The basis of injury rehabilitation

The Basis of Injury
Rehabilitation
Presented By:
Dr Rahman Sheikhhoseini
Assistance professor at Allameh Tabataba’i University
Sep 2016
Advanced Rehabilitation
1

Reference:
1. William E. Prentice. Rehabilitation Techniques in
Sports Medicine, McGraw-Hill Humanities/Social
Sciences/Languages; 5 edition (January 8, 2010).
2

Essential Considerations in
Designing a Rehabilitation
Program for the Injured Athlete
3

THE REHABILITATION TEAM
 Providing a comprehensive rehabilitation program to the athlete requires
a group effort to be most effective.
 This group is intimately involved with the rehabilitative process, beginning
with patient assessment. treatment selection, and implementation and
ending with functional exercises and return to activity.
 The injured athlete must always be informed and made aware of the why,
how, and when factors that collectively dictate the course of an injury
rehabilitation program.
4

The Players on the Sports Medicine
Team
 Physicians
 Dentist
 Podiatrist
 Nurse
 Physicians Assistant
 Physical Therapist
 Athletic Trainer
 Massage Therapist
 Exercise Physiologist
 Biomechanist
 Nutritionist
 Sport Psychologist
 Coaches
 Strength & Conditioning Specialist
 Social Worker
5

What is the philosophy of sports medicine
rehabilitation?
The competitive nature of athletics necessitates an
aggressive approach to rehabihtation.
The goal is to return to activity as soon as is safely
possible.
Consequently the athletic trainer tends to play games
with the healing process, never really allowing enough
time for an injury to completely heal.
6

Understanding the Healing Process in
Sports Medicine
 Decisions as to when and how to alter or progress a rehabilitation
program should be based primarily on the process of injury healing.
 The athletic trainer must possess a sound understanding of both the
sequence and the time frames for the various phases of healing,
realizing that certain physiological events must occur during each of the
phases.
 During the rehabilitation process, the stresses of reconditioning exercises
must not be so great as to exacerbate the injury before the injured
structure has had a chance to adapt specifically to the increased
demands. (The SAID Principle (specific adaptation to imposed demand))
7

Understanding the Pathomechanics of
Injury
 After Injury adaptive changes occur that alter the manner in which various forces
collectively act upon that joint to produce motion. Thus the biomechanics of joint
motion are changed as a result of that injury.
 Understanding the foundation in biomechanics and functional human anatomy
(in normal and abnormal situations (physiological movements and joint plays,…))
may be effective in designing a rehabilitation program.
8

Understanding the Concept of the Kinetic
Chain
 The kinetic chain is composed of not only muscle,
tendons. fascia, and ligaments, but also the articular
system and neural system.
 If any system within the kinetic chain is not working
efficiently, the other systems are forced to adapt and
compensate; this can lead to tissue overload, decreased
performance, and predictable patterns of injury.
 Injury to the kinetic chain rarely involves only one
structure. The kinetic chain functions as an integrated unit.
9

Understanding the Psychological Aspects
of Rehabilitation
Injury and illness produce a wide range of emotional
reactions; therefore the athletic trainer needs to
develop an understanding of the psyche of each
patient.
Individuals vary in terms of pain threshold,
cooperation and compliance, competitiveness, denial
of disability, depression, intrinsic and extrinsic
motivation, anger, fear, guilt, and the ability to adjust
to injury
10

Understanding the Concept of Integrated
Functional Movement
 What is the definition of function?
 Function is integrated, multiplanar movement that requires
acceleration, deceleration, and stabilization.
 The athletic trainer must understand that the kinetic chain operates as an
integrated functional unit.
 Functional strength is the ability of the neuromuscular system to reduce force,
produce force, and dynamically stabilize the kinetic chain during functional
movements in a smooth and coordinated fashion.
 Neuromuscular efficiency is the ability of the central nervous system (CNS) to
allow agonists, antagonists, synergists, stabilizers, and neutralizers to work
efficiently and interdependently during dynamic kinetic chain activities.
11

Understanding the Concept of Integrated
Functional Movement
 Traditionally, rehabilitation has focused on isolated absolute strength gains, in
isolated muscles, using single planes of motion. However, all functional activities
are naturally multiplanar and require a blend of acceleration, deceleration, and
dynamic stabilization.
 The paradigm shift dictates that we train to allow force reduction, force
production, and dynamic stabilization to occur efficiently during all kinetic chain
activities.
12

Using the Tools of Rehabilitation
Manual therapy techniques
Therapeutic modalities
Aquatic therapy
The use of physician-prescribed medications
13

Therapeutic Exercise versus Conditioning
Exercise
The basic principles of training and conditioning exercises also
apply to techniques of therapeutic, rehabilitative, or
reconditioning exercises that are specifically concerned with
restoring normal body function following injury.
The term therapeutic exercise is perhaps most widely used to
indicate exercises that are used in a rehabilitation program.
14

