Universidad politcnica de Quintana Roo

16
Gua de asignatura
Ingls IV

0
Contenido
Gymnastics Wrist Injury Case Study Nursing Essay .......................................................... 2
Pathophysiology: ......................................................................................................................... 3
Aetiology: ....................................................................................................................................... 4
Diagnosis: ...................................................................................................................................... 4
Sprained Wrist - Early Management: ...................................................................................... 5
Medical Treatment ...................................................................................................................... 6
Surgical management: .............................................................................................................. 6
Wrist Exercises ........................................................................................................................... 7
Healing time frame: .................................................................................................................... 8
Hamstring Muscle Strains A Common Injury Physical Education Essay ..................... 9
Injured Athletes Use of Self-Talk. ........................................................................................... 26
Injuries Associated With Tenpin Bowling Health And Social Care Essay ............................ 33
Injuries Within Sports Games Physical Education Essay ............................................... 38
Investigations On Sports Injury Treatment Plans .............................................................. 42
Latest Concepts in Hamstring Rehabilitation and Injury Prevention ............................ 52
Managing Of Minor Injuries Health And Social Care Essay ............................................ 59
Scientists Work to Improve Treatments for Multiple Sclerosis ...................................... 65
Spinal Cord Injury ....................................................................................................................... 68
Osteoporosis Increases Danger of Broken Bones ............................................................ 74

1
Gymnastics Wrist Injury Case Study Nursing Essay
Anne is a 14 year old gymnast who presents with left wrist pain 4 weeks after an
original injury. She completed a tumbling manoeuvre and felt a stabbing pain in her
wrist, which has been throbbing for 1 week. She went for x rays, which found no
fractures. She took several days off training and the pain subsided for the most part.
Her coach strapped her wrist and she has been trying to avoid direct impact moves but
this has only been partially successful. The wrist has been diagnosed as a sprain but
the pain is preventing Anne from doing any weight bearing on her arms.
Gymnastic sports: The impact on the wrist is higher than any other joint, particularly in
this sports the involvement of the upper limb is very much severe because of the
weight bearing support of the body as a closed chain kinematic, in which the wrist joint
was not meant to be. Getting injured at wrist is the most common scenario, the most
common injuries involves ligament sprain and laxity, carpal fracture and compression
syndrome.
History:
Since the duration of the injury is 4weeks therefore it cannot be a muscular sprain, and
there is no obvious symptom of fracture. Therefore it can be a sprain. A careful
evaluation of the signs and symptoms both subjective and objective assessment
involves.
Onset of the pain, Location of the pain with or without movements,

2
Duration, Character of the pain like sharp, throbbing, dull, etc, Releaving/Aggravating
factors
Radiating to any other site, temporal pattern like every night, morning, all day, etc.
(Todd 2006)
Objective assessment involves palpation for tenderness, stiffness, observation for
swelling and redness or erythema, active and passive range of motion of the wrist
joint, deformity etc.

Pathophysiology:
Anne was diagnosed with wrist sprain. Sprain is an ligament associated injury and is
very common among athletes. Ligaments were the connective tissues which connect
and stabilize from one bone to another bone; they could be very strong and made up
of cartilaginous matrix. The degree of ligament injury depends on the severity of the
injury. Sprains are classified majorly into three types: Grade I which is a micro tear or
rupture of a ligament; Grade II which is a partial tearing/ excessive stretching; and
Grade III is a complete or full rupture/tear of the ligament with or within the mid-portion
of the ligament, or it can also be an avulsion fracture ("pulling away") from its
respective attachment to bone. A sprain also has the tendency to upset the normal
rhythm of coordinated movements the wrist bones in which it results in persistent
symptoms like stiffness, tenderness, swelling, pain and possibly joint instability.
Occurrence of sprain can possibly due to excessive loading of force transmitted across
the wrist joint. These occur as the result of a fall of outstretched hand. In gymnastic
sports the force is applied in such a way with violent twisting injury or a torsion force.
There are many ligaments stabilizing the wrist joint by binding the eight carpal bones
to the radius and Meta carpal joints for multidirectional movements. One of the most
common ligament injuries involves the scapho-lunate ligament, this ligament which
connects the scaphoid and lunate bones. In gymnast sports dorsal wrist impingement
occurs when the posterior or back of the radius strikes with the carpal bones,
especially during the performance of walkovers or handsprings. This injury is the result
of prolonged extension thereby stretching force of the joint beyond stressed to its
normal range of motion which is also known as hyperextension. Force placed at the
joint or on the bone especially during axial loading, which can also cause wrist sprain.
The injury is aggravated when the full

3
weight is placed on the wrist while doing handstands on the balance beam or on the
vault.
Aetiology:
Due to enormous amounts of pressure and weight loading placed on gymnast wrists,
there is great potential forgetting injured. Many gymnastics routines involve ballistic,
jerking and repetitive movements of the wrists and hands while loading. Carrying
whole bodyweight at the wrist, especially when the wrist extending backward to
support a handstand can ends up in fractures sometimes and in majority of cases
suffers with sprains and dislocations, any of these condition can ends up with chronic
long-term effects in recovery. Most gymnastics injuries were managed in much same
ways as any other sports injuries, there are about two major chronic injuries called the
dorsal wrist impingement and the distal radial stress fracture which requires a special
medical attention for management.
Dorsal Wrist Impingement
Dorsal wrist impingement is the most common injury among gymnast and it occurs
when the dorsum of the radius impinges with the other carpal bones especially during
the gymnast techniques like walkovers or handsprings. The mechanism of this injury is
the result of constant wrist extension or stretching of the joint beyond its normal range
of motion while loading, which is also known as hyperextension. The force placed
along with the loading of the joint during weight bearing, can also cause this condition
and the injury is aggravated whenever the body weight placed at the wrist while
performing techniques like handstands on the vault or balance beam. (David.C.Rehak,
2009)

Diagnosis:
The diagnosis includes a careful patient history by assessing the possible cause of
injury like how the injury occurred, duration , position of the joint, weight bearing force
followed by a valid clinical examination followed by the signs and symptoms or special
test to identify the particular ligament injury, and finally diagnostic testing by ultrasound
scans or X-rays. Usually patient typically presents with the chief complaints of wrist
pain and stiffness, and followed by loss of strength is a common symptom.
Examination of the wrist will allow pinpointing the tenderness and thus localizing the
site of injury, and also to assess wrist stability. Usually X-rays of scans were obtained
to evaluate any potential fractures or for signs of ligament

4
insufficiency, ligaments alone were cannot be seen on X-rays, the consequence of a
ligament injury may be appreciated indirectly based on abnormal alignment of the wrist
bones. Furthermore additional diagnostic testing may be required like MRI or an MRI-
arthrogram if possible. Potential risks and benefits of the surgery must be considered
relative to the severity of the wrist injury.
The potential aim of the treatment should be:
- Providing pain relief.
- Minimizing the stiffness or loss of motion.
-Immobilization if needed.
- Restore wrist joint stability and movements.
- Reduce the risk of long-term consequences like contracture, arthritis, pain, instability.

Sprained Wrist - Early Management:

P. R.I.C.E protocol is the first line treatment of a sprained wrist. This includes:
Prevention. Golden rule prevention is always better than cure. Have adequate warm-
ups and cool down, wear protective gear while practicing new techniques. Wearing
protective gear, such as wrist straps or guards, may help prevent wrist sprains.
Maintenance of appropriate weight to prevent the overloading (William J. Morgan,
2001)
Rest. Stop activity, then immobilize with a padding or splint and don't use the injured
wrist for the next 48 hours or until the tenderness, pain and swelling should reduced.
Ice. Icing is the best first aid for the wrist injury, applying a cold pack wrapped in a
towel / bag of crushed ice to the wrist for about 10-15 minutes each session, for some
days until swelling subsides.
Compression. Elastic compression or creep bandages should be used to wrap the
wrist to limit swelling. The wrap should start at the base of the fingers to drain the
inflammatory fluids and stop just below the elbow. The wrap should not be a
tourniquet, should be careful not to cut off blood circulation to the fingers.

5
Elevation. Keeping the injured wrist higher than your heart as often as possible during
the night as well as some time of the day for the first two days after the injury. This will
help to drain out the accumulation oedematic fluid and thereby reduce swelling in and
around the wrist. (William J. Morgan, 2001)
Further treatment involves
Over-the-counter drugs. These may include analgesics like Ibuprofen (Motrin, Advil),
Naproxen, Acetaminophen, paracetamol or aspirin.
Bracing. Doctor may recommend using a brace to immobilize the wrist, especially
when practicing the gymnast if needed.
Immobilization. In case of severe sprain, doctor may recommend a splint or cast for
two to three weeks.
Rehabilitation Exercises. A physical therapy intervention needed for flexibility, range of
motion maintenance, and strengthening exercises for the injured wrist.
Surgery. In some case surgical intervention may be needed to repair the torn ligament
or if there is a suspected bone fracture.

Medical Treatment
Usually the wrist sprain treated with conservative means like Velcro strap or wrist
splint/plaster splint (like a cast). Pains, amount of swelling, restriction of movement,
were the concern about an occult or hidden fracture.
For minor sprains, a splint may not be recommended and may be told to limit activity
appropriate to the level of pain range.
In case of severe sprains, Velcro wrist splint that can be taken off and a rigid casting
may be helpful for complete immobilization. (Jonathan L. Gelfand, 2010).
In severe case a steroidal injection may be injected on the sight of injury to reduce
pain, the injection is commonly called as cortisone.

Surgical management:
Surgery is recommended when there is a complete rupture or full tear of the ligament.

6
Percutaneous pinning repair of the ligaments or ligament reconstruction- This
procedure involves by identifying the torn ligament and reconstructing with tendon graft
which is used to replace the ligaments which has been torn.
Fusion of joints suggested if the ligament instability is discovered since long after the
injury and producing the unstable bones, a fusion of carpal bones may be suggested in
advance instability.
After the surgery, the first few treatment sessions the management should be focused
on controlling the pain and swelling following after surgery. Initially start with an
exercise that helps in strengthening and stabilizing the muscles around the wrist joint.
Following after those other supplymentary exercises are also used to improve the fine
motor control and finger dexterity for the hand. (seed, 2006)
Wrist Exercises
Hand exercises should be focused on full range of motion with the natural 3-
dimensional range of motion. Along with that resistance helps in strength, conditions
and balances for the tissues of the hand, wrist, fingers and forearm as well.
Spread the fingers apart and close them several times
Place wrist firmly on a table and repeat ulna and radial deviation.
Place the hand palm facing downwards on a table and lift each finger in turn.
Squeeze a stress ball or a rubber ball, hold for a count of ten minimum and release
the grip.
Supination, pronation movements should be encouraged along with thumb
movements like picking coins and placing on the other side.
Proper stretching of flexors and extensor of the wrist is recommended to prevent
soreness.
Inserting the wrist in a tub of warm water encourages the movement by reducing the
pain and stiffness.
Stress ball or pan cake pressing and making moulds helps in improving dexterity of
the fingers.

7
 Periodic flexibility and stretching of the fingers and wrist is recommended daily to
improve the range of movement.
Joint glides and passive range of motion movements should be done by gliding the
joints with the unaffected side of the fingers.
Using a rubber band splint or rubber band resistance can improve in gaining the
strength of the wrist and fingers.( Hologum.P 2005)
Repeat the exercises regularly during the day as long as there is no pain or
discomfort and in night wear a splint to reduce abnormal movement or lying on the
injured wrist.
Advanced exercises
Throw a ball against a wall later catching the ball, for making more increasing the
distance.
Banging the wall with the wrist will be helpful before loading the wrist completely.

Healing time frame:

Ligaments are made of strong, and have high resistance to length tensile relationship,
when stretched often it takes a long time to heal. Wrist sprain healing time varies from
person to person due to their wrist stress, usage, degree of damage. Some injury can
recover within a few days and others it takes up to several weeks for it. Early treatment
results in early healing, approximately the entire healing process may take about 3 - 10
weeks.
Average healing times are:
Mild sprains--2 to 6 weeks.

Moderate sprains--6 to 8 weeks.

Severe sprains--8 to 10 weeks. (Mukherjee, 2010)

8
Hamstring Muscle Strains A Common Injury Physical
Education Essay
Hamstring muscle strains are one of the common problems for many athletes which
results in significant loss of on-field time. These injuries tend to heel slowly. Hamstring
injuries are more common in sprinters and athletes, as they perform high-speed skilled
movements. Once hamstring injury occurs, without proper rehabilitation and rest the
athlete is at high risk for recurrence.
Some pose complicated challenges remains after the injury rehabilitation, when
returning the athletes quickly and safely to participate in sports. The most common soft
tissue injuries in thigh occur in hamstrings; particularly at the musculo-tendinous
junctions (Fox 1986, King and Robertson 1986). A 4 year study was conducted of
injury rates for Memphis state university football team. The study showed that
hamstring strains were the third most common injuries after knee and ankle injuries
during sports.
The re-injury rate was 12% for hamstring strains when compared with an average re-
injury rate of 7% for all other injuries. The injury recurrence is at highest risk during first
2 weeks of return to sports. Moreover, following return to sport nearly one third of
these injury recurrences appear within the first year. An author, in his study reported
that out of 30 sprinters 15 suffered from preceding hamstring strains.
The commonly utilized rehabilitation programs for hamstring injuries may be
insufficient at resolving reduced tissue extensibility, possible muscular weakness and
altered movement patterns associated with injury suggests the high re-injury rates.
The primary objective of the rehabilitation program for hamstring is to restore the
athlete with the level of activities previously carried out with minimal risk of recurrence
of the injury of their participation in sports.

9
ANATOMY
There are 3 hamstring muscles present in the posterior thigh: the semitendinosus,
semimembranosus and biceps femoris. The semitendinosus originates at the ischial
tuberosity and gets inserted at the pes anserine; the semimembranosus gets origin
from the ischial tuberosity and inserts at the posterior medial tibia. The biceps femoris
has two heads; a long head which originates at the ischial tuberosity and a short head
originate at the postero-lateral femur. Both heads of biceps femoris gets inserted into
the head of the fibula. The hamstring muscle acts as knee flexors and hip extensors.
ANATOMY OF HAMSTRING MUSCLE
MECHANISM OF INJURY:
A muscle is commonly strained or torn during rapid acceleration or deceleration
movements. The most implicated cause of hamstring strains is the imbalance between
the quadriceps and the hamstring muscles. The hamstring muscle group is a two joint
muscle and thus the anatomical configuration of the muscle group is at increased risk
and more susceptible for strains.
Clanton and Coupe (1998) describes about mechanism of injury. The underlying
mechanism for hamstring strains is suggested to be the increased force generated
during eccentric action of muscle as opposed to a concentric contraction suggested
as. The most common 2 factors in hamstring injury are lack of adequate flexibility and
strength imbalances in hamstring muscle group.
Eccentric contractions are characterized by active lengthening of muscle fibres. In
eccentric contraction, as the speed of contraction increases the force of contraction
also increases as well. Conversely, during concentric contractions shortening of
muscle fibres occurs and inverse relationship between the speed and force of
contraction. During late swing phase, the hip is flexed and the knee is extended which
is suggested for injuries to occur. In a high speed running, the hamstring strain occurs
during terminal swing phase of gait cycle. The greatest musculo-tendon stretch is
incurred by the biceps femoris muscle, which is more often injured than the other two
hamstring muscles (semimembranosus and semitendinosus) during high speed
running.
CLASSIFICATIONS OF MUSCLE INJURY:

10
Injuries to muscles and tendons of the hamstrings are generally classified into three
categories. These injuries are mentioned as: the strains of first, second and third
grade.
A first degree strain is less severe. It is the result of a minor stretch of the muscles and
tendons, and is accompanied by a slight pain, stiffness and swelling. In general, very
little loss of function is present after a first degree strain.
A second degree strain is the result of both stretching and some tearing of muscles
and tendons. There is an increased pain and swelling accompanied with a strain in the
second degree. A moderate loss of function of that exacting muscle will be present.
A third degree strain is the most rigorous of the three degrees of strains. Complete tear
or rupture of one or more of the muscles and tendons is said to be third degree strain.
It results in severe pain, massive swelling and gross instability.
RISK FACTORS:
While an athlete performing running or jumping activities in sport, hamstring injuries
happens usually as a result of rapid acceleration or deceleration movements. There
are some main modifiable risk factors which include:
* In-adequate warm-up leading to muscle fatigue
* Muscle tightness
* Imbalance of muscular strength with low hamstring to quadriceps ratio
* Previous injury.
SYMPTOMS AND SIGNS:
In Grade 1 (Mild) : Local pain over posterior thigh, mild spasm, swelling, ecchymosis,
local tenderness, mild pain on passive stretch and active contraction of the involved
muscle, minor disability with loss of function and strength.
In Grade 2 (Moderate) : Local pain, moderate spasm, swelling, ecchymosis, local
tenderness, moderate pain on passive stretch and active contraction of the involved
muscle, moderate disability with impaired muscle function and strength.
In Grade 3 (Severe): Severe pain, severe spasm, swelling, ecchymosis, haematoma,
tenderness, loss of muscle function, palpable defect may be present.
STRETCHING:
Stretching is believed to increase the range of motion around a joint through a
decrease in visco-elasticity and an increase in compliance of muscle. By improving

