Jan 29, 2015Upwardly Immobile
When an athlete’s injury requires a cast or brace, their whole body doesn’t have to remain inactive. A smart rehab plan can help them work effectively within their limitations and come back better than ever.
By R.J. Anderson
R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].
Ask any athlete who has had an arm or leg out of commission about the hardest part of rehab, and most will say it was the beginning–the time when they were partially immobilized and couldn’t do anything with the injured body part. For a person who thrives on being active, nothing is more discouraging than being forced to shut it down completely because an arm or leg has failed them.
For an athletic trainer overseeing these rehabs, there are many hurdles to clear. Although your most important task will be providing a psychological boost to a struggling athlete during those first few weeks, you’ll also need to maintain conditioning, and you’ll want to devise a rehab plan that utilizes the latest techniques.
Fortunately, there are a lot of new ideas about working with partially immobilized athletes that any athletic trainer can tap into. By focusing on the healthy body parts and addressing deficiencies in the kinetic chain, this rehab period can even be a blessing in disguise. A partial immobilization can provide athletes an opportunity to correct imbalances and develop more efficient movement patterns that translate into improved performance and decreased odds of future injury.
FILLING THEIR GLASS
Whether they’re healing from surgery or wearing a new cast, when partially immobilized athletes are crouched in the starting blocks of a rehab, the biggest roadblock is usually fear of the unknown. That’s why a critical first step is showing them exactly where the finish line is, and how you’ll help them reach it. Sharing a detailed rehab plan with the athlete will foster buy-in and provide specific goals to work toward.
“Right away, you have to talk to the athlete about your plan–let them know what’s going to happen and when,” says Aaron Nelson, ATC, PES, CSCS, Head Athletic Trainer for the Phoenix Suns. “You can show them what you want to do day to day, week to week, and month to month.”
“Keeping the finish line in perspective makes the athlete more willing to comply and allows them to stay on the same page as you,” says David Hogarth, PT, PES, CES, Minor League Physical Therapist for the Los Angeles Angels of Anaheim. “Then, as you proceed along the rehab path, keep restating those goals and plans and reassuring the athlete that he or she is making progress toward each one.”
When presenting a rehab plan, it’s not enough to simply explain what it entails. You have to sell it. And you have to sell yourself to the athlete.
“The first time you see a patient in rehab, you have to convince them you know what you’re talking about and give them specific reasons why they need to follow your program,” says Chuck Thigpen, PhD, PT, ATC, Assistant Professor at the University of North Florida’s Brooks College of Health. “Tell them about the benefits–how it’s critical to work on unaffected deficiencies and maintain their conditioning.
“Also explain the risks of not complying during this period,” he continues. “Talk about how athletes who shut everything down during those six or so weeks of immobilization can become deconditioned. I’ll tell them that instead of facing six to eight weeks of training after the injury, if they lose their conditioning, they’ll be looking at three to six months to get everything back.”
Hogarth also sells his athletes by stressing the silver lining of their rehab. “You have to paint a positive picture,” he says. “Your attitude should be that the glass is half full, not half empty. I’ll tell them, ‘It’s unfortunate you can’t use your arm right now, but we’re going to do as much as we can to improve all these other areas. Our goal is to build you back up and make you better than before you got hurt.'”
KEEP ‘EM MOVING
Most athletic trainers agree that the primary goal during partial immobilization is to promote as much cardiovascular conditioning as possible. The less aerobic conditioning athletes lose during their immobilized period, the less they have to regain later on. It also helps athletes maintain or lower their body weight, which reduces stress on their joints when they begin more intense rehab.
For athletes with an upper-body immobilization, there are plenty of traditional methods for maintaining aerobic conditioning, including stationary bike and treadmill work. The most important thing is to make sure the injury site is protected and not at risk of re-injury should the athlete stumble or fall.
For athletes with lower-body immobilization, the options are a bit more limited, but many use an upper-body ergometer or a hand bike. If they’re in a boot, you can sometimes use a stationary bike by carefully fixing the boot to a pedal with a strap or some tape.
Thigpen says this is a good time to get creative. “If the athlete is weight bearing, I’ll have them stand on an elliptical machine and push the pedals with their arms so they still get balanced cardiovascular training,” he says.
