Essential Considerations in Designing a

Rehabilitation Program for the Injured Patient

Chapter 1

Introduction

• Rehabilitation of athletic injuries through programs utilizing progressive therapeutic exercises is a responsibility of the sports medicine team, emphasizing the skills and knowledge of the therapist..

Philosophy of Sports Medicine Rehabilitation

• Key words– Aggressive– Quick return to play (RTP)– Safety– “Balancing Act”

• Finding the balance between to much exercise and not enough exercise

Philosophy of Sports Medicine Rehabilitation

• What sports medicine professional need to understand– Types of injuries– Healing process– Pathomechanics of injuries and illnesses

• Etiology – Cause of disease/injury • Pathology – Study of nature/causes of a disease which

involves changes in structure and function

– Psychological aspect of rehabilitation– Available tools and resources– Therapeutic exercise vs. conditioning exercises– Protocols

Types of Injuries

• Macro vs. microtrauma– Macro

• Sprains (ligaments)• Strains (muscles)• Fractures (bones)• Contusion (soft-tissue and bone)

– Micro• Stress fractures• Tendonitis

Healing Process

• Altering a therapeutic exercise or conditioning program is primarily dependent upon understanding the different phases the body goes through while healing

• Therefore, sports medicine professionals must try to create an environment conducive to the healing process

Healing Response

• Bodies mechanism to rid the body of damaged tissue

• Immediate response to acute injuries• Non-specific to site or stimulus• Essential for tissue repair• Divided into three process

– Acute inflammation, proliferation (fibroblastic-repair) & maturation (maturation-repair)

Healing ResponseInflammation

• Initial injury to body– Microtrauma or

macrotrauma• Used to protect, localize,

and rid the body of injurious agents

• Includes a number of vascular, cellular and cellular changes cell membrane

permeability and edema formation

– Phagocytosis• Concerned w/ 2nd death

of tissue – Secondary hypoxic injury

• Cardinal Signs of Inflammation– Heat and redness

BF and cell metabolism to traumatized tissue

– Swelling • Loss of continuity of

vascular structures• Chemical mediators

– Pain • Chemical mediators• Swelling

– Loss of function • Combination of the

above

Healing ResponseProliferation

• Marked by the removal of the cellular debris and the creation of a vascular network to support new tissue growth

• Rate of proliferation phase in influenced by several factors include cell type, health, age, nutrition

• Looking for the regeneration and restoration of the destroyed/lost tissue, however most tissue will never be identical to the traumatized tissue

• May last 48-72 hrs up to 6 weeks after inflammatory phase

• May begin after 2nd tissue death and cell debris has been cleaned

Healing ResponseMaturation

• “Cleaning-up” period• May last up to a year or more• Fibroblasts, myofibroblasts, macrophages

are reduced to pre-injury state• Scar begins to fade as the extra capillaries

and water are moved from the area• Need to keep encouraging re-organization &

tensile stress to the tissue

Healing Process

• SAID Principle– Specific Adaptation to Imposed Demands

• “When an injured structure is subjected to stress and overloads of varying intensities, it will gradually adapt over time to whatever demands were placed upon it”`

– In some situation failure to do this leads to injury

– Therefore, exercise intensity must be equal to the healing phase

Pathomechanics

• Injuries result in changes to the normal joint arthokinematics and osteokinematics

• Therefore, sports medicine professionals need to have adequate knowledge in structural mechanics and how the structures will react to these changes

Psychological

• This stage is often the most neglected• Injuries/illnesses produce a wide range

of emotions and how an individual and/or athlete reacts will affect his/her interpretation and reaction to pain, cooperation, compliance, denial, etc

Tools

• Sports medicine professional should try to have knowledge of things such as:– Basic first aid principles, understanding of the

differences between different types of exercises based on the phase of tissue healing, how and when to progress an athlete, modalities, ortho evaluation skills

• Athletes differ in their response to rehabilitation therefore avoid “cookbook” or “recipe” approach

