Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue CASE STUDIES / STUDI DE CAZ THE METHODICS OF POSTTRAUMATIC SHOULDER REHABILITATION IN ATHLETES (CASE STUDY) BALTEANU V. (VERONICA BALTEANU)', BALAN L. A. (LUCIAN ANDREI BALAN)! "AL I. Cuza” University lasi, Romania, Faculty of Physical Education and Sport, Str. Toma Cozma nr. 3 asi, 700354, Romania, e-mail: balteanui@uaic.ro Abstract: The rehabilitation of the posttraumatic shoulder requires a complex treatment, which demands the implication of several specialists (specialized physician, radiologist, kinesiotherapist). The patient himself plays an important role: he has to be cooperative, active; he must understand the therapeutic act and respect all dhe indications ofthe specialists ‘The upper limb often suffers raumatisms, more serious and more frequent in certain sports branches. The functional ‘chabilitation — through adequate kinesiatnerapeutic means and methods, methodically and systematically applied, within an optimal time frame — will recover the patent's usual gestures for the respective segment; his social and professional reintegration will also occur as soon as possible, Keywords: shoulder, raumatism, kinesiotherapy, rchabilitation INTRODUCTION The fight against sports accidents is one of the most important tasks of sports medicine. This task ‘comes from the assertion that accidents represent a main cause of the diminution of functional activity; in performance sport, the consequence is the reduction ofthe output and of sports performances, The main prophylactic measures must be applied on a very large scale, starting from the entire causal chain of accident occurrence. This aspect refers to sport character and orientation, to the action possibilities, to the training application and methodics, to the particularities and level of athlete's health education, to the ‘very important roles often played by the meteorological factors, by the hygiene of bases, and by the sports equipment. The active prevention and rehabilitation measures for sports traumatisms have to become ‘commonplace for trainers, coaches, and athletes The kinesiotherapist that activates in the field of sports medicine knows that his collaboration with the aforementioned decision-makers is indispensable. By treating an athlete for a traumatism, the kinesiotherapist has the occasion to assess — retrospectively — the entire mechanism of its occurrence, thus contributing to the research and objective determination of the causes. Naturally, this leads to prevention and/or rehabilitation measures for the said The traumatism within the sports practice is defined as "the outcome of external forces, represented by mechanic agents (hits, pressures, tractions), which produce contusions, wounds, fractures” It is worth noting other traumatisms, such as: sprains, dislocations, and nerve and blood vessel lesions, MATERIAL AND METHOD Many traumatisms may occur on the level of the shoulder joint. This aspect and the complex structure of the shoulder (Fig. 1) make difficult the rehabilitation of the posttraumatic sequelae. ‘Numerous structures‘factors can lead to shoulder pain; by synthesising, four main situations are listed below: ‘© rotator cuff muscles; ‘+ shoulder instability: * acromioclavicular joint; * radiated pain.[7] Their treatment demands a well-elaborated medical act, following a correct diagnosis, The kinesiotherapist has 8 major role in the recovery of normal functionality following a traumatism. 269Sp Soc Int J Ph Ed Sp 201: Volume 14 ~ Special Issue ‘When it comes to the prevention and the rehabilitation of disorders produced by physical activity and to the use of exercise as main mean, one has to take into account certain principles. They have to be strictly cobscrved in order to get optimal results; these are actually the gencral principles of kinesiotherapy. Fig. 1. Shoulder joint.[6] Table 1. Causes of shoulder pain.{7] Frequent causes Less frequent causes “Particular” causes Rotator cuff Rotator cuff Myofascial pain + tendinopathy + twisting + overstretch + calcific tendinopathy Glenohumeral disfocation ‘Adhesive capsulitis Bone tumours ‘Glenohumeral instability Biceps tendinitis Tesions of the glenoid labrum — | “Trap” of the nerves: “Axillary vein thrombosis + suprascapular Tong thoracic Pains radiate from: Fractures: Pains radiate from: + the cervical spine + scapula + the diaphragm + the lumbar spine + the neck of the humerus + the gall-bladder + myofascial structures, + stress fracture of the + perforated duodenal ulcer coracoid process + the heart + the spleen (left shoulder) + the apex of the lungs Fractures of the clavicula "The levator scapulae syndrome The acromioclavicular sprain Muscle overstretches: Brachial plexus + the large pectoral muscle Neuropraxia + the long head of the biceps | (Viral) neuritis The kinesiotherapeutic means must be adjusted to the anatomic and biomechanical particularities of, the segment or joint of interest in the respective traumatism. They arise from the following: - fundamental kinesiotherapy means — physical exercises; = massage — self-massage; = means associated to kinesiotherapy — diet, medication, electrotherapy, hydrotherapy; = additional means ~ elements from various sports branches. Out of the multitude of intervention means available to kinesiotherapy, the specialist will select the ‘most appropriate ones for each phase of the treatment, according to the methodical rules. The therapeutic plan uses certain means necessary to the rehabilitation of a disorder; when elaborating the schedule, these means vary from one phase of the treatment to the other.