BASIC PRINCIPLES OF

JOINT REHABILITATION

Damayanti Tinduh
Surabaya Sport Clinic – East Java Sport Science Center
Sport Injury Rehabilitation Division – Physical Medicine and Rehabilitation Department
Faculty of Medicine Universitas Airlangga - Dr. Soetomo General Academic Hospital
 SCD V (RTG)

PostOp Rehab I

SCD I (Ax-DDx)
Sport Injury Patient
 Rehabilitation Management after
Joint Injury/Repair
• Main factors that need to be taken into account when considering
rehabilitation following articular joint injury/repair :
– The location of defect
– The size of defect
– Conservative vs Surgery
– Single vs Combined Surgery procedures
• The overall aim of the rehabilitation process is to restore function
whilst protecting and facilitating the adaptation of the repair tissue
 Risk Factor of Injury Injury Mechanism

Internal Risk Factors :

prf
• Age ----- x E x C = I
• Sex tms
• Body composition (body weight,
fat mass, BMD, anthropometric)
• Health (history of injury, joint
instability, general health) Exposed Susceptible Injury
• Physical fitness (muscle
strength/power, maximal O2
uptake, range of movement)
• Anatomy (alignment, gap Exposure of External Risk Factors : Inciting event:
between body parts) • Human factors (teammate, opponent, judges) • Playing situation
• Agility level (specific sport • Protective aids (helm, foot protection) • Player/opponent
technic, posture stability) • Sport equipment behavior
• Environment (weather, temperature, ground, • Biomechanics
maintenance) characteristic

A model of injury causation (Meeuwisse, 1994; Bahr & Krosshaug, 2005)

Lunch Symposium JPMR 22 July 2017 11
Factors possibly affecting Outcomes following a
joint injury
 Risk Factors Assessment
• For minimizing joint injury risk we also need to take into account other
factors that affect load on the athletes:
– Age of the athlete
– Individual factors – biomechanics, neuromuscular control, BMI, physiological
systems, psychological factors (confidence, determination)
– Equipment – shoes, floor surface (grip and shock absorption)
– Position on the court – requires different amounts of jumping, landing and
running
– Level of the athlete e.g. development, experienced, length of time in team
– Athletes who play more than one sport
– Nutrition and recovery methods
McGrath A, Ozanne-Smith J. Attacking the goal of netball injury prevention: a review of the literature. Monash University Accident Research Centre 1998:1-105
https://www.monash.edu/__data/assets/pdf_file/0004/217426/muarc130.pdf (assessed: 24 September 2016)
 Rehabilitation Management after
Joint Injury/Repair
• Early controlled movement
– Cyclical compressive stress  naturally nourished in the joint and compressive stress helps
the cartilage to adapt and increase in thickness
– Shear stress  should be avoided as much as possible as it disrupts the articular cartilage
fibers resulting in wear
• In the early stages after surgery,
– Continuous Passive Motion (CPM) machine  controlled passive range of movement
– Gentle exercises for facilitated heel slide
• For the first few weeks :
– Controlled weight bearing with assistive device
– Controlled active range of movement with orthosis
A low load over a long duration is applied to the knee to improve Electrical muscle stimulation is applied
extension. This stretch would be utilized for 10 to 12 minutes, 3 to 4 to the quadriceps to enhance muscle
times per day contraction
Weight-bearing exercises performed on a Functional exercises: lateral lunges Progressive loading program may
‘‘balance trainer’’ device (UniCam Inc, performed onto foam to stimulate include running on an elliptical trainer
Ramsey, NJ). Feedback regarding percent proprioception and neuromuscular
body weight on each lower extremity is control while reducing ground reaction
provided forces
 Training Load
• Training load is important to consider due to the
competitive mentality of athletes to be the best;
training harder and longer will enable them to
perform better.
• This training mentality often pushes athletes to
extreme physical limits. Overloading does not only
cause overuse injuries; it is thought to contribute to
acute soft tissue injuries as well.
• Gabbett 2016, describes the ‘Training-Injury
Prevention Paradox’ established from current
evidence that non-contact soft tissues injuries are a
result of an incorrect training regimes.
– Consistent loading from training has a reduced risk of
injury of less than 10% (based on extrinsic factors or
intrinsic factors (rateable perceived value)) if training
load was 5% less or 10% more than the previous week.
– Injury risk increased rapidly to between 21% and 49%
if the load increased by 15% or more.

