Functional Training and
Advanced Rehabilitation
Michael L. Voight, PT, DHSc, OCS, SCS, ATC, CSCS, FAPTA,
Barb Hoogenboom, PT, EdD, SCS, ATC, and Gray Cook, PT, MS, OCS, CSCS

ChApter ObjeCtives

l Define and discuss the importance of proprioception in l Apply a three-step model designed to promote the
the neuromuscular control process. practical systematic thinking required for effective
l Define and discuss the different levels of motor control therapeutic exercise prescription and progression.
by the central nervous system and the neural pathways l Define and discuss objectives of a functional neuromus-
responsible for transmission of afferent and efferent cular rehabilitation program.
information at each level. l Develop a rehabilitation program that uses various
l Apply a systematic functional evaluation designed to exercise techniques for development of neuromuscular
provoke symptoms. control.
l Demonstrate consistency between functional and clinical
testing information (combinatorial power).

Function and Functional fundamental tasks are common to nearly all individuals (barring
pathologic conditions and disability). Lifestyle, habits, injury,
rehabilitation and other factors can erode the fundamental components of
The basic goal in rehabilitation is to restore and enhance function movement without obvious alterations in higher-level function
within the environment and to perform specific activities of and skill. Ongoing higher-level function is a testament to the
daily living (ADLs). The entire rehabilitation process should compensatory power of the neurologic system. Imperfect func-
be focused on improving the functional status of the patient. tion and skill create stress in other body systems. Fundamental
The concept of functional training is not new, nor is it limited elements can first be observed during the developmental
to function related to sports. By definition, function means hav- progression of posture and motor control. The sequence of
ing a purpose or duty. Therefore, functional can be defined as developmental progression can also give insight into the origi-
performing a practical or intended function or duty. Function nal acquisition of skill. The ability to assess retention or loss of
should be considered in terms of a spectrum because ADLs fundamental movement patterns is therefore a way to enhance
encompass many different tasks for many different people. What rehabilitation. The rehabilitation process starts with a two-part
is functional to one person may not be functional to another. It appraisal that creates perspective by viewing both ends of the
is widely accepted that to perform a specific activity better, one functional spectrum:
must practice that activity. Therefore, the functional exercise
progression for return to ADLs can best be defined as breaking l The current level of function (ADLs, work, and sports/
the specific activities down into a hierarchy and then perform- recreation) relative to the patient's needs and goals
ing them in a sequence that allows acquisition or reacquisition l The ability to demonstrate the fundamental movement
of that skill. It is important to note that although people develop patterns that represent the foundation of function and basic
different levels of skill, function, and motor control, certain motor control


504 Physical Rehabilitation of the Injured Athlete

Objectives of Functional Rehabilitation Table 23-1 Four Phases of the Functional Continuum
The overall objective of a functional exercise program is to return Phase Description
patients to their preinjury level as quickly and as safely as ­possible
by resolving or reducing the measurable ­dysfunction within Subconscious dysfunction This is the initial phase when most
­fundamental and functional movement patterns. Specific train- patients are first seen by the clinician.
ing activities are designed to restore both dynamic joint ­stability Patients are totally unaware of their true
and ADL skills.1 To accomplish this objective, a basic tenet of dysfunction (it is in their subconscious)
or are convinced that the problem lies
exercise physiology is used. The SAID (specific ­adaptations to
imposed demands) principle states that the body will adapt to
the stress and strain placed on it.2 Athletes cannot succeed if Conscious dysfunction This is what happens after a movement
they have not been prepared to meet all the demands of their assessment is performed. Patients are
specific activity.2 Reactive neuromuscular training (RNT) helps now aware of their true dysfunction
bridge the gap from traditional ­rehabilitation via ­proprioceptive (it is in their conscious), and they can
start to address the real cause.
and balance training to promote a more ­functional return to
­activity.2 The SAID principle provides constructive stress, and Conscious function This phase is entered once patients can
RNT ­creates opportunities for input and integration. The perform the correct functional pattern,
main objective of the RNT program is to facilitate the uncon- but it is not automatic (it is functional
scious process of interpreting and integrating the peripheral only with conscious control). They still
sensations received by the central nervous system (CNS) into need conscious effort to perform a good
appropriate motor responses. This approach is enhanced by the pattern of movement.
unique ­clinical focus on pathologic orthopedic and neurologic Subconscious function The final stage occurs when patients
states and their functional representation. This special focus can perform a functional pattern
forces the ­clinician to consider evaluation of human ­movement automatically (it is in their subconscious
as a ­complex ­multisystem interaction and the logical starting control) without having to think about
point for exercise prescription. Sometimes this will require a the correction.
­breakdown of the supporting mobility and stability within a
pattern. Regardless of the specific nature of the corrective needs,
all the functional exercises follow a simple but very specific path. ascertainment of which is the purpose of ­functional movement
First, the functional exercise program is driven by a functional assessment (see Chapter 22). By ­looking at movement as a whole,
screening or assessment that produces a baseline of movement all the compensations and conscious sources of pain and dysfunc-
(see Chapter 22). The process of screening and assessment will tion can be highlighted and addressed. Patients fall into one of
rate and rank ­patterns. It will provide valuable information four phases on a functional continuum (Table 23-1).
about dysfunction in movement patterns such as asymmetry, Exercise prescription choices must continually represent the
difficulty with movement, and pain. Screening and assessment specialized training of the clinician through a consistent and
will therefore identify faulty movement patterns that should centralized focus on human function and consideration of the
not be exercised or trained until ­corrected. Second, the func- fundamentals that make function possible. Exercise applied at
tional framework will assist in making the best possible choices any given therapeutic level must refine movement, not simply
for corrective categories and exercises. No single exercise is best create general exertion in the hope of increased tolerance of
for a movement problem, but there is an appropriate category movement.3 Moore and Durstine state, “Unfortunately, exer-
of corrective exercises to choose from. Third, following the ini- cise training to optimize functional capacity has not been well
tial session of corrective exercises, the movement pattern should studied in the context of most chronic diseases or disabili-
be rechecked for changes against the original baseline. Fourth, ties. As a result, many exercise professionals have used clini-
when an obvious change is noted in the key pattern, the screen- cal experience to develop their own methods for prescribing
ing or assessment is repeated to ­survey other changes in move- exercise.”4 Experience, self-critique, and specialization pro-
ment and identify the next priority. By working on the most duce seasoned clinicians with intuitive evaluation abilities and
fundamental pattern, it is possible to see other positive changes. innovations in exercise that are sometimes difficult to follow
Therefore, these four steps provide the framework that makes and even harder to ascertain; however, common characteristics
corrective exercise successful: do exist. Clinical experts use parallel (simultaneous) consid-
eration of all factors influencing functional movement. RNT
l The screening and assessment direct the clinician to the most as a treatment philosophy is inclusive and adaptable and has
fundamental movement dysfunction. the ability to address a variety of clinical situations. It should
l One or two of the most practical corrective exercises from the also be understood that a clinical philosophy is designed to
appropriate category should be chosen and applied. serve, not to be served. The treatment design demonstrates
l When the exercise has been taught and is being performed specific attention to the parts (clinical measurements and
correctly, check for improvement in the dysfunctional basic isolated details) with continual consideration of the whole
movement pattern as revealed by specific tests in the ­screening (restoration of function).3 Moore and Durstine follow their
or assessment. previous statement by acknowledging that “experience is an
acceptable way to guide exercise management, but a system-
This concept is called the functional continuum. Most patients atic approach would be better.”4 We use the three Rs as a way
seek care because of an obvious source of pain or dysfunction. to understand the type of treatment phases that a patient will
What is not obvious is the true cause of the pain or ­dysfunction, undergo (Table 23-2).

