191

OUTCOMES

1. Explain the principles associated with the cognitive model thatdescribes a patients adjustment to injury.

2. Identify various psychological inuences that can affect aninjured individual, and describe strategies or intervention tech-niques used to overcome these inuences.

3. Explain the importance of dealing with the psychological con-cerns of the patient that may arise during the therapeutic exer-cise program, and identify the referral process if warranted.

4. Describe key factors in the development of a therapeuticexercise program.

5. Explain the four phases of a therapeutic exercise program,including the goals of these phases and methodology ofimplementation.

6. List the criteria used to clear an individual to return to fullparticipation in sport and physical activity.

The ultimate goal of therapeutic exercise is to return the injured participantto pain-free and fully functional activity. For this to be accomplished, atten-tion must focus on modulating pain and restoring normal joint range ofmotion (ROM), kinematics, exibility, muscular strength, endurance, coordination,and power. Furthermore, cardiovascular endurance and strength must be main-tained in the unaffected limbs.

Psychological inuences can inhibit or enhance the progress of the therapeuticexercise program. As such, an awareness of the physical, psychological, emotional,social, and performance factors that may affect the patient during rehabilitation is es-sential. Only then can each component be addressed within a well-organized, indi-vidualized exercise program.

C h a p t e r 8Therapeutic Exercise

In this chapter, several emotional and psychological fac-tors that may affect the injured individual are presented.These factors may either inhibit or enhance progressthrough the rehabilitation program. Next, a therapeutic ex-ercise program following the SOAP (Subjective evaluation,Objective evaluation, Assessment, and Plan) note format isexplained. Phases of a therapeutic exercise program arepresented, including criteria used to determine when anindividual is ready to progress in the program, and ulti-mately to return to sport activity. Practical application ofthe material for the various body segments is included inChapters 10 through 17. Because of the extensive nature ofthe material and the inability to provide in-depth informa-tion in a single chapter, students should enroll in a sepa-rate therapeutic exercise class to gain a more thorough un-derstanding of the subject area, and to learn the clinicalskills necessary to develop a total rehabilitation program.

PSYCHOLOGICAL ASPECTS OF THEINJURED PARTICIPANT

A high school senior soccer player developed acute Achillestendinitis 2 days before the post-season tournament, and justlearned that he will be unable to participate for the remainder ofthe season. How might this athlete react to the inability to partic-ipate in sport? What impact will this reaction have on his motiva-tion to improve? How can the athletic trainer help this personovercome the physical, psychological, and emotional effectsthat may hinder progress in the therapeutic exercise program?

To an individual who enjoys sport and physical activity,an injury can be devastating. For many, the developmentand maintenance of a physically t body provides a focalpoint for social and economic success that is importantfor self-esteem. A therapeutic exercise program mustaddress not only the physical needs, but also the emo-tional and psychological needs in returning the individualto activity.

In general, there are two models that categorize anindividuals adjustment to injury, namely stage and cogni-tive models. The stage model is often linked to theKbler-Ross emotional stages that an individual pro-gresses through when confronted with grief. The stagesinclude denial and isolation, anger, bargaining, depres-sion, and acceptance. Although the model has some intu-itive appeal, the stereotypical linear pattern of distinctemotional responses has not stood up to empiricalscrutiny (1). Furthermore, if individuals react to injury ina linear manner, then the therapist should be able to pre-dict the patients progress during rehabilitation. This israrely the case.

Each person reacts differently to an injury, dependingon individual coping mechanisms that stem from the inter-action of personal and situational factors (Figure 8.1). Assuch, cognitive models were developed to account forthe differences. Personal factors, such as performance anx-iety, self-esteem/motivation, extroversion/introversion,psychological investment in the sport, coping resources, ahistory of past stressors (e.g., previous injuries, academics,

192 S E C T I O N I I Injury Assessment and Rehabilitation

Q

Figure 8.1. Cognitive model of an athletic injury. Personal factors and situationalfactors interact with the cognitive, emotional, and behavioral responses of the patient to inuencethe success or failure of a therapeutic exercise program.

and family life events), and previous intervention strategiesinuence how a patient approaches the rehabilitationprocess. Situational factors may involve the type of sport,relationship with the coach and team members, character-istics of the injury (severity, history, and type), timing ofthe injury (preseason, in-season, playoffs), level and inten-sity of the player, point in the individuals career, and roleon the team. Each of these factors interacts with the cogni-tive, emotional, and behavioral responses of the patient toinuence the success or failure of a therapeutic exerciseprogram. The cognitive appraisal asks: What are youthinking in regard to this injury? The emotional responserefers to what one is feeling, and the behavioral responsefocuses on what the patient is going to do: What are thebehavioral rehabilitation consequences? (1)

Goal Setting

Goal setting is a common practice used to motivatepatients in the recovery program. This practice directs theindividuals effort, provides a sense of control that mayenhance motivation, persistence, and commitment, andfacilitates the development of new strategies to improveperformance. It has been found that patients who set spe-cic personal goals in each training session exhibit anincrease in self-efcacy, or the sense of having the powerto produce intended outcomes, and have greater satisfac-tion with their performance (2-5).

The process begins by establishing a strong and sup-portive rapport between the therapist and patient, as theywork in partnership to assist the individual back to prein-jury status. In order to achieve success, the therapist mustform a genuine relationship with the patient and listenintently for clues that indicate what the individual is or isnot feeling. Goals should be realistic, objective, measura-ble, and attainable. Guidelines for goal setting for thera-peutic exercise can be seen in Box 8.1. Long-term goalscan reduce the patients fears of the unknown, but do lit-tle to motivate the patient on a day-to-day basis. There-fore, short-term goals should be established to serve asdaily motivators. Goals should be personalized and chal-lenging, yet realistic. A timetable for completion shouldbe established, and measured to monitor progress.

Plateaus and setbacks usually occur because some-thing is blocking the patients progress. These barriers fallunder four general categories: lack of knowledge, lack ofskill, lack of risk-taking ability, and lack of social support.

Lack of KnowledgeIt is imperative to inform the patient about the injury andrecovery process. The use of a specic treatment, theintended goal, and any side effects or sensations that maybe experienced should be explained to the patient. Thishelps the individual understand the process, avoids anysurprises, and hopefully, reduces any anxiety the patientmay be experiencing (6).

Lack of SkillIt is important to explain and demonstrate the varioustechniques that a patient will be performing. In somecases, a patient may indicate familiarity with an exercise,but the technique may not be correct. For example, apatient involved in knee rehabilitation states the ability toperform lateral step-ups. However, observation of thepatients actions reveals a pushing off with the plantarexors to raise the body, rather than allowing only theheel to touch the oor and, in doing so, recruiting thequadriceps to raise the body. The exercise is ineffective ifdone improperly. Therefore, the therapist should alwaysdemonstrate the skill and watch the individual completethe exercise. Positive reinforcement and suggestionsshould be provided to correct any errors in technique.

Lack of Risk-Taking AbilityMost individuals experience some level of fear and anxietyof the unknown. In a therapeutic exercise program, suchemotions can block the individuals ability to push himselfor herself to meet the challenges of the exercise program.

C h a p t e r 8 Therapeutic Exercise 193

B O X 8 . 1

Guide to Goal Setting for Therapeutic ExerciseGoals should be:

Specic and Measurable. The athlete must know exactlywhat to do, and be able to determine if gains aremade.

Stated in Positive versus Negative Language. Knowing whatto do guides behavior, whereas knowing what toavoid creates a focus on errors without providinga constructive alternative.

Challenging but Realistic. Overly difcult goals set up fail-ure and pose a threat to the athlete. The lower theathletes self-condence, the more important suc-cess becomes, and the greater the importance ofsetting attainable goals.

Established on a Timetable for Completion.This allows for acheck on progress, and evaluation of whether re-alistic goals have been set.

Integration of Short-, Intermediate-, and Long-Term Goals. Acomprehensive program links daily activities withexpectations for specic competitions, and forseason and career goals.

Personalized and Internalized. The athlete must embracegoals as his or her own, not as something fromthe outside.

Monitored and Evaluated. Feedback must be provided toassess goals, and the goals should be modiedbased on progress.

Linked to Life Goals. This identies sport and rehabilita-tion as learning experiences in life, and helps theathlete put sport in a broader perspective. This isespecially important for athletes whose return tosport is doubtful.

For example, fear of increased pain, discomfort, or reinjuryduring an exercise may limit the individuals motivation toexert full effort. Constant positive feedback from the ther-apist can help overcome many of these obstacles.

Social SupportThe injured patient needs to feel as important as nonin-jured individuals and not feel alone or isolated. Friends,colleagues, coaches, and the athletic trainer can provideemotional, challenging material and informational sup-port to help the patient recognize his or her progress andvalue to the team. It is important to stress the individualsvalue as a person, and maintain connection to the team,friends, family, and any other supportive entities.

Psychological Inuences

Five major factors can signicantly inuence the rehabili-tation process: condence, motivation, anxiety, focus,and the management of pain.

