Paul ThawleyMSc Principles of Rehabilitation

1. Paul ThawleyMScPrinciples of Rehabilitation Guidelines and Exercise Classification

3. The Phases ofRehabilitation • Rehab is usually divided into Several Phases • Phase one—Immobilization • Phase two-Early motion • Phase three-Strengthening • Phase four-Functional activity • Phase five-Return to full activity

4. The Phases ofRehabilitation—Take Two • 1. Initial Injury Phase • 2. Mobility Restoration Phase • 3. Proprioceptive Phase • 4. Resistance Training Phase • 5. Endurance Phase • 6. Sport Specific Function Phase

5. The Phases of Rehabilitation • Depending upon the seriousness of the injury, the first phase may often be skipped over, since surgical and non-surgical injuries differ. • The main difference is that post-surgically, there are sutures and usually a graft or other repair to be protected.

6. Phase One—Restricted Mobility • This phase has grown shorter in recent times: • Immobilizing a body part for too long leads to extreme stiffness and scarring.

7. Phase Two-Early Motion • Regain ranges of motion within the limitations set by the physician. • Typically, this phase begins within hours or days of the surgery or injury.

8. Phase Three-Strengthening • Regain the muscular strength and muscular endurance . • Restoration of strength often assists in regaining the final portions of lost ranges of motion. • A feeling of regained strength often makes the athlete feel more confident.

9. Phase Four-Functional Activity • Restoring functional strength, balance and endurance. • Full motion, sport specific exercises . • Emphasis on regaining balance and proprioception.

10. Phase Five-Return to Full Activity • Regain and redevelop the skills of their particular sport. • Game simulating situations are utilized. • Any inadequacies of the rehabilitation will become apparent and can be reedited at this time.

12. The Core Principles of Injury Rehabilitation • Maintain all aspects of physical conditioning • Let pain be your guide • Work Bilaterally • Know “Why” • Work ALL pertinent muscle groups

14. The Core Principles of Injury Rehabilitation • MODIFY if a certain exercise seems to be creating a problem like swelling or pain. • Change only one parameter at a time.

15. Ways to Generate Resistance • 1.Weights • 2. Elastic bands • 3. Manual resistance • 4. Water • 5. Bodyweight • 6. Isokinetically

16. Forms of Resistance Exercise-Isometric • Contractions developed while the joints remain stationary. • “The irresistible force meets the immoveable object.” • Generally considered the most intense type of muscle contraction.

17. Aqua Therapy

18. Unloading w/o Water

19. Forms of Resistance Exercise-Isotonic • Consists of two types of contractions, together • Concentric—the “up” contraction when a muscle shortens. • Eccentric-the “down” contraction when a muscle lengthens.

20. Isotonic Resistance

21. Isotonic Elastic Tubing Resistance

22. Forms of Resistance Exercise-Isokinetic • Generated by the hydraulic style of weight machines, or by Isokinetic dynamometers. • Resistance is created by restricting the velocity at which a joint can rotate through a Range of Motion. • The subject pushes as hard as s/he can, but the machine only allows the exercising body part to move as fast as the machine is set to go.

23. Isokinetic Dynamometer

24. Open and Closed (Kinetic) Chain Closed Chain Open Chain “Open Chain” may be defined as exercises performed with the working segment free and un-anchored.“Closed Chain” may be defined as exercises performed with the working segment anchored. Open Chain

25. Progressive Resistance Exercise (PRE) • PRE is based on the concept that exercise should begin at a resistance that can be easily be handled by the athlete through a pain free range of motion (ROM), for one set of ten repetitions or more. (DeLorme) • Baseline resistance is usually based on a test of maximum strength.

26. Progressive Resistance Exercise Testing • One method of testing strength, is to pick a weight that is estimated to be easy for the athlete to handle for 10 repetitions. Base this on yours and the athlete’s experiences, or on a set of established norms. • Once this baseline is established, allow three minutes between sets of increased weight. • Add 5%-10% of the initial weight; have the athlete do another set; rest three minutes; perform another set adding 5%-10%, and so on.

