Rehabilitation Sabino Sports Medicine I

Developing a rehab program Assess the injury Assess the injury Establish goals Establish goals Long term—return athlete to full activity Long term—return athlete to full activity Short term Short term Execute program Execute program Reassess as athlete progresses through program Reassess as athlete progresses through program

Format for rehab program Phase I—time period immediately following injury/surgery during which movement in the affected part is either involuntarily limited because of pain, swelling, muscle spasm, etc, or purposely restricted by immobilization in casts, splints, slings, etc. Phase I—time period immediately following injury/surgery during which movement in the affected part is either involuntarily limited because of pain, swelling, muscle spasm, etc, or purposely restricted by immobilization in casts, splints, slings, etc.

Phase I-therapeutic objectives Teach proper ambulation techniques Teach proper ambulation techniques Assist the healing process using appropriate modalities Assist the healing process using appropriate modalities Minimize loss of muscular strength and slow muscle atrophy Minimize loss of muscular strength and slow muscle atrophy Maintain overall level of physical fitness Maintain overall level of physical fitness

Criteria for progression to phase II Remove cast, splint, sling, etc. Remove cast, splint, sling, etc. Sufficient reduction of pain, swelling, inflammation to allow for use of safe and effective therapeutic exercise Sufficient reduction of pain, swelling, inflammation to allow for use of safe and effective therapeutic exercise Acceptable degree of tissue healing to allow use of therapeutic exercise without aggravating injury Acceptable degree of tissue healing to allow use of therapeutic exercise without aggravating injury

Phase II Period of time when more vigorous therapeutic exercise, including joint ROM, is started. Period of time when more vigorous therapeutic exercise, including joint ROM, is started. Using appropriate therapeutic modalities during the time will enhance the healing process and assist in facilitating the use of therapeutic exercise. Using appropriate therapeutic modalities during the time will enhance the healing process and assist in facilitating the use of therapeutic exercise.

Therapeutic Objectives Phase II Establish weight bearing and restore normal gait patterns Restore joint ROM equal to the unaffected part Restore flexibility equal to or exceeding unaffected part Restore muscular strength & endurance equal to unaffected part and consistent with demands of sport involved Maintain acceptable level of physical fitness

Criteria to progress to Phase III Acceptable reduction of local symptoms Acceptable level of healing of “wound” Adequate restoration of gait, ROM, flexibility, strength, endurance, power, & CV fitness to resume at least part of regular practice/conditioning Satisfactory assurance of adequate protection from reinjury Great level of motivation and confidence of athlete

Phase III Period of time during which participation (in part or completely) of the normal practice and conditioning is resumed

Therapeutic Objectives Phase III Continue restoration of joint ROM, flexibility, muscular strength and endurance to safely resume full participation Continue to work on overall physical fitness Re-establish nornal pattern of motor activity—gait patterns, coordination agility, balance, proprioception— as they relate to the sport specific skills Restore athlete’s confidence in resuming full participation

Criteria to progress to Phase IV Restoration of all components of physical fitness Resuming full---complete and unrestricted--- participation

Phase IV That period of time after which “complete” rehabilitation” is achieved and full activity is resumed.

Therapeutic Objectives Phase IV Maintain muscular strength, endurance, power, and flexibility Maintain optimal CV fitness Maintain overall rehabilitated state

Assessing the injury Use SOAP notes (systematic means of documenting the assessment and recording progress of rehab program Use SOAP notes (systematic means of documenting the assessment and recording progress of rehab program

SOAP notes S = Subjective S = Subjective Patient history, symptoms, chief complaint Patient history, symptoms, chief complaint O = Objective O = Objective Signs, information from observation, palpation, stress tests Signs, information from observation, palpation, stress tests A = Assessment A = Assessment Type and severity of injury, any associated problems Type and severity of injury, any associated problems P = Plan P = Plan What will you do? Long & short term goals, what is working, how the athlete is progressing What will you do? Long & short term goals, what is working, how the athlete is progressing

