Dr. Martin's notes

Monday May 15, 2017

Goals of Rehabilitation
The goals of rehabilitating an injured athlete are usually considered different from those for the injured general population. Vigorous, intense, but load-controlled exercise enhances early return to participation and ensures that the injured part is as optimally conditioned as possible. The goal of treatment must be restoration of function to the greatest possible degree in the shortest possible time. That means that rehabilitation should begin at the same time as initial treatment of the injured part. Treatment and rehabilitation should blend imperceptibly into one, as acute care and early rehabilitation can minimize the effects of the injury. Thus a fine balance must be established in the use of stress to enhance proper tissue repair, yet not cause tissue breakdown.

No longer is rehabilitation put off until the injured part is "healed"; rather, rehabilitation is started while healing is taking place, resulting in an earlier return to activity and perhaps an improvement in the quality of the tissue that forms during the healing process. The aim is not necessarily to speed up healing (which cannot as yet be accomplished), but rather to do all that is possible to avoid slowing it down.

The rehabilitation program is influenced by, yet not limited to, a number of factors:
1. Severity of the injury
2. Stage of tissue healing
3. Type of treatment, including surgery and all precautions and restrictions of the particular injury or surgical procedure affecting me rehabilitation program
4. Muscular strength of the involved limb
5. Pain during joint motion
6. Range of joint motion limitations
7. Joint swelling
8. Functional anatomy of the involved structure and segment
9. Neuromuscular pattern of the moving parts
10. Tissue sites capable of elicting pain
11. Responsible faulty neuromuscular mechanism
12. Other conditions within the joint, for example, chondromalacia of the patella
13. Knowledge of the controllable and uncontrollable stresses that will be made by the injured athlete's sport upon the damaged tissues and its associated segments
14. Motivational rationale of the athlete as well as psychological aspects (fear of re-injury). Thus the athlete favors the noninvolved limb, predisposing it to overuse syndromes.

Stages of Rehabilitation Program
The rehabilitation program should proceed in an orderly fashion through a number of planned stages. In judging an athlete's rate of recovery and attempting to determine the timing of return to participation, factors such as functional tests and pain are considered. Guidelines of arbitrary time periods have limited, if any, value in modern athletic treatment as long as healing time is within physiological limits. These stages need to be individualized, but they generally include:

1 Immediate or acute rehabilitation phase. Initially, emphasis should be on cardiovascular fitness and isometric contractions if a joint is immobilized. Exercising the opposite limb may evoke a crossover reaction and maintain the muscles of the injured limb. If permitted, an attempt at limited motion within the confines of the immobilizer may speed healing.

Muscle stimulation and continuous passive motion (CPM) are also frequently used at this stage. CPM is a machine-dependent device that moves a joint though its functional ROM at a constant rate of motion. The various machines use a limb carriage to support the proximal and distal segments of a joint. The control system of the device can change the range of the motion, the position of the motion arc, and the rate at which the motion occurs.

2. Protective phase. When the immobilization is lifted, a pain-free range of motion is regained through graded exercises, proprioceptive neuromuscular facilitation patterns (PNF), adjuncts of transcutaneous electrical nerve stimulation (TENS), and cryotherapy. All of these techniques are used to overcome the neural inhibitions that frequently limit progress at this stage.

3. Restoration of motion, strength, and proprioception. As joint motion and flexibility return, resistance exercises can be increased. Some programs start with limited-range isotonic exercises, but others are achieving excellent and rapid results with low-resistance, moderately high-speed exercise on isokinetic machines, using submaximal intensity through a limited range of motion.

4. Restoration of power and endurance. As strength is developed, more emphasis is placed on speed, power and endurance. These qualities can be achieved through the utilization of circuit training, plyometrics, flexibility exercises, and following the periodization principle.

5. Progressive control of Re-entry phase. As the last step, specific skill patterns and sport-related skills are prescribed, with progressively complex drills. This re-entry phase is paramount, and a progressively controlled stress and/or load implementation must be monitored. The athlete must be effectively observed by the trainer and strict limitations on intensity, frequency, and duration of sport specific skills (drills) must be implemented. Particular attention must be given proprioceptive enhancement to ensure that the athlete has developed sufficient neural protective mechanisms to avoid reinjury For the athlete, this phase is the most critical, most carefully monitored, and most individualized portion of the rehabilitation phases.

The criteria listed below should be measured during and at the end of the rehabilitation program. Before releasing the athlete for full activity, these criteria should be met and equal measurements of opposite uninjured (contralateral) side should be achieved.

These criteria include:
1. Strength of each muscle group
2. Power of each muscle group
3. Endurance of each muscle group
4. Balance between antagonistic muscle groups
5. Flexibility of the muscles of the involved joint along with flexibility of the adjacent joints.
6. Proprioception of the injured joint and affected limb
7. Functional use of that limb in the athlete's sport