11
force absorption for a given length of muscle, thereby making the muscle is limited as
the positive effect was demonstrated in only minor injuries.
Stretching exercises can be carried out as an individual training to enhance the
flexibility of a muscle or as a warm-up planned to avoid injury and prepare the body for
workout to pursue. Stretching gently lengthens the muscles before and after other
exercises and helps to improve tissue elasticity and flexibility. It is suggested that a
person should warm-up previous to stretching to enhance the blood flow. In turn this
improved blood circulation makes the muscles more flexible. It is also not compulsory
that all static stretches are supposed for 15 seconds at least prior to being released in
order to stretch the muscle efficiently.
STRENGTHENING EXERCISES:
The development of muscle strength is an integral component of most rehabilitation or
conditioning programs for individuals of all ages and all ability levels.
Strengthening of the hamstrings is an essential role in rehabilitation after injury to
obtain the muscles back to their complete strength. This strengthening program will
also facilitate to prevent anymore upcoming injuries. The most common adaptation to
heavy resistance exercise is an increase in the maximum force-producing capacity of
muscle, that is, an increase in muscle strength, primarily as the result of neural
adaptations and an increase in muscle fibre size.
PROGRESSIVE AGILITY EXERCISES:
Agility training is a great way to help develop speed as well as becoming agile. This
kind of method in training an athlete is enormously beneficial.
The benefits of agility training can certainly give a progression to any athletes in their
overall performance. The skill to execute on the field and yet off the field is also
improved. It also increases the running speed because running is the supreme
foundation of all athletics. These agility exercises are also worn to increase the speed
and quickness in all sports kind. These agility training vary from conventional speed
training in that they integrate a lot more lateral movement.
TRUNK STABILIZATION EXERCISES:
Trunk stabilization exercises give strong, flexible trunk muscles that support well-
aligned bones. It refers to progressive conditioning of the musculature of the pelvis and
hip girdle, lumbar spine, abdominal region and peri-scapular musculature particularly
as the use of these muscles relates to the performance of specific dynamic tasks
involving the trunk of extremities. These exercises will strengthen the lower back and
abdomen. Strengthening the core is essential to prevent all forms of injury around the
lower back area. The concept of core stability has a theoretical basis in the treatment
and prevention of various musculo-skeletal

12
conditions. Many therapists now include a component of core stability training in the
rehabilitation of a wide variety of lower limb injuries.
This had led some physical therapists to make use of a variety of trunk stabilization
and progressive agility exercises for hamstring rehabilitation programs.
OPERATIONAL DEFINITIONS:
Muscle Strain:
A muscle strain is defined as an excessive stretch, which leads to muscle fibre
damage and disrupts the integrity of related vascular and connective tissue structures.
Stretching:
Stretching is a form of physical exercise in which a specific skeletal muscle (or muscle
group) is deliberately elongated to its fullest length in order to improve the muscle's felt
elasticity and reaffirm comfortable muscle tone.
Strengthening:
Strength training is defined as a systematic procedure of a muscle or muscle group
lifting, lowering or controlling heavy loads (resistance) for a relatively low number of
repetitions or over a short period of time.
Agility:
Agility is the ability to perform a series of explosive power movements in rapid
succession in opposing directions.
Trunk Stabilization:
There is no formally endorsed definition of trunk stabilization. It refers to the balanced
development of the deep and superficial muscles that stabilize, align and move the
trunk of the body, especially the abdominals and muscles of the back.
NEED FOR THE STUDY:
The athlete returning to sport at previous level of functional performance with a
minimal risk of injury recurrence is the primary goal of a rehabilitation program
following a hamstring strain injury. The high re-injury rate may be due to the use of
inappropriate criteria for determining suitability for return to sport or, alternatively, that
traditional rehabilitation methods are insufficient for reducing risk for re-injury.
The need for the study was to determine that improved coordination of the lumbo-
pelvic region allows the hamstrings for its optimal function at safe lengths and loads
during athletic movement, thereby reducing injury risk.
AIM:

13
The aim of this study is to compare the effectiveness of Stretching and Strengthening
program with Progressive agility and trunk stabilization program in the rehabilitation of
acute hamstring strains.
OBJECTIVES:
To compare the effectiveness of two rehabilitation programs for acute hamstring
strains by evaluating the relationship between functional testing performances.
HYPOTHESIS:
Null hypothesis:
There is no significant difference between the Stretching and Strengthening program
against Progressive agility and trunk stabilization program in the functional testing
performance of the athletes for acute hamstring strains on the day of return to sports.
Alternate hypothesis:
There is a significant difference between the Stretching and Strengthening program
against Progressive agility and trunk stabilization program in the functional testing
performance of the athletes for acute hamstring strains on the day of return to sports.
2. REVIEW OF LITERATURE
Bryan C. Heiderscheit, Marc A. Sherry, Amy Silder, Elizabeth and Darryl G. Thelen
(2010) In a study says that there is a mounting evidence that the risk of re-injury can
be minimized by utilizing rehabilitation strategies that incorporate neuromuscular
control exercises and eccentric strength training, combined with objective measures to
assess musculo-tendon recovery and readiness to return to sport.
Mason DL.Dickens V.Vaila(2007) In their study suggested that there is only limited
evidence for rate of recovery can be increased with an increased daily frequency of
hamstring stretching exercises. While managing a hamstring injury, the lumbar spine,
sacroiliac and pelvic alignment along with the postural control mechanisms also must
be concentrated. Lumbar stability and pelvic muscle control may also be a factor in
reducing the rate of recurrence of hamstring injury.
G.Verrall, J.Slavotinek and P.Barnes(2005) Increasing the amount of anaerobic
interval training, stretching whilst the muscle is fatigued and implementing sport
specific training drills resulted in a significant reduction in the number and
consequences of hamstring muscle strain injuries.

14
Thelen. D.G, E.S. Chumanov, M.A. Sherry and B.C. Heiderscheit(2006) In this article
shows that hamstring strains are a common and recurrent injury among sprinting
athletes and describes about the mechanics of hamstring injury and the influence of
muscle co-ordination on hamstring mechanics. These observations are important for
establishing effective injury prevention and rehabilitation programs.
Clanton TO, Coupe KJ (1998) Hamstring strains are among the most common injuries
in athletes. This muscle injury occurs mostly at the myo-tendinous junction, when the
force is concentrated. Concurrent pain-free stretching and strengthening exercises are
essential to regain flexibility and to prevent further injury.
Gabbe BJ, Brason R and Bennell KL (2006) Evaluated the effectiveness of a pre-
season eccentric training program on 220 players for preventing hamstring injuries.
Five exercise sessions are completed over 2 weeks. Their finding suggests that a
simple program of eccentric exercise could reduce the incidence of hamstring injuries.
David J.Magee, James E.Zachazewski, William S.Quillen (2009) Strain or overload of
the hamstring tissues also may be due to a pelvic alignment fault or mal-alignment that
changes the length/tension relationship of the hamstrings. Athletes with hamstring
strain often show an anterior in-nominate tilt on the affected side. Rehabilitation of
hamstring strains using progressive agility and trunk stabilisation exercises has been
found to be more effective than a program emphasizing isolated hamstring stretching
and strengthening and enable to return to activity more quickly than those treated with
more conservative measures.
Robert Donatelli (2007) According to the clinical experience of the author, patello-
femoral pain, hamstring strains, lateral hip pain results from lower quadrant core
muscle deficits. Leerun et al demonstrated that core stability played an important role
in injury prevention. Mascal et al reported that strengthening the hip, pelvis and trunk
musculature resulted in a significant improvement in lower-extremity kinematics and
ability to return to their sporting activities.
Thomas E.Hyde, Marianne S.Gengenbach (2007) Muckel states that hypomobility of
the lower lumbar spinal segments is a cause of repetitive hamstring strains. Anterior
pelvic tilt causing increased stretching of the hamstring also has been incriminated as
a cause.
Peter Brukner and Karim khan (2007) Core stability program have shown the positive
benefit in the management of sporting injuries. Many physiotherapists now incorporate
an element of core stability program in rehabilitation of a wide variety of lower limb
injuries and prevention of various musculoskeletal conditions.
Paul Gamble(2009) Single-leg hop tests of the type of vertical jump test have seen
application in the rehabilitation setting to evaluate functional performance of injured
and uninjured leg.

15
Agre JC (1985) Many of the recurrent injuries to the hamstring musculo-tendinous unit
are the result of inadequate rehabilitation following the initial injury. The treatment for
hamstring injuries should include training to maintain and improve strength, flexibility,
endurance, co-ordination, and agility.
Hopper DM, Strauss GR, Boyle JJ, Bell J(2008) The functional hop performance in
subjects with an ACL reconstruction and the hop tests results showed different levels
of imposed demands on the knee that could be used to assess functional recovery and
readiness to resume sport.
Andrea Reid, Trevor B Birmingham, Paul W Stratford, Robert Giffin (2006) conducted
a study with 42 patients during rehabilitation after ACL reconstruction. The results
show that the described series of hop tests provide a reliable and valid performance
based outcome measures. These results sustain the utilization and facilitation in
interpretation of hop tests for research and clinical practice.
JW Orchard, P Farhart, C Leopold (2004) suggests that the lumbar spine region
pathology is a factor in some of the players who find that they have recurrent
hamstring and calf musculo-tendinous injuries despite regular preventing maintenance.
This brief report prompts us to consider lower lumbar pathology as a source of
hamstring and calf problems (probably strains).
Croisier JL (2004) The risk factors which are examined in the literature have been
associated with injury. Inadequate warm-up, invalid structure and the content of
training, muscle tightness or weakness, agonist/antagonist imbalances,
underestimation of an extensive injury and incomplete or aggressive rehabilitation are
said to be most likely.
Malliaropoulos N, Papalexandris S, Papalada A, Papacostas E (2004) a total of 80
athletes with hamstring muscle strains were recruited in the study and the effects of
stretching in rehabilitation of hamstring injuries were assessed. The results imply that
stretching is of great value in treating muscle strain injuries in that it improves the
effectiveness of the rest rehabilitation program.
Young W, Russell a, Burge P, Clarke a, Cormack S, Stewart G (2008), In a study
determined the relationships between split times within sprint tests over 30m and 40m.
They suggested that sprint tests over 30m and 40m can be conducted to provide
information about independent speed qualities in athletes and concluded that this test
can be used to estimate maximum speed capabilities.
Allen Hedrick, Lt. Jason Sanderson (1996) evaluated the effectiveness of training
program using heavy resistance in improving vertical jump ability. Many strength and
conditioning programs use the vertical jump test to measure the physiological
adaptations from the training. Vertical jump testing is commonly used to measure
improvements in the vertical jump for sports and as a general measure of lower body
power in sports that requires high levels of lower body power.

16
Bill foran (2001) functional performance is a representation of actual efficiency through
specific testing of gross performance (power, speed, etc). 40 yard dash speed
represents the efficiency of the body. It allows the athlete to demonstrate the ability to
store energy, efficiency, co-ordination and momentum management.
3. MATERIALS AND METHODS
MATERIALS (TOOLS)
Stop watch
Measuring tape
Cone markers
Chalk or Ink
Thera-bands
Free weights
Couch
Ice packs
Stationary bike
Data collection sheet and recording sheet

METHODOLOGY
3.1 STUDY DESIGN
An Experimental study design of a pre-test and post-test.
24 athletes with an acute hamstring strain were randomly assigned to 2 rehabilitation
groups.
Group A - 12 athletes were assigned to the protocol consisting of static stretching,
isolated progressive hamstring resistance exercise and icing (STST group).
Group B - 12 athletes were assigned to the program consisting of progressive agility
and trunk stabilization exercise and icing (PATS group).
3.2 STUDY SETTING
This study was carried out with the students in sports team of Sri Ramakrishna
Matriculation School, Sri Ramakrishna Institute of Paramedical Sciences and SNR
College, Coimbatore.
3.3 SAMPLING
All acute hamstring strain patients were included in this study, hence this will be a
simple random sampling.
Each group were assigned with 12 Athletes.
A sample of 24 Athletes were randomly selected and divided into Group A (STST
group) and Group B (PATS group).

17
Both groups were evaluated after the rehabilitation programs for their functional testing
profile by hop test for height and sprint test on the day of return to sports.
3.4 DURATION OF THE STUDY
This study was carried out for the period of one year.
3.5 DURATION OF THE TREATMENT
Group A
Phase I - 40 minutes each session, 2 sessions per day.
Phase II - 60 minutes each session, 2 sessions per day.
Group B
Phase I - 40 minutes each session, 2 sessions per day.
Phase II - 60 minutes each session, 2 sessions per day.
3.6. INCLUSION CRITERIA
14 - 22 yrs of age
Only males
Acute hamstring strains (within past 10 days)
Only first and second degree of injury

3.7 EXCLUSION CRITERIA

Less than 14 yrs or more than 22 yrs of age
Females
Non- acute hamstring injuries
Complete muscle disruption (Third degree injury)
Avulsion injuries
Recent other lower extremity injuries
Inguinal or femoral hernia
Radiculopathy
History of malignant disease
Incomplete healing
Rehabilitation of pelvis or lower extremity features
Nerve entrapment
Lack of daily compliance
Posterior thigh pain not consistent with hamstring
Any other impairment limiting participation in rehabilitation program.

3.8 PARAMETERS OF THE STUDY

a) Hop test for height (in centimetres).

18
b) Sprinting test (in seconds).
3.9 TECHNIQUE
Group A:
Athletes received the protocol consisting of static stretching, isolated progressive
hamstring resistance exercise and icing.
Group B:
Athletes received the program consisting of progressive agility and trunk stabilization
exercise and icing.
3.10 STATISTICAL TOOLS
In this experimental study, statistical method was used to show the effectiveness of
functional testing profile in Group A and Group B was the dependent 't' test.
The dependent 't' test was calculated to find the difference between pre test and post
test within the group, using the formula
Dependent 't' test =
Where,
d = Difference of pre test and post test values.
N = Number of patients
Then the combined standard deviation is calculated using the formula
Combined standard deviation,
S=
Where,
X1 = Difference of post test values and pre test values of Group A
= Mean difference of Group A
X2 = Difference of post test values and pre test values of Group B
= Mean difference of Group B
n1 = Number of patients in Group A
n2 = Number of patients in Group B
With the combined standard deviation value 'S' obtained, and from the values of Group
A and Group B, the independent 't' test is performed to show the effectiveness. The
obtained independent 't' test values is compared with 22 degrees of freedom of two
tailed table value. If the 't' value is greater than table

19
value of 22 degrees of freedom, we can reject the null hypothesis and accept the
alternative hypothesis and show the effectiveness of the study.
Independent 't' test was performed with the formula.
Independent 't' test =
Where:
= Mean difference of Group A
= Mean difference of Group B
S = Combined standard deviation
n1 = Number of patients in Group A
n2 = Number of patients in Group B
4. TREATMENT TECHNIQUE
1. STRETCHING and STRENGTHENING (STST) GROUP:
The 4-phase program theorized that progressive stretching and strengthening of the
injured tissue would help to remodel and align collagen fibres in the scar tissue. The
acute phase (2-4 days) consisted of control of inflammation and early motion of the
lower extremity in the sagittal plane. The sub acute period consisted of stationary
biking, isolated hamstring progressive resistance exercises and pain-free stretching.
The re-modeling phase consisted of continued, isolated, hamstring progressive
resistance exercises (PREs), with the addition of eccentric exercise and continued
hamstring stretching. The functional phase included jogging, sprinting, sport-specific
drills and continued hamstring strengthening and stretching.
Phase 1
Intensity
Low to moderate
Duration
40 minutes
ISOLATED HAMSTRING STRETCHING
Treatment protocol
Stationary biking with no resistance - 10 mins.
Supine hip flexion with knee extension stretch - 4-20 sec.

20
Standing hip flexion with knee extension stretch with slow side to side rotation during
stretch - 4-20 sec.
Contract-relax hamstring stretch in standing with foot on stool - 4-10 sec contraction,
4-20 sec stretch.
Sub-maximal isometric hamstring sets - 10 repetitions.
Icing in long sitting for 20 mins.
Progression criteria:
Athletes were progressed from exercises in phase 1 to exercise in phase 2 when they
could walk with a normal gait pattern and do a high knee march in place without pain.
Phase 2
Intensity
Moderate to high
Duration
60 minutes
STATIONARY BIKING
PRONE LEG CURLS
Treatment protocol:
Stationary biking - 15 mins.
Moderate velocity walk - 5 mins.
Supine hip flexion with knee extension stretch - 4-20 secs.
Standing hip flexion with knee extension stretch with slow side to side rotation - 4-20
secs.
Prone leg curls with ankle weight for resistance - 3-10 repetitions.
Hip extension in standing with knee straight using theraband resistance - 3-10
repetitions.
Non - weight bearing foot catches - 3-30 secs.
Icing for 20 mins (only if there is any local fatigue or discomfort).
ICING IN LONG SITTING
2. PROGRESSIVE AGILITY and TRUNK STABILIZATION (PATS) GROUP:

21
Some other authors have described similar programs. As the pelvis is the origin
attachment site for the hamstring muscles, it has been suggested that neuromuscular
control of the lumbo-pelvic region, including anterior and posterior pelvic tilt, is needed
to create optimal function of the hamstrings in sprinting and high-speed skilled
movement. Changes in pelvic position could lead to changes in length tension
relationships or force - velocity relationships.
This has led some clinicians to utilize various trunk stabilization and progressive agility
exercises for hamstring rehabilitation programs.
Phase 1
Intensity
Low to moderate
Duration
40 minutes
Treatment protocol
Side stepping - 3-1 min.
Grapevine stepping in both directions - 3-1 min.
Steps forward and backward over a tape line while moving sideways - 2-1 min.
Single leg stand progressing from eyes open to eyes closed - 4-20 secs.
Prone abdominal body bridge - 4-20 secs.
Supine Extension Bridge - 4-20 secs.
SIDE STEPPING
GRAPEVINE STEPPING
Side Bridge - 4-20 secs on each side.
Icing in long sitting for 20 mins.
Progression criteria:
Athletes were progressed from exercises in phase 1 to exercise in phase 2 when they
could walk with a normal gait pattern and do a high knee march in place without pain.
Phase 2
Intensity
Moderate to high

22
Duration
60 minutes
Treatment protocol
Side stepping - 3-1 min.
Grapevine stepping - 3-1 min.
Steps forward and backward while moving sideways - 2-1 min.
Single leg stand windmill touches of repetitive alternate hand touches - 4-20 secs.
Push-up stabilization with trunk rotation - 2-15 repetitions on each side.
Fast feet in place - 4-20 secs.
Proprioceptive neuromuscular facilitation trunk pull-downs with theraband to the right
and left - 2-15 repetitions.
PRONE ABDOMINAL BODY BRIDGE
SUPINE EXTENSION BRIDGE
SIDE BRIDGE
Icing for 20 mins (if any symptoms of local fatigue or discomfort are present).
Criteria for return to sport:
Subjects were allowed to return to sports when they demonstrated 5/5 strength when
manually resisting knee flexion in prone with the hip in neutral extension, had no
palpable tenderness along the posterior thigh and when they demonstrated subjective
readiness after completing agility and running tests.
5. DATA ANALYSIS AND INTERPRETATION
The calculations were tabulated for easier statistical calculations and better
comprehension. The pre test and post test values of the functional testing profile are
obtained by hop test for height and sprinting test were as follows:
6. RESULTS
The functional performance between pre-test and post-test of the individuals within the
same group are calculated by using dependent 't' test. For sprinting test, the mean
difference obtained for group A is 2.27 and standard deviation is 0.471. Mean
difference of group B is 2.65 and standard deviation is 0.393. In hop test for height, the
pre and post test values are compared within the group and mean difference of group
A is 13.6, where the standard deviation is 1.61. Mean difference of group B is 15.2 and
its standard deviation is 1.94.