Gabbett T. The training-injury prevention paradox: should athletes be training

smarter and harder? Br J Sports Med 2016;50:273-280. Doi:10.1136/bjsports-2-15-
095788 [published Online First: 12 January 2016]
 Neuromuscular Re-education
One Cognition Another
motor Being active motor
behavior Feed-back/forward behavior
adaptive Repetition adaptive
state state
Similarity
CNS HIGHER CENTERS
• Headquarters at cerebral cortex
• Motor commands can be issued in the
absence of sensory stimulus
Cognitive • Responses to stimuli are modified on Autonomous
the bases of planning, memory &
Cognitive motor learning Motor programmes
Conscious Subconscious
Reflex response
Fragmented Continuous patterns
Energy consuming PNS Energy efficient
Dominance of co- Somatic Somatic Less co-contraction, more
contraction strategy sensory motor reciprocal activation
Ability only to perform the pathways pathways Able to multitask
particular task
Much error Little/no error
Need guidance No guidance
Receptors in
head, neck, body Skeletal muscles
wall, limbs
 Miscommunication
Loss of trust
Potential litigation
Declines in sport participation
Serious medical complication
 General Return-to-Sport Guidelines
After Rehabilitation
Strength at/near pre-injury level or symmetrical with unaffected side
ROM at/near pre-injury level or symmetrical with unaffected side
No joint instability
No tenderness area
No swelling or inflammation
No effusion
Creighton et al, 2010. Return-to-Play in Sport : A Decision-based Model. Clin J Sport Med 2010; 20:379-85
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 6Indicator
steps offor Return to Play :
Professional Athlete

Attempted return to sport

Tissue damage 4. NON CONTACT 5. FULL CONTACT

TRAINING DRILLS PRACTICE
(Increase exercise, (Restore confidence
3. SPORT SPECIFIC
coordination & & assess functional
2. LIGHT AEROBIC EXERCISE
attention) skills)
EXERCISE (Add movement)
1. NO ACTIVITY Progress to complex If symptom free,
Pain (Increase Heart Rate)
reinjur
Drills
(Recovery) training drills return to normal
Walking, Swimming, y impact
NO hard
May start resistance
Complete Rest activities training activities
until Medical Stationary cycling training
HR <70%-15 min HR <80%-45 min
Clearance HR <90%-60 min

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 • Goal adjustment, sense of loss • Relief, escape from pressure
• Optimistic, pessimistic beliefs • Fear of movement, reinjury
• Pressure, stress perceptions • Burnout, fatigue, recovery
• Impression management • Sadness, depression, grief
• Meaning interpretations • Anxiety, fear, tension
• Challenge appraisals • Emotional inhibition
• Causal attributions • Anger, frustration
• Self-perceptions Cognition Affects • Feeling of guilt
• Pain perceptions • Vigor, boredom
Interpretations Emotions
Appraisals Feelings
Beliefs Moods
Biopsychosocial model of post-
sport injury response and
recovery (Reprinted by Wiese-Bjornstal,
2010) Results Efforts
Effects Actions
Surgery vs Consequences Activities
• Health status • Malingering
Conservative • Healing effects Outcome Behavior • Risky behavior
Psychology
• Relapse, reinjury • Substance use
• Recovery progress • Suicidal behavior
Stem Cell • Sport performance • Social connection
• Functional outcomes • Coping, help seeking Rehabilitatio
• Rehabilitation results • Exercise dependence n
Rehabilitation • Return to training or play • Psychological interventions
• Career transition, termination • Rehab adherence, compliance
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1 European Board of Sport Rehabilitation Recommendation
2 Utah State University Recommendation (2011)
3 Surabaya Sport Clinic Recommendation (2012)

PHYSICAL vs PSYCHOLOGICAL
Limb Symmetrical Index LSI Hop Performance Questionnaire
• Proprioceptive test : • Vertical jump : • International Knee
• I/UI JPS : 0-5deg3 90%1,2,3 Documentation Committee
• I/UI TDPM : 60ms3 • Single/double leg Subjective form (IKDC-SF) 3
• Strength jump : 90%2 • Knee Osteoarthritis
• I/UI Quadriceps size : 85%2 • 15 feet hop Outcome Score (KOOS) 3
• I/UI Hamstring & Quadriceps
down & back • Return to Sport After Injury
strength :
• Non pivoting, non contact, • for distance (RTSAI) 3
recreational 85-90%1,2,3 • triple crossover
• Pivoting, contact, competitive • Endurable single leg
100%1 hop : 90%1,3

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