Rehabilitation: Part 2 of our Exercise and Movement series

March 9, 2020


 

In our last article we discussed prehab and noted the difference with rehab.  To recap, by definition, Rehabilitation (according to Oxford dictionary) is "the action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness".  Prehabilitation can be defined as "the process of care, initiated before surgery, whereby patients’ physical, nutritional, medical and mental conditions are strengthened while waiting for surgery in order to face the surgical insult and facilitate postoperative return to preoperative conditions" (McGill perioperative program).  The difference really only is the timing.  Prehab occurs prior to surgery or other intervention, while rehab occurs post surgically or following an injury or chronic illness.  

Rehabilitation as stated above, is the "restoring back to normal".  When there is an injury, there are phases of "restoring back to normal".  Initially, from the treatment stand point, we are first focusing on removing pain and inflammation.  Whether these symptoms are coming from a laceration, a bruise, post-surgical incisions/stitches, burns, tears, or chronic illness, phase 1 in rehab is to heal the damage and reduce the swelling.  In phase 2, we begin restoring range of motion (ROM) and introduce cardiovascular functioning.  Phase 3 involves restoring ROM, improving strength and endurance, proprioception and continued cardiovascular training.  As we meet phase 3 goals, we move into phase 4 where we can continue to build strength while introducing sport specific patterns and the progression of velocity to game speed.  Ultimately, the restoration of strength and function.  Keep in mind that these phases will be discussed from a musculoskeletal injury perspective, but they can definitively be applied to other areas of rehabilitation, i.e chronic illness or depression.  

Phase 1 and 2 (healing the injury and then restoring motion) are the phases that most people know about.  .  We will not focus too much on these phases but put the majority of emphasis on phase 3 and 4. Strength, stability and endurance are often over looked when a professional is not involved in the rehab process.  

Phase 1:  Acute care

Healing of open wounds, reducing inflammation, application of ice, ultrasound, stim, laser, use of NSAIDs (if applicable) are all different modalities of acute care.  This phase can be completed on your own or in the office of a healthcare professional.  The advantages of seeing your healthcare provider during this phase is for the application of modalities that may not be available at home (like laser).  

Phase 2:  Introduction of ROM and cardiovascular training
With any injury, as soon as we can get the part moving, the better the outcome.  This is why you don't stay in the hospital for very long post-surgery.  The longer a body part is immobile, the larger the deficit to the muscles that are immobile.  The introduction of ROM is going to be progressive.  Each day motion continues to improve.  As we move, we help pump blood to the area which provides biochemical components to the area of injury to further help in the healing action.  This is also why introducing some cardiovascular activity is very beneficial.  Keep in mind, you must not do exercises that are contraindicative to the injury.  A stationary bike is great cardiovascular exercise to introduce for multiple injuries to the body, but you have to be able to do it.  

Phase 3:  Restoring ROM, improving strength, endurance, proprioception and continued cardiovascular output.
Part of the restoration of ROM will involve stretching.  During the immobile time, muscles aren't moving how they normally move.  Often there are compensations for ranges that aren't possible due to the injury.  These compensatory muscles then become over worked, they may even get injured themselves, and are often very tight.  Hopefully these tight areas are worked out in earlier phases of rehab, but they may still need to be addressed to fully meet the goals of restored ROM. 

With the introduction of strength post injury, we often start with isometric exercises.  These exercises involve contracting the muscle without changing the length of the muscle.  For example, for the quadriceps muscle, while in a seated position with knee straight, you would squeeze to contract the quads.  You should feel the muscle tighten and then relax as you let the contraction go.  Sometimes we add resistance so you can identify the muscles that need to contract without actually doing the motion of the muscle or group of muscles.  For example, with the cervical flexors try placing your hand on your forehead and push into your hand without actually moving your head (you are performing isometric exercises for the cervical flexors).  Once ROM has improved and isometrics are able to be done without pain, we can add motion to our strengthening (concentric contractions) taking the muscle through its full ROM.  Initially, strengthening will involve individual muscles and then progress as the strength improves to more functional movements involving multiple muscles or muscle groups. 

