It would be fair to state that at some point in an athlete’s career, one would experience dizziness or blurred vision during training when at a high intensity. During a maximum-lift back squat, the athlete utilizes ATP anaerobically as he exerts a large amount of force in a short period of time. Unfortunately, it is difficult to maintain a normal breathing pattern while executing this specific movement. 

During intense exertion, athletes can use the Valsalva maneuver to help stabilize the abdominal and thoracic cavities (McArdle, Katch, 2014). This action helps to enhance the action of the muscle and allow more control through the movement. Based on personal experiences, completing maximum-lift movements was extremely difficult when I would try to breathe normally during the concentric and eccentric portions of the exercise. However, there are possible consequences to this practice. When the Valsalva maneuver is applied, the inferior vena cava, which is a large vein that carries oxygen-depleted blood back to your heart from the lower body, collapses because of increased intrathoracic pressure (Cleveland Clinic, n.d.). When this happens, blood flow to the heart is reduced, blood pressure drops, and the brain’s blood supply diminishes. Post-strain, the athlete’s aortic pulse pressure rises rapidly and overshoots the resting value; feelings of dizziness or fainting is the subsequent reaction if the Valsalva maneuver is prolonged (McArdle, Katch, 2014).

Because the Valsalva method is typically used during short, intense bursts of energy, we can assume these exercises are anaerobic, meaning they don’t require oxygen to complete. When examining anaerobic threshold, it is easy to confuse with lactate threshold and onset of blood lactate accumulation (OBLA); however, OBLA is biochemically more precise. Svedahl and MacIntosh (2003) define each of these terms below:

-Onset of blood lactate accumulation: Onset of blood lactate accumulation is defined as the intensity of exercise at which blood lactate concentration reaches 4 mM during an incremental exercise test.

-Anaerobic threshold: An intensity of exercise, involving a large muscle mass, above which measurement of oxygen uptake cannot account for all of the required energy. Stated in other terms, this is the exercise intensity above which there is a net contribution of energy associated with lactate accumulation.

Though similar, the anaerobic threshold indicates an increased reliance on anaerobic processes where OBLA occurs at a lower level of intensity (oxygen consumption) during more aerobic style exercises like bicycling and the arm-crank exercise (McArdle, Katch, 2014). With OBLA, the production of lactate exceeds the rate it can be broken down, where it accumulates from the muscle to the bloodstream; this indicates there is an imbalance between lactate production and lactate clearance within the muscle than the onset of anaerobic conditions (McArdle, Katch, 2014). We can look at anaerobic threshold as the point where the body shifts from aerobic to anaerobic metabolism. Furthermore, plasma changes in pH, bicarbonate, and H+ concentrations are factors in blood lactate accumulation where they relate to OBLA, but do not help establish the onset of anaerobic metabolism in muscle (McArdle, Katch, 2014). For this reason, OBLA is more biochemically precise. 

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References:

• Cleveland Clinic. (n.d.). Vena Cava. Cleveland Clinic. https://my.clevelandclinic.org/health/body/22619-vena-cava#:~:text=What%20is%20the%20vena%20cava,body%20(below%20your%20diaphragm). 

• McArdle, W. & Katch, F. V., (2014). Exercise physiology: Nutrition, energy, and human performance (8th ed.). Lippincott, Williams & Wilcott.

• Svedahl, K., & MacIntosh, B. R. (2003). Anaerobic threshold: the concept and methods of measurement. Canadian journal of applied physiology, 28(2), 299-323.

The Bruce protocol is a common treadmill test to assess aerobic capacity in normal individuals and cardiac patients (McArdle, Katch, 2014). For this specific test, the patient increases the speed or grade every three minutes. According to McArdle and Katch (2014), the Bruce protocol is most popular for assessing cardiovascular parameters during physician-monitored stress tests. By implementing treadmill tests such as this, the clinician can acquire VO2max values to acquire when oxygen consumption peaks or levels off as exercise intensity increases and the person has reached maximum aerobic metabolism. 

The Bruce Protocol is a valid and reliable test to use, and in fact, is probably preferred over other testing methods. During bicycle tests, subjects complained of intense local discomfort in the thigh muscles during intense activity, which limits their ability to continue with the test  (McArdle, Katch, 2014). But with continuous treadmill tests like the Bruce Protocol, McArdle and Katch (2014) have stated they rarely produce local discomfort and more so complained of fatigue. In terms of measuring maximal oxygen consumption, the Bruce Protocol is reliable as well. According to Will and Walter (1999), treadmill protocols produce a higher maximal oxygen consumption than bicycle ergometer protocols. However, it may be better to utilize a ramped up Bruce Protocol. Will and Walter state that in a general clinical setting, a ramped Bruce treadmill protocol “allows achievement of optimal test duration with higher degrees of workload and greater patient comfort during the test” (1999). The difference between a typical test and a ramped test was that each stage of the ramped test was 15 seconds with both speed, grade or both increasing in minimal amounts. 

To continue with this discussion, it is so important for men and women to maintain and/or increase muscle mass for the purpose of weight control. By gaining muscle, you are replacing fat-mass with lean muscle mass, which takes more energy (meaning more calories) to maintain. Individuals who have a healthy body-weight also have a better functioning diet-induced thermogenesis. Overweight individuals often have a blunted thermic response to eating that contributes to excess body fat accumulation (McArdle Katch, 2014). With the help of adequate protein intake and a hypocaloric diet, physical activity (particularly resistance training), helps to maintain muscle mass and physical function (Cava et al., 2017). With a combination of these factors, individuals are more likely to lose weight while maintaining lean muscle mass, which happens to decrease as we age.  

