Functional Progressions and Functional Testing in Rehabilitation

1. Functional Progressions and Functional Testing in Rehabilitation Rehabilitation Techniques for Sports Medicine and Athletic Training William E. Prentice

2. Introduction • To reduce lasting effects of injury, athletic trainer should direct rehabilitation toward improving neuromuscular coordination and agility as well as strength and endurance • Return athlete to pre-injury activity levels • Function refers to patterns of motion that use multiple joints acting with various axes and multiple planes • Focus on functional rehabilitation will ready patient for activity and competition

3. Role of Functional Progressions in Rehabilitation • A.T. must adapt rehabilitation to the sports specific demands of each individual sport and position • Functional Progression • Succession of activities that simulate actual motor and sport skills • Enable patient to acquire or reacquire skills needed to perform athletic endeavors safely and effectively • Places stresses and forces on each body system in a well-planned positive and progression fashion • Improves patients overall ability to meet the demands of daily activities as well as sport competition

4. Role of Functional Role of Functional Progressions in Rehabilitation • A.T. breaks down activities involved in a given sport into individual components • Patient concentrates on components in a controlled environment before combining them together in an uncontrolled environment • Essential in the rehabilitation process • Tissues not placed under performance level stresses do not adapt to the sudden return of such stresses when full activity is resumed

6. Benefits of using Functional Progressions • Assist patient and A.T. in reaching the goals of the entire program • Restoration of joint ROM • Strength • Proprioception • Agility • Confidence • Allow patient to reach desired level of activity safely and effectively

7. Physical Benefits • Improving functional stability • Maintained by neuromuscular control mechanisms involved in proprioception and kinesthesia • Performance during functional task can be evaluated and corrected • Functional testing can be used to provide objective measure of ability • Muscle strength • Muscles involved will be strengthened dynamically under stresses similar to those encountered in competition • Using SAID and Overload Principles • Endurance • Muscular and cardiorespirtaory endurance can be enhanced with functional progressions • Through repetition of of individual activities and their combination into one general activity

8. Physical Benefits • Flexibility • Injured area stressed within a controlled range during functional progression • Improved mobility and flexibility crucial to patient return to activity • Strength and endurance do not mean much if injured area cannot move through normal ROM • Muscle relaxation • Functional progression can teach an individual to recognize muscle tension and eventually control or remove it by relaxing muscles after exercise • Relieve muscle guarding that may inhibit normal ROM

9. Physical Benefits • Motor Skills • Coordination, agility and motor skills are complex aspects of normal function • Needed to transform strength, flexibility and endurance into full-speed performance • Repetition and practice are are important to learning motor skills • Rehabilitation exercises must stress neuromuscular coordination and agility to increase performance and decrease chance of reinjury • Develop automatic reactions needed during activity

10. Psychological Benefits • Functional progression can help reduce common emotions found after injury • Anxiety • Athlete gradually placed into more demanding situations. • Experience success and not be as concerned with failure • Deprivation • Athlete can engage in activity during practice to remain close in proximity and socially feel little loss in team cohesion • Apprehension • Enable patient to adapt to imposed demands of their sport in a controlled environment • Restore confidence

12. Components of a functional progression • Four principles • Individuality of the patient, sport and the injury • Activities should be positive not negative; no increase in signs or symptoms • Orderly progressive program • Program should be varied to avoid monotony • Vary exercise techniques • Alter the program at regular intervals • Maintain fitness base • Set achievable goals , reevaluate, and modify regularly • Use clinical, home and on field programs • Use sport specific activities to enhance patients return to activity

13. Designing a Functional Progression • No cookbook, be creative and specific to athletes goals and injury status • Progressions should start early in rehab • Start with low impact and progress to high impact • Assess athlete periodically to determine ability to progress to next exercise • Achieving a certain skill level occurs when a the skill can be completed at functional speed with high repetition without increase in pain, swelling or a decrease in ROM

14. Functional Testing • Patient performs certain tasks appropriate to their stage in rehab • Isolate specific deficits • A.T. able to determine current functional level and set functional goals • Indirect measure of muscular strength and power • Uses maximal performance of an activity • Provide A.T. with objective data

15. Functional Testing • Three purposes • Determine risk of injury due to limb asymmetry • Provide objective measure of progress during rehab plan • Measure the ability of the individual to tolerate forces

16. Functional Testing • A.T. must evaluate what test will be used • Validity : test should measure what it intends to measure • Reliability: Test should consistently provide similar results regardless of evaluator • Observe unilateral and bilateral function to determine compensation patterns • A.T. should also consider stage of healing, strength, patients ability and physician approval

17. Functional Testing • Preseason baseline measurements are preferred so A.T. has data to compare post injury activity levels • Not always obtained by A.T., however individual sports may do baseline testing • With or without baseline measurements a score of 85% or better compared to noninjured side is recognized as standard for limb symmetry scores

18. Functional Testing • Uses functional progression drills for the purpose of assessing the athlete’s ability to perform a specific activity • Entails a single maximal effort to gauge how close the athlete is to full return • Pre-season baseline testing for comparison post injury • Variety of tests • Shuttle runs -Vertical jumps • Agility runs -Balance • Figure 8’s -Hopping for distance • Carioca tests -Co-contraction test

19. Lower Extremity Functional Progression • Walking: Normal Gait • Walking: Heels walks • Walking: Toe walks • Side step/Shuffle • Lunge 90° to Lunge 180° • Step ups forward to lateral step ups • Increase speeds

20. Jogging • Begin straight ahead, gradually increase intensity 50%-100% • Introduce curves: Oval,“S” course, figure “8” course, “Z” course • Sprint • Straight ahead varying intensities • Add acceleration/deceleration drills • Box Runs • Carioca

21. Hopping: • Double Leg to Single Leg to Alternate • Jumping: • Plyometrics • Progress intensities • Sport specific • Speed and Agility drills: • Sport specific • Ladder drills • Cutting, jumping on command • Position specific activities

27. Upper Extremity Functional Progression • Assisted PNF techniques • T-band exercises simulating specific sport/position motions • Strength and endurance • Closed chain exercises: Push up progression • Upper Body Plyometrics

28. Interval throwing program • Focus on mechanics and biomechanical dysfunctions • Begin with general warm up • Step 1: 45 ft. phase • Warm up throwing • 25 throws • Rest 10 minutes • Warm up throwing • 25 throws

29. Step 2: 45 ft. phase • Warm up throwing’ • 25 throws • 15 minute rest • Warm up throwing • 25 throws • Rest 10 minutes • Warm up throwing • 25 throws

30. Repeat steps 1 & 2 for 60, 90, 120, 150, 180 ft. • Only progress if pain free and no signs or symptoms develop • When program completed move to position specific throwing • For example: pitcher throw off mound

31. Designing a Functional Progression • Full Return to Play • Physicians release • Pain free • No Swelling • Normal ROM • Normal strength (in reference to contralateral limb) • Appropriate functional testing completed with no adverse reactions