23
Performance on the functional testing profile was compared between the Stretching
and strengthening program and progressive agility and trunk stabilization program and
the t values are calculated using Independent 't' test. In sprinting test, the calculated 't'
value is 2.18 with 22 degrees of freedom is greater than the table value, where p=0.05
respectively. In hop test for height, the 't' value calculated is 2.16 with 22 degrees of
freedom which is greater than the table value gives p=0.05. Hence, The p value is 0.05
in both sprinting test and hop test for height, it shows statistically significant difference
between the two groups in their functional testing profile.
7. DISCUSSION
The purpose of this study is to show the effectiveness of STST group and PATS group
for acute hamstring strains. In this study the rate of re-injury is higher in group of
athletes performing hamstring stretching and strengthening exercises, as compared to
a group performing progressive agility and trunk stabilization exercises after return to
sport. The findings in this study shows that functional performance tested on the day of
return to sports between STST group and PATS group showed statistically significant
differences.
Orchard and Best suggests the early loading of the muscle-tendon unit to avoid
secondary atrophy. The progressive agility and trunk stabilization program used in this
study controls the early range of motion for dynamic activities by controlling the
direction of movement. Frontal plane movements will not increase the length of the
hamstring muscle-tendon unit as much as sagittal plane movements. The controlled
direction of movement permits early retraining of quick changes in agonist and
antagonist muscle contractions of the muscles that control hip and pelvis movement.
Some other authors have hypothesized that the ability to control the lumbo-pelvic
region during higher speed skilled movements may prevent hamstring injury.
Progressive agility and trunk stabilization drills do involve a combination of concentric,
eccentric and isometric contractions of the hamstring muscles in various length-tension
positions.
Statistical analysis of the functional testing profile between individuals in the group A
(STST group) and group B (PATS group), P values based on independent 't' test are
0.05 respectively, which shows statistically significant between two groups. Hop tests
for the injured limb are measured in cms and sprinting tests are measured in seconds.
This study has recognised a limitation that, there is no direct evidence that PATS
group had improved the functional performance of the individuals because of improved
neuromuscular control or trunk stabilization.
8. SUMMARY AND CONCLUSION

24
Based on the results from the data analysed, it is concluded that the rehabilitation
program consisting of progressive agility and trunk stabilization exercises is effective in
promoting the better functional performance in athletes on the day of return to sports
than athletes those who completes more traditional isolated stretching and
strengthening exercise program, who have sustained an acute hamstring strain.
Hence, in this study the null hypothesis is rejected.
9. LIMITATIONS
The sample size of the study is small.
The duration of the study is short.
Only the functional testing profiles between the two groups have been assessed.
10. RECOMMENDATIONS
Similar study can be conducted with large samples and in longer study duration.
In the similar study re-injury rates of athletes between two groups can be evaluated.
Similar study can be conducted in other lower limb injuries as well.
The present study may be repeated by selecting of subjects belonging to other age
groups.

25
Injured Athletes Use of Self-Talk.
A sports injury can be serious and cause profound physical and emotional
distress. The physical aspects of the injury can even contribute to loss of a
sports career. The emotional stress of a sports injury can result in affects such
as anxiety and depression which result in obstacles to healing and future
performance (Myers, Peyton & Jensen, 2004). After injury most athletes will
suffer from a change in their mood for a short length of time. This change in
mood will manifest as anger, depression, tension, and low energy levels.
Normally the athlete returns to their pre-injury mental status once they are on
their way to recovery (McDonald & Hardy, 1990)
Sports injuries can have a devastating impact on athletes and the search for
effective psychological rehabilitation methods have been ongoing. One study
using the open-ended Sports Injury Survey found that athletes that healed the
fastest engaged in more positive self-talk, goal setting and healing imagery than
slower healing athletes. It was found that the mental strategy of goal setting
was the most productive technique and scientists believe the reason for this is
that it is easy to learn and is within the athlete's control. The results of the study
would suggest that there are numerous psychological factors that play an
important role in injury recovery. A number of other studies have demonstrated
that speed of recovery was effected by goal setting, attitude, imagery, social
support, and coping skills (Ievleva & Orlick,1991). One study demonstrated that
imagery can be helpful in injury rehabilitation. Imagery is used often in training
and competition, but athletes don't use it as often for recovery from healing and
need to be reminded of its efficacy (Sordoni, Hall & Forwell, 2000)

26
It has been found that an athlete's inability to return to pre-injury performance
levels was due to psychological factors and stressors rather than physical ones
(Evans, Harding & Fleming, 2000). One of the factors with an impact on
performance levels post-injury is the athlete's perceived inability to demonstrate
the same skills they enjoyed pre-injury. One example of this isa rugby player
who returned to the game after suffering a shoulder injury. He favoured the
injured shoulder and used the other shoulder more frequently. The result of this
behaviour was that he put extra pressure on the one shoulder setting himself up
for future injuries (Evans et al., 2000). When an athlete returns to the game
before they are truly ready the risk for more injures or re-injury is increased.
Even if an athlete has been told by his sports physician that they can return to
competition they may not be ready psychologically (Evans et al., 2000). Cupal
(1998) claims evidence exists that indicates when an athlete returns to the sport
before they are psychologically ready they increase the risk of more injuries
There are different approaches to explaining how an athlete responds to injury.
One of these approaches is designated the cognitive appraisal approach. This
approach focuses on the athlete's perception of the injury and it offers an
explanation for individual differences in responses to injury and their perception
of the injury (Brewer, 1994). Brewer (1994) believes that one of the positive
aspects regarding the cognitive appraisal approach is that it offers explanations
for the diverse responses to injuries unlike other methods that don't provide
such insight. There are a number of influencing factors with cognitive appraisal.
The individual personality characteristics of the athlete that remain constant
over time are a factor. Another factor is the athlete's changeable situation which
they have no control of. One example of this is time of season of the injury
(Gayman & Crossman, 2003).
A study of the psychology of season ending injuries amongst skiers from the
USA Ski Team was conducted (Gould, Udry, Bridges & Beck, 1997a; Gould,
Udry, Bridges &Beck, 1997b). This study included lengthy interviews and
revealed different factors of the injury experience. Researchers discovered that
some athletes received what they perceived were benefits from the injury. If
they had a problem with the stress of the competition they may see this injury
as a blessing in disguise and a way out. Performance anxiety can be another
reason why an athlete sees the injury as beneficial. Also, rehabilitation can be
physically painful and emotionally trying (Gould et al., 1997a). Other factors
researchers uncovered were the sources of stress, social support systems, and
coping strategies. In some instances a severe injury can interfere with social
activities especially if they are sports-oriented (Bianco, Malo, & Orlick,1999).
Bianco et al. (1999) interviewed skiers from the Canadian Alpine Ski Team.
What they learned was that there was an early phase when the athlete is

27
injured or ill and then they move into a phase of rehabilitation where they begin
to recover, and the last phase is when they are fully recovered and back to pre-
injury activity. Every one of these phases included a set of events that
influenced the emotional and cognitive responses (Granito, 2001, pg. 63).
Researchers looked to cognitive appraisal to explain why some athletes suffer
from greater psychological distress following an injury than others (Brewer,
1994). What they found was that the manner in which an athlete perceives the
injury experience plays an important role in how well they recover and are able
to return to pre-injury performance levels (Brewer, 2001, as cited in Gayman &
Crossman, 2003).
The time of the year when an athlete is injured may determine how well and
fast they recover and return to competition. For example, one athlete may be
distraught and stressed over being injured post-season because after all his
hard work and team effort he will not be able to participate in the play-offs.
Another athlete may regard the injury as beneficial because they can get out of
a horrendous season where the team didn't do very well. The athlete who
perceives the injury in a more positive light will have an easier time of recovery
than the athlete who experiences more negative emotions surrounding the
injury (Gayman & Crossman, 2003)
Pre-season is important because after a break from sports the athletes are
ready to get back in the game again and are looking forward to try-outs. An
injury sustained pre-season can be regarded in different ways. The more
severe the injury is the greater the athlete's frustration and disappointment
(Gayman & Crossman, 2003). An injury that isn't serious enough to keep the
athlete out for the entire season may not be as devastating for some because
they become motivated to heal and spend the rest of the season in the game.
Different factors enter the picture for mid-season injuries. An athlete who is out
due to injuries during mid-season can be more stressed because by this time
the team members are bonding. The athlete will also have lost some of their
physical abilities that are important to the game. The team has been traveling
and playing many games together by mid-season and the injured athlete will
feel that they are missing out on the camaraderie and fun (Gayman &
Crossman, 2003). When an athlete is injured end of season the success of the
entire team may be hindered and this is a source of great stress and
disappointment for the athlete. If it's the athlete's last year of college, for
example, the injury could end his career in sports. If the injury is severe enough
regardless the season; it is devastating for the athlete and requires different
and more intense coping techniques (Gayman & Crossman, 2003). Finally, the
playoffs are important because the team has bonded and worked hard together
for an entire season to get that far. Injuries sustained during this time could

28
hamper efforts for the championship title not to mention the personal
satisfaction of success (Gayman & Crossman 2003)
How an athlete reacts to their injury may be based on how they personally view
the situation. For instance, injury in pre-season may be regarded more
negatively by one athlete than another. It all depends on how they perceive the
situation (Gayman & Crossman, 2003). There are different factors in the injury
recovery process. One of those factors is gender differences. One study found
there were differences in the perceptions of male and female injured athletes. It
was found that male athletes had reported a more positive relationship with
their coaches than the females. Males also were more apt to have a special
person in their lives that they received emotional support from. It was
discovered that female athletes were more apt to worry about how their injuries
would affect their future health than the males (Granito, 2002). Regardless of
male or female, it would appear that a good social support network and positive
relationships with coaches are important when an athlete sustains an injury.
There are, however, more factors involved in the success of an athlete's
rehabilitation and recovery than that of emotional support from others. Other
interventions and coping mechanisms involve goal setting, imagery, and self-
talk (Ievleva & Orlick, 1991)
There are numerous psychological intervention strategies for rehabilitation from
sports related injuries. Oftentimes the athletes' erroneous thoughts about
intervention strategies keep them away from getting the help they need to
recover more quickly and fully. The interventions could help them return to
competition not only physically ready but psychologically ready as well. Due to
a lack of knowledge and understanding leading to faulty beliefs about
intervention strategies the athlete doesn't always get the help they need. The
efficacy of any post-injury therapy or treatment depends on the ability of the
athlete to accept and receive different techniques and strategies (Myers et al.,
2004).
One of the strategies in treatment for sports injuries that isn't fully understood is
that of positive self-talk. Self-talk in injury recovery is even less understood than
other techniques and strategies even though athletes do use it for performance
improvements. Athletes have used both self-talk that is instructional in nature
and self-talk that consists of positive affirmations (Van Raalte, Cornelius,
Brewer, & Hatton, 2000). Self-talk has been recognized as an effective tool for
improvements in performance but unfortunately, has not been given as much
thought as a strategy for recovery from injury. One reason that has been given
to explain why there is a lack of knowledge regarding self-talk and its
importance to recovery from injury has to do with understanding the
fundamentals behind performance improvement in sports (Hardy, 2005)

29
There is a relationship between performance improvements and self-talk. It has
been suggested that it's the aspect of self-talk that involves functionality that
sheds light on its relationship with performance. This includes the cognitive and
motivational aspects of self-talk (Hardy, Gammage, & Hall, 2001a).
Theodorakis, Weinberg, Natsis, Douma & Kazakas (2000) investigated the
efficacy of self-talk with athletes using positive self-talk in proportion to the
specific demands of their physical activity. Instructional self-talk was used for
the technical demands and motivational self-talk was used for less technical
demands such as the athlete's strength and stamina. The researchers expected
that instructional self-talk would be more effective when the demands of the
activity involved skills and accuracy and the motivational self-talk would be
more effective when the demands involved strength and stamina. The results
demonstrated that instructional self-talk for technical demands met the
researcher's expectations, however when the demands were for motivational
self-talk the results weren't as expected (Hardy,2005). The researchers
discovered that both types of self-talk generated an increase in performance in
the activity of leg extensions but not in the activity of sit-ups which requires
stamina. Theodorakis et al. (2000) believe one reason for this outcome is that
there wasn't an equal distribution of males and females for the study thus
affecting the results. Theodorakis et al. rightly calls for more research in order to
determine why positive self-talk (or negative) impacts athletic performance
(Hardy, 2005).
One factor that may impact the effectiveness of self-talk on an athlete's
performance is how they interpret their self-talk as far as it relates to motivation.
The athlete may regard their self-talk in either a negative or positive light
(Hardy, Hall, & Alexander, 2001b). If an athlete regards their self-talk asde-
motivating it certainly not help them recover faster and can even keep them
from getting back to pre-injury performance levels. Theodorakis et al.(2000)
explains that the lack of differences across groups in his study is that there are
motivational aspects to the instructional self-talk and some of the self-talk used
by the athletes may have been either motivating or de-motivating. Self-talk is
supposed to be positive for the athlete. The attitude of the injured athlete is
important to their recovery. If the athlete is optimistic their chances of recovery
are greater and they have better coping mechanisms. Suggestions to
encourage the athlete are for them to use only positive words, language and
tone, during the rehabilitation-in and out of the clinic (Mind, Body, pg.1).
Examples of positive self-talk are: "I will get through this" "I will recover fully" "I
will get back to playing my sport, better than I was before" "I will get 115
degrees of flexion today" (Mind, Body, 2005, pg. 1). These self-talk strategies
will create a more positive and healthy mind set in the injured athlete (Mind,
Body,2005). In a study with tennis players it was found that instructional self-

30
talk had a positive outcome on performance but not on self-efficacy (Landin &
Hebert, 1999). It is suggested then that practitioners determine if the athlete
finds self-talk is to be de-motivating or motivating. An athlete can learn to
perceive themselves in a healthier and more self-affirming manner by engaging
in positive self-talk (Hardy, 2005).
The speed with which an athlete recovers from injury can be increased by using
certain mental strategies. It is up to the athlete and their physician to determine,
in light of the patient's situation and personal preferences, what would be the
best strategy to ensure a rapid and full recovery from injury. The athlete and
their sports doctor can be creative in coming up with what techniques seem to
fit. Special attention should be given to the psychological state of the athlete
and the seriousness of the injury. A comprehensive approach to injury
management has been proven to be successful through research suggesting
that by using more goal setting, positive self-talk, and imagery, athletes recover
more quickly from injuries (Mind, Body, 2005, pg. 1)
Self-talk is useful for injury recovery and quite often for the management of
physical pain and distressing emotional states. Self-talk is described as, .the
endless stream of thoughts that run through your head every day (Chronic Pain,
2005, pg. 1). This self-talk or automatic thinking can be positive or negative and
based on logic and reason (Chronic Pain, 2005, pg. 1). There are times when
self-talk can be negative and based on faulty perceptions due to inadequate
information. In order for self-talk to be effective for recovery from injury the
faulty thinking must be recognized and changed. In order to recognize the faulty
thinking it's important to recognize the different categories of non-productive
thinking. One method of thinking that is not positive self-talk is generalizing. An
example of this is when the individual regards one event as a trigger for a never
ending series of negative events. As the pain continues the individual thinks
they will not be able to carry on as before and they begin to devalue
themselves. Another example of negative thinking is when the individual thinks
in terms of catastrophes. With this type of thinking the individual imagines the
worst case scenario. For example, they imagine that the pain from the injury will
become a problem and they will become embarrassed if out in public or with
friends (Chronic Pain, 2005). Another example of catastrophic thinking is when
the athlete thinks things will never change and they will never get any better
(Lake, 2005). Polarizing is another thinking style that leads to negative self-talk.
This is when the individual sees everything as black and white, good or bad,
positive or negative. They cannot concede that there is oftentimes a place in
the middle. One of the more serious consequences of this thinking is that the
individual feels they have to be perfect or else they are a failure; there is no
acceptance of the fact that they are human like everyone else and can make