Resources:

Cava, E., Yeat, N. C., & Mittendorfer, B. (2017). Preserving healthy muscle during weight loss. Advances in nutrition, 8(3), 511-519.

McArdle, W. & Katch, F. V., (2014). Exercise physiology: Nutrition, energy, and human performance (8th ed.). Lippincott, Williams & Wilcott.

Will, P. M., & Walter, J. D. (1999). Exercise testing: improving performance with a ramped Bruce protocol. American heart journal, 138(6), 1033-1037. https://www-sciencedirect-com.logan.idm.oclc.org/science/article/pii/S0002870399700670

Though golf may not be the first sport that comes to mind when we think of building lactate tolerance, the high-performance golfer can surely benefit from increasing their tolerance to increase performance. Unlike with aerobic activity, lactate begins to accumulate with anaerobic activities that involve quick, powerful movements. Producing high blood lactate levels continues to increase with this sort of training, and decreases when training stops (McArdle, Katch, 2014). The energy required to hit a golf ball can be divided into the energy to swing the club and the athlete’s contribution to torque their body through the swing plane (Zoffer, 2022). Because the movement is brief, lasting about two seconds, the anaerobic system of ATP-PC is required. Incorporating exercises into a golfer’s fitness routine that utilizes this energy system will help mimic this reaction on this course. Examples include medicine ball slam or deadlift variations that last no more than 30 seconds with about two minutes of recovery time between sets; this method would properly build lactate tolerance and overall strength in these planes. 

Type II muscle fibers play a larger role in the process of increasing lactate tolerance for overall swing performance. This muscle fiber type possesses rapid contraction speed and high capacity for ATP production via glycolysis, and a well-developed anaerobic capacity will help increase lactate tolerance and further improve performance (McArdle, Katch, 2014). We can assume that a golfer may utilize a mix of Type IIa and IIx fibers, where IIa also possesses a high aerobic capacity. Developing a higher aerobic capacity is also important for the golfer; Type I muscle fibers are activated in between shots as they walk the course and the level of intensity output has decreased. It is important for the golfer to make sure not just calorie, but carbohydrate intake is considered while training and out on the course. According to Zoffer (2022), “slow-twitch fibers would be activated while walking the course, while fast-twitch fibers would be used during the golf swing and further establishes the need for carbohydrate supplementation during competition to refuel both slow-twitch and fast-twitch fibers since golf is played at submaximal levels for several hours.” 

For the athlete, incorporating explosive, powerful exercises with aerobic training efforts will not only help build lactate tolerance and increase swing strength, but will also allow the athlete to maintain these efforts for the entire round. 

Resources:

McArdle, W. & Katch, F. V., (2014). Exercise physiology: Nutrition, energy, and human performance (8th ed.). Lippincott, Williams & Wilcott.

Zoffer, M. (2022). Competitive Golf: How Longer Courses Are Changing Athletes and Their Approach to the Game. Nutrients, 14(9), 1732.

Despite being well-protected, the fragility of the brain can succumb to a concussion, whereupon a sudden jolt can cause the brain to hit the hard exterior of the skull. When this occurs, neurons stretch and tear, axons deteriorate, and then a release of toxins spreads throughout the rest of the brain (Robins, 2017). As this occurs, a patient can experience blurry vision, headaches, altered balance, and a shift in mood and behavior. 

The repercussions of a concussion can also lead to debilitating effects on an athlete’s performance, proprioception, and motor control. Long-term effects of a concussion, called Post-Concussion Syndrome (PCS), can mean learning difficulties and a wide array of additional symptoms that can possibly carry over to athletics. Proprioception is one of three values that make up the somatosensory system, and has a major impact on not just performance but maintaining composure and proper mechanics while in competition. The onset of a concussion means the central nervous system’s (CNS) is not firing properly, where mechanoreceptors send sensory information through polysynaptic pathways to the brain (Tierney et al., 2011). The sensory information provides feedback and feed forward for certain activities. Therefore, proprioception can be altered, where balance control and muscle coordination falter; this is likely due to the functional neurophysiologic changes in the cortex and brainstem’s reticular formation (Guskiewicz, 2011). 

The visual system provides valuable feedback in terms of the patient’s position in space, while the vestibular system provides feedback regarding the position of the head (Tierney et al., 2011). Both of these systems, along with somatosensory system, work together to help maintain balance and posture. The somatosensory system provides “the patient with feedback regarding the body’s position in space relative to other body parts” (Tierney et al, 2011, p. 275). Whether in a static or dynamic position, these systems help maintain an athlete’s center of gravity. The systems are also involved in sensory organization and muscle coordination; the sensory organization of determining corrective postural patterns is composed mainly of somatosensory feedback, while muscle coordination, which involves the sequencing of muscles during select activities, stems from the interaction between all three (Guskiewicz, 2011). A concussion can negatively impact one or all of these feedback systems, making movements and coordinated efforts once expertly executed much harder to replicate post-injury. 

Identifying a concussion early on is of utmost importance to prevent the long-term side effects that can lead to dementia and or Chronic Traumatic Encephalopathy (Robins, 2017). After conducting tests like the Balance Error Scoring System (BESS), the clinician should establish a progressive protocol for the athlete to follow. This includes moving from controlled to uncontrolled situations, providing external feedback to exercises at the beginning of treatment, moving from stable to unstable surfaces, and including more dynamic movements. 