(2] Rehabilitation objectives Regardless of the localization of the traumatism and of the athlete's particularities, the general ‘objectives of the treatment phases are as follows: ~ regaining the state of normaly; 270Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue = regaining the physical qualities lost; + _ integral regain of the body's functionality. Besides these general objectives, the kinesiothcrapcutic treatment also comprises phase objectives. ‘They refer mainly to the affected area, to the evolution of its healing ~ regaining the affected fiction and reducing the consequences of the traumatism, fighting off pain and inflammation, regaining mobility, strength, stability, and ability [8] The objectives of the therapeutic approach for the rehabilitation of traumatisms in athletes are the following ‘+ The necessity to cut short the rest and recovery period, because the athlete must come back to the competition as soon as possible, without risking @ relapse; ‘+ The organization of the activity by determining the kinesiotherapeutic methods, means, and procedures meant to assess the functional level of the affected area; ‘+ Establishing a collaboration between the coach, the athlete, and the kinesiotherapist. The purpose of the paper is to state the importance of observing the right methodology when applying the kinesiotherapeutic treatment and of identifying the most efficient kinesiotherapeutic means and. ‘methods through which the rehabilitation of the traumatisms produced during sports activity leads to the ‘complete, anatomo-functional healing of the structures affected by the traumatism. The functional rehabilitation of the shoulder after posttraumatic lesions is structured on five distinet phases: Phase I - the anatomic recovery is the stage following the traumatism or the surgery (if applicable), ‘which ended in the immobilization of the shoulder girdle. In this period, the shoulder must not be solicited: the entire upper limb, the cervical spine, and the thorax represent the target in this phase. Objectives «Fighting off pain and controlling the inflammation; ‘Facilitating the anatomic recovery by improving local circulation; + Fighting off the vasculotrophie disorders; + Prophylaxis of muscle strength loss for the muscles in contention; + Maintaining functionality on the level of non-affected segments, ‘Means used: © Massage manoeuvres — classical cervical and trapeze muscle massage at the beginning of cach The semi-recumbent positioning; Stretching on the level of the non-affected segments; Anti-inflammatory medication; Kinesiotherapy. Phase I — the functional rehabilitation is the period following the release from immobilization, when the shoulder still cannot be solicited. However, without irritating the lesion, the maintenance ‘movements for the shoulder have to begin in this phase. Immobilization may be given up gradually, by ‘maintaining it during the night or even during the day. Objectives. ‘© Readjusting the joint structures to movement; ‘© Mechanical rebarmonization of the shoulder; © Recovery of joint stability; ‘© Increase in joint mobility; ‘© Maintaining the effort capacity. ‘Means used: ‘© Massage manoeuvres: © analgic/muscle relaxant with @ focus on relaxing manoeuvres, in the cervicodorsal area, shoulder and arm, sometimes more extensively on the lumbar and forearm level; © therapeutic (Cyriax) for the deep areas of the affected muscles, tendons, and capsule. Positioning — the arm is held in external rotation, slight adduction and flexion; Electrotherapy ~ the TENS is applied at the beginning of cach rehabilitation session; ‘+ Mechanical reharmonization of the shoulder: the traumatisms of the shoulder, caused by local configurations, may produce upper instability (upper anterior dislocation) ot lower instability (lower subdislocation), Mechanical reharmonization consists of the prevention or correction of the humeral 21Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue head imbalance; this objective can be reached through various positions, passive mobilizations with ‘actions, or through active exercises. Phase III — ths is the period when the lesion begins to be solicited gradually, through mobilizations impossible to make during phase II. Pain is the major criterion for the confirmation or lack of it in the case of such mobility. This phase has nothing specific, as it is just trial-and-error stage before the beginning of the ‘complex activity (part of the following phase) Phase IV this isthe period of the