31
mistakes while not seeing themselves as losers. Filtering is when the individual
looks at the negative thoughts in a situation through a magnifying glass and
minimizes the positive thoughts. One example given of this is when the
individual did a great job at work that day but when they get home they realize
they forgot to do one thing. The entire evening is ruined because the individual
sits there and ruminates on that one task they failed to do. All the accolades
they received that day from boss and co-workers is forgotten and only the
negative is focused upon. Another negative thinking pattern that leads to
unhealthy self-talk is that of personalizing. When something unpleasant,
unfortunate, or bad happens the individual thinks that they are blame, even if
it's something out of their control and has nothing to do with them.
Emotionalizing is thinking where the heart rules the head. Objectivity is pushed
aside for irrational thinking. One example of this is if an individual feels they are
dull or stupid and therefore they believe that is what they are (Chronic Pain,
2005).
This type of thinking is dangerous for the athlete especially one who is
recovering from an injury. The athlete must recognize the negative thinking and
begin the exercise of positive self-talk. An interesting rule of thumb regarding
the process of positive self-talk is as follows:
Don't say anything to yourself that you wouldn't say to someone else
Be gentle and encouraging. If a negative thought enters your mind, evaluate it
rationally and respond with affirmations of what is good about yourself.
Eventually your self-talk will automatically contain less self-criticism and more
self-acceptance. Your spontaneous thoughts will become more positive and
rational. (Chronic Pain, 2005, pg. 1)
What people say to themselves all too often sets the stage for how they look at
life and what they do about it. One example of this is when the individual comes
home after a day of working and says, I don't want to exercise today. It's cloudy
outside, there's no one to walk with, and besides, I've already exercised twice
this week (Managing Your Pain, 2005, pg.1). A more positive way to respond to
this situation is to say, "I don't feel like exercising today, but I know I'll feel better
afterward and have an easier time falling asleep" (Managing Your Pain, 2005,
pg.1). These examples are very important in retraining the mind to engage in
positive self-talk. The self-talk one engages in can literally change the way an
individual experiences physical pain. Negative messages can lead to increased
pain, while positive messages can help distract you from pain (Managing Your
Pain, 2005, pg. 1)
There are several steps to take in order to change negative self-talk that leads
to increased pain into positive self-talk which speeds up the healing process

32
and leads to decreased pain. The first of these steps is for the individual to
make a list of all negative self-talk engaged in. The second step is to change
each negative statement on the list into a positive statement. One example
would be the following, I'm tired and don't feel like attending my support group
tonight, but if I don't go I might miss out on some good tips like the ones I
learned last month. I can always leave the meeting a little early" (Managing
Your Pain, 2005, pg. 1). The third step is to practice the positive self-talk. Even
though it doesn't come naturally and may take some time to become
comfortable with keep at it until it becomes second nature (Managing Your
Pain, 2005, pg. 1).
Injuries Associated With Tenpin Bowling Health And Social
Care Essay
Published: 23, March 2015
Tenpin bowling is an indoor sport in which a player scores points by striking down as
many pins as possible with a bowling ball rolled along a wooden or polyurethane lane.
According to an estimate, more individuals play bowling than any other sports; with the
notable exception of football. Also, bowling is considered to have more registered
players than any other competitive sport. The governing body for bowling, FIQ
(Fédération Internationale des Quilleurs) has been pushing for Olympic
recognition for the game.
Many theories abound regarding the origin of bowling. According to some, the
beginning of bowling dates back millennia. In 1930, the British anthropologist, Sir
Flinders Petrie, while excavating a grave in Egypt, found objects similar to bowling
balls and bowling pins.
Others are of the opinion that bowling originated in Germany about 1700 years ago.
Kegal, as it was then called in Germany, was played using 9 pins as opposed to 10
pins used in the modern game. The first textual reference to bowling comes from
Britain. King Edward III, in 1366, supposedly banned his soldiers from participating in
the game since it proved to be a major source of distraction for their duties.
Bowling in America was introduced by the Germans, the Dutch, and the English. The
Germans were, however, mainly responsible for the rise in popularity of the sports in
and around the American Civil War.
The immediate post-Second World War era is considered to be the 'golden age' of
bowling. Immense rise in popularity was witnessed during these years. For the first

33
time, the game came to be seen as one to be played and enjoyed by the masses.
Introduction of technology in the form of semi and fully automatic pinspotters during
this time was also a contributing factor. Introduction of television lead to increased
popularity of all sports; bowling was no exception. In the 1980s, computerised systems
made scoring simpler and the game more enjoyable. More recently, recognising the
importance of family entertainment centres, bowling alleys are being constructed as
parts of leisure centres and shopping malls. Electronic versions of the game including
PlayStation, Jamdat, and Brunswick Circuit Pro, to name a few, are further adding to
the popularity of the sport.
Types of Injuries and the associated mechanisms
Although, bowling is not a contact sport, it has its shares of injury risks. Injuries due to
chronic repetitive stress as well as faulty techniques can cause injuries in bowling. Use
of a ball which is too heavy can also, over time, cause injuries. Repetitive lateral
flexion, twisting, extensions as well as tremendous ground reaction forces acting on
the lower back and knee, in particular are causes of concern. Since, overuse injuries
are more common in bowling, the number of times an individual bowls per week
assumes significance. Keeping track of the work load can help competitive athletes
peak at the right moments for an important tournament.
Acute injuries like back, leg or arm injury due to a fall during approach, hand or parts of
the body getting caught in the ball retriever, as well as wrist and finger dislocation or
sprains due to fingers getting caught in the holes of the ball are quite common place.
Anatomical Sites of Injury
More often than not, injuries in bowling involve the upper extremity, chiefly fingers,
wrists, elbow and shoulder. However, knee and lower back injuries are a common
occurrence as well. Occasionally, injuries due to fall can occur, especially in novice
players and involve a variety of anatomical sites.
Upper Extremity
Finger sprain
These are caused due to damage to the ligaments due to movements in excess of that
allowed at a particular joint. Symptoms involve swelling, pain during movement,
restriction of movement and in severe cases, instability of the joint.
Thumb sprain
Similar to finger sprains, symptoms include pain and swelling over the base of the
joint, pain on movement and in the webbing between the thumb and the forefinger.
Severe cases are characterised by instability of joint. Treatment involves usual
application of the RICE principle. Early mobilisation during rehab is usually

34
warranted. Injuries with instability either occurring acutely or as a residual component
require surgical intervention.
Carpal tunnel syndrome
Repetitive activity as well as trauma or fractures which reduce the space in the carpal
tunnel formed by the wrist bones on beneath and a band of fibrous tissue over it can
cause Carpal tunnel syndrome. Impingement of the median nerve is immediate cause
of the syndrome. It is characterised by tingling numbness with weakness or pain over
the hand or fingers. Some authorities suggest worsening of symptoms nocturnally.
Diagnosis is usually clinical but an EMG study can confirm the diagnosis.
Biceps tendinopathy
'Biceps tendinopathy' is a general term used to describe a variety of injuries involving
the tendon of origin of the biceps. As the names suggest, tendinitis and peritendinitis
involves inflammation of the tendon or tendinous sheath. Chronic micro trauma due to
repetitive nature of activity with minimal rest is mainly responsible. Degenerative
change in the tendon is referred to as tendinosis whereas degenerative changed over
a bony prominence due to repetitive movement of a tendon is called tenosynovistis.
Pain over the bicipetal groove (front of the shoulder) radiating down to the elbow,
which increases in intensity on shoulder flexion, elbow flexion or forearm supination
(actions of biceps) is the hallmark of diagnosis of bicipetal tendinopathy. Seldom seen
as a single entity, it usually accompanies injuries of the shoulder such as a rotator cuff
tear.
Modality of treatment specific to this type of injury involves scapular stabilisation.
Strengthening of trapezius, serratus anterior muscle and latissimus dorsi is usually
advocated. Correction of posture with conscious efforts of 'pinching' the shoulder
blades together as well as use of posture braces forms an important part of treatment.
De Quervain's tenosynovistis
Pain over the thumb side of the wrist, with or without swelling, and presence of
crepitus is diagnostic of the condition.
Inflammation due to repetitive movement of tendons of two small muscles of the
thumb, Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB), over the
lower part of radius bone leads to this condition. Holding the heavy ball, wringing as
well as pinching, over a period of time, is thought to be the cause de Quervain's
tenosynovistis. Previous injury with subsequent scar tissue at the site as well as a
generalised disease like arthritis also contributes to the aetiology of the condition.

35
Along with routine treatment, use of a thumb spica splint is considered important in
rehabilitation.
Lower extremity
Ankle sprains
Sudden change of direction, twisting, improper landing and falls; with the ankle joint
bearing most of the brunt causes ankle sprains. Pain, bruising swelling, bleeding into
the joint and varying grades of rupture of the supporting ligaments can occur. In severe
cases, bones may be involved.
Most commonly, the lateral ligament (on the outer aspect of the joint) is injured.
Inversion sprains are considered to be responsible. However, deltoid ligament sprains
(on the inner side of the joint) can also occur.
An important aspect of rehabilitation of ankle injury is the use of wobble boards or
trampoline to improve balance and proprioception.
Knee joint ligaments injuries
Similar to the ankle joint, sudden change in direction, twisting and improper landing
can lead to injuries to the knee joint. Most commonly involved structures are the
ligaments of the knee joint, namely, the cruciates, the menisci or the collaterals.
Pain, bruising, swelling and instability of the joint are the usual features. Depending on
the grade of injury, healing may require between four to twelve weeks. Use of knee
braces forms an important part of rehab of knee ligament injuries. Sever grades of
injury may require surgical reconstruction of structures.
Patello-femoral Syndrome
During ball release, the body balances on the front leg with flexed knee. In addition,
there is twisting of the trunk to the same side. At this moment tremendous ground
reaction forces act on the front knee. Such stress over time can cause patello-femoral
syndrome. Chronic bearing of body weight on a semi-flexed knee with resultant
grinding of the patella over the femoral bone and subsequent inflammation is
considered to cause the condition. Symptoms include gradually increasing pain in the
front of the knee, typically felt while climbing a flight of stairs. Over period of time,
simple activities like sitting in a chair, kneeling and jogging causes pain.
Faulty foot structure as well as mal-alignment of the leg can also cause the syndrome.
Important aspects of rehabilitation include VMO and glutes strengthening, use of
braces to strengthen surrounding structures and orthotics to correct structural
abnormalities, if any.

36
Shoulder injuries
The shoulder goes through various movements during different stages of bowling. In
the cocking phase, before delivery of the ball, abduction, posterior flexion and external
rotation occurs. During release, there is forceful adduction with forward flexion and
internal rotation which is followed by sweeping of the arm across the chest during
follow through. This multitude of actions can cause shoulder ligaments tears,
impingement syndromes (involving tendons of the rotator cuff or biceps), etc.
Lower back
Injuries affecting the lower back in bowling can be due to muscle fatigue, undue and
sudden stretching of stiffened muscles, improper techniques of bowling and repetitive
trauma with minimal strengthening program and rest.
In addition, muscle strains or spasms involving the quadriceps, hamstrings or the
adductor group of muscles can also occur.
Preventive Measure for Injuries in Bowling
A general plan for staying free from injuries in bowling should involve:
Use of proper technique: inputs from your coach to improve technique and reduce
injury risks
Designing and implementation of a fitness regimen: Strengthening of musculature and
supporting structures forms the first line in the prevention of injuries. Particular
emphasis on finger and wrist strength as well as muscles specific to bowling like
quadriceps, hamstrings, and adductors is called for. Flexibility training for the back,
legs, arms and wrists is as important, if not more, as resistance training. Additionally,
cardiovascular fitness training is recommended for a minimum of 3 days a week
Warm up: for up to 20 minutes, include cardio work or calisthenics (exercises using
body weight). This gets the blood flowing, making the muscles warm and flexible
Stretching: with specific emphasis on muscle used in bowling like quadriceps,
hamstrings, shoulders, and lower back.

37
Injuries Within Sports Games Physical Education Essay
A great number of injuries occur in the context of recreational rugby games. It has
been generally presumed that after a sports injury, the sports injury management
programme is highly depend on compliance to sports physiotherapist recommended
rehabilitation regime. Even the best treatment plan made by sports therapist specially
designed for the patients could not guarantee that the patient would follow that
treatment plan. Effectiveness of the specially designed treatment plan depends on the
compliance of the patient. Compliance to the sports injury management program is
generally less then hundred percent (Spetch and Kolt, 2001). Bassett (2003) found
that 65% of athletes are either, following their rehabilitation program fully or partially
and 10% of athletes did not follow their specially designed sports specific treatment
plan at all.
The England Rugby Injury & Training Audit, the world's largest continuous injury
study in professional rugby union, carried out by Kemp et al (2009) reported that the
sixth season of the study recorded 769 match injuries from the Guinness Premiership,
EDF Energy Cup and European competitions and 258 training injuries. Simon et al
(2009) pointed out that the likelihood of sustaining a match injury increased in the
2008-9 season, reversing the downward trend that had been established since the
2002-3 season.
For an early return to sports, when amateur rugby players were injured, they need
sports specific injury rehabilitation. Since the sports therapist is the first point of contact
after the rugby player is injured on the pitch, they the sports therapist are, therefore in
a sole position to analyse the player's health status and to impact the sports specific
injury treatment.
Sports therapy is a vibrant profession that entails a sports therapist to be proficient in a
number of different specialities. Although, the sports therapist must be qualified and
experienced to take full charge of the physical side of the sports injury 39

38
treatment, for a sports therapist simply to know how to investigate, analyse and treat a
sports injury is not an adequate enough to guarantee that an amateur rugby football
player is able to be rehabilitated as swiftly and effectively as possible. An imperative
feature of the sports physiotherapist responsibility is to approach concerns of
adherence to the sports specific injury treatment, and to communicate effectively with
the player to make sure that they endeavour the essential ability to speed up their
rehabilitation. The sports therapist acknowledges the significance of psychological
factors in sports specific injury management adherence (Board of Certification Role
Delineation Study, 2004).
It is important that the therapist gets qualification and training in the psychological side
of the players' injury, although most accept that they did not get any sports
psychological rehabilitation training (Roh & Perna, 2000). Nevertheless, identifying the
variables that are significant in promoting adherence and incorporating approaches to
deal with these factors is a complex matters. Shuer & Dietrich, (1997) argued that
practitioners have investigated sports injuries from orthopaedic standpoint, but
psychological treatment of amateur rugby players has not been fully addressed.
Fisher, Mullins & Frye (1993) argued that literature, concentrating on sports specific
injury treatment, could be divided into three distinctive categories; sports therapist
communication with the player, sports specific injury management features and injured
amateur rugby player's characteristics. Researchers have found that the players'
responses and awareness have been affected by their psychological attributes. To be
close to the sports therapy clinic enhance participation and a friendly atmosphere is
favourable to the sports injury rehabilitation adherence (Fisher & Hoisington, 1993).
Prentice (1994) stated that amateur rugby players opinion of the sports therapist also
influence the association between the player and the sports therapist and affect the
sports injury adherence. Investigating the perspectives of this professional affiliation
can improve the sports physiotherapist concepts of the amateur rugby players'
attitudes of, and contentment with, their sports therapist (Fisher & Hoisington, 1993).
Unruh (1998) pointed out that if the rugby player is satisfied with the sports
physiotherapist injury rehabilitation management, then he/she would have more self
assurance in the sports therapist during the sports specific injury rehabilitation
management program.
Fitzpatrick (1991) argued that patient contentment studies with their sports therapists
supported the principal that if the rugby players' are more satisfied with the sports
therapist, the more they will trust him/her. Even though, the association between the
sports therapist and rugby players' is decisive, none of the research examined that
how a sports therapist can formulate or constitute a connection to optimize their
adherence.
Brook et al (2005) argued that in the last decade amateur rugby players got injured at
a higher rate. Since a quick return, and continuation in performance, is directly

39
related to the results of sports injuries, how an amateur rugby football player deals with
it, then further research concerning the psychological side of players' is ever more
significant. However, the majority of literature that has focused on injury rehabilitation
has concentrated on the musculoskeletal aspects and until recently has ignored the
emotional feature that could potentially play a significant role for professional athletes.
With some exceptions the psychological research to date has mainly concentrated on
specific factors that influence an athlete's rehabilitation, such as social support
(Bianco, 2001), adherence (pizzari et al, 2002), self confidence (Magyr and Dua,
2000), coping and psychological skills.
Tracey (2003) has suggested that both primary and secondary appraisals fluctuate
depending upon the personal and situational factors of each individual athlete.
However, there are significant relationships between the primary and secondary
appraisal and copying strategies. Shelly (1999, p. 306) called for further investigation
into the unique perceptions and perspectives of injured athletes during rehabilitation as
a means of adding depth to the research. The use of qualitative data collection on
multiple occasions allows injured athletes to reflect on their experiences as they
happen and to scrutinize changes over time (Podlog and Eklund, 2006).
Adherence has been defined as "an active, voluntary involvement of the patient in a
mutually acceptable course of behaviour to produce a desired preventative or
therapeutic effect. Adherence behaviour in sports injury rehabilitation may include
clinic-based activities, modifying sports activities, taking medications, and completing
home based activities. A number of sources, including surveys with sports medicine
professionals, and research studies, suggested that low and non-adherence could be
an issue in sports therapy practice.
In the last decade the primary focus of the studies, carried out by researchers, to
investigate the sports injury rehabilitation was to identify predictors of adherence
behaviour. Brewer (2004) argued that in order to draw conclusions about the most
significant issues affecting adherence to sports specific injury rehabilitation, additional
research is required. Qualitative research proposes a complementary approach to
quantitative studies in understanding sports specific injury rehabilitation in amateur
rugby football players. Qualitative research also outlines new factors for contemplation
and provides further support to previous findings.
The purpose of this qualitative study was to explore amateur rugby football player's
experiences and perceptions of adhering to a sport injury rehabilitation program. In this
study, the researcher used interviews to investigate their attitudes and contentment
with their sports therapy rehabilitation. Qualitative research methodology focuses on
individuals' lived experiences as they are presented in thoughts, ideas, feelings,
attitudes, and perceptions. Stake (1995) suggested that qualitative research gives a
new approach to finding out more knowledge into the multifaceted association which
took place during sports injury management.