Proprioception is another component in this phase of rehab that needs to be addressed.  Proprioception is the ability to understand where a joint of the body is positioned in space.  This information is transmitted to the brain via small nerves called proprioceptors.  We have proprioceptors all over the body, the most in our ankles, second in our neck.  We rely on several factors to tell our brain where we are positioned in space, mainly vision, vestibular functioning and proprioception.  When there is an ankle sprain for example, essentially we tear tissue in the ankle, ligments, small capillaries and nerve endings called proprioceptors.  You can retrain these nerve endings to send adequate info back to our brain through various balance exercises.  You can test your proprioception by standing on one leg with eyes open.  Once you can hold this for 10 seconds, close your eyes.  How well is your brain able to keep you balanced?  Do you fall over as soon as you close your eyes?  Or can you hold it for 10 seconds?  With an injury, our rehab needs to also address the proprioceptive component to be able to maintain stability and balance. 

Cardiovascular training in this phase is going to help contribute to some strengthening but also build up endurance to the point where some might think that they are finished rehabilitation.  (but we know that we need to finish with phase 4). 

Phase 4:  Sport specific training, power, game speed performance.

To enter this phase of rehab, full ROM needs to be restored and strength needs to be adequate.  Here we can work on sport specific movements that will prepare for return to play, or for those that are not athletes, movements that were done regularly pre-injury, i.e., lifting weighted objects overhead for someone that does stocking in a grocery store.  For runners, we would incorporate a lot of one-legged stance exercises, cross body motions and changing weight from one side of the body to the opposite.  Football players would need to work on a lot more pivoting and changing direction of the body, reaching and leaping motions if they are receivers or throwing motions if they are quarterbacks.  For any sport, phase 4 means breaking down the motions of that sport, working on those individual motions, then combining them to perform full body movements.  Here we can also introduce power development and speed.  How can we use the body properly to transfer the force development to throw the ball further, swing a bat faster or drive a ball an extra 20 yards.  Force development comes from a combination of muscles, joints and body parts working together in a particular sequence at the right speed and moving at the right time.  Developing power does not have to be a sport specific motion.  A golfer, a runner, a basketball player or a steel worker could all look the same in the gym but you may not be able to identify their specific sport or job.  Power training involves creating a force to move a mass with speed.  Some examples of power training exercises could include vertical jumps, hurdle jumps, medicine ball slams, squat jumps, overhead 2-handed throw, sprints, long jump, and the list goes on.  Another must in any rehab program is developing core strength and proper core contraction.  There are multiple was to do this, however, I believe the best core trainers are Pilates instructors.  Please see the link in our article about Stacey Ziebarth and her Studio Zee Pilates in Hamilton.

 Rehabilitation for a musculoskeletal injury needs to continue through all four phases of rehab to fully “restore normal health”.  We have identified all of the phases of rehab and discussed in detail the aspects that need to be followed.  Injuries can make a big impact on ones’ life and the lives of those around them.  Although some injuries may appear to be completely repaired after phase 2 or 3, the lack of muscle strength and power that should have been rehabbed in phase 4 may present itself with further injuries down the road.  If you or someone you know has been injured, please see a health professional, like Dr. Marnie Mabee D’Andrea, that can take you through these phases of rehab.  Stay tuned in April when we discuss Corrective Exercise, Part 3 in our exercise and movement series. 


 

Prehabilitation:  Part 1 of our Exercise and Movement series

February 12, 2020


Prehabilitation is a newer buzz word that is used often in the healthcare industry, in particular, more amoungst physical therapy providers like chiropractors, physiotherapists, occupational therapists, athletic therapists, massage therapists and some orthopedic surgeons.  By definition, Rehabilitation (according to Oxford dictionary) is "the action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness".  Prehabilitation can be de...

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Common Fractures

December 29, 2019

The image above illustrates the various types of fractures that can occur.  The terms "Compound Fracture" is used to describe a fracture that breaks through the skin resulting in an open wound or also called an "Open fracture".  Many displaced fractures, meaning the two ends of the bone do not align, are Compound fractures.  The term "Simple fracture" refers to fractures that are "closed" or do not penetrate through the skin.  The terms in the image above are used to describe the fracture lin...

