| THE ATHLETIC TRAINER’S APPROACH TO REHABILITRATION - Primary responsibility for the rehabilitation program in o Design o Implementation o Supervision - Short-term goals; o Controlling pain o Maintaining or improving flexibility o Restoring or increasing strength o Re-establishing neuromuscular control o Maintaining levels of cardiorespiratory fitness - Long-term goal o To return the injured athlete to practice or competition as quickly and safety as possible THERAPEUTIC EXERCISE VERSUS CONDITIONING EXERCISE - Exercise is an essential factor in; o Fitness conditioning o Injury prevention o Injury rehabilitation - Therapeutic exercises are concerned with restoring normal body function after injury SUDDEN PHYSICAL INACTIVITY AND IMMOBILIZATION - The generalized loss of physical fitness that occurs when activity is stopped - The specific inactivity of the injured part, resulting from protective splinting of the soft tissue. Effect of general Inactivity - A sudden lack of activity causes loss of muscle strength, endurance, and coordination Effects of Immobilization - 24 hours immobilization definite adverse muscular changes - Immobilization of a part causes atrophy of slow-twitch (Type I) muscle fibers - Decreased neuromuscular efficiency (returns within 1 week) Joints and Immobilization - Joint immobilization decreases normal lubrication - The use of continuous passive motion, electrical muscle stimulation, or hinged casts has in some cases retarded loss of articular cartilage. Ligament and Bone and Immobilization - Both ligaments and bones adapt to normal stress by maintaining their strength or becoming stronger. - Once immobilization has been removed, high-frequency, low-duration endurance exercise positively enhances the mechanical properties of ligaments. - Endurance activities tend to increase both the production and the hypertrophy of the collagen fibers. - Full remodeling of ligaments after immobilization may take as long as 12 months or more Cardiorespiratory System and Immobilization - The resting heart rate increases approximately one-half beat per minute each day of immobilization. - The stroke volume, maximum oxygen uptake, and vital capacity decrease concurrently with the increase in heart rate. MAJOR COMPONENTS OF A REHABILITATION PROGRAM - Minimizing swelling o The process of rehabilitation begins immediately after injury o RICE principle - Controlling pain - Restoring full range of motion o Contracture of connective tissue (ligaments, joint capsules) o Resistance to stretch of the musculotendinous (muscle, tendon, and fascia) o Some combination of the two Physiological versus Accessory Movements o Physiological movement § Active muscle contraction that moves extremity through flexion, extension, abduction, adduction, & rotation. § Voluntary o Accessory motions § The manner in which one articulating joint surface moves relative to another § Spin, Roll and Glide § Normally accompany physiological movement Restricted physiological movement = stretching Restricted accessory motion = joint mobilization - Restoring muscle strength and endurance o Major goal in performing strengthening exercises is for athlete to work through full pain-free range of motion Isometric Exercise o Isometrics increase static strength and assist in decreasing the amount of atrophy o Lessen swelling by causing a muscle pumping action to remove fluid and edema Progressive Resistance Exercise o Free weights, exercise machines, rubber tubing, or manual resistance Concentric and eccentric muscle contractions o Strength deficits or inability of a muscle to tolerate these eccentric forces can predispose an athlete to injury. o Eccentric contractions are used to facilitate concentric contractions in plyometric exercises and may also be incorporated with functional proprioceptive neuromuscular facilitation strengthening exercises. Isokinetic Exercise o During later phases of a rehabilitation program o Fixed speed with accommodating resistance to provide maximal resistance throughout the range of motion o Isokinetic exercise performed at high speeds tends to decrease the joint’s compressive forces. o Short-arc submaximal isokinetics spread out synovial fluid that helps to nourish the articular cartilage and therefore to prevent deterioration. Testing Strength, Edurance, and Power o Manual muscle tests, isotonic resisted exercises, or isokinetic dynamometers o Isokinetic testing generally provides the most reliable objective measure of changes in strength. - Re-establishing Neuromuscular Control, Proprioception, Kinesthesia, and Joint Position Sense o Neuromuscular control is the mind’s attempt to teach the body conscious control of a specific movement o Required many repetitions of the same movement through a step-by-step progression from simple to more complex movements o 4 elements are critical for re-establishing neuromuscular control § Proprioceptive and kinesthetic awareness § Dynamic stability § Prepatory and reactive muscle characteristics § Conscious and unconscious functional motor patterns o Proprioception is the ability to determine the position of a joint in space o Kinesthesia refers to the ability to detect movement. § The ability to sense the position of a joint in space is mediated by mechanoreceptors found in both muscle and joints and by cutaneous, visual, and vestibular input. § Neuromuscular control relies on the central nervous system to interpret and integrate proprioceptive and kinesthetic information and then to control individual muscles and joints to produce coordinated movement Joint Mechanoreceptors o Found in ligaments, capsules, menisci, labra, and fat pads o They include Ruffini’s endings, Pacinian corpuscles, and free nerve endings o They are most active in the end ranges of motion Muscle Mechanoreceptors o Found in muscles and tendons are the muscle spindles and the Golgi tendon organs o The muscle spindles are sensitive to changes in length of the muscle o Golgi tenson organs are sensitive to changes in tension - Regaining Balance o Balance involves the complex integration of muscular forces, neurological sensory information received from the mechanoreceptors, and biomechanical information - Maintaining cardiorespiratory fitness - Incorporating functional progressions Functional Testing o Sprint tests o Agility runs o Figure 8’s o Shuttle runs o Carioca tests o Side stepping o Vertical jumps o Hopping for time or distance o Balance tests o Co-contraction tests DEVELOPING A REHABILITATION PLAN - All exercise rehabilitation must be conducted as part of a carefully designed plan. Exercise Phases - Phase 0 – Preoperative phase o Exercise performed during the preoperative phase can often assist recovery after surgery - Phase 1 – Acute phase o Begins immediately when injury occurs and may last as long as 4 days o Inflammatory stage of the healing process is attempting to control and clean up the injured tissues, thus creating an environment that is conductive to the fibroblastic stage o The primary focus of rehabilitation during this phase is to control swelling and to modulate pain by using RICE immediately after injury. o Rest of the injured part is critical during this phase o The post surgical exercise phase should start 24 hours after surgery o By day 3 or 4, swelling begins to subside and eventually stops altogether o Team physician may choose to have the athlete take (NSAIDs) to help control swelling and inflammation - Phase 2 – Repair phase o Fibroblastic cells are laying down a matrix of collagen fibers and forming scar tissue o This stage may begin as early as 4 days after the injury and may last for several weeks o As soon as inflammation is controlled, immediately begin to incorporate into the rehabiliation program activities that can help the athlete maintain levels of cardiorespiratory fitness, restore full range of motion, restore or increase strength, and re-establish neuromuscular control - Phase 3 – Remodeling o May last for several years, depending on the severity of the injury o The injury is no longer painful to the touch, although some progressively decreasing pain may still be felt on motion o The collagen fibers must be realigned according to tensile stresses and strains placed on them during this phase functional sport-specific exercises o The focus on regain sport-specific skills Controlled Mobility during Rehabilitation - Wolff’s law states that after injury both bone and soft tissue will respond to the physical demands placed on them, causing them to remodel or realign along lines of tensile force. - Functional progressions incorporate sport-specific skills into the rehabilitation program Adherence to a Rehabilitation Program - Encouragement and positive reinforcement necessary for the athlete to make a commitment - Creative in designing and varying the exercise routine - Support from peers, coaches, and rehabilitation staff - Attitude of the athletic trainer - Treatment plan instructions - Coach must support the rehabilitation concept - Effort to fit the rehabilitation program into the athlete’s schedule rather than the reverse - Pain free Criteria for Full Return to Activity - Physiological healing constraints - Pain status - Swelling - Range of motion - Strength - Neuromuscular control/Proprioception?Kinesthesia - Cardiorespiratory fitness - Sport-specific demands - Functional testing - Prophylactic strapping, bracing, padding - Responsibility of the athlete - Predisposition to injury - Psychological factors - Athlete education and preventive maintenance program ADDITIONAL APPROACHES TO THERAPEUTIC EXERCISE REHABILITATION Open versus Closed Kinetic Chain Exercises - In a weight-bearing position, the lower extremity kinetic chain involves the transmission of forces among the foot, ankle, lower leg, knee, thigh, and hip. - In the upper extremity, the hand as a weight-bearing surface transmits forces to the wrist, forearm, elbow, upper arm, and shoulder girdle Aquatic Exercise - Reduce muscle spasm - relax tense muscles - Increase the range of joint motion - Re-establish correct movement patterns - Increase strength - Power - Muscular endurance Proprioceptive Neuromuscular Facilitation Techniques Techniques of PNF Strengthening techniques o Rhythmic initiation o Repeated contraction o Slow reversal o Slow-reversal-hold o Rhythmic stabilization Stretching techniques o Contract-relax o Hold-relax o Slow-reversal-hold-relax Basic Principles for Using PNF Techniques 1. The athlete must be taught through brief, simple descriptions the PNF patterns for sequential movements from starting position to terminal positions 2. When learning the patterns, the athlete should look at the moving limb for feedback on directional and positional control 3. Verbal commands should be firm and simple – push, pull, or hold 4. Manual contact with the hands can facilitate a movement response 5. The athletic trainer must use correct body mechanics when providing resistance 6. The amount of resistance given should facilitate a maximal response that allows smooth, coordinated motion 7. Rotational movement is a critical component in all the PNF patterns 8. The distal movements of the patterns should occur first and should be completed by no later than halfway through the pattern 9. The stronger components are emphasized to facilitate the weaker components of a movement pattern 10. Pressing the joint together causes increased stability, whereas traction pulls the joint apart and facilitates movement 11. Giving a quick stretch causes a reflex contraction of that muscle PNF patterns Joint Mobilization Traction - Restoring accessory movements to the joints, thus allowing for full, nonrestricted, pain-free range of motion - Reducing pain - Decreasing muscle guarding - Stretching or lengthening tissue surrounding a joint, especially capsular and ligamentous tissue - Reflexogenic effects that either inhibit or facilitate muscle tone or the stretch reflex - Proprioceptive effects that improve postural and kinesthetic awareness Mobilization Techniques Maitland’s system Grade I – Small-amplitude glide at the beginning of the range of movement Grade II - Large-amplitude glide within the midrange of movement Grade III - Large-amplitude glide up to the pathological limit in the range of movement Grade IV - Small-amplitude glide at the end of the range of movement Grade V - Small-amplitude, quick thrust delivered at the end of the range of movement |
| Using Therapeutic Exercise in Rehabilitation |