CondenceCondence is perhaps the most critical factor to a com-plete and timely recovery. Low condence can lead to ahost of negative thinking and talk, which in turn can leadto increasing anxiety, negative emotions (e.g., bitterness,confusion, anger, or guilt), and low motivation, whichcan interfere with the individuals focus. Four main typesof condence can affect the patients recovery: program,adherence, physical, and return-to-sport. Program con-dence refers to the strength of the individuals belief thatthe rehabilitation program will enable recovery, and issignicantly inuenced by the therapists condence inthe effectiveness of the program. Adherence condencerefers to the individuals belief that the prescribed exer-cise program can be completed. This factor can be en-hanced by showing the individual that skills learned insports, such as goal-setting and understanding theprocess of rehabilitation can heighten success in the re-habilitation program. Physical condence is knowing thatthe individuals body is capable of handling the demandsplaced on it during rehabilitation and subsequent compe-tition. Responding well to the rigors of the exercise pro-gram, maintaining a positive attitude about the ups anddowns of rehabilitation, and using imagery can enhancethis factor. Return-to-sport condence relates to the indi-viduals belief that his or her return to competition is at alevel equal to or better than the preinjury status (7).

MotivationMotivation has the greatest inuence on adherence inrehabilitation. Low motivation can result in poor atten-dance, incomplete exercises, low effort and intensity, lackof attentiveness to instructions, undened goals, using un-

specied pain to avoid exercise, and insupportable ex-cuses. Motivation can be enhanced through goal setting byreminding the individual that rehabilitation is a type of ath-letic performance, improving commitment, providing cleardirection and the means to achieve full recovery, and of-fering deliberate steps to recovery. High motivation buildscondence, reduces anxiety and the perception of pain,and refocuses the individuals attention on the positiverather than the negative aspects of rehabilitation (3, 5).

AnxietyAnxiety is the negative and threatening psychological andphysical reaction to the injury, and produces a widerange of physical, cognitive, emotional, social, and per-formance problems. Many of these signs and symptomscan be seen in Box 8.2. Anxiety often is caused by anumber of factors, such as pain, slow healing, low con-dence, pressure from others, and a lack of familiarity,predictability, and control. Anxiety can restrict oxygen in-take and blood ow, increase muscle tension and pain,reduce condence and motivation, and lead the individ-ual to focus on the negative rather than positive aspectsof rehabilitation. Physically active individuals can controlanxiety by using deep breathing, passive and active re-laxation, soothing music, smiling, and therapeutic mas-sage. A rehabilitation routine can benet the patients re-covery by encompassing all the activities necessary for

194 S E C T I O N I I Injury Assessment and Rehabilitation

B O X 8 . 2

Signs and Symptoms of Anxietyin RehabilitationPhysical Muscle tension and bracing; short,

choppy breathing; decreased coordination; fatigue; rushed speech; minor secondary injuries or nagging illness with recurrent physical complaints; and sleeping problems

Cognitive Excessive negativity and overly self-critical, statements of low condence in rehabilitation, extreme thinking and unrealistic expectations, and verynarrow focus

Emotional Anger, depression, irritability, moodi-ness, and impatience

Social Decreased communication, social with-drawal, intolerance, and abruptness with others

Performance Overall decline in motivation and enjoy-ment in rehabilitation, loss of interest in sports and other activities, nerv-ousness and physical tension during therapy, trying too hard in therapy or giving up in response to obstacles and setbacks, and decrease in school or work performance

total preparation, including a review of the goals for thatday, mental preparation to ensure prime condence, mo-tivation, intensity, and focus, and physical preparationsuch as stretching and warm-up (7).

FocusOften misunderstood and ignored, focus is critical in therehabilitation process. In essence, focus is the ability toperceive and address various internal (e.g., thoughts,emotions, physical responses) and external (e.g., sights,sounds) cues and, when needed, to shift focus to othercues in a natural, effortless manner. Focus differs fromconcentration in that concentration is usually linked tothe ability to attend to one thing for a long period of time.In contrast, focus is the ability to attend to various cuesoccurring simultaneously, and shift focus when the needarises. For example, a patient may be executing an exer-cise and have to shift focus externally to listen to the in-structions for an exercise. The patient then needs to focusinternally in order to consciously monitor the intensityand any pain being experienced. The ability to focus isoften compared with the beam of a Mag-Lite ashlight inthat the beam can be adjusted to illuminate a wide areaor focused to brighten a narrow area (7).

Cues that interfere with rehabilitation include negativethoughts, anxiety, pain (as an inhibitor), preoccupationwith the injury after returning to sport participation, peerpressure to recover quickly, any distraction during physi-cal therapy, and comparisons to others upon return tosport. Facilitating cues may include pain (as information),proprioceptive responses, physical dimensions such asROM and strength, information that the therapist pro-vides, support from others, and feedback from the thera-peutic exercise equipment. In order to maintain onesprime focus, the patient must balance the focus on short-and long-term goals, and pay attention to the four princi-ples (Ps) of focus. In general, the patient should focuson the:

Positive attributes of the rehabilitation rather than thenegative

Present time rather than the pastProcess and what needs to be done on a day-to-day

basis to enhance recoveryProgress while moving through the rehabilitation

program

The patient also must avoid being distracted during the ex-ercise session. Too often, distractions in the room (noise,talking, or music) can result in the individual redirectinghis or her eyes and attention toward something else ratherthan internally focusing on the exercise. It is important tolearn to control the eyes and only process benecial infor-mation, such as instructions on how to complete the exer-cise. The use of keywords and rehabilitation imagery alsomay be helpful. For example, if muscle tension is present,a keyword might be relax, or the individual could imagine

the muscle relaxing and elongating. Each of these cueshelps focus the patient to the task at hand.

Pain ManagementPain is the most debilitating obstacle to overcome inrehabilitation. It can have signicant physical, psycholog-ical, and emotional effects on the individual. Physicallyactive individuals must be able to differentiate betweenbenign and harmful pain. Benign pain is usually charac-terized as dull, generalized, not long-lasting after exer-tion, and not associated with swelling, localized tender-ness, or long-term soreness. In contrast, harmful pain issharp, localized to the injury site, experienced during andpersisting after exertion, and usually is associated withswelling, localized tenderness, and prolonged soreness.

Although pain can be controlled with medication,individuals can use nonpharmacologic means to controlpain in two manners, namely pain reduction and painfocusing (Box 8.3). Pain reduction techniques (e.g., mus-cle relaxation training, deep breathing, meditation, andtherapeutic massage) directly affect the physiologic

C h a p t e r 8 Therapeutic Exercise 195

B O X 8 . 3

Pain Management TechniquesPAIN REDUCTIONDeep breathing Emphasize slow, deep,

rhythmical breathingMuscle relaxation Passive or progressive

relaxationMeditation Repetitive focusing on

mantra or breathingTherapeutic massage Manual manipulation of

muscles, tendons, and liga-ments (see Chapter 6)

PAIN FOCUSINGExternal focus Listening to relaxing or

inspiring music; watching a movie; playing chess

Soothing imagery Generating calming images (lying on a beach, oating in space)

Neutral imaginings Imagining playing chess orbuilding a model airplane

Rhythmic cognitive Saying the alphabet activity backward; meditation

Pain acknowledgment Giving pain a hot color, such as red, then changing it to a less painful cool color, such as blue

Dramatic coping Seeing pain as part of an epic challenge to overcomeinsurmountable odds

Situational assessment Evaluating the causes of painto take steps to reduce it

aspects of pain by decreasing the actual amount of painthat is present. Pain focusing directs attention onto (asso-ciation) or away from (dissociation) the pain by reducingor altering the perception of pain. Strategies for focusingpain include external focus, such as emotionally power-ful or intellectually absorbing activities, pleasant or neu-tral imaging, rhythmic cognitive activity, dramatic coping,and situational assessment (7).

Interventions

Knowing that an individual may be very concerned aboutthe physical, psychological, social, and performance ram-ications of his or her injury, the therapist can help theindividual confront and overcome the concerns by usinga variety of techniques. The more common techniquesare discussed in the following.

Cognitive RestructuringThe therapist should recognize when negative thinkingcreeps into the rehabilitation process. By restructuring themanner in which the patient views the process, the neg-ative effects can be limited. For example, if a patient isdistressed over the anticipated length of time the exerciseprogram will continue, the therapist can point out waysthat the injury can allow the individual time to rest andcatch up with studies, complete other projects that havebeen neglected, or simply re-evaluate priorities and enjoythe absence of pressure from constant training and com-petition.

Concentration SkillsSuccess upon return to sport can be enhanced by teach-ing the individual ways to focus on skills that help over-come negative progress. Eating correctly, getting plentyof rest, effectively managing time, and avoiding situationsthat may lead to reinjury can all help accomplish certaingoals during the rehabilitation program.

Condence TrainingThe patient should be encouraged to direct his or herown course of action and choose to succeed. In doingso, the patient is made aware of the internal and externalfactors that affect condence, and is taught to use thosefactors to personal benet.

Coping RehearsalUse of a performance-enhancing audiotape or videotapecan prepare the patient for challenges. The informationallows the patient to think about several issues that mayarise when he or she returns to sport participation. Thisallows the individual to focus on the issues and develop

strategies to overcome them prior to actually returning tosport participation.

