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By Analisa Jobe

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Analisa Jobe

on 13 August 2014

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Transcript of By Analisa Jobe

Thank You!
Beginning Rehab: Setting Goals
There are lots of things to look into before jumping right into rehabilitative exercises. Each of these will help decide what path to take for therapy.
Wong-Baker Faces Pain Scale
Borg's Perceived Exertion Scale
First Stages of Rehab
Starting Off Small
Exercises Cont.
How to Determine How Much Exercise the Pt can Handle:
By Analisa Jobe
Rehabilitation of Singers with Diaphragm Injuries
Mechanism of Injury (M.O.I.):

Traumatic Diaphragm Injuries (DI) are very rare. 75% of these injuries occur from blunt force trauma, such as car accidents and falls. The other 25% typically occur from penetrating trauma such as gun shot and stab wounds.
Most DIs occur in men
It his highly likely that those who suffer from a DI have other injuries in the thoracic and abdominal cavity that occurred from the same event that caused the DI.
Dwivedi explains how DIs from blunt force trauma occur, stating that, " A direct anterior blow to the abdomen leads to a sudden transmission of force through the abdominal viscera that acts as a hydrodynamic fluid wave leading to significantly increase intra-abdominal pressure and disruption." Thus, causing the diaphragm to rupture.
Identifying the Injury
Because DIs are most often associated with other major injuries, its may be masked by symptoms of other injuries.
The most common symptoms of DI are:
Respiratory Distress
Shoulder or Epigastric Pain
Bowel Sounds in the Thoracic Cavity
DIs are most commonly diagnosed by chest x-rays, or during surgery if other injuries warrant it.
Healthy Chest Cavity vs. DI
After Diagnosis:
A surgery called laparoscopy will be performed to assess and repair the damage to the diaphragm.
If the damage is too massive, the patient will receive a "prosthetic non-absorbable mesh to reconstruct the diaphragm." (Dwivedi)
The patient (pt.) will spend time recovering from their DI as well as any other associated injuries. (Dwivedi)
It is important here to note that everyone is different, and every injury is different. This means recovery times will vary depending on each person and their situation (Sarchet).
The physician will release the pt. when they feel they are no longer at risk for further damage to their injuries. This is typically after two to three weeks of recovery time. Referrals will be made by the physician if they feel the pt. needs rehabilitation (Sarchet).
Other Existing Injuries:
Due to the nature of DIs, it is important to learn if the pt. suffered any other injuries along with their DI. If so, consider the following:
How will each injury affect the pt's daily life?
Which ones are going to make it hardest to perform simple activities of daily living (ADLs) such as bathing, eating, walking, dressing, etc. (Rodgers)?
This may mean that DI therapy may not take first priority until the needs of other injuries have been met (Sarchet).
Lifestyle Prior to Injury: Pt's Version of "Normal":
It is very important to ask questions about the patient's lifestyle prior to their injuries to help get a sense of what was normal for them. That information will help you determine how high to set your goals for your pt. Here are a few things to ask:

