1. Chapter 16: Using Therapeutic Exercise in Rehabilitation
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2. Athletic Trainer’s Approach to Rehabilitation
Begins ________________ after injury
One of clinician’s primary responsibilities is to design, implement and supervise rehab plans
Easy part is designing the program based on short and long term goals
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Components
Control pain and inflammation
Maintain or improve _________
Restore and increase strength
Re-establish neuromuscular control
Maintain levels of cardiorespiratory fitness
Difficult part is knowing when and how to progress relative to the injury
Return to play must be based on functional outcomes
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Due to __________________ nature of sports, rehab must be aggressive
Must return to competition quickly and safely
Rehab should be based on framework of healing process
Understand time and sequence of healing and physiological principals
Provide optimal healing environment
No ____________ approach to rehab
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5. Sudden Physical Inactivity and Injury Immobilization
Body requires physical activity to maintain proper __________ functioning
When injury occurs
Generalized loss of physical fitness due to loss of activity
Specific inactivity of injured part resulting from immobilization or splinting of soft tissue
Effects of General Inactivity
Highly conditioned athlete will experience rapid generalized loss of fitness
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Loss of muscle strength, endurance and coordination
Athlete must continue to work entire body w/out aggravating the injury
Effects of ___________________
Cause a number of disuse problems that impact muscle, joints, ligaments, bones, neuromuscular efficiency and cardiorespiratory system
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7. Major Components of a Rehabilitation Program
Well-designed rehab program should routinely address several key components before the athlete can return to pre-injury competitive levels
Minimizing Initial _____________
Swelling is caused by many factors and must be controlled immediately after injury
Minimizing swelling significantly speeds the healing process
RICE!!!
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Controlling __________
Some degree of pain will be experienced
Pain will be dependent on the severity of the injury, athlete’s response, perception of pain and the circumstances
RICE, analgesics and medication can be used to modify pain
Pain can interfere w/ rehab and therefore must be addressed throughout the rehab process
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Reestablishing ___________________ and kinesthesia should be of primary concern
Proprioception is joint position sense (determine position of joint in space)
Kinesthesia is the ability to detect movement
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10. Establishing or Enhancing Core Stability
Important component of all strengthening and comprehensive injury prevention program
Core is defined as the lumbo-pelvic complex, area where center of gravity (CoG) is located
Will improve dynamic postural control, ensure appropriate muscular balance, allow for expression of dynamic functional strength, improve neuromuscular efficiency
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A ________________ is a fundamental problem of inefficient movements which leads to injury
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12. Core Stabilization Exercises
Figures 16-2
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13. Regaining or Improving Range of Motion
Injury to a joint will always be associated w/ some loss of _________
Contracture of connective tissue or resistance to stretch of musculotendinous unit = decreased ROM
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14. Restoring or Increasing Muscular Strength & Endurance
Must work through a full pain free range of motion when working on strength
Figure 16-3
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_______________
Performed in early part of rehab following period of immobilization
Used when resistance through full range could make injury worse
Increase static strength, work to decrease/limit atrophy, create a muscle pump to decrease swelling
Strength gains are limited primarily to angle at which joint is exercised, no functional force or eccentric work developed
Difficult to motivate and measure force being applied
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_________ allows for a variety exercises
Not encumbered by design of the machine
Wide variety at low cost
Figure 16-3
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____________ Exercise
Incorporated in later stage of rehabilitation process
Uses fixed speeds w/ accommodating resistance to provide maximal resistance throughout ROM
Isokinetic units allow for calculation of torque, force, average power, and work ratios which can be used by the clinician diagnostically
Allows for work at more functional speeds
Work at higher speeds tends to reduce joint compressive forces
Can be used to develop neuromuscular pattern for functional speed and movements
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Testing Strength, Endurance and Power
Can be performed through
Manual muscle tests
Isotonic resistance
Isokinetic dynamometers
Isokinetic testing generally provides the most reliable and objective measures of change in strength
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Figure 16-4
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Regaining Balance
Involves complex integration of muscular forces, neurological sensory information from mechanoreceptors and biomechanical information
Entails positioning center of gravity (CoG) w/in the base of support
If CoG extends beyond this base, the limits of stability have been exceeded and a corrective step or stumble will be necessary to prevent
Even when “motionless” body is constantly undergoing constant postural sway w/ reflexive muscle contractions which correct and maintain dynamic equilibrium in an upright posture
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Balance Equipment
Figure 16-5
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22. Maintaining Cardiorespiratory Fitness
When injury occurs an athlete is forced to miss training time which results in decreased _______________________ endurance unless training occurs to help maintain it
