Rehabilitation

Sabino Sports Medicine I

Developing a rehab program

Assess the injury Establish goals

Long termreturn athlete to full activity Short term

Execute program Reassess as athlete progresses through program

Format for rehab program

Phase Itime period immediately following injury/surgery during which movement in the affected part is either involuntarily limited because of pain, swelling, muscle spasm, etc, or purposely restricted by immobilization in casts, splints, slings, etc.

Phase I-therapeutic objectives

Teach proper ambulation techniques Assist the healing process using appropriate modalities Minimize loss of muscular strength and slow muscle atrophy Maintain overall level of physical fitness

Criteria for progression to phase II

Remove cast, splint, sling, etc. Sufficient reduction of pain, swelling, inflammation to allow for use of safe and effective therapeutic exercise Acceptable degree of tissue healing to allow use of therapeutic exercise without aggravating injury

Phase II

Period of time when more vigorous therapeutic exercise, including joint ROM, is started. Using appropriate therapeutic modalities during the time will enhance the healing process and assist in facilitating the use of therapeutic exercise.

Therapeutic Objectives Phase II

Establish weight bearing and restore normal gait patterns Restore joint ROM equal to the unaffected part Restore flexibility equal to or exceeding unaffected part Restore muscular strength & endurance equal to unaffected part and consistent with demands of sport involved Maintain acceptable level of physical fitness

Criteria to progress to Phase III

Acceptable reduction of local symptoms Acceptable level of healing of wound Adequate restoration of gait, ROM, flexibility, strength, endurance, power, & CV fitness to resume at least part of regular practice/conditioning Satisfactory assurance of adequate protection from reinjury Great level of motivation and confidence of athlete

Phase III

Period of time during which participation (in part or completely) of the normal practice and conditioning is resumed

Therapeutic Objectives Phase III

Continue restoration of joint ROM, flexibility, muscular strength and endurance to safely resume full participation Continue to work on overall physical fitness Re-establish nornal pattern of motor activitygait patterns, coordination agility, balance, proprioception as they relate to the sport specific skills Restore athletes confidence in resuming full participation

Criteria to progress to Phase IV

Restoration of all components of physical fitness Resuming full---complete and unrestricted--participation

Phase IV

That period of time after which complete rehabilitation is achieved and full activity is resumed.

Therapeutic Objectives Phase IV

Maintain muscular strength, endurance, power, and flexibility Maintain optimal CV fitness Maintain overall rehabilitated state

Assessing the injury

Use SOAP notes (systematic means of documenting the assessment and recording progress of rehab program

SOAP notes

S = Subjective

Patient history, symptoms, chief complaint

Signs, information from observation, palpation, stress tests Type and severity of injury, any associated problems What will you do? Long & short term goals, what is working, how the athlete is progressing

O = Objective

A = Assessment

P = Plan

Establish Goals

Short term goals

Control swelling using proper immediate first aid

PRICE PRICE, use of modalities such as ice, heat, e-stim Dynamic, static, PNF stretching activities

Reduce/minimize pain

Restore full ROM

Restore/increase muscular strength, endurance, power

Isometrics, isotonics, isokinetics, plyometrics through full, pain-free ROM

Isometrics
Performed early in rehab when joint is immobilized Used when performing exercises through full ROM may be detrimental Increase static strength Assist in decreasing amount of atrophy Lessen swelling by causing muscle pumping action

Isometrics

Isometrics

Isotonics (progressive resistance exercises or PREs)

Most commonly used strengthening technique Use free weights, exercise machines, tubing, bands, etc., with fixed weight through ROM Use isotonic muscle contractions

Force is generated while the muscle is changing length

Use eccentric (lengthening) and concentric (shortening) muscle contractions

Isotonics

Isotonics

Isokinetics
Occasionally used in rehab Incorporated in later phases of rehab Used primarily for diagnostic purposes Uses a fixed speed with accommodating resistance to provide maximal resistance throughout ROM Measures commonly used as criteria for return to functional activity

Isokinetics

Cybex

Isokinetics

Cybex

Kincom

Isokinetics

Isokinetics

Kin com

Biodex

Plyometrics
Incorporated in later stages of rehab Use a quick stretch of muscle to facilitate a subsequent concentric muscle contraction Useful in restoring/developing athlete's ability to produce dynamic movements associated with muscular power Ability to generate force rapidly is key to successful performance in many sports

Plyometrics

Plyometrics

Plyometrics

Short term goals

Reestablish neuromuscular control

Minds attempt to teach the body conscious control of specific movementsusing strengthening exercises that are more functional
Balance training and postural stability Single most neglected component, use pool, bike, upper body ergometer, stairclimber, elliptical trainer, etc.