shoulder functionality rehabilitation per se. Objectives ‘regaining the range of movements; + regaining the joint flexibility: + regaining the muscle force, ‘Means used: ‘© Heat, antalgic electrotherapy withthe role of preparing the area; + Kincsiotherapy: © Capsule-ligament stretching manoeuvres (the techniques are executed in two tempos); © Proprioepive facilitation exetess: the Kabat method (contracton-eaxation; © Setf-assisted passive exercises — various sets; © Active exercises: for the increase in mobility; © Resistance exercises, for the increase in muscle mass. Phase V ~ it is not mandatory for all patients. This phase concerns regaining the particular motor performances of the patient before the traumatism and it applies to the athletes or to those who do particular types of exercise, The rehabilitation programme and the functional exercise will be specific to the sport practiced by the patient.[1, 4] CASE STUDY INDIVIDUAL CHART Personal data L.L, 17, male, lagi County, urban background; Clinical diagnosis: anterior subcoracoid right shoulder dislocation; ‘Sports category: performance sport, member of the LPS lasi handball team. Anamnesis Local examination symptoms: he presented pain, tumefaction, deformation of the area, hemarthrosis, and functional impotence on the level of the shoulder: the right arm was in 25° adduction and 10° internal rotation. History: the patient came to the emergency room with pain on the level of the right shoulder joint, ‘which appeared after a physical contact during the training and which ended with a fall on the right upper limb. The patient had a history of previous shoulder subdislocations and he was diagnosed with chronic shoulder instability. Treatment: Orthopaedic — to reduce the dislocation; immobilization with Desault’s bandage for three weeks; Medication — indicated for pain reduction; Anialgic electrotherapy — the therapeutic of the continuous, discontinuous current, ultrasounds, TENS; Hydrothermotherapy treatment ~ it uses heat as therapeati factor. The balneo-physiotherapeutic treatment ~ during the period of complete remission, after the complete or almost complete healing of the lesion, the patient can benefit from a kinesiotherapentic programme in various balneoclimateric resorts, where the association of natural factors (mineral water, therapeutic mud, and climate) is beneficial and, together with adequate kinesiotherapy programmes, they will ensure the prevention of relapses. General rehabilitation plan — the carly kinesiotherapeutic treatment, meant to avoid the onset of stiffness and to respect the general regimen; General objectives of the therapeutic approach: 272Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue + fighting off pain and controlling inflammation; + regaining joint mobility and muscle force; * the rehabilitation of joint stability + regaining controlled movements and skills; # maintaining the effort capacity; + maintaining the ideomotor images related to the handball-specifie motor gestures. Particularities: ‘© avoiding passive mobilization; active-passive mobilizations are recommended; ‘© the mechanical harmonization is contraindicated in the second phase; it can be applied in the third phase, after a minimum 70° arm elevation; ‘© in the first 15 days, the movement of abduction, external rotation, and retropulsion should be avoided; isometric exercises are allowed, but the arm must be held in a low position; simple analytic movements will be resumed on a low range of movements (below 60°70' The rehabilitation programme was carried on for eight weeks — between 25 October and 17 Decemiber 2012 ~ and it included two intermediary tests (after two and after three weeks) and a final test In the first three weeks, the rehabilitation took place at the Nicolina Medical Centre Iasi; the rest of the programme was carried on inthe patent's domicile and inthe treatment room. The immobilization was done by means of Desault’s bandage for three weeks; in this period, the patient applied the treatment at home, with advice from the physician and the kinesiotherapist; + isometric contractions of the shoulder girdle muscles; cervical spine self-control, control of the shoulders and thorax position by observing it in the mirror; mobilizations of the entire let upper limb and mobilizations ofthe right fingers and fist; cervical massage and massage ofthe trapeze muscle; mental training ofthe basic movements in handball (pass, throw towards goal, et). This phase has not been included in the eight-week rehabilitation programme, reason for which the programme debuted with gradually releasing from immobilization (the bandage was preserved at night and ‘when the patients felt tired). Also during this phase, the mechanical reharmonization of the shoulder was carried on (through positionings, axial tractions, Codman’s exercises, and active mobilizations) This phase coincided with the second phase of the classical recovery treatment. The third phase of the treatment regimen debuted 10 days after giving up on the immobilizing bandage; it was carried