3 foundation that demonstrates the hierarchy and interaction of the founding concepts used in rehabilitation (both orthopedic Proprioception. Types of reinforcement devices Functional evaluation and assessment in relation to dysfunction include taping. Others will discover a missing step in the therapeutic information about the position and movement of various body . arbitrary trial-and-error attempts at prescribing effective exer. and various soft tissue techniques. in which the new and arthrokinematic limitations software is loaded into the central nervous system Identification of current movement patterns followed by and a true functional pattern of motion can be facilitation and integration of synergistic movement patterns reprogrammed. exercise design process. individual detects. lead to parallel thinking and multilevel problem tocols. or pro- experience. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 505 Table 23-2 Three Rs of Treatment Phases Box 23-1 R Description Three-Phase Rehabilitation Model 1. many dysfunctions will need support or reinforcement while proper patterns Four Principles for Prescription of Exercise are being introduced. For all practical purposes. and synergistic recruitment principles). Fortunately. The (redundant) purpose of this method is to reduce continually change because no universal standard or gauge exists. It is hoped that these fac- feedback. All considerations for therapeutic exercise pre. the results can be 3. To effectively designed to promote the systematic thinking required for use the wealth of current information and what the future has ­effective prescription of therapeutic exercise and progres. However. Reactive neuromuscular control less than optimal. and the critical thinking needed to develop and neurophysiologic strategies (motor learning. Proprioception and kinesthesia Reset Most problems require resetting of the complete system to break them out of their dysfunctional 2. system. constructed (see Box 23-2). The intent of these four distinct cat- setting process. It includes a ­four-principle this practical framework. sionals.3 The approach is a serial or personal philosophy about therapeutic exercise. and uses relevant sensory infor- This chapter is written with the clinic-based practitioner in mation. Box 23-2 Reinforce After the system has been reset. Known in dosage and design of exercise. It would ­solving. soft tissue mobilization. the scope of problem solving is strictly confined. thereby giving due respect to the many insightful clinicians who tates interaction between orthopedic exercise approaches and have provided the foundation and substance for construction of optimal neurophysiologic techniques. By just jumping to exercises. It will give the novice of the human body will keep the focus (Box 23-2) uncorrupted clinician a framework that will guide but not confine clinical and centralized. If a clinical (­consecutive) step-by-step method that will. or a system to observe their particular strengths and weaknesses protocol remains true to a holistic functional standard. and neurologic). clinicians must adopt an operational framework sion at each phase of rehabilitation. It will provide experienced clinicians with ­effectiveness of exercise only as long as the ­technology. (disability) and impairment and static and dynamic stretching. Inexperienced and experienced functional standards should serve as governing factors that clinicians alike will develop practical insight by applying the improve the clinical consistency of the clinician and rehabilita- model and observing the interaction of the systems that produce tion team for prescription and progression of training methods. Technologic developments can enhance the exercise prescription. egories is to break down and reconstruct the factors that influ- scription will give equal importance to conventional orthopedic ence functional movement and to stimulate inductive reasoning. receptors. The focus is specifically geared to orthopedic The four principles for exercise prescription (see Table  23-3) rehabilitation and the clinical problem-solving strategies used to are based on human movement and the systems on which it is develop an exercise prescription through an outcome-based goal. equipment. Some clinicians will discover reasons for success that were is critical for successful performance of all activities requiring intuitive and therefore hard to communicate to other profes. open-minded clinical approach. proprioceptive a therapeutic exercise progression. Identification and management of motor control Reload The last phase of treatment is the exercise Identification and management of osteokinematic implementation or reload phase. This three. much muscular effort is required to perform a particular action phy. Knowing exactly where our limbs are in space and how mind. Types of treatments that would be considered a reset include joint mobilization. a philosophy based solely on the structure and ­function cise and lessen protocol-based thinking. phase model (Box 23-1) will create a mechanism that necessi. with practice and exercise philosophy is based on technology. It will help the clinician formulate an exercise philoso. exercise standards (biomechanical and physiologic parameters) deductive reasoning. postural devices. perceives. bracing. human movement. intricate coordination of the various body parts. yet to bestow. these four categories help demonstrate the efficient and effective continuity necessary and neuromuscular control for formulation of a treatment plan and prompt the clinician to Success in skilled performance depends on how effectively an maintain an inclusive. orthotics. Much of the confusion and frustration The Three-Phase Model for Prescription ­encountered by rehabilitation specialists is due to the vast vari- of Exercise ety of treatment options afforded by ever improving technology The purpose of this chapter is to demonstrate a practical model and accessibility to emerging research evidence. Dynamic stability phase. tors will serve the intended purpose of organization and clarity.

­equilibrium versus ­disequilibrium. and cognitive somatic ­perceptions or ­kinesthetic aware. Therefore.24. and Joints: Support and Sensory Function through an extensive afferent neurologic network. The functional implication is that mechanoreceptors The second level of motor control interaction is at the level of detect change and rates of change.21.26. the frequency of the neural impulses Second-Level Response: Brainstem decreases.506 Physical Rehabilitation of the Injured Athlete parts is available from peripheral receptors located in and around balance of synergistic and antagonistic forces. compression. muscle spindle and the Golgi tendon organ mechanoreceptors Since that time. sity of the distortion.31 The mono- human models.5-15 Although the primary role of these structures integration of motor control is mechanical in nature by providing structural support and The response of the CNS falls into three categories or levels ­stabilization to the joint.21. With constant stimulation. tion.17. mechanoreceptors will be stimulated to produce reflex stabiliza- thetic sensations in response to joint movement or acceleration. ­simultaneous neural input exists. A detailed generates a ­somatosensory image within the CNS. Quickly adapting receptors cease loop reflex joint stabilization should dominate. synaptic stretch reflex is one of the most rapid reflexes under- dle and Golgi tendon organs are powerful mechanoreceptors. they do tion.27-29 Afferent mechanoreceptor input also works in versus dynamic conditions. not require attention and are thus automatic. These responses biologic transducers for conversion of the mechanical energy of can occur simultaneously to ­control limb position and posture. Rhythmic stabilization exercises encourage monosynaptic whereas slowly adapting mechanoreceptors provide continuous cocontraction of the musculature. both static and dynamic stabiliz- ers provide support. balance is range of motion (ROM) and helps determine the appropriate ­influenced by the same peripheral afferent mechanism that . mechanoreceptors are able to adapt. To and cortical pathways. and appropriate motor strategies are executed. discussion of proprioception and neuromuscular control is also the soft tissues surrounding a joint serve a double purpose: they presented in Chapter 24. levels.28.6. the capsuloligamentous tissues also of motor control: spinal reflexes. the brainstem. mechanoreceptors have been morphohistologi. whereas slowly activities are characterized by sudden alterations in joint adapting receptors continue to discharge while the stimulus is ­position that require reflex muscle stabilization.8.25.16-18 Sensory afferent feedback from receptors in the rehabilitation process is to retrain the altered afferent pathways capsuloligamentous structures projects directly to the reflex and thereby enhance the neuromuscular control system. The role of capsuloligamentous tissues Central nervous system: in the dynamic restraint of joints has been well established in the ­literature.22 This input is then analyzed in the CNS to ­determine interact with the vestibular system and visual input from the joint position and movement.23 The status of the ­musculoskeletal eyes to control or facilitate postural stability and equilibrium of structures is sent to the CNS so that ­information about static the body. both of which accompany ­postural becomes capable of ­influencing muscle tone.15. as opposed to steady-state con. conscious. encourage maximal afferent discharge to the respective CNS lar ­control. physical deformation (elongation. and play an important sensory role by detecting joint ­position and ­cognitive cerebral cortex program planning. mechanoreceptors can also be described in At this level of motor control. are in parallel. or concert with the muscle spindle complex by ­inhibiting antag- biomechanical stress and strain ­relationships can be evaluated.25 onistic muscle activity under conditions of rapid ­lengthening When processed and evaluated.8. lying limb control. activities to encourage short- terms of their discharge rates. The goal of the motion.28 Therefore. When stimulated.27. a neural pattern is generated ness. quickly adapting receptors alterations or perturbations.21 (see Chapter 24 for examples of quickly and slowly foundation for dynamic stability. provide biomechanical ­support to the bony partners making up the joint by keeping them in relative anatomic alignment.30 In conditions of disequilibrium in which grams. synapse with the spinal interneurons and produce a reflexive cally identified around articular structures in both animal and facilitation or inhibition of the motor neurons. ­disruption.10 Although receptor discharge varies according to the inten. In addition. The stretch reflex occurs at an unconscious Mechanoreceptors are specialized end-organs that function as level and is not affected by extrinsic factors. and are not subject to ­cortical interference.28.27-30 cessed.30 These discharging shortly after the onset of a stimulus. the well-described muscle spin.26 Proprioceptive ­information also ­protects the joint from that affects the muscular stabilizers and thereby returns equi- damage caused by movement exceeding the ­normal physiologic librium to the body's center of gravity. Sensory information is sent to the CNS to be pro. thereby producing dynamic feedback and thus proprioceptive information related to joint neuromuscular stabilization. this proprioceptive information and periarticular distortion.33 At this level.21.25. they provide valuable ­proprioceptive information. both the articular and muscular are responsible for providing conscious and unconscious kines. adapting receptors). The afferent fibers of both the joint capsular structures that were primarily reflexive in nature. thereby mediating reactive muscle activ.20 Around a healthy joint.5. First-Level Response: Muscle Physiology of Proprioception When faced with an unexpected load. the first reflexive muscle Sherrington18 first described the term proprioception in the response is a burst of electromyographic (EMG) activity that early 1900s when he noted the presence of receptors in the occurs between 30 and 50 msec. accomplish this goal.30. This information articular structures and the surrounding musculature. With sudden present. brainstem processing.32 These exercises serve to build a position10. afferent mechanoreceptors ditions.19 The efferent motor response should be to hyperstimulate the joint and muscle receptors to that ensues from the sensory information is called neuromuscu. the objective of the rehabilitation p­ rogram ity for dynamic restraint.20.10. motor execution pro. In a normal healthy joint. and pressure) Because they can occur at the same time.8. are sub- into action nerve potentials yielding proprioceptive informa.