Jim Thornton, MS, ATC, PES, Head Athletic Trainer at Clarion University, believes in the power of the pool–provided the injured athlete’s incisions have properly healed and they aren’t wearing a cast. “We use exercises that provide cardiovascular benefits and offer some resistance,” he says. “For example, they’ll do agility exercises in chest-deep water or tread water in the diving well.
“You don’t have to do it every day,” he continues. “It can even be a reward for hard work in the athletic training facility.”
If an athlete is hesitant about hydrotherapy, you may have to carefully explain its benefits. “A lot of athletes don’t like to change the way they train. Someone with a leg injury who is used to running all the time may not want to work out in the pool because that’s not who they are,” Thigpen says. “You have to explain that they need this type of training to maintain their cardiovascular fitness. Stress that if they want to regain what they’ve lost in the injured area and return in a reasonable amount of time, this is what they have to do.”
Along with getting the athlete’s heart pumping, you can use this initial rehab time to uncover and fix deficiencies. More and more athletic trainers view this downtime as a window of opportunity to remedy inefficiencies, imbalances, and kinks in an athlete’s kinetic chain.
“We begin by looking at every injured athlete as a kinetic chain and examining the efficiency of their movement patterns,” Hogarth says. “For example, if someone is coming off shoulder surgery, we go through their ankles, knees, hips, and low back with a fine-tooth comb from a flexibility and strength point of view. They may have underlying movement inefficiencies in those areas that exacerbated their shoulder problem.
“Then, while protecting the shoulder, we’ll devise exercises that clean up those other deficiencies,” Hogarth continues. “When the athlete completes their immobilization, they’ll have a better foundation for the later stages of rehab and reconditioning.”
For Nelson, identifying weak links begins before the athlete is even injured. “We do a kinetic chain assessment in the preseason,” he says. “Then, if an immobilization period is required, we already know what the athlete’s deficiencies are, and we can focus on correcting them.”
Nelson says that was the case when all-star forward Amare Stoudemire underwent microfracture surgery on his left knee in 2005. With Stoudemire’s leg immobilized for six weeks, Nelson used that time to improve his known weaknesses, which included flexibility, core strength, and the strength of his upper gluteus maximus muscles. To do so, Nelson had Stoudemire perform foam roller exercises, stretching, isolated and non-weight bearing corrective exercises, and core strengthening work, including plenty of hydrotherapy work once his incisions healed.
“Correcting an athlete’s imbalances puts them in a position for faster recovery and a shortened rehab time because their movement patterns are more efficient,” Nelson says. “In some cases, those imbalances actually contributed to the injury that led to the immobilization. So if we correct them, we can decrease re-injury risk and help prevent new injuries.”
If no preseason assessment is conducted, an exam of an athlete’s non-injured side can provide key information. “When problems exist on one side, there’s a good chance they are also present on the other side and may have contributed to the injury,” says Thornton. “When we do a post-injury assessment, I look very closely at the non-injured side. For example, if I have a kid with a left ACL injury, I’ll have him do things like a single-leg squat test with his right side. I’ll also evaluate his posture and look to see if his foot pronates or supinates, or if he has flat feet. In addition, I’ll ask about knee, hip, and sciatic pain.”
With that knowledge, Thornton designs a program the athlete can perform using their non-injured side during the injury immobilization period. Then, when the athlete regains mobility, the program can be repeated on the injured side.
When an athlete has an arm or leg immobilized to facilitate healing, you can’t do much to train that injured part itself. Or can you?
Although its effects haven’t been confirmed by research, the concept of bilateral transfer is picking up steam in the injury rehabilitation community. The theory is that when exercising the non-injured limb, the brain also sends impulses to the injured limb, providing residual benefits.
“By strengthening the opposite side, you get a neurological crossover of activation,” Hogarth says. “Basically, by doing strength work with your left biceps, you’ll get some activation going to your right biceps.”
Anecdotally, Hogarth has seen evidence of bilateral transfer with his injured baseball players. “Recently, we had a player coming off right shoulder surgery so we had him do pull-ups with his left arm on an assisted pull-up machine,” he says. “You could actually see his right arm going into a neurological flexion pattern to mimic the movement on his left side.”
When appropriate, Hogarth has applied the bilateral transfer theory to functional work. For example, when a baseball player has an immobilized arm, Hogarth has him do hitting drills one-handed with the non-injured arm.
“You do have to be careful that bilateral transfer isn’t your only focus, though” he says. “Someone on crutches who is using their unaffected side to get around is already working that uninjured limb a lot, and you don’t want to overtrain it.