40
This study would explore the status of research on the sport injury rehabilitation
adherence. Studies identifying variables that are correlated with adherence would be
synthesized to produce a body of knowledge that will aid in the explanation of
individual behavioural responses towards injury rehabilitation programs. From this
qualitative investigation, using thematic coding of the interview data, categories of
variables influencing adherence would emerged. In this study, the researcher would
analyse acquiescence among armature rugby football players during rehabilitation.
In order to improve amateur rugby football players adherence to the sports specific
rehabilitation programme, strategies would be outlined for the sports physiotherapists.
The predictors of sport injury rehabilitation adherence would be discussed, strategies
to enhance rehabilitation adherence would be reported, and considerations for future
research would be suggested. This study would provide valuable information that
could be used by researchers and sports therapy practitioners to identify strategies
that should enable sports therapists to structure an independent supportive
atmosphere that would promote higher levels of self-regulation, enthusiasm, and
strength of mind. This will help to improve adherence to the rehabilitation programmes.

41
Investigations On Sports Injury Treatment Plans
Published: 23, March 2015
The subsequent account accentuates subordinate themes expressed by participants
regarding their knowledge and understanding of compliance to a sports injury
treatment plan. The subordinate themes to emerge focused around key issues
regarding lack of time, support from the therapist, communication with therapist,
motivation, presence of therapist during exercise, confidence, importance of therapy
sessions, social support, pain, and attitude towards exercises.
Home Exercises - Lack of time
The important aspect affecting the completion of home exercise was reported to be
lack of time. Compliant participants tended to identify time availability as a factor in
adhering to rehabilitation but also emphasized the need for greater organization when
time was limited.
"Yes, actually, I did all exercises regularly at home, because I had injuries in the past
and I did not have proper sports therapy rehabilitation for that. Due to no proper
rehabilitation for my old injuries, now I am having problems. I was more aware of the
fact that I should be doing my exercises when I was told to do those exercises this
time round, so I did all the exercises at home regularly. You have to prioritise and you
get to be good at doing that, you know, in your mind you're already thinking "I've
planned this and planned that, and we can do it you know. . . . " (Marion)
From Alison's account, it appeared that she was regular in her therapy sessions
because she wanted to get fit and play again.
"I was doing my exercises regularly every day. I hate to be injured, and I get frustrated.
I was attending clinic once a week and doing all the exercises at home everyday to get
fit" (Alison)

42
From Andrew's quote, it was interpreted that though he did not have a sports specific
rehabilitation programme, he was making the effort to do some exercises.
"Yeah I have been doing any exercises at home. I was doing just press ups here and
there, no any specific home rehabilitation programme" (Andrew)
For Gordon adherence to home exercises is important to get back to match fitness
"Yes, I was doing all the exercises at home quite regularly because I wanted to get my
match fitness back. I was doing some exercises at home with thera-band and range of
movement exercises" (Gordon)
Time is of the essence with injury rehabilitation of amateur rugby players as a player's
work schedule and other family related commitments can be significant obstacles to
home based exercises. A profusion of work, and social commitments reduced the
amount of time available for the home exercise programme.
"When after school, I was coming back, I was working all night long. I was very very
tired. It was very difficult to fit in a home rehabilitation program in my time at home.
There were definitely time constraints. I was really tired after work in school and then I
have to do all the marking, planning and assessments. Because of my course, the time
I should have been spending on my knee rehabilitation was just not possible"
(Christine)
Christine's account highlights her difficulty in managing time effectively due to her work
and busy schedule. Diane introduced other issues that she found particularly
challenging when undertaking rehabilitation:
"Sometimes, I did exercises other times I did not. I was really busy at times. I was
doing them whenever I got some spare time. I did not have a good routine for
exercises. Maybe if I had a better routine of doing them, say every morning after
breakfast or before going to bed and stuck to it. But I have spare time now, so I do it
now. It was really a bit ad hoc" (Diane)
It is clear that Diane had difficulty scheduling her rehabilitation around other areas of
her life and, as a result, she was unable to do her home rehabilitation regularly, as she
should have. Chapel indicated that as a PE teacher he had enough exercises at
school and he could not do more.
"Not very often, no, I did not do much exercise at home. I do exercise at work, do
training, and play football" (Chapel)
In David's view, doing exercises at clinic is enough and he can keep home exercises
minimal
"Yeah I have done exercises only when I was getting in and out the bed, not every
day" (David)

43
This was mainly accurate for the noncompliant participants in the study, but it was also
noted that short of time was often used as a justification for noncompliance regardless
of sufficient time being available.
Support from Therapist
The informational and emotional support provided by therapists throughout sports
injury treatment sessions was important to all participants. Particularly in the initial
stages of rehabilitation, information regarding the injury and rehabilitation process was
thought to be vital for compliance. When information was lacking, noncompliance
resulted.
"Yeah, actually, I was very lucky that as soon as I was injured, the therapist assessed
me. The therapist gave me the same diagnosis as the consultant after the scan. The
information given to me throughout my rehabilitation was brilliant" (Marion)
Encouragement from the therapist, the comfort, and convenience of the rehabilitation
clinic, and the constant progression of therapy rehabilitation exercises were important
influences on attendance at the Club's therapy clinic for all participants. Diane recalls:
"My therapist was very good at that time. She explained to me about the injury and its
treatments. She was always friendly, co-operative and approachable" (Diane)
Lack of understanding about the injury and rehabilitation plan were viewed as being
major contributors to poor compliance. Chapel emphasised that to know about the
injury and the management plan is important for good compliance
"Therapist told me that I had torn my ligament in my lower back. He explained that was
the reason I could not move. The therapist has known me for a long time. He knows
my problem. That is why he quickly assessed and diagnosed my problem. If I did not
come due to work problems, he fully understands that" (Chapel)
Communication with Therapist
The most important part of the rehabilitation process for most participants was their
communication with their therapists. Therapists were described as, gracious, friendly,
knowledgeable and supportive, and most participants pointed out that their positive
relationship with the therapist helped with attending the clinic and completing therapy
sessions.
"Yes, I trust her completely as she knows a lot more than I do. I trust the therapist
more than the surgeon. At one point, he did not allow me to flex and extend my leg. I
thought it was wrong as I can lose all mobility in my knee joint. The therapist
suggested that I should keep moving my knee joint to maintain my ROM" (Christine)

44
Open interaction gives amateur players the opportunity to make a contribution to the
decision making process related to their injury treatment plan, and the increase in
autonomy linked with taking ownership and responsibility is connected with higher
levels of self-regulation. The therapist was described as gracious, friendly,
knowledgeable, and supportive.
"When I was injured the therapist told me what the injury was, and what will happen
and the best exercises to do, sort of time line for pain, stuff like this. She did give me
all the information. The therapist is cooperative and friendly. She is as if you not turn
up, it's your performance hindering. It is not the case she has no other people to see. It
is end of the day you are wasting your time" (Alison)
Some of the participants pointed out that the therapist did not explain any information
about their injury.
"In accident and emergency the doctor explained me about my injury. In sports therapy
clinic the therapist did not explain me anything about my injury, which I did not find
helpful. He also did not explain me what will be my rehabilitation programme, he just
after short assessment, started treatment" (Andrew)
In Gordon's view not knowing, the treatment plan could be a reason for non-adherence
"The Orthopaedic surgeon, in hospital told me that my shoulder was dislocated and he
put it back. But the, therapist in private therapy clinic did not explain me what
happened to my shoulder and what would be treatment plan?" (Gordon)
Motivation
The most important psychological attribute was that of self-motivation. All participants
throughout the interviews used the word motivation, constantly, and perceived to be
particularly important for completion of home exercises.
"I have been training for four months now trying to get back to fully fit season to play
best season I can get. Therefore, it has been a long slop to get to the point, where the
season will start. so I am pretty determined that I say the most effective things I have
been doing is to trying get my shoulder ready for the season" (John)
John's experiences suggest that motivation was a facilitative influence during their
rehabilitation. Despite this, however, Andrew goes on to declare a negative affective
state, generated because of too much motivation.
"Well, I was a bit too motivated, that is why I came back to player too early after my
first injury. That is why I re-injured my same shoulder again. I learned from this
experience. After my second shoulder injury, even though I was eager to come back
as soon as possible, I absolutely made sure that I would get fully fit and then return to
game" (Andrew)

45
Compliant respondents talked of being motivated throughout the rehabilitation process
whether external influences were present or not.
"I was extremely motivated. I hated not to play. I hated to be injured. I wanted to come
back to player as soon as possible. I wanted to make sure that my arm is strong
enough to be able to play again, that's why I was doing exercise at home as well to
make sure my arm is same as before injury" (Alison)
David's account captured the level of enthusiasm, he has to get fit again as he hated
to be an spectator
"Obviously, I wanted to play again as soon as possible, as season was underway. I
was very keen to play again as I did not like to watch from bench" (David)
The compliance respondents displayed greater self-direction of rehabilitation. They
controlled the amount, intensity, and progress of rehabilitation, relying less on
therapists' input.
"I wanted to come back and play, definitely. I get really frustrated because I could not
play. I don't make sense in some ways that I was not doing my exercises more and
sometimes I was not sure if those exercises were working or not? That was probably
the reason, I went to see cranio- skeletal specialist. It helped me a lot and he was also
not prescribing home exercises" (Diane)
Some of the participants acknowledged the importance of being motivated in order to
sustain rehabilitation activity. For instance, Marion recalled motivation was a key
indicator of adherence:
"It was more probably to go to club, because I can see all other players were getting
ready, going out for training, coming back in training, talking about what they have
done, it was really difficult. I was stuck in therapy room doing my exercises. It was de-
motivating, as part of a team you miss that a lot. When I was at home I considered as
a part of my training. My motivation was definitely there to get fit quicker because I did
want to get back in the team again" (Marion)
Exercising with a friend, a team, in therapy, and under instruction from another person
were all methods of promoting motivation and completing rehabilitation.
"In the beginning, I did not like doing heel slide. I really like doing group exercise
sessions. We were all in a big room together or at the pitch. We were doing all the
rehabilitation together it was more of a team thing. I really enjoyed that, even though
our injuries were different, but it was quite nice to rehab all together and the therapist
there was looking, and watching what we were doing" (Marion)
Chapel's account captured the participant's despair in not being able to participate in
the physical and social elements deemed integral features of their lives. As such, the
absence of these activities can be interpreted as being the key sources of motivation,
prompting participants to adhere to their rehabilitation programs.

46
"Knowing I would not be able to play for three to four months was sufficient motivation
to make me want to stick to my therapy program. I was extremely annoyed at not only
being not capable of competing, but also missing out on the social side. Simple things
like having a drink after the game and taking part in organised social events were
things I really enjoyed" (Chapel)
Is presence of a therapist is important?
Some participants expressed difficulty adhering to home-based rehabilitation
exercises. In particular, Christine reported that the absence of the therapist's
motivational support contributed toward a lack of home-based rehabilitation activity:
"Without the therapist, I would not know what exercises to do, and how often to do
them. I would not have any motivation and direction. I might give it a go but I might
come back too soon and try to do too much too fast and try to comeback too quick.
The therapist gave me a lot of direction and focus, little tasks to do, build up bit-by-bit,
rather than run before you can walk" (Christine)
Gordon pointed out that it is important to do exercises even though the therapist is not
there, in order to get better
"Presence of a therapist does matter, because you know there is an expert there
watching you doing the exercise. The therapist can see you using different techniques,
what you are doing and how you are doing it. However, at home if you are not looking
in a mirror it's hard to see if you are doing the exercises right. I was doing all the
exercises at home regularly because I knew that exercises will get me better" (Gordon)
Diane emphasise the importance of encouragement from therapist
"I think it work better if the therapist is there, definitely, because you get assurance you
are doing it right and if you are doing exercise at home and looking in the mirror and
thinking is it right technique. If the therapist is there he/she can correct your technique
if you are doing it wrong. I just think when you have a little bit of encouragement, that
is also the second reason, I like therapist to be there" (Diane)
In Alison's view, a patient cannot do exercise with the correct technique without the
therapist
"The presence of the therapist is very important. If you are doing something wrong
then the therapist can correct it. The therapist can change the way you are doing the
exercise if she/he thinks one way is not working. Therefore, the presence of a therapist
there allows you to see what you are doing well or not. I don't think doing exercise at
home was as good as doing it at the clinic in the presence of a therapist" (Alison)

47
Andrew thinks that the patient might sometimes get too excited and do too much
exercise, which could be harmful
"Definitely, it is important that the therapist should be there when you are doing
exercise. When I was doing my gym exercises, occasionally, the therapist came to see
me and advised me to adjust the weights for my shoulder exercises. It was important
that the therapist be there as I was a bit head strong on my own. The therapist was
there to keep a check on me and make sure that I would not re aggravate my injury,
which I have once already done once" (Andrew)
Confidence
Another shared experience identified by participants to account for poor home-based
rehabilitation concerned their lack of belief in their ability to perform exercises at home:
"Though all the recommended exercises were new to me, I felt assured performing
them in the club therapy clinic because I knew I was being supervised by the therapist.
Nevertheless, I felt unsure performing exercises at home by myself . . . . I wasn't fully
sure I was performing the exercises precisely. Having this concern made it harder for
me to adhere to home-based exercises" (David)
Diane's account clearly showed that she was not very confident in doing exercise
alone
I was not doing my exercises often and sometimes I was not sure if those exercises
were working or not? (Diane)
From Diane's account, it is apparent that her degree of self-efficacy for completing
rehabilitation hinged on the expert supervision of the therapist. Due to the absence of
the therapist in the home environment, self-doubts regarding performing exercises
exacerbated fears of further damaging her injury and ultimately led to the avoidance of
home-based activity.
For Christine, being unable to incorporate rehabilitation into an already hectic lifestyle
was a key issue:
"I was very very tired. It was very difficult to fit in the home rehabilitation program in my
time at home. I wanted to do it but physically I was busy with my course work.
Whenever I had time, I was doing all the exercises because I knew that the
rehabilitation exercises were very important. There were definitely time constraints. I
was really tired after work in school and then I have to do all the marking, planning and
assessments" (Christine)
Social support

48
In addition to receiving task support from the therapist, all of the participants
highlighted the importance of receiving support during their rehabilitation from people
with whom they held a close relationship. For example, Diane recalled:
"I think support from family played an important role in my rehabilitation. Just to be
able to speak about my frustrations and be able to come back. When you have re-
iteration, keep going, keep going, you are doing the right things, you will be back in no
time, you know. Definitely, some individual whom I can talk to helps a lot. When I get
frustrated, I would call him and he plays rugby as well. He would be like, you know you
going to be back, you going to comeback at the right time because players get injured"
(Diane)
Christine's experience suggested that support from family, team mates, the therapist,
and the coach could play an important role in your rehabilitation and facilitate the early
return to play
"When I was injured my family, friends, and teammates were brilliant. My mum and
dad were very supportive and helped me to get around. Obviously my teammates
were very supportive. Other players are disappointed that I cannot play with them, so
yeah supporting each other is very important. The therapist and the coach as well
were fabulous in help and supporting me" (Christine)
Teammates, coaches, family member, and therapists all emerged as important others
who are significant in an injury rehabilitation program. Marion's and David's accounts
highlight the key importance of close friends and family support.
" I think it is important for people to be there to pick you up and say actually this is not
the end of the world, you will be back, you can get back from it, you will be off the
crutches within 2-3 weeks. My family and players at the rugby club were all brilliant.
They were great in getting you involved in things even if it is a social night out or
getting me involved in different things with the club. You need people there to give you
support. It was also important that whenever I needed to rest my leg there were my
family there to help" (Marion)
"When I was injured, I was unable to drive. At that time, my family helped me and took
me around in the car. Definitely, you need support from family and friends to get back
to your game and fitness" (David)
Christine's, Marion's, and David's experiences suggest that material, emotional, and
practical support from friends and family were a facilitative influence during their
rehabilitation.
Pain
In many instances, participants described pain not to be an issue, which contributed to
rehabilitation adherence. For Christine, the prospect of pain was

49
perceived as an indicator that her injury was worsening and as a result, would
influence his rehabilitation behaviour:
"If I had a lot of pain, I was more likely to go and see the therapist to see if she can find
out the reason why my pain increased. Whether I needed to change any exercise to
decrease the pain. No, pain would more likely make me go to a therapy session
because I wanted to know why my knee was more painful that day. There was no any
other reason, which could stop me going for rehabilitation session" (Christine)
From Christine's account, it was interpreted that her perception of pain was a
consequence of her having a fear of her injury worsening and the prospect of long-
term problems as a result. Therefore, Christine instead of staying at home would rather
go to the therapy clinic session to find out the reason why her pain had increased.
Another thought expressed by participants, related to pain. For instance, Alison
recalled:
"No, I do not think pain stopped me coming to rehabilitation sessions or exercises at
home, because there is no gain without pain. You have to tolerate some pain to make
yourself stronger" (Alison)
From Alison's quote, it appeared that during therapy players have to tolerate pain
some times, in order to get fully fit, and back to play. This interpretation was
corroborated by Andrew's views about pain during treatment session
"No, pain never stopped me coming for rehabilitation sessions. During treatment when
I was getting massage it was painful but I knew that it was going to benefit me in the
end and felt the benefits afterwards" (Andrew)
Diane's account highlights that attending rehabilitation session is important even
though sometimes pain is not affecting your activities of daily living
"I was feeling more pain when I go to bed at night. It never stopped me from coming to
therapy session, because it obviously, like when I was out and about through the day,
the kind of pain I would have would not stop me doing every day things. It stopped me
playing rugby because of the nature of the sport but it could not stop me driving the
car, writing or working on the computer" (Diane)
From Diane's quote it is evident that although she has pain during night times, and she
was not fit enough to play rugby, but it did not affect her normal life activities.
"Pain never stopped me attending therapy session. You know, sometimes the muscles
around my shoulder got tight. Therefore, it is nice to come here for therapy and get it
relieved and the massage ease it off a bit" (Gordon)
Gordon believed that most of times therapy helps to reduces pain

