les auteurs se concentrent sur le developpement des habiletes biomecaniques specifiques en fonction du sport pratique, un objectif trop souvent neglige. II est.
Dexter S. Nelson, MSc, CAT Dale J. Butterwick, MSc, CAT
Guidelines for Return to Activity After Injury A
SUMMARY Complete and effective rehabilitation is dependent on many factors and may be identified and measured by eight objectives. Use of these objectives should help to prevent many of the common errors in rehabilitation. Of these eight objectives, the authors concentrate on development of specific sports-related biomechanical skill patterns, an objective that is frequently neglected. Analysis of the specific demands of each sport for each athlete is required to tailor rehabilitation protocols as well as to provide a standard to determine when the athlete can return. Progressive sportsspecific activity will help to return the athlete safely to activity. (Can Fam Physician 1989; 35:1637-1638, 1655.) Key words: rehabilitation, sports medicine
RESUME Une readaptation complete et efficace implique de nombreux facteurs qu'on peut identifier et mesurer par huit objectifs. L'utilisation de ces objectifs devrait contribuer a prevenir les erreurs les plus courantes du processus de readaptation. De ces huit objectifs, les auteurs se concentrent sur le developpement des habiletes biomecaniques specifiques en fonction du sport pratique, un objectif trop souvent neglige. II est necessaire d'analyser les exigences specifiques de chaque sport et pour chaque athlete afin d'adapter les protocoles de readaptation et d'obtenir une uniformisation des criteres qui determineront quand l'athlete pourra securitairement revenir au jeu.
Mr. Nelson is a Certified Athletic Therapist and Chairman of the Department of Leisure Services and Physical Education at Mount Royal College in Calgary. Mr. Butterwick is a Certified Athletic Therapist, Head Athletic Therapist, and Senior Instructor in the Faculty of Physical Education, the University of Calgary. Requests for reprints to: Dexter Nelson, Department of Leisure Services and Physical Education, Mount Royal College, 4825 Richard Rd. S.W., Calgary, Alta. T3E 6K6 T HE PRINCIPLES and practices governing return to athletic activity following injury are many and, to some extent, varied. One may be confused as to the best method of determining whether an athlete has been progressively and completely rehabilitated. To understand what you are trying to accomplish, it is important to develop a series of objectives, CAN. FAM. PHYSICIAN Vol. 35: AUGUST 1989
to which all progress can be compared. The goals of rehabilitation can
best be described by the following objectives: * control of the inflammatory process; * control of pain; * restoration of joint range of motion and soft tissue extensibility; * improved muscular strength; * improved muscular endurance; * development of specific sports-related biomechanical skill patterns; * improved general cardiovascular endurance; and * maintenance programs.' Only when each of these goals has been attained can the athlete return to competition. Logical progression is important to provide consistency in success and to minimize the potential for re-injury.' 12 Occasionally, medical practitioners may err in advising athletes and therapists performing the reconditioning
process. The assumption that clinical success assures safe athletic performance is incorrect and may be the reason certain injuries have high rates of re-injury. Although the athlete may be considered to be completely rehabilitated if assessment is limited to a traditional clinical setting, one can give no assurance of restoration to expected levels of athletic
performance. There must be a means of "bridging the gap" between clinical evaluation and return to high-level athletic performance. Medical personnel must provide guidance on activity suitability during each phase of athletic rehabilitation, following the logical progression of the above objectives. Within the framework of these objectives of rehabilitation, one must understand the psyche of the athlete and the coach. While some athletes require encouragement, the majority 1637
require a firm hand to prevent premature return and exposure to injury. Roy and Irvin"1 cite common mistakes in rehabilitation as follows. 1. Rehabilitation is often focused on a single muscle group only. After evaluation of the athlete to find out which muscles are particularly weak, all muscles of the limb need to be exercised, concentrating on those that are weaker. However, the limitations imposed by the injury or surgery should be observed. 2. Rehabilitation is seldom continued until the injured limb is found to be equal or superior to the uninjured side. 3. Exercises for developing proprioception are often forgotten. 4. Postural defects and anatomical malalignment, as well as biomechanical imbalances, are frequently neglected when the rehabilitation program is developed. 5. Specific sports skills and the SAID principle (specific adaptation to imposed demands) are often not incorporated into the program. Exercises should be adapted to the specific needs of the athlete's particular position in a sport.11 One of the objectives that gives rise to the greatest neglect or misunderstanding is the development of specific sport-related biomechanical skill patterns. The development of these skill patterns will serve to give the athlete and coach ample opportunity to understand the athlete's new limitations, if any, as well as to psychologically prepare the athlete for return to full competition.
