Current concepts in the rehabilitation of the injured athlete

Competitive athletes: preinjury and postinjury mood state and self-esteem

In a prospective study, we determined whether preinjury and postinjury differences existed in the mood state and self-esteem of competitive athletes. The influence of severity of injury, gender, level of participation in sports, and type of sport on these dependent variables was also measured. Among 238 male and 38 female athletes from hockey, basketball, baseball, and volleyball teams, 36 sustained 43 injuries. Significant postinjury increases were noted for depression (P < 0.0001) and anger (P = 0.0012), whereas vigor (P < 0.0001) was significantly less after injury. When the 36 injuries were classified, 27 were minor or moderate (nonparticipation in sports for only one or two weekly assessments), and 9 were severe (nonparticipation for three or more weekly assessments). When a stepwise multiple regression equation was used to predict the scores for postinjury depression, the only significant predictor was the severity of injury (F = 8.48 [1, 34]; R2 = 0.30; P = 0.0063). Of the following physical and psychosocial variables--level of participation, type of sport, age, previous injury, preinjury stress, gender, mood state scales, and self-esteem--only level of participation (P < 0.0001) and type of sport (P = 0.0004) were predictors of injury. The significant preinjury and postinjury differences in mood state suggest that postinjury mood disturbances reported in previous studies are likely attributable to the occurrence of injury, are related to the severity of injury, and do not merely reflect a disturbed preinjury mood.

Rehabilitative techniques for athletes after reconstruction of the anterior cruciate ligament

A wide spectrum of protocols is available for rehabilitation after anterior cruciate ligament reconstruction, and little agreement exists on the specifics of strengthening exercises or the sequence of activities. In this article, we discuss the current rehabilitative techniques used at the Mayo Clinic for athletes who have undergone anterior cruciate ligament reconstruction. These techniques are based on established principles of rehabilitation, clinical experience, and new information about the related biomechanics of the knee. An illustrative case reflects the benefits of this rehabilitation program, which lasts up to 1 year and is divided into five stages. The early stages focus on protected mobilization and a strengthening program that emphasizes closed rather than open kinetic chain exercises. Later, neuromuscular-proprioceptive training and sport-specific agility training redevelop the reaction time and the "coordination engrams" necessary for athletic competition. High-quality surgical care and a closely supervised rehabilitation program, based on kinesiologic and biomechanical factors as they pertain to the anterior cruciate ligament, are necessary for a successful outcome.

The psychological effects of sports injuries. Coping

Epidemiological reports of sports injury confirm a high incidence of injuries occurring at all levels of sport participation, ranging in severity from cuts and bruises to spinal cord injury. The psychosocial dynamics accompanying sport injury should be known to ensure psychological recovery, an important aspect in rehabilitating the injured athlete. Earlier studies demonstrating psychological differences between athletes and nonathletes indicated the need for actual research on the athlete's postinjury response in lieu of accepting the hypothesis that the emotional responses of athletes to injury parallels existing (i.e. terminally ill) 'loss of health models'. Recent research has shown that injured athletes experience simultaneous mood disturbance and lowered self-esteem. Due to a paucity of research on the coping methods of injured athletes, studies involving the coping methods of several nonathletic patient populations were reviewed. These patients benefitted primarily from a concrete, problem-focused, behaviourally orientated programme which minimises uncertainty. This approach is theoretically ideal for injured athletes, congruent with the goal setting and performance outcome emphasis common to exercise and sport training programmes but to date the effectiveness of these strategies for injured athletes have not been fully examined. Therefore, until such research is available, these coping strategies (also used for performance enhancement) are provided as therapeutic guidelines for dealing with the emotional distress experienced by injured athletes. Individual responses of injured athletes varied from those who took injury in stride to those who required psychiatric intervention. This marked individual variation in response underscores the importance of neither assuming mood disturbance nor overlooking a serious emotional response in the injured athlete. Awareness of the emotional responses of athletes to injury and employment of appropriate coping strategies should facilitate optimal rehabilitation and return to sport.