ImageryImagery has long been used in the training process as away to enhance performance. Imagery involves the men-tal execution of a skill prior to actually performing theskill. In the rehabilitation process, imagery can be used tomentally practice the skills or processes that will expediteand promote a safe return to activity, such as envisioninghealing, soothing (i.e., pain management), or perform-ance (i.e., proper technique of an exercise). Imagery alsocan be enhanced by preceding it with relaxation exer-cises, such as passive or progressive relaxation. Relax-ation can reduce anxiety and the physical manifestationsof pain, and increase the vividness and control in im-agery. Mental imagery can serve to motivate the patient torealize that this technique can facilitate the individualsperformance upon return to sport activity.

Positive Self-TalkInjured individuals often express negative feelings aboutthe injury, themselves, and occasionally their coachesand teammates. These negative feelings inhibit the indi-vidual and produce a self-defeating attitude. Thesethoughts and feelings can be redirected into positive,task-oriented thoughts that direct and motivate the indi-vidual to succeed in the rehabilitation process.

The Athletic Trainers Role

The cognitive, or knowledge, appraisal and response toinjury is inuenced by the patients recognition of the in-jury, understanding of the goal adjustments, and the indi-viduals belief that he or she directly inuences the suc-cess of the exercise program. However, the athletictrainer must not negate the emotional responses that willbe exhibited throughout the exercise program. Seriouslyinjured individuals may experience a variety of fears, so-cial isolation, and loss of income or potential scholar-ships. This fear of the unknown may lead to increasedtension, anger, and depression during the exercise pe-riod. If the patient does not perceive a gradual rate of re-covery, frustration and boredom may deter a successfuloutcome. The athletic trainer should encourage the in-jured individual to develop a positive attitude by usingsocial support networks and psychological skills to man-age pain, and in doing so, direct the patients energiesinto compliance with the treatment protocols. Positiveencouragement may allow the patient to feel better aboutpushing himself or herself to a higher intensity despitediscomfort, fatigue, or pain.

It is critical that the sports medicine team include thepatient as an integral part of the rehabilitation process.

196 S E C T I O N I I Injury Assessment and Rehabilitation

This is especially important when goals are establishedthat direct the exercise program. The goals must be re-alistic and provide some means to measure progress sothe patient can perceive a gradual rate of recovery.Whenever possible, the rehabilitation program shouldmirror the individuals regular training program, includ-ing the level of intensity, frequency, and duration. Insome cases, activity modication and creativity may en-able the physically active individual to do limited exer-cise or activity with the team. This may reduce the feel-ing of isolation and being left out of daily interactionwith the coach and other players. Using graphs or chartsto document progress also can help the individual seeimprovement. The athletic trainer must develop a posi-tive professional relationship with the patient to assistthe individual in recovering physically and psychologi-cally from the injury.

Referral for Psychological Problems

Athletic trainers seldom have the extensive understandingor clinical training to handle psychological problems. In arecent survey of athletic trainers, 90% indicated that it wasimportant to address the psychological aspects of an in-jury, but fewer than 25% had ever referred an athlete forcounseling because of an injury, and only 8% had a stan-dard procedure for referral (8). A clearly dened andwell-organized procedural plan should be developed toguide the athletic trainers actions and ensure conden-tiality (Box 8.4). Initially, criteria should be developedthat establish when psychological distress or clinical is-sues are evident. During rehabilitation, several psycho-logical factors can arise, including anxiety, depression,anger, pain, and treatment noncompliance.

As a general rule, any psychological difculty thatpersists for more than a few days and interferes with theprogress of rehabilitation should be referred to a li-censed clinical psychologist or appropriate counselingcenter. Failure to address the issues can lead to an esca-lation in the distress and frustration of the patient. Whena concern arises, the athletic trainer can telephone theclinical psychologist to discuss the symptoms and deter-mine if the individual should be referred. If a decision ismade to refer the individual, it should be discussed withthe patient to facilitate the process. It should be pointedout that the referral is a positive step in helping the pa-tient recover and return to sport participation. If possi-ble, it may be advantageous to mention the previoususe of a psychologist having helped other individualsrecover. In this manner, the patient is likely to view thereferral as a normal and positive aspect of the rehabili-tation process (8,9).

Once referral has been made, it is important for theathletic trainer to follow-up with the clinical psychologistand provide any additional information about the pa-tients progress. It is important to remember that ethicalconsiderations prohibit mental health professionals from

discussing cases with third parties unless the patient givesexplicit written permission. In cases involving athletes, itis benecial to get this permission in advance, allowingthe psychologist and athletic trainer to discuss the ath-letes condition and develop strategies to facilitate the re-habilitation process.

Locating an individual with the qualications and clin-ical experience of working in a sports rehabilitation set-ting can be difcult. It may be helpful to investigate theavailability of personnel in college and university settings.Many schools may have a clinical psychologist on staffexperienced in sports injury rehabilitation. Area hospitalsalso may be contacted, because many have a psychiatricor psychology department with a clinical psychologistspecializing in various rehabilitation issues.

The soccer player is unable to participate for the remainder ofthe season. Clearly, his emotional and psychological state willhave a direct impact on the success or failure of the therapeu-tic exercise program. Goal setting and intervention strategiescan address many psychological inuences that may inhibitthe program. If progress is inhibited for several days becauseof suspected psychological issues, the athletic trainer shouldcontact a specially trained clinical professional for referral.

C h a p t e r 8 Therapeutic Exercise 197

B O X 8 . 4

Psychological Distress Checklist forPossible ReferralDirections. Place a next to each behavior that you ob-serve on a consistent basis in an athlete. The persistentpresence of any of these behaviors may warrant a re-ferral. The more items checked, the greater the need fora referral.

1. Not accepting injury2. Denying seriousness or extent of injury3. Displaying depression4. Displaying anger5. Displaying apprehension or anxiety6. Failing to take responsibility for own

rehabilitation7. Not adhering to rehabilitation program8. Missing appointments9. Overdoing rehabilitation

10. Not cooperating with rehabilitation professional11. Bargaining with rehabilitation professional over

treatment or time out of competition12. Frequent negative statements about injury and

rehabilitation13. Reduced effort in physical therapy14. Poor focus and intensity in physical therapy15. Unconrmable reports of pain16. Interfering behaviors outside of rehabilitation

(e.g., using injured area)17. Inappropriate emotions18. Emotional swings

A

Reprinted with permission from Taylor (7), page 70.

DEVELOPING A THERAPEUTICEXERCISE PROGRAM

A high school soccer player has Achilles tendinitis. The indi-vidual has increased pain with active plantar exion and ac-companying muscle weakness in plantar exion. What short-and long-term goals might the athletic trainer and the athleteestablish for the therapeutic exercise program? How willprogress be measured?

In designing an individualized therapeutic exercise pro-gram, several sequential steps help identify the needs ofthe patient (Box 8.5). First, the individuals level of func-tion is assessed, including ROM, muscle strength, neuro-logic integrity, joint stability, and quality of functional ac-tivities. Second, the assessment is interpreted for thepurpose of identifying primary and secondary structuralor functional decits. Based on the specic decits, listsof short- and long-term goals are established to return theindividual safely to participation. Subsequently, an exer-cise program is developed to address each problem. Thisprocess is ongoing throughout rehabilitation. As contin-ued assessment of the exercise program occurs, alter-ations in short-term goals may result in changes in treat-ment or exercise progression. The process is dependenton the patients progress and adaptation to the therapeu-tic exercise program.

Assess the Patient

The subjective evaluation (i.e., history of the injury) isrecorded in the Subjective, or S, portion of the SOAPnote. This information should include the primary com-plaint, mechanism of injury, characteristics of the symp-toms, functional impairments, previous injuries to thearea, and family history. The objective evaluation (i.e., ob-servation and inspection, palpation, and physicalexamination tests) establishes a baseline of measurable in-formation, and is recorded in the Objective, or O, portionof the SOAP note. This information documents the visualanalysis of the injury site, symmetry and appearance,

determines the presence of a possible fracture, identiesabnormal clinical ndings in the bony and soft-tissuestructures at the injury site, and measures functional test-ing (i.e., active, passive, and resisted range of motion), lig-amentous and capsular integrity, neurologic testing, andsport-specic functional testing. In paired body segments,the dysfunction of the injured body part is always com-pared with the noninjured body part to establish standardsfor bilateral functional status.

Interpret the Assessment

When assessment is completed, the data are interpretedto identify factors outside normal limits for an individualof the same age and tness level. Primary decits orweaknesses are identied. These decits, along with sec-ondary problems resulting from prolonged immobiliza-tion, extended inactivity, or lack of intervention, areorganized into a priority list of concerns. Examples ofmajor concerns may include decreased ROM, muscleweakness or stiffness, joint contractures, sensorychanges, inability to walk without a limp, or increasedpain with activity. Physical assets are then identied todetermine the individuals present functional status. Forexample, normal gait and bilateral, equal ROM should bedocumented. From the two lists, specic problems arethen recorded in a section called the Problem List,which is a part of the Assessment, or A, portion of theSOAP note.

Establish Goals

Long-term goals are then established for the individ-uals expected level of performance at the conclusionof the exercise program and typically focus on func-tional deficits in performing activities of daily living(ADLs). These goals might include bilateral, equalrange of motion, flexibility, muscular strength, en-durance, and power; relaxation training; and restora-tion of coordination and cardiovascular endurance.Next, short-term goals are developed to address thespecific component skills needed to reach the long-term goals. The athletic trainer and patient should dis-cuss and develop the goals. The individual must feel apart of the process, because this may educate and mo-tivate the individual to work harder to attain the statedgoals. Many sport-specic factors, such as the demandsof the sport; position played; time remaining in the sea-son; regular-season versus post-season or tournamentplay; game rules and regulations regarding prostheticbraces or safety equipment; the location, nature, andseverity of injury; and the mental state of the individual,may affect goal development.