50
"Pain never stops me going for therapy session. In a couple of session I did stop doing
exercises, as it was too much pain for me. That was frustrating because I knew that I
can do those exercises but it was just too painful" (Marion)
From Marion's account it was interpreted that even though sometimes the player gets
frustrated because of the pain during the therapy session, but it could not be the
reason not to attend sessions. For Chapel the therapist's advice is important, when he
has pain
"If I have pain first thing, I will try to get here for therapy. If the pain gets worse, then
get advice from therapist. I asked the therapist about going to hospital or what else I
can do. The therapist will be my first point of contact. Therefore, no, pain will not stop
me coming for therapy sessions" (Chapel)
Attitudes towards exercises
While a positive disposition towards exercise could increase motivation, more
important was the willingness and ability to accommodate the exercises into everyday
life:
"Obviously with playing here in this club and university, training 3-4 times a week, and
playing twice per week, it is a hard routine to fit in anything else. Especially my work
and studies on top of that. However, in order to get stronger you need to do all the
exercises at home" (Alison)
Those who ceased exercising often cited conict with regular routines to explain why
continuing with exercises was not possible:
"I wanted to do it but physically I was busy with my course work. Whenever I had time,
I was doing all the exercises because I knew that rehabilitation exercises were very
important. There were definitely times constraints" (Christine)
Christine expressed her desire to do exercises regularly but due to her work
commitments, she was doing exercises as much as she could.
"I was really busy at times. I was doing them whenever I got some spare time. I did not
have a good routine for exercises. May be if I had a better routine of doing them, say
every morning after breakfast or before going to bed and stuck to it. But, say I have
spare time now so I can do it" (Diane)
By giving these explanations, Christine and Diane could have been trying to portray
themselves in a favourable light by indicating that their non-compliance was due to
work and other commitments and obligations. Nevertheless, later in their interviews
both went on to admit some personal responsibility for their lack of compliance. Diane,
for example, indicated that non-compliance resulted from a combination of a busy life
and a reduced commitment to the therapy:
"I wanted to come back and play, definitely. I get really frustrated because I could not. I
don't make sense in some ways that I was not doing my exercises regularly" (Diane)
Diane stopped the exercises because as she had not noticed much improvement in
her symptoms. There did not seem to be a strong rationale for continuing.
"I was not sure if those exercises were working or not? That was probably the reason,
I went to see cranio-skeletal specialist" (Diane)

51
Latest Concepts in Hamstring Rehabilitation and Injury
Prevention
Hamstring injuries can be frustrating injuries. The symptoms are typically persistent
and chronic. The healing can be slow and there is a high rate or exacerbation of the
original injury (Petersen J et al. 2005).
The classical hamstring injury is most commonly found in athletes who indulge in
sports that involve jumping or explosive sprinting (Garrett W E Jr. 1996) but also have
a disproportionately high prevalence in activities such as water skiing and dancing
(Askling C et al. 2002).
A brief overview of the literature on the subject shows that the majority of the
epidemiological studies in this area have been done in the high-risk areas of Australian
and English professional football teams. Various studies have put the incidence of
hamstring strain injuries at 12 - 16% of all injuries in these groups (Hawkins R D et al.
2001). Part of the reason for this intense scrutiny of the football teams is not only the
high incidence of the injury, which therefore make for ease of study, but also the
economic implications of the injury.
Some studies (viz. Woods C et al. 2004) recording the fact that hamstring injuries have
been noted at a rate of 5-6 injuries per club per season resulting in an average loss of
15 -21 matches per season. In terms of assessing the impact of one hamstring injury,
this equates to an average figure of 18 days off playing and about 3.5 matches
missed. It should be noted that this is an average figure and individuals may need
several months for a complete recovery. (Orchard J et al. 2002). The re-injury rate for
this group is believed to be in the region of 12 - 31% (Sherry M A et al. 2004).

52
The literature is notable for its lack of randomised prospective studies of treatment
modalities and therefore the evidence base for treatment is not particularly secure.
If one considers the contribution of the literature to the evidence base on this subject,
one is forced to admit that there is a considerable difficulty in terms of comparison of
various differences in terminology and classification. Despite these difficulties this
essay will take an overview of the subject.
Classification of injuries
To a large extent, the treatment offered will depend on a number of factors, not least of
which is the classification of the injury. In broad terms, hamstring injuries can have
direct or indirect causation. The direct forms are typically caused by contact sports and
comprise contusions and lacerations whereas the indirect variety of injury is a strain
which can be either complete or incomplete. This latter group comprises the vast
majority of the clinical injuries seen (Clanton T O et al. 1998).
The most extreme form of strain is the muscle rupture which is most commonly seen
as an avulsion injury from the ischial tuberosity. Drezner reports that this type of injury
is particularly common in water skiers and can either be at the level of the insertion
(where it is considered a totally soft tissue injury) or it may detach a sliver of bone from
the ischial tuberosity (Drezner J A 2003). Strains are best considered to fall along a
spectrum of severity which ranges from a mild muscle cramp to complete rupture, and
it includes discrete entities such as partial strain injury and delayed onset muscle
soreness (Verrall G M et al. 2001). One has to note that it is, in part, this overlap of
terminology which hampers attempts at stratification and comparison of clinical work
(Connell D A 2004).
Woods reports that the commonest site of muscle strain is the musculotendinous
junction of the biceps femoris (Woods C et al. 2004).
In their exemplary (but now rather old) survey of the treatment options of hamstring
injuries, Kujala et al. suggest that hamstring strains can usefully be categorised in
terms of severity thus:
Mild strain/contusion (first degree): A tear of a few muscle fibres with minor swelling
and discomfort and with no, or only minimal, loss of strength and restriction of
movements.
Moderate strain/contusion (second degree): A greater degree of damage to muscle
with a clear loss of strength.
Severe strain/contusion (third degree): A tear extending across the whole cross
section of the muscle resulting in a total lack of muscle function.
(Kujala U M et al. 1997).

53
There is considerable debate in the literature relating to the place of the MRI scan in
the diagnostic process. Many clinicians appear to be confident in their ability to both
diagnose and categorise hamstring injuries on the basis of a careful history and clinical
examination. The Woods study, for example, showing that only 5% of cases were
referred for any sort of diagnostic imaging (Woods C et al. 2004). The comparative
Connell study came to the conclusion that ultrasonography was at least as useful as
the MRI in terms of diagnosis (this was not the case if it came to pre-operative
assessment) and was clearly both easier to obtain and considerably less expensive
than the MRI scan (Connell D A 2004).
Before one considers the treatment options, it is worth considering both the
mechanism of injury and the various aetiological factors that are relevant to the injury,
as these considerations have considerable bearing on the treatment and to a greater
extent, the preventative measures that can be invoked.
It appears to be a common factor in papers considering the mechanisms of causation
of hamstring injuries that the anatomical deployment of the muscle is a significant
factor. It is one of a small group of muscles which functions over two major joints
(biarticular muscle) and is therefore influenced by the functional movement at both of
these joints. It is a functional flexor at the knee and an extensor of the hip. The
problems appear to arise because in the excessive stresses experienced in sport, the
movement of flexion of the hip is usually accompanied by flexion of the knee which
clearly have opposite effects on the length of the hamstring muscle.
Cinematic studies that have been done specifically within football suggest that the
majority of hamstring injuries occur during the latter part of the swing phase of the
sprinting stride (viz. Arnason A et al. 1996). It is at this phase of the running cycle that
the hamstring muscles are required to act by decelerating knee extension with an
eccentric contraction and then promptly act concentrically as a hip joint extensor
(Askling C et al. 2002).
Verrall suggests that it is this dramatic change in function that occurs very quickly
indeed during sprinting that renders the hamstring muscle particularly vulnerable to
injury (Verrall G M et al. 2001).
Consideration of the aetiological factors that are relevant to hamstring injuries is
particularly important in formulating a plan to avoid recurrence of the injury.
Bahr, in his recent and well-constructed review of risk factors for sports injuries in
general, makes several observations with specific regard to hamstring injuries. He
makes the practical observation that the older classification of internal (intrinsic) and
external (extrinsic) factors is not nearly so useful in clinical practice as the
consideration of the distinction between those factors that are modifiable and those
that are non-modifiable (Bahr R et al. 2003).

54
Bahr reviewed the evidence base for the potential risk factors and found it to be very
scanty and largely based on theoretical assumptions (Bahr R et al. 2003 pg 385). He
lists the non-modifiable factors as older age and being black or Aboriginal in origin (the
latter point reflecting the fact that many of the studies have been based on Australian
football).
The modifiable factors, which clearly have the greatest import for clinical practice,
include an imbalance of strength in the leg muscles with a low H : Q ratio (hamstring to
quadriceps ratio) (Clanton T O et al. 1998), hamstring tightness (Witvrouw E et al.
2003), the presence of significant muscle fatigue, (Croisier J L 2004), insufficient time
spent during warm-up, (Croisier J L et al. 2002), premature return to sport (Devlin L
2000), and probably the most significant of all, previous injury (Arnason A et al. 2004).
This is not a straightforward additive compilation however, as the study by Devlin
suggests that there appears to be a threshold for each individual risk factor to become
relevant with some (such as a premature return to sport) being far more predicative
than others (Devlin L 2000).
There is also some debate in the literature relating to the relevance of the degree of
flexibility of the hamstring muscle. One can cite the Witvrouw study of Belgian football
players where it was found that those players who had significantly less flexibility in
their hamstrings were more likely to get a hamstring injury (Witvrouw E et al. 2003).
If one now considers the treatment options, an overview of the literature suggests that
while there is general agreement on the immediate post-injury treatment (rest, ice,
compression, and elevation), there is no real consensus on the rehabilitation aspects.
To a large extent this reflects the scarcity of good quality data on this issue. The
Sherry & Best comparative trial being the only well-constructed comparative treatment
trial, (Sherry M A et al. 2004) but even this had only 24 athletes randomised to one of
two arms of the trial.
In essence it compared the effects of static stretching, isolated progressive hamstring
resistance, and icing (STST group) with a regime of progressive agility and trunk
stabilisation exercises and icing (PATS group). The study analysis is both long and
complex but, in essence, it demonstrated that there was no significant difference
between the two groups in terms of the time required to return to sport (healing time).
The real significant differences were seen in the re-injury rates with the ratio of re-
injury (STST : PATS) at two weeks being 6 : 0, and at 1 year it was 7 : 1.
In the absence of good quality trials one has to turn to studies like those of Clanton et
al. where a treatment regime is derived from theoretical healing times and other
papers on the subject. (Clanton T O et al. 1998). This makes for very difficult
comparisons, as it cites over 40 papers as authority and these range in evidential

55
level from 1B to level IV. (See appendix). In the absence of more authoritative work
one can use this as an illustrative example.
Most papers which suggest treatment regimes classify different phases in terms of
time elapsed since the injury. This is useful for comparative purposes but it must be
understood that these timings will vary with clinical need and the severity of the initial
injury. For consistency this discussion will use the regime outlined by Clanton.
Phase I (acute): 17 days
As has already been observed, there appears to be a general consensus that the initial
treatment should include rest, ice, compression, and elevation with the intention to
control initial intramuscularly haemorrhage, to minimise the subsequent inflammatory
reaction and thereby reduce pain levels. (Worrell T W 2004)
NSAIAs appear to be almost universally recommended with short term regimes (3 - 7
days) starting as soon as possible after the initial injury appearing to be the most
commonly advised. (Drezner J A 2003). This is interesting as a theoretically optimal
regime might suggest that there is merit in delaying the use of NSAIAs for about 48 hrs
because of their inhibitory action on the chemotactic mechanisms of the inflammatory
cells which are ultimately responsible for tissue repair and re-modelling. (Clanton T O
et al. 1998).
There does appear to be a general consensus that early mobilisation is beneficial to
reduce the formation of adhesions between muscle fibres or other tissues, with Worrell
suggesting that active knee flexion and extension exercises can be of assistance in
this respect and should be used in conjunction with ice to minimise further tissue
reaction (Worrell T W 2004).
Phase II (sub-acute): day 3 to >3 weeks 0
Clanton times the beginning of this phase with the reduction in the clinical signs of
inflammation. Goals of this stage are to prevent muscle atrophy and optimise the
healing processes. This can be achieved by a graduated programme of concentric
strength exercises but should not be started until the patient can manage a full range
of pain free movement (Drezner J A 2003).
Clanton, Drezner and Worrell all suggest that multiple joint angle, sub-maximal
isometric contractions are appropriate as long as they are pain free. If significant pain
is encountered then the intensity should be decreased. Clanton and Drezner add that
exercises designed to maintain cardiovascular fitness should be encouraged at this
time. They suggest stationary bike riding, swimming, or other controlled resistance
activities.
Phase III (remodelling); 16 weeks

56
After the inflammatory phase, the healing muscle undergoes a phase of scar retraction
and re-modelling. This leads to the clinically apparent situation of hamstring shortening
or loss of flexibility. (Garrett W E Jr. et al. 1989). To minimise this eventuality, Clanton
cites the Malliaropoulos study which was a follow up study with an entry cohort of 80
athletes who had sustained hamstring injuries.
It was neither randomised nor controlled and the treatment regime was left to the
discretion of the clinician in charge. It compared regimes which involved a lot of
hamstring stretching (four sessions daily) or less sessions (once daily). In essence the
results of the study showed that the athletes who performed the most intensive
stretching programme were those who regained range of motion faster and also had a
shorter period of rehabilitation. Both these differences were found to be significant.
(Malliaropoulos N et al. 2004)
Verrall suggests that concentric strengthening followed by eccentric strengthening
should begin in this phase. The rationale for this timing being that eccentric
contractions tend to exert greater forces on the healing muscle and should therefore
be delayed to avoid the danger of a rehabilitation-induced re-injury. (Verrall G M et al.
2001). We note that Verrall cites evidence for this from his prospective (un-
randomised) trial
Phase IV (functional): 2 weeks to 6 months
This phase is aimed at a safe return to non-competitive sport. It is ideally tailored to the
individual athlete and the individual sport. No firm rules can therefore be applied.
Worrell advocates graduated pain-free running based activities in this phase and
suggests that Pain-free participation in sports specific activities is the best indicator of
readiness to return to play. (Worrell T W 2004)
Drezner adds the comment that return to competitive play before this has been
achieved is associated with a high risk of injury recurrence. (Drezner J A 2003)
Phase V (return to competition): 3 weeks to 6 months
This is the area where there is perhaps the least agreement in the literature. All
authorities are agreed that the prime goal is to try to avoid re-injury. Worrell advocates
that the emphasis should be on the maintenance of stretching and strengthening
exercises (Worrell T W 2004).
For the sake of completeness one must consider the place of surgery in hamstring
injuries. It must be immediately noted that surgery is only rarely considered as an
option, and then only for very specific indications. Indications which the clinician should
be alert to are large intramuscular bleeds which lead to intramuscular haematoma
formation as these can give rise to excessive intramuscular fibrosis and occasionally
myositis ossificans (Croisier J L 2004).

57
The only other situations where surgery is contemplated is a complete tendon rupture
or a detachment of a bony fragment from either insertion or origin. As Clanton points
out, this type of injury appears to be very rare in football injuries and is almost
exclusively seem in association with water skiing injuries (Clanton T O et al. 1998).
It is part of the role of the clinician to give advice on the preventative strategies that are
available, particularly in the light of studies which suggest that the re-injury rate is
substantial (Askling C et al. 2003).
Unfortunately this area has an even less substantial evidence base than the treatment
area. For this reason we will present evidence from the two prospective studies done
in this area, Hartig and Askling
Hartig et al. considered the role of flexibility in the prophylaxis of further injury with a
non-randomised comparative trial and demonstrated that increasing hamstring
flexibility in a cohort of military recruits halved the number of hamstring injuries that
were reported over the following 6 months (Hartig D E et al. 1999).
The Askling study was a randomised controlled trial of 30 football players. The
intervention group received hamstring strengthening exercises in the ten week pre-
season training period. This intervention reduced the number of hamstring injuries by
60% during the following season (Askling C et al. 2003). Although this result achieved
statistical significance, it should be noted that it involved a very small entry cohort.
Conclusions.
Examination of the literature has proved to be a disappointing exercise. It is easy to
find papers which give advice at evidence level IV but there are disappointingly few
good quality studies in this area which provide a substantive evidence base. Those
that have been found have been presented here but it is accepted that a substantial
proportion of what has been included in this essay is little more than advice based on
theory and clinical experience.

