Essential Considerations in Designing a rehabilitation Program for the Injured Patient

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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Establishing Short and Long Term Goals • 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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

33. 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

34. 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?

35. 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

36. 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