Chapter 16:Chapter 16:Therapeutic ExerciseTherapeutic Exercise

Therapeutic ExerciseTherapeutic Exercise

The long term goal is to return the The long term goal is to return the injured athlete to practice or injured athlete to practice or competition as quickly and safely competition as quickly and safely as possible!as possible!

Therapeutic ExerciseTherapeutic Exercise

Designing programs for rehabilitation Designing programs for rehabilitation is relatively simple and involves is relatively simple and involves several basic short-term goals:several basic short-term goals:

a.a. controlling paincontrolling pain

b.b. maintaining or improving flexibilitymaintaining or improving flexibility

c.c. restoring or increasing strengthrestoring or increasing strength

d.d. re-establishing neuromuscular controlre-establishing neuromuscular control

e.e. maintaining levels of cardiovascular maintaining levels of cardiovascular fitnessfitness

Therapeutic ExerciseTherapeutic Exercise

At best, the athletic trainer can only At best, the athletic trainer can only try to create an environment that is try to create an environment that is conducive to the healing process. conducive to the healing process.

Little can be done to speed up the Little can be done to speed up the process physiologically, but many process physiologically, but many things can be done to impede things can be done to impede healinghealing

Therapeutic ExerciseTherapeutic Exercise

A cookbook approach to A cookbook approach to rehabilitation is impossible. rehabilitation is impossible.

In fact, use of rehabilitation In fact, use of rehabilitation recipes are strongly discouraged. recipes are strongly discouraged.

Therapeutic exercises are Therapeutic exercises are concerned with restoring normal concerned with restoring normal body function after injury.body function after injury.

Therapeutic ExerciseTherapeutic Exercise

A sudden loss of physical activity A sudden loss of physical activity leads to a generalized loss of leads to a generalized loss of physical fitness.physical fitness.

When a body part is immobilized When a body part is immobilized for as short as a period of twenty-for as short as a period of twenty-four hours, definite adverse four hours, definite adverse muscular changes occur.muscular changes occur.

Therapeutic ExerciseTherapeutic Exercise

Components of a rehabilitation program Components of a rehabilitation program include:include:

1.1. minimizing swellingminimizing swelling

2.2. controlling paincontrolling pain

3.3. restoring full range of motionrestoring full range of motion

4.4. restoring muscular strength and endurancerestoring muscular strength and endurance

5.5. re-establishing neuromuscular controlre-establishing neuromuscular control

6.6. regaining balanceregaining balance

7.7. maintaining cardiorespiratory fitnessmaintaining cardiorespiratory fitness

8.8. incorporating functional progressionsincorporating functional progressions

Isometric ExerciseIsometric Exercise

Isometric exercises are commonly performed in Isometric exercises are commonly performed in the early phase of rehabilitation when a joint is the early phase of rehabilitation when a joint is immobilized for a period of time. immobilized for a period of time.

They are useful when resistance training through They are useful when resistance training through a full range of motion may make the injury worse. a full range of motion may make the injury worse.

Isometrics increase static strength and assist in Isometrics increase static strength and assist in decreasing the amount of atrophy. decreasing the amount of atrophy.

Isometrics can also lessen swelling by causing a Isometrics can also lessen swelling by causing a muscle pumping action to remove fluid and muscle pumping action to remove fluid and edema. edema.

Strength gains are limited primarily to the angle Strength gains are limited primarily to the angle at which the joint is exercised. at which the joint is exercised.

No functional force or eccentric work is No functional force or eccentric work is developed.developed.

Contraction TypesContraction Types Progressive resistance exercises uses Progressive resistance exercises uses

isotonic contractions in which force is isotonic contractions in which force is generated while the muscle is generated while the muscle is changing length.changing length.

Isotonic contractions may be either Isotonic contractions may be either concentric (shortening) or eccentric concentric (shortening) or eccentric (lengthening).(lengthening).