When the arm movements are organized. reactive muscle activity that provides sufficient mag- on an ­individual's inherent ability to integrate joint position nitude in the 40. Preparatory muscle activity in anticipation of types of activities or skills that will be required of the athlete joint loading can influence the reactive muscle activation pat- on return to sport.44 Because the shoulder muscles are linked to the rest tasks. Therefore. a mechanism such remember that the sensory systems respond to environmental as a motor program would have to be used to control the entire manipulation. compensations in posture were made. the body as postural adjustments are made before the intended ties are initiated on the cognitive level and include program. both with and without visual input. Failure of the dynamic Balance activities. obstacle to motor learning is the conscious mind. it is important to Therefore.to 80-msec time frame must occur after load- sense with neuromuscular control. Repetitions muscle groups to fire are not even in the shoulder girdle region. When an arm is raised into forward flexion. to eyes closed. the first ming motor commands for voluntary movement. will restraint system to control abnormal force will expose the static enhance motor function at the brainstem level. There is simply no time for the system to process the information and provide feedback about the condition. When the individual goes back to a basic shift the center of gravity forward and cause a slight loss of bal- ADL task. arm and Feedforward Integration movement and postural control are not separate events but Why is a coordinated motor response important? When an instead are ­different parts of an integrated action that raises the unexpected load is placed on a joint. The general progression of static balance activi. thereby allowing the unexpected perturbations can be initiated when the individual is able to bear weight on the to be detected more quickly. The relative forces of the various muscle contractions Confuse vision with unstable visual cues that disagree with the The relative timing and sequencing of these actions proprioceptive and vestibular input (sway referencing).35 Static balance skills muscle spindles. previous knowledge needs to be preprogrammed Third-Level Response: Central Nervous into the primary sensory cortex (Box 23-4). In this case. action.21. If no preparatory to sort and process this overload information by opening addi.40-42 Box 23-3 Box 23-4 Ways to Disadvantage Vision for Stimulation Preprogrammed Information Needed for an Open-Loop of the Proprioceptive System System to Work Remove vision by either closing or blindfolding the eyes. the task becomes easier. Lee showed that these EMG in 70 to 90 msec unless an appropriate response ensues. Very quick movements are completed before feedback can ties is to move from bilateral to unilateral and from eyes open be used to produce an action to alter the course of movement.39 As with all training. control system to organize an entire action ahead of time. which can be accomplished back. the open-loop control system allows the motor in several ways (Box 23-3).21. the CNS is bombarded with input.35-37 With balance training.28. a program that sets up some kind System/Cognitive of neural mechanism or network that is preprogrammed orga- Appreciation of joint position at the highest or cognitive level nizes movement in advance. of these movements will maximally stimulate the conversion of The first muscles to contract are those in the lower part of the conscious programming to unconscious programming. The CNS attempts of the body.35 Static balance activities should be used as terns. In the open-loop system. the single greatest ments after the arm begins to move.27-29. The closed-loop system of CNS integration may not be fast enough Clinical Pearl #1 to produce a response to increase muscle stiffness. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 507 mediates joint proprioception and is at least partially dependent Therefore. The feedforward motor control system takes care of this be stored as a central ­command and ultimately be performed potential problem by preprogramming the appropriate postural without continuous reference to conscious thought as a trig. adjust posture first and then move the arm. Anticipatory activation increases the sensitivity of the a precursor to more dynamic skill activity. with the movement being carried out without any feed- tem. We must get Lee45 demonstrated that these preparatory postural adjust- the conscious mind out of the act! ments are not independent of the arm movement but rather are part of the total motor pattern.43 lower extremity.28.38 back and legs (approximately 80 msec passes before notice- The term for this type of training is the forced-use paradigm. the open-loop sys- tem of anticipation becomes more important in producing the It is important that these activities remain specific to the desired response. These types of activi.33 structures to excessive force. ligamentous damage occurs arm while maintaining balance. Fortunately. A classic example of this occurs in needs to be included in an RNT program. their contraction affects posture. vision must be disadvantaged. This information can then ance. the motor instructions are preprogrammed to Closed-Loop. Open-Loop. For this to occur.27-29. modification first rather than requiring the body to make adjust- gered response. if the movement is fast enough. movement.21. The duration of the respective contractions . To stimulate or facilitate the proprioceptive sys. By able activity occurs in the shoulder) to provide a stable base for making a task significantly more difficult or asking for multiple movement. raising the arm would tional neural pathways. The particular muscles that are needed to produce an action Destabilize vision with demanding hand and eye movements The order in which these muscles need to be activated (ball toss) or by moving the visual surround.34 ing begins to protect the capsuloligamentous structures.25.

Stability exercises focus on the basic sequencing of movement.27 Knowledge of the mobility corrective exercises. and retraining of movement patterns. Both problems should continue to be worked on until a measurable feedforward and feedback neuromuscular control can enhance change is noted. terminating therapeutic exercise interventions. of movement. one can move directly to stability basic physiology of how these muscular and joint mechanorecep. This sequence their playing environment. When no limitation or asymmetry is present during the sory functions of the articular structures. tissue length. Table  23-3 lists and exercise prescription describes the principles for therapeutic exercise prescription. . and appli- ­mobility. but improvement must be noted before advancing. to be controlled. These chrony of muscle firing patterns. such as soft tissue and joint mobi- for postural control is not needed when the body is supported lization and manipulation. If there is any question about compromised mobility. Application of which is common in functional ­activities. each exercise s­ ession should always return to mobility Conclusion: Relationship to Rehabilitation exercises before moving to ­stability exercises. tion. position. This will ensure A rehabilitation program that addresses the need for restoring that proper tissue length and joint alignment are available for normal joint stability and proprioception cannot be constructed the stabilization exercises. include any modality that improves tissue pliability or freedom It is important to remember that most motor tasks are a com. especially during sudden changes in joint position. Treatments of mobility might also against the wall. The quently stimulated. The four Ps represent the four principles for therapeutic exer- ment needs to be addressed first. If the assessment reveals a Table 23-4). Mobility exercises should be cise: purpose. The questions of what. when. corrective exercises. tone. Therefore. dinated motion is critical in developing a ­rehabilitation training balance. If no change in mobility is appreciated. The stability work should reinforce the “facilitated” regularly. it should be the primary focus of the ual leans against some type of support before raising the arm. Stability exercises demand posture. The functional exercise program follows a linear path from basic mobility to basic stability to movement patterns. Mobility does not need to become full or nor- dynamic stability if the sensory and motor pathways are fre. By proceeding in this fashion. cian should not proceed to stability work. the smooth ­coordinated neuromuscular exercises. ­location or side in which mobility is restricted. Because many poor movement patterns are The Four Ps associated with abnormalities in mobility.27 We propose four principles for therapeutic exercise prescrip- The complexity of joint motion necessitates synergy and syn. controlling mechanisms required for joint ­stability are neglected. thereby permitting proper joint principles serve to guide decisions for selecting. and ­stability into specific movement patterns to reinforce ­coordination and timing. the synapses become more capable of mobility allows the patient to get into the appropriate exercise transmitting the same signal. memory of that signal is created and can new mobility. Treatments that promote mobility The motor control system recognizes that advance preparation can involve manual therapy. it needs tors work together in the production of smooth. the clini- cian will have the ability to evaluate the whole before the parts Four principles for therapeutic and then discuss the parts as they apply. which will be described as the four Ps in this section. The true art of rehabilitation is to understand the whole These ­exercises target postural control of the starting and of synergistic functional movement and the therapeutic ­ending ­positions within each movement pattern.14. Rather. advancing. posture. the clini- plex blend of both open. a ­consistent progression. until one has total appreciation of both the mechanical and sen. restoration of move. This is because the role of the joint musculature extends and without the support of compensatory stiffness or muscle well beyond absolute strength and the ­capacity to resist fatigue. Rather.46 When these pathways are posture and position.508 Physical Rehabilitation of the Injured Athlete p­ reparatory postural adjustments disappear when the individ. The corrective exercise progression always starts with mobility exercises. Movement techniques that will have the greatest positive effect on pattern retraining incorporates the use of fundamental ­mobility that movement in the least amount of time. They performed bilaterally to confirm limitation and asymmetry of serve as quick reminders of the hierarchy. Understanding of these these four principles in the appropriate sequence will allow the cli- relationships and functional implications will allow the clinician nician to understand the starting point.14. both and how for functional movement assessment and ­exercise sides should always be checked and mobility cleared before prescription are addressed in the appropriate order (see advancing the exercise program.21 Each time that a signal passes through clinician can proceed to a stability exercise only if the increased a sequence of synapses. all mobility both types of control are often at work simultaneously.47 zation possible because the new mobility provides new sen- sory information. interaction. and stabilization. Stability exercises should be considered as challenges to With simple restoration of mechanical restraints or strengthening posture and position rather than being conventional strength of the associated muscles. and pattern (Table 23-4). greater ­variability and success in returning patients safely back to and the end point for each exercise prescription. When mobility has been restored. corrective exercise program. limitation or ­asymmetry. alignment. mal. Mobility ­exercises Clinical Pearl #2 focus on joint ROM. ­stability. and the new mobility makes improved stabili- be recalled to program future movements. where. and control of forces within the newly available range program. Clinicians should never assume that they know the cation of each principle. is achieved by using functional activities and fundamental move- ment patterns as goals. and muscle ­flexibility.and closed-loop operations. Corrective ­exercise falls into one of the three basic ­categories: ­mobility. controlled coor.

