considerations in designing a rehab programcsusap.csu.edu.au/~sbird/ehr315/lecture...

Dr Stephen Bird EHR315

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Considerations in Designing a Considerations in Designing a Rehab ProgramRehab Program• Philosophy of Sports Medicine

• Healing Process

• Pathomechanics of Injury

• Psychological Aspects

• Goals of Rehab• Goals of Rehab

Reading: Chapter 1

Quiz 1: Anatomy review

The Rehabilitation Team• Group effort

• AEP/Athletic trainer involved with rehab process

Athlete

Athletic trainer

PhysicianCoach

p

– from assessment to treatment and R2S

• New England Patriots

– Importance of the Rehab Team

Athlete

Athletes family

S&C

AEP


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Exercise Physiologist• Responsibilities

1. Injury prediction / prevention

2. Recognition, evaluation and assessment

3. Exercise rehabilitation of injuries

4. Healthcare administration

5. Professional development

• Work under physician supervision– Rehabilitation program designRehabilitation program design

Philosophy of Sports Medicine Rehabilitation

• Aggressive Rehabilitation

– Competitive nature of athletics necessitates aggressive approach

– Stage of injury (injury healing process)?

• .

– Pushing too hard or not hard enough

• Tight-rope approachTight rope approach

• Negative impact on athlete’s R2S?


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The Healing Process• Progression through rehab based on injury healing

1. AEP must possess understanding of injury healing time sequences• physiological events associated with healing process

2. Must create environment conducive to healing process• Other factors

• Hamstring strain: what do you do?

Liebenson, C. (2006). Functional training for performance enhancement - Part 1: The basics. Journal of Bodywork and Movement Therapies, 10(2), 154-158.


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• Ability of body to adapt to load (stress) imposed on it

– Critical to consider during rehabilitation

Load tolerance

SAID Principle

– Load tolerance

• Indications of having applied too much stress:

pain

swelling (InF)

ligament laxity

strength / ROMg

• As healing progresses = exercise intensity

Organism makes specific adaptations to imposed demands

Mathews, D. K. and Fox, E. L. 1976. The physiological basis of physical education and athletics, Philadelphia, Pennsylvania: W. B. Saunders Company.

Understanding Pathomechanics of Injury

• Due to injury normal joint/anatomic function compromised

Adaptive changes result in alterations in biomechanics– Adaptive changes result in alterations in biomechanics• Give me one adaptive change related to posture….

• Background in anatomy/biomechanics critical

• Must identify adaptive or compensatory actions resulting from injury and correct the pathomechanics

– Core function 1 Identify 2 key points from these clips

– Core function 2

– Core function 3

– Core function 4


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Page, P. (2006). Sensorimotor training: A “global” approach for balance training. Journal of Bodywork and Movement Therapies, 10(1), 77-84.

Concept of the Kinetic Chain

Kinetic chainKinetic chain::

–– Muscles, tendons, bones, ligaments, fascia; Muscles, tendons, bones, ligaments, fascia; ArticularArticular and neural systemand neural system

–– Each system works to provide Each system works to provide structural/functionalstructural/functional efficiencyefficiency


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Contributing components;

1. Length-tension relationships

2. Force couples

Concept of the Kinetic Chain

3. Precise arthrokinematics

4. Optimal NM control

• Malfunctioning systems = compensatory OL = perf

predictable injury patterns

• Compensatory OL injury rarely involves one structure

– Comprehensive rehabilitation must examine

• Muscle imbalances

• Myofascial adhesions

• Altered arthrokinematics

• Neuromuscular control

• Goal is to restore optimal KC functioning p g– What happens at one segment will affect the next segment

Myer, G. D., Ford, K. R., Brent, J. L., & Hewett, T. E. (2012). An integrated approach to change the outcome part II: targeted neuromuscular training techniques to reduce identified ACL injury risk factors.

Journal of Strength and Conditioning Research, 26(8), 2272-2292.


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Conditioning Ex vs. Therapeutic ExConditioning Ex

– Essential in injury prevention and rehab

– Unfit athletes more susceptible to injury

– Basic conditioning principles ExRx apply

Therapeutic ex – Specifically concerned with restoring

normal function following injury

– Ex associated with rehabilitation

Name 2 fundamental conditioning principles

Importance of Controlling Swelling

• Initial injury management an swelling control is critical

Swelling = pressure = pain = altered neuromuscular function– Swelling = pressure = pain = altered neuromuscular function

– Slows healing process and normal function is not regained until

• Pain will dictate rate of progression– Interfere with rehab process

– Comfortably uncomfortable

– Optimal loadingOptimal loading

PRICER principle should be applied

Bleakley et al. (2011). PRICE needs updating, should we call the POLICE? British Journal of Sports Medicine.


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Reestablishing Neuromuscular Control

• Joint position sense is mediated by mechanoreceptors

• NM control relies on CNS to interpret and integrate proprioceptive/kinesthetic information

– Translating into coordinated motion

• Injuries alter this ability

– Early stages of rehab: regain previously established sensory patterns

– Practice is required until the patterns become automatic

Brant, J. J., & Findley, B. W. (2001). Postrehabilitation balance training for the strength and conditioning professional. Strength and Conditioning Journal, 23(5), 55-59.

Page, P. (2006). Sensorimotor training: A “global” approach for balance training. Journal of Bodywork and Movement Therapies, 10(1), 77-84.