What is your occupation?
For a singer with a DI, this will increase the importance of making sure the DI is fully recovered and strenghtened.
What were your hobbies prior to your incident?
Were they a singer? Marathon runner? Couch potato?
You will want to assess if they can physically reacquire the ability to participate in their hobbies, and consider them when setting goals.
What are they looking to get out of therapy?
Are they wanting to get recovered enough to pick up their old hobbies?
This will help you determine how hard they are willing to let you push them to get better (Sarchet).
This scale is a good way to help the pt. communicate to you their level of pain when doing rehab. You want the pt to push past a little bit of pain, where they are uncomfortable, but you don't want them to be hurting too much either. It is important to remember that everyone perceives pain, and feels pain differently.
As they are doing exercises, have the pt. point to the face that best describes their pain level. You don't want to push them past what they consider to be a 3 or a 4.
This is a also a good way to help you read the Pt's body language.
For example, if they say their pain level is a 10, and they are smiling or they don't appear to be in pain, the Pt. might be over-exaggerating, or they aren't really listening to what their body is telling them.
This scale is a good way to tell how hard someone is truly working by connecting their perceived exertion to their heart rate. Here's how it works:
Ask the Pt. how hard they believe they are working.
If they are at rest it should be about a 6, and then it should go up as they continue to work harder.
Laskowski states that a normal resting heart rate for a healthy adult is around 60-100 beats per minute (BPM)
Ideally, if the Pt. is being honest with themselves and really listening to their bodies, their perceived exertion rate should be an indicator of their heart rate ("Perceived Exertion").
You should be able to ask the Pt. their perceived rate of exertion (PRE), add a zero to the end of the number, and the new number should coincide with the Pt's actual heart rate ("Perceived Exertion").
For example, at rest the Pt's PRE should be between 6 and 10. If they tell you they believe their number to be an 8, then that means their heart rate should be in the 80's. You can take the Pt's heart rate to confirm if they were right.
By being able to relate the Pt's heart rate to their PRE, you can determine if they are truly being honest with themselves about how hard they are working (Sarchet).
Re-Teaching Proper Breathing Technique
It is important to start re-training the Pt. to use proper breathing technique as soon as possible after their injury. Here are a few reasons why:
You can't stop breathing just because you had a diaphragm injury, which also means that you can't immobilize it until it heals (Rodgers).
Because you can't just stop breathing, the Pt. might have formed bad breathing habits by breathing from the chest in an effort to alleviate the pain of breathing from the abdomen and rib cage (Sarchet).
The sooner you correct the bad habit, the easier it is to break it.
The Pt. needs to use proper breathing technique in all the exercises that will follow.
If the Pt. is using proper breathing technique during their therapy to address other injuries, it gives them a leg up when they are finally able to rehab their DI (Rodgers).
Encourage the Pt. as quickly as possible to practice breathing with a full expansion of the rib cage and abdomen, and not solely from the chest (Rodgers).
Have them lay flat and watch their abdomen rise as they breathe
Have them put their hand on their stomach, ribs, or sternum to feel that they are getting expansion in all of the right places (Rodgers).
The sooner they re-train themselves to breathe properly, the sooner you can progress to other exercises.
Working with a Spirometer
A spirometer is a tool that helps measure how much air someone can take in by having them breathe into the mouthpiece of the device, and watching the piston inside rise. The spirometer is labeled in milliliters , and as you breathe in the piston coordinates with the labels to show how many milliliters you have taken in. There is a tab on the side of the tool that can be raised or lowered to set a goal for the Pt. to reach ("How to Use and Incentive Spirometer"). To use it for exercises, follow these tips:
Have the Pt. breathe in using proper technique and give their best effort at a deep inhale, hold their breath for as long as possible, and exhale slowly("How to Use an Incentive Spirometer"). Record the number they reach and set it as a goal for the Pt. to learn to reach consistently (Sarchet).
Ask the Pt. to practice with the spirometer several times a day, and do 10 repetitions each time they practice (Sarchet).
When the Pt. can reach the goal all ten times, set a higher goal.
As the Pt. recovers and gets stronger they will be able to take deeper and deeper breaths, so keep encouraging them to breathe properly and keep working towards higher goals (Sarchet).
Medicine Ball and Walking Exercises
Medicine Ball Benefits:
Sitting on a medicine ball requires light exercise of the core, which will help increase core stability. The core muscles also play key roles in breathing, and assist the diaphragm. Strengthening these muscles will indirectly help strengthen the diaphragm (Sarchet).
Benefits of Walking:
Walking will help slightly increase the Pt's heart rate from resting, which will require the Pt. to take more frequent, and deeper breaths. This will also help improve overall endurance levels.
Exercises that can be done while walking or sitting on a medicine ball:
Practice Proper Breathing Technique (Rodgers).
Use the Spirometer (Sarchet).
Have a conversation while practicing taking good breaths (Rodgers).
Do some light vocal warm-ups, or some very mild singing (the Pt. SHOULD NOT push the extremes of their range at this point) (Rodgers).