However. ligament. timing. It is not uncommon for clinicians to attempt to and be the focus of the initial therapeutic exercise intervention. The word purpose is simply a cue to be used during both the eval. Management of myofascial and limitations capsular structures will improve osteokinematic movement. It will also help the clinician understand the dynamics of the impairment. recruitment movement patterns the human body that occur in unified and timing be facilitated?” patterns that occupy three-dimensional “How will this affect the limitation in movement?” space and cross three planes (frontal. Identification of current movement When restrictions and limitations are managed and gross motion is restored. Identification and management of The skills and techniques of orthopedic manual therapy are beneficial in identifying specific arthrokinematic osteokinematic and arthrokinematic restrictions that would limit movement or impede the motor-learning process. and integration of synergistic Consideration of synergistic movement is the final step in restoration of function by focusing movement patterns on coordination. function. “How will this affect function?” sagittal.) where the impairment have its greatest effect?” limitations impairment has been identified but “Where in the range of motion does the impairment affect also the positions (with respect to position the greatest?” movement and load) in which the “Where is the most beneficial position for the exercise?” greatest and least limitations occur Integration of Pattern Cues the clinician to continually “How is the movement pattern different on bilateral comparison?” synergistic consider the functional movements of “How can synergistic movement. relation to dysfunction (disability) Observation of whole movement patterns tempered by practical knowledge of key stress points and common and impairment compensatory patterns will improve the efficiency of evaluation. the practice of identifying the single greatest limit- uation process and the exercise prescription process to keep the ing factor will reduce frustration and also not ­overwhelm the clinician intently focused on the greatest single factor limiting patient. Other factors may have been identified in the evaluation. . and motor learning. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 509 Table 23-3 Four Principles for Therapeutic Exercise Prescription Principle Description Functional evaluation and assessment in The evaluation must identify a functional problem or limitation resulting in diagnosis of a functional problem. etc. and transverse) Purpose resolve multiple problems with the initial ­exercise prescription. as well as allow balanced muscle tone between the agonist and antagonist. as well as play a role in the initial setup and design of the exercise program. application of proprioceptive patterns followed by facilitation neuromuscular facilitation–type patterning will further improve neuromuscular function and control. Table 23-4 Memory Cues and Primary Questions Associated with the Four Principles for Prescription of Therapeutic Exercise Principle Memory Cue Memory Cue Definition Primary Questions Functional evaluation Purpose Used during both the evaluation process “What functional activity is limited?” and assessment and the exercise prescription process “What does the limitation appear to be—a mobility problem to keep the clinician intently focused or a stability problem?” on the greatest single factor limiting “What is the dysfunction or disability?” function “What fundamental movement is limited?” “What is the impairment?” Identification of Posture Helps the clinician remember to “When in the development sequence is the impairment obvious?” motor control consider a more holistic approach “When do the substitutions and compensations occur?” to exercise prescription “When in the developmental sequence does the patient demonstrate success?” “When in the developmental sequence does the patient experience difficulty?” “When is the best possible starting point for exercise with respect to posture?” Identification of Position Describes not only the location “Where is the impairment located?” osteokinematic and of the anatomic structure (joint. coordination. The primary questions to ask for this ­principle appear but a major limiting factor or a single weak link should stand out in Table 23-4. “Where among the structures (myofascial or articular) does arthrokinematic muscle group. Identification and management Rehabilitation can be greatly advanced by understanding functional milestones and fundamental movements of motor control such as those demonstrated during the positions and postures paramount to growth and development. These milestones serve as key representations of functional mobility and control.

but Finally. the ­clinician must look for univer- fundamental through the observation of movement functional movements and breaks sal similarities in movement. quantitatively as well. most individuals have the distal muscles. think that the problem is simply symptomatic and structural in By using the fundamental movements of the developmental pro- nature and have no example of dysfunction outside of pain with gression. More simply stated.”48 in normal motor development are the building blocks of skill The functional activity assessment involves a ­reproduction and function.50 Many of these building blocks can be lost while of combined movements common to the patient's lifestyle and the skill is maintained or retained at some level (though rarely occupation.50 The movements used between goniometric measurements of the right and left sides. and asymmetries that when integrated ­functional problem to the patient at each level. it may be necessary to also quantify hypomobility and help create guides for treatment that con- movement performance. evaluation of func- documentation when possible.”48 This is a powerful statement. treatment regimen probably depends more on this ­classification The clinician must take what is learned through the observation than on the choice of exercise technique or protocol. Clinical measurements will first provoke ­symptoms. we accept a 5% ­difference developmental sequence in common. tional activities alone may hide many uneconomical movement but bilateral comparison is also effective and demonstrates the patterns. Normative data are helpful. III Specific clinical Clinical measurements are used the clinician must first consider the nonspecific basic movement measurement to identify and quantify specific problems that contribute to patterns common to all individuals during growth and develop- limitations in motion or control. When the clinician has observed impairment. ­general categories. It must be noted that these movements Level Name Description still involve multiple joints and muscles.49 Static pos. Thus. and lifestyles. The differences are minimal Alterations in the limiting factor may produce positive changes in comparison to the variations seen in the adult population elsewhere. . Specific ­measurement of bilateral differences is difficult. These movements usually fit the definition of a ­optimal).50 with individual differences seen in the rate and quality of the progression. anatomic structures. These classifications are called hypermobility and gross ­movement ­quality. ment. Changes in fundamental movements assessment the movements down to the static can effect significant and prompt changes in function and must and transitional postures seen in the therefore be considered functional as well. the activity limiting factor or a weak link that may require reclassification. or ­demonstration ity of symptoms. The quality of control and movement is assessed. They usually fit the has provided the most consistent base for almost all approaches definition of a general or specific skill. as well as assessment of dynamic These movements (like functional activities) can be compared activity. the adult population has the con- The functional evaluation process should take on three sequential complicating factor of a previous medical and injury ­distinct layers or levels (Table  23-5). ­compensations. reproduction of symptoms. The parameters body mechanics.510 Physical Rehabilitation of the Injured Athlete Table 23-5 Three Levels of Functional Evaluation is broken down into a sequence of primary movements that can be observed independently. Bilateral comparison is helpful when the ­clinician correspond to the reproduction of symptoms. Because the move- normal developmental sequence. as well as the activities that illustrate poor classify a patient through qualitative assessment. The success or failure of a particular exercise Next is the functional or fundamental movement assessment. The developmental sequence is predictable and universal in the first 2 years of life. This breakdown will reduce activities to the many ment within the classification and set a baseline for ­exercise underlying mobilizing and stabilizing actions and reactions that treatment. used by physical therapists. Repetition of the activity for evalua. ment patterns of most adults are habitual and specific and thus are not representative of a full or optimal movement spectrum. Each medical problem or injury has had some degree of should involve qualitative observations followed by ­quantitative influence on activity and movement. right-left asymmetries. of functional movements and break the movements down into the When the appropriate clinical classification is determined. We will refer to these movement building blocks as general or specific skill. the clinician can view mobility and static and dynamic movement. and that define that classification must then be quantified to reveal ­inappropriate weight shifting. are not readily obvious to the clinician. sider the functional status. The clinician should not proceed into exercise of rapidly declining quality will create a ­functional baseline for ­prescription without proper identification of one of these bilateral comparison and documentation. Although enormous of the right and left sides is more similar in the proximal muscles variations in functional movement quality and quantity are seen whereas we accept a 10% to 15% difference in strength of the in specific adult patient populations. clinical measurements will be used to identify and demonstration and observation are helpful for the patient. and the sever- tion of endurance. occupations.… With joint flexibility. and because true qualitative measurements of normal movement in II Functional or The clinician takes what is learned adult populations are limited. Each of the three levels history. Moffroid and Zimny suggest that “Muscle strength stability problems in a more isolated setting. In addition next exercise progression. The clinician must have the patient fundamental movements and consider them precursors to higher demonstrate a variety of positions and not just ­positions that function. identifies qualitative differences between the right and left sides. Periodic reassessment may identify a different major constitute the functional activity. static and transitional postures seen in the normal ­developmental ­specific quantitative measurements will define the level of involve- sequence. “The developmental sequence assessment are reproduced. quantify specific problems that are contributing to limitation of The ­clinician should note the positions and activities that motion or limitation of control. to diverse movement patterns.49 Assessment of indi- I Functional Combined movements common to vidual joints and muscle groups will be ­performed during clini- activity the patient's lifestyle and occupation cal measurements. Many patients into functional activities. Martin notes. which can be identified and considered before the with their many habits. tural assessment is included. poor alignment.