Development of Biomechanical Skill Patterns When the athlete and therapist recognize the absence of pain and a return to a full range of motion and bi-
lateral symmetry in strength and endurance, they typically assume that specific sports-related biomechanical skill patterns will be resumed normally when, in fact, the athlete's motor patterns must be retrained. It is naive to assume that the stresses involved with all-out competition may be resumed immediately without specifically retraining the previously injured structures. The progression of exercises must be tailored not only to 1638
the nature of the injury, but also to the type of surgery (if appropriate) and the specific nature of the sport. Rhea9 suggests a progression for knee rehabilitation that begins with walking, then progresses to jogging, running, hopping, and jumping. The next progression would be sport-specific activities performed first individually and then in a team or group.
Sport-Specific Activities [These activities are] a planned, progressively difficult sequence of exercises designed to meet the specific needs of each injured athlete and to return him or her to activity as soon as possible without risking
reinjury.7 There are two categories of sportspecific activities: 1) functional drills, progressing to 2) specific preparation. Functional drills precede and yet complement performance ability in a specific sport. For example, Rhea10 suggests the following for football: 1. a straight ahead run the length of the football field; 2. beginning to run in a circle (9 m in diameter) and decreasing the diameter to roughly 1 m; stopping, and then running the opposite direction, starting with a 1-m diameter and slowly enlarging to 9 m; 3. repeat the above exercise, but in the reverse order of direction; 4. recovery walking; 5. perform crossovers: with each foot crossing an imaginary line through the middle of the body while walking in a straight line. Cross over to the extent comfort allows; progress to high knee action; and 6. slow jogging in an S pattern in 4- to 9-m increments, increasing in speed as symptoms allow and progressing to a Z pattern. The athlete should place equal stress on both knees. 10 These exercises are one example of the start of a progressive sport-specific activity. Once these functional drills are completed, more specific preparation must begin. Reintegration to a competitive practice situation should be limited initially to walk-through drills, leading to halfspeed drills, and then full-speed drills. The specialist, physician, therapist,
coach, parent, and athlete must work as a team by communicating effectively and co-ordinating their efforts in order to facilitate a rapid, safe return to competition.
Developing Activities Sport-specific activities must be created or modified for suitability to the specific sport to which an athlete may be returning. The following guidelines apply to this process. * Analyze inherent stress of the sport on the involved body part. * Identify tasks reflecting stress. * From these tasks, create a continuum of progressively increasing stress. * Rehabilitation must continue while the athlete progresses through the continuum of sport-specific activities. The nature of sport-specific activities generally may be divided into two categories. 1. One group of exercises reflects the offensive versus defensive nature of most sports. One would begin with slow speeds, progressing to faster speeds. With this in mind, begin with practising simple offensive skills, leading to offensive skills with a dummy defender, then performing as a dummy defender, and finally acting in a live offensive, then defensive, situation. 2. The second group of exercises is position-specific. One would start with individual fundamental skills, followed by practising skills in a team context, first slowly and then progressing to full speed. If contact is part of the sport, it should be one of the final components added. Begin with half-speed and bag hitting (as in football) and progress to full-speed bag hitting, then half-speed live contact; progress to full-speed live contact.
