Rehabilitation and Reconditioning chapter 20 Rehabilitation and Reconditioning David H. Potach, PT; MS; CSCS,*D; NSCA-CPT,*D Terry L. Grindstaff, DPT; ATC; SCS; CSCS,*D

Chapter Objectives Identify members of the sports medicine team and their responsibilities during injury rehabilitation and reconditioning. Recognize types of injuries athletes sustain. Comprehend timing and events of tissue healing. Understand goals of each tissue healing phase. Describe the strength and conditioning profes-sional’s role during injury rehabilitation and reconditioning.

Rehabilitation and Reconditioning Principles of Rehabilitation and Reconditioning Healing tissues must not be overstressed. The athlete must fulfill specific criteria to progress from one phase to another during the rehabilitative process. The rehabilitation program must be based on current clinical and scientific research. The program must be adaptable to each individual and his or her specific requirements and goals. Rehabilitation is a team-oriented process requiring all the members of the sports medicine team to work together.

Section Outline Sports Medicine Team Sports Medicine Team Members Communication

Sports Medicine Team Sports Medicine Team Members All members of the sports medicine team are responsible for educating coaches and athletes regarding injury risks, precautions, and treatments. The sports medicine team also works to prevent injuries and rehabilitate injured athletes. Several different professionals play important roles in assisting an injured athlete’s return, so effective communication is necessary.

Key Terms team physician: A person that provides med-ical care to an organization, school, or team. athletic trainer: A person typically responsible for the day-to-day physical health of the athlete; certified by the National Athletic Trainers’ Association Board of Certification as a Certified Athletic Trainer (ATC).

Key Terms physical therapist: A person with a back-ground in orthopedics or sports medicine that can play a valuable role in reducing pain and restoring function to the injured athlete.

Key Terms strength and conditioning professional: A person who plays a valuable role within the sports medicine team and is an integral part of the rehabilitation and reconditioning process. Ideally, this person should be certified by the National Strength and Conditioning Association (NSCA) Certification Commission as a Certified Strength and Conditioning Specialist (CSCS) to ensure that he or she has the knowledge and background to contribute to the rehabilitation process.

Key Terms exercise physiologist: A person who has a formal background in the study of the exercise sciences and uses his or her expertise to assist with the design of a conditioning program that carefully considers the body’s metabolic response to exercise and the ways in which that reaction aids the healing process.

Key Terms nutritionist: A person who has a background in sport nutrition may provide guidelines regard-ing proper food choices to optimize tissue recovery. Ideally, the nutritionist has been formally trained in food and nutrition sciences and is a Registered Dietitian (RD) recognized by the American Dietetic Association.

Key Terms psychologist or psychiatrist: A licensed professional with a background in sport may provide strategies that help the injured athlete better cope with the mental stress accom-panying an injury.

Sports Medicine Team Communication Strength and conditioning professionals must understand the following: The diagnosis of the injury Indications—forms of treatment required Contraindications—activity or practice prohibited due to the injury They must also inform the rest of the sports medicine team about the exercises performed by the athlete and the athlete’s response to the exercise.

Key Point The sports medicine team includes a large number of professionals working together to provide an optimal rehabilitation and reconditioning environment. The relation-ship among members requires thoughtful communication to ensure a safe, harmoni-ous climate for the injured athlete.

Section Outline Types of Injury

Key Point Macrotrauma is a specific, sudden episode of overload injury to a tissue, resulting in disrupted tissue integrity. Microtrauma results from repeated, abnormal stresses applied to a tissue by continuous training or training with too little recovery time. Each injury requires specific rehabilitation strategies to allow return to function.

Macrotrauma (acute) Bone Joint Ligamentous trauma – sprain Contusion Fracture Joint Dislocation Subluxation Ligamentous trauma – sprain First degree Second degree Third degree Musculotendinous trauma Strain Rupture

Microtrauma (chronic) Results from repeated abnormal stress applied to a tissue by continuous training or training with too little recovery time Can be due to: Training errors (poor program design) Suboptimal training surfaces (too hard or uneven) Faulty biomechanics or technique during performance Insufficient motor control Decreased flexibility Skeletal malalignment and predisposition

Microtrauma (chronic) Bone Most common overuse injury is a stress fracture Rapid increase in training volume Excessive training volume on hard surfaces Tendon Tendinitis – inflammation of a tendon

Section Outline Tissue Healing Inflammation Phase Repair Phase Remodeling Phase

Table 20.1

Tissue Healing Inflammation Phase Inflammation is the body’s initial reaction to injury and is necessary for normal healing to occur. Injured area becomes red and swollen Locally hypoxic environment leads to tissue death Further increase in blood flow and capillary permeability Allows escape of fluid surrounding tissues

Tissue Healing Repair Phase Once the inflammatory phase has ended, tissue repair begins; this phase allows the replacement of tissues that are no longer viable following injury. Original damaged tissue is regenerated and scar tissue is formed New capillaries and connective tissue form in the area Collagen fibers are randomly laid down to serve as framework for tissue repair (haphazardly positioned) Not optimal strength This phase of tissue healing begins as early as two days after injury and may last up to two months.

