I have recently completed a work hardening programme with a client who sustained a left knee injury when he tripped downstairs at work. When the client was referred to Absolute Balance, he was completing pre-injury duties as tolerated but was still experiencing knee discomfort, difficulty with squatting movements and was avoiding using stairs at work preferring to take the lift instead. The client was highly motivated to remain at work due to the financial implications and associated stress of not being fit to work offshore. As the client had previously undergone an arthroscopic meniscectomy on the left knee, he was keen to avoid further surgery.
Client: 59 years old male
Injury Details: Left Knee Medial Meniscal Tear
Pre-Injury Job Role: Production Technician (Offshore)
Medical Restriction: Pre-Injury Duties
Rehabilitation Goals: Reduce symptoms, increase tolerance to all work-related tasks and educate on self-management strategies for long term injury management.
We assessed the client, gathered an injury history and completed physical testing. The key findings were; end range restriction with left-sided knee flexion and extension, pain during knee flexion with a 4/10 on the Visual Analog Scale (VAS). There was a reduced ability to complete exercises involving loaded knee flexion such as squatting tasks, lifting from floor to waist and step-ups. The client experienced 6-8/10 knee pain on the VAS when under load.
The client also presented with poor movement patterns with squatting and lunging tasks. There was a reduced amount of proprioception on the left side, with an average of 14 seconds single leg balance, compared to 30 seconds on the right side. Other relevant information we gathered was that the client has never used a gym before and found the gym environment intimidating. The client also mentioned that they avoided descending stairs as he believed this would make his injury worse and increase his chance of sustaining long-term structural damage to his knee.
We identified the key critical physical demands of the job role to include;
- Up to 80% of the day walking and standing
- Up to 20% of the day completing office work at a seated workstation.
- Occasional floor to waist lifting up to 10kg.
- Carrying up to 10kg up to 100m.
- Ascending and descending flights of stairs carrying up to 10kg.
- Squatting crouching and reaching, sustained awkward postures while completing work tasks.
The exercise programme was prescribed based on the physical presentation in the initial assessment and the critical physical demands of the pre-injury job role. As the client had no prior gym experience and had some anxiety around attending the gym independently, we initially accompanied him to the supervised exercise sessions when he not working. We also set him up with a home-based exercise rehabilitation programme that he completed independently.
We then equipped the client with a phone exercise app called TrackActive, allowing us to upload his exercise programmes electronically and being able to access pictures and videos of exercise technique with instruction on sets and repetitions. Discussions were held with the employer to make sure there were qualified gym staff that could assist the client with his prescribed gym programme when working offshore, until he gained enough confidence to complete his programme independently.
Eventually the client gained confidence to attend the gym independently and learnt sound knowledge of exercise technique. We also challenged unhelpful injury beliefs by providing education on pathology, injury causation, and evidence-based rehabilitation. We slowly started to implement stair descent into his daily routine until he was confident to complete this as required when at work rather than using the lift.
Below are some examples of the specific exercises prescribed throughout the programme and the rationale for incorporating them based on the physical presentation of the client and the critical physical demands of the job role.
Side Bridge with hip abduction
Addressing hip and trunk strength and stability to assist with functional movement patterns and hip knee alignment when squatting, lunging and stepping up.
Increasing gluteal, quadricep and hamstring strength. Improving neuromuscular control, proprioception and building confidence to descend stairs.
Lunge and Row
Challenging proprioception, increasing unilateral leg strength, increasing ability to carry out work-specific tasks and work in awkward crouched postures while completing upper body tasks.
After completing a twelve-week exercise programme with Absolute Balance including supervised sessions and self-managed rehabilitation while offshore the client improved his functional capacity and his ability to complete pre-injury duties, he built confidence to complete his exercise programme independently and now understands how to manage his condition long term. At the conclusion of the programme his Doctor issued him with a final medical certificate.
For more information on return to work exercise rehabilitation programmes contact Absolute Balance on 9244 5580 or email us at firstname.lastname@example.org.
Lisa Wallbutton (BSR, MClinicalExPhysiol(Rehab))
Accredited Exercise Physiologist (AEP) (ESSAM)