adm

این مقاله که در Int J Sports Phys Ther . 2019 Dec;14(6):978-993 چاپ شده است ، به تاثیر انجام تمرینات درمانی در آب بعد از باز سازی ACL می پردازد.

The properties of water (buoyancy, density, hydrostatic pressure and viscosity) can be utilized to implement an aquatic rehabilitation program which if planned correctly may help optimize patient outcomes after ACLR

The six major applied benefits of aquatic therapy include

1. Reduction of pain and swelling and restoration of joint range of motion 2. Recovery of normal gait cycle 3. Maintenance and/ or development of cardiovascular (CV) fitness 4. Movement pattern/ coordination training 5. Early introduction of plyometric training 6. Between-session recovery and optimal load management

resolving impairments as early as possible after surgery is important to target early gait restoration.👌👌👇👇

the depth of immersion is important, If the water pressure is higher than diastolic blood pressure this will result in fluid shifts forcing fluid out of the joint and supporting optimized venous return and lymphatic system drainage (return). This could thus help with resolution of inflammation/ swelling, facilitate reduced swelling and positively influence (increase) joint range of motion. Immersion in water also desensitizes the injured area, as pain perception is diminished, due to an elevated pain threshold, which may be due to the stimulation of sensory nerve endings in the skin and sensory overflow

during the early stages of the functional recovery period after ACLR, walking gait should be first trained in the pool at various water depths (progressing from deeper to shallower), in order to enable the removal of a proportion of body weight to facilitate optimal gait patterns, as needed. Furthermore, walking in water can present a challenge to dynamic stability and support the retraining of dynamic movement control in a safe environment. The walking gait re-education program should include selective movement retraining exercises to support the motor re-training process (e.g. standing marches in place, with optimal lumbar pelvic control and hip, knee and ankle flexion).

یک نکته بسیار مهم برای ورزشکاران مثلا فوتبالیست ها که می خواهند بعد از یک مدت طولانی به زمین باز گردند حفظ توانایهای قلبی _ عروقی آنان می باشد.

Maintenance and/or development of cardiovascular fitness Preserving CV fitness parameters such as maximal aerobic capacity, lactate thresholds and running economy during the rehabilitation process is important for endurance and game sport athletes (e.g. football players) following long-term injuries such as ACLR.

اما باید شدیدا به عمق آب برای انجام هر کدام تمرینات دقت کامل داشت مثلا برای اساس این مطالعات

Koury and Miller et al. recommended performing aquatic plyometrics in waist height water. They suggest that deeper water may impair movement control and coordination, making it more difficult to maintain stability in an upright position, whilst also decreasing the stretch-shortening cycle reaction time, and increasing drag due to arm swing through the water

بنابر این فاز ریکاوری را در چهار خلاصه می کند

The use of hydrotherapy in the recovery process after ACLR Has 4 stages :

1) Post-op pool , 2-4 Weeks after surgery

2) Movement and CV conditioning ,Weeks 5-12 after surgery

3) High intensity pool and field preparation ,Weeks 13-18 after surgery

4) Recovery pool Weeks 19 + after surgery

در دنباله 😊😉 تمرینات در هر مرحله ، به صورت خلاصه ذکر خواهد شد.

🔴 Post-op pool

⭐️Typical duration:

Weeks 2-4 after surgery

⭐️ Entry criteria: -Medical clearance to commence hydrotherapy - Surgical wounds: no signs of inflammation (soreness, redness, increased temperature swelling) - Surgical wounds: stiches removed by medical staff: General goals for the phase: Support the resolution of swelling - Aid the recovery of ROM

⭐️ Pool exercises: -Walking, cycling, stretching, basic motor patterning (e.g., standing marching exercises) and gait re-training ⚡️⚡️⚡️⚡️⚡️⚡️⚡️ ⭐️ Activity outside the pool: Rehabilitation gym - Bed based isometric strengthening - ROM exercises, - Treatment modalities (TENS, electrical stimulation, ICE, ⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️

🔴🔴 Movement and CV conditioning

Typical duration: Weeks 5-12 after surgery ⚡️ ⭐️ Entry criteria: - Ready to transition to mid-stage rehabilitation: - Minimal pain (0-1 NPRS) - Minimal swelling (zero or trace effusion) - Knee extension to 0 º - Knee flexion > 120 º - Sufficiently normalized gait outside the water without aids (e.g., no crutches) - No evidence of quadriceps dysfunction (e.g., quadriceps lag test) General goals for the phase: -Restoration of basic motor patterning - Introduction and utilization of DWR for motor patterning and subsequent use for CV conditioning - Late recovery of flexibility - Continued fluidity exercises to support active range of motion - Progressive introduction of BL and then UL landing and jumping work to develop eccentric functional control (10 weeks + ) - Sport-specific neuroplasticity exercises (heading, catching, throwing... ⚡️ ⭐️ Pool exercises:

