Essential Considerations in Designing a rehabilitation Program for the Injured Patient William E. Prentice Rehabilitation Techniques for Sports Medicine and Athletic Training

Introduction Majority of injuries in athletics are non-life threatening Will require treatment and rehabilitation for a timely, but safe return to activity Athletic Trainer will assume primary responsibility for the design, implementation and supervision of the rehab. program Must have as complete understanding of the injury as possible Knowledge of mechanism of injury Major anatomical structures affected Degree or grade of trauma Stage or phase of injury’s tissue healing

Rehabilitation Team Rehabilitation in athletic setting requires a group effort to be most effective Athletic Trainer and A.T. students Team Physician Coach Athlete and athletes family Strength and conditioning coach Other specialist A.T. will direct athlete and facilitate communication

Rehabilitation Team A.T. is the one individual who will deal directly with the patient/athlete throughout the entire period of rehabilitation From time of injury to return to unrestricted return to activity A.T. works closely with and under direct supervision of team physician Develop and design rehabilitation and reconditioning protocols Appropriate therapeutic exercise, rehab. Equipment, manual therapy techniques, and therapeutic modalities

Rehabilitation Team Communication Athlete must always be informed and made aware of the why, when and how factors of their rehab. program Relationship takes time to develop Must build trust and rapport with athletes Must involve coach in discussions of athletes progression and athletes return to activity Can help determine what and athlete can and cant do during practice. Failure to communicate may cause misunderstanding between those involved and possibly exacerbating the athletes injury or symptoms

Philosophy of Sports Medicine Rehabilitation Approach in athletic setting is considerably different than in most other rehab. settings Competitive nature of athletics necessitates an aggressive approach to rehabilitation Competitive season is relatively short and athlete does not have the luxury of time Goal is to return the athlete to activity as soon and as safely as possible A.T. tends to play games with healing process and return athletes before complete healing has occurred “Balancing act” between not pushing athlete enough and being too aggressive Mistake in judgment may hinder the athletes return to activity

Understanding healing process Progression of rehab program must be based on the process of injury/tissue healing A.T. Must have a sound understanding of the different phases of tissue healing and apply appropriate treatment/rehab Failure to do so may interfere with tissue healing and increase the length of time required for rehabilitation, thus slowing the athletes return to activity Little can be done to speed the healing process physiologically, but many things can be done to impede healing

Understanding healing process Exercise intensity SAID Principle: Specific Adaptations to Imposed Demands When an injured structure is subjected to stresses and overloads of varying intensities, it will gradually adapt over time to whatever demands are placed on it Exercises must not be too great that they will exacerbate the injury before it has had time to adapt Exercise that is too intense can be detrimental to the rehab program Indications include an increase in swelling, pain, loss or plateau in strength and range of motion.

Understanding healing process Exercise intensity must be commensurate with tissue healing Submaximal exercise in short bouts initially, several times a day As recovery increases, the intensity of exercise increases

Understanding Psychological Aspects of Rehabilitation Psychological aspects of how athlete deals with injury are critical and often neglected factor Wide range of emotional reactions A.T. needs to develop an understanding of the psyche of each individual and adjust rehab accordingly Pain threshold, cooperation and compliance, competitiveness, denial, intrinsic and extrinsic motivation, anger, fear, guilt and ability to adjust to injury are all factors Sports psychology can also be used to improve total athletic performance

Understanding the Pathomechanics of Injury When joint or anatomical structures are injured, normal biomechanical function is compromised A.T. must have solid foundation in biomechanics and human anatomy to design effective rehab program Must be able to identify and correct postural and biomechanical dysfunctions in order to appropriately design rehab plan

Understanding the Concept of the Kinetic Chain Entire body is a kinetic chain that operates as an integrated functional unit Composed of muscular systems (muscles, tendons, fascia), articular systems and neural systems All systems function simultaneously with the others for structural and functional efficiency CNS sorts info. from these systems for neuromuscular control. If any system in kinetic chain is not working effectively, other systems are forced to adapt and compensate Can lead to tissue overload, decreased performance, and predictable patterns of injury

Understanding the Concept of the Kinetic Chain Movements in everyday activity require dynamic and postural control through multiple planes of motion and different speeds of motion Rehabilitation should focus on functional movements that integrate all components necessary to achieve optimal movement performance Concepts of muscle imbalances, myofascial adhesions, altered arthrokinematics, and abnormal neuromuscular control need to be addressed

Understanding the Concept of Integrated Functional Movement Function: Integrated, multiplanar movement that requires acceleration, deceleration and stabilization Rehab. must address all links of the kinetic chain to develop functional strength and neuromuscular efficiency Functional Strength: ability of neuromuscular system to reduce force, produce force, and dynamically stabilize the kinetic chain during functional movement in a smooth coordinated fashion

Understanding the Concept of Integrated Functional Movement Neuromuscular Efficiency: ability of CNS to allow agonist, antagonist, synergist, stabilizers and neutralizers to work efficiently and interdependently during dynamic kinetic chain movements Rehab may begin with isolated strengthening in single planes of motion, but progress to multi-plane functional movement that mimic sport activity

Using Tools of Rehabilitation Tool Belt A.T. have many tools in their tool belt Manual therapy techniques Therapeutic modalities Aquatic Therapy Physician prescribed medications Therapeutic Exercise How A.T. utilizes tools is often a matter of individual preference and experience Patients differ in their responses to various treatment techniques A.T. should avoid “cookbook" rehabilitation protocols A.T. should develop broad theoretical knowledge from which specific techniques can be selected and practically applied to each individual case