58
Managing Of Minor Injuries Health And Social Care Essay
Introduction: As part of this minor injuries course we have been asked to provide a
3000 word assignment utilising a case method as means of researching a patient
scenario we experienced during clinical practise.
Case study method enables a researcher to investigate an individual and evaluate
these findings and relate this evidence to clinical practice ( REFERENCE 1) Case
studies are also often subjective and based around a personal experience or
memorable patient (REFERENCE 2), whilst identified by (REFERENCE 3) that these
case studies do not provide a great amount of empirical and statistical evidence,
(REFERENCE 4) highlights that case study methods stimulate critical thinking and
help practitioners apply theory to clinical practice.
For this case study I have chosen a patient who I treated for an Achilles tendon
rupture. This assignment will aim to
document the assessment of a patient in the acute stage of injury
discuss the initial management of the injury
discuss the treatment plans available
conclude how this case study has impacted on my clinical practise

The Achilles tendon is given its name by Greek hero Achilles as the largest and
strongest tendon within the human body, Patel and Haddad (2006). It connects the calf
muscle (gastrocnemius) to the heel bone (calcaneus) and is located below the skin at
the back of the ankle.(reference needed) As the calf muscle contracts it provides it
enables the foot to be pointed downwards (plantarflexion) It is this action that enables
us to walk, run, jump and to stand on our toes.(reference

59
needed) Despite great forces applied through this tendon it is vulnerable due to its
limited blood supply, the least vascularised area being 2 to 6 cm above the calcaneum.
This diminished blood supply predisposes this region to chronic tendonitis and
potential rupture. (reference 5)
Kerr (2005) suggests three main attributing factors are leading to an increase in
rupture.
Increased sedentary lifestyle
Rising popularity of recreational sports especially in older men
An increasing proportion of people are overweight
75% of Achilles injuries occur during sporting activities, and research indicates this is
occurring with patients who describe themselves as novice or beginners (Josza et al,
1989). As ENP's it is important that we are able to differentiate between an acute
tendon injury and other complaints i.e. gastrocnemius tears in order to treat, advice
and refer appropriately. Misdiagnosis or delay in treatment can lead to gait dysfunction
and chronic pain.
The following case study is a true event of a patient I assessed during my clinical
placement. To maintain the patient's confidentiality he will be referred to as Mr Smith.
CASE STUDY: 68 year old retired gentleman, no drug allergies, no significant past or
ongoing medical problems. Mr Smith attended the emergency department at 10.00
and was booked in with a limb problem. I greeted Mr Smith, explained my role as a
training Emergency Nurse Practitioner (ENP) and gained consent for his assessment.
Mr Smith had been out dancing the previous night and thought he had been kicked in
the back of his right lower leg. Since, he had described difficulty walking and not been
able to "bend his foot" as normal. Despite walking tentatively Mr Smith manoeuvred
himself onto the examination couch. From his facial expression he appeared
comfortable and his pain had been reduced having taken his own paracetamol and
ibuprofen. The worst pain had been last night and the patient described an ache this
morning. Further analgesia was offered but declined by the patient.
Physical examination:
This was broken down into 5 key areas described by Guly (2002)
Look (inspection)
Feel (palpation)
Movement
Specialist tests
Function
61

60
During our course we have assessed neurovascular function as a separate
examination. This will be assessed between movement and specialist tests.
Look: Mr Smith was examined in a private cubicle. His trousers removed in order to
expose both lower limbs for comparison. Mr Smith had no wounds, no obvious
deformity, no erythema /cellulites and no bruising noted. There was noticeable swelling
around the base of the calf in the soleus region on the medial aspect of the limb. Both
limbs were of equal colour and warmth. No surgical scarring was observed on either
limb.
Feel: Palpation of lower leg then took place. In accordance with Gully (2002) this
should take place from the joint above to the joint below. Palpation started from the
knee joint downwards. From the examination of the knee joint no pain over bony land
marks was elicited by the patient. The palpation moved distal towards the ankle, no
bony tenderness was identified. The ankle was examined for bony tenderness. No
tenderness was found at the posterior edge or tip of both the medial and lateral
maleolus, the base of the 5th metatarsal or the navicular bone. Using Ottawa ankle
rules (Hopkins, 2010) there was no indication to xray the ankle. Mr Smith was then
asked to go into the prone position, this enabled a good comparative view of both
limbs mainly the gastrocnemius muscles and the Achilles tendons. The gastrocnemius
muscle was then palpated; although uncomfortable towards the distal muscle a
specific tender point was not identified. The Achilles tendon was then palpated; this
gave a specific origin for the pain. There was also bogginess (palpable step) in the
lower third of the Achilles. Although a step was palpable Kerr (2005) indentified that
not all ruptures have a palpable step, the cause of this unknown.
Movement: Ankle movements were examined both active and passive. Mr Smith had
good active dorsi flexion and normal plantar flexion of both ankles. However when
examined with passive resistance there was a marked deficit on his right ankle.
Sterling (2001) highlighted that even though normal range of motion is witnessed
during active movement it is essential passive movement is carried out, and
assumptions should not be made to the integrity of the Achilles tendon. Both medial
and lateral ligaments were stressed with no laxity and good end feel. Finally an
anterior draw test was performed, the ankle was stable.
Neurovascular status: Mr Smith had normal sensation of his first web space, dorsum of
foot and anterior and lateral aspect of lower leg. Mr Smith was able to dorsiflex and
had normal toe plantar mechanism. Pedal pulse was also present.
Specialist tests: Mr Smith was then asked to kneel onto the trolley and support himself
using the wall. A Thompson- Simmons (calf squeeze) test was then performed. At this
time Mr Smith had no plantar flexion movement. Johnson and Morelli (2001) details
this is highly suggestive of a ruptured Achilles tendon. Prior to undertaking this
assignment I was not aware of any other specialist tests other than ultrasound. These
shall be discussed later. 62

61
Function: Guly (2002) states the examination of a joint should include its functionality.
Mr Smith was then asked to perform a calf heel raise (stand on tip-toes). He was
unable to perform this task. Sterling et al (2001) summarised that a patient whose
other plantar flexors are still functioning will not be able to perform this task if their
Achilles is ruptured.
Treatment: Mr Smith was diagnosed and treated as an Achilles tendon rupture. He
was placed in an equinas cast and was given crutches to mobilise with, which he did
very well. A referral was then made to our fracture clinic where he would be followed
up with the orthopaedic team. Take home analgesia was offered but declined by the
patient. Mr Smith asked about the long term plan of action, would he need surgery to
repair his tendon. I answered honestly and stated I didn't know but endeavoured to
find out from one of my colleagues. It was this lack of follow on care knowledge that
has been one of the focuses for this case study. Having an extended knowledge base
would further enable a holistic approach to care not only in the acute care environment
but to also provide accurate information about the care the patient should expect to
receive. This sharing of knowledge will hopefully enable the patient to make an
informed choice about how they would like to proceed. The follow on from acute injury
to referral to fracture clinic is currently within 3 days. The patient will be presented if
suitable with two options; surgical repair or conservative management. From reviewing
the literature contributing towards this assignment it is clear the orthopaedic world is
divided over these two strategies of care. However the common goal summarised by
Patel and Haddad (2006) is a restoration of the normal length and tension of the
Achilles tendon, allowing patients to regain their functional and desired level of activity.
Fotiadis et al (2007) supports this and further discusses the importance of restoring
length as this will preserve strength of the gastrocnemius and the soleus muscles,
again improving functionality.
Surgical repair: the procedure involves making a longitudinal incision on the medial
aspect of the Achilles tendon. Normally the incision is between 8 and 10cm, the ends
of the tendon are then sewn together using non-absorbable suture. Two types of stitch
are favoured, Krackow or Bunnell. (see appendix A) Kerr (2005) highlights the
advantages of surgical repair as
Increased strength
Reduced calf atrophy
Less likely hood of re-rupture
Faster return to sporting activities.
However with any invasive procedure there will be a risk off
Deep wound infection
Deep vein thrombosis
Delayed wound healing
Scar adhesions
63

62
 Hyperesthesia or numbness of the skin

After surgery the limb is immobilised with an equinas plaster or brace for between 6 to
8 weeks followed by physiotherapy.
Non Surgical Management: Johnson and Morelli (2001) outlines that conservative
management involves the patient being placed initially in an equinas cast. The
immobilisation of the ankle plantar flexed between 40 and 60 enables the tendon
to be stress free promoting the unification of the partial tear or rupture tendon. Having
discussed the current treatment guidelines with my orthopaedic colleagues at the
hospital the patient would be expected to return to fracture twice over a 6 week period.
This would be to have a new POP each time and gradually have the degree of plantar
flexion increased. The patient would remain on crutches, non weight bearing on the
affected limb, to reduce the potential stress placed on the tendon.
Having presented the case study and outlined initial management and expected follow
up care, I would now like to introduce new methods of assessing for Achilles tendon
rupture as stated on page 3.
Matles Test: The patient is laid in the prone position with knees flexed at 90. Both
feet and ankles are observed for plantar flexion. The diagram below indicates the there
is an increase in dorsi-flexion on the injured limb (right)
Source: foot and ankle hyperbook (2011)
The O'Brien test: the patient lies in the prone position knees flexed at 90. A small
gauge needle is then inserted 10cm form the superior border of the calcaneus into the
Achilles tendon. Passive dorsiflexion and plantar flexion movements are applied;
absence of movement indicates a potential rupture.
The Copeland test: the patient is laid in prone position with knees flexed at 90. A
sphygmomanometer is placed around the bulk of the calf and the pressure raised to
100mmHg with the ankle plantar flexed. When the ankle is dorsiflexed, in a non-
injured Achilles tendon, pressure increases to 140mmHg. Where the Achilles is
ruptured the pressure remains the same (Sterling et al, 2000).
Other specialist diagnostic procedures can be performed i.e. ultrasound or MRI. These
have been highlighted by Patel and Haddad (2006) as more accurate at detecting
partial tears. Ultrasound is operator dependent and requires an experienced technician
and radiologist and MRI carries a high cost and limited clinical value of what has
already been diagnosed clinically.
Differential diagnosis: During the initial history taking it is paramount an accurate detail
history is taken leading up to the events. Majewski et al(2008) outlines 44% of Achilles
injuries are misdiagnosed as ankle sprains or gastrocnemius injuries and advocates
the use of the two specialists test previously identified; the calf 64

63
squeeze test and the Maltes test. Majewski et al (2008) concludes along with proficient
palpation of the Achilles tendon two positive tests is good evidence of a rupture.
However reinforces the need for sonography (ultra-sound) to differentiate between
partial and full tears.
As ENP's we are usually the first clinician patients see with an acute injury. We have a
vital role in demonstrating accurate history taking, assessment, treatment and referral
to the appropriate speciality. Despite the patient having an injury it is important that we
can provide the patient with accurate education and health promotion advice. It is
recognised within our department that weekends have a high increase is sporting
injuries who attend the emergency department. The main sports are rugby league and
football. We have a great opportunity to impart knowledge to patients with injuries in
order to hopefully reduce the incidence of new or re-occurring injury. In relation to
Achilles injury or Achilles tendonitis Walker (2005) promotes warm up techniques, the
benefits include:
Increased blood flow to working muscles
Increased range of movements
Improved speed of contraction
Increased temperature and hence increased elasticity
Improved oxygen saturation

As previously identified there is reduced vascularisation to part of the tendon, Henry et

al (1986) concludes that warming up increases the flexibility of the joint involved and
best results occur from static stretching.
Another important factor to advice patients about is footwear. If possible hard backs of
shoes should be padded as identified by Milroy (1994) these areas nudge the Achilles,
often at the site of injury and wherever possible heels should be slightly raised to
shorten the Achilles resulting in less injury from sudden lengthening.
It is this information that I will be now documenting i.e. did they warm up prior to
exercise and also conveying this to patients in order to reduce further injuries.
Conclusion:
As identified there is an increase in Achilles tendon rupture injuries hence more people
will be attending the Emergency Department through direct referral from General
practitioners and Walk in Centres/ Minor injuries units or from self presentation. From
reviewing literature it is evident there is a significant number of misdiagnosis occurring
around the area of injured Achilles tendons. 65

64
Scientists Work to Improve Treatments for Multiple
Sclerosis
Multiple sclerosis is not very easy to say. Those who suffer from the disease may also
have difficulty naming it. One sign of multiple sclerosis is losing the ability to speak
clearly. It is estimated that more than two million five hundred thousand people
worldwide suffer from multiple sclerosis, which also is called MS.
MS is a disease of the brain and spinal cord. The cause of the disease is not known. In
patients with MS, the covering of the nerves is destroyed. This temporarily blocks
signals that pass through the nerves to the muscles of the body and back to the brain.
The disease especially affects the ability to see, the sense of touch and the use of the
arms and legs. Most forms of MS are described as progressive. This means that the
disease gets worse as time passes.
The central nervous system of the body includes the brain and the spinal cord. The
system contains millions of nerve cells joined together by long thin fibers, like wires.
Electric signals start in nerve cells and travel along these fibers to and from the brain.
A fatty substance called myelin covers and protects the fibers. Myelin works in the
same way that protective coverings work on electric wires.
In patients with MS, the myelin becomes infected. It swells, or grows larger, and loses
its connection with the nerve fibers. As time passes, the unconnected myelin is
destroyed. Hardened, scar tissue then forms over the nerve fibers. The process of
hardening is called sclerosis. The word is from Latin and means scar. The many areas
of hardened or scar tissue give the disease its name.
In people with MS, when nerve signals reach a damaged area, some of the signals are
blocked or delayed from traveling to or from the brain. This results in problems in
different parts of the body. These problems may appear and then disappear, 66

65
sometimes resulting in long periods when there are no problems at all. Or, they may
happen more and more often and become worse. Doctors do not know what causes
this process.
Experts say the disease affects women at least two times as often as men. And the
experts say the average age of people found to have the disease is between twenty
and fifty years old.
For years, doctors believed that the cause of multiple sclerosis was environmental.
They believed this because most of those suffering from the disease lived in northern
Europe and the northern half of the United States.
In recent years, however, they have changed their beliefs about the causes of MS.
Studies support the theory that there are several causes, instead of a single
environmental cause or genetic problem. The studies appear to show that genetic
problems are involved in making people likely to get the disease.
The studies also appear to show that environmental causes such as viruses or
bacteria may be involved. However, researchers have not identified just what those
causes might be. Another likely cause is a problem within the body's defenses against
disease, when the defenses misunderstand signals and attack the body.
Multiple sclerosis is different from many other diseases. The signs or symptoms of MS
are not always the same. Sometimes, symptoms of the disease appear and then
disappear for a long time. For example, one of the symptoms is a lack of feeling in one
part of the body or another.
Two other symptoms of the disease are muscle weakness and tiredness. However,
these also could be caused by other health problems that are not MS. Other symptoms
include a loss of the ability to move normally or a loss of balance. A person suffering
from MS also may have difficulty seeing well or speaking clearly.
Doctors who suspect a patient has MS must carry out a number of tests and study the
patient's history of health problems. MS symptoms can depend on where the nerve
scars are in the body's central nervous system. And some of these signs are not
always easy to see.
Magnetic Resonance Imaging is one way to tell if a patient has multiple sclerosis. The
test, also known as MRI, involves studying the magnetic signals from all the cells in the
body. An MRI can show if there are scars from MS along a patient's nerves. A doctor
can use this test to tell if a patient might have the disease, as well as by studying the
patient's medical history.
There are four main kinds of multiple sclerosis. The first kind is called Relapsing-
Remitting. About eighty-five percent of MS patients begin with this form of the disease.
More than half of the patients have this form at any one time. These 67

66
patients have one or two major MS-related problems every one to three years. Then
they have periods with no signs of the disease.
The symptoms appear suddenly and last a few weeks or months before slowly
disappearing. However, the symptoms may also become worse each time they
appear.
The second kind of MS is called Primary Progressive. In this form, the signs of the
disease appear and begin to grow worse, with no periods of disappearance. About ten
percent of patients begin their struggle with the disease this way.
The third kind of MS is called Secondary Progressive. This form of the disease affects
about fifty percent of those with the Relapse-Remitting form of MS. It begins to affect
them several years after they have had Relapse-Remitting MS. When the disease
changes to Secondary Progressive, the disease begins to grow worse.
The fourth kind of MS is called Progressive Relapsing. It is the worst form of multiple
sclerosis. New signs of MS appear while existing ones grow worse. This form of the
disease is rare. It affects only five percent of MS cases.
Scientists say multiple sclerosis does not appear to be passed from parents to
children. However, it does appear to be found in families. The National Multiple
Sclerosis Society says one in every seven hundred fifty Americans is at a risk of
developing MS. But the risk rises to one in every forty people among those who have a
close family member with the disease.
It does not appear that one gene is responsible for MS. Instead, several genes may
increase the possibility that a person will develop MS. Common viruses or bacteria
may also increase the chances that some people will develop the disease.
There is no cure for multiple sclerosis. MS does not always result in severe disability.
Many patients with the disease are able to live normal lives. The National Institute of
Neurological Disorders and Stroke says many patients do well with no treatment at all.
The agency notes that many medicines to treat the disease have serious side effects
while some carry risks.
Several kinds of medicine are used to treat the symptoms. Some drugs reduce the
swelling in nerve tissue. Drugs known as beta interferons also are used to treat MS.
Interferons are genetically engineered copies of proteins found naturally in the body.
These proteins help fight viral infections and help the body's defenses against disease.
The United States Food and Drug Administration has approved three forms of beta
interferon for treatment of Relapsing-Remitting MS. The FDA also has approved a
man-made form of myelin basic protein to treat this kind of MS. And, a treatment to
suppress the body's defenses against disease was approved to treat severe cases of
MS. 68

67
The FDA has approved sales of the drug natalizumab to treat people with relapsing
forms of MS. But the drug can be given only in centers where specially-trained doctors
can observe patients.
Scientists are working to develop new treatments for MS. The National Multiple
Sclerosis Society says more than one hundred studies are continuing around the
world. Doctors are hopeful that new treatments will help patients with multiple sclerosis
in the future.
Spinal Cord Injury
SPINAL CORD TRAUMA
Loss of sensory and motor function below the injury site is caused by trauma to
the spinal cord.
Appproximately 10,000 people experience serious spinal cord injury each year.
There are four general types of spinal cord injury, cord maceration and
laceration, contusion and solid core injury. There are three phases of SCI
response that occur after injury:the acute, secondary, and chronic. The most
immediate concern is patient stabilization. Additionally interventions may be
instituted in an effort to improve function and outcome. Through education, and
future development one day there will be hope for recovery from the spinal cord
injury.
Spinal Cord Trauma
Introduction
Loss of sensory and motor function below the injury site is caused by trauma to
the spinal cord. As indicated by Huether & McCance (2008) normal activity of
the spinal cord cells at and below the level of injury ceases due to loss of
continuous tonic discharge from the brain and brain stem. Depending on the
extent of the injury reflex function below the point of injury may be completely
lost. This involves all skeletal muscles, bladder, bowel, sexual function and
autonomic control. In the past hope for recovery has been minimal. With
medical advancements and better understanding today hope for recovery is
better but still limited.
Risk Factors and Incidence 69

