Within a modern functional rehabilitation program it is necessary to pay particular attention to the initial phase of load recovery on the operated limb. This phase, in fact, is particularly delicate and can significantly influence the course of rehabilitation.
The purpose of this article is to analyze the criteria and tools to be adopted to define the correct progression of loads in the different situations that we face every day in the gym with our patients.
I deliberately decided not to analyze the advantages offered by the aquatic environment and by hydrokinesitherapy, since they deserve to be treated separately for their specificity and importance.
SELECTION CRITERIA
When, how and with what we decide to stimulate the patient during the rehabilitation process represent questions that are not always easy to answer.
First of all it is necessary to identify the elements useful to the physiotherapist to correctly set the therapeutic program, with particular attention to the progression in the recovery of the load. The term "load" means both the "support of the limb on the ground with consequent gravitational stimulus, and the stresses that we propose through therapeutic exercises for muscle strengthening."
Indications and times prescribed by the surgeon. Taking into consideration the indications given by the surgeon may seem like a "foregone conclusion but, since communication between the rehabilitation operators and the orthopedic surgeon is not always easy, I believe it essential that the re-educator promotes direct contact with the doctor who performed the" surgery. In fact, he is the only person able to actually know what the surgical procedures were and what fixation means were used, so as to be able to indicate the loads to which the joint can be subjected in the period following the intervention.
Another situation that may arise is that in which the times dictated by the surgeon are standardized by pathology and need to be adapted to the psycho-physical-athletic conditions of the patient. These times may in fact undergo significant variations, linked to the patient's responses to the proposed stimuli. Also in this case, constant contact with the surgeon will be essential to agree on any changes with respect to the standard protocols or to what emerged during the last check-up visit.
Patient reaction to stimuli. Each patient is an individual in his own right and his tissues will react differently to the various stimuli proposed. The expert re-educator must therefore also take into account the metabolic aspects of exercise, but also the lifestyle, motivations and psychological aspects of the patient that can influence recovery after the injury. For example, our experience with rugby players has taught us how different the ability and willingness to bear pain is different for certain categories of athletes. Pain is a precious guide for us physiotherapists, but it is we who must read the patient's reactions considering that, depending on who we are dealing with, this guide can be more or less reliable. In fact, from a physiological point of view, a knee operated for example by chondroplasty, requires the same rest and protection times regardless of whether it is a rugby player or a classical dancer. However, in daily practice our approach probably would not be the same with these two athletes, since it would be difficult for us not to be influenced by the personal characteristics of the individual in front of us.
Tools available. Among the many tools we have available to offer the patient a correct progression of loads, we must certainly favor the equipment that allows you to perform exercises in a closed kinetic chain and that allow good load modulation. Among the various leg-presses available today, those that use elastic resistance respond optimally to this need. In particular, an excellent help to manage the delicate phase of passage from the absence of load to the full load is provided by a newly built equipment: the Minivector (fig. 1). It is a simple elastic press that has the possibility of being used also at the patient's home and which allows the patient to be provided with truly modest and easily increased loads.
In the Minivector there are six rubber bands, each of which provides a resistance of 1 kg. at the start, up to 5 kg. at maximum tension: this therefore allows the load on the operated joint to be stressed in a progressively increasing manner, monitoring its improvements.
FIG. 1 MINIVECTOR
The criteria analyzed above assume that every rehabilitation operator has a clear idea of the concept of PROGRESSION which in my opinion is the basis of every rehabilitation treatment whether we are dealing with an athlete or a sedentary, whether we rehabilitate a knee or a shoulder. .
It is based on the principle that in re-education the recovery of functionality must be obtained by trying to:
- avoid underloading the muscle-tendon-articular structures as this would not provide sufficient stimuli to produce the required adaptations and would cause a lengthening of recovery times;
- avoid overloading, with the consequence of exposing the tissues to functional overload pathologies, such as tendinitis, bursitis and muscular overexertion that force the patient to rest periods and further therapies, with evident delay in achieving functional goals expected.
Instead, the so-called area of homeostasis should be sought (fig. 2), that is the situation in which the appropriate stimuli for that precise moment are proposed both from a metabolic and reparative point of view, with the advantage of optimizing recovery times by constantly adapting the workloads to the patient's condition. It is not a simple job, as it obliges the re-educator to constantly "read" his patient and to adapt the work program almost daily, in order to find the most appropriate solicitation, which will produce a positive stimulus on the tissues avoiding damaging them.
As an example, let's consider a patient operated on for a knee pathology and identify, for simplicity, three distinct phases during which the resumption of the load is of particular importance:
1) PROTECTION PHASE
Once the repair or surgical reconstruction has been performed, there should be a period of no load on the operated limb, to promote tissue healing.
Unloading doesn't have to mean no stimulation. In this first phase, manual solicitations will be proposed to restore proprioceptive sensitivity and joint perception in space. Exercises against elastic resistance, limited to the ankle joint and the intrinsic muscles of the foot. The patient will walk with two brachials and will not be allowed any load during the walk.
