Showing posts with label Shimpi. Show all posts
Showing posts with label Shimpi. Show all posts

Monday, 25 June 2018

The Path to Success - The Double OCD syndrome





Dedicated to my daughter Aabha, my nephew Yash and all my little friends and upcoming Physios who are the future of this great country.

“You are what you choose to be”, said Hogarth Hughes to the Iron Giant with a heart (From the movie Iron Giant). But is it really that simple. We always say how much life has been unfair to us all, how we so rightly deserved something but never got that reward. But is life so unfair to us at all? And if it is, what did we do to deserve something so bad???



Well, the problem is that we have been trained to crib about everything in life. We have seen our parents, families, friends, and neighbours, practically everyone around crib so much that we start believing in an unjust, unfair, miserable life. We believe that there are only selective people who have got the luck to be successful and we are the unsuccessful lot. Well, the truth is that success is not a physical domain. It is a state of the mind. Success is based on how well we can understand the Double OCD syndrome.

Most of us understand OCD syndrome as the Obsessive Compulsive Disorder Syndrome, which is a behavioural challenge of doing something repeatedly. It is generally taken in a negative term.
The Double OCD syndrome we are talking about is the Opportunity, Challenges, Determination, Option, Choice and Decision syndrome. This is not any medical condition. It is just how we look at life in its vivid ways.



We all feel that life never give us an opportunity. Well, the fact is that we are given abundance of opportunities, just that we did not realise them. I remember the story of a devotee trapped in floods who was waiting for God to rescue him. He refused to take help from a passing car who offered to help him. As the waters rose, a rescue boat came. He refused their help saying that God will save him. When the waters rose to drown him, a rescue helicopter came to take him. He refused saying God will save him and alas, he drowned. In heaven, he asked God why such an injustice was done on such a faithful devotee. God replied, child I had given you the opportunities by sending the car, the boat and the helicopter. I was fair and just to you. So is life really so complicated? We don’t fail because we don’t get the opportunities, we fail because we do not realise them. Successful people look at opportunities in every aspect. They look at every challenge as a means to perceive things in a new way. They are successful only because they look at everything with a different perspective. Thus success in always a state of mind which helps us realise the best solutions in the worst case scenario.




Challenges are a part of life. In fact, challenge is a stimulus for growth, a stimulus for inventions and innovations. But many of us are too safe in our cosy zone and thus we resist change. When I read the book ‘Who moved my cheese’ by Spencer Johnson, there was a beautiful realisation of the need to understand this change. Heraclitus had rightly said, “Change is the only constant of life”. Even a stream has to flow, gushing through rocks and pebbles to boulders to become a mighty river. A stagnant pond is also of no use for sustaining life within itself. Challenges help us understand the force, direction and magnitude of this change. Thus, by simple law of physics, challenge is a vector quantity and thus can always be used for gaining mechanical advantage, provided we can determine the direction to success.




There are many challenges that we encounter in life. Everybody’s childhood may be filled with challenges, from learning to earning. But understanding the way in which we can use these challenges helps us understand the way to achievement. My mother’s accident in my 11th standard introduced me not just to become self sufficient and self determined, but it also introduced me to the profession of Physiotherapy, which invariably became my stepping stone to success.




Once we have learned to change our perspective to the opportunities and give direction to the challenges, what we need is the determination to do it. Salman’s famous dialogue is the best example, ‘Ek baar jo maine commitment kar di toh mei apne aap ki bhi nahi sunta’ (Once I am committed to something, I don’t even listen to my own self). Determination is the key element to success cause if you are not determined; you may get short term benefits, but will lose on the long term gains. We had seen a wonderful video on 'The Compound Effect' by Darren Hardy. Whatever changes are to be brought about can never be seen unless you are determined with it. It can be as simple as losing your weight. If you workout for a month or two, there may be short term benefits. But to achieve those six packs, there’s always a compound effect of determination to do it, no matter what! There is no short cut to success and only the determined walk through the path to achieve their goals.