References:

Guskiewicz, K. M. (2011). Balance assessment in the management of sport-related concussion. Clinics in sports medicine, 30(1), 89-102.

Robins, C. (July 2017). What happens when you have a concussion? TED Ed. [You Tube Video] [6:15].https://www.youtube.com/watch?v=xvjK-4NXRsM&t=354s.

Tierney, R.T., Driban, J. B., & Scifers, J. R. (2011). Proprioception. In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. (pp. 273-288). F. A. Davis Company.

Aerobic conditioning, especially for collegiate athletes, is just as important to incorporate into a rehabilitation protocol as strength, range of motion, and stretching techniques. Aerobic conditioning comes in many forms, but it essentially involves the conditioning and combined effort of the heart, lungs, blood vessels, and blood to remove deoxygenated blood from the venous system and replace it with oxygen through the arterial system (Higgins, 2011). To perform optimally in an activity that requires the use of the oxidative system, aerobic conditioning is an important method to incorporate into training protocols to utilize oxygen and remove waste most efficiently.

For this patient, aerobic conditioning can offset the decrease in VO2max seen after an ACL injury and reconstruction; a decrease in VO2max can be detrimental to performance as it plays an important factor in overall endurance. According to Almeida et al. (2018, p.6), “cardiac output is reduced after knee surgery in soccer players.” We can apply this knowledge to a hockey player who utilizes the same energy systems in similar ways. Cardiac output is determined by stroke volume and heart rate. It is found that if athletes are aerobically deconditioned and have a reduction in muscle power and strength, this can have a negative impact on pulmonary functions where skeletal muscle O2 extraction is lower (Almeida et al., 2018). Therefore cardiac output suffers because we have a lower stroke volume and less oxygen being transported to the working muscles. From there, VO2max will not be as high as previously recorded before reconstruction. 

For this particular patient, I would recommend traditional aerobic training to get him back into competitive aerobic shape. Not only does traditional aerobic interval training influence positive physiological changes, but there is also a positive impact on performance. Stone and Kilding (2009) found that not only are there significant increases in VO2max from traditional training, but lactate threshold and running economy improved as well. These findings correlated with improvements in overall soccer performance. As we know, VO2max is the most widely accepted method for measuring cardio fitness, and the oxidative improvements have been shown to carry over into performance parameters as well (Higgins, 2011). I would recommend traditional aerobic training over classic team or sport-specific conditioning. We can assume that at the collegiate level, this player is highly skilled and that there is a greater emphasis on building aerobic capacity than building off of their functional skills through specific movement aerobic protocols. For there to be an improvement in aerobic functionality, high-intensity would need to be achieved; Stone and and Kilding (2009, p.629) observed that “athletes with already high aerobic capacity, and with a good skill level, the aerobic energy system would not be fully stimulated under these training conditions” when discussing sport-specific training. Additionally, the patient likely has limited lower body range of motion, so utilizing the treadmill, stationary bike, or elliptical at a moderate-duration high-intensity would be a great place to start. This method has been shown to increase VO2max in athletes (Higgins, 2011).  

References:

Almeida, A. M. D., Santos Silva, P. R., Pedrinelli, A., & Hernandez, A. J. (2018). Aerobic fitness in professional soccer players after anterior cruciate ligament reconstruction. PLOS One, 13(3), e0194432

Higgins, M. (2011). Aerobic Conditioning. Therapeutic exercise: From theory to practice. F. A. Davis Company

Stone, N.M., Kilding, A.E.  (2009). Aerobic Conditioning for Team Sport Athletes. Sports Med 39, (615–642). https://doi.org/10.2165/00007256-200939080-00002

The high-speed movement I will be discussing is the golf swing. This dynamic movement requires multiple muscle groups that need to activate instantaneously, most notably during the downswing. Isokinetic training can be used as a great tool to develop the muscle activation needed for the movement, while ensuring power and power endurance are maintained. 

Peak torque is a term that would be applicable to the training and development of a golfer’s power and strength. Peak torque is the “maximum rotational force production for a single point in the single best repetition of the set” (Higgins, 2011, p.215). I think the clinician should evaluate the peak torque, average peak torque, and work fatigue when starting an isokinetic training protocol for a golfer. There is currently minimal research regarding not just isokinetic training for golfers, but protocols outside of general strength, isotonic, close-chained variables (Parker et al., 2017). But, isokinetic training is of great importance because according to Donatelli (n.d.), accommodating resistance (a fixed, preset speed with accommodating resistance throughout the range of motion) through open-kinetic chain isokinetic training serves to allow significant improvements in functional training. 

To properly train the golf swing through isokinetic training, I would implement standing rotational movements and loaded squats. A golf swing moves in the transverse plane, so testing for rotational power would be important. Testing lower body strength and power holds significance as well, due to the ground reaction force that occurs during the swing that assists with club head speed and velocity. Low reps would be recommended due to the fact that golfers perform one swing at a time with breaks in between. I think recognizing the concentric and eccentric ratios would be important, due to the swing path and the nature of counteracting muscles (specifically in the core). Recognizing ratios outside of simple peak torque measurements for agonist and antagonist groups would be beneficial because simple peak torque measurements have a “limited ability to characterize the entire torque variations inherent to the length-tension relationship” (Cozette et al., 2019, p. 1). The athlete should train at higher speeds to replicate that of a golf swing. I would set a minimum speed of 120/150 degrees/second, and go upwards to the 240/300 degrees/second range. 