68
According to Huether & McCance (2008) approximately 10,000 people
experience serious spinal cord injury each year. 81% of those injuries are males
with an average age of 33.4 years. As indicated by Hulsebosch (2002) the
majority of injuries are divided into four separate groups; 44% of the injuries are
young people sustained through motor vehicle crashes or other high energy
traumatic accident; 18% are sustained through sports activities, and 24% are
sustained through violence and 22% are sustained in the elderly population
either through falls or congenital narrowing of the spinal canal.
Catagories of Injury
According to Hulsebosch (2002) there are four general types of spinal cord
injury: 1) cordmaceration 2) cord laceration 3)contusion injury, and 4) solid cord
injury. In the first two injuries, the surface of the cord is penetrated surrounding
with injured connective tissue. In the latter two the spinal cord surface is not
breached andthe peripheral connective tissue reaction is minimal. The
contusion injury is a progressive injury that enlarges overtime.
Cellular Level Physiology
Hulsebosch (2002) gives us three phases of response directly after the injury of
the spinal cord. The acute phase begins with the moment of injury andextends
for the first few days. A variety of pathophysiologicalprocesses begins. There is
immediatemechanical soft tissue damage, includingendothelial cells of the
vasculature. Celldeath, resulting from mechanical forces and ischemic
consequences isinstantaneous. Over the nextfew minutes there are significant
electrolytic shifts, intracellular concentrations of sodium increase. Extracellular
concentrations of potassium increase. Intracellular levels of calcium increase.
Extreme intracellular calcium levels contribute toa failure in neural function.
Electrolyte shifts cascade to a generalized demonstration of spinal shock, which
is representative of a circuitry failure in the spinal neural network. As indicated
by Shewmon (1999) spinal shock is a transient functional depression of a
structurally intact cord below the site of an acute spinal cord injury. It does not
occur with slowly progressive lesions. Limited function or loss of function
typically lasts two to six weeks followed by recovery of functions. The
secondary phase occurs over the next few minutes to the next few weeks.
Electrolyte shifts, edema and cellular death continues. As a result of cell lysis
extracellular concentrationsof glutamate and other amino acids reach toxic
concentrations within the first fifteen minutes after injury. Free-radical
production amplifies.
Neutrophils accumulate in the spinalparenchyma within 24 hours. Lymphocytes
follow the neutrophils and reach their peak numbers within forty eight hours. 70

69
Local concentrations of cytokines and chemokines increase as part of the
inflammation process. As inflammation and ischemia proceed the injury site
grows in size from the initial mechanical force response site into the area
around the site, encompassing a larger region of cell death. Regeneration is
inhibited by factors expressed within the dominos of responsive reactions. The
chronic phase can last for years. Cell death continues. The cord becomes
scarred and tethered. Conduction deficits result from demyelination of the cord.
Regeneration and emergence of axons is exhibited but inhibitory factors
suppress any resultant growth. Alteration of neural circuits often results in
chronic pain syndromes for many spinal cord injury patients.
Therapeutic Management
Spinal cord injury is diagnosed by physical examination, radiological exam, CT
scans, MRI scans, and myelography. The most immediate concern in the
management of an acute spinal cord injury is patient stabilization. The vertebral
column is subject to surgical stabilization using variety of surgical rods, pins,
and wires. Hardware must be meticulously placed. Surgical intervention has the
potential to instigate additional spinal trauma. Hemostatic body systems must
be supported through fluid resuscitation, medication management and
electrolyte support. Additionally the following interventions may be instituted in
an effort to improve function and outcome:
Edema Reduction
Treatment interventions include the reduction of the inflammatory response.
Steroids have provided a primary tool to reduce edema and inflammation,
methylprednisolone (MP) has been proven most successful of the steroids in
inflammation and edema reduction. According to Bracken (1993) the
administration of methylprednisolone early following injury has been found to
show improvement in recovery in areas distal to the injury; it also leads to
greater recovery at the injury level. Analysis shows early administration of the
steroid to be of critical importance.
Decrease neurological recovery sensory and motor function is associated with
delayed treatment with methylprednisolone after the initial injury.
Inhibition of Inflammation: Anti-Inflammatory Agents
Recent research has demonstrated that the inflammatory cascade can be
damaging to injury core cells and surrounding cells; with edema leading to
ischemia and the death of additional cells after the initial injury. 71

70
Anti-inflammatory agents have been administered with successful limitation of
the inflammatory process. As indicated by Hains, Yucra and Hulsebosch (2001)
selective cyclooxygenase (COX)-2inhibitors given systemically to spinal card
injury patients have demonstrated significantimprovements. Provision of
inhibition of the enzyme activation sequence appears to be the safest
medication action at this time.
Reduction of temperature: either whole body hypothermia or local cord
hypothermia cooling appears to hold promise for those suffering from neuro
trauma. Lowering of the temperature reduces inflammation and appears to
decrease the mortality of neural cells. According to Hayes, Hsieh, Potter, Wolfe,
Delaney, and Blight (1993) localspinal cord cooling within eight and a half hours
of injury in ten patients produced a better-than-expected rate of recoveryof
sensory and motor function.
Rescue from Neural Cell Death
Spinal cord injury produced cell death. As presented by Eldadah and Faden
(2000) one approach to cellrescue is the inhibition of caspases. Caspases are
regulated signaling proteases that that accomplish a primary role in mediating
cell apoptosis thru division at specific sites within proteins. These proteins
inhibit programmed cell death and are a part of the bcl-2 oncogene products.
According to Shibata, Murray, Tessler, Ljubetic, Connors and Saavedra (2000)
recent work has demonstratedprevention of retrograde cell loss and atrophy
reduction by direct intraspinal administration of the Bcl-2 proteininto the injured
site.
Another group of proteins with potential cell death inhibition properties are
calpains. Calpains are calcium-activated proteases that assist in degradation of
cytoskeletal demolition of injured cells. Substances with calpain inhibitor
properties could prove of benefit in reduction of cell death.
Demyelination and Conduction
According to Hulsebosch (2002) the strategy of inhibitingthe neural injury
induced by the increased barrage of actionpotentials early in the injury phase or
by inhibiting the voltage- dependentsodium channels, which provide the ionic
basis for the actionpotential may be beneficial. As indicated by Waxman
(2001)neural injury and axonal transection may introduce altered ionic
channelfunction on nerve processes that would result in impaired conduction
properties, which produces persistent hyperexcitabilityleading to the basis for
chronic pain after CNS neural trauma.
Many axons are demylinated as a result of injury to the spinal cord. Infusion of
a fast, voltage-sensitive potassium channel blocker may provide partial 72

71
restoration of conduction properties to demylinated axons. As presented by
Guest, Hiester and Bunge (2005) another strategy for the improvement in
demyelinationis the transplantation of Schwann cells which may contribute to
the restoration of myelin sheaths around some spinal axons.
Promotion of Axonal Regeneration
During development of the central nervous system, an assortment of axonal
growth promoting proteins are present in the extracellular environment. The
environment stimulates axon growth and neural development. Once the central
nervous system is established the growth stimulating agents decline. The adult
central nervous system shifts toward inhibition of axonal growth permitting a
stable and circuitry. These inhibition and stimulatory factors provide an
opportunity for research that will promote axonal growth after a spinal cord
injury perhaps rebuilding a neural communication network.
Cell Replacement Strategies
After spinal cord injury function of nerve cells and cells that produce myelin that
insulates and provides a positive impulse conduction venue has vanished.
Cellular replacement to rebuild conduction properties is a promising therapy. As
indicated by Normura, Tator and Shoichet (2006) there is promise in technology
utilizing cellular treatment procedures including dorsalroot ganglia, adrenal
tissue, and neural stem cells. Olfactory ensheathing cells, and Schwann cells
show promise in the formation of myelin on peripheral nerves. These cellular
treatments have potential to promote repair of the injured spinal cord. It is
proposed
these tissues could provide a regenerativepathway for injured adult neurons,
which could integrateand encourage the regeneration of the neural system
circuitry and restore sensory and motor function. As indicated by Nakamura
(2005) there is promise that bioengineering technology utilizing cellular
treatment advances can promote repair of the injured spinal cord.
Transplantation of these cells promotes functional recovery of locomotion and
reflex responses.
The engineering of cells not only provides the therapeutic advantage but also
employs a delivery system. If distribution of neurotrophins is desired, cells that
secrete neutrophins and cells that create myelin can be engineered to stimulate
axon growth and rebuild nerve function.
In an effort to further enhance beneficial effects autoimmune agents such as
macrophages can be extracted from the patient's own system and inserted at
the injury site. The macrophages will scavenge degenerating debris. By doing
73

72
the clean up work not only do they decrease toxin levels but also encourage
regeneration of cells without creating an immune response.
Retrain the Brain with Aggressive Physical Therapy
Recovery of sensory and motor function along with locomotion may depend on
sensory input that can re-establish spinal circuit communication. According to
Calancie, Alexeeva, Broton and Molano (2005) it may take six or more months
for reflexes to appear following acute SCI suggesting they might be due to new
synaptic interconnections.
Electrical Stimulation.
Compute controlled Functional electrical stimulation (FES) contributes to
physiological improvements such as better bladder and bowel function, cardiac
conditioning, improved muscle mass and better blood flow. FES has also been
shown to decrease medical complications often suffered by spinal cord injury
patients including deep vein thrombosis, bone fractures and skin ulcerations.
Functional electrical stimulation of the phrenic nerve encourages
communication of the respiratory pathways.
Chronic Central Pain
As indicated by Siddall & Cousins (1997) pain continues to be a significant
problem in patients with spinal cord injuries. There is little consensus regarding
the terminology, definitions and nature of the pain. Treatment studies have
lacked congruence due to inaccurate identification of pain types. Understanding
the pathophysiology of chronic central pain has shown little development.
Chronic central pain (CCP) syndromes develop in the majority of spinal cord
injury patients. As indicated by Que, Siddall and Cousins (2007) chronic pain is
a disturbing aspect of spinal cord injury, often interfering with basic activities,
effective rehabilitation and the quality of life of the patient. Clinical literature
provides evidence that neurons in pain pathwaysare pathophysiologically
altered after spinal cord injury. Development of the chronic pain state correlates
with ongoing structural alterations. According to Que, Siddall and Cousins
(2007)
pain in the cord-injured patient is often resistant to treatment. Recognition of
Chronic Central Pain has led to utilization of nonopioid analgesics. According to
Siddall and Middleton (2006) Baclofen, onceused only in treatment of muscle
spasticity andthe anticonvulsant gabapentin originallyused to treat seizures,
have had some success with moderating muskuloskeletal CCP syndromes. The
tricyclic antidepressant amitriptyline has shown effectivein treatment of
dysesthetic pain. 74

73
Conclusion
Stem cell therapy will offer hope for spinal cord injury patients with opportunities
for the abundance of cell replacement strategies. Advances in the field of
electronic circuitry will lead to better FES and robotic devices. Pharmacological
advances offer intervention direction to aid in recovery and improve patieints'
quality of life every day. The re-establishment of cell, nerve and muscle
communication interconnections will be potentially possible. Through tenacity,
education, and future development one day victims of spinal cord injury will be
told there is hope of recovery.
Osteoporosis Increases Danger of Broken Bones
A new study shows that binge drinking by teenagers may increase the possibility of
osteoporosis in later life. Researchers in the United States say drinking a lot of alcohol
over a short period may influence genes involved in bone formation.
Bone biologist John Callaci led a team studying the effects of alcohol on young rats.
He teaches and leads a research laboratory at Loyola Universitys medical school in
the state of Illinois. His teams findings appear in Alcohol and Alcoholism, a
publication of Oxford University Press.
Binge drinkers swallow large amounts of alcohol over a short period. One definition
says binge drinking happens when a woman has at least four alcoholic drinks in a
hurry. For men, binge drinking can mean five drinks in a short time.
Americas Substance Abuse and Mental Health Services Administration says binge
drinking can begin when a person is about thirteen years old. It says binge drinking
generally worsens in young adulthood, and slowly decreases after that.
Professor Callacis team studied adolescent laboratory rats to learn the effects of binge
drinking on their genes. The team injected alcohol into the animals. The injections
resulted in a blood alcohol level of zero-point-two-eight. In many American states, a
person is legally drunk when the level of alcohol in the blood reaches zero-point-zero-
eight.
Some rats received a daily injection of alcohol for three days. The researchers say the
alcohol affected about three hundred bone-related genes in those rats. The other rats
received alcohol over a similar three-day period, but the injections continued for four
consecutive weeks. In these rats, one hundred eighty genes were affected. 75

74
The injections added ribonucleic acid, also known as RNA, to the genes of some rats.
In the other rats, the RNA in the genes decreased. Ribonucleic acid tells the gene how
to make proteins, the substances necessary for bones and other tissues. These
changes interfered with the pathway of molecules responsible for building bones and
keeping them strong.
Professor Callaci says one of the most worrying findings came thirty days after the
injections stopped. At that time, the animals still showed differences in the way their
genes were expressed. Thirty days of a rats life are about the same as three human
years.
Professor Callaci says it is not necessarily true that what happens to rats genes will
happen to human genes. But he says the findings suggest that young peoples binge
drinking could signal problems in their future.
Bones are living tissue. Tissues continually break down and then replace themselves.
However, as people get older, more bone breaks down, than gets replaced. The result
is that small spaces inside the bone get larger. The shell of the bones also gets
thinner.
The word osteoporosis means porous bones, or bones that are not solid enough. The
disease harms bones by removing calcium and other minerals from tissue. The
National Osteoporosis Foundation says eight of every ten osteoporosis patients are
women. It says the disease is most common in Caucasian women over age fifty.
Two years ago, the National Osteoporosis Foundation suggested that doctors extend
their list of persons to watch for osteoporosis. The additions included Latina, African-
American, Asian and other women. The group also called attention to the fact that men
can also suffer from osteoporosis.
Before people develop osteoporosis, they have a condition called osteopenia.
Treatment can prevent this condition from becoming osteoporosis. Doctors can identify
osteoporosis and osteopenia by measuring the mineral density of a persons bones. In
this case, density means the strength of the bones.
Bone mineral density can be measured in a number of ways. Doctors use the tests to
examine the hip and spine, or backbone. The National Osteoporosis Foundation says
a test called Dual-energy X-ray absorptiometry, or DXA, is the best test for
osteoporosis. DXA uses radiation from x-rays. The patient does not get much radiation
from the process, which lasts only a few minutes.
Another way to measure bone-density is called peripheral bone mineral density
testing. It is often used in the United States to show people if they are in danger of
osteoporosis. A moveable machine does the test. 76

75
Medical testing companies sometimes perform the exam at an office or other place of
business. The exam costs less than the DXA. Peripheral testing measures only one
part of the body. Usually that place is the wrist, the heel, or the bones between finger
joints.
If the testing device is in good condition, it probably will give satisfactory results. But
what if the patient has normal bones in the tested areas, but not in others? A person
could appear normal on the test. But she still might have osteoporosis in her backbone
or hips.
Bone mineral density in the spine decreases first. A womans bone mineral density
becomes about the same in all parts of her body after she is seventy years old. The
lower-cost test may not give complete answers. But it can warn that osteoporosis
threatens or has started.
The National Osteoporosis Foundation has advised several steps toward the goal of
healthy bones. Its experts say get enough calcium and vitamin D. They say do not
smoke or drink too much alcohol. Talk to your doctor about bone health and a possible
bone mineral density test.
The National Osteoporosis Foundation says people over fifty should get one thousand
two hundred milligrams of calcium every day. It also says this age group should get
eight hundred to one thousand International Units of Vitamin D. It says Vitamin D-Two
and Vitamin D-Three are both good for bones.
Milk and milk products contain calcium. So do fish with soft bones, like salmon, and
dark green leafy vegetables. Some orange juice, bread and cereals may have calcium
added.
Some people take pills containing calcium. However, be careful about how much
calcium you take. You should not have more than two thousand five hundred
milligrams a day. That total includes calcium from food and all other sources. Too
much calcium can cause problems like kidney stones.
Vitamin D absorbs, or takes up, calcium. Fish, cereal and milk are rich in Vitamin D. If
you spend at least fifteen minutes a day in the sun without a product to block the suns
radiation, you probably get enough Vitamin D.
Several kinds of drugs treat osteoporosis. Americas Mayo Clinic medical centers say
bisphosphonates are the most popular. Fosamax, Actonel and Boniva are products of
this family of drugs.
Doctors who treat osteoporosis patients say physical exercise can help the bones. For
active people, lifting weights or playing tennis, slow running and dancing can be
helpful.
Some people who have not exercised worry about the effect of exercise on their joints,
especially the knees. They are afraid exercise might cause osteoarthritis. In 77

76
that condition, connective tissue around the bones wears down. One study in The
Netherlands shows that might be possible. The results linked knee osteoarthritis to
high mechanical strain -- activities that are hard on joints.
Another study found that regular physical exercise does not harm joints. Scientists
from Germany and the United States considered earlier research on the effect of
exercise on joints. They did not find a link between normal exercise and knee
osteoarthritis.
If you are still worried about exercise for osteoporosis, try taking a walk. The Mayo
Clinic says walking helps your bones. However, you have to do it correctly. The Mayo
Clinic says hold your head high. Straighten your back and neck as much as possible.
Tighten the chest muscles. As you move along, let your shoulders and arms move
freely and naturally.
Walking raises the levels of chemicals in the brain known as endorphins. They reduce
pain and make you feel happier.

77