Life gives us options in every simple opportunity presented to us. In the earlier case, God had given many opportunities to the devotee. What he lacked was not just the understanding of the opportunities, but the lack of understanding the options and making a choice. We all understand the power of options in many physical dimensions of life, options while shopping, voting, attempting exams etc. But it is much difficult to understand the options in the factors of life. Although we interchange the words options and choice, choice is the action which we take on the situations called as options. We choose to act morally or immorally on the option of the moral decision, to react rationally or irrationally in a confounding situation. The choice that we make on the options of our life is called as our judgement. It is easy to pocket a wallet full of money that you find on the road. But to return it to its owner is a choice based on the options that you had. It is easy to be unfaithful to a person, but to love, cherish and care for that person forever is a choice that you take on the options that you have. This pair of options and choice is what makes us a human.





And finally, the judgemental call that you take is your decision. It is a virtue to act on a strong foundation and firm belief that should imminently lead to good, moral and noble character. Thus success is not only a mental factor, it is a spiritual factor as well. There may be someone who looks at robbery or murder as an opportunity to be successful, does an excellent planning to overcome the challenges and is determined to commit the crime. Only a noble character will realise the options to commit or not to commit the crime, to be an accomplice or not and will take a rational choice and a judgemental decision to act in good faith. Options, choice and decisions help us understand the consequences of the opportunities, challenges and determinations. They are the situations that make a twin brother a police officer and the other a criminal. What one saw as an opportunity to learn, a challenge to progress and determination to succeed with an option to choose the correct decision was perceived by the other as an opportunity to commit crime to overcome the challenge of poverty and the determination to become a master criminal with an option to choose the wrong decision. A person became a drunkard because his father was a drunkard. Another chooses to start an alcohol de-addiction centre because his father was a drunkard. Thus, it is a judgement in the same situation which makes us good or bad, loved or hated.



The path to success may seem difficult to us all. But preparing the mind to be willingly successful and the heart to be morally successful  is extremely important. Success can only be achieved when we understand the Double OCD syndrome and not only morale our thoughts, but also make our thoughts moral.



Dr. Apurv Shimpi

Sunday, 26 February 2017

Rehabilitation in Athletes Post ACL Reconstruction


ACL Rehabilitation from a Physios perspective
¢  Young patient/ Athlete
¢  Active lifestyle/ Activity level
¢  Future Participation expectations
¢  Traumatic injury mechanism
¢  General health and presence of co morbidities
¢  Functional Goal Setting: Athlete may need to attain functional independence in BADL’s and also in relation to work demands and rarely to attain the sports activities being played.
¢  But these functional goals will be constantly changing based on aging, lifestyle and general health.
¢  Important is to prepare the athlete for a long term, not just for the coming season.
¢  Nyland J, 2010

Indications for Arthroscopic Repair/ Reconstruction:
¢  Injured ligament (different healing capabilities)
¢  Location & size of lesion
¢  Degree of instability experienced by patient
¢  Other associated injury – meniscal tear, articular damage etc
¢  Patients desired level of function
¢  Risk of re-injury
¢  Prevention of future impairment


ACL Recon – Physiotherapists consideration
— Indication for ligament surgery – Failed conservative mgmt, early degenerative changes seen, pain/ loss of function.
— Type of ligament surgery:
     Intra articular, extra articular, combined procedures
— Grafts used:
     Autograft, allograft, synthetic, area of harvesting etc.
¢ Type of fixation in bone tunnel/ socket

Pre operative physiotherapy
¢  Patients with ACL deficiency should participate in preoperative physical therapy before ACL reconstruction to maximize dynamic knee-stabilizing potential
                        Keays SL et al, 2006
¢  Deficits in pre-operative quadriceps strength influence function 6 months after ACL reconstruction
                        David Logerstedt et al, 2013

Pre-Operative management & goals
¢  Oedema Control
¢  Minimize muscular atrophy
¢  Maintain ROM as much possible
¢  Protected ambulation
¢  Patient education

Pre-Operative Exercises
¢  Open and closed kinetic chain exercises,
¢  Dynamic quadriceps-hamstring co-activation
¢  Calf muscle strengthening
¢  Small arc plyometrics
¢  Single-leg balance activities
¢  Lower extremity stretching
¢  Neuro-muscular training
¢  Patient education

Surgical Context
¢  Less invasive surgery reduces acute care and increases rehabilitation timetable decisions.
¢  Nyland J et al, 2010
¢  Repair, instead of reconstruction, with lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet- rich plasma and stem cells has prompted reconsideration of primary ACL repair.
¢  ACL repair rather than reconstruction is more likely to preserve the native neuro-sensory system, entheses, and ACL footprints.
¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2017 Feb.