Establishing short and long-term goals in
a rehabilitation program
Short-term goals included:
1. Providing correct immediate first aid and management following injury to
limit or control swelling
2. Reducing or minimizing pain
3. Establishing core stability
4. Reestablishing neuromuscular control
5. Improving postural stability and balance
6. Restoring full range of motion
7. Restoring or increasing muscular strength, endurance, and power
8. Maintaining cardiorespiratory fitness
9. Incorporating appropriate functional progressions.
15

Thus, what is the long term goal in rehabilitation?
 The long-term goal is almost invariably to return the injured patient to practice or competition as
quickly and safely as possible.
16

 Establishing reasonable, attainable goals and integrating specific
exercises or activities to address these goals is the easy part of
overseeing a rehabilitation program. The difficult part comes in knowing
exactly when and how to progress, change, or alter the rehabilitation
program to most effectively accomplish both long- and short-term
goals.
 The athletic trainer should not make the mistake of giving an injured
patient an exact time frame or date !!!!!!!!.
17

What is The Importance of Swelling
Control?
 Swelling produces an increased pressure in the injured area, and increased
pressure causes pain!!
 Swelling can also cause neuromuscular inhibition, which results in weak muscle
contraction.
 Once swelling has occurred, the healing process is significantly retarded.
 Swelling is most likely during the first 72 hours after an injury.
 If the swelling can be controlled initially in the acute stage of injury, the time
required for rehabilitation is likely to be significantly reduced.
18

Swelling Control
The PRICE principle:
 Protection (braces. Tape,
Crutches, …)
 Restricted activity
 Ice,
 Compression
 Elevation
19

Pain control
 PRICE
 Medications by Physicians
 Cryotherapy/Thermotherapy
 Electrical stimulation
 Etc.,..
20

Establishing Core Stability
 Core stability is absolutely essential to every
aspect of the rehabilitation process
 Without proximal or core stability, the distal
movers cannot function optimally to
efficiently utilize their strength and power.
21

Reestablishing Neuromuscular Control
 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.
 Following injury and subsequent rest and immobilization, the
central nervous system “forgets” how to put together information
coming from muscle and joint mechanoreceptors, and from
cutaneous, visual, and vestibular input.
 Neuromuscular control is the mind’s attempt to teach the body
conscious control of a specific movement.
22

Restoring Postural Control and Stability
(Balance)
 The ability to maintain postural stability and balance
is essential to acquiring or reacquiring complex
motor skills.
 A rehabilitation program must include functional
exercises that incorporate balance and
proprioceptive training that prepares the patient for
return to activity
23

Restoring Range of Motion
 Following injury to a joint, there will always be
some associated loss of motion.
 That loss of movement can usually be attributed
to a number of pathological factors, including
resistance of the musculotendinous unit (i.e.,
muscle, tendon, fascia) to stretch; contracture of
connective tissue (i.e., ligaments, joint capsule); or
some combination of the two.
 Muscle imbalances, postural imbalance, neural
tension, and joint dysfunction can also lead to a
loss in range of motion.
24

Restoring Muscular Strength, Endurance,
and Power
 Isometric Exercise
 Progressive Resistive Exercise
 Isokinetic Exercise
 Plyometric Exercise
 Open- versus Closed-Kinetic-Chain Exercise
25

Maintaining Cardiorespiratory Fitness
 When injury occurs and the patient is
forced to miss training time,
cardiorespiratory fitness can decrease
rapidly.
26

Functional Progressions
 The purpose of any program of
rehabilitation is to restore normal
function following injury.
 Progression through the
rehabilitation program may be
broken down into three phases:
the stabilization phase, the
strengthening phase, and the
power phase.
27

Stabilization Phase:
 Begins with exercises designed to correct the deficits in the structural integrity of the
kinetic chain including muscle dysfunction, joint dysfunctions, neuromuscular deficits,
and postural control and stability.
 Follow by: aggressive rehabilitation program to correct muscle imbalances, recondition
injured structures, prepare tissues for the physical demands of the rehabilitation
program, prevent tissue overload through progressive adaptation, improve work
capacity, and improve stabilization strength;
 Exercises should progress from isometric to multiplanar activities designed to recruit
joint stabilizers, thus improving neuromuscular efficiency, core stability, functional
strength, and functional flexibility
28

The strength phase is used to enhance stabilization
strength and endurance during functional movement patterns by
incorporating high volume resistive exercises that force motor unit
recruitment after the prime movers are fatigued.
The power phase is particularly important for an injured
athlete who is attempting to return to high-level physically demanding
activity. During this phase the goal is to enhance neuromuscular
efficiency and power production by increasing motorneuron excitability
thus increasing speed strength throughout the entire range of motion.
29

Functional Testing
 Functional testing involves a single maximal effort performed to indicate how
close the patient is to a full return to activity.
30

Criteria for Full Recovery
In considering the patient’s return to activity, the
following concerns should be addressed:
 Physiological healing constraints.
 Pain status
 Swelling
 Range of motion
 Strength
 Neuromuscular control/ proprioception/
kinesthesia
 Cardiorespiratory fitness
31
• Sport-specific demands
• Functional testing
• Prophylactic strapping, bracing, padding
• Responsibility of the patient
• Predisposition to injury
• Psychological factors
• Patient education and preventive
maintenance program

The End
32

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