Transcript Functional Progression in Rehabilitation

Functional Progressions &
Functional Testing
in Rehabilitation
Chapter 16
How do you move forward in Rehab?
• Function in rehab = patterns of motion that use
multiple joints acting with various axes & in multiple
planes
– Essential part of rehab that places tissues under stresses that
return tissues to levels of full activity
– Places stresses & forces on each body system
• Traditional rehab techniques often stress only single
joints in single planes of motion
• To complement traditional rehab, you can use
functional rehab to ready your patient for activity
Functional Progression
• Functional progression = succession of activities
that simulate actual motor & sport skills
– Enables the patient to acquire or reacquire the skills
needed to perform activity
– Must be able to adapt rehab to the sport-specific
demands & specific position
• The clinician breaks down the activities into
individual components.
– The patient can focus on each specific part of an
activity.
Benefits for Using Functional
Progression
• Helps patient reach goals of entire program
• Goals of functional progression:
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Restoration of joint ROM
Restoration of strength
Restoration of proprioception
Restoration of agility
Restoration of confidence
• Provides both physiological & psychological
benefits to the patient
Benefits for Using Functional
Progression
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Improves functional stability
Muscular strength – SAID principle
Endurance – muscular & cardiorespiratory
Flexibility – elongating tissue to proper length
Muscle relaxation – reduce muscle tension
Motor skills – coordination & agility, automatic
reactions
Psychological & Social Considerations
• Anxiety – uncertain about future
• Deprivation – losing contact with team &
coaches
• Apprehension – precursor to re-injury
• Success of activity gives confidence &
motivates to attain the next goal
Components of a Functional Progression
• Phase 1 – Acute Injury Phase
– Focus on restoring joint ROM, muscular strength, &
muscular endurance
• Phase 2 – Repair Phase
– Focus on incorporating proprioception & agility exercises
• Phase 3 – Remodeling Phase
– Focus on restoring everything to pre-injury status
• Progression should allow for planned sequential
activities that challenge the athlete while allowing for
success
Activity Considerations
• Principles for activity selection
– Individuality of athlete, sport and injury
– Should be positive (no increase in symptoms should
occur)
– Orderly progressive program should be utilized
– Variety – avoid monotony, but don’t cause confusion
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Vary exercise techniques used
Alter the program at regular intervals
Maintain fitness base to avoid re-injury with return to play
Set achievable goals, reevaluate, & modify regularly
Use clinical, home, & on-field programs to vary activity
Activity Considerations
• Make sure the patient understands the rehab
process
• You need to emphasize the importance of
sport-specific activities to enhance the patient’s
return
– Incorporate the inherent demands of the sport
• Physical & athletic fitness should be merged to
maximize athlete response & return to previous
levels
Designing a Functional Progression
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No cookbook method
You are only limited by creativity
Should be initiated early in progression
Guidelines
– Evaluate the patient’s current status
– Review expectations of the patient and physician
• Do they work together?
– Understand demands of sport and position played
• May require incorporation of athlete, coach and other athletic trainers
– Analyze demands that will be placed on athlete (rank order)
– Set goals and means to assess levels of function and progress
– Set parameters for return to play criteria
Components of Physical Fitness
& Athletic Fitness
Full Return to Play
• Decision requires full evaluation of athlete’s condition
– Objective observation and subjective evaluation
• Athlete should feel ready physically and mentally
• Controlled return
– Added stress to injury can slow healing and result long and
painful recovery or re-injury
• Criteria
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Physician’s release
Pain free, no swelling
Normal ROM, strength
Completion of functional testing minus adverse effects
Functional Testing
• Patient performs certain tasks appropriate to the stage in the
rehab process in order to isolate and address specific deficits
• Purpose for functional testing
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Determines risk of injury due to limb asymmetry
Provides objective measures of progress
Measures ability of individual to tolerate forces
Used as an indirect measure of strength and power
• Functional tests serve as good correlation to functional ability
• Utilize valid and reliable tests
• Should look at both unilateral & bilateral function
– Allows clinician to determine if athlete is compensating
• Must consider stage of healing, appropriate rest & selfevaluation
Functional Testing
• Limitations of functional testing
– Might be limited due to lack of availability of normative
values or pre-injury baseline values for comparison subjective decisions must be made based on test results
• E.g.: BESS