Post operative management & goals
¢  Restoration of joint stability & motion
¢  Pain free & stable weight bearing
¢  Sufficient post operative strength & endurance to meet functional demands
¢  Ability to return to pre injury activities
¢  ‘Injuries around the Knee’ Symposium: Sancheti Parag et al, Br J Sports Med, 2010
¢  Reduction of Kinesiophobia which common post ACL reconstruction.
¢  Shah RC, Sancheti PK. IJPR, 2017

Post operative management
Nyland J et al, 2010
Phase
Goal
Duration
1
Maximum protection phase
Early acute care
Re-establish independent activity of daily living function
Sensori-motor training bias
0–4 wk
2
Moderate protection phase
Progressive transition from “patient” to “athlete” role
Re-establish strength, power, and endurance
Blend resistance and neuromuscular training
5–26 wk
3
Minimum Protection phase
Sport-specific training
Neuromuscular training bias
27–36 wk
4
Return to Sports Phase
Return to play decision-making
1, highly controlled functional activities to individual tasks performed on the playing field with oversight by the clinician;
2, individual workouts with oversight by the coach and clinician;
3, workouts with two or three teammates with oversight by the coach and clinician;
4, return to unrestricted practice with full team;
5, release to competition.
37–52 wk

Maximum protection phase – weeks 0 – 4
            TREATMENT GOALS:
¢  Protect healing tissues and surgical wound care
¢  Prevent reflex inhibition of muscles with pain management
¢  Reduce joint effusion
¢  ROM 0 – 110°
¢  Active control of ROM
¢  Weight bearing 75% to tolerance (depends on specificity of tissue repaired)
¢  Early controlled weight bearing does not compromise knee joint stability and provides a better outcome in terms of VMO function
                        Tyler TF Clin Orthop Relat Res, 1998


Intervention
           
Early: Days 0 – 14
¢  Pain Management
¢  Gait training – crutches PWB
¢  Passive to active ROM (with range limiting braces if required)
¢  Using CPM for ROM does not offer any additional benefits
¢  Rosen MA Am J Sports Med, 1992
¢  Patellar mobilization
¢  Muscle setting exs. – Quads, hams, adductors at multiple angles
¢  Assisted SLR in supine (with brace when needed)
¢  Ankle pumps


Late: weeks 2 – 4
¢  Continue previous exs.
¢  Full weight bearing & closed chain exs for hip & knee muscles (with permission)
            (Not in meniscal injuries)
¢  Low resistance PRE in open chain activities
¢  Core stabilisation exs
¢  Aerobic conditioning – static cycles
¢  Side planks
¢  Optimal muscle lengthening (rectus femoris, TFL, Glutei, hip ext rotators, adductors, hamstrings)

Establishing the self confidence of the Athlete
¢  Functional exercises simulating the athlete’s role extremely important in the early phase.
¢  This helps in gaining an early neuromuscular control and functioning.
¢  More useful in re establishing patients self efficacy and confidence as movements closely resemble the athletes sports specific movements.
¢  May also be useful in reducing kinesiophobia post surgery.

BRACING
¢  Using a functional brace or a neoprene sleeve post arthroscopic repair helps in improving joint position sense in early rehab phase.
                        Beynnon BD, J Orthop Sports Phys Ther, 2002
                                Brandson S et al Scand J Med Sci Sports, 2001
¢  More useful for patients with innate ligamentous laxity.
¢  Useful in increasing patients’ confidence and lowering the kinesiophobia.
             