References:

Cozette, M., Leprêtre, P. M., Doyle, C., & Weissland, T. (2019). Isokinetic Strength Ratios: Conventional Methods, Current Limits and Perspectives. Frontiers in physiology, 10, 567. https://doi.org/10.3389 /fphys.2019.00567.

Donatelli, R. (n.d.). Isokinetic Exercise. Sportsmed.com.  https://www.sportsmd.com/isokinetic-exercise/. 

Higgins, M. (2011). Isokinetics. Therapeutic exercise: From theory to practice. F. A. Davis Company.

Parker, J., Lagerhem, C., Hellström, J., & Olsson, M. C. (2017). Effects of nine weeks isokinetic training on power, golf kinematics, and driver performance in pre-elite golfers. BMC Sports Science, Medicine and Rehabilitation, 9(1), 1-12.

Plyometric training would be applicable and recommended for collegiate offensive linemen and female soccer players. Both roles require immense, explosive movements; a soccer player requires more long-term aerobic fitness than an offensive lineman, but both players need to exert force at a moment’s notice throughout different points in the game or match. Plyometric training applied to either athlete’s rehabilitation program would benefit their return-to-play efforts, as it is important that they can generate power that is required of them during competition. However, elements and considerations would differ between the two patients.

We can define plyometric training as “the use of counteractive movement to produce a strong powerful concentric action through the use of elastic properties of the tendons and muscles” (Higgins, 2011, p. 185). An offensive lineman goes from a stationary position to a powerful movement to block and counter an opposing player, while a soccer player is required to cut and move not just quickly but with intention; both of these examples initiate a proprioceptive response in the body where a neurological signal is sent from the muscle spindle to the spinal cord (Davies et al., 2015). 

When looking at both of these patients, the clinician needs to consider the gender differences and how plyometrics may be a valuable tool for recovery. Wang and Zhang (2016) found that even in situations where female soccer players are as well trained as their male counterparts, the rate of knee injury is higher in females and improvements following a jump training program were not as substantial. Furthermore, there are arguments whether differences in injury and performance rates are due to coaching and training as opposed to physiological and anatomical differences. However, due to the demands that soccer requires, female soccer players involved in plyometric training still achieve increases in VO2 max, maximal strength, sprinting speed, endurance, and agility (Wang, Zhang, 2016). The clinician should consider the current and previous injuries displayed by the female athlete and possibly spend more time in the preparatory phase to ensure proper strength and technique are exhibited before moving into the submaximal phase.

The weight of the lineman should be considered as well. Larger athletes should be closely monitored due to an increased risk of joint stress and injury, and therefore should only complete exercises appropriate for their size; this means refraining from performing plyometrics in the maximal stage (Higgins, 2011). Not all athletes are lumped into one category; factors such as strength, technique, speed, and kinesthetic sense are all considered when programming plyometrics and advancing them to more difficult movements (Higgins, 2011). 

Continuing our discussion of movement, linemen and soccer players will likely perform exercises unique to their sport. Linemen will move primarily in the sagittal plane, at least in terms of where most of their power will be directed. Soccer players need to be more versed moving in different planes; if a clinician were to implement exercises solely in the sagittal plane, the player will likely be underdeveloped in the frontal and transverse planes, leading to poor performance and possibly a greater chance of reinjury. The Specific Adaptation of Imposed Demands (SAID) would be relevant in this situation. Programming plyometrics should not only help develop power, but refine and improve the skills and demands required of their sport (Davies et al., 2015). Specific goals based on the sport and position of the athlete are required to appropriately increase force generation through certain motions, angular velocities, and metabolic demands (Davies et al., 2015).

References:

Davies, G., Riemann, B. L., & Manske, R. (2015). Current concepts of plyometric exercise. International journal of sports physical therapy, 10(6), 760–786.

Higgins, M. (2011). Therapeutic exercise: From theory to practice. F. A. Davis Company.

Wang, Y. C., & Zhang, N. (2016). Effects of plyometric training on soccer players. Experimental and therapeutic medicine, 12(2), 550-554.

The core encompasses 29 muscles that can be categorized as intersegmental muscles (motion sensors and spinal stabilizers) or multisegmental muscles (motion producers and spinal stabilizers) (Higgins, 2011). Core stabilization exercises are not all one in the same, and programming from one patient to another can vary significantly. Not only does the core need to exhibit strength, but neuromuscular control and passive strength as well (Akuthota et al., 2008). There are imbalances and weaknesses a clinician can look out for when deciding whether to prescribe core stabilization exercises or not.

Determining whether a core exercise program is necessary should include an evaluation of muscle groups that we may not always think about when focusing on core strength and stabilization. Someone with tight postural muscles could potentially have tight hip flexors and weak hip extensors, causing increased lumbar extension and therefore excessive force on the posterior spine (Akuthota et al., 2008). It is evident that those with lower back pain are unable to effectively recruit their core muscles; whether a patient works at a desk all day or is a high-performing athlete, lower back pain can be seen across the board and should be addressed appropriately. With a weak core, athletes are more susceptible to musculoskeletal and ligamentous injuries; according to Akuthota et al. (2008, p.43), “female athletes may be particularly susceptible to injury to the anterior ligament if core weakness is found.” Just because someone is physically fit, it doesn’t necessarily mean they have a strong core; we can see this in cases where powerlifters succumb to frequent back pain or the inability to do something as simple as balance on one leg. Great ways to assess core and lower-extremity strength and flexibility is to perform a functional movement screen (FMS), the Biering-Sorenson extensor endurance test, and/or a straight-leg test described by Ashmen and Kendall (Higgins, 2011). Other considerations include greater general flexibility where core strength could help with stability, those with a positive prone instability test, and the presence of irregular movement during spinal range of motion (Akuthota et al., 2008).

