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Essential Considerations in Designing a Rehabilitation Program for the Injured Patient


Introduction Rehabilitation of athletic injuries through programs utilizing progressive therapeutic exercises is a responsibility of the sports medicine team, ... – PowerPoint PPT presentation

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Title: Essential Considerations in Designing a Rehabilitation Program for the Injured Patient

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

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

Healing Response
  • Bodies mechanism to rid the body of damaged
  • 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

Healing Response Inflammation
  • 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 Response Proliferation
  • 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,
  • 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 Response Maturation
  • 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
  • Therefore, exercise intensity must be equal to
    the healing phase

  • 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

  • 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

  • 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
  • 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 Note Every 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 Rehabilitation Inflammation
  • 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
  • Used in the treatment of bursitis, tenosynovitis,
    and tendonitis

Goals of Rehabilitation Inflammation
  • 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 Rehabilitation Proliferation
  • Goals is to prevent muscle atrophy and joint
    deterioration while preventing destruction of new
  • 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 Rehabilitation Maturation
  • 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

Exercise Strategies Proliferation
  • Major goal is to work through full pain-free
  • 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 Strategies Maturation
  • 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 Chain Characteristics
  • 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
  • ? Acceleration forces
  • ? Resistance force
  • Concentric acceleration and eccentric
    deceleration forces
  • Promotion of functional activity

Closed vs. Open Chain CKC Advantages
  • Safer and produces stress and force that are
    potentially less of a threat to the healing
  • Muscular co-activation required for joint
  • Decrease in shear force, caused by muscular
  • Lower extremity activities tend to be more
    functional in nature
  • Requires synchronism of the agonist and

Closed vs. Open Chain OKC 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

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
    athletes 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

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
  • Recommend from 0-60, utilizing full hip
  • 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
  • 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
  • Toe clips facilitate HS contractions on the
  • 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
  • Anterior deltoid along with the infraspinatus and
    teres minor in the frontal plane
  • Subscapularis counterbalanced by the
    infraspinatus and teres minor in the transverse
  • 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
  • Also used in later stages to
  • Promote muscular endurance and stability (Dynamic
    and ballistic motions)

OKC CKC Exercises for the GH Joint
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
OKC CKC Exercises for the Scapulothoracic Joint
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
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
  • 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

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