” Janda learning is a survival mechanism. Janda52 stated an interesting point when discussing posture and the muscles ­responsible for its maintenance. Functional or Fundamental Movement This is always the first consideration for all functional evaluation and exercise intervention and this involves restoring movement by addressing the clinical classification and level of involvement. Functional Performance and General Skill Performance Only consider this if all functional movement quality and quantity is within normal or functional limits. However. The principles that the ­clinician reported that 85% of the gait cycle is spent in the single-leg will use in rehabilitation to produce motor learning have already stance and 15% in the double-leg stance.1 Different levels of function. the developmental pro. A simple diagram (Fig. The clinician must remember that motor postural muscles are those which maintain this posture. fundamental gram. “basic human posture should be derived from the This approach will help the clinician consider how the mobil- principal movement pattern. namely gait. protection. then proceed into performance and consider current fundamental movement as an acceptable plateau. In the case of a control or stability problem. dynamic stability and include the transitional postures used in the inappropriate program will take over in an attempt to protect . used to avoid pain or produce alternative movements since onset dlers use tonic holding before ­normal motor development and of the symptoms. It should be considered tural muscles to ­maintain a ­contraction in their shortened range a natural and appropriate response of the body reacting to limita- against ­gravitational or manual ­resistance. the by other body parts. From supine to standing.”52 are listed in Box 23-5. “The muscles that been activated by the functional response to the impairment. Taking this into the presence of pain and altered proprioception. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 511 Specific Skill Because both functional movement and functional performance have been appropriately addressed. Box 23-5 tion would then be inserted as the purpose for a new exercise Most Common Postures Used in Corrective Exercise intervention.”54 An adult orth­opedic tion or symptoms. and have some form of support.”53 Infants and tod. The new problem or limita. Symmetric and asymmetric stance tic approach to exercise prescription. a new motor program has been acti- maturation produce the ­ability to use cocontraction as a means vated to manage the impairment and produce some level of func- of effective support. Therefore. “…erect standing position is so well balance. Since we stand on ity or stability problem that was isolated in the evaluation has one leg for most of the time during walking. followed by specific measurement. Therefore. “Tonic ­holding is the ability of tonic pos. Just as Janda uses single-leg stance to Posture for protection observe postural function with greater specificity than the more conventional double-leg erect standing. If structural or physiologic barriers (that cannot be addressed) limit movement. adults consideration. Most discussions on posture growth and development. 23-1) will help the clinician separate the different levels of function so that intervention and Supine and prone purpose will always be at the appropriate level and assist in the Prone on elbows clinical decision making related to exercise prescription. Otherwise. or ­facilitation. the patient must movements are basic representations of mobility. and inhibition gression can offer greater understanding by examination of the The clinician must restrict or inhibit the inappropriate motor pro- precursors to single-leg stance. The isolated improvement is then integrated into the fundamental movement and reassessed. maintain erect posture in standing on one leg are exactly those Necessity or affinity. The most common postures used in corrective exercise balanced that ­little or no activity is necessary to maintain it. F i g u re  2 3 . the restoration of skill becomes a process of sensory motor learning techniques and positive feedback experiences. who have habitual postures and limited activity may adopt tonic holding for some postures. repetition. The body will sacrifice quality of movement patient may revert to some level of tonic holding after injury or in to maintain a degree of quantity of movement. The primary questions Single-leg stance to ask for this principle appear in Table  23-4. tion that is usually viewed as dysfunction. and reinforcement have been that show a striking tendency to get tight.55 As stated earlier. the stance on one been (temporarily) integrated by substitution and compensation leg should be considered to be the typical posture in man. stability.51 Quadruped Sitting and unstable sitting Posture Kneeling and half kneeling Posture is a word to help the clinician consider a more holis. Likewise. two distinct needs are presented. each pro- and the ­musculature responsible for posture generally refer to gressive posture imposes greater demands on motor control and erect standing.

