Transcript Essential Considerations in Designing a rehabilitation Program for

William E. Prentice
Rehabilitation Techniques for
Sports Medicine and Athletic Training

Majority of injuries in athletics are non-life
threatening


Will require treatment and rehabilitation for a
timely, but safe return to activity
Athletic Trainer will assume primary responsibility
for the design, implementation and supervision of
the rehab. program
 Must have as complete understanding of the injury as
possible




Knowledge of mechanism of injury
Major anatomical structures affected
Degree or grade of trauma
Stage or phase of injury’s tissue healing

Rehabilitation in athletic setting requires a
group effort to be most effective
Athletic Trainer and A.T. students
 Team Physician
 Coach
 Athlete and athletes family
 Strength and conditioning coach
 Other specialist

 A.T. will direct athlete and facilitate communication

A.T. is the one individual who will deal
directly with the patient/athlete throughout
the entire period of rehabilitation


From time of injury to return to unrestricted return
to activity
A.T. works closely with and under direct
supervision of team physician
 Develop and design rehabilitation and reconditioning
protocols
 Appropriate therapeutic exercise, rehab. Equipment,
manual therapy techniques, and therapeutic modalities

Communication
Athlete must always be informed and made aware of
the why, when and how factors of their rehab.
program
 Relationship takes time to develop
 Must build trust and rapport with athletes
 Must involve coach in discussions of athletes
progression and athletes return to activity

 Can help determine what and athlete can and cant do
during practice.
 Failure to communicate may cause misunderstanding
between those involved and possibly exacerbating the
athletes injury or symptoms

Approach in athletic setting is considerably
different than in most other rehab. settings

Competitive nature of athletics necessitates an
aggressive approach to rehabilitation
 Competitive season is relatively short and athlete does
not have the luxury of time
 Goal is to return the athlete to activity as soon and as
safely as possible
 A.T. tends to play games with healing process and
return athletes before complete healing has occurred
 “Balancing act” between not pushing athlete enough and
being too aggressive
 Mistake in judgment may hinder the athletes return to
activity

Progression of rehab program must be based
on the process of injury/tissue healing

A.T. Must have a sound understanding of the
different phases of tissue healing and apply
appropriate treatment/rehab
 Failure to do so may interfere with tissue healing and
increase the length of time required for rehabilitation,
thus slowing the athletes return to activity
 Little can be done to speed the healing process
physiologically, but many things can be done to
impede healing

Exercise intensity

SAID Principle: Specific Adaptations to Imposed
Demands
 When an injured structure is subjected to stresses and
overloads of varying intensities, it will gradually adapt
over time to whatever demands are placed on it
 Exercises must not be too great that they will exacerbate
the injury before it has had time to adapt
 Exercise that is too intense can be detrimental to the
rehab program
 Indications include an increase in swelling, pain, loss or
plateau in strength and range of motion.

Exercise intensity must be commensurate with
tissue healing

Submaximal exercise in short bouts initially, several
times a day
 As recovery increases, the intensity of exercise increases

Psychological aspects of how athlete deals with
injury are critical and often neglected factor

Wide range of emotional reactions
 A.T. needs to develop an understanding of the psyche
of each individual and adjust rehab accordingly
 Pain threshold, cooperation and compliance,
competitiveness, denial, intrinsic and extrinsic motivation,
anger, fear, guilt and ability to adjust to injury are all
factors
 Sports psychology can also be used to improve total
athletic performance

When joint or anatomical structures are
injured, normal biomechanical function is
compromised

A.T. must have solid foundation in biomechanics
and human anatomy to design effective rehab
program

Must be able to identify and correct postural and
biomechanical dysfunctions in order to
appropriately design rehab plan

Entire body is a kinetic chain that operates as
an integrated functional unit

Composed of muscular systems (muscles, tendons,
fascia), articular systems and neural systems
 All systems function simultaneously with the others for
structural and functional efficiency
 CNS sorts info. from these systems for neuromuscular
control.
 If any system in kinetic chain is not working effectively,
other systems are forced to adapt and compensate
 Can lead to tissue overload, decreased performance, and
predictable patterns of injury


Movements in everyday activity require
dynamic and postural control through multiple
planes of motion and different speeds of
motion
Rehabilitation should focus on functional
movements that integrate all components
necessary to achieve optimal movement
performance

Concepts of muscle imbalances, myofascial
adhesions, altered arthrokinematics, and abnormal
neuromuscular control need to be addressed

Function: Integrated, multiplanar movement
that requires acceleration, deceleration and
stabilization


Rehab. must address all links of the kinetic chain to
develop functional strength and neuromuscular
efficiency
Functional Strength: ability of neuromuscular
system to reduce force, produce force, and
dynamically stabilize the kinetic chain during
functional movement in a smooth coordinated
fashion

Neuromuscular Efficiency: ability of CNS to
allow agonist, antagonist, synergist, stabilizers
and neutralizers to work efficiently and
interdependently during dynamic kinetic chain
movements

Rehab may begin with isolated strengthening in
single planes of motion, but progress to multi-plane
functional movement that mimic sport activity

Tool Belt

A.T. have many tools in their tool belt
 Manual therapy techniques
 Therapeutic modalities
 Aquatic Therapy
 Physician prescribed medications
 Therapeutic Exercise
 How A.T. utilizes tools is often a matter of individual
preference and experience
 Patients differ in their responses to various treatment
techniques
 A.T. should avoid “cookbook" rehabilitation protocols
 A.T. should develop broad theoretical knowledge from
which specific techniques can be selected and practically
applied to each individual case