The short-term goals are developed in a graduatedsequence to address the list of problems identied duringthe assessment. For example, a high-priority short-termgoal is the control of pain, inammation, and spasm.

198 S E C T I O N I I Injury Assessment and Rehabilitation

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B O X 8 . 5

The Rehabilitation Process1. Assess the present level of function and dysfunction

from girth measurements, goniometric assessment,strength tests, neurologic assessment, stress tests,and functional activities.

2. Organize and interpret the assessment to identifyfactors outside normal limits.

3. Establish short- and long-term goals.4. Develop and supervise the treatment plan, incorpo-

rating therapeutic exercise, therapeutic modalities,and medication.

5. Reassess the progress of the plan, and adjust asneeded.

Each short-term goal should be moderately difcult, yetrealistic. Specic subgoals should include an estimatedtime table needed to attain that goal. These subgoals aretime dependent, but not xed, because it is important totake into consideration individual differences in preinjurytness and functional status, severity of injury, motivationto complete the goals, and subsequent improvement.Constant reinforcement from the athletic trainer toachieve the subgoals can be an incentive to continuallyprogress toward the long-term goals. Long- and short-term goals may be recorded in the Assessment, or A, por-tion of the note; however, many athletic trainers chooseto begin the treatment plan, or P, portion of the note withthe objectives. Possible short-term goals for the injuredsoccer player can be seen in Box 8.6.

Develop and Supervise the Treatment Plan

Any therapeutic exercise and therapeutic modality usedto achieve the goals is recorded in the Plan, or P, sectionof the note, along with any medications prescribed by thephysician. In order to return the individual safely to par-ticipation, the therapeutic exercise program is dividedinto four phases. The termination of one phase and initi-ation of the next may overlap. However, each phase hasa specic role. In phase one, the inammatory response,pain, swelling, and ecchymosis are controlled. Phase tworegains any decits in ROM at the affected joint and be-gins to restore proprioception. Phase three regains mus-cle strength, endurance, and power in the affected limb.Phase four prepares the individual to return to activityand includes sport-specic skill training, regaining coor-dination, and improving cardiovascular conditioning.These phases and their expected outcomes are discussedin more detail later in the chapter. Box 8.7 lists the vari-ous phases of a therapeutic exercise program.

Each phase of the exercise program is supervised anddocumented. In addition, progress notes are completedon a weekly or biweekly basis. In many health care set-tings, these records are also used for third-party reim-bursement of services rendered. They also provide docu-mentation of services provided to an individual shouldlitigation occur.

Reassess the Progress of the Program

Short-term goals should be exible enough to accommo-date the progress of the individual. For example, if thera-peutic modalities or medications are used, and the indi-vidual attains a short-term goal sooner than expected, anew short-term goal should be written. It is possible thatsome conditions, such as edema, hemorrhage, musclespasm, atrophy, or infection, may impede the healingprocess and delay attaining a short-term goal. Periodicmeasurement of girth, ROM, muscle strength, endurance,power, and cardiovascular tness determine whetherprogress occurs. If progress is not seen, the individualshould be re-evaluated. The athletic trainer must deter-mine if the delay is caused by physical problems, non-compliance, or psychological inuences, necessitatingreferral to the appropriate specialist (e.g., physician orclinical psychologist). The individual then can continueto progress through the short-term goals until the long-term goals are attained, and the individual is cleared forfull activity.

Long-term goals for the soccer player might include: pain-freebilateral ROM, muscle strength, endurance, and power; main-tenance of cardiovascular endurance; restoration of normaljoint biomechanics; increased proprioception and coordina-tion; restoration of bilateral function of ADLs; and pain-free,unlimited motion in sport-specic skills. Short-term goals arelisted in Box 8.6.

C h a p t e r 8 Therapeutic Exercise 199

B O X 8 . 6

Short-Term GoalsWeek Goals

1 Control inammation, pain, and swelling inthe right Achilles tendon region.

Restore bilateral active range of motion(ROM) and passive range of motion(PROM), as tolerated.

Protect the involved area, and decrease activitylevel.

Maintain strength at the knee, ankle, and foot.Maintain cardiovascular endurance with

weight-bearing exercise.2 Restore full bilateral AROM and PROM at the

ankle.Initiate strengthening exercises for the af-

fected lower leg.Restore bilateral strength at the knee, ankle,

and foot.Maintain cardiovascular endurance and gen-

eral body strength.2-3 Improve strength of plantar exors from fair

to good.Maintain full ROM at the knee, ankle, and foot.Improve cardiovascular endurance.Begin sport-specic functional patterns with

no resistance.3-4 Increase muscle strength, endurance, and

power in the lower leg.Improve cardiovascular endurance.Restore sport-specic functional patterns with

moderate resistance.Begin functional return to activity with neces-

sary modication.4-5 Improve general body strength, endurance,

and power.Improve cardiovascular endurance.Increase speed and resistance on sport-

specic skills.Return to full functional activity as tolerated.

A

PHASE ONE: CONTROLLINGINFLAMMATION

The soccer player has pain and tenderness over the distal por-tion of the Achilles tendon, and weakness in active plantarexion. Consistent with acute care protocol, a crushed icepack was applied to the area. Would it be appropriate to beginany rehabilitation exercises during this initial phase of injurymanagement?

Phase one of the exercise program begins immediatelyafter injury assessment. The primary goal is to controlinammation by limiting hemorrhage, edema, effusion,muscle spasm, and pain. The individual can move intophase two when the following criteria have beenattained:

Control of inammation with minimal edema,swelling, muscle spasm, and pain

Range of motion, joint exibility, muscularstrength, endurance, and power are maintained inthe general body

Cardiovascular tness is maintained at the prein-jury level

Collagenous scar formation, a natural component of the re-pair and regeneration of injured soft tissue, is less efcientand tolerant of tensile forces than the original mature tissue.

The length of the inammatory response is a key factor thatinuences the ultimate stability and function of scar tissue.The longer the inammatory process progresses, the morelikely the resulting scar tissue will be less dense and weakerin yielding to applied stress. Furthermore, immobilizationfor more than 2 or 3 weeks may lead to joint adhesions thatinhibit muscle ber regeneration. Therefore, all inamma-tory symptoms need to be controlled as soon as possible.PRICE, a well-known acronym for protect, restrict activity,ice, compression, and elevation, is used to reduce acutesymptoms at an injury site.

Control of Inammation

Following trauma, hemorrhage and edema at the injurysite lead to a pooling of tissue uids and blood productsthat increases pain and muscle spasm. The increasedpressure decreases blood ow to the injury site, leading tohypoxia (i.e., deciency of oxygen). As pain continues,the threshold of pain is lowered. These events lead to thecyclical pattern of pain-spasm-hypoxia-pain. For this rea-son, cryotherapy (i.e., ice, compression, and elevation) ispreferred during the acute inammation to decrease cir-culation, cellular metabolism, the need for oxygen, andthe conduction velocity of nerve impulses to break thepain-spasm cycle. An elastic compression wrap can de-

200 S E C T I O N I I Injury Assessment and Rehabilitation

B O X 8 . 7

The Therapeutic Exercise ProgramPhase One: Control Inammation

Control inammatory stage and minimize scar tissue with cryotherapy using PRICE principles (protect, restrict activity, ice, compression, and elevation).

Instruct patient on relaxation and coping techniques. Maintain range of motion (ROM), joint exibility, strength, endurance, and power in the unaffected body parts. Maintain cardiovascular endurance.

Phase Two: Restore Motion Restore ROM to within 80% of normal in the unaffected limb. Restore joint exibility as observed in the unaffected limb. Begin proprioceptive stimulation through closed isotonic chain exercises. Begin pain-free, isometric strengthening exercises on the affected limb. Begin unresisted, pain-free functional patterns of sport-specic motion. Maintain muscular strength, endurance, and power in unaffected muscles. Maintain cardiovascular endurance.

Phase Three: Develop Muscular Strength, Power, and Endurance Restore full ROM and proprioception in the affected limb. Restore muscular strength, endurance, and power using progressive resisted exercise. Maintain cardiovascular endurance. Initiate minimal-to-moderate resistance in sport-specic functional patterns.

Phase Four: Return to Sport Activity Analyze skill performance, and correct biomechanical inefciencies in motion. Improve muscular strength, endurance, and power. Restore coordination and balance. Improve cardiovascular endurance. Increase sport-specic functional patterns, and return to protected activity as tolerated.

Q

crease hemorrhage and hematoma formation, yet still ex-pand in cases of extreme swelling. Elevation uses gravityto reduce pooling of uids and pressure inside the venousand lymphatic vessels, to prevent uid from ltering intosurrounding tissue spaces. The result is less tissue necro-sis and local waste, leading to a shorter inammatoryphase. Field Strategy 8.1 explains acute care of soft-tis-sue injuries using the PRICE principle.