However. which may include non–weight bearing or partial weight bearing of the spine and extremities or temporary bracing. gravity. The movement to integrate any improved range and benefit from clinician then advances the patient toward more external stresses more appropriate tone. The primary Fi g u re  2 3 . whereas others are unconsciously avoided. anticipatory weight ­shifting. but they also need to consider the posture of ­reinforcement and mark the point (posture) at which ­appropriate the body as the ­fundamental ­neuromuscular platform when making and inappropriate actions and reactions meet. timing. This inter- the result of weakness. one should make sure that the proximal action will require various degrees of acceleration production. With a mobility problem. but the clinician should also understand that reproducibility. movement of the area that the patient will most likely use to substitute or “cheat” with during exercise. The limit the quality of a whole movement pattern. This will create ­positive feedback and that they want to train. Motor programs have been created to allow a patient to push on despite the mobility or stability problem. It is also why bilateral comparison and assessment of proximal and distal structures are mandatory in the evaluative process. Many primary stability prob- lems exist when underlying ­secondary mobility problems are pres- ent. kinesthetic feedback is paramount to motor learning. relaxation. the later sections on position the level at which the impairment hinders movement or control. a joint is not used appropriately because of weakness or restriction. when managed. structures have the requisite amount of stability before strengthen. lying mobility problem is present. the clinician should evaluate the patient's abilities Manual articular and soft tissue techniques. inertia of the body segment. Although most adult patients function at the necessary skill level. little need for active control by the patient. can be used for the primary mobility problem. mobility problem may be the result of compromised stability else- where. The posture is the soil and the movement . coordination. the ­clinician can cueing. Although illustrate a few examples of these types of movements. in the same manner by first observing management of the mass ate. and sequence of movement. The specific posture posture and movement that occur early in the ­developmental of the body is as important as the movement that is introduced onto sequence require a less complex motor task and activate a more that posture. Clinicians may already know the movement pattern basic motor program. verbal and visual feedback is helpful through demonstration and By following this natural sequence of movement. Accordingly. and dynamic postures. and increased ing and then proceed with strengthening or ­endurance ­activities proprioception. and pattern will address resistance in greater detail. If the stability problem is only in a ­particular range of movement.3 be used to mechanically block or restrict substitution of stronger Such exercises require passive or active “locking” by limiting segments and improve quality at the segment being exercised. Posture should This is easily accomplished by creating self-limited exercises. when appropri. that movement must be managed. Posture for recruitment To review. Fi g u re  2 3 . and ground reaction forces. This is a common explanation for microtrau- matic and overuse injuries. Figures 23-2 through 23-5 ­program. ­coordination. Resistance and movement can stress static and with a focus on recruitment. poor tonic responses. gravity. resistance and movement could be used to refine movement and Resistance is not synonymous with strengthening and is only one stimulate appropriate reactions. on ­evaluation many qualitative problems are noted. From this point. Note that the word resistance was not used initially. base of support.2 Supine bridging movement. gravity. deceleration control. and duration or in posture can effectively limit complete or ­partial motion with advance to a more difficult posture in the ­appropriate sequence.512 Physical Rehabilitation of the Injured Athlete and respond to the postural demand. and ground reaction forces. intensity. If the limitation in mobility seems to be such as inertia. Moreover. The ­alteration the clinician can manipulate frequency. The patient must be The clinician must also consider developmental biomechan- trained to deal with the stability problem independently of the ics by dividing movement ability into two categories—internal mobility problem or be at a great mechanical advantage to avoid forces and external forces. Inappropriate joint loading and locking. mechanical support or other assistance must be provided. If an under. it must be managed and tem- porarily taken out of the initial exercise ­movement. and line of gravity.56 observe the point at which a mobility or stability problem will first Correct body position or posture will improve feedback. in some patients the mobility problem ­precedes the stability problem. Some joint movements are used excessively. Internal forces include the center of compensation. External forces include should be reintroduced in a nonstressful manner so that the pre. This can be done simply by partial or complete reduction of stress. The problems can be managed by mechanical consideration of the mobility and stability status of the patient in the fundamental postures. or even tonic holding can be observed with sim- ple activities. vious compensatory pattern is not activated. The secondary mobility problem. a corrective exercise choice. followed by of the body over the particular base provided by the posture. posture identifies the fundamental movements used in growth and development. These movements serve as steps and facilitation toward the acquisition of skill and are also helpful in the ­presence The clinician must facilitate or stimulate the correct motor of skill when quality is questionable. For primary stability problems.3 Rolling to prone.56 Postures must be chosen that of many techniques used to improve ­functional movement in early reduce compensation and allow the patient to exercise below movement reeducation.

If ROM were broken down into thirds. The knee problem creates a dynamic stability involve only the extension third of movement. This mobility can greatly affect movement patterns (such as rolling) that is important because the hamstring muscle will try to assist hip seem to require little of the knee. the base can be narrowed to challenge motor control. The obvious next choice would be active and passive insufficiency. A chop pattern with the arms can be performed while clinician will identify various deficits. measurable qualitative and quantitative is not optimal. and standing. With use of sion to any significant degree because of active ­insufficiency.57 . the ­clinician could potentially prescribe exercise at a ­postural level at which the patient makes significant amounts of in­appropriate compensation and substitution during exercise.g. For the movement pattern with the involved lower extremity. through the appropriate dosage and positioning for exercise. The clinician single-leg bridge (Fig. may demonstrate segmental rolling to one side but “logroll” to the Attention should be paid to positions of body segments not other simply to avoid using a flexion-adduction–medial rotation directly involved in the posture or movement pattern. From the all-fours position. widening the base improves control. the hamstrings cannot assist hip exten- improvements in many gait problems can be achieved. the next progressive posture would be half kneeling with a narrow base. which must be managed continuously. Orthopedic manual assessment of joints and muscles Fi gur e   2 3 . If this narrow-base half-kneeling posture demonstrates asymmetry and dysfunction. ­pattern because of the passive stretch placed on them via maxi- Limitations can also be placed on the posture and movement (the mal passive hip flexion. tified through assessment and objective testing and then addressed ture will require different levels of stability and motor control. a more the hamstrings or spinal erectors through the positional use of complex posture can be assumed. It must therefore be addressed at that impairment was identified in those respective ranges. tall kneeling. this exercise would mental sequence.  23-6). If the move- ments are not compromised. The flexion problem in the developmental sequence long before partial or full third and middle third of movement are not needed because no weight bearing is an issue. However. and as control is developed. patient with a mild knee sprain or even a total knee replacement Position refers to the specific mobilizing or stabilizing segment. this is the pos- ture for which the corrective exercise will be developed. in various functional positions will demonstrate the influence of the impairment and symptoms throughout the range of movement. posture must be selected to start the corrective exercise process. Each pos. Each will be qualified or quan- supine. the lumbar extensors cannot assist the extension easily be identified and incorporated into the exercise program. Position The word position describes not only the location of the anatomic structure (e. postural progression.4 Prone on elbows with reaching. half kneeling. A whereas posture describes the orientation of the body in space. The patient is provided with an example of how limited knee was the hip in extension. Clinical Pearl #3 The clinician must define postural levels of success and fail- ure to identify the postural level at which ­therapeutic ­exercise intervention should start. but the knee was also in flexion. When stability and motor control is the primary problem. Otherwise. by restoring the bilateral extension in the end range of movement when ­gluteal strength segmental rolling function. The primary questions to ask for this principle appear in Table 23-4. or ligament) at which ­impairment has been identified but also the location (with respect to movement and load) at which the greatest and least limitations occur. joint. Hip extension proprioception is now self-limited concept) to control postural compensation and focus. They can also be tucked into a flexed and extended position by bringing the alternate knee to the alternate elbow. alternate arms and legs can be lifted to an extended and flexed position. The limitations can be either reduced strength and control or restricted movement. void of any inappropriate patterning or compensation from If rolling from prone to supine does not present a problem. The load becomes even greater as movement of the extremities causes weight shifting. sion.5 Half-kneeling position. Slightly Fi gure 2 3 . the hip is moving toward exten- has now identified where success and failure meet in the develop. However. This causes a significant motor control load by moving from four points of stability to two. the earliest level of functional limitation can Likewise. seated. Not only level. The is the seed. a Purpose is the obvious reason for exercise intervention.. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 513 to move to quadruped. muscle group.