on for 11 days. The fourth phase lasted 14 days and it included exercises for increase in the range of motion, for regaining joint flexibility and the muscle force. The fifth phase ~ 21 days long — was carried on in the treatment room and it consisted of practicing the basi handball techniques. At the beginning, less force was used and there was no focus on the precision of the execution; however, at the end of the rehabilitation programme, the initial force and precision were regained The apprehension test that was applied during the second and the third phase was positive because of the emergence of pain; it disappcared during the fourth and the fifth phase, reason for which the test was negative. Hence, the patient was able to execute the test specific movements. Taking into account the patient's age 17, the rehabilitation went very well; after the two months of rehabilitation, he regained the joint force and mobility prio tothe accident, Itis worth stating thatthe patient was truly involved in this programme; his collaboration was very ‘200d and he observed the rehabilitation regimen tothe letter. The values ofthe tests and measurements are listed below: ‘Table 2. Joint assessment Name ofthe | Normal | Initial test | Intermediary | Intermediary | Final test movement | values | 25,10."12 test test 17.12.12 05.11.12 26.11.12 Flexion TRO" 80 To 150" TRO" Extension 30" 15" 25" 40" 307 ‘Abduction 180" 80 120" 150" 180" 273Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue Aadduction F F F & External rotation | 80" 357 307 80 Internal rotation | _90° 50° 60 90° ‘Table 3. Muscle assessment Name of the Tnitial test] Intermediary | Intermediary test] _ Final test muscles 25.10."12 test 26.1 05.11.12 17.12.12 Flexors 4 a 3 Extensors 4 a 5 Abductors 4 a 3 ‘Adductors a a 3 External rotators 32 4 a 3 Tnternal rotators 3 4 4 5 ‘Table 4. Specific tests for the assessment of shoulder stability Name of the Tnitial test | Intermediary test | Intermediary test | Final test test 25.10."12 05.11.12 26.11.12, 17.12.12 ‘Apprehension | positive positive negative: negative test pain= 3 pet__| pain= 2 pet pain= 0 pet pain= 0 pet Painful arc test | positive positive negative negative pains 2pet__| pain= I pet pain= O pet pain= Opet Apley Test positive positive: negative negative pain= 2 pot ppain= | pet pet Legend: Opis = no pain I pts = low intensity (SVA degree of 1-3); 2 pts= average intensity (SVA degree of 4-7); 3 pls = high intensity (SVA degree of 8-10) RESULTS AND DISCUSSION ‘iatemod ig. 2. Evolution of the right shoulder joint mobility 274Fig. 3. Evolution of the muscle force for the right shoulder joint CONCLUSIONS ‘Though it respects the general rehabilitation regimens, kinesiotherapy in sports traumatisms features ‘a series of particularities, generated by both the types of lesions and the alterations of the physiopathological substrate, induced by the sports effort and by the necessity of a rapid rehabilitation, which includes the “restituto ad integra”. ‘The application and observation of @ kinesiotherapeutic programme, combined with other recovery ‘means and methods, have led to formulating a number of conclusions, listed below: + an early beginning of the rehabilitation programme (even while stil in a bandage) prevents ‘the onset of mechanical joint sequelae (muscle-tendon-capsule retractions, vicious callus, posttraumatic arthritis, te) and the joint stiffness; * accidents can be prevented successfully by adopting a well-claborated warm-up and stretching programme; ‘the immobilization atrophy, the vascular disorders, the oedemas and paralyses of the upper limb peripheral nerves can be avoided by executing passive, passive-active, and active mobilizations, associated with techniques such as hydrokinesiotherapy, electrotherapy, and ‘occupational therapy; ‘the outcomes were influenced by both the athlete's age and the interest manifested by him, with the purpose of regaining the physical condition prior to the accident; + the structure and number of exercises within a rehabilitation session will be different from the ones used for the notrathlete with the same condition, The rehabilitation programme should also take into account preserving the athlete’s effort capacity or at least preventing its decrease and preserving the ideomotor images related to the motor gestures specific to the sports discipline practiced. References [1] Avramescu TE, Kinetoterapia in activititi sportive. Bucuresti: Editura Didactica si Pedagogicd. 2006. Romanian [2] Balteanu V. Ailoaic LM. Compendiu de kinetoterapie, tehnici si metode. Iasi: Editura Tchnicd, Stiingifica si Didactic Cermi, 2005. Romanian [3] Borza I. Niculescu B. Traumatologie sportiva. Timisoara: Editura Mirton. 2009, Romanian [4] Bratu M. Kinetoterapia in afectiunile posttraumatice ale sportivilor. Bucuresti: Editura Bren, 2004. Romanian [5] Georgescu L. Prim ajutor si traumatologie sportiva aplicata. Craiova: Ed. Universitaria, 2006, Romanian [6] Netter FH. Atlas de Anatomie Umana, Editia a treia, Bucuresti: Fditura Medicals CALLISTO. 