Tissue Healing Remodeling Phase The weakened tissue produced during the repair phase is strengthened during the remodeling phase of healing. Collagen fiber production has decreased Improves structure, strength and function Increased loading allows collagen fibers of scar tissue to hypertrophy and align along the lines of stress Tissue remodeling can last up to two to four months after injury.

Key Point Following injury, all damaged tissues go through the same general phases of heal-ing: inflammation, repair, and remodeling. Characteristic events define each phase and separate one phase from another.

Section Outline Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning Inflammation Phase Treatment Goal Exercise Strategies Repair Phase Remodeling Phase Exercise Strategies (continued)

Section Outline (continued) Rehabilitation and Reconditioning Strategies Program Design Resistance Training Aerobic and Anaerobic Training

Rehabilitation and Reconditioning Strategies The process of returning to competition following injury involves: Healing of the injured tissues Preparation of these tissues for the return to function Use of proper techniques to maximize rehabilitation and reconditioning

Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning Choose a level of loading that neither overloads nor underloads healing tissue. Healing tissue must never be overstressed. But, controlled therapeutic stress is needed to optimize collagen matrix formation. The athlete must meet specific objectives (established by the physician, athletic trainer, physical therapist, or a combination of these) to progress from one phase of healing to the next.

Loading During Rehabilitation Figure 20.3 (next slide) Loading during rehabilitation should neither overload nor underload the athlete’s healing tissue.

Figure 20.3

Soft Tissue Injury Response Figure 20.4 (next slide) Pain is often used as a guide for tissue health. Pain levels often decrease well before tissue healing is complete, which may lead athletes to believe they can return to competition before the body is actually ready.

Figure 20.4 Reprinted, by permission, from Leadbetter, 1992.

Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning Inflammation Phase Treatment Goal Preventing disruption of new tissue Exercise Strategies General aerobic and anaerobic training and resistance training of uninjured extremities, with priority given to maximal protection of the injured area

Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning Repair Phase Treatment Goal Preventing excessive muscle atrophy and joint deterioration in the injured area; maintaining muscular and cardiovascular function in uninjured areas Exercise Strategies (after consultation with team physician, athletic trainer, or physical therapist) Submaximal isometric exercise Isokinetic exercise Specific exercises to improve neuromuscular control

Rehabilitation and Reconditioning Strategies Goals of Rehabilitation and Reconditioning Remodeling Phase Treatment Goal Optimizing tissue function by continuing and progressing the activities performed during the repair phase and adding more advanced, sport-specific exercises Exercise Strategies Transition from general exercises to sport-specific exercises Specificity of movement speed an important variable Velocity-specific strengthening exercises (velocities must progress to those used in the athlete’s sport)

Rotator Cuff Rehabilitation Figure 20.5 (next two slides) Exercises generally transition from (a, b) isolation exercises to (c, d) multijoint, sport-specific exercises.

Figure 20.5a and b

Figure 20.5c and d

Key Term closed kinetic chain: An exercise in which the terminal joint meets with considerable resistance that prohibits or restrains its free motion; that is, the distal joint segment is stationary.

Closed Kinetic Chain Exercises Figure 20.6 (next slide) Closed kinetic chain exercises: (a) squat exercise (b) push-up exercise

Figure 20.6

Key Term open kinetic chain: An exercise that uses a combination of successively arranged joints in which the terminal joint is free to move; open kinetic chain exercises allow for greater concentration on an isolated joint or muscle.

Open Kinetic Chain Exercise Figure 20.7 (next slide) Example of an open kinetic chain exercise—leg (knee) extension exercise

Figure 20.7

Kinetic Chain: Sprinting Figure 20.8 (next slide) Sprinting offers an example of open and closed kinetic chain movements occurring together.

Figure 20.8

Rehabilitation and Reconditioning Strategies Program Design Resistance Training Several programs have been developed to assist with the design of resistance training programs for injured athletes, including the De Lorme and Oxford programs and Knight’s DAPRE program. DAPRE allows more manipulation of intensity and volume. The demands of the athlete’s sport determine the training goal, which should dictate the design of the resistance training program during the remodeling phase.

Rehabilitation and Reconditioning Strategies Program Design Resistance Training Daily adjustable progressive resistive exercise (DAPRE) system First set requires 10 repetitions of 50% of the estimated 1RM. Second set requires six repetitions of 75% of the estimated 1RM. Third set requires the maximum number of repetitions of 100% of the estimated 1RM. The number of repetitions performed during the third set determines the adjustment to be made in resistance for the fourth set.

Table 20.2

Rehabilitation and Reconditioning Strategies Program Design Aerobic and Anaerobic Training Although research has yet to determine an optimal aerobic training program for use in the rehabilitation setting, the program should mimic specific sport and metabolic demands.

Key Point Designing strength and conditioning programs for injured athletes requires the strength and conditioning professional to examine the rehabilitation and recondi-tioning goals to determine what type of program will allow the quickest return to competition.