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RehabilitationRehabilitation
Sabino Sports Medicine ISabino Sports Medicine I
Developing a rehab Developing a rehab programprogram
Assess the injuryAssess the injury Establish goalsEstablish goals
Long term—return athlete to full Long term—return athlete to full activityactivity
Short termShort term Execute programExecute program Reassess as athlete progresses Reassess as athlete progresses
through program through program
Format for rehab Format for rehab programprogram
Phase I—time period immediately Phase I—time period immediately following injury/surgery during following injury/surgery during which movement in the affected part which movement in the affected part is either involuntarily limited is either involuntarily limited because of pain, swelling, muscle because of pain, swelling, muscle spasm, etc, or purposely restricted spasm, etc, or purposely restricted by immobilization in casts, splints, by immobilization in casts, splints, slings, etc.slings, etc.
Phase I-therapeutic Phase I-therapeutic objectivesobjectives
Teach proper ambulation techniquesTeach proper ambulation techniques Assist the healing process using Assist the healing process using
appropriate modalitiesappropriate modalities Minimize loss of muscular strength Minimize loss of muscular strength
and slow muscle atrophyand slow muscle atrophy Maintain overall level of physical Maintain overall level of physical
fitnessfitness
Criteria for progression Criteria for progression to phase IIto phase II
Remove cast, splint, sling, etc.Remove cast, splint, sling, etc. Sufficient reduction of pain, Sufficient reduction of pain,
swelling, inflammation to allow for swelling, inflammation to allow for use of safe and effective therapeutic use of safe and effective therapeutic exerciseexercise
Acceptable degree of tissue healing Acceptable degree of tissue healing to allow use of therapeutic exercise to allow use of therapeutic exercise without aggravating injurywithout aggravating injury
Phase IIPhase II
Period of time when more vigorous Period of time when more vigorous therapeutic exercise, including joint therapeutic exercise, including joint ROM, is started. ROM, is started.
Using appropriate therapeutic Using appropriate therapeutic modalities during the time will modalities during the time will enhance the healing process and enhance the healing process and assist in facilitating the use of assist in facilitating the use of therapeutic exercise.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 injuryAssessing the injury
Use SOAP notes (systematic means Use SOAP notes (systematic means of documenting the assessment and of documenting the assessment and recording progress of rehab recording progress of rehab programprogram
SOAP notesSOAP notes
S = SubjectiveS = Subjective Patient history, symptoms, chief complaintPatient history, symptoms, chief complaint
O = ObjectiveO = Objective Signs, information from observation, palpation, Signs, information from observation, palpation,
stress testsstress tests A = AssessmentA = Assessment
Type and severity of injury, any associated Type and severity of injury, any associated problemsproblems
P = PlanP = Plan What will you do? Long & short term goals, What will you do? Long & short term goals,
what is working, how the athlete is progressingwhat is working, how the athlete is progressing
Establish GoalsEstablish Goals Short term goalsShort term goals
Control swelling using proper immediate Control swelling using proper immediate first aidfirst aid PRICEPRICE
Reduce/minimize painReduce/minimize pain PRICE, use of modalities such as ice, heat, e-stimPRICE, use of modalities such as ice, heat, e-stim
Restore full ROMRestore full ROM Dynamic, static, PNF stretching activitiesDynamic, static, PNF stretching activities
Restore/increase muscular strength, Restore/increase muscular strength, endurance, powerendurance, power Isometrics, isotonics, isokinetics, plyometrics Isometrics, isotonics, isokinetics, plyometrics
through full, pain-free ROMthrough full, pain-free ROM
IsometricsIsometrics Performed early in rehab when joint is Performed early in rehab when joint is
immobilizedimmobilized Used when performing exercises Used when performing exercises
through full ROM may be detrimentalthrough full ROM may be detrimental Increase static strength Increase static strength Assist in decreasing amount of atrophyAssist in decreasing amount of atrophy Lessen swelling by causing muscle Lessen swelling by causing muscle
pumping actionpumping action
Isometrics
Isometrics
Isotonics (progressive resistance Isotonics (progressive resistance exercises or PRE’s)exercises or PRE’s) Most commonly used strengthening Most commonly used strengthening
techniquetechnique Use free weights, exercise machines, tubing, Use free weights, exercise machines, tubing,
bands, etc., with fixed weight through ROMbands, etc., with fixed weight through ROM Use isotonic muscle contractionsUse isotonic muscle contractions
Force is generated while the muscle is changing Force is generated while the muscle is changing lengthlength
Use eccentric (lengthening) and concentric Use eccentric (lengthening) and concentric (shortening) muscle contractions(shortening) muscle contractions
Isotonics
Isotonics
IsokineticsIsokinetics Occasionally used in rehabOccasionally used in rehab Incorporated in later phases of rehabIncorporated in later phases of rehab Used primarily for diagnostic purposesUsed primarily for diagnostic purposes Uses a fixed speed with accommodating Uses a fixed speed with accommodating
resistance to provide maximal resistance to provide maximal resistance throughout ROMresistance throughout ROM
Measures commonly used as criteria for Measures commonly used as criteria for return to functional activityreturn to functional activity
Isokinetics
Cybex
Isokinetics
Cybex Kincom
Isokinetics
Isokinetics
Kin com Biodex
PlyometricsPlyometrics Incorporated in later stages of rehabIncorporated in later stages of rehab Use a quick stretch of muscle to Use a quick stretch of muscle to
facilitate a subsequent concentric facilitate a subsequent concentric muscle contractionmuscle contraction
Useful in restoring/developing athlete's Useful in restoring/developing athlete's ability to produce dynamic movements ability to produce dynamic movements associated with muscular powerassociated with muscular power
Ability to generate force rapidly is key to Ability to generate force rapidly is key to successful performance in many sportssuccessful performance in many sports
Plyometrics
Plyometrics
Plyometrics
Short term goalsShort term goals
Reestablish neuromuscular controlReestablish neuromuscular control Mind’s attempt to teach the body conscious Mind’s attempt to teach the body conscious
control of specific movements—using control of specific movements—using strengthening exercises that are more strengthening exercises that are more functionalfunctional
Improve balanceImprove balance Balance training and postural stabilityBalance training and postural stability
Maintain cardiorespiratory fitnessMaintain cardiorespiratory fitness Single most neglected component, use pool, Single most neglected component, use pool,
bike, upper body ergometer, stairclimber, bike, upper body ergometer, stairclimber, elliptical trainer, etc.elliptical trainer, etc.