Alternative activities must be substituted that allow athlete to maintain fitness
Figure 16-6
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23. Incorporating Functional Progressions
Involves a series of gradually progressive activities designed to prepare the individual for return to a specific sport/activity
Should be incorporated into treatment as early as possible
Adequate program will gradually assist athlete regain pain free ROM, restoration of strength, and neuromuscular control
Progression moves from simple to complex, slow to fast, short to long, light to heavy
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_________________ Testing
Uses functional progression drills for the purpose of assessing the athlete’s ability to perform a specific activity
Can be used to determine risk of injury due to limb asymmetry, provide objective measures of progress, and determine level of activity tolerance
Variety of tests
Shuttle runs -Vertical jumps
Agility runs -Balance
Figure 8’s -Hopping for distance
Carioca tests -Co-contraction test
** Cost efficiency, time demands, and space are concepts that must be considered
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Battery of tests should be used
Validity and reliability must be considered
Other factors to consider
Subjective injury evaluation
Performance of functional tests successfully
Relative to pre-injury status if available
Presence of other signs and symptoms
Stage of healing
Appropriate rest time
Self-evaluation
Findings from other clinical tests
Physician approval
Should assess unilateral and bilateral function
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26. Developing a Rehabilitative Plan
Must be carefully designed
Must have complete understanding of the injury:
how it was ______________
major anatomical structures involved
the grade of trauma
stage or phase of healing
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Setting ________
Best way to achieve successful rehab outcomes
Goals should be measurable, realistic, attainable
Athlete should be made aware of goals
Short-term goals
Developed to help achieve long term goals
Need to be linked to problem that patient is seeking help for
Will help patient accept ownership of rehab program
Provides patient with a road map to follow
Long-term goals
Return to work, return to full competition
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28. Criteria for Full Return to Activity
Rehab plan must determine what is meant by complete recovery
Patient is fully reconditioned, achieved full ________, strength, neuromuscular control, cardiovascular fitness and sports specific functional skills
Patient is mentally prepared
The decision to return to play should be a group decision (sports medicine team)
Team physician is ultimately responsible
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Decision should address the following concerns
Physiological healing constraints
Pain status
Swelling
ROM, strength, neuromuscular control, proprioception, kinesthesia, cardiovascular fitness
Sports-specific demands
Functional testing
Prophylactic strapping, bracing, padding
Responsibility of the patient
Predisposition of the patient
Psychological factors
Education and preventative maintenance program
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30. Additional Approaches to Therapeutic Exercise
Open versus Closed Kinetic Chain Exercises
Anatomical functional relationship in upper and lower extremities
Open kinetic chain exists when foot or hand is not in contact w/ ground or other surface
___________________________= foot or hand is weight bearing
Forces begin at ground and work their way up -- forces must be absorbed by various tissues and structures, rather than just dissipating
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_____________ Exercise
Water submersion offers an excellent environment for beginning a program of exercise therapy or it can compliment all phases of rehab
Buoyancy and hydrostatic pressure present versatile exercise environment
Assistive
Supportive
Resistive
Can engage in sports skills, restore functional capacities, perform a variety of upper and lower extremity exercises
Full weight bearing activities can also be performed
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32. Aquatic Exercises Figure 16-8 & 9
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33. Proprioceptive Neuromuscular Facilitation Technique
Exercise that uses proprioceptive, cutaneous, and auditory input to produce functional improvement in motor output
Used to increase strength, flexibility and coordination
Based on the physiological properties of the stretch reflex
Strengthening Techniques
Rhythmic initiation
Progressive series, first of passive movement then active assistive movements, followed by active movement through an agonist pattern
Helps patient w/ limited movement progressively regain strength through ROM
Can be initiated early
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Repeated Contraction
Used for general weakness at one specific point
Move isotonically against maximum resistance of the clinician until fatigue is experienced
At point of fatigue, stretch is applied at that point in range to facilitate greater strength production
Must be accommodated resistance
Slow Reversal
Movement through a complete range against maximal resistance
Promotes normal reciprocal coordination
Reversal of movement pattern is initiated before previous pattern completed
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Slow-reversal-hold
Part is moved isotonically using agonists, immediately followed by an isometric contraction
Used to develop strength at a specific point in the ROM
Rhythmic stabilization
Uses isometric contraction of agonists and antagonists - repeated contraction to strengthen at a particular point
Stretching techniques
Contract-relax
Passively moved until resistance is felt; patient contracts antagonist isotonically against resistance for 10 seconds or until fatigue; athlete relaxes for 10 seconds and then the limb is pushed to a new stretch
Repeated 3 times
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Hold-relax
The patient moves until resistance is felt; patient contracts isometrically against resistance for 10 seconds; relaxes for 10 seconds and then the limb is pushed to a new stretch actively by the patient or passively by the clinician
Repeated 3 times
Slow-reversal-hold-relax