27. Progressive Resistance Exercise • When the athlete can lift a weight that they can only complete for one repetition with GOOD FORM. This becomes their 1RM. • An alternative way to arrive at 1RM is to stop once the athlete reaches the weight that they can only lift for three (3) repetitions with good form. This will be at about 90% -95% of 1RM.

28. Progressive Resistance Exercise • Resistance can be calculated by multiplying the 1RM by .50 for 50%, .60 for 60%, and so on. • Several resistance/repetition levels have been associated with the acquisition of particular qualities of the muscles being worked.

29. Progressive Resistance Exercise • Muscular endurance = Less than 60% of 1RM performed for 12 or more repetitions. • Moderate strength gains and hypertrophy of the muscle = 70%-80% of 1RM performed for 8-10 repetitions. • Maximal strength gains = 85%-100% of 1RM performed for 1-6 repetitions .

30. Progressive Resistance Exercise • For the treatment of tendonitis of the rotator cuff, 5%-8% of bodyweight performed for 10-20 repetitions, is recommended. • 20% of bodyweight may be the indicated starting point for the reconditioning of patellar tendonitis or Achilles tendonitis.

31. Progressive Resistance Exercise • Rubber tubing or bands are color-coded for resistance, and provide a handy, portable source of resistance. • Because the bands do not provide specified levels of resistance (just relative levels, when different thicknesses are compared) trial and error must be used to locate the level of repetitions appropriate for that band or tube. • Close attention must be paid to good form and the patient’s pain level in order to establish a certain level of resistance with which to begin exercise.

32. Progressive Resistance Exercise • On “selectorized” weight machines, often an arbitrary weight must be chosen as an estimate of lifting capability for 10 or more repetitions. • Since the weight-stack increments are established by the machine manufacturer, increases are dictated by the machine.

33. Plyometrics

34. Endurance Exercise “Endurance” can refer either to muscular endurance or to cardio-respiratory endurance. Therefore, the use of stationary bikes, swimming pools, upper body ergometers, treadmills, elliptical trainers, or other modalities designed to develop cardio-respiratory fitness must be utilized at least three times per week for a minimum of 20 minutes per session.

35. Cardio Endurance Exercise

36. Muscular Endurance Muscular endurance is developed in two ways: • The stronger a muscle is, the more times it can be expected to be able to move a sub-maximal resistance. • Several sets of sub-maximal resistances that allow for 12 or more consecutive repetitions of each exercise with only minimal rest periods between sets (15-60 seconds).

37. Balance and Proprioception Balance: Whole-body stability as regulated by the inner ear and by visual cues. Proprioception:The body’s ability to sense the position of its segments and maintain that positioning by making conscious or unconscious neuro-muscular adjustments.

38. Proprioception and Balance

39. Balance and Proprioception • Balance and proprioceptive sensitivity is reduced immediately following an injury. • These spacial senses often return slowly, and sometimes never fully recover, unless they are specifically trained as part of the post-injury rehabilitation process.

40. Balance and Proprioception • Proprioception and balance can be trained progressively, by having the athlete first perform balancing exercises on an even surface with their eyes open. • Next, the same exercises may be challenged on an even surface with the eyes shut. • Next, the same sort of exercises might be performed on an uneven or unstable surface (such as on a teeter board) with the eyes open, and then closed.

41. Balance and Proprioception • Further instability • Playing catch with the athlete, using a “medicine” ball, while the athlete balances on progressively less-stable surfaces. • Gentle-but-sudden manual nudges or taps, called “perturbations,” may also be used to add difficulty to proprioception and balance drills. • There are commercially available, automatic balancing platforms, but these can be cost -prohibitive to obtain.

42. Flexibility-Contract-Relax Stretching

43. Flexibility-Static Stretching

45. Guidelines---Return to Practice and Play • Athlete must have regained full, pre-injury strength • Athlete must have regained full, pre-injury range of motion (some surgeries only allow you to get close to full ROM). • Athlete must have regained full, pre-injury speed. • Athlete must have regained full, pre-injury balance and proprioception. • Athlete must have regained full, pre-injury muscle mass. • Athlete must be FULLY confident in their rehabilitation.