Essential Considerations in Designing a Rehabilitation Program for the Injured Patient

1
Essential Considerations in Designing a
Rehabilitation Program for the Injured Patient

• Chapter 1

2
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..

3
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

4
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

5
Types of Injuries

• Macro vs. microtrauma
• Macro
• Sprains (ligaments)
• Strains (muscles)
• Fractures (bones)
• Contusion (soft-tissue and bone)
• Micro
• Stress fractures
• Tendonitis

6
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

7
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)

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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

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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

10
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

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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

12
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

13
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

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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

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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

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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

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Therapeutic Exercise TemplateEvery
Assignment/TestYou 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

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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.

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Why Document Using SOAP

• Legal ramifications
• Communication
• Organization
• Professionalism
• Patient motivation
• Review goals
• Review objective data progress

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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

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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

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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

23
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

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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

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Exercise StrategiesMaturation

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

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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

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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

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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

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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

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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

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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
  athletes ability to perform a specific activity

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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

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Specific Closed Chain Exercises
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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

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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

36
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

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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

38
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

39
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)

40
OKC CKC Exercises for the GH Joint
Phase CKC OKC
Acute 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
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OKC CKC Exercises for the Scapulothoracic Joint
Phase CKC OKC
Acute Isometric punches, strengthening, and press-ups Isotonic 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
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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)

43
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

44
Upper Extremity

• Slide Board
• Promote strength and stability and improves
  muscular endurance
• Hands move forward, side to side, wax-on-wax off

45
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

46
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

47
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