“I suggest staying within traditional strength parameters as far as sets and reps–you don’t have to go high velocity to trigger the nervous system,” Hogarth continues. “In a rehab environment, just using a traditional 2×12 or 3×8 set and rep range with a controlled cadence will help you achieve neurological impulse transfer.”
Another potentially negative byproduct of working the non-injured limb while not working the injured limb is increased strength imbalance between the two. However, Thornton says with all the focus placed on the injured body part as an athlete progresses through their rehab, any strength gaps are quickly erased.
“We purposely work hard to make the uninjured leg as strong as we can,” he says. “That way, when we eventually build the injured leg up to meet the healthy leg’s level, it has to get that much stronger, which is a positive thing.”
As long as proper precautions are followed, the area around an immobilized joint can also be addressed. For example, when treating an immobilized elbow, the athletic trainer can sometimes access the patient’s shoulder, wrist, and hand.
“You look at what you can and can’t do around the injury itself, then you analyze what you can do near it,” Hogarth says. “For example, if somebody is protecting an elbow and we don’t want them contracting their forearm, we can put a light cuff weight around their upper arm and they can do early shoulder raise exercises.
“If their wrist is immobilized, we can put a cuff weight on their splint and do exercises to work the elbow and shoulder,” Hogarth continues. “Or if you need to protect a shoulder joint and you understand the range-of-motion limitations, you can activate the scapula while still protecting the joint position.”
ON THE SAME PAGE
Sometimes it’s hard for an injured athlete to stay motivated during an immobilization period. That’s why it is important for the athletic trainer to make sure they always remain on the same page as these athletes. Communication and trust are the keys to making this happen.
“There’s a lot of psychology involved during a period of extended rehab,” Nelson says. “You need to communicate the long-term goal, the benefits of doing everything correctly, and what can happen if they don’t do what you ask of them.”
Hogarth says it’s extremely important to encourage immobilized athletes to take ownership of their rehab. “I tell them it’s their injury, not mine,” he says.
But he also tries to understand everything they’re going through. “It’s all about figuring out the extent of their restrictions and communicating that to the athlete,” Hogarth says. “Then put yourself in their place and imagine what they’re feeling. That gives you a better chance to help them battle the demons of immobilization.”
Sidebar: FOOD FOR THOUGHT
Another way to help an immobilized athlete optimize downtime is by promoting proper nutrition. Learning to eat right will boost the healing process and help avoid unwanted weight gain due to decreased activity.
“One good thing about rehabilitation is that you get a lot of one-on-one time with the athlete,” says Aaron Nelson, ATC, PES, CSCS, Head Athletic Trainer for the Phoenix Suns. “You have a chance to talk about many things, and for us, nutrition is always a big point of conversation.”
Nelson says those discussions cover a lot of ground. “The athlete basically becomes a student, and we teach them what we know about nutrition,” he says. “We explain things like caloric intake, the benefits of getting more proteins versus fat, and the role of carbohydrates. We warn them about late-night eating, cover good and bad snacks, and encourage them to ask questions.”
David Hogarth, PT, PES, CES, Minor League Physical Therapist for the Los Angeles Angels of Anaheim, uses the downtime to challenge injured athletes to improve their nutrition with the goal of enhancing performance. “We stress to our immobilized athletes that they should make the most of this time,” Hogarth says. “So when they ask, ‘What can I do better?’ we tell them they can improve their nutritional intake. We say, ‘Let’s take the next six weeks and learn to eat better–that’s your goal.’
“We explain that if they come out of an arm rehab with better movement efficiency throughout the kinetic chain and improved conditioning because they dropped 10 pounds and have a lower body fat percentage, then all of a sudden they’re putting a better product on the field,” Hogarth adds. “In addition to having an injury-free shoulder, the athlete is leaner, runs faster, and moves better. If you can get someone to buy into that, you’ll have a very productive rehab process.”
Sidebar: FURTHER READING
To find other articles related to this topic, use the search window at: www.training-conditioning.com.
For an article about how bilateral transfer affects lateral dominance, type “A Tale of Two Sides” into the search window.
To read about Aaron Nelson’s use of corrective exercise during knee microfracture rehab, search “Micro Holes, Macro Results.”
For more on nutrition’s role during rehab, search “The Better to Heal You With.