Cryotherapy, intermittent compression, and electricalmuscle stimulation (EMS) may be used to control hemor-rhage and eliminate edema. Electrical therapy also hasbeen shown to decrease pain and muscle spasm,strengthen weakened muscles, improve blood ow to anarea, and enhance the healing rate of injured tendons.Transcutaneous electrical nerve stimulation (TENS) alsomight be used to limit pain (see Chapter 7). The modalityof choice is determined by the size and location of the in-jured area, availability of the modality, and preference ofthe supervising health care provider. A decision to dis-continue treatment and move to another modality shouldbe based on the cessation of inammation. Placing theback of the hand over the injured site shows any temper-ature change as compared with an uninjured area. In-creased heat may indicate that inammation and edemaare still present. A cooler area may indicate diminishedcirculation in an area.

Effects of Immobilization

The effects of immobilization on the various tissues of thebody have been extensively covered in the literature. It iswell accepted that muscle tension, muscle and ligamentatrophy, decreased circulation, and loss of motion pro-long the repair and regeneration of damaged tissues.

MuscleImmobilization can lead to a loss of muscle strengthwithin 24 hours. This is manifested with decreases in mus-cle ber size, total muscle weight, mitochondria (energysource of the cell) size and number, muscle tension pro-duced, and resting levels of glycogen and ATP (adenosinetriphosphate), which reduces muscle endurance. Motornerves become less efcient in recruiting and stimulatingmuscle bers. Immobilization also increases muscle fati-gability as a result of decreased oxidative capacity. Therate of loss appears to be more rapid during the initialdays of immobilization; however, after 5 to 7 days, the lossof muscle mass diminishes (10). Although both slow-twitch (type I) and fast-twitch (type II) muscle bers atro-phy, it is generally accepted that there is a greater degen-eration of slow-twitch bers with immobilization. Musclesimmobilized in a lengthened or neutral position maintain

C h a p t e r 8 Therapeutic Exercise 201

F I E L D S T R A T E G Y 8 . 1 Acute Care of Soft-Tissue Injuries

ICE APPLICATION Apply crushed ice for 30 minutes directly to the skin (40 minutes for a large muscle

mass such as the quadriceps). Ice applications should be repeated every 2 hours when awake (every hour if the

athlete is active), and may extend to 72 hours postinjury. Skin temperature can indicate when acute swelling has subsided. For example, if the

area (compared bilaterally) feels warm to the touch, swelling continues. If in doubt, itis better to extend the time of a cold application.

COMPRESSION On an extremity, apply the wrap in a distal-to-proximal direction to avoid forcing

extracellular uid into the distal digits. Take a distal pulse after applying the wrap to ensure the wrap is not overly tight. Felt horseshoe-pads placed around the malleolus may be combined with an elastic

wrap or tape to limit ankle swelling. Maintain compression continuously on the injury for the rst 24 hours.

ELEVATION Elevate the body part 6 to 10 inches above the level of the heart. While sleeping, place a hard suitcase between the mattress and box spring, or place

the extremity on a series of pillows.

RESTRICT ACTIVITY AND PROTECT THE AREA If the individual is unable to walk without a limp, t the person for crutches and

apply an appropriate protective device to limit unnecessary movement of the injuredjoint.

If the individual has an upper extremity injury and is unable to move the limbwithout pain, t the person with an appropriate sling or brace.

muscle weight and ber cross-sectional area better thanmuscles immobilized in a shortened position. When short-ened, the length of the bers decreases, leading to in-creased connective tissue and reduced muscle extensibil-ity. Muscles immobilized in a shortened position atrophyfaster and have a greater loss of contractile function.

Articular CartilageThe greatest impact of immobilization occurs to the articu-lar cartilage, with adverse changes appearing within 1week of immobilization. The effects depend on the lengthof immobilization, position of the joint, and joint loading.Intermittent loading and unloading of synovial joints isnecessary to ensure proper metabolic exchange necessaryfor normal function. Constant contact with opposing boneends can lead to pressure necrosis and cartilage cell (chon-drocyte) death. In contrast, noncontact between two sur-faces promotes growth of connective tissue into the joint.Diminished weight bearing, and loading and unloading,also can increase bone resorption. In general, articular car-tilage softens and decreases in thickness. Immobilizationlonger than 30 days can lead to progressive osteoarthritis.

LigamentsSimilar to bone, ligaments adapt to normal stress byremodeling in response to the mechanical demands placedon them. Stress leads to a stiffer, stronger ligament, whereasimmobilization leads to a weaker, more compliant struc-ture. This causes a decrease in the tensile strength, thus re-ducing the ability of ligaments to provide joint stability.

BoneMechanical strain on a bone affects the osteoblastic (bonecell formation) and osteoclastic (bone cell resorption)activity on the bone surface. The effects of immobilizationon bone, accordingly, are similar to other connective tis-sues. Limited weight-bearing and muscle activity lead tobone loss, and can be detected as early as 2 weeks afterimmobilization (10). As immobilization time increases,bone resorption occurs, resulting in the bones becomingmore brittle and highly susceptible to fracture. Disuse atro-phy appears to increase bone loss at a rate ve to 20 timesgreater than that resulting from metabolic disorders affect-ing bone (11). Therefore, nonweight-bearing immobiliza-tion should be limited to as short a time as possible.

Effects of Remobilization

Early controlled mobilization can speed the healingprocess. Bone and soft tissue respond to the physicaldemands placed on them, causing the formation of colla-gen to remodel or realign along the lines of stress, thuspromoting healthy joint biomechanics (Wolffs law).Continuous passive motion (CPM) can prevent joint

adhesions and stiffness, and decrease joint hemarthrosis(blood in the joint) and pain. Early motion, and loadingand unloading of joints, through partial weight-bearingexercise maintain joint lubrication to nourish articular car-tilage, menisci, and ligaments. This leads to an optimalenvironment for proper collagen bril formation. Tissuesrecover at different rates with mobilization; musclerecovers faster, and articular cartilage and bone respondleast favorably.

MuscleMuscle regeneration begins within 3 to 5 days aftermobilization. Both fast-twitch and slow-twitch musclebers can completely recover after 6 weeks. Muscle con-tractile activity rapidly increases protein synthesis. How-ever, maximal isometric tension may not return to normaluntil 4 months after mobilized activity. The use of elec-trotherapy (i.e., EMS) may be helpful in re-educatingmuscles, limiting pain and spasm, and decreasing effu-sion through the pumping action of the contracting mus-cle. Unfortunately, neither EMS nor isometric exercise hasbeen shown to prevent disuse atrophy.

Articular CartilageThe effects of immobilization, whether there is contact orloss of contact between joint surfaces, can adverselyinterfere with cartilage nutrition. Articular cartilage gener-ally responds favorably to mechanical stimuli, with struc-tural modications noted after exercise. Soft-tissuechanges are reversible if immobilization does not exceed30 days. These structural changes may not be reversible ifimmobilization exceeds 30 days.

LigamentsThe bone-ligament junction recovers slower than themechanical properties in the midportion of the ligament.In addition, other nontraumatized ligaments weaken withdisuse. Recovery depends on the duration of immobiliza-tion. Studies have shown that, following 12 weeks ofimmobilization, there was a recovery of 50% of normalstrength in a healing ligament after 6 months, 80% after 1year, and 100% after 1 to 3 years, depending on the type ofstresses placed on the ligament and on the prevention ofrepeated injury (12). Although the properties of ligamentsreturn to normal with remobilization, the bone-ligamentjunction takes longer to return to normal. This factor mustbe considered when planning a rehabilitation program.

BoneAlthough bone lost during immobilization may beregained, the period of recovery can be several timesgreater than the period of immobilization. In disuse os-teoporosis, a condition involving reduced quantity of

202 S E C T I O N I I Injury Assessment and Rehabilitation

bone tissue, bone loss may not be reversible upon remo-bilization of the limb. Isotonic and isometric exercisesduring the immobilization period can decrease somebone loss and can hasten recovery after returning to anormal loading environment.

Protection After Injury

The type of protection selected and length of activitymodication depend on injury severity, structures dam-

aged, and the philosophy of the supervising health careprovider. Several materials can be used to protect thearea, including elastic wraps, tape, pads, slings, hingedbraces, splints, casts, and crutches. Many of these itemswere discussed and illustrated in Chapter 4. If an individ-ual cannot walk without pain or walks with a limp,crutches should be recommended. Proper crutch ttingand use are summarized in Field Strategy 8.2.

Restricted activity does not imply cessation of activitybut simply means relative rest, decreasing activity to a

C h a p t e r 8 Therapeutic Exercise 203

F I E L D S T R A T E G Y 8 . 2 Fitting and Using Crutches and Canes

FITTING CRUTCHES

1. Have the individual stand erect in at shoes with the feet close together.

2. Place the crutch tip 2 inches in front, and 6 inches from the outer sole, of the shoe.

3. Adjust crutch height to allow a space of about 2 nger widths between the crutch padand the axillary skin fold, to avoid undue pressure on neurovascular structures.

4. Adjust the hand grip so the elbow is exed 25 to 30, and is at the level of the hipjoint (greater trochanter).

FITTING FOR A CANE

1. Place the individual in the same position as above. Adjust the hand grip so the elbowis exed at 25 to 30, and is at the level of the hip joint (greater trochanter).

SWING THROUGH GAIT (NONWEIGHT-BEARING)

1. Stand on the uninvolved leg. Lean forward and place both crutches and the involvedleg approximately 12 to 24 inches in front of the body.