2005. Romanian [7] Rusu L. Rosulescu E. Kinetoterapia in recuperarea afecfiunilor ortopedo — traumatice. Craiova: Editura Universitaria, 2007, Romanian [8] Sbenghe T. Kinetologie profilacticd, terapeuticd si de recuperare.Bucuresti: Editura Medicali. 1987. Romanian 275Sp Soc Int J Ph Ed Sp 201: Volume 14 — Special Issue METODICA RECUPERARII UMARULUI POSTTRAUMATIC LA. SPORTIVI (STUDIU DE CAZ) BALTEANU V. (VERONICA BALTEANU)', BALAN L. A. (LUCIAN ANDREI BALAN)! ‘Universitatea "Alexandru Ioan Cuza", Facultatea de Educatie Fizied si Sport, Str. Toma Cozma nr. 3, lai, 700554, Romania,e-mail: balteanu@uaic.ra Rezumat: ‘Recuperarce umarului posttraumatic nocesité un tratament complex care presupune implicarca mai multor specialisti (medic de specialitate, radiolog, kinetoterapeut). Pacientul insusi are un rol important, tebuie si fie ccooperant, activ, sf infeleagi actul terapeutic si sf respecte toate indicatile specialistlor. Membrul superior sufera ‘desea traumatisme, mai grave gi mai freevente in unele ramuri sportive, Recuperarea functionalé, prin mijloace si ‘metode kineloterapeutice adecvate, aplicate metodic, sistematic, in timp optim va asigura pacientului gestica wavala a segmentuli,reintegrarea sociald i profesional avestuia, in tmp edt mai seurt posi Cuvinte ehele: umir, sraumatism, kinetoterapi, recuperare, INTRODUCERE Lupta impotriva accidentelor sportive constituie una din sarcinile cele mai importante ale medicinii sportive. Aceastd sarcind decurge din considerentul ci accidentele reprezint’ o cauzi principalé a diminulri activittii fumetionale, iar in sportul de performanga, de reducere @ randamentului si a performanfelor sportive. Principalele misuri profilactice trebuie aplicate pe o seard foarte larg’, pornind de la intregul lang cauzal al producerii accidentelor. Acest aspect se referi la caracterul si orientarea sportului, posibilititle de actionare, de aplicarca si metodica antrenamentului, de particularitiile gi nivelul de educatic sanitaré a sportivului, de rolul foarte important pe carc-1 ocupi descori factorii metcorologici, igiena bazclor, echipamentul sportiv. ste necesar ca misurile active de prevenire gi recuperare a traumatismelor sportive. si devin un bun al instructoritor, antrenorilr sal sportivlor Kinetoterapeutul care activeaz in domeniul medicinii sportive prin colaborarea lui cu factorii ecizionali enunjati este indispensabil Tratind un sportiv cu traumatism, kinetoterapeutul are posibilitatea dea verifica retrospect, {ntregul mecanism al produccrii acestuia, contribuind astiel la cercetarca si stabilirea obiectivi a cauzelor, din care decurg in mod firese misurile de prevenire saw recuperare a acestora Traumatismul apdrut in practica sportiva este definit ca find "recultatul forfelor externe reprezentate de agentii mecanici lovitur, presiuni, tractiuni) care produc contuci, plagi, facturi"[3, 5] Se pot inti i altele:entorse, luxai,leziun ale nervilor si vaselor de sng MATERIAL SI METODA, Traumatismele la nivelul articulate’ umirului sunt in numir mare, ccea ce determing, impreuni cu structura complex’ a umrului (Fig. 1), recuperarea dificilé a sechelelor posttraumatic. Exist numeroase structurifactori care pot conduce la durere la nivelul umdrului, sintetizand se pot identifica 4 situati principale: ‘+ musculatura coifului rotatoritor; ‘+ instabilitetea umirului; + articulatia acronio-claviculara; © durerea iradiat8.(7] Tratarea acestora presupune un act medical, bine constitu, dupii precizarea corectd a diagnosticului Rolul kinetoterapcutului este major in redarca functionalitatii normeale posttraumatice. Pentru prevenirea si recuperarea afecfiunilor produse in urma activititii fizice, pentru folosirea exercitilor fizice ca mijloc de baz, trebuic sd se tind scama de anumite principii, care si fie respectate cu strictefe pentru a objine rezultatele dorte principiile generale ale kinetoterapici 216Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue Fig. 1. Articulafia umérului(6] Tabel 1. Cauze ale durerii de umir.[7] Cauze frecvente ‘Caze mai putin frecvente Cauze "particulare”™ Coifulrotatorilor Coifulrotatorilor Durere miofascialé + tendinopatie + rasucire + intindere + tendinopatie caleificata Taxatie gleno — humeral Capsulits adeziva “Tumori esoase Tnstabilitate gleno — humeral | Tendinita bicepsului ‘Leziuni ale abrumului *Capeana” nervilor: “Tromboza venei axilare slenoidal + supraseapular + toracie lung. Durere iradiate de i Fracturi: Durer radiate de la + miiduva cervical + scapula + diafragm + miiduva Lombard + colul humeral + vezicula bliara + structuri miofasciale ‘ fracturd de stres a procesulai | + ulcer duodenal perforat coracoid + inima + splina (umar sting) + apex pulmonar Fracturi ale clavieulei ‘Sindromul ridiestorului seapule Entorsa acromio — claviculara Tatinderi muscular: Plex brahial + pectoral mare Neuropraxia + capul lung al bicepsului Nevrita (virala) Mijloacele kinetoterapeutice trebuie adaptate la particularitatile anatommice si biomecanice ale scgmentului sau articulafici intercsate in traumatismul suferit. Acestea provin din: ~ mijloacele