• Do what is right and not what is seen. Strict application of knowledge and using all knowledge separates a great therapist from everyone else

Therapeutic Exercise vs. Conditioning Exercise

• Therapeutic exercise– Any kind of movement of any of the body parts to

rehabilitate to optimal function and to reduce symptoms– Problem orientated

• Conditioning exercise

– Used to maintain cardiovascular and physical fitness to avoid injury

• Need to consider the affects of each of these on the types of exercise – Effects on muscles– Effects on joints– Effects on cardiorespiratory system

Goals of Rehabilitation

• Provide correct/immediate medical intervention to limit or minimize swelling and injury

• Decrease or minimize pain

• Restore full ROM• Restore or increase

strength, endurance, and power

• Re-establish neuromuscular control

• Increase balance and proprioception awareness

• Maintain cardiovascular endurance

• Functional progression

Therapeutic Exercise Template

Every Assignment/Test*You now have the keys to modalities & Ther X

• Modalities Pain/Edema Neurological functioning

• Scar tissue formation• Joint Mobs, distraction,

myofascial release• ROM• Flexibility /restore• Balance/Gait training• Establish core stability• Postural stability/balance• Restore/increase strength

atrophy, hypertrophy

• Restore or increase endurance• Restore or increase power• Reestablish neuromuscular

control• Restore/ balance &

proprioception• Maintain/ cardiovascular

endurance• Functional

exercise/progression– Multiple planes

• Modalities– As needed

• Functional testing• Return to activity testing

Keys – Daily SOAP NoteEvery Assignment/Test

• Subjective– How does the patient

feel, NSAIDs/drugs, Pain level, residual pain

• Objective– Short term/long term

goals– List entire treatment

in detail. Ortho special tests, modality settings/time, exercise, sets/reps/weight, duration

• Assessment– How did the patient

react to the treatment. Specific problems, effort, adherence, special tests/documentation as needed

• Plan– Add, delete, or

continue rehab plan. Special test or measurements to be done in the future.

Why Document Using SOAP

• Legal ramifications• Communication• Organization• Professionalism• Patient motivation

– Review goals– Review objective data progress

Goals of RehabilitationInflammation

• Prevent new tissue disruption using PRICE– Protection

• Splints, pads, immobilization if necessary– Restricted Activity (Rest)

• Research has shown that complete mobility can be bad, rather controlled mobility may aid in reducing scar formation, revascularization of tissue, muscle regeneration and reorientation of muscle fibers and tensile strength

– Ice• Decreases pain & promotes vasoconstriction, thereby

controlling hemorrhage & edema– Decreases 2nd tissue death– Decreases muscle spasms and provides an analgesic

effect– Used in the treatment of bursitis, tenosynovitis, and

tendonitis

Goals of RehabilitationInflammation

– Compression • Most important factor in controlling swelling

– Purpose is to mechanically reduce the amount of space available for swelling by applying pressure around the injured area

– Wrap distal to proximal– Elevation

• Eliminates the affects of gravity on blood and other fluid pooling in an extremity

– Assists in venous and lymphatic drainage– Greater the degree of elevation the more

effective it is in reducing swelling

Goals of RehabilitationProliferation

• Goals is to prevent muscle atrophy and joint deterioration while preventing destruction of new tissues

• Begin to apply low-load stress to prevent a loss of joint motion, however need to because about the amount of load and point of application

• Continue to maintain cardiovascular and cardiorespiratory function

Goals of RehabilitationMaturation

• Optimizing tissue function is the primary goal during the final phase of healing

• Include the addition of functional and sports-specific activities, however, still need to maintain the balance between too much and not enough

Exercise StrategiesProliferation

• Major goal is to work through “full pain-free ROM”

• Accomplished through the use of:– Isometric exercise

• Submaximal• However, they are joint angle specific

– Isotonic• Movement with a constant external resistance

– Gravity– Resistance bands– Dumbbells– Weight machines

– Proprioception• Refers to conscious and unconscious

appreciation of joint position

Exercise StrategiesMaturation

• Focus is placed on:– Functional activities– Sport-specific exercises– Closed and open chain exercises– Exercises to improve proprioception

Closed vs. Open Chain

• Panaereillo defines CKC as– “activity of the extremities as an activity in

which the foot or hand is in contact with the ground or a surface.”