-First half (weeks 5-8)– DWR, squat, step up, standing balance and neuromuscular control exercises, functional strength exercises using additional modalities (e.g., standing press against rubber ring) - Second half (weeks 9-12): Introduction of landing and jumping exercises for neuromuscular control DWR for CV conditioning ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym First half (weeks 5-8) - Resistance training exercises using low-loads for muscle endurance training (12-20 RM range) - Off-feet core corrective training (e.g., transverse abdominus, bridges, clams, side leg raises etc.) - Basic motor control drills (BL squat, marching exercises, gait, walking on treadmill) - Off-feet CV conditioning (bike, cross-trainer) Second half (weeks 9-12) - Progression to land based functional exercises (single leg squat, hip hinge, step up, split squat) - Standing lumbopelvic strengthening exercises (standing clam, lateral band walks) - Moderate load resistance training for hypertrophy and strength development in open and closed kinetic chain exercises (8-12 RM range) - Running re-education with alter-G/ trampoline/ treadmill🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

🔴🔴🔴 High intensity pool and field preparation

Typical duration: Weeks 13-18 after surgery ⚡️ ⭐️ Entry criteria: - No pain/swelling - Symmetrical/full ROM - Knee flexor and extensor LSI > 80% - Good subjective movement quality on land-based foundation tasks (e.g., bilateral and unilateral squat, step up, lunge and hip hinge) - Ability to run on the treadmill at 8 km/h for 10 minutes with good mechanics General goals for the phase: -Restoration of basic motor patterning - Introduction and utilization of DWR for motor patterning and subsequent use for CV conditioning - Late recovery of flexibility - Continued fluidity exercises to support active range of motion - Progressive introduction of BL and then UL landing and jumping work to develop eccentric functional control (10 weeks + ) - Sport-specific neuroplasticity exercises (heading, catching, throwing ⚡️ ⭐️ Pool exercises: -Running for low-load conditioning - Plyometric training - Coordination drills for preparation for the field ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym / Movement environment - LB high load isolated strength training (3-6 RM) - LB functional strength training (8-12 RM) - Landing drills, jumping drills - Core strength/ stability (load transfer) - Bilateral plyometrics On-field / sand - Linear running (forward, lateral) - Jump and landing drills - Linear acceleration and deceleration - Multidirectional running drills (pre-planned) 🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

🔴🔴🔴🔴 Recovery pool

Typical duration: -Weeks 19 + after surgery ⚡️ ⭐️ Entry criteria: -Be undertaking return to sport training General goals for the phase: -Accelerate recovery between on-field and gym land based sessions - Allow for reduced loading training such as plyometric exercise and CV conditioning at lower body loads ⚡️ ⭐️ Pool exercises: -Deep water running - Plyometric exercises - Flexibility – dynamic and static stretching ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym / Movement environment - LB high load isolated strength training - LB functional strength training - Landing drills, jumping drills - Core strength/ stability (load transfer) - UB strength, core endurance and aerobic fitness on recovery days On-field - Multidirectional agility drills - Technical based sports re-training - Fitness training - Plyometric training 🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

☝️Unilateral plyometric exercise☝️ involving forward A, step off from step, B, landing followed by immediate jump and C, single leg stabilisation on box and lateral drop jumps (D, step off, E, landing and jumping transition and F, lateral landing on step)

☝️Bilateral jumping for power☝️ development with A, countermovement phase, B, flight phase and C, landing phase🔴 Post-op pool

⭐️Typical duration:

Weeks 2-4 after surgery

⭐️ Entry criteria: -Medical clearance to commence hydrotherapy - Surgical wounds: no signs of inflammation (soreness, redness, increased temperature swelling) - Surgical wounds: stiches removed by medical staff: General goals for the phase: Support the resolution of swelling - Aid the recovery of ROM

⭐️ Pool exercises: -Walking, cycling, stretching, basic motor patterning (e.g., standing marching exercises) and gait re-training ⚡️⚡️⚡️⚡️⚡️⚡️⚡️ ⭐️ Activity outside the pool: Rehabilitation gym - Bed based isometric strengthening - ROM exercises, - Treatment modalities (TENS, electrical stimulation, ICE, ⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️

