Chapter 16: Using
Therapeutic Exercise in Rehabilitation
Athletic TrainerΉs
Approach to Rehabilitation
Begins
immediately after injury
Initial
first aid has a substantial impact on the injury
One
of ATCΉs primary responsibilities is to design, implement and supervise rehab
plans
Design
programs based on short and long term goals
Short term goals
Long term goals
Due to competitive nature of
sports, rehab must be aggressive
Therapeutic Exercise Versus
Conditioning Exercise
Effects of General Inactivity
Effects of Immobilization
Atrophy and fiber conversion
Decreased neuromuscular
efficiency
Joints and Immobilization
Ligaments and Bone and
Immobilization
Full remodeling of ligament
can take 12 months or more following immobilization
Cardiorespiratory System and
Immobilization
–Resting
heart
–Stroke
volume, maximum oxygen uptake and vital
Key Components of
Rehabilitation
Controlling
Pain
Restoring
Range of Motion
Restoring
Muscular Strength, Endurance and Power
–Must
work through a full pain free range of motion when working on strength
Isometrics
Progressive Resistance
Exercise (PRE)
Traditionally focus on
concentric exercises
Eccentrics involved in deceleration of limbs
Facilitate concentric contractions for plyometrics
& incorporated w/ functional PNF strengthening exercises
Both forms are contraction can be created using a
variety of equipment
Machines tend to limit movement in functional planes
Machines and free weights are difficult to operate at
functional speeds w/out injury
Tubing
Isokinetic Exercise
–Incorporated
in later stage of rehabilitation process
–Uses
fixed speeds w/ accommodating resistance to provide maximal resistance
throughout ROM
–Isokinetic
units allow for calculation of torque, force, average power, and work ratios
which can be used by the clinician diagnostically
–Allows
for work at more functional speeds
–Work
at higher speeds tends to reduce joint compressive forces
–Can
be used to develop neuromuscular pattern for functional speed and movements
Testing Strength, Endurance
and Power
Re-establishing Neuromuscular
Control, Proprioception, Kinesthesia and Joint Position Sense
Following injury, body forgets how to integrate
information coming in from multiple biological sources
Neuromuscular control is mindΉs attempt to teach the
body conscious control of a specific movement
Re-establishing neuromuscular control requires
repetition of same movement, step by step until it becomes automatic
(progression from simple to difficult task)
Closed kinetic chain (CKC) exercises are essential for
re-establishing control but can be difficult
–Closed
kinetic chain = foot or hand is weight bearing
Joint Mechanoreceptors
–Found
in ligaments, capsules, menisci, labra, and fat pads
Sensitive to changes in shape
of structure and rate/direction of movement
Most active at end of ranges
of motion
Muscle Mechanoreceptors
–Muscle
spindles - sensitive to changes in length of muscle
–Golgi
tendon organs - sensitive to changes in tissue tension
Regaining Balance
Maintaining Cardiorespiratory
Fitness
Functional Testing
–Uses
functional progression drills for the purpose of assessing the athleteΉs
ability to perform a specific activity
–Entails
a single maximal effort to gauge how close the athlete is to full return
–Variety
of tests
Shuttle runs -Vertical
jumps
Agility runs -Balance
Figure 8Ήs -Hopping
for distance
Cariocca tests -Co-contraction
test
Preoperative Exercise Phase
(PREHAB)
–Only
applies to those requiring injury
–Exercise
may be used as a means to improve outcome
–By
allowing inflammation to subside, increasing strength, flexibility,
cardiovascular fitness and neuromuscular control the athlete may be better
prepared to continue rehab after surgery
Phase I - Acute Inflammatory
Response Phase
Phase 2: Repair Phase
Phase 3: The Maturation/Remodeling
Phase
Longest of 3 phases
Pain is minimal (none to the
touch) and collagen must be realigned according to tensile strength applied to
them during functional activities
Focus is on regaining
sport-specific skills
Functional training -
repeated performance of athletic skill for purpose of perfecting that skill
Strengthening exercises
should be used to place athlete under stresses and strains normally associated
w/ athletic participation
Plyometrics can be used to
improve power and explosiveness
Functional testing should be
