RehabilitationRehabilitation

Sabino Sports Medicine ISabino Sports Medicine I

Developing a rehab Developing a rehab programprogram

Assess the injuryAssess the injury Establish goalsEstablish goals

Long term—return athlete to full Long term—return athlete to full activityactivity

Short termShort term Execute programExecute program Reassess as athlete progresses Reassess as athlete progresses

through program through program

Format for rehab Format for rehab programprogram

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

Phase I-therapeutic Phase I-therapeutic objectivesobjectives

Teach proper ambulation techniquesTeach proper ambulation techniques Assist the healing process using Assist the healing process using

appropriate modalitiesappropriate modalities Minimize loss of muscular strength Minimize loss of muscular strength

and slow muscle atrophyand slow muscle atrophy Maintain overall level of physical Maintain overall level of physical

fitnessfitness

Criteria for progression Criteria for progression to phase IIto phase II

Remove cast, splint, sling, etc.Remove cast, splint, sling, etc. Sufficient reduction of pain, Sufficient reduction of pain,

swelling, inflammation to allow for swelling, inflammation to allow for use of safe and effective therapeutic use of safe and effective therapeutic exerciseexercise

Acceptable degree of tissue healing Acceptable degree of tissue healing to allow use of therapeutic exercise to allow use of therapeutic exercise without aggravating injurywithout aggravating injury

Phase IIPhase II

Period of time when more vigorous Period of time when more vigorous therapeutic exercise, including joint therapeutic exercise, including joint ROM, is started. ROM, is started.

Using appropriate therapeutic Using appropriate therapeutic modalities during the time will modalities during the time will enhance the healing process and enhance the healing process and assist in facilitating the use of assist in facilitating the use of therapeutic exercise.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 activity

—gait patterns, coordination agility, balance, proprioception—as they relate to the sport specific skills

Restore athlete’s 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 injuryAssessing the injury

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

SOAP notesSOAP notes

S = SubjectiveS = Subjective Patient history, symptoms, chief complaintPatient history, symptoms, chief complaint

O = ObjectiveO = Objective Signs, information from observation, palpation, Signs, information from observation, palpation,

stress testsstress tests A = AssessmentA = Assessment

Type and severity of injury, any associated Type and severity of injury, any associated problemsproblems

P = PlanP = Plan What will you do? Long & short term goals, What will you do? Long & short term goals,

what is working, how the athlete is progressingwhat is working, how the athlete is progressing

Establish GoalsEstablish Goals Short term goalsShort term goals

Control swelling using proper immediate Control swelling using proper immediate first aidfirst aid PRICEPRICE

Reduce/minimize painReduce/minimize pain PRICE, use of modalities such as ice, heat, e-stimPRICE, use of modalities such as ice, heat, e-stim

Restore full ROMRestore full ROM Dynamic, static, PNF stretching activitiesDynamic, static, PNF stretching activities

Restore/increase muscular strength, Restore/increase muscular strength, endurance, powerendurance, power Isometrics, isotonics, isokinetics, plyometrics Isometrics, isotonics, isokinetics, plyometrics

through full, pain-free ROMthrough full, pain-free ROM

IsometricsIsometrics Performed early in rehab when joint is Performed early in rehab when joint is

immobilizedimmobilized Used when performing exercises Used when performing exercises

through full ROM may be detrimentalthrough full ROM may be detrimental Increase static strength Increase static strength Assist in decreasing amount of atrophyAssist in decreasing amount of atrophy Lessen swelling by causing muscle Lessen swelling by causing muscle

pumping actionpumping action

Isometrics

Isometrics

Isotonics (progressive resistance Isotonics (progressive resistance exercises or PRE’s)exercises or PRE’s) Most commonly used strengthening Most commonly used strengthening

techniquetechnique Use free weights, exercise machines, tubing, Use free weights, exercise machines, tubing,

bands, etc., with fixed weight through ROMbands, etc., with fixed weight through ROM Use isotonic muscle contractionsUse isotonic muscle contractions

Force is generated while the muscle is changing Force is generated while the muscle is changing lengthlength

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

Isotonics

Isotonics

IsokineticsIsokinetics Occasionally used in rehabOccasionally used in rehab Incorporated in later phases of rehabIncorporated in later phases of rehab Used primarily for diagnostic purposesUsed primarily for diagnostic purposes Uses a fixed speed with accommodating Uses a fixed speed with accommodating

resistance to provide maximal resistance to provide maximal resistance throughout ROMresistance throughout ROM

Measures commonly used as criteria for Measures commonly used as criteria for return to functional activityreturn to functional activity

Isokinetics

Cybex

Isokinetics

Cybex Kincom

Isokinetics

Isokinetics

Kin com Biodex

PlyometricsPlyometrics Incorporated in later stages of rehabIncorporated in later stages of rehab Use a quick stretch of muscle to Use a quick stretch of muscle to

facilitate a subsequent concentric facilitate a subsequent concentric muscle contractionmuscle contraction

