Functional Progressions & Functional Testing in Rehabilitation

1. Functional Progressions & Functional Testingin Rehabilitation Chapter 16

2. How do you move forward in Rehab? • Function in rehab = patterns of motion that use multiple joints acting with various axes & in multiple planes • Essential part of rehab that places tissues under stresses that return tissues to levels of full activity • Places stresses & forces on each body system • Traditional rehab techniques often stress only single joints in single planes of motion • To complement traditional rehab, you can use functional rehab to ready your patient for activity

3. Functional Progression • Functional progression = succession of activities that simulate actual motor & sport skills • Enables the patient to acquire or reacquire the skills needed to perform activity • Must be able to adapt rehab to the sport-specific demands & specific position • The clinician breaks down the activities into individual components. • The patient can focus on each specific part of an activity.

4. Benefits for Using Functional Progression • Helps patient reach goals of entire program • Goals of functional progression: • Restoration of joint ROM • Restoration of strength • Restoration of proprioception • Restoration of agility • Restoration of confidence • Provides both physiological & psychological benefits to the patient

5. Benefits for Using Functional Progression • Improves functional stability • Muscular strength – SAID principle • Endurance – muscular & cardiorespiratory • Flexibility – elongating tissue to proper length • Muscle relaxation – reduce muscle tension • Motor skills – coordination & agility, automatic reactions

6. Psychological & Social Considerations • Anxiety – uncertain about future • Deprivation – losing contact with team & coaches • Apprehension – precursor to re-injury • Success of activity gives confidence & motivates to attain the next goal

7. Components of a Functional Progression • Phase 1 – Acute Injury Phase • Focus on restoring joint ROM, muscular strength, & muscular endurance • Phase 2 – Repair Phase • Focus on incorporating proprioception & agility exercises • Phase 3 – Remodeling Phase • Focus on restoring everything to pre-injury status • Progression should allow for planned sequential activities that challenge the athlete while allowing for success

8. Activity Considerations • Principles for activity selection • Individuality of athlete, sport and injury • Should be positive (no increase in symptoms should occur) • Orderly progressive program should be utilized • Variety – avoid monotony, but don’t cause confusion • Vary exercise techniques used • Alter the program at regular intervals • Maintain fitness base to avoid re-injury with return to play • Set achievable goals, reevaluate, & modify regularly • Use clinical, home, & on-field programs to vary activity

9. Activity Considerations • Make sure the patient understands the rehab process • You need to emphasize the importance of sport-specific activities to enhance the patient’s return • Incorporate the inherent demands of the sport • Physical & athletic fitness should be merged to maximize athlete response & return to previous levels

10. Designing a Functional Progression • No cookbook method • You are only limited by creativity • Should be initiated early in progression • Guidelines • Evaluate the patient’s current status • Review expectations of the patient and physician • Do they work together? • Understand demands of sport and position played • May require incorporation of athlete, coach and other athletic trainers • Analyze demands that will be placed on athlete (rank order) • Set goals and means to assess levels of function and progress • Set parameters for return to play criteria

11. Components of Physical Fitness & Athletic Fitness

12. Full Return to Play • Decision requires full evaluation of athlete’s condition • Objective observation and subjective evaluation • Athlete should feel ready physically and mentally • Controlled return • Added stress to injury can slow healing and result long and painful recovery or re-injury • Criteria • Physician’s release • Pain free, no swelling • Normal ROM, strength • Completion of functional testing minus adverse effects

13. Functional Testing • Patient performs certain tasks appropriate to the stage in the rehab process in order to isolate and address specific deficits • Purpose for functional testing • Determines risk of injury due to limb asymmetry • Provides objective measures of progress • Measures ability of individual to tolerate forces • Used as an indirect measure of strength and power • Functional tests serve as good correlation to functional ability • Utilize valid and reliable tests • Should look at both unilateral & bilateral function • Allows clinician to determine if athlete is compensating • Must consider stage of healing, appropriate rest & self-evaluation

14. Functional Testing • Limitations of functional testing • Might be limited due to lack of availability of normative values or pre-injury baseline values for comparison - subjective decisions must be made based on test results • E.g.: BESS • If normative data/pre-injury status is available objective decisions can be made • Functional test should be easily understood by athletic trainer & patient • Must consider cost efficiency, time and space demands