Though core stabilization exercises are quite effective at combating select deficiencies and easing lower back pain, there are cases where they shouldn’t be recommended. Heavy resistance training seen in some of the progressive stages of core stabilization programs can be unsafe, specifically for the lumbar extensors (Akuthota et al., 2008). Traditional sit-ups are very easy to execute incorrectly, where excessive compressive forces can initiate in the lumbar spine–I have always seen past clients and gym-goers performing sit-ups incorrectly where they are creating more harm than good. Lastly, functional full range of motion exercises aren’t recommended early in the day to avoid an increase in disk pressure (Higgins, 2011).

Overall, the clinician should advise a progressive program that starts with learning how to activate the abdominal wall structure, to then incorporating the “big 3” exercises (curl-ups, side planks, and bird dogs), to then improving balance and coordination in all three of the cardinal planes (Akuthota et al., 2008).

References:

Akuthota, V., Ferreiro, A., Moore, T., & Fredericson, M. (2008). Core stability exercise principles. Current sports medicine reports, 7(1), 39–44. https://doi.org/10.1097/01.CSMR.0000308663.13278.69.

Higgins, M. (2011). Core Stability. Therapeutic exercise: From theory to practice. F. A. Davis Company.

As a patient moves through the rehabilitation process, we ultimately want to regain strength, decrease pain, and increase range of motion post-injury or surgery. Clinicians can apply mobilization and manipulation techniques as a form of manual therapy. Chiropractic adjustments would be classified as a manipulation, which is applied at the end range of motion of the joint and is delivered with a small, quick thrust (Scifers, 2011). Mobilizations, on the other hand, are a passive and slower technique which allows for more control of joint motion (Scifers, 2011). It is important for the clinician to differentiate between the two and when it is necessary to use one technique over the other. 

Both of the aforementioned techniques are considered arthrokinematic, which entails involuntary distraction, compression, sliding, rolling, and spinning movements (Scifers, 2011). In fact, manipulation and mobilization techniques are effective treatment plans for neck pain. However, there has been growing concern over the safety of applying chiropractic adjustments. Ernst (2001) revealed in his study that despite the high degree of regularity of adverse side effects from spinal manipulation, there is a lack of research behind its safety. Though serious injuries stemming from spinal manipulation are rare, it is suggested (though not proven) that the likelihood of this happening would stem from the care of a physiotherapist and not a chiropractor (Ernst, 2001). It was suggested that mobilization techniques are recommended over spinal manipulation to decrease the likelihood of mild adverse effects from a spinal adjustment (Ernst, 2001).

Because mobilization does not employ thrusting maneuvers, there are very few incidences of serious complications despite its widespread use (Leaver et al., 2010). When examining neck manipulation in the study performed by Leaver et al. (2010), neck manipulation did not provide a more rapid recovery over mobilization, nor did it show better outcomes in pain or function. For the clinician to differentiate between the two and weigh the pros and cons with both, it appears one method is not superior over the other in terms of effectiveness, and mobilization tends to cause less adverse complications. Although mobilizations and manipulations have been used interchangeably, mobilizations are completed with applied pressure to a joint in a specific yet passive motion at the beginning, middle or end of the movement, while manipulations are delivered more abruptly at the end range of motion (Scifers, 2011).  

References:

Ernst, E. (2001). Prospective investigations into the safety of spinal manipulation. Journal of pain and symptom management, 21(3), 238-242.

Leaver, A. M., Maher, C. G., Herbert, R. D., Latimer, J., McAuley, J. H., Jull, G., & Refshauge, K. M. (2010). A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Archives of physical medicine and rehabilitation, 91(9), 1313-1318. 

Scifers, J. R. (2011). Joint mobilization. In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. (pp. 105-125). F. A. Davis Company.

When we discuss health and exercise modalities to implement into our fitness routine or physical therapy protocol, stretching is an important element that should not be ignored. When an individual experiences progressive shortening of tissue over time, called contracture, this can lead to ailments that can affect range of motion, performance, and joint biomechanics (Scifers, 2011). Fortunately, due to the extensibility of muscle and tendon tissue, limited flexibility can improve. For pediatric and geriatric patients, there are additional factors to consider, but some of the same principles apply when coordinating an effective stretch protocol. 

It is widely prescribed that dynamic stretching is recommended over static stretching before physical activity, but when it comes to an older population (65<), static muscle stretches totaling less than 45 seconds is a perfectly reasonable protocol that shouldn’t have a negative impact on strength, power, or speed type tasks (Stathokostas et al., 2012). Similar to the general population, PNF stretching seems to be the most effective measure in terms of improving flexibility outcomes, but according to the study done by Stathokostas et al. (2012), the duration of stretches, number of repetitions, and types of stretches is inconclusive, and is really based on a circumstances specific to the patient. In general, as with most patients, the clinician should start with static, passive stretches first before moving on to dynamic and/or PNF stretching (Scifers, 2011). 

