Rehab Principles

• Principles are used to achieve goals and objectives of the exercise program

• 7 Principles of Rehab: “ATC IS IT”

Rehab Principles“A”: Avoid Aggravation

• Do not further aggravate the injury

• Exercises done incorrectly or that are administered at wrong time can worsen an injury

• Continue to progress without aggravating

• Need to know how body responds to injury, be able to determine which exercises to use & when to progress them, and be able to recognize the athlete’s responses

Rehab Principles“T”: Timing

• Rehab should begin ASAP without aggravating

• Sooner rehab begins = sooner return to play

• Following injury, some rest is necessary but too much is detrimental

• Studies show that 3-4% of strength is lost each day with immobilization; rate of recovery is much slower and not achieved in equivalent amount of time

Rehab Principles“C”: Compliance

• Key to the success of the rehab program

• Injured patient feels powerless; involving them in the rehab plan & educating them will give them more power = increased likelihood of compliance

• Inform the patient of the content and expected course of progression of the rehab program

• Compliance = consistency (regular treatment sessions, does what they are asked, completes the HEP)

Rehab Principles“I”: Individualization

• Each patient will respond differently to an injury and the rehab program

• Don’t get in the habit of comparing one patient to another

• Undetectable differences can change an individual’s response to injury

• Nonphysical variables can also influence the patient’s recovery

Rehab Principles“S”: Specific Sequencing

• A specific sequence should be followed determined by the body’s healing process

Rehab Principles“I”: Intensity

• Intensity level of rehab must challenge the patient and injured area but must not aggravate the injury

• Modify as needed

• Knowledge of progression very important

• Creativity and being able to use your imagination goes hand in hand with knowledge • will increase likelihood of patient compliance

• will make process more interesting for patient and you

Rehab Principles“T”: Total Patient

• Keep unaffected areas finely tuned• The whole body should be the focus of rehab program when patient is

injured, not just the injured area• Work on maintaining cardiovascular system at pre-injury level• Maintain the ROM, strength, coordination, and endurance of the uninjured

limbs and joints• Don’t forget the mind may need some rehab too!

Rehab Objectives

• 1) Prevent Deconditioning• Provide exercises to work CV system

• Provide exercises to work the uninvolved areas of the injured extremity

• Provide exercises for the uninvolved extremity

• 2) Rehabilitate the Injured Part• Use good judgment with knowledge to ensure safe & effective progression

• Therapeutic exercise can be used effectively to enhance & promote recovery, but can also be harmful & ineffective if used incorrectly

Rehab Goals

• Ultimate goal: return to full activity

• Return needs to be SAFE, but QUICK . . .EFFECTIVE yet EFFICIENT . . .and pursued in an AGGRESSIVE yet GUARDED manner

• Fine line between going too slowly and advancing too quickly• Program should stress the patient just enough to provide gains, not losses, with regular

progression

• Goals should be OBJECTIVE and MEASURABLE whenever possible

• Subjective goals can sometimes be made objective (i.e.: pain)

• How?

Short-Term vs. Long-Term Goals

• Need to set STG and LTG for more severe injuries that will limit participation for extended time

• LTG is the final, desired outcome of a therapeutic exercise program• Examples:

• STG provide athlete and clinician with objective goals to guide towards achieving the LTG

Short-Term vs. Long-Term Goals,Continued

• STG should be reasonable & attainable, but also challenging for the athlete

• STG should be established weekly or biweekly, depending on progress• Examples:

• LTG can be overwhelming at beginning of rehab; STG will give athlete something concrete to work towards and help boost their morale

Examination and Assessment

• Continually examine and assess injury from time injury occurs until return to normal life

• Aids in establishing LTG and STG and setting new goals along the way

Exercise and Program Progression• Good rehab program will progress in challenging yet

safe manner

• Exercise Progression• Example of strength progression: isometrics isotonics isokinetics plyometrics

• Program Progression• Designed to emphasize different types of goals as it

progresses• Example: need to achieve flexibility & ROM before strength can be achieved; need

flexibility & strength before functional activities can be introduced

Components of Therapeutic Exercise

• To be successful, rehab program must address parameters sequentially as follows:• 1) Flexibility and ROM

• 2) Strength and Muscle Endurance

• 3) Proprioception, Coordination, and Agility

• Why is this order so important?