fundamentale ale kinctoterapici — exercitiile fizice; ~ masaj-automasaj; - mijloacele asociate kinctotcrapici— alimentatia, medicatia, electroterapia, hidroterapia; = mijloacele ajutatoare elemente din diferite ramuri de sport Din multitudinea de mijloace de interventie de care dispune kinetoterapia, specialistul va selecta conform regulilor metodice pe cele mai potrivite fiecdrei etape de tratament. In alcatuirea planului terapeutic se folosesc anumite mijloace necesare recuperarii unei afecfiuni, iar {in alcituirca programului acestea variazi de la © etapa de tratament Ia alta[2] Obiectivele recuperiiit Indiferent de localizarea traumatismului si particularitayie sportivului fn eauzd, obiectivele generale ale etapelor de tratament sunt urmatoarele: = refacerea stiri de normalitate; + refacerea calititilor fizice pierdute; 27Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue _ = tefacerea integrala a functionalitatii organismmlui In afara acestor obiective generale, pe parcursul tratamentului kinetoterapeutic se stabilese obiective de etapa care se refera in principal la zona afectatd, la evolufia vindecdrii acesteia - recdstigarca functici afectate si diminuarca consecinjelor traumatismului, combaterea durcrii, inflamatiei, refacerea mobilitatii, forte, stabilitiii abiltati [8] Obiectivete demersului terapeutic in cazul recuperirié traumatismelor ta sportivi: ‘© Necesitatea scurtirii perioadei de repaus si de recuperare, in vederea revenirii ct mai rapide 2 sportivului in competitie, fara a risca recidiva; ‘© Organizarea activitiii prin stabilirea metodelor, mijloacelor si procedeclor kinctoterapeutice de evaluare a nivelului functional al zonei afectate; ‘© Stabilirea relaiilor de colaborare intre antrenor, sporti si kinetoterapeut. Scopul lucrarii este de a preciza importanta respectiit. metodologiei adecvate in aplcarea tratamentulu kinetoterapeutic sia identificdriicelor mai eficiente mijloace si metode kinetoterapeutice prin care recupcrarea traumatismclor produse in activitatca sportivi determin vindecarca integral, anatomofunctionalé a stucturilr afectate de traumatism, Recuperarea functional a umérului dupi leciuni posttraumatice distincte: Faza I ~ refacerea anatomicd este perioada imediat urmatoare traumatismulu, sau dupa interventia, chirargicala, care s-a soldat cu imobilizatea centuri scapulare. in aceasta perioad marl mu trebuie solicitat, se are in vedere membrl superior in otalitate, coloana cervicala si oracle Obiectve ‘© Combaterea durerii si controlul inflamatiei; + Facilitatearefacerii anatomice prin imbunititiea circuliei locale; + Combatereatulburirilorvasculo-tofie; + Profilaxiapicrderi forfei masculaturii flat sub sistemul de conten; + Mentinerea fanetionalitti la nivelul segmentelor neafectate Mijloace folosite: © Manevre de masaj — masaj clasic cervical gi al muschiului trapez la inceputul fiecdrei sedinte; + Posturarea antidecivi; Stretching la nivelul segmentelor neafectat; este structurati pe cinci etape ‘Medicatie antinflamatorie Kinetoterapie, Faca a H-a~ recuperarea functional este perioada imediat urmatoare suspendirit imobilizarit in care umirul ma poate fi solicitat, dar fird a irita leziunea trebuie redneeputi migcarea de intretinere a ‘umirului. Imobilizarea se poate suspenda treptat menfindndu-se noaptea sau chiar in timpal zilei Obicetive: Readaptarea structurilor artculare la migcare; Rearmonizarea mecanic’ a umiruluis Recuperarea stabilitati articulare; Cresterea mobilititiarticulare; ‘© Mentinerea capacititii de efort Mijloace folosite: © Manevre de masaj © antalgic/decontracturant cu accent pe manevre relaxante, efectuat in zona cervico-dorsalé, ‘umr si brat, uncori si mai extins la nivel lombar si antebrat; © terapeutic (Cyriax) pentru zonele profunde ale muschilor,tendoanelor si capsulei afeetate. + Posturarea ~ se va ageza bratul in rotatie extern’, usoara adductie gi flexie; * Electroterapie a inceputul fiecarei sedinje de recuperare se aplic’ TENS; © Rearmonizarea mecanicii a umérului: traumatismele umarului, din cauza configuratiei locale, pot produce o instablitate superioard (subluxatie superioard) sau o instabilitate inferioara (subluxatic inferioara). Rearmonizarea mecanicd este corectarea sau prevenirea dezaxarii capului humeral, obiectiy realizat prin anumite posturi, mobiliziri pasive cu tractiuni sau prin exercitii active. Faza a Il-a ~ este perioada in care leziunea incepe si fie treptat solicitaté prin mobilizari ce mu pputeau fi ficute in faza a Ll-a, Durerea constituie eriteriul major de confirmare sau nu a unei migeari, Aceasta fazi nu are nimic specific, fiind o tatonare a inceperi activtatii complexe din faza urmitoate. Faza a 1V-a- este perioada recuperdeii propriu-zise a functionalitatii umarului 278Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue Obiective ‘+ refacerea amplitudinii de miscare; + recdstigarea supleti articulare; # recdstigarea forfei musculare. Mijloace folosit. ‘© Calldura, masajul, clectroterapia antalgicd cu rol de a pregiti zona; = Kinctoterapie: © Manevre de intindere capsulo-ligamentara (tehnicile se executd fn 2 timpi); Exercitii de facilitare proprioceptivi: metoda Kabat (contractic-relaxare); Exerciti autopasive la seripete — diferite montaje; Exerciti active: pentru cresterea mobilittii: Exercitii cu revistenta pentru cresterca forjei muscular Faza a Vea ~ mi este obligatorie pentra toti pacientii, Accasti faz se adreseaza redobandirii performantelor motorii partculare pe care pacientul le avea inainte de traumatism si se aplici sportivilor sau acelora care desfisoard activitati fizice deosebite. Programul de recuperare, exerciiile functionale vor fi specifice sportului practicat de pacient.