Incorporate appropriate functional Incorporate appropriate functional progressionsprogressions Involve series of gradually progressive activities Involve series of gradually progressive activities
designed to prepare athlete for return to designed to prepare athlete for return to participationparticipation
Monitor activity to determine athlete’s ability to Monitor activity to determine athlete’s ability to perform and physical toleranceperform and physical tolerance
Advance the activity as long as there is not any Advance the activity as long as there is not any swelling or additional painswelling or additional pain
Use position specific drills and activitiesUse position specific drills and activities Walking, jogging on track-walk curves, jogging full track, Walking, jogging on track-walk curves, jogging full track,
running on track—jog curves, running full track, running 2-running on track—jog curves, running full track, running 2-3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, 3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, acceleration/deceleration runs, shuffle runs, cariocaacceleration/deceleration runs, shuffle runs, carioca
ModalitiesModalities
Those things you can use to Those things you can use to assist/enhance the healing of injuriesassist/enhance the healing of injuries
3 categories3 categories
Thermal-used to move heat into or Thermal-used to move heat into or out of the body-----heat & coldout of the body-----heat & cold
Mechanical---ultrasound, massage, Mechanical---ultrasound, massage, traction, intermittent compressiontraction, intermittent compression
Electrical—muscle stimulationElectrical—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 (10 -15 minutes) Chemical cold packs (15 minutes???
Watch for chemical burns)
Cold
Cold
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--10-15
minutes)
Heat
Heat
Heat
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
UltrasoundUltrasound
ApplicationApplication Must use a coupling agentMust use a coupling agent
Conductive gel, lotion, waterConductive gel, lotion, water Keep sound head moving with even Keep sound head moving with even
pressure over the area being treatedpressure over the area being treated Area shouldn’t be larger than 3-4 inchesArea shouldn’t be larger than 3-4 inches Treatment time 3-8 minutesTreatment time 3-8 minutes
UltrasoundUltrasound
Indications for useIndications for use Chronic injuriesChronic injuries Acute injuries (non-thermal setting)Acute injuries (non-thermal setting) StrainsStrains SprainsSprains TendonitisTendonitis ContusionsContusions Tight tissueTight tissue
ultrasoundultrasound
Contraindications for useContraindications for use Heart, eyes, ears, brain, spinal cord, Heart, eyes, ears, brain, spinal cord,
genitalsgenitals Epiphyseal platesEpiphyseal plates Acute injuriesAcute injuries Areas with poor circulationAreas with poor circulation Stress fracturesStress fractures Open woundsOpen wounds Infected areasInfected areas Tumors Tumors
TractionTraction
Pulling force that deliberately Pulling force that deliberately separates joints of the body that have separates joints of the body that have been compressed together or are stiffbeen compressed together or are stiff
Commonly used at cervical or lumbar Commonly used at cervical or lumbar areaarea
Can be done mechanically or manuallyCan be done mechanically or manually Separates bonesSeparates bones Puts gentle stretch on areaPuts gentle stretch on area
Traction
Traction Traction
Indications for useIndications for use Disc herniation/protrusionDisc herniation/protrusion Degenerative disc diseaseDegenerative disc disease Degenerative joint diseaseDegenerative joint disease Soft tissue compressionSoft tissue compression Nerve root compressionNerve root compression Muscle spasmMuscle spasm
TractionTraction
Contraindications for useContraindications for use OsteoporosisOsteoporosis Fractured vertebraeFractured vertebrae Spinal hypermobilitySpinal hypermobility Infections of spineInfections of spine
Massage Massage
Intentional & methodical kneading Intentional & methodical kneading and stroking of soft tissueand stroking of soft tissue
Increases circulationIncreases circulation Decreases muscle spasmDecreases muscle spasm Relieves swelling (move towards Relieves swelling (move towards
heart)heart)
Massage Massage StrokesStrokes
EffleurageEffleurage Stroke w/ palm of handStroke w/ palm of hand
PetrissagePetrissage Kneading tissue by squeezing between Kneading tissue by squeezing between
hands/fingershands/fingers Tapotment (percussion)Tapotment (percussion)
Light chopping motion with handsLight chopping motion with hands VibrationVibration
Tissue shakes vigorously Tissue shakes vigorously FrictionFriction