Improve balance

Maintain cardiorespiratory fitness

Incorporate appropriate functional progressions

Involve series of gradually progressive activities designed to prepare athlete for return to participation Monitor activity to determine athletes ability to perform and physical tolerance Advance the activity as long as there is not any swelling or additional pain Use position specific drills and activities

Walking, jogging on track-walk curves, jogging full track, running on trackjog curves, running full track, running 2-3 miles 3x week, lunges90 degree pivot, 180 degree pivot, sprintsW, Triangle, 20 yd, 40 yd, 120 yd, acceleration/deceleration runs, shuffle runs, carioca

Modalities
Those things you can use to assist/enhance the healing of injuries 3 categories Thermal-used to move heat into or out of the body-----heat & cold Mechanical---ultrasound, massage, traction, intermittent compression Electricalmuscle stimulation

Cold

Types of cold use

Ice pack (15-20 minutes) Ice massage (5-15 minutes) Cold whirlpool (15-20 minutes) Slush bucket (15-20 minutes) Cryokinetics (10 -15 minutes) Chemical cold packs (15 minutes??? Watch for chemical burns)

Cold

Cold

Cold

Physiological effects
Decrease tissue temperature Decrease blood flow Decrease inflammation Decrease pain---analgesic Decrease muscle spasm Increase muscle tone

Cold

Indications for use

Acute injuries Pain Swelling Inflammation Preparing for exercise

Cold

Contraindications for use

Open wounds Cold related allergy Areas with sensory or circulatory deficits

Heat

Types of heat modalities

Hydrocollator pack (moist heat) (10-15 minutes) Electrical heat pack (15-20 minutes) Warm whirl pool (10-15 minutes) Paraffin bath (dip several times--10-15 minutes)

Heat

Heat

Heat

Heat

Physiological effects
Increase tissue temperature Increase blood flow Increase tissue extensibility Increase ROM Decrease swelling Decrease muscle tone

Heat

Indications for use

Chronic inflammatory conditions Tight tissueconnective, muscle, tendon , ligament Chronic pain Chronic muscle spasm

Heat

Contraindications for use

Acute injuries Areas with sensory deficits

Ultrasound

Thermal or non-thermal modality that stimulates blood flow

Continuous or pulsed

Sound waves pass through pizoelectric crystal in sound head to create mechanical energy Mechanical energy cause vibration of tissue cells which create heat Heat can reach depth of 3-5 centimeters

Ultrasound

Ultrasound

Application

Must use a coupling agent

Conductive gel, lotion, water

Keep sound head moving with even pressure over the area being treated Area shouldnt be larger than 3-4 inches Treatment time 3-8 minutes

Ultrasound

Indications for use

Chronic injuries Acute injuries (non-thermal setting) Strains Sprains Tendonitis Contusions Tight tissue

ultrasound

Contraindications for use

Heart, eyes, ears, brain, spinal cord, genitals Epiphyseal plates Acute injuries Areas with poor circulation Stress fractures Open wounds Infected areas Tumors

Traction

Pulling force that deliberately separates joints of the body that have been compressed together or are stiff Commonly used at cervical or lumbar area Can be done mechanically or manually Separates bones Puts gentle stretch on area

Traction

Traction

Indications for use

Disc herniation/protrusion Degenerative disc disease Degenerative joint disease Soft tissue compression Nerve root compression Muscle spasm

Traction

Contraindications for use

Osteoporosis Fractured vertebrae Spinal hypermobility Infections of spine

Massage

Intentional & methodical kneading and stroking of soft tissue Increases circulation Decreases muscle spasm Relieves swelling (move towards heart)

Massage

Strokes

Effleurage

Stroke w/ palm of hand Kneading tissue by squeezing between hands/fingers Light chopping motion with hands Tissue shakes vigorously Deep pressure/movement of hand or fingers used to break up scar tissue or relieve spasm/tight tissue

Petrissage

Tapotment (percussion)

Vibration

Friction

Massage

Indications for use

Promotes relaxation Muscle spasm Pain Soft tissue stiffness

Massage

Contraindications for use

Non-union fracture Open wounds Acute injuries Dermatological conditions

Intermittent compression

Compression that is on and offusually about 30-45 seconds on and 15 seconds off Treatment time is 15 minutes 1 hour Helps venous blood flow from extremity

Intermittent Compression

Intermittent compression

Indications
Post acute edema Lymphedema Chronic swelling/edema

Intermittent Compression

Contraindications for use

Acute injuries Possible fracture Compartment syndromes

Electrical Muscle Stimulation

The application of electrical current to the surface of the skin Types

Galvanic stimulation TENS Interferential Combo (US & e-stim)

Galvanic Stim

Used for treatment of

Contusions Sprains Strains Acute edema Muscle re-education

Galvanic stim

Physiological response of body depends on the polarity of the current Negative current: vasoconstriction, hardens tissues, local analgesic, decreases nerve excitability Positive current: vasodilatation, softens tissue, increases nerve excitability, increases venous and lymphatic return

Galvanic stim

Place electrodes so pain is between the pads Place electrodes at either end of the muscle being treated Can be used in conjunction with heat or cold Treatment time is 10-20 minutes

E-Stim

Interferential Stimulation

Uses interfering electrical currents to regulate blood flow, reduce pain, decrease edema, relieve muscle spasm, strengthen muscle tissue Used to treat: contusions, sprains, strains, etc. Should feel slight vibration

Inferential

Uses 4 electrodes set at a diagonal pattern Covers larger area Electrical currents interfere with each other to create a bigger surface areas Can be used with heat or cold Treatment time is 10-20 minutes

Interferential

TENS
(transcutaneous electrical muscle stimulation)

Used primarily for pain control Electrodes are placed on skin over painful area to block the sensation of chronic or acute pain Cause a muscle contraction Used for 30 minutes to 1 hour treatment time Can be used so patient can exercise without pain

TENS

Ultrasound/muscle stim combo

US combined with muscle stim Electricity comes through the US head Combine deep heating with benefits of muscle contraction Used for treating strains, muscle spasms, trigger points, tight muscles Treatment time is 5-15 minutes

Combo