For a geriatric patient, completing active stretches may not be as easy to complete compared to a young 20-something who plays sports. There is a greater chance they are less mobile, so the use of towels and bands would be helpful. One such example is if the patient is trying to complete a Thomas test, they can wrap a towel or strap around the posterior aspect of their leg in the event they don’t have the strength or range to reach with just their arms and hands. When considering strength and range of motion, dynamic stretching may not be applicable in a geriatric setting. Dynamic stretching involves actively moving a joint through its normal range of motion to slightly elongate the muscle and increase blood flow to the tissue (Scifers, 2011). Though dynamic stretching is preferred prior to initiating high muscular recruitment over static stretching, there is a sense of neuromuscular control that should be considered. If we look at a typical geriatric patient, they may not have the ability to perform dynamic stretches while maintaining balance and control. PNF techniques, though effective in treatment of neurological and musculoskeletal conditions, may be difficult for a geriatric patient to complete. If the patient lacks strength in certain areas, it would be important for the clinician to ease into certain exercises where isometric contractions are required during PNF movements. Lastly, another aspect to consider is the geriatric patients’ lifestyle; modern civilization has made it very easy for individuals to be sedentary, and on top of that, there are typically reduced, physical demands for those 65 and older (Studenski, n.d.). Therefore, the level of activity and duration needs to be reviewed. 

Stretching routines for pediatric patients can have its challenges as well. According to Koskinen (2021), there has been a  rapid decline in children’s flexibility over the past few years. Stretching isn’t exactly “fun”, and I know based on my personal experiences trying to get my eight-year old ballet dancer to stretch at home (parenting advice is welcome). To modify a pediatric patient’s stretching protocol, a clinician should consider a minimal number of stretches to do at home to make it feel less like homework. Koskinen (2021) continues to say in her article that there should be an “added element of fun”, such as counting in a different language, using ropes or bands, or adding pretend play. Also, the clinician should be very specific in their direction while guiding pediatric patients through the motions. They need to know that static stretches should be held for 30 to 60 seconds, emphasizing the need to count the seconds the stretch is held. Ultimately, with pediatric patients, clinicians should adapt a less rigid approach and implement a brief, yet effective stretching protocol with elements that would make the exercises more enjoyable. 

References:

Koskinen, D. (2021). Five ways to make stretching fun. www.moovkids.com.  https://www.moovkids.fi/2020/10/04/five-ways-to-make-stretching-fun/.

Scifers, J.R. (2011). In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. F. A. Davis Company.

Stathokostas, L., Little, R. M., Vandervoort, A. A., & Paterson, D. H. (2012). Flexibility training and functional ability in older adults: a systematic review. Journal of aging research, 2012, 306818, 1-30. https://doi.org/10.1155/2012/306818.

            Studenski, S. (n.d.). Current Geriatric Diagnosis & Treatment. Doctorlib.                                      https://doctorlib.info/geriatrics/diagnosis/42.html.

Though less common, medial ankle sprains involve eversion and abduction of the foot where the deltoid ligament, a medial ligament of the talocrural joint, is affected (Physiopedia, n.d.). For this patient, an acute ankle sprain means the injury happened within the week and an immune response is occurring. The clinician should take the time post-injury to observe the foot, ankle, and lower leg of the injured side (Kaminski et al., 2013). While the clinician addresses the tenderness of the injured ligament, the clinician should also assess the structural integrity as well (Kaminski et al., 2013). Based on the significant inflammation, limited range of motion, and pain in all directions, we can conclude the patient is in the inflammatory response of the healing process. Though we can’t be certain the grade of the ankle sprain, we can expect the patient to be in this phase for up to seven days.

It is during this stage that managing discomfort, minimizing swelling, and promoting optimal conditions for healing should be of most importance (Driban, Tiernery, 2011). Ultimately, we would want to protect the ankle using the P.R.I.C.E. method (protection, rest, ice, compression, and elevation). Means of protection include horseshoe taping or a functional ankle brace for Grade I and II sprains, or a removable immobilizer boot for some Grade II and Grade III sprains (Brown et al., 2011). To reduce effusion, elevating the ankle or base of the bed four the eight inches, while compression in the form of wraps sleeves and vasopneumatic pumps can help as well  (Brown et al., 2011). It has also been found that high-voltage pulsed current (HVPC) and nonsteroidal anti-inflammatory drugs (NSAIDs) to ease acute symptoms and improve short-term function (Kaminski et al., 2013).

Depending on where the patient is in the healing process, therapeutic exercise is an intervention that should be introduced as the patient heads into the subacute phase of rehabilitation. When compared to immobilization, functional treatment to restore range of motion, strength, and sensorimotor function has been shown to speed recovery (Kaminski et al., 2013). However, strength exercises should be saved for the repair/regeneration phase of healing to prevent while considering the patient’s signs and symptoms. Incorporating range of motion exercises in the acute and subacute phases of injury will surely help the patient regain strength and sensorimotor function later in their recovery. Dorsiflexion, plantar flexion, inversion, and eversion exercises using a wall, slant board, and towel are especially necessary for this patient who has limited range of motion in all directions. A couple of effective exercises are listed below:

-Dorsiflexion: The patient wraps a towel around the plantar aspect of the metatarsal heads, then pulls the ankle into dorsiflexion until pain is felt.