Isokinetic exercises uses fixed speed Isokinetic exercises uses fixed speed with accommodating resistance to with accommodating resistance to provide maximal resistance provide maximal resistance throughout the range of motion.throughout the range of motion.

Neuromuscular ControlNeuromuscular Control Neuromuscular control is the mind’s Neuromuscular control is the mind’s

attempt to teach the body conscious attempt to teach the body conscious control of a specific movement.control of a specific movement.

Re-establishing neuromuscular control Re-establishing neuromuscular control requires many repetitions of the same requires many repetitions of the same movement through a step-by-step movement through a step-by-step progression from simple to more progression from simple to more complex movements. complex movements.

Strengthening exercises, particularly Strengthening exercises, particularly those that tend to be more functional, those that tend to be more functional, are essential for re-establishing are essential for re-establishing neuromuscular control.neuromuscular control.

Neuromuscular ControlNeuromuscular Control Four elements are critical for re-Four elements are critical for re-

establishing neuromuscular control: establishing neuromuscular control:

1.1. proprioceptive and kinesthetic proprioceptive and kinesthetic awareness awareness

2.2. dynamic stabilitydynamic stability

3.3. preparatory and reactive muscle preparatory and reactive muscle characteristicscharacteristics

4.4. conscious and unconscious functional conscious and unconscious functional motor patterns.motor patterns.

Proprioception and Proprioception and KinesthesiaKinesthesia

Proprioception is the ability to Proprioception is the ability to determine the position of the joint determine the position of the joint in space.in space.

Kinesthesia is the ability to detect Kinesthesia is the ability to detect movement.movement.

Stages of RehabilitationStages of Rehabilitation

Phase 1 – acute phasePhase 1 – acute phase

Phase 2 – repair phasePhase 2 – repair phase

Phase 3 – remodeling phasePhase 3 – remodeling phase

Phase 1 - The Acute Injury Phase 1 - The Acute Injury Phase:Phase: Phase 1 begins immediately when an injury Phase 1 begins immediately when an injury

occurs and may last as long as four days. occurs and may last as long as four days. This inflammatory stage of the healing This inflammatory stage of the healing

process is attempting to control and clean process is attempting to control and clean up the injured tissue, thus creating an up the injured tissue, thus creating an environment that is conducive to the environment that is conducive to the fibroblastic stage. fibroblastic stage.

The primary focus of rehabilitation during The primary focus of rehabilitation during this phase is to control swelling and to this phase is to control swelling and to modulate pain by using by using rest, ice, modulate pain by using by using rest, ice, compression, and elevation (RICE) compression, and elevation (RICE) immediately after injury.immediately after injury.

Throughout this phase, rest, ice, Throughout this phase, rest, ice, compression, and elevation (RICE) should compression, and elevation (RICE) should be used as much as possible.be used as much as possible.

Phase 1 - The Acute Injury Phase 1 - The Acute Injury Phase:Phase: Rest of the injured part is critical during Rest of the injured part is critical during

this phase. this phase. It is widely accepted that early mobility It is widely accepted that early mobility

during rehabilitation is essential. during rehabilitation is essential. However, if the athletic trainer becomes However, if the athletic trainer becomes

overly aggressive during the first 48 hours overly aggressive during the first 48 hours after injury and does not allow the injured after injury and does not allow the injured body part to rest during the inflammatory body part to rest during the inflammatory stage of healing, the inflammatory process stage of healing, the inflammatory process never gets a chance to accomplish its never gets a chance to accomplish its purpose. purpose.

Consequently, the length of time required Consequently, the length of time required for inflammation may be extended. for inflammation may be extended.

Immobility during the first two days after Immobility during the first two days after injury is necessary to control inflammation.injury is necessary to control inflammation.