Using Tools of Rehabilitation Therapeutic Modalities Useful tools in injury rehabilitation When used appropriately can greatly enhance the patients chance for safe and rapid return to full activity A.T. should have knowledge of scientific basis of various modalities and their physiological effects. Therapeutic Exercise however, is more critical than the use of modalities

Using Tools of Rehabilitation Therapeutic Exercise: Exercises that force the injured anatomical structure to perform its normal function Key to successful rehabilitation AROM, PROM, RROM and functional exercises

Using Tools of Rehabilitation Medications to facilitate Healing Prescription and over the counter (OTC) medications can effectively aid the healing process during rehabilitation A.T. must have some knowledge of the effects of medications and make decisions on appropriate use with guidance from team physician

Establishing Short and Long Term Goals Short Term Goals Provide correct immediate care and management following injury to limit or control swelling Reduce or minimize pain Establishing core stability Re-establishing neuromuscular control Improving postural stability and balance Restoring full range of motion Restoring or increasing muscular strength, endurance and power Maintaining cardiorespiratory fitness Incorporating functional progressions

Establishing Short and Long Term Goals To return to athlete to practice or competition as quickly and as safely as possible Establishing reasonable and attainable goals and integrating specific exercises or activities to address these goals is critical to rehab. plan. Can be difficult knowing when and how to progress, change, or alter rehab program to most effectively accomplish short and long term goal

Establishing Short and Long Term Goals Important not to give exact time frame or date May discourage athlete if time frame not met Set series of progressions or successes to keep athlete motivated Keep athlete involved in goal setting and planning the processes of their rehab plan.

Importance of Controlling Swelling Initial first aid and management techniques may be the most critical part of any rehab program Has significant impact on the course of the rehabilitation process One major factor is the presence of swelling Swelling caused by bleeding, production of synovial fluid, accumulation of inflammatory by-products, edema or combination of these factors Produces increased pressure that causes increased pain Can also cause neuromuscular inhibition, thus weak muscular contractions Usually occurs in first 72 hours after injury

Importance of Controlling Swelling If swelling can be controlled initially in acute stage of injury, the time required for rehab is likely to be significantly reduced Follow P.R.I.C.E acronym Protection Rest Ice Compression Elevation

Importance of Controlling Swelling Protection: Injury protected from further injury Splints, braces, pads or other immobilization devices Lower Extremity: Non weight bearing or limited weight bearing until acute inflammatory response has subsided

P.R.I.C.E Rest (Restricted Activity): Critical component Healing process begins immediately after injury occurs If interrupted will delay healing or not allow healing process to begin and lengthen time of rehab Controlled mobility vs. immobilization better for scar formation, revascularization, muscle regeneration and reorientation of muscle fibers Severity of injury determines length of rest time, but usually 24 to 48 hours Involve athlete in core, cardio respiratory and exercises for un-affected parts of body

P.R.I.C.E Ice Most commonly used immediately after injury and for 72 hours after to decrease pain and controlling hemorrhage and edema Through local vasoconstriction Decrease secondary cell death by hypoxia by lowering metabolism and tissue need for oxygen Reduce muscle spasm and guarding that accompany pain Analgesic effect through decreased velocity of nerve conduction and bombarding sensory nerves with cold so pain impulses are lost Times for icing vary for different areas of body

P.R.I.C.E Compression Single most important technique for controlling swelling Mechanically decrease amount of space available for swelling by applying pressure around injured area Applied distally to proximally Kept in place despite pain because of importance for swelling Worn for 72 hours or until swelling is eliminated

P.R.I.C.E Elevation: Eliminate the effects of gravity on blood pooling in the extremities Assist venous and lymphatic drainage of blood and other fluids from the injured area back to central circulatory system Greater the degree of elevation the more effective As much as possible for first 72 hours

Controlling Pain Pain will interfere with progression of rehab. Assess pain on a daily basis and with exercises Persistent pain will make range of motion and strengthening exercises more difficult Manage with medication, modalities and P.R.I.C.E.

Establishing Core Stability Essential to every aspect of rehab process Include in all phases of rehab program Muscles of lumbo-pelvic-hip complex Functions to dynamically stabilize entire kinetic chain during functional movement Train proximally or locally to distally or globally

Other Factors Re-establishing Neuromuscular Control Ability to sense he position of a joint in space Altered after injury Re-establishing postural control and balance Restoring Range of Motion Restoring muscular strength, Endurance and Power Maintaining Cardio-respiratory Fitness Functional Progressions and Testing

Criteria for Full Recovery Decision to release a patient recovering from injury to a full return to activity is the final stage of rehabilitation process Should be carefully considered by all members of sports medicine team Ultimately team physicians decision , however it should be based on input from A.T.. Coach and the patient

Criteria for Full Recovery Is athlete pain free? Do they have full non restricted pain free range of motion? Is their strength equal to non injured side or enough to protect from re-injury? Do they have neuromuscular control and balance? Are they reconditioned for their sport, cardio-respiratory fitness and functional testing? Is the athlete psychologically ready for full return without fear or hesitation?

Documentation A.T. should be proficient in record keeping Initial injury report Rehab progression Reports, treatment logs and S.O.A.P. Notes Should be accurate and detailed Important for appropriate progressions of rehab, consistency among different practioners, third party re-imbursement, and defense in a malpractice suit

Legal Considerations States vary considerably in their laws governing what an A.T. may and may not do in supervising a program A.T. should not act outside their scope of knowledge and practice and within the laws of their state