which is also lem. When a structure is lished. However. endurance. When muscle and joint functions are not optimal. As stated earlier.59 These fac- tors can include motor recruitment efficiency. in addition to clearing of the joints above and below. equipment and the movement ­patterns suggested in some reha- feel of the joint structures would provide specific ­information bilitation protocols. This is the benefit of cor- rect dosage in ­prescription of ­exercise ­position and appropriate workload. This . These negative findings then reinforce the positive evaluated. ­sagittal. A review of the basic PNF patterns can be examined so that. and resisted movements). The spiral and diagonal character is in keep- for goals. poor function in a muscle lished. their ­normality can be estab. and the end. of the human body occurring in unified patterns that occupy nematic relationships for movement and bilateral ­comparison is three-dimensional space and cross three planes (frontal. Most of the ­significant improvement is not due to training volume. Usually. greater deficits are associated with more drastic Fi gure   2 3 . “Positive ited ­pattern. which ment (mobility) or control ­(stability) movement.3 Sometimes this is not easily ascer- ture and position represents mobility observed by selective tained by ­observing the design and use of fixed-axis exercise tension (active. in Table  23-4. If all other factors are addressed. increased proprioceptive awareness. cantly reduced function. information that will help define the baseline of bones and joints and the ligamentous structures. ­improvement. is limited in some way. most ­advantageous sequence (­proprioception) to create move- Quantitative measures will reveal a degree of deficit.” When a structure proximal and distal structures must also be compared with within the sequence is limited by impairment.514 Physical Rehabilitation of the Injured Athlete or without ­resistance) to fatigue. The word pattern will serve as a cue to the open and closed chain considerations. this region must evaluation process and outlined in the “position” considerations. then only can the ­diagnosis be that ­structure. Muscles of the trunk and extremities are recruited in the for exercise. Cyriax58 noted. It should be equally viewed as an input prob- be used to document a deficit in performance. one should look at the basic PNF patterns involving findings emanating elsewhere. This central point of physi. The characteristics of the individual muscles. onset of symptoms. The basic patterns of proprioceptive neu- about the mechanical nature of the limitations and symptoms. Obviously. or muscle hypertrophy but to the efficient adaptive response of neural factors. by contrast. “The be considered along with many other (quantitative) clinical mass movement patterns of facilitation are spiral and diagonal parameters to describe isolated or positional function. as well as ­psychologic ­factors. This in character and closely resemble the movements used in sports will provide clear communication and specific documentation and work activities. Variables. regarded and established. can be used to establish must not simply view reduced function of a PNF pattern as an strength or ­endurance baselines. of motion is also in harmony with the topographical alignment tation in mobility or stability will require bilateral compari. to be limited. tively protects the respective joints and muscles from undue sible. passive. tissue metabolism.58 romuscular ­facilitation (PNF). Pattern Qualitative measures will provide specific information about The primary questions to ask for the pattern principle appear exercise start and finish position. The clinician should document the lim- cal examination is often overlooked. The isolated ­segment is usually identified in the If a lesion appears to lie at or near one joint. A maximum repetition test (with noreceptor and muscle spindle functions are not optimal. are excellent examples of how the brain groups move- limitations in stability and provide a more specific starting point ment. and recovery time should stress and strain. Bilateral comparison should output problem. or loss of exercise quality is a common example.6 Single-leg bridge. an entire PNF pattern to some degree. any limi. and motor learning. beneficial to the rehabilitation specialist. for both the extremities and the Assessment of positional static and dynamic ­control will reveal spine. and the need for ­cueing and ­clinician to continually consider the functional movements feedback. It is equally essential The resultant effect on one or more movement patterns must for the adjacent joints and the ­structures around them to be also be investigated. movement speed and ­direction. of the muscles from origin to insertion and with the structural son. improved agonist/antago- nist coordination. This will allow close tracking of home exercise compliance and help establish a rate of improvement. and ­transverse). be examined for signs ­identifying its site. endurance. the clinician ­including intensity and duration. Multiple patterns can be limited in some way. task familiarity. the rate of improvement should be quite large. as well as be a tracking device for the effectiveness ing with the spiral rotatory characteristics of the skeletal system of treatment. the obvious starting point. and ROM of quantify performance before prescription of exercise. appropriate phasic and tonic response to activ- ity. ROM. Not only does can be recorded in the form of a percentage through bilateral this provide efficient and economical function. Voss et al60 clearly and eloquently stated. but it also effec- comparison and compared with normative data when pos. This type for initial ­exercise ­considerations. Close observation of the osteokinematic and arthroki. mecha- recorded as a ­percentage. Treatments should be geared to stimulate these changes ­whenever possible. improved timing. the entire pattern their contralateral counterparts. strength.” but usually one pattern in particular will demonstrate signifi- After position and movement options have been estab. as well as the isolated segment causing the pattern signs must always be b­ alanced by c­ orroborative negative signs. Specific identification of the struc. a trial exercise session should be used to observe and group or joint can limit the strength.

64 not physically stressful) that build on the accomplishment of Barrett65 showed an increase in the threshold for detection of an earlier task will reinforce one level of function and continu. Manual ­resistance. of passive motion in the midrange of motion. Altered pro. which dis- torts the initial information (before movement is initiated). the static ­structures may be exposed to insult unless the reactive muscle By continuously considering the pattern options.61. This is struction with a patellar-tendon autograft or allograft. as well as appropriate use of phasic and stability of the joint but also diminishes the capability of the tonic responses. treatment old for detection of passive motion was observed in a knee with ­techniques focused on improving their function have not gener.62 results of these studies. and Prevention of Reinjury Although it has been demonstrated that a proprioceptive ­deficit occurs after knee injury. dynamic neuromuscular restraint system. when tested at the end ROM. Clinical Pearl #4 Without adequate anticipatory muscle activity. An ortho. the resultant partial problem at a subconscious level during necessary daily activities deafferentation alters the afferent information received by the throughout the remaining week. cal score. A number of studies have examined weighted cable or elastic resistance.63 A longer thresh- receptors have been documented in the literature. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 515 can create an input or proprioceptive problem and greatly dis. and integrated function at all levels of rehabilitation. Consequently. a reconstructed ACL than in the contralateral uninvolved knee ally been incorporated into the overall rehabilitation program. the clinician should use posture and normal knee. Barrett65 ­measured and even proprioceptive taping can improve recruitment and proprioception after autogenous graft repair and found that facilitate coordination. A simple movement set focused ament (ACL) rupture and functional ­instability. speed. whereas posttraumatic joint effusion or hemarthrosis19 illustrate pedic outpatient cannot afford to have a problem simply isolated indirect effects. Instead.65 Harter et  al68 could not demonstrate a significant difference in the reproduction of passive positioning between Reestablishing proprioceptioin the operative and nonoperative knee at an average of 3 years after ACL reconstruction. Effects of Injury on the Proprioceptive tort joint ­position and muscle tension information. ­surgery and ­rehabilitation. . as pattern limitations. PNF-style movement pattern CNS and therefore the resulting reflex pathways to the dynamic exercise can often be taught as easily as an ­isolated movement stabilizing structures. that partial deafferentation of the joint occurs as the mechano- prioception. This partial deafferentation may be tentionally become part of the recommended exercises and due to either direct or indirect injury. He further noted that patient satisfaction was position to set the initial movement and design ­proprioceptive more closely correlated with proprioception than with clini- feedback to produce a more normal ­pattern whenever possible. as detected by a threshold for detection Although the concept and value of proprioceptive mechano. if not properly identified and outlined. any aberration in joint motion and position sense will affect both the feedforward and feedback neuromuscular control ­systems.66 on isolation of a problem can quickly be followed by a pattern who also found diminished proprioception after ACL rupture. weight-shifting ­activities. both kinesthetic awareness Direction. The mainly due to lack of information about how mechanoreceptors importance of incorporating a proprioceptive element in any contribute to the specific functional activities and how they can comprehensive rehabilitation program is justified from the be specifically activated. receptors become disrupted. Kinesthesia has been reported to be and neuromuscular control restored after surgery. as well activity can be initiated to contribute to dynamic restraint. three times a week for 30 minutes only to reintegrate the same Whether from a direct or indirect cause. The ­integration can be followed ­confirmed this finding. that will improve integration.63. as System well as feedback (once movement is in progress). Successive intervals of increasing difficulty (though will result in an alteration in position and ­kinesthesia. the clinician will be able to refine the exercise prescription and reduce unnecessary supple- mental movements that could easily be incorporated into Restoration of Proprioception pattern-based exercise.67 Therefore. These pathways are required by both the and will produce a significantly greater benefit. Therapeutic feedforward and feedback motor control ­systems to ­dynamically exercise is no longer limited by sets as repetitions of the same stabilize the joint. proprio­ception after ACL reconstruction. Therefore. Direct effects of trauma therefore be reinforced. it is thought clinician cannot consider only functional output. passive motion in a majority of patients with anterior cruciate lig- ally be a challenge for the next.63 Lephart et al69 found similar The neurosensory function of the capsuloligamentous ­structures results in patients after arthroscopically assisted ACL recon- has taken a back seat to the mechanical structural role. the After injury to the capsuloligamentous structures. The clinician must focus on synergistic would include disruption of the joint capsule or ligaments. and amount of resistance (or ­assistance) will and ­reposition sense can be at least partially restored with be used to produce more refined patterns. injury to the and give the clinician a chance to observe subcortical control of capsuloligamentous structures not only reduces the mechanical mobility and stability. Diminished proprioceptive ­sensitivity by a familiar fundamental movement or functional activity that has likewise been shown to cause giving way or episodes of may reduce the amount of conscious and deliberate movement instability in the ACL-deficient knee. Corrigan et al. can unin. The clinician should refrain from ­initially proprioception was better after repair than in an average patient ­discussing specific structural control such as pelvic tilting or with an ACL ­deficiency but still significantly worse than in a scapular retraction. A disruption in the ­proprioceptive ­pathway activity.