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How do I know if my low back pain is serious?

November 12, 2019



Believe it or not, this is not a common question.  Often, I find myself letting patients know the serious symptoms that may arise with a back injury so they are aware of what to look for.  I wonder sometimes if this scares people, but I know that in discussing this with patients they will be better prepared to recognize these symptoms and may not ignore the symptoms if and when they arise. 

One of the first signs or symptoms to look for is the presence of “saddle parathesia”.  This is n...


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What causes low back pain?

November 12, 2019

There are several sources of low back pain. 

To understand the symptoms of low back pain, we must be aware of all the anatomical structures and how they contribute to the movement of the spine.  These sources can be grouped into our “mechanical” sources of low back pain (LBP). 
There are other sources of LBP that tend to be secondary to another condition that we will also briefly discuss.  We will refer to this second group as “non-mechanical” sources. 

Mechanical Sources of Low Bac...


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Delayed Onset Muscle Soreness (DOMS)

November 7, 2019


When we use the term DOMS or Delayed Onset Muscle Soreness, we are referring to the post workout pain that tends to peak around the 24 to 48 hour mark.  We want to discuss the potential treatment for DOMS and recommendations for the prevention of this pain.  After reading a great, lengthy article on this subject by Paul Ingraham (painscience.com) , I will summarize some his points. 

How delayed is this muscle pain?  The muscle soreness can come on almost immediately post exercise, but tends ...

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Cold cream review

October 7, 2019
What is your cold cream of choice  for use on sore and ache muscles?  We had a fun little experiment on one of our Monday afternoon meetings where we each tried out the cold creams that either we sell in the clinic, or various other products that companies have sent samples to us to try out.  Here are the contenders:
Biofreeze


Fisocream


Motion Medicine

Medistik solid 46%


Medistick spray 22%

 
After testing all five on each of our forearms, we rated each on smell, coldness, absorption rate, and leng...

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Proper Backpack fitting

August 13, 2019

As we prepare for the back to school season, let us remind you of how a backpack should be worn.  Remember the weight should be 15% of your body weight if you are older than 12.  Younger than 12, the backpack should only be 10% of your body weight.  If you have a scale at home, it is really easy to see how much your bag weighs.  Simply pack your backpack up for school with all the items you normally take with you and place it on the scale.  These rules also apply for all the other types of ba...


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Camping in Pain: Choosing Your Sleep System

July 9, 2019

Camping is a wonderful, age old summer tradition for outdoorsy Canadians. Something about natural landscapes and outdoor activities being good for your health. A road block for a lot of people can be pain. We know from the science that restriction of activities due to pain can lead to co-occuring mental health disorders like depression.

But it doesn't have to be that way.

It can be possible to adapt to pain while still doing what you love or even trying something new. When it comes to camping, ...


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Is your bike ready for summer? Summer Bike Tune Up.

June 6, 2019




The weather has been... well ok we won't talk too much about the weather as it has been raining a fair bit in the last while but I swear it can't rain all the time and when you catch those sunny days you will want your bike to be in ready-to-ride condition. A lot of people bring their trusty steeds up out of the basement between April and June to drop off at the local bike shop for tune ups but the truth is, a lot of the bikes only need a few small and simple adjustments that can be done at h...

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Range of Motion Training

May 9, 2019

 There is always a lot of talk about specific exercises for certain injuries or rehab protocols for different muscle groups.  One theory that has emerged in the last few years looks at the reason why many injuries happen, and that theory revolves around having an inaccurate range of motion. 

 The dancer above would not be able to move the way she does if she did not have full ankle planter flexion and toe flexion, knee flexion, hip flexion and extension, spinal extension, shoulder flexion, abd...

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Acute care for your Temporal Mandibular Joint Pain and Dysfunction

April 9, 2019
We have previously discussed Temporal Mandibular Joint (TMJ) Pain and Dysfunction in more detail (click here for previous article).  In this article, we want to review some acute care procedures you can do at home to help care for this problem.  