Flexibility and ROM

• Flexibility: refers to the mobility of muscles and the length to which they can extend • If a muscle is immobilized for a period, it loses its flexibility.

• Inflexibility usually refers to the muscles, not the joints, having limited mobility

• ROM: refers to the amount of movement possible at a joint• If muscles lack flexibility, a joint may not have full ROM

• ROM also affected by mobility of joint capsule, ligaments, fascial restraints, scar tissue

Flexibility and ROM,Continued

• ROM is also affected by strength (which is why AROM and PROM measurements may be different)

• A properly designed rehab program will place priority on regaining lost ROM and flexibility first• Other parameters are based on these

• Affects the healing process

• During healing, scar tissue is laid down and as it matures, it contracts = loss of motion

Flexibility and ROM,Continued

• There is a window of opportunity during healing in which scar tissue mobility can be influenced and changed to gain ROM

• Once time frame has passed, full ROM is not likely • Example: ACL reconstruction

Muscular Strength and Muscular Endurance

• Muscular Strength: refers to maximum force that a muscle or muscle group can exert in one repetition

• Muscular Endurance: the muscle’s ability to sustain a sub-maximal force in either a static activity or a repetitive activity over time• Static: iron-cross hold in gymnastics

• Repetitive: baseball pitcher; marathon runner

Muscular Strength and Muscular Endurance, Continued

• These are obvious parameters sought after an injury, but should not be focus until ROM achieved

• Relationship between muscular strength and endurance is important

• Strength and endurance affect each other: when strength improves, there are also gains in endurance and vice versa

Proprioception, Coordination, and Agility

• A variety of factors affect these components; many other factors are affected by these components

• This is an area often neglected in rehab programs• To develop proprioception and coordination, enough flexibility and strength

must be gained• Accurate execution of sport specific skills requires that all parameters be

attained• During this stage the athlete will regain confidence to prepare for RTP

Concerns to be Addressed Prior to Return to Play (RTP)

• Physiological – Has rehabilitation progressed to the later stages of healing process?

• Pain – Has pain disappeared, or is athlete able to play within levels of pain tolerance?

• Swelling - Is there still a chance that swelling could be exacerbated by RTP?

• ROM – Is ROM adequate to allow the athlete to perform both effectively and with minimal risk of reinjury?

• Strength - Is strength, endurance, or power great enough to protect the injured structure from reinjury?

• Neuromuscular/kinesthesia -Has the athlete relearned how to use the injured body part?

• Cardiorespiratory – has the athlete been able to maintain fitness at or near the level necessary for competition?

Concerns to be Addressed Prior to Return to Play (RTP)

• Sport-specific demands- Are the demands of the sport or a specific position such that the athlete will not be at risk of reinjury?

• Functional testing - Does testing indicate the extent of recovery is sufficient to allow for successful performance?

• Accessory Equipment - Are any additional supports necessary for the athlete to RTP?

• Psychological – Is the athlete capable of returning to activity and competing at a high level without fear of reinjury?

• Education/Prevention - Does the athlete understand the importance of continuing to engage in conditioning exercises that can greatly reduce the chances of reinjury?

Return-to-Play Criteria

• Full readiness to RTP:• No pain

• No swelling

• No atrophy

• Full ROM, flexibility, strength, and endurance

• Able to perform sport-specific skills at appropriate levels

• Physician has final say on when patient is cleared

Case Study

• After a week of managing a first-degree hamstring strain, a track athlete has decided that she is ready to compete. She has no signs of inflammation. She has regained full strength and ROM. What other things should be taken into consideration before she is allowed to compete again?