– If normative data/pre-injury status is available objective
decisions can be made
• Functional test should be easily understood by athletic
trainer & patient
• Must consider cost efficiency, time and space demands
Examples of Functional Progression &
Testing The Upper Extremity
• Possible functional activities that can enhance upper
extremity performance
– PNF, swimming, pulley machines, rubber tubing
– All can be used to simulate sports activity
• Must focus on proprioception & neuromuscular control
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Awareness of proprioception
Dynamic stabilization restoration
Preparatory and reactive muscle facilitation
Replication of functional activities
• Kinesthesia training can use similar activities
– Requires removal of external cues
• Promotion of joint position sense
– Activities that can be used
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Isokinetic exercise
Proprioception testing devices
Goniometry
Electromagnetic motion analysis
– Can be practiced with visual cue progressing to no cues
– Activities can be active or passive
– Can also work to reproduce specific paths of motion to
increase functional component of activity
– Must stress joint at both ends of ROM and at mid-range
• Results in capsuloligamentous afferents & musculotendinous
mechanoreceptors, respectively
• Dynamic stability
– Stresses the training of force couples provided by scapula
stabilizers & muscles of the glenohumeral joint
– CKC exercises enhance co-activation
• Preparation and Reaction
– Incorporates rhythmic stabilization activities along with
CKC exercises
• Rhythmic stabilization prepares athlete for motion and improves
muscle stiffness while training for reaction
– Plyometrics are an excellent alternative activity
• Functional Activities
– Stress sports specific skills
– PNF patterns can be used as early alternative to sports
specific activity (more function, less stress)
• Program should focus on core, scapulothoracic
stabilizers and the glenohumeral joint
– Quadruped position allows athlete to work muscles of
trunk/core and upper extremity
• While most activities are OKC oriented, CKC
activities are important for restoration of proper
function
• Throwing Progression
– Instruct athlete in complete an appropriate warm-up
• Should incorporate throwing motion practice (slow
velocity with low stress)
– Progress through increasingly difficult stages
• Shoulder serves as template for upper extremity
rehabilitation and progression
– Many of the activities for the shoulder are equally effective
for the elbow, wrist and hand
Functional Testing for the Upper Extremity
• Timed performance is simplest & most common means
used for testing
• Velocity
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Controlled environment (indoors to decrease effect of weather)
Set up a standard pitching distance (60’6”)
Have athlete use a wind-up motion
Measure a maximum of 5 throws measured in mph with radar gun (if
no radar gun – use stop watch)
• Compute the mean and compare to pretest values
• CKC Upper Extremity Stability Test
• Use sports specific drill to assess performance &
readiness
Progression for the Lower Extremity
• Utilizes same basic pattern as upper extremity
• Can use sprint times, agility runs for time, hopping
(height and distance), co-contraction tests, carioca
runs and shuttle runs
• Sprint test
– Set distance
– Run the distance for time
– 3-5 sprints should be completed and the mean
computed
– Pre-test and post-test measures are compared
• Agility test
– Same premise as sprint test
– Difference involves the course
• Not just straight ahead running
• Incorporates changes in direction, acceleration, deceleration, starts &
stops
– Other agility tests
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Box runs
Zigzag runs
Cutting maneuvers
Figure 8 runs
Back pedaling drills
– Changes in shape and size can make drills more difficult
• Vertical Jump
– Record height athlete is able to jumps (3-5 trials)
– Test can also be varied
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Bilateral jump vs. Single leg jump
Countermovement vs. static squat start
Approach step vs. stationary start
Upper extremity use for propulsion vs. restricted use
• Co-Contraction Semicircular Test
– Athlete moves about a semicircular pattern while
tethered to taut Theraband using a forward facing
shuffle
– Athlete will complete 3 trials of 5 repetition for time
– Provides a dynamics pivot shift for the ACL
insufficient knee
• Hopping Test
– Single leg hop for distance
– Timed hop test (ability to hop 6 meters for time)
– Triple hop for distance (distance covered in 3 consecutive
hops
– Crossover hop (distance covered in 3 hops)
• Carioca Test
– Run performed for time
– Run a total of 80 feet, 40 feet to the right and 40 feet to the
left, both facing the same direction
– Record 3 trials and calculate a mean
• Shuttle Run
– Four 20 feet sprints (with 3 direction changes)
– Suicide sprints – sprint, touch mark and return to starting
position (total time to complete drill)
• Balance Test
– Helps determine deficits in proprioception and balance
– Single leg stance (hold position for time)
• Can incorporate different surfaces, and eye condition
• May also incorporate sports skills into test
• Functional Hop Test
• Subjective Evaluations
– Incorporation of subjective questionnaires or numeric
scales to assess function