Establish Goals Short term goals Short term goals Control swelling using proper immediate first aid Control swelling using proper immediate first aid PRICE PRICE Reduce/minimize pain Reduce/minimize pain PRICE, use of modalities such as ice, heat, e-stim PRICE, use of modalities such as ice, heat, e-stim Restore full ROM Restore full ROM Dynamic, static, PNF stretching activities Dynamic, static, PNF stretching activities Restore/increase muscular strength, endurance, power Restore/increase muscular strength, endurance, power Isometrics, isotonics, isokinetics, plyometrics through full, pain-free ROM Isometrics, isotonics, isokinetics, plyometrics through full, pain-free ROM

Isometrics Isometrics Performed early in rehab when joint is immobilized Performed early in rehab when joint is immobilized Used when performing exercises through full ROM may be detrimental Used when performing exercises through full ROM may be detrimental Increase static strength Increase static strength Assist in decreasing amount of atrophy Assist in decreasing amount of atrophy Lessen swelling by causing muscle pumping action Lessen swelling by causing muscle pumping action

Isometrics

Isotonics (progressive resistance exercises or PRE’s) Isotonics (progressive resistance exercises or PRE’s) Most commonly used strengthening technique Most commonly used strengthening technique Use free weights, exercise machines, tubing, bands, etc., with fixed weight through ROM Use free weights, exercise machines, tubing, bands, etc., with fixed weight through ROM Use isotonic muscle contractions Use isotonic muscle contractions Force is generated while the muscle is changing length Force is generated while the muscle is changing length Use eccentric (lengthening) and concentric (shortening) muscle contractions Use eccentric (lengthening) and concentric (shortening) muscle contractions

Isotonics

Isokinetics Isokinetics Occasionally used in rehab Occasionally used in rehab Incorporated in later phases of rehab Incorporated in later phases of rehab Used primarily for diagnostic purposes Used primarily for diagnostic purposes Uses a fixed speed with accommodating resistance to provide maximal resistance throughout ROM Uses a fixed speed with accommodating resistance to provide maximal resistance throughout ROM Measures commonly used as criteria for return to functional activity Measures commonly used as criteria for return to functional activity

Isokinetics Cybex

Isokinetics CybexKincom

Isokinetics

Kin comBiodex

Plyometrics Plyometrics Incorporated in later stages of rehab Incorporated in later stages of rehab Use a quick stretch of muscle to facilitate a subsequent concentric muscle contraction Use a quick stretch of muscle to facilitate a subsequent concentric muscle contraction Useful in restoring/developing athlete's ability to produce dynamic movements associated with muscular power Useful in restoring/developing athlete's ability to produce dynamic movements associated with muscular power Ability to generate force rapidly is key to successful performance in many sports Ability to generate force rapidly is key to successful performance in many sports

Plyometrics

Short term goals Reestablish neuromuscular control Reestablish neuromuscular control Mind’s attempt to teach the body conscious control of specific movements—using strengthening exercises that are more functional Mind’s attempt to teach the body conscious control of specific movements—using strengthening exercises that are more functional Improve balance Improve balance Balance training and postural stability Balance training and postural stability Maintain cardiorespiratory fitness Maintain cardiorespiratory fitness Single most neglected component, use pool, bike, upper body ergometer, stairclimber, elliptical trainer, etc. Single most neglected component, use pool, bike, upper body ergometer, stairclimber, elliptical trainer, etc.

Incorporate appropriate functional progressions Incorporate appropriate functional progressions Involve series of gradually progressive activities designed to prepare athlete for return to participation Involve series of gradually progressive activities designed to prepare athlete for return to participation Monitor activity to determine athlete’s ability to perform and physical tolerance Monitor activity to determine athlete’s ability to perform and physical tolerance Advance the activity as long as there is not any swelling or additional pain Advance the activity as long as there is not any swelling or additional pain Use position specific drills and activities Use position specific drills and activities Walking, jogging on track-walk curves, jogging full track, running on track—jog curves, running full track, running 2-3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, acceleration/deceleration runs, shuffle runs, carioca Walking, jogging on track-walk curves, jogging full track, running on track—jog curves, running full track, running 2-3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, acceleration/deceleration runs, shuffle runs, carioca