-Plantarflexion: The clinician wraps a towel around the dorsal aspect of the metatarsal heads, then gently pulls the ankle into plantarflexion. 

-Weight-bearing gastrocnemius/soleus stretch: With hands on a wall or table, the patient places the injured foot behind the non-injured foot. With toes pointed forward and heels down, the patient slowly leans forward. The patient can keep the leg straight to highlight the gastrocnemius, or keep it bent to highlight the soleus.

As the patient progresses in their treatment, the use of wobble boards (starting with non-weight bearing), strength, and proprioception exercises are recommended to further the success of their recovery to ultimately decrease the risk of re-injury and RTP in as close to a pre-injury state as possible. 

References:

• Brown, G.P., Skocypec, J., Faust, J. (2011). In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. F. A. Davis Company.  

• Driban, J. & Tiernery, R. (2011). In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. F. A. Davis Company.  

• Kaminski, T. W., Hertel, J., Amendola, N., Docherty, C. L., Dolan, M. G., Hopkins, J. T., Nussbaum, E., Poppie, W. & Richie, D. (2013). National Athletic Trainers' Association position statement: conservative management and prevention of ankle sprains in athletes. Journal of Athletic Training, 48(4), 528-545. doi: 10.4085/1062-6050-48.4.02.

• Physiopedia. (n.d.). Medial ankle ligament. https://www.physio-pedia.com/Medial_ankle_ligament.

The psychological response of an injured athlete involves many personal and situational factors that can ultimately determine how the athlete evaluates their recovery and how they behave. One athlete may simply enjoy the time off from athletics due to burnout, while another athlete who is the same gender, age, and plays the same sport may exhibit much more negative feelings, such as anxiety, stress, depression, and fear of reinjury. When it comes to determining what intervention techniques to use with an injured patient, one must evaluate each patient independently, because one intervention strategy for one patient may not work for another.

Injuries, for both the recreational or competitive athlete, is perceived as a negative life event, which can become a major source of stress (Covassin et al., 2015). When first determining how the clinician should intervene, it helps to first refer to stress and grief models before proceeding. The five-stage grief reaction response is formatted in these five stages: denial, anger, bargaining, depression, and acceptance (Wiese-Bjornstal et al., 1998). When using a stress model, the clinician considers the sports injury as a stressor that prompts cognitive appraisals, which then influence emotional response then behaviors (Wiese-Bjornstal et al., 1998). I think it would help the clinician to utilize these models, along with other factors.

I believe the gender and type of sport the athlete is involved in plays a role in the type of intervention technique used. For a male in a sport like football, wrestling, or boxing, it is possible they have been conditioned to consider injuries as just part of the game, and therefore find it normal to “give up” their bodies for the sake of the sport (Wiese-Bjornstal et al., 1998, p.62). The masculine identity that stems from this thought process would surely make it difficult for the athlete to be 100% transparent with how they are truly feeling in terms of pain level and emotional wellbeing. Cognitive restructuring and communication of feelings are techniques a clinician can use in this scenario. Speaking with a clinician, without the external pressure of coaches, parents, and/or teammates can allow the athlete space to discuss their fears and trepidations, while cognitive restructuring can help the athlete refocus on positive aspects of their situation (Lynch, 1988). 

Other factors to consider are the athlete’s age and the severity of the injury. A young, very competitive athlete who suffers from a severe injury is more likely to exhibit a more extreme response to their injury (Wiese-Bjornstal et al., 1998). A main area of concern is suicidal tendencies, and should be carefully considered when the athlete has undergone a medical procedure, was successful in their sport pre-injury, and failed to recover to pre-injury levels despite their adherence to their rehabilitation protocol (Wiese-Bjornstal et al., 1998). In this case, the clinician can implement effective communication techniques, motivation, and goal setting to help the athlete progress. The clinician should implement the 4Es of the Bayer education model to engage, emphasize, educate, and enlist (and to really focus on engaging and emphasizing to build trust with the athlete) (Covassin et al., 2015). Motivation and goal setting will also help give the athlete something they can strive for; in fact, goal setting was perceived to be among the top two psychological strategies in addressing negative responses (Covassin et al., 2015). In some cases, a sports therapist may need to be recruited depending on the severity of the situation. 

All in all, clinicians have many techniques they can use regarding mental and psychological care of an injured athlete. It is not unrealistic to consider that stress and bodily malfunctions are closely aligned, which can mean that negative feelings during the rehabilitation process can delay healing or perhaps could be less successful (Lynch, 1988). For the best outcome, the clinician should not only focus on rehabbing the injury but consider the negative repercussions that can stem from the athlete’s stress response to the injury itself. 

References:

• Covassin, T., Beidler, E., Ostrowski, J., & Wallace, J. (2015). Psychosocial Aspects of Rehabilitation in Sports. Clinics in Sports Medicine, 34(2), 199–212. https://doi.org/10.1016/j.csm.2014.12.004.

• Lynch, G. P. (1988). Athletic injuries and the practicing sport psychologist: Practical guidelines for assisting athletes. The Sport Psychologist, 2(2), 161-167.

• Wiese-Bjornstal, D. M., Smith, A. M., Shaffer, S. M., & Morrey, M. A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of applied sport psychology, 10(1), 46-69.

There are many explanations as to why a patient may not recover as fast as another athlete with the same injury. For the purposes of this discussion, we will look at fracture healing and management. With the three phases  of acute, repair/regeneration, and remodeling, variations in the healing process can occur.

