Davis-F_Rehab-Plan_2022

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May 26, 2024

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Case Study #1 A football lineman injured his back in a game four weeks ago. He was referred to an orthopedic surgeon because of continued low back and right lower-extremity pain. Magnetic resonance imaging (MRI) revealed that he has a disk bulge of 3mm at L 4-5. The physician indicated that this patient is not a surgical candidate because the problem may be resolved with rehabilitation, corticosteroid injections, or Medrol dose pack. The patient has had two of the three injections and reports significant relief of his back and leg pain. He is now coming to you for a rehabilitation program. He moves well when he enters the examination room. He does not appear to hesitate to walk or get up from a chair. When he moves around the room, however, you notice that he has very poor body mechanics, bending from the back to sit down and bending and twisting sideways to retrieve his backpack. His examination reveals a straight-leg raise to 50˚ on the right and 55˚ on the left, and his internal hip rotation is 20˚ bilaterally. In a forward bend, he is able to touch his fingers to his knees; in a side-bend he can touch 10cm above his knee; and in backward bending he has good motion. Forward bending produces some discomfort. You notice that when he bends, most of the motion comes from the thoracic spine, with the lumbar spine remaining essentially flat. The neurological examination reveals no deficiencies in sensory, motor or reflex innervation. The patient’s gluteal muscles and abdominals each test at 4/5 strength. He is unable to perform a side sit-up on the right side. The paraspinals, quadratus lumborum, and hip external rotators are all tender to palpation, especially on the right; and you can palpate restriction of soft-tissue mobility in those tender areas. Questions for Analysis – in addition to providing your answer, you must provide a justification for every element that you include. (50 points) 1. What will be your initial treatment? a. Since the patient’s pain is mostly managed, and the patient does not hesitate to move, my initial treatment will deal with the soft-tissue restrictions on the right- side musculature. I would begin the process of releasing any trigger points, as well as begin scraping to remove some of the adhesions in those areas. By increasing the mobility of those structures, I’d hope to help improve some of the poor body biomechanics witnessed. 2. What precautions do you need to take with treating this injury in the current phase? a. Based on the information provided, the patient seems to be transitioning from the Acute phase to the sub-acute phase. We want to continue to avoid any motions that exacerbate pain, avoid flexion and rotation-based exercises, and making sure to keep the spine in neutral for all exercises. 3. What instructions would you give the patient when they are leaving for the day? Include information regarding activities of daily living and any home exercises/stretches they should be doing. a. I would instruct the patient to avoid flexion and rotation-based movements as much as possible. I would educate patient on proper body movement patterns and instruct them to use a lumbar roll when sitting, and I would help them establish comfortable positions for sitting and sleeping. I would also instruct the patient to avoid or minimize activities that aggravate his spine. In addition, I would discuss the positive mental mindset needed to go into any rehabilitation process.

4. Outline and describe the exercises you will use for this patient during the next 5 days of treatment. This should include a rehab chart/sheet that you could give to athlete for tracking as well as a separate section that provides the goals of the treatment for the week, justification for the inclusion of each element of your rehab program (including sets and reps with justification). Day : Goal : Exercise: Justification Modality : Justification: 1 Maintain reduction of pain Begin activation of transverse abdominis and spinal multifidi Ensure proper firing of surrounding musculature Reduction of soft tissue restrictions Moist Heat for 15 minutes Warm-Up: 10 minutes on stationary bike Trigger Point Myofascial Release in paraspinals/QL/ hip ERs Static Stretching: Hip flexors, hamstrings, quadriceps, QL, paraspinals Supine Transverse Abdominis Bracing: 5 sets of 45s contractions Quadruped Transverse Abdominis Bracing: 5 sets of 45s contractions Prone Glute Isometrics: 3 sets of 12 repetitions with 3s holds Prone Multifidi Isometrics: 3 sets of 12 reps with 3s hold By increasing the heart rate and warming the tissue, I can increase overall temperature in the muscle. Warm tissue helps increase the tissue extensibility potential, which we want to help gain motion back in the patient. Static stretching after warm-up and tissue mobilization takes advantage of the increased muscular extensibility. Since patient has decreased flexibility available, a static hold will help increase ROM and provide and emphasis on postural awareness and body alignment. TA bracing helps to ensure neuromuscular control. Sets and reps are designed for muscular endurance at the beginning. This is to help mimic the longevity of the use of the muscle. Glue isometrics are to help ensure proper glue firing and prevention of ‘dumb butt’. Again, sets and reps are set for muscular endurance to help mimic how long the muscles will be used in proper form. Pre-Exercise: moist heat for 15 minutes Find and release trigger points in paraspinals/QL/hip ERs Post-Exercise: Ice for 15-20 minutes Moist heat is preferred in this case because it can penetrate deeper into the muscle tissues. Trigger point release is a pain management technique and a way to increase ROM on the right side. Ice is a pain management technique. Will help to manage any pain created by exercise and decrease the potential for development of swelling.