– Emphasizes that the body weight must be supported for a closed-kinetic chain to exist

• Note: Few exercises can be absolutely classified as open or closed chain kinetic exercises

• Most such as running and jumping fall somewhere in between

Closed vs. Open ChainCharacteristics

CKC Joint compression

force Joint congruency

(stability) Shear force Acceleration force• Larger resistance

force• Stimulation of

proprioceptors

OKC Distraction and

rotational forces Deformation of joint

and muscle mechanoreceptors

Acceleration forces Resistance force• Concentric acceleration

and eccentric deceleration forces

• Promotion of functional activity

Closed vs. Open ChainCKC Advantages

• Safer and produces stress and force that are potentially less of a threat to the healing tissue

• Muscular co-activation – required for joint stabilization

• Decrease in shear force, caused by muscular co-activation

• Lower extremity activities tend to be more functional in nature

• Requires synchronism of the agonist and antagonist

Closed vs. Open ChainOKC Advantages

• Motion isolated to a single joint within a specific plane

• Used to improve strength and ROM• Applied to single joint manually as in

PNF and joint mobilizations or threw some type of machine

• Isokinetic exercises are an example of open chain exercises

Guidelines for Progression of CKC Exercises

• Static stabilization dynamic stabilization• Stable surface unstable surface• Single plane movements multi-plane

movements• Straight planes diagonal planes• Wide base of support small base of support• No resistance resistance• Fundamental movements – dynamic movements• Bilateral support unilateral support• Consistent movements perturbation training

Functional Progression/Functional

Testing• Functional Progression

– Gradually helps achieve normal pain-free ROM

– Helps to restore adequate strength levels– Helps to regain neuromuscular control and

balance

• Functional Testing– Uses functional progression drills to assess

the athlete’s ability to perform a specific activity

Developing Relationships

• Developing and working with rehabilitating athletes requires– Communication between all involved parties

• Do not be afraid to consult others– The Power of Consultation

– Understanding all individuals’ rehabilitation philosophies (AT, MD, Athlete, etc)

– Continually working to improve and re-assess the athletes functional status

– ABOVE ALL ELSE “DO NO HARM”

Specific Closed Chain Exercises

Lower Extremity Exercises

• Mini-squats / Wall slides / Lunges– Involves simultaneous hip and knee extension and is

performed between 0-40°• 60-90° increases tibial translation compared to

OKC exercises– Concurrent shift helps minimize the flexion moment

at the knee– Half squat produces less shear at the knee than

OCK exercises in full extension– Slight flexion flexion of the trunk anteriorly helps to

increase hip flexion moment and decrease knee moment

Lower Extremity Exercises

• Leg Press – Utilize the CKC, while providing stability and

decreasing strain on low back – Allows for lower resistance and unilateral

exercises– Recommend from 0-60°, utilizing full hip

extension

• Lateral Step-Ups– Adjusted to the needs of the athlete and

progress up to 8 in.– Generate significantly more quad activity

Lower Extremity Exercises

• Stair-Climbing– Steeping machines are true CKC exercises– Body should be held erect with slight trunk

flexion– EMB studies have show that the gastrocnemius

fires considerably • Terminal Extension with Tubing

– Anterior tibial translation occurs between 0-30° of flexion

– Application of resistance anteriorly at the femur produces anterior shear of femur, eliminating anterior translation of the tibia

– Tubing produces an eccentric contraction of the quad when moving into knee flexion