🔴🔴 Movement and CV conditioning

Typical duration: Weeks 5-12 after surgery ⚡️ ⭐️ Entry criteria: - Ready to transition to mid-stage rehabilitation: - Minimal pain (0-1 NPRS) - Minimal swelling (zero or trace effusion) - Knee extension to 0 º - Knee flexion > 120 º - Sufficiently normalized gait outside the water without aids (e.g., no crutches) - No evidence of quadriceps dysfunction (e.g., quadriceps lag test) General goals for the phase: -Restoration of basic motor patterning - Introduction and utilization of DWR for motor patterning and subsequent use for CV conditioning - Late recovery of flexibility - Continued fluidity exercises to support active range of motion - Progressive introduction of BL and then UL landing and jumping work to develop eccentric functional control (10 weeks + ) - Sport-specific neuroplasticity exercises (heading, catching, throwing... ⚡️ ⭐️ Pool exercises:

-First half (weeks 5-8)– DWR, squat, step up, standing balance and neuromuscular control exercises, functional strength exercises using additional modalities (e.g., standing press against rubber ring) - Second half (weeks 9-12): Introduction of landing and jumping exercises for neuromuscular control DWR for CV conditioning ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym First half (weeks 5-8) - Resistance training exercises using low-loads for muscle endurance training (12-20 RM range) - Off-feet core corrective training (e.g., transverse abdominus, bridges, clams, side leg raises etc.) - Basic motor control drills (BL squat, marching exercises, gait, walking on treadmill) - Off-feet CV conditioning (bike, cross-trainer) Second half (weeks 9-12) - Progression to land based functional exercises (single leg squat, hip hinge, step up, split squat) - Standing lumbopelvic strengthening exercises (standing clam, lateral band walks) - Moderate load resistance training for hypertrophy and strength development in open and closed kinetic chain exercises (8-12 RM range) - Running re-education with alter-G/ trampoline/ treadmill🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

🔴🔴🔴 High intensity pool and field preparation

Typical duration: Weeks 13-18 after surgery ⚡️ ⭐️ Entry criteria: - No pain/swelling - Symmetrical/full ROM - Knee flexor and extensor LSI > 80% - Good subjective movement quality on land-based foundation tasks (e.g., bilateral and unilateral squat, step up, lunge and hip hinge) - Ability to run on the treadmill at 8 km/h for 10 minutes with good mechanics General goals for the phase: -Restoration of basic motor patterning - Introduction and utilization of DWR for motor patterning and subsequent use for CV conditioning - Late recovery of flexibility - Continued fluidity exercises to support active range of motion - Progressive introduction of BL and then UL landing and jumping work to develop eccentric functional control (10 weeks + ) - Sport-specific neuroplasticity exercises (heading, catching, throwing ⚡️ ⭐️ Pool exercises: -Running for low-load conditioning - Plyometric training - Coordination drills for preparation for the field ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym / Movement environment - LB high load isolated strength training (3-6 RM) - LB functional strength training (8-12 RM) - Landing drills, jumping drills - Core strength/ stability (load transfer) - Bilateral plyometrics On-field / sand - Linear running (forward, lateral) - Jump and landing drills - Linear acceleration and deceleration - Multidirectional running drills (pre-planned) 🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

🔴🔴🔴🔴 Recovery pool

Typical duration: -Weeks 19 + after surgery ⚡️ ⭐️ Entry criteria: -Be undertaking return to sport training General goals for the phase: -Accelerate recovery between on-field and gym land based sessions - Allow for reduced loading training such as plyometric exercise and CV conditioning at lower body loads ⚡️ ⭐️ Pool exercises: -Deep water running - Plyometric exercises - Flexibility – dynamic and static stretching ⚡️ ⭐️ Activity outside the pool: Rehabilitation gym / Movement environment - LB high load isolated strength training - LB functional strength training - Landing drills, jumping drills - Core strength/ stability (load transfer) - UB strength, core endurance and aerobic fitness on recovery days On-field - Multidirectional agility drills - Technical based sports re-training - Fitness training - Plyometric training 🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟🌟

☝️Unilateral plyometric exercise☝️ involving forward A, step off from step, B, landing followed by immediate jump and C, single leg stabilisation on box and lateral drop jumps (D, step off, E, landing and jumping transition and F, lateral landing on step)

☝️Bilateral jumping for power☝️ development with A, countermovement phase, B, flight phase and C, landing phase