Therapeutic Modalities
Useful tools in injury rehabilitation
 When used appropriately can greatly enhance the
patients chance for safe and rapid return to full
activity
 A.T. should have knowledge of scientific basis of
various modalities and their physiological effects.
 Therapeutic Exercise however, is more critical than
the use of modalities


Therapeutic Exercise:

Exercises that force the injured anatomical structure
to perform its normal function
 Key to successful rehabilitation
 AROM, PROM, RROM and functional exercises

Medications to facilitate Healing

Prescription and over the counter (OTC) medications
can effectively aid the healing process during
rehabilitation

A.T. must have some knowledge of the effects of
medications and make decisions on appropriate use
with guidance from team physician

Short Term Goals









Provide correct immediate care and management
following injury to limit or control swelling
Reduce or minimize pain
Establishing core stability
Re-establishing neuromuscular control
Improving postural stability and balance
Restoring full range of motion
Restoring or increasing muscular strength,
endurance and power
Maintaining cardiorespiratory fitness
Incorporating functional progressions

Long Term Goals

To return to athlete to practice or competition as
quickly and as safely as possible

Establishing reasonable and attainable goals and
integrating specific exercises or activities to address
these goals is critical to rehab. plan.

Can be difficult knowing when and how to progress,
change, or alter rehab program to most effectively
accomplish short and long term goal

Important not to give exact time frame or date

May discourage athlete if time frame not met

Set series of progressions or successes to keep athlete
motivated

Keep athlete involved in goal setting and planning
the processes of their rehab plan.

Initial first aid and management techniques
may be the most critical part of any rehab
program



Has significant impact on the course of the
rehabilitation process
One major factor is the presence of swelling
Swelling caused by bleeding, production of synovial
fluid, accumulation of inflammatory by-products,
edema or combination of these factors
 Produces increased pressure that causes increased pain
 Can also cause neuromuscular inhibition, thus weak
muscular contractions
 Usually occurs in first 72 hours after injury


If swelling can be controlled initially in acute
stage of injury, the time required for rehab is
likely to be significantly reduced
Follow P.R.I.C.E acronym





Protection
Rest
Ice
Compression
Elevation

Protection:

Injury protected from further injury
 Splints, braces, pads or other immobilization devices
 Lower Extremity: Non weight bearing or limited
weight bearing until acute inflammatory response has
subsided

Rest (Restricted Activity):

Critical component
 Healing process begins immediately after injury occurs
 If interrupted will delay healing or not allow healing
process to begin and lengthen time of rehab
 Controlled mobility vs. immobilization better for scar
formation, revascularization, muscle regeneration and
reorientation of muscle fibers
 Severity of injury determines length of rest time, but
usually 24 to 48 hours
 Involve athlete in core, cardio respiratory and exercises
for un-affected parts of body

Ice

Most commonly used immediately after injury and
for 72 hours after to decrease pain and controlling
hemorrhage and edema
 Through local vasoconstriction
 Decrease secondary cell death by hypoxia by lowering
metabolism and tissue need for oxygen
 Reduce muscle spasm and guarding that accompany
pain
 Analgesic effect through decreased velocity of nerve
conduction and bombarding sensory nerves with cold
so pain impulses are lost
 Times for icing vary for different areas of body

Compression

Single most important technique for controlling
swelling
 Mechanically decrease amount of space available for
swelling by applying pressure around injured area
 Applied distally to proximally
 Kept in place despite pain because of importance for
swelling
 Worn for 72 hours or until swelling is eliminated

Elevation:
Eliminate the effects of gravity on blood pooling in
the extremities
 Assist venous and lymphatic drainage of blood and
other fluids from the injured area back to central
circulatory system
 Greater the degree of elevation the more effective
 As much as possible for first 72 hours


Pain will interfere with progression of rehab.



Assess pain on a daily basis and with exercises
Persistent pain will make range of motion and
strengthening exercises more difficult
Manage with medication, modalities and P.R.I.C.E.

Essential to every aspect of rehab process

Include in all phases of rehab program

Muscles of lumbo-pelvic-hip complex
Functions to dynamically stabilize entire kinetic
chain during functional movement
 Train proximally or locally to distally or globally


Re-establishing Neuromuscular Control







Ability to sense he position of a joint in space
Altered after injury
Re-establishing postural control and balance
Restoring Range of Motion
Restoring muscular strength, Endurance and
Power
Maintaining Cardio-respiratory Fitness
Functional Progressions and Testing

Decision to release a patient recovering from
injury to a full return to activity is the final
stage of rehabilitation process

Should be carefully considered by all members of
sports medicine team

Ultimately team physicians decision , however it
should be based on input from A.T.. Coach and the
patient






Is athlete pain free?
Do they have full non restricted pain free range of
motion?
Is their strength equal to non injured side or
enough to protect from re-injury?
Do they have neuromuscular control and balance?
Are they reconditioned for their sport, cardiorespiratory fitness and functional testing?
Is the athlete psychologically ready for full return
without fear or hesitation?

A.T. should be proficient in record keeping

Initial injury report

Rehab progression Reports, treatment logs and
S.O.A.P. Notes
 Should be accurate and detailed
 Important for appropriate progressions of rehab,
consistency among different practioners, third party reimbursement, and defense in a malpractice suit

States vary considerably in their laws
governing what an A.T. may and may not do in
supervising a program

A.T. should not act outside their scope of knowledge
and practice and within the laws of their state