Modalities Those things you can use to assist/enhance the healing of injuries 3 categories Thermal-used to move heat into or out of the body-----heat & cold Mechanical---ultrasound, massage, traction, intermittent compression Electrical—muscle stimulation

Cold Types of cold use Ice pack (15-20 minutes) Ice massage (5-15 minutes) Cold whirlpool (15-20 minutes) Slush bucket (15-20 minutes) Cryokinetics ( minutes) Chemical cold packs (15 minutes??? Watch for chemical burns)

Cold

Physiological effects Decrease tissue temperature Decrease blood flow Decrease inflammation Decrease pain---analgesic Decrease muscle spasm Increase muscle tone

Cold Indications for use Acute injuries Pain Swelling Inflammation Preparing for exercise

Cold Contraindications for use Open wounds Cold related allergy Areas with sensory or circulatory deficits

Heat Types of heat modalities Hydrocollator pack (moist heat) (10-15 minutes) Electrical heat pack (15-20 minutes) Warm whirl pool (10-15 minutes) Paraffin bath (dip several times minutes)

Heat

Physiological effects Increase tissue temperature Increase blood flow Increase tissue extensibility Increase ROM Decrease swelling Decrease muscle tone

Heat Indications for use Chronic inflammatory conditions Tight tissue—connective, muscle, tendon, ligament Chronic pain Chronic muscle spasm

Heat Contraindications for use Acute injuries Areas with sensory deficits

Ultrasound Thermal or non-thermal modality that stimulates blood flow Continuous or pulsed Sound waves pass through pizoelectric crystal in sound head to create mechanical energy Mechanical energy cause vibration of tissue cells which create heat Heat can reach depth of 3-5 centimeters

Ultrasound

Ultrasound Application Application Must use a coupling agent Must use a coupling agent Conductive gel, lotion, water Conductive gel, lotion, water Keep sound head moving with even pressure over the area being treated Keep sound head moving with even pressure over the area being treated Area shouldn’t be larger than 3-4 inches Area shouldn’t be larger than 3-4 inches Treatment time 3-8 minutes Treatment time 3-8 minutes

Ultrasound Indications for use Indications for use Chronic injuries Chronic injuries Acute injuries (non-thermal setting) Acute injuries (non-thermal setting) Strains Strains Sprains Sprains Tendonitis Tendonitis Contusions Contusions Tight tissue Tight tissue

ultrasound Contraindications for use Contraindications for use Heart, eyes, ears, brain, spinal cord, genitals Heart, eyes, ears, brain, spinal cord, genitals Epiphyseal plates Epiphyseal plates Acute injuries Acute injuries Areas with poor circulation Areas with poor circulation Stress fractures Stress fractures Open wounds Open wounds Infected areas Infected areas Tumors Tumors

Traction Pulling force that deliberately separates joints of the body that have been compressed together or are stiff Pulling force that deliberately separates joints of the body that have been compressed together or are stiff Commonly used at cervical or lumbar area Commonly used at cervical or lumbar area Can be done mechanically or manually Can be done mechanically or manually Separates bones Separates bones Puts gentle stretch on area Puts gentle stretch on area

Traction

Traction Indications for use Indications for use Disc herniation/protrusion Disc herniation/protrusion Degenerative disc disease Degenerative disc disease Degenerative joint disease Degenerative joint disease Soft tissue compression Soft tissue compression Nerve root compression Nerve root compression Muscle spasm Muscle spasm

Traction Contraindications for use Contraindications for use Osteoporosis Osteoporosis Fractured vertebrae Fractured vertebrae Spinal hypermobility Spinal hypermobility Infections of spine Infections of spine

Massage Intentional & methodical kneading and stroking of soft tissue Intentional & methodical kneading and stroking of soft tissue Increases circulation Increases circulation Decreases muscle spasm Decreases muscle spasm Relieves swelling (move towards heart) Relieves swelling (move towards heart)

Massage Strokes Strokes Effleurage Effleurage Stroke w/ palm of hand Stroke w/ palm of hand Petrissage Petrissage Kneading tissue by squeezing between hands/fingers Kneading tissue by squeezing between hands/fingers Tapotment (percussion) Tapotment (percussion) Light chopping motion with hands Light chopping motion with hands Vibration Vibration Tissue shakes vigorously Tissue shakes vigorously Friction Friction Deep pressure/movement of hand or fingers used to break up scar tissue or relieve spasm/tight tissue Deep pressure/movement of hand or fingers used to break up scar tissue or relieve spasm/tight tissue