Restoring Range of Motion• Loss of ROM associated with;

– Resistance of musculotendinous units

– Connective tissue stretch contractures

– Muscle imbalances

– Postural imbalances

– Neural tension

– Joint dysfunction

• Physiological mvt constraints / accessory motion deficits

What principle is related to greatest gains on ROM?

• Physiological mvt constraints / accessory motion deficits must be determined and treated accordingly – Stretching / Joint mobilization / traction

– Release and lengthen


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Regaining Muscular Strength, Endurance and Power

• Essential to restoring pre-injury status

Work through full pain free ROM– Work through full pain-free ROM

• Incorporate single plane force production and functionalactivities that stress tri-planar motion

– Combinations of muscle contractions emphasized (3 types)

– Pelvic/trunk stability and NM control

What is the athletic postural environment?

Liebenson, C. (2002). Functional training part 1: New advances. Journal of Bodywork and Movement Therapies, 6(4), 248-254.

Isometric

– Initial stages of rehabilitation

– Useful when training through a full ROM is contraindicated

– Increase static strength, decrease atrophy, create muscle pump to reducing edemag

Progressive Resistance Exercise (PRE)

– Most commonly used strengthening technique

– Incorporates free weights, machines and tubing

– Utilizes isotonic contractions (CON and ECC actions)


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Isokinetic

– Incorporated in later stages of rehabilitation

– Uses fixed speeds with accommodating resistance

– Provides maximal resistance through full range of motion

– Commonly used as criteria for return to functional activityy y

Plyometrics

– Later stages of rehab

– Relies on a quick ECC stretch to facilitate a subsequent CON action

– Explosive, dynamic mvts associated with power (speed strength)

– Due to the need to generate power in athletic activities critical toDue to the need to generate power in athletic activities, critical to incorporate within a the rehab process

– Question


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Core Stabilisation

– Essential for functional strength

– Core functions to dynamically stabilize the kinetic chain

– Core strength enables distal segments to function optimally and efficiently during force and power generation

What core muscle works in feedforward activation?y g p g

Open vs. Closed Kinetic Chain Exercise

– Deals with the functional relationship in upper and lower extremities

• OKC = foot or hand operating in space

• CKC = foot or hand are weight-bearing

– CKC ex incorporate ISO CON and ECC muscle actions simultaneouslyCKC ex incorporate ISO, CON and ECC muscle actions simultaneously in differing muscle groups within KC

– Examples ???????OKC CKC


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Restoring Balance and Postural Stability (BAPS)• Involves integration of muscular forces, sensory and

biomechanical information

• Postural stability essential to reacquiring complex motor tasks

– linked with deficits in kinesthetic/ proprioceptive function and/or muscle weakness

– May limit ability to adjust to postural disturbances

BAPS is about functionality. Functional approach to warm-up =

Bird, S.P., & Stuart, W. (2012). Integrating balance and postural stability exercises into the functional warm up for youth athletes.

Strength and Conditioning Journal, 34(3), 73-79.

Maintaining Cardiorespiratory Fitness

• Most neglected aspect of rehabilitation

CV fitness rapidly during periods of inactivity– CV fitness rapidly during periods of inactivity

– Alternative activities should be substituted to minimize the decrements in fitness levels


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Functional Progression• Gradual progressive activities designed to prepare for R2S

– Skill progression/reacquisition within limitation of injury and rehab

• Functional progression will help injured athlete return to normal pain-free ROM, strength and NM control

Progression based on injury response

Beam, J. W. (2002). Rehabilitation including sport-specific functional progression for the competitive athlete. Journal of Bodywork and Movement Therapies, 6(4), 205-219..

Functional Testing• Assess athletes ability to perform a specific activity

– May involve single maximal effort

• Commonly used tests

– Agility runs

– Sidestepping

– Vertical jump

– Hops for distance/time

Co contraction test– Co-contraction test

Lindstedt, S.L. et al. (2001). When active muscles lengthen: Properties and consequences of eccentric contractions. News in Physiological Sciences, 16(6), 256-261.


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Criteria for Full Recovery• What is complete recovery?

– Restoration to normal function – all aspects

– Determined by nature of injury and philosophy of physician; AEP; S&C; Athletic trainer

• Based on objective and subjective criteria

– Strength testing and athlete monitoring questionnaires

– Functional tests

• Physician has the final say in return to play

Do you have a Return-to-Play Criteria? Clover, J., & Wall, J. (2010). Return-to-play criteria following sports injury.

Clinics in Sports Medicine, 29(1), 169-175.

Factors to Consider Prior to Return to Play

• Physiological healing

P i t t

• Functional testing

St i d b i• Pain status

• Swelling

• Range of motion

• Strength

• Neuromuscular control

• Strapping and bracing

• Responsibility of athlete

• Predisposition to injury

• Psychological factors

• Athlete education• Neuromuscular control

• Cardiorespiratory fitness

• Sports-specific demands

• Athlete education


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Documentation in Rehabilitation• Detailed records must be maintained

– Injury evaluations

– Treatment records

– Progress notes

• Lawsuits and malpractice

• Clinical setting record keeping critical for third-party billing

– While time consuming it can not be neglected

Summary: Key Points1. Healing Process

– .

2. Adaptive or compensatory actions– .

3. Fundamental training principles– Training mode

– .

– .

4. Reactivation continuum– .

considerations in designing a rehab programcsusap.csu.edu.au/~sbird/ehr315/lecture...

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