The first goal of the healing process is to promote angiogenesis, which is the process in which new blood cells form. This can take up to 7 days, where the inflammation response forms a hematoma (Driban, Tiernery, 2011). To prevent further blood loss and initiate clots at the fracture site, platelets are required at this stage of the healing process to also prevent the site from becoming hypoxic (low levels of oxygen in tissue) and acidic (Driban, Tiernery, 2011). If a patient’s intake of Vitamin K is deficient, it could take longer to promote the callus development needed in the repair/regeneration phase. Vitamin K, which is required for normal blood coagulation, is found in plants and dark leafy vegetables like spinach broccoli, brussel sprouts, and kale (Vermeer, 2012). If a patient is not consuming enough of these foods, they could possibly be low in Vitamin K which can negatively affect the healing process of a fracture. 

During the repair/regeneration process, it is important to gradually restore range of motion. Though this shouldn’t start until a few weeks after the injury to provide time for callus to develop, you want the patient to work on mobilizing the site to prevent stiffness that could lead to less-than-optimal range of motion at the end of the healing process (Driban, Tiernery, 2011). If one patient works on mobilizing the site while the other does not, there could easily be differences in the range of motion between the two patients. 

As the patient moves through the remodeling phase of recovery, new bone is remodeled by osteoclasts and osteoblasts based on mechanical loading (Driban, Tiernery, 2011). It is important to restore muscle strength by initiating mechanical loading during this time, and if the patient neglects to incorporate appropriately designed resistance training into their routine, the strength they had previous to the injury will be negligible in comparison. Other factors to consider are the parathyroid hormone, vitamin D, and calcitonin that most affect bone metabolism (Kalfas, 2001). Calcitonin is secreted by the thyroid gland to regulate calcium levels while the parathyroid hormone increases calcium levels (Kalfas, 2001). Since osteoblasts produce new bone, and osteoblasts are the only bone cells that have parathyroid receptors, it is vital that these receptors are properly secreted. If a patient has an underactive thyroid, or other issues that can disrupt thyroid or parathyroid function, these properties can lead to an imbalance in the remodeling stage of fracture healing. 

Between proper nutrient intake, utilization of resistance and range of motion training, and a healthy thyroid and parathyroid function, a patient with the same injury as someone else could possibly not recover as quickly if one of these healing factors are not being recognized. All in all, it is important for the clinician and patient to follow their treatment goals to ensure the best possible recovery. 

Resources:

• Driban, J. & Tiernery, R. (2011).In M. Higgins (Ed.), Therapeutic exercise: From theory to practice. F. A. Davis Company.  

• Kalfas, I. H. (2001). Principles of bone healing, Neurosurgical Focus FOC, 10(4), 1-4.https://doi.org/ 10.3171/foc.2001.10.4.2.

• Vermeer, C. V. (2012). Vitamin K: the effect on health beyond coagulation–an overview. Food & nutrition research, 56(1), 5329.

There is much to consider when determining a return-to-play (RTP) timeline. Despite the fact that athletes from the same sport in the same position can endure the same injuries, the healing process and rehabilitation methods can vary significantly. The initial evaluation is an integral part of the process that will set the tone for the path to recovery, including many additional factors.

The Evaluation

As mentioned, the evaluation process provides the clinician with an enormous amount of details regarding the injury and the athlete. Past medical history provided during the evaluation process should be taken into account, especially since previous injury is associated with up to a 4-fold increase in the risk of reinjury (Creighton et al., 2010). The mechanism of the injury, including factors that aggravate and alleviate pain, should also be considered, as it helps the clinician know what activities to avoid during the acute stages of the recovery process (Scifers, 2011). Formulating a problem list based on the findings from the subjective and objective evaluations would provide a clear list of issues that should be addressed, which would also help determine treatment goals discussed between the clinician and athlete. These goals are important, as it helps direct development of treatment, provides milestones during the rehabilitation process, and encourages a team effort between the clinician and athlete (Scifers, 2011). Lastly, the type of sport and position of the athlete helps in the RTP decision-making; there could be a huge difference in the RTP timeline for a soccer player with a fractured wrist and a football player with an ACL tear. 

Deciding Factors

The desire of the athlete to RTP by a specific date is a tricky situation for a clinician to be in. After evaluating the health status and participation risk of the athlete, the desire to return is considered a decision modifier, along with season timing, external pressure from the coach and parents, and conflict of interest that could be due to financial reasons (Creighton et al., 2010). After following a Decision-Based RTP Model, the primary decision is left up to the clinician. However, there are certain situations where a player desires to RTP at an earlier date; examples would be to compete during playoffs or have the opportunity to try out for a college team. Missing both could lead to repercussions that could negatively affect the athlete’s future success. Overall, the health and safety of the athlete is far more important to consider when determining RTP; a more rational and logical analysis outweighs the pressure from the athlete, though the RTP date could be modified after all medical and sport risk factors are heavily considered. 

References:

1. Creighton, D. W., Shrier, I., Shultz, R., Meeuwisse, W. H., & Matheson, G. O. (2010). Return-to-play in sport: a decision-based model. Clinical Journal of Sport Medicine, 20(5), 379-385.

        2. Scifers, J. R. (2011). Introduction to designing a rehabilitation program. In M. Higgins                    (Ed.), Therapeutic exercise: From theory to practice. F. A. Davis Company.