Phase 2 - The Repair Phase:Phase 2 - The Repair Phase: This stage may begin as early as four days after This stage may begin as early as four days after

the injury and may last for several weeks.the injury and may last for several weeks. At this point, swelling has stopped completely.At this point, swelling has stopped completely. The injury is still tender to the touch but is not The injury is still tender to the touch but is not

as painful as the last stage. as painful as the last stage. Pain is also less on active and passive range of Pain is also less on active and passive range of

motion. motion. Modalities in this phase, as in the acute phase, Modalities in this phase, as in the acute phase,

should be used to control pain and swelling.should be used to control pain and swelling. Cryotherapy should be used during the early Cryotherapy should be used during the early

portion of this phase to reduce the likelihood of portion of this phase to reduce the likelihood of swelling. swelling.

Electrical stimulating currents can help to Electrical stimulating currents can help to control pain and improve strength and range of control pain and improve strength and range of motion.motion.

Phase 3 - The Remodeling Phase 3 - The Remodeling Phase:Phase: The remodeling phase is the longest of the The remodeling phase is the longest of the

three phases and may last for several years, three phases and may last for several years, depending on the severity of the injury. depending on the severity of the injury.

The ultimate goal during this maturation stage The ultimate goal during this maturation stage of the healing process is return to activity. of the healing process is return to activity.

The injury is no longer painful to the touch, The injury is no longer painful to the touch, although some progressively decreasing pain although some progressively decreasing pain may still be felt on motion. may still be felt on motion.

The focus during this phase should be on The focus during this phase should be on regaining sport-specific skills. regaining sport-specific skills.

At this point, some type of heating modality is At this point, some type of heating modality is beneficial to the healing process. beneficial to the healing process.

The deep-heating modalities should be used The deep-heating modalities should be used to increase circulation to the deeper tissues. to increase circulation to the deeper tissues.

Rehab SuccessRehab Success

For rehabilitation to be successful, For rehabilitation to be successful, the injured athlete must comply with the injured athlete must comply with and adhere to the plan of and adhere to the plan of rehabilitation. rehabilitation.

In the field of athletic injury, In the field of athletic injury, compliance is the biggest deterrent compliance is the biggest deterrent to successful rehabilitation.to successful rehabilitation.

Criteria for Full ReturnCriteria for Full Returnto Activity:to Activity:

physiological healing physiological healing constraintsconstraints

pain statuspain status minimal swellingminimal swelling complete range of complete range of

motionmotion full strengthfull strength neuromuscular neuromuscular

control/proprioceptiocontrol/proprioception/ kinesthesian/ kinesthesia

cardiorespiratory cardiorespiratory fitnessfitness

sport-specific sport-specific demandsdemands

functional testingfunctional testing prophylatic strapping, prophylatic strapping,

bracing, paddingbracing, padding responsibility of the responsibility of the

athleteathlete predisposition to injurypredisposition to injury psychological factorspsychological factors athlete education and athlete education and

preventative preventative maintenance programmaintenance program

PNF:PNF:Proprioceptive Neuromuscular Proprioceptive Neuromuscular

FacilitationFacilitation

PNF techniques are generally used PNF techniques are generally used in rehabiliation for the purposes of in rehabiliation for the purposes of facilitating strength and increasing facilitating strength and increasing range of motion.range of motion.

Flexibility is increased by Flexibility is increased by techniques of contract-relax, hold-techniques of contract-relax, hold-relax, and slow-reversal-hold-relax.relax, and slow-reversal-hold-relax.

AssignmentAssignment Find at least one exercise or modality for Find at least one exercise or modality for

each of the following techniques:each of the following techniques:1.1. minimizing swellingminimizing swelling2.2. controlling paincontrolling pain3.3. restoring full range of motionrestoring full range of motion4.4. restoring muscular strength and restoring muscular strength and

enduranceendurance5.5. re-establishing neuromuscular controlre-establishing neuromuscular control6.6. regaining balanceregaining balance7.7. maintaining cardiorespiratory fitnessmaintaining cardiorespiratory fitness8.8. incorporating functional progressionsincorporating functional progressions