2. Body weight should rest on the hands, not the axillary pads.

3. With the good leg, step through the crutches as if taking a normal step. Repeatprocess.

4. If possible, the involved leg should be extended while swinging forward to preventatrophy of the quadriceps muscles.

THREE-POINT GAIT (PARTIAL WEIGHT BEARING)

1. This is indicated when one extremity can support the body weight, and the injuredextremity is to be touched down, or to bear weight partially.

2. As tolerated, place as much body weight as possible onto the involved leg, taking therest of the weight on the hands.

3. Make sure a good heel-toe technique is used, whereby the heel strikes rst, then theweight is shifted to the ball of the foot.

4. Increase the amount of weight bearing by decreasing the force transferred through thearms; mimic a normal gait.

GOING UP AND DOWN STAIRS

1. Place both crutches under the arm opposite the handrail.

2. To go up the stairs, step up with the uninvolved leg while leaning on the rail.

3. To go down the stairs, place the crutches down on the next step and step down withthe involved leg.

USING ONE CRUTCH OR CANE

1. Place one crutch or cane on the uninvolved side and move it forward with the involvedleg.

2. Do not lean heavily on the crutch or cane.

level below that required in sport, but tolerated by the re-cently injured tissue or joint. Detraining, or loss of thebenets gained in physical training, can occur after only 1to 2 weeks of nonactivity, with signicant decreases meas-ured in both metabolic and working capacity (13).Strengthening exercises in a weight-lifting program can bealternated with cardiovascular exercises such as jogging orswimming, or use of a stationary bike, or upper body er-gometer (UBE). These exercises can prevent the individ-ual from experiencing depression as a result of inactivity,and can be done simultaneously with phase one exercisesas long as the injured area is not irritated or inamed.

After following acute care protocol in treating the Achilles ten-don injury, early controlled mobilization, pain-free range-of-motion exercises at the ankle, and general load-bearing,strengthening, and cardiovascular exercises may be com-pleted as long as the injured area is not irritated.

PHASE TWO: RESTORATION OF MOTION

It is now 4 days postinjury. The acute inammatory symptomshave subsided. What exercises can be used to increase exi-bility and strength in the Achilles tendon? Are there anymodalities that could be used to supplement the exerciseprogram?

Phase two begins immediately after inammation is con-trolled. This phase focuses on restoring ROM and exi-bility at the injured site as well as continuing to maintaingeneral body strength and cardiovascular endurance. Thephase may begin as early as 4 days after the injury, whenswelling has stopped, or may have to wait for severalweeks. The injured site may still be tender to touch, butit is not as painful as in the earlier phase. Also, pain ismuch less evident on passive and active ROM. If the pa-tient is in an immobilizer or splint, remove the splint fortreatment and exercise. The splint then can be replacedto support and protect the injured site. The individual canmove into phase three when the following criteria havebeen completed:

Inammation and pain are under control. Range of motion is within 80% of normal in the

unaffected limb. Bilateral joint exibility is restored and propriocep-

tion is regained. Cardiovascular endurance and general body

strength are maintained at the preinjury level.

Assessment of normal ROM should be done with agoniometer on the paired, uninjured joint (see Chapter 5).Cryotherapy may be used prior to exercise, to decreaseperceived pain, or EMS or thermotherapy may be used towarm the tissues and increase circulation to the region.When the tissue is warmed, friction massage or joint mo-bilization may be helpful to break up scar tissue to regainnormal motion.

Progression in this phase begins gradually with restora-tion of ROM, proprioception, and total joint exibility(Box 8.8). Prolonged immobilization can lead to muscleslosing their exibility and assuming a shortened position,referred to as a contracture. Connective tissue aroundjoints has no contractile properties. Connective tissue issupple and elongates slowly with a sustained stretch,However, similar to muscle tissue, it adaptively shortens ifimmobilized. Connective tissue and muscles may belengthened through passive and active stretching, andproprioceptive neuromuscular facilitation (PNF) exercises.

Passive Range of Motion

Two types of movement must be present for normalmotion to occur about a joint. Physiologic motion, meas-ured by a goniometer, occurs in the cardinal movementplanes of exion-extension, abduction-adduction, androtation. Accessory motion, also referred to asarthrokinematics, is involuntary joint motion thatoccurs simultaneously with physiologic motion, but can-not be measured precisely. Accessory movements involvethe spinning, rolling, or gliding of one articular surfacerelative to another. Normal accessory movement must bepresent for full physiologic ROM to occur. If any acces-sory motion component is limited, normal physiologicmotion will not occur.

Limited passive range of motion (PROM) is calledhypomobility. These discrete limitations of motion pre-vent pain-free return to competition and predispose anindividual to microtraumatic injuries that reiname theoriginal injury. Restoring PROM prevents degenerativejoint changes and promotes healing.

Joint MobilizationJoint mobilization utilizes various oscillating forcesapplied in the open packed position to free up stiffjoints. The oscillations produce several key benets in thehealing process, including:

Breaking up adhesions and relieve capsularrestrictions

Distracting impacted tissues Increasing lubrication for normal articular cartilage

204 S E C T I O N I I Injury Assessment and Rehabilitation

Q

A

B O X 8 . 8

Factors that Limit Joint Motion Bony block Joint adhesions Muscle tightness Tight skin or an inelastic dense scar tissue Swelling Pain Fat or other soft tissues that block normal motion

Reducing pain and muscle tension Restoring full ROM and facilitate healing

However, joint mobilization is contraindicated in severalinstances (Box 8.9). Maitland described ve grades ofmobilization (14):

Grade I: A small-amplitude movement at the begin-ning of the ROM. Used when pain and spasm limitmovement early in the ROM.

Grade II: Large-amplitude movement within themid-ROM. Used when spasm limits movementsooner with a quick oscillation than with a slowone, or when slowly increasing pain restrictsmovement halfway into the range.

Grade III: A large-amplitude movement up to thepathologic limit in the ROM. Used when pain andresistance from spasm, inert tissue tension, or tis-sue compression limit movement near the end ofthe range.

Grade IV: A small-amplitude movement at the veryend of the ROM. Used when resistance limitsmovement in the absence of pain and spasm.

Grade V: A small-amplitude, quick thrust deliveredat the end of the ROM, usually accompanied by apopping sound called a manipulation. Used whenminimal resistance limits the end of the range.Manipulation is most effectively accomplished bythe velocity rather than the force of the thrust.

In performing joint mobilization, the individual is placed ina comfortable position with the joint placed in an openpacked position. This allows the surrounding tissues to be aslax as possible and the intracapsular space to be at its great-est. The direction of force is dependent on the contour ofthe joint surface of the structure being mobilized. The con-cave-convex rule states that, when the concave surface isstationary and the convex surface is mobilized, a glide of theconvex segment should be in the direction opposite to therestriction of joint movement. If the convex articular surfaceis stationary and the concave surface is mobilized, gliding ofthe concave segment should be in the same direction as the

restriction of joint movement (Figure 8.2). Typical treat-ment involves a series of three to six mobilizations lasting upto 30 seconds, with one to three oscillations per second (14).Figure 8.3 demonstrates joint mobilization technique.

FlexibilityFlexibility is the total ROM at a joint that occurs pain-free in each of the planes of motion. Joint exibility is acombination of normal joint mechanics, mobility of softtissues, and muscle extensibility. For example, the hipjoint may have full passive ROM, but when doing active

C h a p t e r 8 Therapeutic Exercise 205

B O X 8 . 9

Contraindications to Joint MobilizationAcute inammationAdvanced osteoarthritisCongenital bone deformitiesFracturesHypermobilityInfectionsMalignancyNeurologic signsOsteoporosisPremature stressing of surgical structuresRheumatoid arthritisVascular disease

Figure 8.2. Concave-convex rule. If the joint surface to bemoved is convex, mobilize it opposite the direction of motion restric-tion. If the joint surface of the body segment being moved is con-cave, move it in the direction of motion restriction.

Figure 8.3. Joint mobilization technique. Posteriorhumeral glide uses one hand to stabilize the humerus at the elbowwhile the other hand glides the humeral head in a posterior direction(indicated by the arrow) to increase exion and medial rotation atthe joint.

hip exion from a seated position, as in touching onestoes, resistance from tight hamstrings may limit full hipexion. This type of resistance may be generated fromtension in muscle bers or connective tissue.

Muscles contain two primary proprioceptors that can bestimulated during stretching, namely the muscle spindles

and Golgi tendon organs. Because muscle spindles lieparallel to muscle bers, they stretch with the muscle(Figure 8.4). When stimulated, the spindle sensory bersdischarge and through reex action in the spinal cord ini-tiate impulses to cause the muscle to contract reexively,thus inhibiting the stretch. Muscles that perform the

206 S E C T I O N I I Injury Assessment and Rehabilitation

Figure 8.4. Anatomy of the muscle spindle and Golgi tendon organ.

desired movement are called agonists. Unlike musclespindles, Golgi tendon organs are connected in a seriesof bers located in tendons and joint ligaments, andrespond to muscle tension rather than length. If thestretch continues for an extended time (i.e., over 6 to8 seconds), the Golgi tendons are stimulated. This stimu-lus, unlike the stimulus from muscle spindles, causes a re-ex inhibition in the antagonist muscles. This sensorymechanism protects the musculotendinous unit from ex-cessive tensile forces that could damage muscle bers.