{1, 4] STUDIU DE CAZ FISA INDIVIDUALA Date personate L. L, 17 ani, sex M, judetul Iasi, medi urban; Diagnostic clinic: luxatie anterioard subcoracoidiand de umar drept; Categorie sportiva: sportiv de performanti, component al echipei de handbal LPS Lagi. Anamnezi ‘Simptome examen local: prezinti durcre, tumefactic, deformatic a regiunii, hemartroz’ si impotent’ fanctionalé la nivelul umirului, bratul drept se aflé posturat in adductic de 25° gi rotajie interna de 10°. Istoric: pacientul s-a prezentat in cadrul serviciului de urgent, acuzand durere la nivelul articulatiei umdrului drept, durere aparuti fn urma unui contact fizic din timpul antrenamentului si finalizat cu 0 cddere pe membrul superior drept. Pacientul a mai suferit in trecut subluxafii ale umarului si a fost diagnosticat cu instabilitate cronicd la unr Tratament ‘© Ortopedic ~ in vederea reducerit luxafiei si imobilizare cu bandaj Desault timp de 3 siptdmani Tratament medicamentos — indicat pentru reducerea dureris Flectroterapie antalgicé — aplicayile terapeutice ale curentului contimmy, discontinau, ultrasnete, TENS; Tratamentul prin hidro-termoterapie — foloseste ca factor terapeutic cildura, Tratamentul baineofizioterapeutic ~ in perioada de remisiune completd, dup trecerea completé sau aproape completi a leziunii, botnavul poate beneficia de tratament kKinetoterapeutic in diverse statiuni balneo-climaterice, unde asocierea factoritor naturali (apa mineral, nmol terapeutic, climatul) este beneficd si, impreund cu programele de kinetoterapie adecvate, vor asigura prevenirea recidivelor. Plan general de recuperare ~ tratamentul kinetoterapeutic precoce pentru a evita instalarea redorii si si respecte schema general, Obiective generale ale demersului terapeutie: © combaterea dureri si controlul inflamatiei; refacerea mobilititi articulare si a forfei musculare; recuperarea stabilitiiarticulare; refacerea misearilor controlate gi abilitilor; ‘menfinerea capacitiii de efort; ‘menfinerea imaginilor ideomotorii legate de gesturile motrice specifice handbalului Particulariti 219Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue evitarea mobilizrii pasive, recomandate sunt mobilizarile activo-pasive; este contraindicat armonizarea mecanicd in faza a II-a, putdnd fi aplicatd in faza a Illa dupa ce s-a realizat minim 70° clevatia brafului; evitarea in primele 15 zile a miscarilor de abductie, rotatie externa si retropulsie; exereifile izometrice sunt permise cu braful in pozitie joas’; migcdrile simple analitice se rciau la un nivel jos de amplitudine (sub 60°- 70°), Programul de recuperare s-a desfisurat pe © perioadi de 8 siptimani, intre 25 octombrie si 17 decembrie 2012, timp in care s-au efectuat dou’ testiri intermediate (Ia 2 respectiv 3 siptimani), gio testare finala. Jn primele 3 saptimani recuperarea s-a desfisurat in Central Medical Nicolina Iasi, iar restul programului s-a efectuat tat la domiciliul pacientulu cat si in sala de antrenament. Pacientul a suportat o imobilizare in bandaj de tip Desault pentru 3 saptamini, in aceasta perioads, pacientul a efectuat programul acasi, la sfatul medicului si kinctoterapeutului: + contractii izometrice ale musculaturii centuri scapulare; autocontrolul coloanei cervical, a pozitiei umerilor si toracelui prin urmarrea acesteia in oglinda, ‘mobilizari ale intregului membru superior sting si mobilizari ale degetelor si pummmutui drept; ‘masaj cervical si masaj al muschiului trapez; antrenament mental al migearilor de baza in handbal (pas, aruncare la poartl etc). Aceastii clap nua fost inclusd in programul de recuperare de 8 siptimni, astfel programul de recuperare a debutat cu suspendarea treptatii a imobilizirit (s-@ menjinut bandajul pe timpul noptit si in momentele in care s-a simtit oboseala). In aceasta etapd s-a efectuat rearmonizarea mecanicd a umérului prin posturari, tractiuni axiale, exercitii Codman si mobilizari active. Etapa respectiva a coincis cu faza a Ila a ‘ratamentului recuperator clasic. Faza a Tila a schemei de tratament a debutat dupa 10 zile de la renunjarea la bandajul imobilizator gi a durat 1 zile Faza a 1V-a s-a intins pe o perioada de 14 zile, in aceasté fazi sau fieut exercitile pentru refacerea amplitudinii de miseate, recdstigarea supleiiarticulare gia fortei musculare. Faza a V-a, cu 0 duratd de 21 de zile s-a desfisurat la sala de antrenament si a constat in exersarea tehnicilor de baz din handbal. La inceput s-a folosit o forta mai mica si mu s-a