Rehab progression

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Cards (29)

  • Rehab progression – Phase I - pain relief:
    • Isometric work, up to 70% MVC (Rio et al 2015, [patellar])
    • Not effective in all (O’Neill et al 2018, [Achilles], Holden et al 2019 [patellar])
  • Rehab progression - Phase 2 - build strength:
    • isotonic progression through range
  • Rehab progression - Phase 3 - power development:
    • Incorporation of speed and elastic recoil
  • Rehab progression - Phase 4 - return to sport
    • Maintenance
    • management of load
  • Rehab progression summary
    A) unload
    B) isometric
    C) capacity
    D) pain
    E) isotonic
    F) explosive
    G) strength
    H) endurance
    I) power
    J) functional
  • Phase 1:
    • Isometric holds 45 - 60 secs x 4 , 4 days a week
    • Use 70% MVC, good to load
    • Pain free positions initially
    • Avoid compression positions
    • Use if isotonic > 3/10 pain
  • Phase 2 - Limited range:
    • Aim to develop strength
    • Isotonic exercise – slow (6 secs) and heavy
    • Minimal pain
    • 6 - 10 x 4 for 3 days a week (high load)
    • Or, 15 x 4 done daily (Low load)
  • Phase 2 - Progressive range:
    • Improve load tolerance
    • Moving towards function
    • More provocative
  • Phase 3:
    • Energy storage and power loading
    • Mostly for athletic populations
    • Minimal pain
    • Speed work into range
    • Development of kinetic chain motor control
    • Volume before intensity
    • 6 - 8 weeks (??concurrent with activity)
  • Phase 4:
    • Sports specific activity
    • Gradual increase
    • Overlaps with elements of phase 3
    • Long term maintenance programme advisable/essential beyond resolution of symptoms
  • sample rehab protocol
    • Consider dosage = frequency x volume (days per week x sets/reps)
    • Allow time for recovery
    • Repetitive hard days is too much
    • Monitor by 24h response (VAS 0-3 ok, 3-5 caution, 6-10 avoid)
    • Avoid spikes in activity – slow progression, use % of previous load
    • High load for tendons involve SSC components eg jump, hop
  • What to expect during rehab:
    • Pain - during rehab not as important as reactivity next day
    • Education & expectations - Slow recovery, ensure buy-in and compliance
    • Consider biopsychosocial contribution (fear, threat, etc) in acute/chronic presentation
    • Investigations - Structural change poorly correlated with symptoms, but structure changes – UTC studies
    • Exercise is for muscle as well as tendon (M-T unit)
    • Benefits of exercise go beyond physiological changes locally - strength, sensitivity, confidence, tissue capacity
  • Less common adjuncts and alternatives to exercises:
    • Surgery – minimal invasive, outside tendon
    • High Volume Injections
    • Excision
    • Scrapping
    • Plantaris
    • Shock Wave Therapy
  • More common adjuncts and alternatives to exercises:
    • Corticosteroids
    • GTN
    • Ice
    • Taping
    • Sclerosing agents
    • Alternative medicine
    • Platelet Rich Plasma PRP