15. Examples of Functional Progression & Testing The Upper Extremity • Possible functional activities that can enhance upper extremity performance • PNF, swimming, pulley machines, rubber tubing • All can be used to simulate sports activity • Must focus on proprioception & neuromuscular control • Awareness of proprioception • Dynamic stabilization restoration • Preparatory and reactive muscle facilitation • Replication of functional activities • Kinesthesia training can use similar activities • Requires removal of external cues

16. Promotion of joint position sense • Activities that can be used • Isokinetic exercise • Proprioception testing devices • Goniometry • Electromagnetic motion analysis • Can be practiced with visual cue progressing to no cues • Activities can be active or passive • Can also work to reproduce specific paths of motion to increase functional component of activity • Must stress joint at both ends of ROM and at mid-range • Results in capsuloligamentous afferents & musculotendinous mechanoreceptors, respectively • Dynamic stability • Stresses the training of force couples provided by scapula stabilizers & muscles of the glenohumeral joint • CKC exercises enhance co-activation

17. Preparation and Reaction • Incorporates rhythmic stabilization activities along with CKC exercises • Rhythmic stabilization prepares athlete for motion and improves muscle stiffness while training for reaction • Plyometrics are an excellent alternative activity • Functional Activities • Stress sports specific skills • PNF patterns can be used as early alternative to sports specific activity (more function, less stress) • Program should focus on core, scapulothoracic stabilizers and the glenohumeral joint • Quadruped position allows athlete to work muscles of trunk/core and upper extremity

18. While most activities are OKC oriented, CKC activities are important for restoration of proper function • Throwing Progression • Instruct athlete in complete an appropriate warm-up • Should incorporate throwing motion practice (slow velocity with low stress) • Progress through increasingly difficult stages • Shoulder serves as template for upper extremity rehabilitation and progression • Many of the activities for the shoulder are equally effective for the elbow, wrist and hand

19. Functional Testing for the Upper Extremity • Timed performance is simplest & most common means used for testing • Velocity • Controlled environment (indoors to decrease effect of weather) • Set up a standard pitching distance (60’6”) • Have athlete use a wind-up motion • Measure a maximum of 5 throws measured in mph with radar gun (if no radar gun – use stop watch) • Compute the mean and compare to pretest values • CKC Upper Extremity Stability Test • Use sports specific drill to assess performance & readiness

20. Progression for the Lower Extremity • Utilizes same basic pattern as upper extremity • Can use sprint times, agility runs for time, hopping (height and distance), co-contraction tests, carioca runs and shuttle runs • Sprint test • Set distance • Run the distance for time • 3-5 sprints should be completed and the mean computed • Pre-test and post-test measures are compared

21. Agility test • Same premise as sprint test • Difference involves the course • Not just straight ahead running • Incorporates changes in direction, acceleration, deceleration, starts & stops • Other agility tests • Box runs • Zigzag runs • Cutting maneuvers • Figure 8 runs • Back pedaling drills • Changes in shape and size can make drills more difficult

22. Vertical Jump • Record height athlete is able to jumps (3-5 trials) • Test can also be varied • Bilateral jump vs. Single leg jump • Countermovement vs. static squat start • Approach step vs. stationary start • Upper extremity use for propulsion vs. restricted use • Co-Contraction Semicircular Test • Athlete moves about a semicircular pattern while tethered to taut Theraband using a forward facing shuffle • Athlete will complete 3 trials of 5 repetition for time • Provides a dynamics pivot shift for the ACL insufficient knee

23. Hopping Test • Single leg hop for distance • Timed hop test (ability to hop 6 meters for time) • Triple hop for distance (distance covered in 3 consecutive hops • Crossover hop (distance covered in 3 hops) • Carioca Test • Run performed for time • Run a total of 80 feet, 40 feet to the right and 40 feet to the left, both facing the same direction • Record 3 trials and calculate a mean • Shuttle Run • Four 20 feet sprints (with 3 direction changes) • Suicide sprints – sprint, touch mark and return to starting position (total time to complete drill)

24. Balance Test • Helps determine deficits in proprioception and balance • Single leg stance (hold position for time) • Can incorporate different surfaces, and eye condition • May also incorporate sports skills into test • Functional Hop Test • Subjective Evaluations • Incorporation of subjective questionnaires or numeric scales to assess function