2) TRANSITION PHASE
This phase is certainly the most important after the interventions on the cartilage. This tissue is in fact super-specialized to support loads and, in its healing process, it needs to be solicited in this sense.
In this second phase we will insert activities with loads that involve a fraction of the body weight. In particular, walking with two forearm legs will be carried out with a lightly loaded load that must give the patient full awareness of the amount of load to which the operated limb is subjected. For this purpose, all the exercises on weight scales and walking with particular insoles telemetry connected to a Personal Computer which, specially calibrated, allow you to set the desired load. If the set threshold is exceeded, an acoustic feedback is heard, which allows the patient to learn to have greater awareness of what is actually soliciting the his injured limb.
The first push exercises will then begin on the foot both on soft surfaces (such as sponge balls of various consistencies) and against the manual resistance of the therapist and with the help of the minivector.
During this second phase, exercises in standing position will also be proposed, which will prepare the patient for free walking: walking exercises with a forearm performed under the control of the physiotherapist, aerobic training on an elliptical machine with support on the arms, exercises on step-machines, all with a progression that will lead the patient to bear the full load.
3) MATURATION PHASE
The operated tissues must be able to functionally mature in complete safety and this is possible if you have perfect muscles.
This phase is characterized by the recovery of muscle strength, which must necessarily take place following a "careful progression of loads. For this purpose it may be useful to remember that each exercise can be performed initially using the contralateral limb as well, then moving on to a monopodalic execution only. subsequently and in the absence of unwanted reactions on the part of the joint.
The constant research of the homeostasis area through the continuous adaptation of workloads will allow the re-educator to obtain the best possible results in the shortest time.
FIG. 2 THE "AREA OF HOMEOSTASIS IN REEDUCATION
To be able to work within the homeostasis area it is useful to know that in fitness gyms beginners (as we can consider our patients) obtain the same result in terms of trophism and increase in strength with loads equal to 20-40. -60% of 1 RM (maximum repetition). In re-education it is therefore advisable to start with loads close to 30% of 1 RM since we obtain the same result without the risk of overload. Conversely, we must consider that advanced athletes (our patients towards the end of re-education) respond best to stimuli that are close to "80-90% of 1 RM, so we will have to manage, at the end of re-education, to administer even very heavy loads to them. This is to obtain a real improvement and not simply to maintain the results obtained up to that moment.
Depending on the type of intervention, we will also have to evaluate whether to favor work in an open or closed kinetic chain, a complete or reduced joint excursion during the execution of the exercises. In addition, the functional and sporting needs of each patient must be taken into account, to address the solicitations towards the achievement of functional objectives compatible with the characteristics of the sport practiced.
Parameters to be evaluated every time you propose an exercise to a patient and want to work within the homeostasis area:
- Biomechanical impact on the joint
- Type of contraction required (isometric, concentric, eccentric)
- Full or reduced range of motion (R.O.M.)
- Metabolic demands
- Speed of execution of the exercise
- Correct technical execution of the exercise
- Total volume of loads administered
- Frequency of stimuli (weekly, daily and within the same session)
- Time in which the exercise is administered (at the beginning or at the end of the session).
TAB. 1: Fundamental parameters to be evaluated in order to work within the homeostasis area.
We remind you that the correct progression of the loads provides, in addition to an increase in the resistances provided by the equipment, the introduction of more complex gestures with greater impact on the articulation. I am referring to the leaps and jumps which must also be proposed with the right progression and only when the patient is able to bear these stresses.
For example, if walking on a conveyor belt produces a load on the knee equal to 100% of the body weight, we must think that running at a speed of 10km / h can produce a load greater than 500% and plyometric exercises (with a fall from above). they can produce much higher loads. Our patient will have to perform these gestures when he returns to sport and, consequently, our task will be to accompany him during the re-education to face this type of stress in complete safety. bipodalic jumps on the Vector elastic press (fig. 3), then moving on to jumps on the trampoline and finally proposing real plyometric exercises in the gym and on the sports field.
Let us remember that the muscles also play the role of shock absorbers on the joints and in particular through the eccentric contraction they are able to absorb the kinetic energy and cancel, or at least reduce, the impact forces that are produced during the most intense activities. In the rehabilitation program it will therefore be necessary to insert a targeted strengthening of the musculature in an eccentric mode.
FIG. 3 EXERCISES IN LOADING ON VECTOR
To conclude we can say that, given the importance of the correct progression of loads in a rehabilitation program, the physiotherapist must necessarily know the "" arsenal "of equipment indicated for this purpose. Above all, he will have to develop the sensitivity and the ability to interpret the signals that the patient sends him during rehabilitation, in order to be able to work constantly within the "homeostasis area": this will allow him to always propose the most appropriate solicitations to the patient. This way of acting usually makes a difference and allows the patient to heal in the best way and in the shortest possible time!
Marco Zanobbi
Physiotherapist
Isokinetic Rehabilitation Network
