dynamic nature of the running (Adams
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