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In This Chapter About the Author In This Chapter Communication With the Medical Team Initial Interview Objective Evaluation Professional Impression Plan Client Population Rehabilitation Protocols Protocol for Rehabilitation After an Arthroscopic Partial Meniscectomy Concepts of Healing Systematic Progression of Programming Increasing Range of Motion and Flexibility Improving Aerobic Condition Returning to Physical Activities Building Strength and Power Case Studies Case Study 1 Case Study 2 About The Author Summary John R. Martínez, P.T., M.P.T., is the owner and president of Executive Operations Management, L.L.C., a medical consulting firm, and Physical Therapy Experts, P.L.L.C., a private medical practice, both in New York City. He is a teacher of neurology, anatomy, and physiology to undergraduate students in Manhattan. Martinez received his Bachelor of Arts and teaching certification in 1988 from Swarthmore College and has taught elementary through graduate school students and a variety of topics in science, recreation, wellness, and exercise. In 1997, Martinez received his Bachelor of Science and Master of Physical Therapy degrees from the Philadelphia College of Pharmacy and Science. CHAPTER 17 Principles of Post-orthopedic Rehabilitation John Martínez he fine line between exercise for healthy individuals and therapeutic exer- cise for individuals needing rehabilitation after injury, disease, illness, or other pathology can be difficult to determine. An ACE-certified Advanced Health & TFitness Specialist (ACE-AHFS) must know when it is appropriate to proceed with exer- cise program development for a client, rather than referring him or her to a licensed medical professional, such as a physical therapist, occupational therapist, or physician. Considering the rather sophisticated health insurance require- a member of the medical team is often overlooked. However, ments and restrictions, as well as their increasing costs, clients the client’s understanding of his or her own body and its func- who need further attention from these medical profession- tions, as well as the fact that the client is in attendance at all als may have to rely on the ACE-AHFS for their continued the treatments with each of the medical professionals, makes rehabilitation. Thus, the principles of post-orthopedic reha- him or her a crucial source of information regarding health bilitation have changed over the past few decades, requiring history and healthcare needs. Obtaining as much information, fitness professionals to add a strong clinical component to both subjective and objective, as possible regarding the cli- their educational foundation. The ability to maintain current ent’s health will help establish a strong foundation for making knowledge of these medical principles and apply that knowl- exercise program development successful for the client. In edge successfully with the appropriate clients will be the key particular, obtaining information from the new medical team to an ACE-AHFS becoming an invaluable member of the members regarding the precautions and contraindications modern medical team. related to exercise is crucial, especially in orthopedic rehabilita- tion. Doing so will help protect the client from re-injury or any Communication With the regression of the medical condition, which could damage the ACE-AHFS’s relationship with not only the medical team, Medical Team but also the client and future referred clients. The concept of “protection” is an important one for the ACE-AHFS to t is impossible to overstate the importance of consistent understand. Often, immediately following an acute orthopedic communication with the medical team, which includes the injury or surgical intervention, the client is placed on a status Iphysician or physicians involved in the medical care of the of “maximal protection” (e.g., non-weightbearing after a hip client, the physical and/or occupational therapist, any other replacement). This type of information is crucial to protect the medical or integrative medicine professional treating the client client during a time when he or she is at high risk for re-injury (e.g., chiropractor, acupuncturist, nutritionist), and the client or worsening the medical condition. As the individual pro- him- or herself, who will have acquired a tremendous amount gresses, his or her status progresses to “moderate protection” of information from all of these sources. Including the client as (e.g., toe-touch weightbearing); to “minimal protection” (e.g., 422 Chapter Seventeen Principles of Post-orthopedic Rehabilitation weightbearing as tolerated); and, lastly, to “unre- soreness), injury, disease, or other type of pathol- stricted protection” (e.g., full weightbearing as risk ogy. It will also lead to a discussion regarding what decreases with physical recovery, both anatomically type of activities or circumstances exacerbate and physiologically). A clear understanding of the the pain or discomfort versus ones that provide concept of protection and how it relates to the relief. This type of exchange will provide valuable performance of activities that are contraindicated information on what exercises can be tolerated (higher risk) and to activities that are precautions by the client. During post-orthopedic rehabilita- (lower risk) is mandatory for the ACE-AHFS. tion, respecting pain is important and protecting The request for this specific information, along clients from further injury or exacerbation of their with the collection of the client’s general medical signs and symptoms must be a primary goal. Of history, will help to build the trust and confidence course, upon exacerbation of pain or other signs necessary from the entire medical team that will and symptoms, immediate adjustments are neces- support the ACE-AHFS’s work. sary, and communication with the medical team is mandatory to formulate a plan for continued safe Initial Interview participation in an exercise program. cquiring accurate information from any Objective Evaluation new client during the first meeting is Acritical to establishing a reliable history of ost-orthopedic rehabilitation clients the client’s health. Clients can be a valuable source will often come to the ACE-AHFS just of personal health information, but since their Pshort of returning to their pre-injury reports often come from their untrained medical health status. Given a limited amount of sessions perspective, this information can have a variety with the rehabilitation team due to health insur- of inaccuracies. Discerning which pieces of infor- ance and cost restrictions, clients will often be mation are more or less useful requires focused discharged from these medical services with the listening along with targeted questioning from functional ability to return to their activities of the ACE-AHFS. Bringing a skillful investigatory daily living (ADL), but not to their normal level technique and style to an initial interview is crucial of activity. It is therefore important to measure a to the success of exercise program development client’s physical abilities before initiating a train- for the post-orthopedic rehabilitation client. This ing program to establish a baseline of objective process will provide the ACE-AHFS with the physical capabilities that can be referred to as the health information necessary to make informed client progresses. It is also necessary to continue to decisions on the frequency, intensity, type, and document the client’s progress overall in the tran- duration of exercise that is best for the client. This sition from one medical team member to another. is particularly true if the client must discontinue Documenting the role of the ACE-AHFS in the his or her medical treatment but wants to con- overall picture of a client’s health recovery is an tinue the recovery from injury, disease, or illness important component of the fitness professional’s with an ACE-AHFS. To further aid in bridging responsibilities as a member of the medical team. the gap between the clinical and fitness settings, The ACE-AHFS’s assessment of the client’s the ACE-AHFS should also consult with the cli- physical condition must be objective and some- ent’s rehabilitation specialist as described in the what comparable to the discharge assessment of previous section. the rehabilitation medical professionals. Acquiring Questioning a client regarding his or her level an understanding of the rehabilitation special- of pain or discomfort during this initial interview ist’s measuring and assessment approaches will is also extremely important when developing safe provide the ACE-AHFS with a solid foundation exercise programming. A client’s description of his from which to build his or her own unique evalu- or her pain will help the ACE-AHFS decipher if ation. Performing careful measurements from it is due to normal physical stress (such as muscle objective fitness testing techniques and activities ACE ADVANCED HEALTH & FITNESS SPECIALIST MANUAL Principles of Post-orthopedic Rehabilitation Chapter Seventeen 423423 will greatly benefit the client and the rest of the Sample Assessment Summary medical team by providing a consistent method The client is a 5'7"(1.7 m) 63-year-old for reviewing the client’s progress over time and female weighing 110 lb (50 kg) with a diag- from one professional to another. Allowing the nosis of osteoporosis. She has had back pain client’s subjective and objective goals to guide the for the past 3 years. She comes to the ACE- assessment will make the evaluation more efficient. AHFS after completion
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