Finding Your TMJ

First, lets remind ourselves how to accurately feel where your TMJ is on our skull.  If you place your hands on the side of your face, just in front of your ear, your hand should be right over your TMJ (see diagram below).  To test if ...
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Tabata Workouts

March 2, 2019


Most people have one of two relationships with cardiovascular exercise... tolerate or hate. It's hard to refute the benefits of cardiovascular exercise for heart health. If you are in the hate category, Tabatas might be the right fit for you. Tabata exercises were created by Dr. Izumi Tabata, who researched new approaches to training the Japanese Olympic speed skating team. He created a 4 minute cardio workout that involves 20 seconds of work and 10 seconds of rest for 8 cycles. His research ...

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Spotlight on Women's Cardiac Health

February 26, 2019

March 8 is International Women’s Day and we decided to focus our newsletter on women’s heart health, an understudied, under-diagnosed and under-treated health concern for women. Though there have been incredible improvements in cardiovascular mortality rates in women, heart disease is still the leading cause of mortality in women. Regardless of age, women tend to die more frequently within 1 year of their first heart attack (at 26% vs men at 19%), and within 5 years, at 47% vs men at 36%,...


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Welcome to the gun show!

February 11, 2019

You guessed it!  The guns we are referring to are the biceps.  In this article, we will discuss proper motion, common injuries, exercises and things not to do at the gym! 

The biceps brachii have two muscle bellies and attach the shoulder to the elbow.  For those that would like to know more specific anatomy, the short head, attaches to the coracoid process of the scapula and the long head attaches to the supra glenoid tubercle of the scapula.  Together, both muscle bellies come together to ...


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Gout: Recognizing, Risk Factors and Treatment

December 5, 2018

Gout is an inflammatory arthritis caused by excess uric acid in the bloodstream.  The symptoms of gout arise due to uric acid crystals that are deposited in the joints and the body’s response to them.  The pain is often so intense, anything touching the joint involved, including clothing or socks, causes extreme pain.  The most common joint affected is the big toe, with patients often commenting that even their bedsheet hurts the toe.  As this is a potentially destructive joint disease, it ...


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Fall 2018

October 16, 2018



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Does weather really affect our joints?

October 11, 2018


How many times have you heard the statements "My ankle hurts more when rain is coming"?  Or cold weather brings ache joints.  Often we have an influx of acute neck or low back pain during a "change in seasons" period.  Is there some validity to the theory that changes in weather can bring changes in joint pain sensitivity or even pathology to joints.  Let us take a look at some of the literature on this theory.  

If you search for "joint pain and weather" in Google, the first listed website th...
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Preparing for tryout season

September 4, 2018

Back to school is around the corner and that also means tryout time for school and out of school sports teams.  In my family, our baseball season is coming to an end, but within the first two weeks of school we have tryouts for next years baseball and basketball teams.  This can be a period of extreme stress for some, particularly if they are trying out for a new team with kids they don't know and coaches that may be very different from coaches they have had in the past.  Are their athletic s...


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Natural Bug Repellents

July 8, 2018


Last month I gathered together more information than any usual citizen should sift through and read about mosquitoes, ticks and bug spray. I wanted to better understand how these insects find us, and how well different repellents work and what the safety usage guidelines were for each of them. This is a condensed version of my findings because the whole thing worked out to be 5 pages! If you're interested to know all of it, let me know as it is the basis of my Natural Bug Repellent workshop! ...


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Patellar Tendonopathy

June 4, 2018

What it is

Patellar Tendinopathy, also known as patellar tendinosis, jumpers knee, or Landers knee is an overuse injury at the knee. There is no specific injury or trauma to cause it, but the repetitive motions over time result in the tendinopathy.


Suprapatellar vs Infrapatellar tendinopathy

Supra- or superior refers to   tendinopathy above the patella (knee bone). This area is also call the quadriceps tendon. This portion of the tendon connects the quadriceps muscle and the knee. Infra...