Massage Indications for use Indications for use Promotes relaxation Promotes relaxation Muscle spasm Muscle spasm Pain Pain Soft tissue stiffness Soft tissue stiffness

Massage Contraindications for use Contraindications for use Non-union fracture Non-union fracture Open wounds Open wounds Acute injuries Acute injuries Dermatological conditions Dermatological conditions

Intermittent compression Compression that is on and off—usually about seconds on and 15 seconds off Compression that is on and off—usually about seconds on and 15 seconds off Treatment time is 15 minutes – 1 hour Treatment time is 15 minutes – 1 hour Helps venous blood flow from extremity Helps venous blood flow from extremity

Intermittent Compression

Intermittent compression Indications Indications Post acute edema Post acute edema Lymphedema Lymphedema Chronic swelling/edema Chronic swelling/edema

Intermittent Compression Contraindications for use Acute injuries Possible fracture Compartment syndromes

Electrical Muscle Stimulation The application of electrical current to the surface of the skin The application of electrical current to the surface of the skin Types Types Galvanic stimulation Galvanic stimulation TENS TENS Interferential Interferential Combo (US & e-stim) Combo (US & e-stim)

Galvanic Stim Used for treatment of Used for treatment of Contusions Contusions Sprains Sprains Strains Strains Acute edema Acute edema Muscle re-education Muscle re-education

Galvanic stim Physiological response of body depends on the polarity of the current Physiological response of body depends on the polarity of the current Negative current: vasoconstriction, hardens tissues, local analgesic, decreases nerve excitability Negative current: vasoconstriction, hardens tissues, local analgesic, decreases nerve excitability Positive current: vasodilatation, softens tissue, increases nerve excitability, increases venous and lymphatic return Positive current: vasodilatation, softens tissue, increases nerve excitability, increases venous and lymphatic return

Galvanic stim Place electrodes so pain is “between” the pads Place electrodes so pain is “between” the pads Place electrodes at either end of the muscle being treated Place electrodes at either end of the muscle being treated Can be used in conjunction with heat or cold Can be used in conjunction with heat or cold Treatment time is minutes Treatment time is minutes

E-Stim

Interferential Stimulation Uses interfering electrical currents to regulate blood flow, reduce pain, decrease edema, relieve muscle spasm, strengthen muscle tissue Uses interfering electrical currents to regulate blood flow, reduce pain, decrease edema, relieve muscle spasm, strengthen muscle tissue Used to treat: contusions, sprains, strains, etc. Used to treat: contusions, sprains, strains, etc. Should feel slight vibration Should feel slight vibration

Inferential Uses 4 electrodes set at a diagonal pattern Uses 4 electrodes set at a diagonal pattern Covers “larger” area Covers “larger” area Electrical currents “interfere” with each other to create a bigger surface areas Electrical currents “interfere” with each other to create a bigger surface areas Can be used with heat or cold Can be used with heat or cold Treatment time is minutes Treatment time is minutes

Interferential

TENS (transcutaneous electrical muscle stimulation) Used primarily for pain control Used primarily for pain control Electrodes are placed on skin over painful area to “block” the sensation of chronic or acute pain Electrodes are placed on skin over painful area to “block” the sensation of chronic or acute pain Cause a muscle contraction Cause a muscle contraction Used for 30 minutes to 1 hour treatment time Used for 30 minutes to 1 hour treatment time Can be used so patient can exercise without pain Can be used so patient can exercise without pain

TENS

Ultrasound/muscle stim combo US combined with muscle stim US combined with muscle stim Electricity comes through the US head Electricity comes through the US head Combine deep heating with benefits of muscle contraction Combine deep heating with benefits of muscle contraction Used for treating strains, muscle spasms, trigger points, tight muscles Used for treating strains, muscle spasms, trigger points, tight muscles Treatment time is 5-15 minutes Treatment time is 5-15 minutes

Combo