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Rehabilitation encourages Dependency. Discuss

Rehabilitation encourages Dependency. Discuss

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An essay for the 2011 Undergraduate Awards Competition by Elaine Hopkins . Originally submitted for Psychological Aspects of Physiotherapy Intervention at University of Limerick, with lecturer Dr. Lauren Hamel in the category of Psychology
An essay for the 2011 Undergraduate Awards Competition by Elaine Hopkins . Originally submitted for Psychological Aspects of Physiotherapy Intervention at University of Limerick, with lecturer Dr. Lauren Hamel in the category of Psychology

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Published by: Undergraduate Awards on Aug 29, 2012
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10/27/2013

 
Rehabilitation Encourages Dependency. DiscussThere are many different definitions of rehabilitation available, whether it be found in a medicaldictionary or sourced through the internet. Creating and/or restoring independence is a themecommon to the majority of the explanations. In the professional sporting world, rehabilitation maybe perceived by many as being associated with physiotherapists and other members of the sportsmedicine team assisting one towards a physical return to activity after an injury. However, the goalof rehabilitation is concerned with much more than the physical aspects of managing an injury. Asdefined by the World Health Organisation (WHO), Rehabilitation is a
“process aimed at enabling
 people to reach and maintain their optimal physical, sensory, intellectual, psychological and social  functional levels. It also provides disabled people with the tools they need to attain independenceand self-
determination” 
(World Health Organisation, 2010).As physiotherapists we are highly involved in the physical rehabilitation of athletes, yet in order forour treatment to be efficient we must take a more holistic approach to this patient group andconsider the other aspects of a rehabilitation programme. A physiotherapist is
“concerned 
withidentifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation, and rehabilitation. This encompasses physical,
 psychological, emotional, and social well being” 
(World Confederation for Physical Therapy, 2010).Although dependency may be acquired through certain stages of the rehabilitation programme it isnot encouraged by rehabilitation. Therefore, I am arguing against the statement that
“Rehabilitation
encourages de
 pendency”.
There will be consideration of the physical and psychological aspects of rehabilitation, with a specific focus on the rehabilitation of a professional athlete after sustaining anAnterior Cruciate Ligament (ACL) injury, discussing how a rehabilitation programme can facilitateindependence in an athlete, as well the physiotherapist
’s
role in promoting independence. I willfocus on the areas of a) the initial injury b) prehabilitation and c) rehabilitation post surgery,discussing the role each has in promoting independence.ACL injuries are one of the most common injuries sustained by sportspeople, especially thoseinvolved in high intensity, pivoting sports such as rugby, soccer and basketball. (Brukner and Khan,2009). Incidence of ACL injury among the general population is estimated to be 3 in 10,000 people inDenmark (Kvist, 2004). Prevalence in elite sports professionals is even higher (Bjordal et al, 1997). Astudy carried out in 2004 found that of injuries classified as major, ACL injuries were the most
 
prevalent in a professional rugby club, contributing to 11% of the clubs injuries over a 3 year period(Orchard et al, 2000). Furthermore, research indicates that knee injuries sustained by Englishprofessional rugby union players accounted for the highest number of days absent from competitivegames, with ACL injuries making up the greatest proportion of missed days at 29% (Dallalana et al,2007). This study concluded that at any one time of the playing season in question, there was 5% of the squad unavailable due to knee injuries. The above studies clearly indicate the high level of ACLinjury incidence among sports professionals in the modern game. Rehabilitation plays a major role inplayers regaining their functional independence and is fundamental if they are to return to sport.Not all ACL tears are treated surgically. However for athletes who intend to return to their previouslevel of sport it is the most common protocol, as the knee is placed under increased sporting andfunctional demands (Kvist, 2004). This essay aims to illustrate that it is the rehabilitation prior andpost-surgery that are the key elements which encourage
the athlete’s independence.
Initial Injury 
There are no definite guidelines as to when rehabilitation begins. However, literature in the area of stroke rehabilitation suggests that
“rehabilitation should commence as soon as possible after theonset of the acute event” 
(Ernst, 1990) and this too is applicable in the case of an ACL injury. Withthe resources accessible to the professional athlete, treatment and subsequent rehabilitation beginsalmost immediately after sustaining the injury. An ACL injury occurs mainly in a non-contactsituation. There is an initial onset of severe acute pain along with an aud
ible “pop”. Physical
presentations of an acute ACL tear include a decrease in knee extension, widespread tenderness anda feeling of instability, resulting in an initial disruption to the normal gait pattern (Brukner and Khan,2009). Physiotherapists facil
itate the athlete’s independence through education and the prescr
iptionof aids immediately post-injury which illustrates the immediate effect rehabilitation has in creatingindependence. In the case of professional athletes, independence is encouraged as soon as theplayer gets to the treatment table of the dressing room. As we are among the first of the sportsmedicine team to come in contact with the player, we have the ability to prevent the occurrence of chronic oedema developing and therefore prevent negative rehabilitation outcomes in the future(PRICE Guidelines, 2008). It is common for the athlete to be fitted with either a knee brace orcrutches which will allow the athlete to mobilise independently. Education surrounding the PRICEregime allows the athlete takes an active part in the initial management of their injury, providingthem with the skills to assist the healing of the injury. Active gentle range of motion (ROM) exercises
 
are also encouraged which further involves the athlete. There are no passive treatments carried outby the physiotherapist, which does not allow the athlete create an initial dependency on thetherapist.In the initial stages of an injury the athlete is highly susceptible to cognitive dependency due to thepreliminary psychological response. In order for rehabilitation to be a success there must beconsideration of both the physical and psychological training and preparation (Cox, 2002). Thereforeas physiotherapists we must recognise the psychological characteristics of an athlete that can lead tocognitive dependency if we are going to promote independence. Wiese-Bjornstal et al, (1995)
developed a model of an athlete’s psychological response which
takes into consideration cognitive
appraisal and the athlete’s emotional
and behavioural response to injury. Research indicates thatshock and disbelief are the main emotions experiences after the initial injury (Evans and Hardy,1999). Many of the emotions experiences after an injury are negative in nature (Tracey, 2003) withanger and frustration developing. Competitive athletes are seen to experience higher levels of 
negativity surrounding the injury (Cox, 2002). According to one of the UK’s leading sportspsychologists’ Louise Eillis, (2010) professional athletes tend to ex
perience the same psychologicalresponse to that of a grieving individual after sustaining a serious injury. There is an associated lossof identity as many professional athletes have their self-identity tied to their sporting achievements(Cox, 2002). A loss of identity may lead to a decrease in self-efficacy. Albert Bandura (1982)describes self-efficacy as
“the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations”.
This decrease in self-efficacy may lead to acognitive dependency as the athlete
’s
identity is altered. Cognitive dependency is described byBornstein et al, (1995) as
“the perception of the self as powerless and ineffectual, with the belief that 
others are relatively powerful in t 
he control of the outcomes of situations”.
Physiotherapists play anactive role in preventing the development of cognitive dependency in the professional athlete duringrehabilitation. This can be achieved through the use of cognitive therapy which can be carried out bya physiotherapist or a sports psychologist, which may be more common place among the majorprofessional sports clubs. Early patient education regarding the estimated recovery time, and thepathophysiology of the injury by either member of the sports medical team will assist towards amore positive cognitive appraisal, which will provide a better emotional and behavioral response topost-
operative rehabilitation. It is also important to diffuse the patient’s negative thoughts
surrounding their condition and put the injury into perspective. A professional athlete may becomevulnerable to catastrophising the injury due to severe sense of loss they experience, not only their

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