done to determine specific skill weaknesses that need to be addressed
Thermal modalities should be
used to enhance tissue environment (reduce spasm, increase circulation, waste
removal and reduce pain)
Criteria for Full Return to
Activity
–Open
kinetic chain exists when foot or hand is not in contact w/ ground or other
surface
–Closed
kinetic chain = foot or hand is weight bearing
Forces begin at ground and
work their way up -- forces must be absorbed by various tissues and structures,
rather than just dissipating
–Most
activities involve some degree of weight bearing, therefore CKC exercise are
more functional than open chain activities
–Isolation
exercise typically make use of one specific muscular contraction to produce or
control movement
–CKC
exercises integrate a combination of contractions in different muscle groups
w/in the chain
–There
are a variety of popular exercises
Mini-squats, leg presses, step-ups, terminal knee
extension w/ tubing, push-ups and weight shifting exercises on a medicine ball
Core Stabilization Training
Core Stabilization Exercises
Aquatic Exercise
Proprioceptive Neuromuscular
Facilitation Technique
Exercise
that uses proprioceptive, cutaneous, and auditory input to produce functional
improvement in motor output
Used
to increase strength, flexibility and coordination
Based
on the physiological properties of the stretch reflex
Basic Principles for Using
PNF Technique
PNF Patterns
Involves
3 components
–Flexion/extension
–Abduction/adduction
–Internal/External
rotation
Joint Mobilization and
Traction
Used to improve joint
mobility or decrease pain by restoring accessory motion -allowing for
non-restricted pain free ROM
Mobilization may be used to
–Reduce
pain
–Decrease
muscle guarding
–Stretch
or lengthen tissue surrounding a joint
–Produce
reflexogenic effects that either inhibit or facilitate muscle tone or stretch
reflex
–For
proprioceptive effects that improve postural and kinesthetic awareness
Mobilization based on
concave-convex rule
Mobilization can also be used in conjunction w/
traction
Traction
–Pull
articulating segments apart (joint separation)
–Occurs
in perpendicular treatment plane
–Used
to treat pain or joint hypomobility
Treatment Planes
Joint Mobilization Techniques
Myofascial Release
–Locate
restriction and move into the direction of the restriction
–More
subjective and relies heavily on experience of the clinician
–Focuses
on large areas
–Can
have a significant impact on joint mobility
–Progression,
working from superficial to deep restrictions
–As
extensibility increases in tissue should be stretched
–Strengthening
should also occur to enhance neuromuscular reeducation to promote new more
efficient movement patterns
–Acute
cases resolve in a few treatments, while longer conditions take longer to
resolve
–Sometimes
treatments result in dramatic results
–Recommended
that treatment occur 3 times/wk
Strain/Counterstrain
Technique used to decrease muscle tension and
normalize muscle function
Passive technique that places body in a position of
comfort - thereby relieving pain
–Locate
tender points (tense, tender, edematous spots, <1cm in diameter, may
run few centimeters long in muscle, may fall w/in a line, or have multiple
points for one specific joint)
–Tender
points monitored as athlete placed in position of comfort (shorten muscle)
–When
position is found, tender point is no longer tense
–After
being held for 90 seconds, point should be clear
–Patient
should then be returned to neutral position
Positional Release Therapy
Active Release Therapy
ART is relatively new type of therapy used to correct
soft tissue problems caused by formation of fibrotic adhesions
–Result
of acute injury and repetitive overuse injuries or constant pressure/tension
–Disrupt
normal muscle function affecting biomechanics of joint complex leading to pain and dysfunction
–Way
to diagnose and treat underlying causes of cumulative trauma disorders
Deep tissue technique used
for breaking down scarring and adhesions
Locate point and trap
affected muscle by applying pressure over lesion
Athlete actively moves body
part to elongate muscle
Repeat 3-5 times/treatment
Uncomfortable treatment but
will gradually soften and stretch scar tissue, increase ROM, strength, and
improve circulation, optimizing healing
Must follow up w/ activity modification,
stretching and exercise
Active Release Therapy