Multifidi isometrics are to help achieve proper neuromuscular control. Sets and reps are for muscular endurance, and the 3s contraction at the end is to create metabolic stress on the muscle. This also helps build muscular endurance and strength. 2 Maintain reduction of pain Begin activation of transverse abdominis and spinal multifidi Ensure proper firing of surrounding musculature Moist Heat for 15 minutes Warm-Up: 10 minutes on stationary bike Static Stretching: Hip flexors, hamstrings, quadriceps, QL, paraspinals Supine Transverse Abdominis Bracing: 5 sets of 45s contractions Quadruped Transverse Abdominis Bracing: 5 sets of 45s contractions Prone Glute Isometrics: 3 sets of 12 repetitions w 3s hold Prone Multifidi Isometrics: 3 sets of 12 repetitions w a 3s hold By increasing the heart rate and warming the tissue, I can increase overall temperature in the muscle. Warm tissue helps increase the tissue extensibility potential, which we want to help gain motion back in the patient. Static stretching after warm-up and tissue mobilization takes advantage of the increased muscular extensibility. Since patient has decreased flexibility available, a static hold will help increase ROM and provide and emphasis on postural awareness and body alignment. TA bracing helps to ensure neuromuscular control. Sets and reps are designed for muscular endurance at the beginning. This is to help mimic the longevity of the use of the muscle. Glue isometrics are to help ensure proper glute firing and prevention of ‘dumb butt’. Again, sets and reps are set for muscular endurance to Pre-Exercise: moist heat for 15 minutes monitor trigger points Post-Exercise: Ice for 15-20 minutes Moist heat is preferred in this case because it can penetrate deeper into the muscle tissues. Ice is a pain management technique. Will help to manage any pain created by exercise and decrease the potential for development of swelling.

Bird-Dogs (alternating UE/LE): 1 of 12 repetitions (R/L arm/leg counts as 1) Ice help mimic how long the muscles will be used in proper form. The 3s contraction in the isometric is create metabolic stress on the muscle. This also helps build muscular endurance and strength. Multifidi isometrics are to help achieve proper neuromuscular control. Sets and reps are for muscular endurance, and the 3s contraction at the end is to create metabolic stress on the muscle. This also helps build muscular endurance and strength. Bird Dogs help assist with proper firing on the TA and develop extension-based strength. Having the patient maintain pelvic neutral also teaches proper biomechanics during shifting body movements. Sets and reps are designed for muscular endurance. 3 Maintain reduction of pain Begin activation of co-contraction transverse abdominis and spinal multifidi Ensure proper firing of surrounding musculature Reduction of Moist Heat for 15 minutes Warm-Up: 10 minutes walking Soft Tissue mobilization: scraping of any noted myofascial restrictions in affected area Static Stretching: Hip By increasing the heart rate and warming the tissue, I can increase overall temperature in the muscle. Warm tissue helps increase the tissue extensibility potential, which we want to help gain motion back in the patient. Static stretching after warm-up and tissue mobilization takes advantage of the increased muscular extensibility. Since Pre-Exercise: moist heat for 15 minutes Soft tissue mobilization using a scraping technique. Post-Exercise: Ice for 15-20 minutes Moist heat is preferred in this case because it can penetrate deeper into the muscle tissues. Scraping is a technique used to help decrease myofascial restrictions and can increase ROM on the right side. Ice is a pain management technique. Will help to manage any pain created by exercise and decrease the potential for development of swelling.

soft tissue restrictions flexors, hamstrings, quadriceps, QL, paraspinals Quadruped Transverse Abdominis Bracing: 5 sets of 45s contractions Prone Glute Isometrics: 3 sets of 12 repetitions with a 3s contraction Bird-Dogs (alternating UE/LE): 3 rounds of 12 repetitions (R/L arm/leg counts as 1) Supine Glute Bridges: 3 sets of 12 reps with a 3s hold Ice patient has decreased flexibility available, a static hold will help increase ROM and provide and emphasis on postural awareness and body alignment. TA bracing helps to ensure neuromuscular control. Sets and reps are designed for muscular endurance at the beginning. This is to help mimic the longevity of the use of the muscle. Glue isometrics are to help ensure proper glue firing and prevention of ‘dumb butt’. Again, sets and reps are set for muscular endurance to help mimic how long the muscles will be used in proper form. The 3s contraction in the isometric is create metabolic stress on the muscle. This also helps build muscular endurance and strength. Bird Dogs help assist with proper firing on the TA and develop extension-based strength. Having the patient maintain pelvic neutral also teaches proper biomechanics during shifting body movements. Sets and reps are designed for muscular endurance. Supine glute bridges are used a focus on glute, hip, core, and back neuromuscular control. It

helps assist with extension-based strength, and the sets and reps are set for muscular endurance. 4 Maintain reduction of pain Begin activation of co-contraction transverse abdominis and spinal multifidi Moist Heat: 15 minutes Warm-Up: 10 minutes stationary bike Static Stretching: Hip flexors, hamstrings, quadriceps, QL, paraspinals Quadruped Transverse Abdominis Bracing: 5 sets of 45s contractions Plank Holds: 3 sets of 30s hold Bird-Dogs (alternating UE/LE): 3 rounds of 12 repetitions (R/L arm/leg counts as 1) Supine Glute Bridges: 3 sets of 12 reps with a 3s hold Clam Shells: 3 sets of 12-15 reps By increasing the heart rate and warming the tissue, I can increase overall temperature in the muscle. Warm tissue helps increase the tissue extensibility potential, which we want to help gain motion back in the patient. Static stretching after warm-up and tissue mobilization takes advantage of the increased muscular extensibility. Since patient has decreased flexibility available, a static hold will help increase ROM and provide and emphasis on postural awareness and body alignment. TA bracing helps to ensure neuromuscular control. Sets and reps are designed for muscular endurance at the beginning. This is to help mimic the longevity of the use of the muscle. Plank holds help increase overall core stability. Sets and reps are set to help increase muscular endurance. Glue isometrics are to help ensure proper glue firing and prevention of ‘dumb butt’. Again, sets and reps are set for Moist heat is preferred in this case because it can penetrate deeper into the muscle tissues. Ice is a pain management technique. Will help to manage any pain created by exercise and decrease the potential for development of swelling.

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