Useful in restoring/developing athlete's Useful in restoring/developing athlete's ability to produce dynamic movements ability to produce dynamic movements associated with muscular powerassociated with muscular power

Ability to generate force rapidly is key to Ability to generate force rapidly is key to successful performance in many sportssuccessful performance in many sports

Plyometrics

Plyometrics

Plyometrics

Short term goalsShort term goals

Reestablish neuromuscular controlReestablish neuromuscular control Mind’s attempt to teach the body conscious Mind’s attempt to teach the body conscious

control of specific movements—using control of specific movements—using strengthening exercises that are more strengthening exercises that are more functionalfunctional

Improve balanceImprove balance Balance training and postural stabilityBalance training and postural stability

Maintain cardiorespiratory fitnessMaintain cardiorespiratory fitness Single most neglected component, use pool, Single most neglected component, use pool,

bike, upper body ergometer, stairclimber, bike, upper body ergometer, stairclimber, elliptical trainer, etc.elliptical trainer, etc.

Incorporate appropriate functional Incorporate appropriate functional progressionsprogressions Involve series of gradually progressive activities Involve series of gradually progressive activities

designed to prepare athlete for return to designed to prepare athlete for return to participationparticipation

Monitor activity to determine athlete’s ability to Monitor activity to determine athlete’s ability to perform and physical toleranceperform and physical tolerance

Advance the activity as long as there is not any Advance the activity as long as there is not any swelling or additional painswelling or additional pain

Use position specific drills and activitiesUse position specific drills and activities Walking, jogging on track-walk curves, jogging full track, Walking, jogging on track-walk curves, jogging full track,

running on track—jog curves, running full track, running 2-running on track—jog curves, running full track, running 2-3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, 3 miles 3x week, lunges—90 degree pivot, 180 degree pivot, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, sprints—”W”, Triangle, 20 yd, 40 yd, 120 yd, acceleration/deceleration runs, shuffle runs, cariocaacceleration/deceleration runs, shuffle runs, carioca

ModalitiesModalities

Those things you can use to Those things you can use to assist/enhance the healing of injuriesassist/enhance the healing of injuries

3 categories3 categories

Thermal-used to move heat into or Thermal-used to move heat into or out of the body-----heat & coldout of the body-----heat & cold

Mechanical---ultrasound, massage, Mechanical---ultrasound, massage, traction, intermittent compressiontraction, intermittent compression

Electrical—muscle stimulationElectrical—muscle 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 tissue—connective, 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

UltrasoundUltrasound

ApplicationApplication Must use a coupling agentMust use a coupling agent

Conductive gel, lotion, waterConductive gel, lotion, water Keep sound head moving with even Keep sound head moving with even

pressure over the area being treatedpressure over the area being treated Area shouldn’t be larger than 3-4 inchesArea shouldn’t be larger than 3-4 inches Treatment time 3-8 minutesTreatment time 3-8 minutes

UltrasoundUltrasound

Indications for useIndications for use Chronic injuriesChronic injuries Acute injuries (non-thermal setting)Acute injuries (non-thermal setting) StrainsStrains SprainsSprains TendonitisTendonitis ContusionsContusions Tight tissueTight tissue

ultrasoundultrasound

Contraindications for useContraindications for use Heart, eyes, ears, brain, spinal cord, Heart, eyes, ears, brain, spinal cord,

genitalsgenitals Epiphyseal platesEpiphyseal plates Acute injuriesAcute injuries Areas with poor circulationAreas with poor circulation Stress fracturesStress fractures Open woundsOpen wounds Infected areasInfected areas Tumors Tumors

TractionTraction

Pulling force that deliberately Pulling force that deliberately separates joints of the body that have separates joints of the body that have been compressed together or are stiffbeen compressed together or are stiff

Commonly used at cervical or lumbar Commonly used at cervical or lumbar areaarea

Can be done mechanically or manuallyCan be done mechanically or manually Separates bonesSeparates bones Puts gentle stretch on areaPuts gentle stretch on area

Traction

Traction Traction

Indications for useIndications for use Disc herniation/protrusionDisc herniation/protrusion Degenerative disc diseaseDegenerative disc disease Degenerative joint diseaseDegenerative joint disease Soft tissue compressionSoft tissue compression Nerve root compressionNerve root compression Muscle spasmMuscle spasm

TractionTraction

Contraindications for useContraindications for use OsteoporosisOsteoporosis Fractured vertebraeFractured vertebrae Spinal hypermobilitySpinal hypermobility Infections of spineInfections of spine

Massage Massage

Intentional & methodical kneading Intentional & methodical kneading and stroking of soft tissueand stroking of soft tissue

Increases circulationIncreases circulation Decreases muscle spasmDecreases muscle spasm Relieves swelling (move towards Relieves swelling (move towards

heart)heart)