Flexibility can be increased through ballistic or staticstretching techniques. Ballistic stretching uses repeti-tive bouncing motions at the end of the available ROM.Muscle spindles are repetitively stretched, but becausethe bouncing motions are of short duration, the Golgitendon organs do not re. As such, the muscles resist re-laxation. Because generated momentum may carry thebody part beyond normal ROM, the muscles beingstretched often remain contracted to prevent over-stretching, leading to microscopic tears in the musculo-tendinous unit. In a static stretch, movement is slowand deliberate (Box 8.10). Golgi tendon organs are ableto override impulses from the muscle spindles, leadingto a safer, more effective muscle stretch. When the mus-cle is stretched to the point where a mild burn is felt,

joint position is maintained statically for about 15 sec-onds and repeated several times. This technique is oftenused with vapo-coolant sprays to desensitize myofascialtrigger points.

Proprioceptive neuromuscular facilitation (PNF)promotes and hastens the response of the neuromuscularsystem through stimulation of the proprioceptors. Thepatient is taught how to perform the exercise throughcutaneous and auditory input. The individual often looksat the moving limb while the examiner moves the limbfrom the starting to terminal position. Verbal cues are usedto coordinate voluntary effort with reex responses.Words such as push or pull are commonly used to askfor an isotonic contraction. Hold may be used for an iso-metric or stabilizing contraction, followed by relax. Man-ual (cutaneous contact) helps to inuence the direction ofmotion and facilitate a maximal response, because reexresponses are greatly affected by pressure receptors.

These exercises increase exibility in one musclegroup (i.e., agonist), and simultaneously improvestrength in another muscle group (i.e., antagonist). Fur-thermore, if instituted early in the exercise program, PNFstretches can aid in elongating scar tissue. As scar tissuematures and increases in density, it becomes less recep-tive to short-term stretches and may require prolongedstretching to achieve deformation changes in the tissue.

Proprioceptive neuromuscular facilitation techniquerecruits muscle contractions in a coordinated pattern asagonists and antagonists move through a ROM. One tech-nique utilizes active inhibition whereby the musclegroup reexively relaxes prior to the stretching maneu-ver. Common methods include contract-relax, hold-relax,and slow reversal-hold-relax (Box 8.11). The examinerstabilizes the limb to be exercised. Alternating contrac-tions and passive stretching of a group of muscles arethen performed (Figure 8.5). Contractions may be heldfor 3, 6, or 10 seconds, with similar results obtained (15).

A second technique, known as reciprocal inhibition,uses active agonist contractions to relax a tight antagonistmuscle. In this technique, the individual contracts themuscle opposite the tight muscle, against resistance. Thiscauses a reciprocal inhibition of the tight muscle, leadingto muscle lengthening. An advantage to PNF exercise isthe ability to stretch a tight muscle that may be painful orin the early stages of healing. In addition, movement canoccur in a single plane or diagonal pattern that mimics ac-tual skill performance.

Active Assisted Range of Motion

Frequently, PROM at the injured joint may be greater thanactive motion, perhaps because of muscle weakness. Aperson may be able to sit on top of a table and slide theleg across the tabletop away from the body to fullyextend the knee. However, if the individual sits at theedge of the table with his or her legs hanging over theedge then attempts to straighten the knee, the individual

C h a p t e r 8 Therapeutic Exercise 207

B O X 8 . 1 0

Guidelines for Static Stretching toImprove Flexibility1. Stretching is facilitated by warm body tissues; there-

fore, a brief warm-up period is recommended. If it isnot possible to jog lightly, stretching could be per-formed after a supercial heat treatment.

2. In the designated stretch position, position yourselfso a sensation of tension is felt.

3. Do not bounce; hold the stretch for 10 to 30 secondsuntil a sense of relaxation occurs. Be aware of thefeeling of relaxation, or letting go. Repeat thestretch six to eight times.

4. Breathe rhythmically and slowly. Exhale during thestretch.

5. Do not be overly aggressive in stretching. Increasedexibility may not be noticed for 4 to 6 weeks.

6. If an area is particularly resistant to stretching, part-ner stretching or proprioceptive neuromuscular fa-cilitation may be used.

7. Avoid vigorous stretching of tissues in the followingconditions: After a recent fracture After prolonged immobilization With acute inammation or infection in or around

the joint With a bony block that limits motion With muscle contractures or when joint adhesions

limit motion With acute pain during stretching

may be unable to move the limb voluntarily into fullextension. In this situation, normal joint mechanics existand full PROM is present. However, in order to attain fullactive ROM the individual may require some assistancefrom an athletic trainer, a mechanical device, or theopposite limb (active assisted range of motion, AAROM).Working the limb through available pain-free motion withassistance restores normal active ROM more quickly thanworking the limb within limited voluntary motion.

Active Range of Motion

Active range of motion (AROM) exercises performed bythe individual enhance circulation through a pumpingaction during muscular contraction and relaxation. Full,pain-free, AROM need not be achieved before strength ex-ercises are initiated, but certain skills and drills requiringfull functional motion, such as throwing, full squats, or cer-tain agility drills, must wait until proper joint mechanicsare restored. Active range of motion exercises should berelatively painless, and may be facilitated during certainstages of the program by completing the exercises in awhirlpool to provide an analgesic effect and relieve thestress of gravity on sensitive structures. Examples of AROM

exercises include spelling out the letters of the alphabetwith the ankle, and using a wand or cane with the upperextremity to improve joint mobility. Field Strategy 8.3illustrates selected ROM exercises.

Resisted Range of Motion

Resisted range of motion (RROM) may be either static ordynamic. Static movement is measured with an isometricmuscle contraction, and can be used during phases 1 and2 of the exercise program in a pain-free arc of motion.Dynamic resisted motion (dynamic strengthening) is dis-cussed in the next section.

Isometric training measures a muscles maximumpotential to produce static force. The muscle is at a con-stant tension while muscle length and joint angle remainthe same. For example, standing in a doorway and push-ing outward against the door frame produces a maximalmuscle contraction, but joints of the upper extremity donot appear to move. Isometric exercise is useful whenmotion: (1) is contraindicated by pathology or bracing;(2) is limited because of muscle weakness at a particularangle, called a sticking point; or (3) when a painful arcis present. Isometric strength exercises are the least ef-fective training method because, although circumferenceand strength increase, strength gains are limited to arange of 10 on either side of the joint angle. An adverse,rapid increase in blood pressure occurs when the breathis held against a closed glottis, and is referred to as theValsalva effect. This can be avoided with properbreathing. In performing an isometric contraction, amaximal force is generated against an object, such as theexaminers hand, for about 10 seconds and repeated 10times per set. Contractions, performed every 20throughout the available ROM, are called multiangle iso-metric exercises.

208 S E C T I O N I I Injury Assessment and Rehabilitation

B O X 8 . 1 1

Active Inhibition TechniquesTo stretch the hamstring group on a single leg using thethree separate proprioceptive neuromuscular facilita-tion techniques, do the following:

CONTRACT-RELAX1. Stabilize the thigh and passively ex the hip into the

agonist pattern until limitation is felt in the hamstrings.2. The individual then performs an isotonic contraction

with the hamstrings through the antagonist pattern.3. Apply a passive stretch into the agonist pattern until

limitation is felt; repeat the sequence.

HOLD-RELAX1. Passively move the leg into the agonist pattern until

resistance is felt in the hamstrings.2. The individual then performs an isometric contrac-

tion to hold the position for about 10 seconds.3. Allow the individual to relax for about 5 seconds.4. Then apply a passive stretch into the agonist pattern

until limitation is felt; repeat the sequence.

SLOW REVERSAL-HOLD-RELAX1. The individual consciously relaxes the hamstring

muscles while doing a concentric contraction of thequadriceps muscles into the agonist pattern.

2. The individual then performs an isometric contrac-tion, against resistance, into the antagonist patternfor 10 seconds.

3. Allow the individual to relax for 10 seconds.4. The individual then actively moves the body part fur-

ther into the agonist pattern; repeat the sequence

Figure 8.5. Proprioceptive neuromuscular facilitation.In performing proprioceptive neuromuscular facilitation stretchingtechniques, the athletic trainer passively stretches a muscle group.In this photo, the hip exors are being stretched. When slight ten-sion is felt, the individual isometrically contracts the muscle groupagainst resistance for 3, 6, or 10 seconds. The muscle is then pas-sively stretched again. This process is repeated four to ve times.

C h a p t e r 8 Therapeutic Exercise 209

F I E L D S T R A T E G Y 8 . 3 Range of Motion Exercises for the Lower and Upper Extremity

A. Ankle. Write out the letters of the alphabet using sweeping capital letters. Do allletters three times.

B. Achilles tendon. In a seated position, wrap a towel around the forefoot and slowlystretch the Achilles tendon.

C. Knee. In a seated position with the knee slightly exed, wrap a towel around thelower leg and slowly bring the ankle and foot toward the buttocks.

D. Hip. Lying down, bring one knee toward the chest. Repeat with the other knee.

E. Wrist or elbow. Using the unaffected hand, slowly stretch the affected hand orforearm in exion and extension.

F. Shoulder exion. With a wand or cane, use the unaffected arm to slowly raise thewand high above the head.

G. Shoulder lateral (external) rotation. With a wand or cane, use the unaffected arm toslowly do lateral (external) rotation of the glenohumeral joint.