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Movement screening to prevent injury

June 4, 2018

Some of you may have experienced some new testing that I have done to assess how your body moves.  In the fall of 2017, I began studying a method to assess movement throughout the whole body.  The Selective Functional Movement Assessment, or SFMA, is a tool that takes a patient through a series of 10 movements.  These 10 movements are then classified as being normal functioning or dysfunctional.  This assessment tool is part of the Functional Movement System, which includes other screening te...


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Degenerative Disc Disease (DDD) vs Degenerative Joint Disease (DJD)

June 4, 2018

Have you been given one of these diagnoses DDD or DJD?  Depending on how specific your healthcare practitioner is, you may have heard these terms before as the source of your spine pain.  Degenerative disc disease or DDD can be the cause of many different symptoms resulting in localized pain or pain that radiates down the leg.   Degenerative joint disease or DJD is very different, but can have overlapping symptoms with DDD.  We will discuss both of these conditions a little more thoroughly so...


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Stretching: A guide to becoming the most flexible you

April 15, 2018

Static Stretching

Static stretching is the most common type of stretching we think of when we hear the word stretch.

This type of stretching increases muscle extensibility, in turn, increasing that joints' range of motion (ROM).

Following a short jog, a few jumping jacks or even a heating pack to increase muscle temperature, complete the recommended stretches holding the stretch for 10-30 seconds feeling a light tingle or slight discomfort. Consider a scale from one to ten, one being barely a...


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Travelling with Acute Pain

March 7, 2018
Pain alone, is enough to have to worry about and deal with.  Now add in the travel component and this could make for some very aggravated pain episodes, not to mention the irritated travel companions.  The following is a list of things to consider and some tips for dealing with your pain while on the go.
  1. Explain your injuries to your travel companions.  Nothing is more awkward then letting your frustration make the best of you while with your travel companions that know nothing of your current...

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Travel Tummy Tammer: An Aromatic Remedy

March 7, 2018

I've done enough trips away from home to have learned my belly just doesn't like it. Whether it's the stress and worry about sleeping away from home, eating unfamiliar foods or drinking unfamiliar water, I have learned the value of having a travel kit for my gut.

Without getting into all the ugly details, colic and bowel upset are awful, especially when you are supposed to be away having fun. Emergency trips to walmart to buy tea, metamucil, or jumping off the bus to gnaw on a raw lump of gi...


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Orthotics

February 8, 2018

For some people, orthotics are the only device that provides any relief from pain.  For others, congenital deformities in the foot or toes prevent them from having a normal gait.  Whether you are experiencing pain or just looking for cushioning, orthotics can be very helpful for many.  

At MMD Chiropractic Health Centre, Dr. D'Andrea uses a foam mold to cast a patient for orthotics.  Orthotics are made by a local Chiropodist, Robert Nekrasas, and come in a wide variety of choices.  If you requ...


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Laser Therapy

February 8, 2018

The laser we use at MMD Chiropractic Health Centre is the Theralase therapeutic laser.  Theralase therapeutic laser treatments provide patients with a safe, effective and painless therapy that uses the body's own natural healing systems to relieve pain, increase joint mobility, increase tissue integrity and promote cell regeneration.

Theralase lasers work by supplying energy to the body in the form of billions of photons of light. The body absorbs this laser light on a cellular level and trans...


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Recognizing Clinical Depression in Youth

January 31, 2018

The teenage years are often a busy and trying time for both kids and their parents.  Teens are learning to deal with more adult situations as their bodies continue to take on an adult size and their brains are developing to their full potential (anatomically and chemically).  Their parents are dealing with their babies now making different choices and often choices that they don’t necessarily agree with.  But no matter what the events are that occurring, as parents, we need to recognize whe...


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Assessing Posture

January 31, 2018


What Causes Poor Posture

Poor posture can result from a combination of 5 reasons:

  1. Central nervous system disorders,

  2. Peripheral nervous system disorders,

  3. Eye problems,

  4. Ear problems,

  5. Musculoskeletal system problems.

In terms of Chiropractic, chiropractors focus more on the musculoskeletal system and its relation to the nervous system. Many musculoskeletal problems can affect posture, but in terms of the effects of posture, the most common problem is decondit...


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