Massage Massage StrokesStrokes

EffleurageEffleurage Stroke w/ palm of handStroke w/ palm of hand

PetrissagePetrissage Kneading tissue by squeezing between Kneading tissue by squeezing between

hands/fingershands/fingers Tapotment (percussion)Tapotment (percussion)

Light chopping motion with handsLight chopping motion with hands VibrationVibration

Tissue shakes vigorously Tissue shakes vigorously FrictionFriction

Deep pressure/movement of hand or fingers used Deep pressure/movement of hand or fingers used to break up scar tissue or relieve spasm/tight to break up scar tissue or relieve spasm/tight tissuetissue

MassageMassage

Indications for useIndications for use Promotes relaxationPromotes relaxation Muscle spasmMuscle spasm PainPain Soft tissue stiffnessSoft tissue stiffness

Massage Massage

Contraindications for useContraindications for use Non-union fractureNon-union fracture Open woundsOpen wounds Acute injuriesAcute injuries Dermatological conditionsDermatological conditions

Intermittent Intermittent compressioncompression

Compression that is on and off—Compression that is on and off—usually about 30-45 seconds on and usually about 30-45 seconds on and 15 seconds off15 seconds off

Treatment time is 15 minutes – 1 Treatment time is 15 minutes – 1 hourhour

Helps venous blood flow from Helps venous blood flow from extremityextremity

Intermittent Compression

Intermittent Intermittent compressioncompression

IndicationsIndications Post acute edemaPost acute edema LymphedemaLymphedema Chronic swelling/edemaChronic swelling/edema

Intermittent Compression

Contraindications for use Acute injuries Possible fracture Compartment syndromes

Electrical Muscle Electrical Muscle StimulationStimulation

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

TypesTypes Galvanic stimulationGalvanic stimulation TENSTENS InterferentialInterferential Combo (US & e-stim)Combo (US & e-stim)

Galvanic StimGalvanic Stim

Used for treatment ofUsed for treatment of ContusionsContusions SprainsSprains StrainsStrains Acute edemaAcute edema Muscle re-educationMuscle re-education

Galvanic stimGalvanic stim

Physiological response of body Physiological response of body depends on the polarity of the currentdepends on the polarity of the current

Negative current: vasoconstriction, Negative current: vasoconstriction, hardens tissues, local analgesic, hardens tissues, local analgesic, decreases nerve excitabilitydecreases nerve excitability

Positive current: vasodilatation, Positive current: vasodilatation, softens tissue, increases nerve softens tissue, increases nerve excitability, increases venous and excitability, increases venous and lymphatic returnlymphatic return

Galvanic stimGalvanic stim

Place electrodes so pain is Place electrodes so pain is “between” the pads“between” the pads

Place electrodes at either end of the Place electrodes at either end of the muscle being treatedmuscle being treated

Can be used in conjunction with heat Can be used in conjunction with heat or coldor cold

Treatment time is 10-20 minutesTreatment time is 10-20 minutes

E-Stim

Interferential Interferential StimulationStimulation

Uses interfering electrical currents Uses interfering electrical currents to regulate blood flow, reduce pain, to regulate blood flow, reduce pain, decrease edema, relieve muscle decrease edema, relieve muscle spasm, strengthen muscle tissuespasm, strengthen muscle tissue

Used to treat: contusions, sprains, Used to treat: contusions, sprains, strains, etc.strains, etc.

Should feel slight vibrationShould feel slight vibration

InferentialInferential

Uses 4 electrodes set at a diagonal Uses 4 electrodes set at a diagonal patternpattern

Covers “larger” areaCovers “larger” area Electrical currents “interfere” with Electrical currents “interfere” with

each other to create a bigger surface each other to create a bigger surface areasareas

Can be used with heat or coldCan be used with heat or cold Treatment time is 10-20 minutesTreatment time is 10-20 minutes

Interferential

TENS TENS (transcutaneous electrical (transcutaneous electrical

muscle stimulation)muscle stimulation) Used primarily for pain controlUsed primarily for pain control Electrodes are placed on skin over Electrodes are placed on skin over

painful area to “block” the sensation of painful area to “block” the sensation of chronic or acute painchronic or acute pain

Cause a muscle contractionCause a muscle contraction Used for 30 minutes to 1 hour Used for 30 minutes to 1 hour

treatment timetreatment time Can be used so patient can exercise Can be used so patient can exercise

without painwithout pain

TENS

Ultrasound/muscle stim Ultrasound/muscle stim combocombo

US combined with muscle stimUS combined with muscle stim Electricity comes through the US Electricity comes through the US

headhead Combine deep heating with benefits Combine deep heating with benefits

of muscle contractionof muscle contraction Used for treating strains, muscle Used for treating strains, muscle

spasms, trigger points, tight musclesspasms, trigger points, tight muscles Treatment time is 5-15 minutesTreatment time is 5-15 minutes

Combo