Walking on a treadmill with big arm movements (Sarchet).
As the Pt. gets stronger, try incorporating LIGHT weights (No more than 5-10 pounds). Here are some examples:
Practice walking and breathing with light weights in both hands (Sarchet).
Sitting on a medicine ball, hold light weight to the chest and practice breathing (Sarchet).
Middle and Final Stages of Rehab
As the Pt. improves, you will want to continue to make exercises they have already been doing more challenging by adding more repetitions, or weights, and you will want to begin to incorporate new exercises that are more difficult. The core exercises are the key to building strength, while cardio such as vigorous walking, jogging, or swimming will improve endurance and lung capacity (Sarcher).
At this stage, the Pt. should have enough strength to begin singing again. Remind them to continue to use healthy breathing habits as they have been instructed, and address other vocal issues as they arise. They may not be back to 100% yet, but they will get there over time.
Bosu Ball Plank
Plank to Pike
Russian Twists With and Without Weights
Lateral Planks (Windmills)
Lateral Hip Raises
Leg Lift
Reverse Crunch
Ab Wheel
Bosu Balance
Back Extensions
Straight Leg Dead Lift
Kettle Bell Swing
Oblique Extensions
Cardio exercises will help the Pt. increase their endurance levels, as well as their lung capacity (Sarchet). The Pt. should try to achieve 20 minutes of cardio per day. Jogging and walking, as well as swimming are excellent ways to get the Pt's heart rate up to achieve endurance and lung capacity.
For these exercises, the patient may jog at a pace that is challenging, but not too difficult, or walk at a brisk pace.
Interval training is a good way to get the heart rate up, and keep it up, while still allowing opportunities to take a break. This can be done by briskly walking or jogging for two minutes, and then slowing the pace for one minute (Sarchet).
Do not have the patient stop moving during their breaks, but do allow them to slow down and catch their breath (Sarchet).
This is a good opportunity to encourage the patient to pace their breathing (Rodgers). Have them breathe in through their nose for four counts, and out through the mouth for four counts. The counts should be at a slow, even pace.
If your patient knows how to swim, there are several exercises that they can benefit from. Before allowing the patient to get into the water, make sure that any open wounds have completely healed. This is to protect the patient from getting an infection, and to prevent the spreading of germs to anyone else in the water.
This exercise is a good way to get the Pt's heart rate up, and practice breath pacing (Rodgers).
This exercise is done with the stomach and face down in the water.
With alternating arms, reach one arm above the head, and then pull the arm through back down to the side of the body. This is called a stroke.
Repeat this step with the opposite arm.
This should be done in fluid motions without any break in movement.
The face should stay down in the water, except for every four strokes when the patient will turn their head to the opposite side of whichever arm is fully extended above the head to take a breath.
The pattern for breathing according to the strokes is 1-2-3-breathe.
This exercise will help improve the Pt's lung capacity (Rodgers).
Have the Pt. take a deep breath, and then go under the water.
They will swim as far as possible while holding their breath.
When they can no longer hold their breath, the Pt. will slowly blow out the air.
Next, the Pt. will come up for air, take a breath, and continue the exercise.
Final Notes
Because DI's occur in rare, and traumatic situations, it is important to remember that a Pt. who suffers from one has a long road to recovery (Sarchet). Here are a few things to keep in mind throughout the entire rehabilitation process:
ALWAYS be encouraging and positive towards the Pt. They may experience some frustration with trying to get better, so give them positive reinforcement throughout the whole process.
Emphasize the importance of healthy breathing habits in every single exercise. This will help the vocalist to carry those good habits over into their singing.
Don't be afraid to push them out of their comfort zone. If an exercise has become too easy for the Pt., find a way to make it more challenging.
Don't do the same exercises in the same order every time. Mix things up by doing different exercises each day in varying orders. Set up a circuit were the Pt. rotates through different exercises a number of times.
This type of training is called muscle confusion, and it is the best way to prevent the Pt. from hitting a plateau (Sarchet).
Works Cited
Brohi, Karim. "Late Presentation of Diaphragm Rupture Following Blunt Thoracic Trauma." Trauma.org. Web. 26 July 2014.

Dwivedi, Sankalp. “Treating Traumatic Injuries of the Diaphragm.” Journal of Emergencies, Trauma, and Shock. U.S. National Library of Medicine; April 2010. Web. 26 July 2014.

Gaillard, Frank. "Normal Chest X-Ray." Radiopaedia.org. Web. 26 July 2014.

“How to Use an Incentive Spirometer.” Cleveland Clinic. Clevelandlcinic.org. Web. 24 July 2014.

Laskowski, Edward R. "What is a Normal Resting Heart Rate?" Mayo Clinic. Mayoclinic.org. Web. 26 July 2014.

"Management of a Patient with a Minor Burn Injury." vicburns.org. Web. 26 July 2014.

McLean, Brian. "How Hard Am I Actually Working During Exercise?" Ivyrehab.com. Web. 26 July 2014.

“Perceived Exertion (Borg Rating of Perceived Exertion Scale).” Physical Activity for Everyone: Measuring Intensity: Perceived Exertion. CDC.Gov, 30 March 2011. Web. 24 July 2014.

Rodgers, Kimber. MAT, ATC, LAT. Personal Interview. 29 July 2014. License Number: AT4023

Sarchet, Paige. OTR. Personal Interview. 24 July 2014. License Number: 109165

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