Deep pressure/movement of hand or fingers used Deep pressure/movement of hand or fingers used to break up scar tissue or relieve spasm/tight to break up scar tissue or relieve spasm/tight tissuetissue
MassageMassage
Indications for useIndications for use Promotes relaxationPromotes relaxation Muscle spasmMuscle spasm PainPain Soft tissue stiffnessSoft tissue stiffness
Massage Massage
Contraindications for useContraindications for use Non-union fractureNon-union fracture Open woundsOpen wounds Acute injuriesAcute injuries Dermatological conditionsDermatological conditions
Intermittent Intermittent compressioncompression
Compression that is on and off—Compression that is on and off—usually about 30-45 seconds on and usually about 30-45 seconds on and 15 seconds off15 seconds off
Treatment time is 15 minutes – 1 Treatment time is 15 minutes – 1 hourhour
Helps venous blood flow from Helps venous blood flow from extremityextremity
Intermittent Compression
Intermittent Intermittent compressioncompression
IndicationsIndications Post acute edemaPost acute edema LymphedemaLymphedema Chronic swelling/edemaChronic swelling/edema
Intermittent Compression
Contraindications for use Acute injuries Possible fracture Compartment syndromes
Electrical Muscle Electrical Muscle StimulationStimulation
The application of electrical current The application of electrical current to the surface of the skinto the surface of the skin
TypesTypes Galvanic stimulationGalvanic stimulation TENSTENS InterferentialInterferential Combo (US & e-stim)Combo (US & e-stim)
Galvanic StimGalvanic Stim
Used for treatment ofUsed for treatment of ContusionsContusions SprainsSprains StrainsStrains Acute edemaAcute edema Muscle re-educationMuscle re-education
Galvanic stimGalvanic stim
Physiological response of body Physiological response of body depends on the polarity of the currentdepends on the polarity of the current
Negative current: vasoconstriction, Negative current: vasoconstriction, hardens tissues, local analgesic, hardens tissues, local analgesic, decreases nerve excitabilitydecreases nerve excitability
Positive current: vasodilatation, Positive current: vasodilatation, softens tissue, increases nerve softens tissue, increases nerve excitability, increases venous and excitability, increases venous and lymphatic returnlymphatic return
Galvanic stimGalvanic stim
Place electrodes so pain is Place electrodes so pain is “between” the pads“between” the pads
Place electrodes at either end of the Place electrodes at either end of the muscle being treatedmuscle being treated
Can be used in conjunction with heat Can be used in conjunction with heat or coldor cold
Treatment time is 10-20 minutesTreatment time is 10-20 minutes
E-Stim
Interferential Interferential StimulationStimulation
Uses interfering electrical currents Uses interfering electrical currents to regulate blood flow, reduce pain, to regulate blood flow, reduce pain, decrease edema, relieve muscle decrease edema, relieve muscle spasm, strengthen muscle tissuespasm, strengthen muscle tissue
Used to treat: contusions, sprains, Used to treat: contusions, sprains, strains, etc.strains, etc.
Should feel slight vibrationShould feel slight vibration
InferentialInferential
Uses 4 electrodes set at a diagonal Uses 4 electrodes set at a diagonal patternpattern
Covers “larger” areaCovers “larger” area Electrical currents “interfere” with Electrical currents “interfere” with
each other to create a bigger surface each other to create a bigger surface areasareas
Can be used with heat or coldCan be used with heat or cold Treatment time is 10-20 minutesTreatment time is 10-20 minutes
Interferential
TENS TENS (transcutaneous electrical (transcutaneous electrical
muscle stimulation)muscle stimulation) Used primarily for pain controlUsed primarily for pain control Electrodes are placed on skin over Electrodes are placed on skin over
painful area to “block” the sensation of painful area to “block” the sensation of chronic or acute painchronic or acute pain
Cause a muscle contractionCause a muscle contraction Used for 30 minutes to 1 hour Used for 30 minutes to 1 hour
treatment timetreatment time Can be used so patient can exercise Can be used so patient can exercise
without painwithout pain
TENS
Ultrasound/muscle stim Ultrasound/muscle stim combocombo
US combined with muscle stimUS combined with muscle stim Electricity comes through the US Electricity comes through the US
headhead Combine deep heating with benefits Combine deep heating with benefits
of muscle contractionof muscle contraction Used for treating strains, muscle Used for treating strains, muscle
spasms, trigger points, tight musclesspasms, trigger points, tight muscles Treatment time is 5-15 minutesTreatment time is 5-15 minutes
Combo
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