Emotional responses of athletes to injury

Increased participation in sports is associated with increased related injuries. This study was conducted to identify the emotional responses of athletes to injury and to determine which responses might interfere with rehabilitation and necessitate psychologic or psychiatric intervention. In 72 patients, follow-up surveillance was continued from the time of injury until resumption of sports activity. Patients completed the Emotional Responses of Athletes to Injury Questionnaire and the Profile of Mood States (POMS) test, and significant differences were found when the POMS scales of depression and anger were compared with college norms. Mean POMS scores were compared (by multivariate analysis of variance) by sex, age, and severity of injury. No gender differences were found, and only for anger were age groups significantly different (younger athletes were most angered). Three severity-of-injury groups (based on the duration of time the athlete was unable to participate in sports) were also compared. The most seriously injured group experienced significantly more tension, depression, and anger and less vigor than college norms, a mood disturbance that lasted 1 month. Emotional disturbance can occur after a sports-related injury, and its prompt recognition may facilitate the athlete's optimal rehabilitation and a safe return to participation in sports.

Musculoskeletal injuries in competitive swimmers

Competitive swimming is a rigorous sport being engaged in by an increasing number of young athletes. In swimmers, shoulder pain is the most common musculoskeletal complaint and is usually due to supraspinatus or biceps tendinitis. Glenohumeral instability (often multidirectional) can also be a cause of shoulder pain in swimmers and may be more common than has been reported. Surgical treatment is seldom indicated. Physical therapy modalities and training modifications are the mainstay of treatment. Medial knee pain in breaststroke swimmers and extensor tendon inflammation over the dorsum of the foot are less common injuries and respond to conservative therapy. These overuse syndromes are best prevented by proper training schedules, strength training, flexibility exercises, and avoidance of errors in stroke technique. The rehabilitation program for a competitive swimmer should be chosen with an understanding of the goals of the swimmer and the cooperation of the coach.

Impact of physical training on the ultrastructure of midthigh muscle in normal subjects and in patients treated with glucocorticoids

Exercise-training might be a logical method to reverse muscle atrophy and weakness in patients treated with glucocorticoids. The purpose of the present investigation was to establish whether a treatment with low dose prednisone (10 +/- 2.9 mg/d) modulates the effect of a moderate strength type isokinetic training during 7 wk (21 sessions of 20 min) on "muscle efficiency" (power output/muscle mass) and on concomitant changes in ultrastructure of the thigh muscle measured by quantitative electron-microscopic morphometry. Training caused a similar increase in "muscle efficiency" in patients on prednisone (n = 9) as in normal volunteers (n = 9). In normal subjects the increase in muscle efficiency was associated with an increase in sarcoplasm, whereas in patients on prednisone the functional improvement was associated with an increase in sarcoplasm, capillaries, and mitochondria content. Thus, a therapy with low dose prednisone does not abrogate training-induced improvement of muscle efficiency but modulates the ultrastructural response of the muscle to the training.

Thigh muscle mass and function in patients treated with glucocorticoids

Treatment with glucocorticoids causes wasting of proximal skeletal muscles. There is evidence that physical training improves muscle mass and strength in glucocorticoid-treated rats. Whether this is also true in humans is unknown. The present investigation was designed to establish in what respect moderate physical training may alter muscle mass and function as assessed quantitatively by computed tomography (CT) and with an isokinetic dynamometer (Cybex II). Compared with matched controls, both female (n = 17) and male (n = 22) patients treated with prednisone (15.4 +/- 6.6 mg die-1) had a lower mid-thigh muscle area of 20 and 45% and an increased mid-thigh fat/muscle ratio of 25 and 100%, respectively. The mean peak torque and the total work output of the thigh muscle were lower by 20-30% (n = 14). Fifty days of isokinetic training in six patients increased the thigh muscle area, decreased the thigh fat area and normalized the mean peak torque and total work output. Thus, glucocorticoid-induced muscle wasting can be reversed by increasing physical activity.