Lower Extremity Exercises

• Bike– Utilized for cardiovascular, strengthening, and

ROM– Toe clips facilitate HS contractions on the upstroke

• BAPS Board and Mini-tramp– Provide unstable base– Allows simultaneous work for strength and ROM

while regain NMC and balance

• Slide Board and Fitter– Weight shifts and more functional activities– Re-establishes dynamic control

Upper Extremity

• Glenohumeral joint force couples must be re-established– Anterior deltoid along with the infraspinatus and

teres minor in the frontal plane– Subscapularis counterbalanced by the infraspinatus

and teres minor in the transverse plane

• Scapulohumeral rhythm is also necessary to ensure proper positioning of the scapula during motion– Force couple between the inferior traps and upper

trap and levator scaupla– Rhomboids and middle traps counterbalanced by

the serratus anterior

Upper Extremity

• CKC GH joint exercises are used during the early phases of rehabilitation, especially with unstable shoulders to– Promote co-contraction and muscle

recruitment and preventing shut down of the RC 2nd to pain and inflammation

• Also used in later stages to:– Promote muscular endurance and

stability (Dynamic and ballistic motions)

OKC & CKC Exercises for the GH Joint

Phase CKC OKCAcute Isometric press-up, push-up,

and strengthening; WB shifts; axial compression against wall

Subacute Resisted wall circles and wall abduction/adduction; slide board; push-ups; PNF

Isotonic and isokientic strengthening

Chronic Push-ups on balance board; lateral stet-ups; shuttle walking; Stairmaster; plyometric push-ups

Isotonic and isokinetic strengthening; plyometrics; sport-specific training

OKC & CKC Exercises for the Scapulothoracic Joint

Phase CKC OKCAcute Isometric punches,

strengthening, and press-upsIsotonic strengthening

Subacute Push-ups, military presses, press-up

Isotonic and isokinetic strengthening, rowing, prone horizontal abduction

Chronic NMC drills, rhythmic stabilization, circles, diagonal patterns

Progression of isotonic strengthening exercises

Upper Extremity

• Weight Shifts– Used to facilitate GH and ST dynamic stability– Done in standing, quadruped, tripod, or biped

moving from stable to unstable– Movements are from side to side, front to back,

and diagonal– Progress from a wide base to a small base– Provide resistance to stimulate rhythmic

stabilization (Used also to regain NMC of scapular muscles with the hand in a CKC and random pressure applied to the scapula border)

Upper Extremity

• Push-ups, Push-Ups with a Plus, Press-Ups and Step-Ups– Push-ups and press-ups are done to regain

NMC– Push-ups with a plus are done to strengthen

the serratus anterior which is critical for dynamic stability in overhead activities

– Press-ups (sitting on the table and lifting body weight up) involves isometric contraction of the GH stabilizers

Upper Extremity

• Slide Board– Promote strength and stability and

improves muscular endurance• Hands move forward, side to side, wax-

on-wax off

Upper Extremity Immediately after GH joint subluxation or

dislocations• Acute

– Isometric press-up & isomeric weight bearing & shifts, axial compression against a table or wall

• These movements produce joint compression and approximation which enhances muscular co-contraction about the joint, leading to dynamic stabilization

• Sub-acute– Resistance is applied to the distal segment

• Include resisted arm circles against a wall, resisted axial load side to side either against a wall or on a slide board, and push-ups

• Resistance can be applied in different amounts to multiple positions

Upper Extremity Immediately after GH joint subluxation or

dislocations• Advanced

– Weight bearing exercises are usually high-demanding movements that require a tremendous degree of dynamic stability

• Push-up with the hands on a ball, which produces axial load on the joint but keeps the distal segment somewhat free to move (additional unstable foot platform)

• Lateral step-ups using the hands and retrograde lateral walking on the hands on a treadmill or stair steppers

• Requires a fair amount of dynamic stability and strength

Exceeding Healing Tissue Strength

• Pain• Swelling• Loss/plateau of

strength• Loss/plateau of

ROM• Increase in joint

laxity

• When do I increase weights or difficulty of therapeutic exercise plan?– Refer to left