Conclusion Safe return to athletic activity is facilitated by the gradual and progressive re-introduction to sport. Development of specific biomechanical skills patterns related to the sport is attempted after the patient is clinically rehabilitated, followed by a maintenance and cardiovascular training program. This mental and physical re-education fulfills the objectives of rehabilitation and allows re-entry to U competition. Continued on page 1655 CAN. FAM. PHYSICIAN Vol. 35: AUGUST 1989
and sports physical therapy. Toronto: rehabilitation. Englewood Cliffs, NJ: C.V. Mosby Co., 1985:181-98. Prentice-Hall, Inc., 1983:113-22. 6. Kegerreis S. The construction and im- 12. Torg JS, Vegso JJ, Torg E. References plementation of functional progressions as Rehabilitation of athletic injuries: an atlas 1. Saal JA. General principles and guide- a component of athletic rehabilitation. J of therapeutic exercise. Chicago: Year lines for rehabilitation of the injured ath- Orthop Sports Phys Ther 1983; 5(1):14-9. Book Medical Publishers, Inc., 1987:1-8. lete. Phys Med Rehabil, 1987; 7. Kegerreis S, Malone T, McCarroll J. 1(4):523-36. Functional progressions: an aid to athletic For Further Reading 2. Arnheim DD. Modern principles of rehabilitation. Physician Sports Med 1984; 1. Arvidsson I, Eriksson E, Pitman M. athletic training. 6th ed. Toronto: Times 12(12):67-71. Mirror/Mosby College Publishing, 8. Markey KL. Exercise therapy for the Neuromuscular basis of rehabilitation: techniques of evaluation. In: 1985:369-88. knee. In: Hunter LY, Funk FJ Jr, eds. muscle Hunter LY, Funk FJ Jr, eds. 3. Bergfeld JA, Anderson TE. Achieving Rehabilitation of the injured knee. Toron- Rehabilitation of the injured knee. ToronC.V. to: Mosby Co., 1984:336-72. mobility, strength, and function of the into: C.V. Mosby Co., 1984:210-34. jured knee. In: Hunter LY, Funk FJ Jr, 9. Rhea J. Organizing knee rehabilitation eds. Rehabilitation of the injured knee. program: general guidelines. In: Hunter 2. Dillingham MF. Strength training. Toronto: C.V. Mosby Co., 1984:288-97. LY, Funk FJ Jr, eds. Rehabilitation of the Phys Med Rehabil, 1987; 1(4):555-68. injured knee. Toronto: C.V. Mosby Co., 3. Saal JS. Aerobic and anaerobic train4. Dalzell M-A. The physiotherapist's aring in the injured athlete. Phys Med mamentarium. In: Welsh PR, Shephard 1984:373-82. RJ, eds. Current therapy in sports 10. Rhea J. Functional rehabilitation for Rehabil, 1987; 1(4):569-82. medicine. Toronto: C.V. Mosby Co., specific sports. In: Hunter LY, Funk FJ 4. Wilmore JH, Costill DL. Training for 1985:279-81. Jr, eds. Rehabilitation of the injured knee. sport and activity: the physiological basis 5. Gould JA, Davies GJ. Orthopaedic Toronto: C.V. Mosby Co., 1984:383-9. of the conditioning process. 3rd ed. Dubuand sports rehabilitation concepts. In: 11. Roy S, Irvin R. Sports medicine: pre- que, IA: Wm. C. Brown Publishers, Gould JA, Davies GJ, eds: Orthopaedic vention, evaluation, management, and 1988:195-213.