Moderate protection phase weeks 5 – 26
TREATMENT GOALS:
¢  Full pain free ROM
¢  Strength Gr. 5/5
¢  Dynamic joint (knee) control
¢  Improved kinesthetic awareness
¢  Normalise gait pattern & ADL function
¢  Home exercise program

Intervention
            Early – weeks 5 – 6:
¢  Multiple angle isometrics
¢  Advanced closed chain strengthening & PRE
¢  Stretching exs
¢  Endurance training
¢  Proprioceptive training – single leg, tilt board
¢  Stabilization exercise with elastic bands


Proprioceptive training and core strengthening
¢  Both form important aspects of phase 2 rehabilitation.
                            Lephart SM Am J Sports Med, 1997
¢  Lack of core strengthening and proprioceptive training post arthroscopic cruciate reconstruction have been found to be associated with reduced stability and performance in patients
                        Cinar-Medeni O, Am J Phys Med Rehabil, 2014


Intervention
            Late – weeks 7 – 10:
¢  Continue with previous exs
¢  Advance strengthening (PNF patterns)
¢  Endurance & flexibility training
¢  Advanced Proprioceptive training
¢  Walking/ jogging
¢  Initiate plyometrics training (with permission in athletes)


Virtual Reality Training
Non Immersive VRT can also be used as an effective mode of training for enhancement of balance and knee functions post ACL recon.
Wani S, Shah S, Sancheti PK, 2017 (Unpublished)

Minimum protection phase
 weeks 27 - 36:
TREATMENT GOALS:
¢  Increase strength, power & endurance
¢  Improve neuromuscular control, dynamic stability & balance
¢  Improve cardio pulmonary fitness

Joint stability achieved by Neuro-musculoskeletal system

Intervention
¢  Continue stretching program
¢  Advanced PRE. Initiate isokinetic training if desired.
¢  Advanced close chain exercises & plyometrics drills.
¢  Advanced Proprioceptive training.
¢  Progressive agility drills (fig of 8, specific drills)
¢  Progress running program



Sports specific training of a badminton player post ACL reconstruction Using a stability trainer, BOSU ball with dome up and with flat side up. Training with single ball, double balls and badminton racquet and shuttle cock. 

Return to Sports phase: 
6 months & beyond
TREATMENT GOALS:
¢  Increase strength, power & endurance
¢  Regain ability to function at highest desired level
¢  Maintenance program
¢  Reduce risk of re-injury

¢  Balance and Proprioception training for a sprint athlete

¢  Plyometrics training (Sports Specific)

¢  Sports specific training for a basket ball player using multi-planar motions and BOSU ball

Intervention
¢  Progress PRE & flexibility exercises
¢  Advanced agility drills
¢  Sports specific drills
¢  Need of protective bracing prior to return to sports.


Return to Sports Criteria
¢  Adequate restoration of operated limb strength, power, endurance and perceived function.
¢  Ability to perform 10 sec duration, maximal effort single leg hops on operated leg in multiple directions to overcome GRF.
¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2013
¢  Force plates can be used to understand the reduction in torque production and need for additional rehabilitation.
¢  Nyland J. J Electromyogr Kinesiol. 2011.
¢  Acceptable is till 90% of force production as compared to the normal limb.


Sports Maintenance Therapy
¢  Continue Neuro-muscular conditioning.
¢  Monitor single leg press capability.
¢  Nyland J, Neurophysiol. 2003
¢  Perform regular pre-season and in-season neuromuscular training with special focus on the landing techniques.
¢  Training of neuromuscular responsiveness and balancing of the hip and the ankle-foot in addition to the knee.
¢  Nyland J, Knee 2014

Current trends in rehabilitation
¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual
¢  Functional training programs – exercises similar to sports specific requirements of the individual athlete.
¢  Limited Use of CPM machines
¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling
¢  Functional Testing to assess joint stability
¢  Emphasis on Proprioceptive and Neuromuscular Training
¢  Patient Perceived joint stability most important criteria for Prognosis
¢  Time not a major factor in determining treatment progression
¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression.
¢  Less invasive surgery reduces acute care and accelerates rehab.
¢  Nyland J. OAJSM. 2010

Things to remember!
¢  No fixed Protocol for rehab
¢  Modify Exercises by regular client evaluation
¢  Task Specific and Functional Exercises more effective. Train not just the knee, but also the brain.
¢  Return to sports is a biological, psycho-behavioural and biomechanical readiness factor.
¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program.

References:
Available on request