pus accentul pe precizia executiei, ca la sfaryitl programalui de recuperare sa se ajungi la forfa si precizia intial Testul de aprehensiune in faza a Il-a sia Lll-a de recuperare, a fost unul pozitiv, din cauza apariici durerii, aceasta dispardnd in faza a IV-a si a V-a, testul devenind negativ, astfel pacientul reusind s& facd miscirile specifice testului. Avand in vedere varsta pacientului, 17 ani, recuperarea s-a desfigurat foarte bine, ajungind ca dupa cele 2 luni de recuperare sé-si revind la forta si mobilitatea articulard anterioara accidentului, Trebuie precizat faptul cd, in cadrul acestui program, pacientul s-a implicat total, colaborarea a fost foarte bund sia respectat intocmai schema de recuperare. Valorie testirilor si misurdtorilor efectuate au fost urmétoarele: Tabelul 2. Bilan{ articular enum Valori_] Testare Testare Testare Testare miscirii | normale | inigiali | intermediari | intermediari | final 25.10.12 | _05.11.712 26.11.12 17.12.12, Flexie TRO" 80 TIO 150" 180" Bxtensie 507 15% 257 07 50° Abductie 180" 80" 120" TSO" 180" Adductie e o oF e o Rotatia externa | 80" 20" 35° 30 BO ‘Rotatie intern | 90° 355 50° 60 90 ‘Tabelul 3. Bilant museular Denumirea Testare Testare Testare Testare final muschilor inijiali | intermediark | intermediara 25.10."12 05.11.°12 26.11.12 17,12.712, 280Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue Flexort a = 3 Extensori 4 a 5 ‘Abductori 4 4 5 ‘Adductori 4 a 5 ‘Rotator’ externi 4 a 5 Rotator interni 4 a 3 ‘Tabelul 4. Teste specifice pentru aprecierea stabilitatii umarului Denumires Testare Testare Testare Testare final testului initia intermediara intermediar’ 25.10."12 05.11."12 26.11.12 17.12.12 Testul de pozitiv pozitiv negativ negativ aprehensiune | darere=3 pet | durere=2 pot durere=O pet durere= Opet Testul Areului_| pozitiv pozitiv negativ negativ dureros darere=2pet__| durere= I pet darere= O pet durere= O pet Testul Apley | pocitiv pozitiv negativ negativ durere= 3 pet durere= I pet durere= O pet Opet = fara durere 1 pet = intensitate micd (nota 1-3 pe SA); 2 pet = intensitate medie (nota 4-7 pe SVA); 3 pet = intensitate mare (nota 8-10 pe SVA), REZULTATE $I DISCUTII en 180 ints 10 | cenit — » — 2 a cal Fein Evita Aegina ion aire Fig. 2. Evolutia mobilitatii articulare a umarului drept Fig. 3. Evolufia forjei musculare pentru articulafia umarului drept CONCLUZII Kinetoterapia in traumatismele sportive desi respect schemele generale de recuperare, prezintd 0 setie de particulartati, generate atat de tipurile lezionale si de modificarile de substrat fiziopatologic induse de efortul sporti cat si de necesitatea recuperirii in timp optim si pana la ,restitutio ad integrum”. Aplicarea si respectarea unui program kinetoterapeutic combinat si cu alte metode si mijloace de rrecuperare au condus la formularea unui numér de concluzii, dup cum wrmeaza: 281Sp Soc Int J Ph Ed Sp 2014 - Volume 14 ~ Special Issue prin aplicarea ct mai devreme a programului de recuperare (chiar din timpul imobilizarii in ‘bandaj) se previne instalarea sochelelor de tip mecanic articular (retracjii musculo-tendo- capsulare, calus vicios, artrité posttraumatied ete.) precum sia apariici redorilor articulare; ‘© prevenirea accidentarilor se poate face cu succes prin adoptarea unui program de incdlzire si stretching bine efectuat; * atrofia de imobilizare, tulburirile de natura vascular’, edemele si paraliziile nervilor periferici ai membrului superior pot fi evitate prin efectuarca de mobilizari pasive, pasivo- active si active, asociate de tehnici precum hidrokinetoterapia, electroterapia si terapia ccupaionala; ‘© rezultatele au fost influentate atat de varsta jucdtorului cat ide interesul manifestat de acesta, {n scopul abtinerii conditieifizice anterioare accident © structura si mumarul exerciiilor dintr-o sedinfé de recuperare va fi diferit de cel utilizat la nesportivul cu aceeasi afecfiune, Programul de recuperare trebuie dublat de menjinerea capacititii de efort a sportivului, sau micar prevenirea scdderii acesteia si de mentinere a imaginilor ideomotorii legate de gesturile mottice specifice disciplinei sportive practicate Bibliografie [1] Avramescu TE. Kinetoterapia in activititi sportive. Bucuresti: Editura Didactica si Pedagogicd. 2006. Romanian [2] Balteamu_ V. Ailoaic LM. Compendiu de kinetoterapie, tehnici si metode. Iasi: Editura Tchnicd, Stingifica si Didactica Cermi. 2005. Romanian [3] Borza I. Niculescu B. Traumatologie sportiva. Timisoara: Editura Mirton, 2009. Romanian [4] Bratu M. Kinetoterapia in afectiunile posttraumatice ale sportivilor. Bucuresti: Editura Bren, 2004. Romanian [5] Georgescu L. Prim ajutor si traumatologie sportiva aplicatd. Craiova: Ed. Universitaria, 2006, Romanian [6] Netter FH. Atlas de Anatomie Umana. Editia a treia, Bucuresti: Editura Medical CALLISTO. 2005. Romanian [7] Rusu L, Rosulescu E. Kinetoterapia in recuperarea afectiunilor ortopedo ~ traumatice. Craiova: Editura Universitaria, 2007, Romanian [8] Sbenghe T. Kinetologie profilact Romanian |. terapeuticd gi de recuperare. Bucuresti: Editura Medicali. 1987, 282