Patient moves until resistance is felt; patient contracts isometrically against resistance for 10 seconds; relaxes for 10 seconds, relaxing the antagonist while the agonist is contracted moving the limb to a new limit
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________ Patterns
Involves 3 components
Flexion/extension
Abduction/adduction
Internal/External rotation
Distinct diagonal patterns w/ rotational movements of upper & lower extremities, upper & lower trunk and neck
D1 and D2 patterns for each extremity
Named according to movement occurring at hip or shoulder
Figure 16-11
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38. ________________Technique
Manually applied stretching techniques that utilize principles of neurophysiology to relax overactive muscles and/or stretch chronically shortened muscles
Variation of PNF contract-relax and hold-relax techniques
Based on stretch reflex
Voluntary contraction of muscle in a specifically controlled direction at varied levels of intensity against a distinctly executed counterforce applied by the clinician
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Patient provides intrinsic corrective force and controls intensity of muscular contraction while clinician controls precision and localization of procedure
5 components necessary for MET
__________ muscle contraction by the patient
A muscle contraction oriented in a specific direction
Some patient control of contraction intensity
Athletic trainer controlled joint position
Athletic trainer applied appropriate counterforce
Procedure
Locate resistance barrier; patients contracts antagonist isometrically for 10 seconds, relaxes, inhales and exhales maximally while body part is moved to new resistance barrier (repeat 3-5 times or until full ROM achieved
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40. Joint Mobilization and Traction
Used to improve joint mobility or decrease pain by restoring accessory motion -allowing for non-restricted pain free ROM
Mobilization may be used to/for
Reduce pain
Decrease muscle guarding
Stretch or lengthen tissue surrounding a joint
Produce reflexogenic effects that either inhibit or facilitate muscle tone or stretch reflex
Proprioceptive effects that improve postural and kinesthetic awareness
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Mobilization Techniques
Used to increase accessory motion about a joint
Involve small amplitude movements (glides) w/in a specific range
Should be performed w/ patient and athletic trainer in comfortable position
Joint should be stabilized as near one articulating surface as possible; other should be held firmly
Treatment occurs in parallel treatment plane
Maitland Grading System
Grade I (for pain) - small amplitude at beginning of range
Grade II (for pain) - large range at midrange
Grade III (treating stiffness) - large amplitude to pathological limit
Grade IV (treating stiffness) - small amplitude at end range
Grade V (manipulation) - quick, short thrust
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Mobilization based on concave-convex rule
When concave surface is stationary, convex surfaces is glided in opposite direction of bone movement
When convex surface is stationary, concave surface is glided in direction of movement
Mobilization can also be used in conjunction w/ traction
____________
Pull articulating segments apart (joint separation)
Occurs in perpendicular treatment plane
Used to treat pain or joint hypomobility
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43. Joint Mobilization Techniques
Figure 16-15
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Myofascial Release
Group of techniques used to relieve soft tissue from abnormal grip of tight fascia
Specialized form of stretching
___________ is essentially a continuous connective tissue network that runs throughout the body, encapsulating muscles tendon, nerves, bone, and organs
If damage occurs in one section it can impact fascia in sites away from the affected area
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Form of ______________ mobilization
Locate restriction and move into the direction of the restriction
More subjective and relies heavily on experience of the clinician
Focuses on large areas
Can have a significant impact on joint mobility
Progression, working from superficial to deep restrictions
As extensibility increases in tissue it should be stretched
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Strengthening should also occur to enhance neuromuscular reeducation, promoting new and more efficient movement patterns
Acute cases resolve in a few treatments, while longer conditions take longer to resolve
Sometimes treatments result in dramatic results
Recommended that treatment occur _____ times/wk
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Graston Technique
__________________ assisted soft tissue mobilization
Used to break down scar tissue & facial restrictions; stretch muscle tissue
Use stainless steel instruments for scanning and treatment of the injured area
Help to magnify location of tissue lesions and can then be used to treat the area with precise pressure on tissue restrictions
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Used to relieve ________________ and restore normal function
Application
Use of lubricant to reduce friction of instruments
Using multi-directional cross friction, restricted tissues are irritated to stimulate small inflammatory response
Increase rate and amount of blood flow to facilitate healing
Patient may experience some discomfort
Strengthening and stretching should be used in conjunction with technique to facilitate healing
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Graston Instruments
Figure 16-17
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50. Soft Tissue Mobilization
Soft tissue mobilization (_______________________ or ART) is a relatively new type of therapy used to correct soft tissue problems caused by formation of fibrotic adhesions
Can occur in muscle, tendon or fascia
Soft tissue mobilization is a way to diagnose and treat underlying causes of cumulative trauma disorders
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51. Purchasing and Maintaining Therapeutic Exercise Equipment
Price can range from $2 for surgical tubing to $____________ for computer driven isokinetic and balance units
Debate on effectiveness and availability of expensive equipment versus hands and creativity of clinician
Must consider budget restraints when purchasing
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