Continued from page 1638
INDICATIONS AND CUNICAL USES: PONSTAN (mefenamic acid) is indicated for the relief of pain of moderate severity in conditions such as muscular aches and pains, dysmenorrhea, headaches and dental pain. CONTRAINDICATIONS: PONSTAN (mefenamic acid) should not be used in patients who have previously exhibited NSTAN hypersentivity to it. Mefenamic acid is contraindicated in patients with active ulceration or chronic inflammation of the upper or lower gastrointestinal tract. Ponstan , XLE .E should not be administered to patients who have previously experienced diarrhea as a result of taking the drug. Mefenamic acid should be avoided in patients with (Mefenamic Acid) Capsules In patients with a history of ulceration or chronic inflammation of the upper or lower gastrointestinal tract, PONSTAN (mefenamic THERAPEUTIC CLASSIFICATION pre-existing renaldisease. URNINGS: and only after consulting the Adverse Reactions Section. Certain patients who develop diarrhea may be unable to tolerate acid) should be given under close supervision the drug because of recurrence of the symptoms on subsequent exposure. In these subjects, the drug should be promptly discontinued. PRECAUTIONS: If rash occurs, Analgesic the drug should be promptly discontinued. A false-positive reaction for urinary bile, using the diazo tablet test, may result after mefenamic acid administration. If biliuria is suspected, other diagnostic procedures, such as the Harrison spot test, should be performed. In chronic animal toxicity studies PONSTAN (mefenamic acid) at 7 to 28 times the recommended human dose, caused minor microscopic renal papillary necrosis in rats, edema and blunting of the renal papilla in dogs, and renal papillary edema in monkeys. In normal human volunteers, BUN levels were slightly elevated following the prolonged administration of mefenamic acid at greaterthan therapeutic doses. Since mefenamic acid is eliminated primarily through the kidneys, it should not be administered to patients with significantly impaired renal function. As with other non steroidal antiinflammatory drugs, borderline elevations of liver function tests may occur. Meaningful (3 times the upper limit of normal) elevations of SGPT or SGOT occurred in controlled clinical trials in less than 1% of patients. Severe hepatic reactions including jaundice and cases of fatal hepatitis, have been reported with other nonsteroidal antiinflammatory drugs. Although such reactions are rare, if abnormal liver tests persist orworsen, if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (eg. eosinophilia, rash, etc.), mefenamic acid should be discontinued. Mefenamic acid may prolong acetylsalicylic acid induced gastrointestinal bleeding. However, mefenamic acid itself appears to be less liable than acetylsalicylic acid to cause gastrointestinal bleeding. Mefenamic acid 500 mg and acetylsalicylic acid 650 mg four times a day both caused significant further lowering of the prothrombin concentration (mefenamic acid 3.48% and acetylsalicylic acid 2.75%) in patients in whom the concentration had been initially lowered by anticoagulant therapy. Caution, therefore, should be exercised in administering mefenamic acid to patients on anticoagulant therapy and should not be given when prothrombin concentrations is in the range of 10 to 20% normal. Careful monitoring of blood coagulation factors is recommended. It is recommended that estimations of hemoglobin and blood counts be carried out at regular intervals. Mefenamic acid should be used with caution in known asthmatics. Us In prognancy and In women of childbering potental: The safety of mefenamic acid on reproductive capacity and pregnancy has not been established. Thus, mefenamic acid should be used in women of childbearing potential and during pregnancy only when the potenfial benefits are expected to outweigh the potential risks. Nursing mothers: Trace amounts of mefenamic acid may be present in breast milk and transmitted to the nursing infant: thus mefenamic acid should not be taken by the nursing mother because of the effects of this class of drugs on the infant cardiovascular system. Use In children: Safety and effectiveness in children below the age of 14 have not been established. ADVERSE REACTIONS: The most frequently reported adverse reacfions associated with the use of PONSTAN (mefenamic acid) involve the gastrointestina tract. The following disturbances were reported in decreasing order of frequency: diarrhea (approximately 5% of patients), nausea with or without vomiting, other gastrointestinal symptoms and abdominal pain. The occurrence of the diarrhea is usually dose related. Other gastrointestinal reactions less frequently reported were anorexia, pyrosis, flatulence, and constipation. Gastrointestinal ulceration wifth orwithout hemorrhage has been reported. Hematopoietic: Cases of autoimmune hemolytic anemia have been associated with the continuous administration of Ponstan for 12 months or longer. Decreases in hematocrit have been noted in 2-5% of patients and primarily in those who have received prolonged therapy. Leukopenia, eosinophilia, thrombocytopenic purpura, agranulocytosis, pancytopenia and bone marrow hypoplasia have also been reported on occasion. Nervous System: Dizziness, drowsiness, blurred vision, insomnia, nervousness and headache have occurred. Integumentary: Urticaria, rash and facial edema have been reported. Renal: As with other nonsteriodal antiinflammatory agents, renal failure, including papillary necrosis, have been reported. In elderiy patients renal failure has occurred after taking mefenamic acid for 2-6 weeks. The renal damage may not be completely reversible. Hematuria and dysuria have also been reported with mefenamic acid. Other: Eye irritaton, ear pain, perspiration, mild hepatic toxicity and increased need for insulin in a diabetic have been reported. There have been rare reports of palpitation dyspnea and reversible loss of color vision. DRUG INTERACTION: Protein-bound Drugs. Because PONSTAN (mefenamic acid) is highly protein bound, it could be displaced from binding sites by, or it could displace from binding sites, other protein-bound drugs such as oral anticoagulants, hydantoins, salicylates, sulfonamide and sulfonylureas. Patients receiving mefenamic acid with any of these drugs should be observed for adverse effects. Anticoagulants and Thrombolytic Agents. Mefenamic acid enhances the hypoprothrombinemic effect of warfarin, therefore, concurrent administration of the drugs should be avoided whenever possible. Ifthe drugs must be used concurrently, prothrombintme should be determined frequently and anticoagulant dosage adjusted accordingly; the pafient should be observed for adverse effects. In addition, the ulcerogenic potential of mefenamic acid and the effect of the drug on platelet function may further contribute to the hazard of concomitant therapy with any anficoagulant or thrombolytic agent (eg. streptokinase). DOSAGE AND ADMINISTRATION: Administration is by the oral route, preferably with food. The recommended regimen in acute pain for adults and children over 14 years of age is 500 mg as an initial dose followed by 250 mg every 6 hours as needed, usually not to exceed one week. For the treatment of primary dysmenorrhea, the recommended dosage is 500 mg as an initial dose followed by 250 mg every 6 hours, starting with the onset of bleeding and associated symptoms. Clinical studies indicate that effective treatment-can be initiated with the start of menses and should not be necessary for more than 2 to 3 days. MAILABIUTY: PONSTAN (mefenamic acid) is available in No. 1 Coni-snap capsule with an ivory opaque body and an aqua blue opaque cap. Each available in bottles of 100 and 500. TEXT REFERENCES 1. Budoff PW. Use of mefenamic acid in the treatment of primary dysmenorrhea. JAMA 241 (25):2713-2716, June 22, 1979. 2. Smith RP, Powell JR. The objective evaluation of dysmenorrhea therapy. Am J Obstet Gynecol 137 (3):314-319, 1980. 3. Powell R, Smith R.P. Treatment of primary dysmenorrhea with an Reg T M Parke, Davis & Company antprostaglandin agent. (In) Symposium on "The Role of Prostaglandins in Menstrual Disorders, " Academy of Medicine Toronto, Ontario, June 20, 1980 pp 29-37. 4. Parke-Davis Canada Inc auth user Gabka J. Ponstan dental study. Berin. July9, 1974. 5. Walsh et al. Ponstan bioavailabilitytrial: granulated vs. non-granulated forms. Dept. for Pharmaceutical Research & Development Parke, Davis & Co., Pontypool, U.K., January 21, 1974. 6. Sword IP (issuer), Amos L. Jenner WN (contributors). Assessment of comparative PARKE-DAVIS A bioavailability of different formulations of Ponstan (mefenamic acid) after acute and chronic administration to human volunteers. Bioavailability study, Inveresk PARCa ParkeDues Canada Inc Scarsernuan Orrare Research Intemational, Scotland. March 28, 1975. SarW
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