H. Shoulder medial (internal) rotation. With a wand or cane, use the unaffected arm toslowly do medial (internal) rotation of the glenohumeral joint.

Proprioception

Proprioception is a specialized variation of the sensorymodality of touch that encompasses the sensation of jointmovement (kinesthesia) and joint position. Sensoryreceptors located in the skin, muscles, tendons, liga-ments, and joints provide input into the central nervoussystem (CNS) relative to tissue deformation. Visual andvestibular centers also contribute afferent information tothe CNS regarding body position and balance. The abilityto sense body position is mediated by cutaneous, muscle,and joint mechanoreceptors.

Joint MechanoreceptorsJoint mechanoreceptors are found in the joint capsule,ligaments, menisci, labra, and fat pads, and include fourtypes of nerve endings: Rufnis corpuscles, Golgi recep-tors, pacinian corpuscles, and free nerve endings.Rufnis corpuscles are sensitive to intra-articular pres-sure and stretching of the joint capsule. Golgi receptorsare intraligamentous and become active when the liga-ments are stressed at the end ranges of joint movement.Pacinian corpuscles are sensitive to high-frequency vibra-tion and pressure, and the free nerve endings are sensi-tive to mechanical stress and the deformation and loadingof soft tissues that comprise the joint.

Muscle MechanoreceptorsAs mentioned, the receptors found in muscle and ten-dons are the muscle spindles and Golgi tendon organs.Muscle spindles are innervated by both afferent andefferent bers, and can detect not only muscle length, butmore importantly, the rate of change in muscle length.Golgi tendon organs respond to both contraction andstretch of the musculotendinous junction. If the stretchcontinues for an extended time (i.e., over 6 to 8 seconds),the Golgi tendons are stimulated, causing a reex inhibi-tion in the antagonist muscles. This sensory mechanismprotects the musculotendinous unit from excessive ten-sile forces that could damage muscle bers.

Regaining ProprioceptionBalance involves positioning the bodys center of gravityover a base of support through the integration of informa-tion received from the various proprioceptors within thebody. Even when the body appears motionless, a constantpostural sway is caused by a series of muscle contractionsthat correct and maintain dynamic equilibrium in an up-right position. When balance is disrupted, as in falling for-ward or stumbling, the response is primarily automaticand reexive. An injury or illness can interrupt the neuro-muscular feedback mechanisms. Restoration of the pro-prioceptive feedback is necessary to promote dynamicjoint and functional stability to prevent reinjury.

Proprioceptive exercises must be specic to the type ofactivity that the individual will encounter in sport participa-tion. In general, the progression of activities to develop dy-namic, reactive neuromuscular control is achieved througha progression that moves from slow speed to high speed,low force to high force, and controlled to uncontrolled ac-tivities. A patient might begin with Rombergs test, whichrequires the individual to stand with the feet together, armsat the sides, and eyes closed. The examiner looks for anytendency to sway or fall to one side. A single-leg stance test(e.g., stork stand) requires the individual to maintain bal-ance while standing on one leg for a specied time withthe eyes closed. In the next stage, with the eyes open, thepatient can progress to playing catch with a ball. This ex-ercise can be made more difcult by having the patient bal-ance on a trampoline and playing catch with a ball. Use ofa biomechanical ankle platform system (BAPS) boardmight begin with bilateral balancing and progress to one-legged balancing, dribbling a basketball, or playing catchwith a ball. Many of these exercises can be adapted to theupper extremity. An individual can begin in a push-up po-sition and shift his or her weight from one hand to another,or perform isometric or isotonic press-ups, balance on onehand, balance on a BAPS board or ball, or walk on thehands over material of different densities or heights.

Open versus Closed Kinetic Chain Exercises

A common error in developing an exercise program isfailure to assess the proximal and distal segments of theentire extremity, or kinetic chain. A kinematic chain is aseries of interrelated joints that constitute a complex mo-tor unit, constructed so that motion at one joint will pro-duce motion at the other joints in a predictable manner.Whereas kinematics describes the appearance of motion,kinetics involves the forces, whether internal (e.g., mus-cle contractions or connective tissue restraints) or external(e.g., gravity, inertia, or segmental masses) that affect mo-tion. Initially, a closed kinetic chain (CKC) was character-ized as the distal segment of the extremity in an erect,weight-bearing position, such as the lower extremitywhen a person is weight bearing. Subsequently, when thedistal segment of the extremity is free to move withoutcausing motion at another joint, such as whennonweight bearing, the system was referred to as anopen kinetic chain (OKC). When force is applied, the dis-tal segment may function independently or in unison withthe other joints. Movements of the more proximal jointsare affected by OKC and CKC positions. For example, therotational components of the ankle, knee, and hip reversedirection when moving from an OKC to CKC position.

Because of incongruities between the lower and upperextremity, particularly in the shoulder region, severalauthors have challenged the traditional denition of OKCand CKC positions (16-18). Stabilizing muscles in thescapulothoracic region produces a joint compression

210 S E C T I O N I I Injury Assessment and Rehabilitation

force that stabilizes the glenohumeral joint much in thesame manner as a CKC in the lower extremity. Althoughdebate continues on dening CKC and OKC relative to theupper extremity, there remains general agreement thatboth CKC and OKC exercises should be incorporated intoan upper and lower extremity rehabilitation program.

Injury and subsequent immobilization can affect theproprioceptors in the skeletal muscles, tendons, and joints.In rehabilitation, it is critical that CKC activities be used toretrain joints and muscle proprioceptors to respond to sen-sory input. Closed kinetic chain exercises are recom-mended for several reasons (Box 8.12). Closed kineticchain exercises stimulate the proprioceptors, increase jointstability, increase muscle coactivation, allow better utiliza-tion of the SAID (Specic Adaptations to Imposed De-mands) principle, and permit more functional patterns ofmovement and greater specicity for athletic activities.

In contrast, OKC exercises can isolate a specic musclegroup for intense strength and endurance exercises. In ad-dition, they can develop strength in very weak musclesthat may not function properly in a CKC system because

of muscle substitution. Although OKC exercises may pro-duce great gains in peak force production, the exercisesare usually limited to one joint in a single plane (unipla-nar), have greater potential for joint shear, have limitedfunctional application, and have limited eccentric andproprioceptive retraining. However, OKC exercises canassist in developing a patient-athletic trainer rapportthrough uniplanar and multiplanar manual therapeutictechniques. Figure 8.6 illustrates open and closed kineticchain exercises for the lower extremity.

When ROM has been achieved, repetition of motionthrough actual skill movements can improve coordinationand joint mechanics as the individual progresses intophase three of the program. For example, a pitcher maybegin throwing without resistance or force application infront of a mirror to visualize the action. This also canmotivate the individual to continue to progress in thetherapeutic exercise program.

In phase two, passive stretching and AROM exercises shouldbe conducted at the ankle. In particular, Achilles tendonstretching and strengthening of the plantar exors should bemajor parts of the rehabilitation plan. Cryotherapy, ther-motherapy, EMS, or massage can complement the exerciseprogram, as needed. The soccer player should be able to con-tinue many of the exercises at home to supplement the exer-cise program performed in the athletic training room.

PHASE THREE: DEVELOPINGMUSCULAR STRENGTH,ENDURANCE, AND POWER

The soccer player has regained normal ROM at the ankle andwants to start playing on an indoor soccer team. Is this a goodidea? Is reinjury likely to occur?

Phase three focuses on developing muscular strength,endurance, and power in the injured extremity as com-pared with the uninjured extremity. The individual can

C h a p t e r 8 Therapeutic Exercise 211

Q

A

B O X 8 . 1 2

Advantages of Closed Kinetic Chain Exercises It provides greater joint compressive forces. Multiple joints are exercised through weight bear-

ing and muscular contractions. Velocity and torque are more controlled. Shear forces are reduced. Joint congruity is enhanced. Proprioceptors are re-educated. Postural and dynamic stabilization mechanics are

facilitated. Exercises can work in spiral or diagonal movement

patterns.

Figure 8.6. Open- and closed-chain exercises for the lowerextremity. A, Open-chain exercise for the hamstrings. B, Closed-chainexercise for the hip and knee extensors.

move into phase four when the following criteria havebeen completed:

Bilateral ROM and joint exibility are restored. Muscular strength, endurance, and power in the

affected limb are equal or near equal to the unaf-fected limb.

Cardiovascular endurance and general bodystrength are at or better than the preinjury level.

Sport-specic functional patterns are completedusing mild-to-moderate resistance.

The individual is psychologically ready to return toprotected activity.

Muscular Strength

Strength is the ability of a muscle or group of muscles toproduce force in one maximal effort. Although staticstrength (isometric strengthening) is used during phasesone and two in a pain-free arc of motion, dynamic strength-ening is preferred in phase three of the program. Two typesof contractions occur in dynamic strength: concentric, inwhich a shortening of muscle bers decreases the angle ofthe associated joint, and eccentric, in which the muscle re-sists its own lengthening so that the joint angle increasesduring the contraction. Concentric and eccentric also maybe referred to as positive and negative work, respectively.Concentric contractions work to accelerate a limb. For ex-ample, the gluteus maximus and quadriceps muscles con-centrically contract to accelerate the body upward from a