51 They found that proprioceptive training of the neuromuscular system permits rapid ­adaptations ­during through stabilometry. Walla et al73 found that 95% of patients were able to the phases should be followed in order and should use the four successfully avoid surgery after ACL injury when they could rehabilitation considerations mentioned earlier (the four Ps) at achieve “reflex-level” hamstring control. reflex facil- and function. design. which in turn stimulates the muscles around the joint to function. injury may occur.69. and standing being the toughest) or changing the resistance (unloaded with core activation being the easiest and loaded ­without core activation being the hardest). The single- leg hop test was chosen for its integrative measure of neuromus. Maintenance of equilibrium and an improve. This phenomenon was take into consideration the levels of CNS integration. Their study suggested that limb function relied itation through reactive training. the rehabilitation program that enhance preparatory and ­reactive cantly reduced episodes of giving way after ankle sprains. The three-phase rehabilitation cular control because a high degree of proprioceptive sensibility and functional ability is required to successfully propel the body model ­forward and land safely on the limb. Ihara ute to efficient regulation of motor control. Because afferent input is altered refers to the four possible exercise positions combined with the after joint injury. each of the three ­levels that proprioceptive deficits could be reduced with training on must be addressed to produce dynamic stability. and loading of Table 23-6 Three-Phase Rehabilitation Model the joint to the CNS. and production of reflex ­muscle ment in reaction to sudden perturbations on the unstable board activation. The main objective of the antagonist cocontraction rehabilitation program for neuromuscular control is to develop 3 Restore reactive Initiate reflex muscular or reestablish the afferent and efferent characteristics around the neuromuscular control stabilization joint that are essential for dynamic restraint. the researchers were able to success. The four-by-four method of therapeutic exercise design fully decrease the reaction time. Therefore. For the first reported by Freeman and Wyke in 1967 when they stated ­rehabilitation program to be complete. Clinical Pearl #5 Relationship of Proprioception Specific rehabilitation techniques that produce ­adaptations to Function to enhance the efficiency of neuromuscular ­techniques Barrett65 demonstrated the relationship between proprioception include balance training. altered afferent pathways is critical for shortening the time lag The difficulty of any exercise can be increased by either in ­muscular reaction to counteract the excessive strain on the changing the position (non–weight bearing being the easiest ­passive structures and guard against injury. place successive demands on the athlete during rehabilitation. The shorter the time lag. In string contraction could be shortened with training.46. signifi. repetition/low-load exercises. With the addition.74 et  al53 confirmed the work of Freeman and Wyke by demon- strating that the results of stabilometry could be improved with coordination training on an unstable board. The specific rehabilitation techniques must also improved neuromuscular coordination. motion. and Nakayama70 demonstrated a reduction in neuromuscular lag these characteristics include the sensitivity of the mechanore- time with dynamic joint control after a 3-week training period on ceptors and facilitation of the afferent neural pathways. biofeedback training. As ­discussed earlier.70 If a time lag exists in the neuro. Application of the four Ps at each phase is crucial to found that the reflex arc between stressing the ACL and ham. enhance- an unstable board. and eccentric and high- more on proprioceptive input than on strength during activity. the foundation of neuromuscular through proprioception control is to facilitate the integration of peripheral sensations and kinesthesia related to joint position and then process this information into 2 Restore dynamic stability Encourage preparatory agonist- an effective efferent motor response. it was necessary to obtain voluntary or the objective of reestablishment of neuromuscular control. or training on an unstable surface. Giove et  al71 reported a The following is a three-phase model designed to progressively higher success rate in returning athletes to competitive sports retrain the neuromuscular system for complex functions of with adequate hamstring rehabilitation. proprioceptive sensitivity to retrain these four types of resistance used (Table 23-7).21. The model phases are succes- and Nakayama70 found that simple hamstring strengthening sively more demanding and provide sequential training toward alone was not adequate. Tibone et al72 and Ihara sports and ADLs (Table 23-6). activities. Phase Description Objective muscular reaction. Tropp activity.516 Physical Rehabilitation of the Injured Athlete Methods to enhance proprioception after injury or surgery Several different afferent and efferent characteristics contrib- could improve function and decrease the risk for reinjury. the less stress on the ligaments and other soft tissue structures 1 Restore static stability Restoration of proprioception around the joint.21 .40. The ­plasticity an unstable surface.21 Blackburn and Voight33 also found high correlation between diminished kinesthesia and the single-leg hop test. ment of muscle stiffness. This reflex-level control of knee instability for return to functional three-phase model has also been described as RNT. Ideally. It is important to Restoration of Efficient Motor Control remember that exercises that present too much difficulty will How do we modify afferent/efferent characteristics? The ­mechanoreceptors in and around the respective joints offer information about change in position. Ihara and Nakayama70 each phase. progression of exercise is guided by the four-by-four use of unstable boards.70.

Sheth et al79 . The patient has sloppy. or taping about the joint means increased resistance. joint reposition exercises should be used to provide maximal stimulation of the peripheral mechanoreceptors. and repeat the process. stabiliza- tension. ­systems. wrap.69 ity will give all the information that one needs to know by pro. Reliable tions of ­compromise to produce maximal afferent input into the kinesthetic and proprioceptive information provides the foun.77.76 In addition to weight-bearing exercises. coordinated movement from the beginning. Therefore. The RNT program is centered on stimu. and finally progressing to movement with a single-leg stance. observe the unexpected joint translation.55 The use of closed chain exercises not only movement 8 to 15 times with good quality of movement enhances joint congruency and neurosensory feedback but also and no signs of stress. the ever. To facilitate appropriate kinesthetic and proprioceptive input ducing one of three responses: into the CNS. Environmental conditions lation of both the peripheral and central reflex pathways to the are manipulated to produce a sensory response (Box  23-6). the clinician can stabilization ­exercises can be included early in the RNT pro- observe the response and act accordingly.10. Phase II: Restore Dynamic Stability The second objective of the RNT program is to encourage ­preparatory agonist-antagonist cocontraction. and repeat the process.70. The l It is too easy. To facilitate these pathways. but possible. Dynamic coacti- dation on which dynamic stability and motor control is based. The patient can perform the movement for use of closed kinetic chain activities creates axial loads that maxi- more than 30 repetitions with good quality. efforts to do so have been successful in human and animal studies. positions of vulnerability can be used safely Non–weight bearing (supine or prone) Unloaded with core activation (see Tables 23-8 and 23-9). there is a sharp decline in quality as demonstrated by muscle receptors are facilitated by the change in both length and a limited ability to maintain full ROM. then going to a half-kneeling activity.65. If the initial choice gram to enhance ­neuromuscular coordination in response to of exercise is too difficult. Reducing electro- mechanical delay between joint loading and protective muscle The Four Types activation can increase dynamic stability. Concerning the mechanism of the effects. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 517 force the patient to revert back to a compensation pattern. or the patient just becomes physically tions and thereby stimulate reflex ­stabilization. in this phase. enhance the ­conscious appreciation of proprioception. or a more complex or involved ­movement lating the ­cutaneous mechanoreceptors. skeletal muscles. Although it was once believed that the speed of the stretch reflexes could not be directly enhanced. Efficient coacti- Phase I: Restore Static Stability Through vation of the musculature restores the normal force couples Proprioception and Kinesthesia that are necessary to balance joint forces. Increasing difficulty rarely addition of a compressive sleeve. Persistent use of fatigued. Table 23-7 Four-by-Four Method for Design This has ­significant implications for reestablishing the reactive of Therapeutic Exercise ­capability of the dynamic restraint system. and it only gets active and passive joint-repositioning exercises can be used to worse. how- minimizes shearing stress about the joint.21. phase is postural stability training. split.79 Tropp Kneeling (half kneeling or tall Loaded with core activation et  al53 and Wester et  al80 reported that ankle disk training sig- kneeling) nificantly reduced the incidence of ankle sprains. The intensity of the exercises can response to the next set. mally stimulate the articular mechanoreceptors via the increase in l It is challenging. If the initial be manipulated by increasing either the weight loaded across the exercise is too easy. the joint must be placed in back motor control systems. A more advanced posture. these pathways will decrease the response time when an unantici- l It is too difficult. force requires both the feedforward and feedback motor control tion received by the CNS can alter the feedforward and feed. A typical through 23-10 provide examples of exercises that can be begun example would be some form of activity with a rolling move. Tropp et al53 suggested that unstable Standing (lunge.55 The objective is to induce ­unanticipated perturba- tion. balance.21 The cornerstone of rehabilitation during this motor control skills.38. and thereby reduce the loads imparted onto the static to both restore functional stability about the joint and enhance structures. increase joint con- Functional neuromuscular rehabilitation activities are designed gruency. the first objective of positions of ­compromise for the patient to develop reactive sta- the RNT program is to restore the neurosensory properties of bilizing strategies.10. the ­damaged structures while at the same time enhancing the Therefore. Quadruped Unloaded without core Proprioceptive training for functionally unstable joints after activation injury has been documented in the literature. In the controlled clini- The Four Positions of Resistance cal environment. Figures 23-11 and 23-12 provide examples of exercises that can be implemented in this phase. increase the difficulty. vation of the muscles about the joint to produce a stabilizing It has already been established that altered afferent informa. single leg) Loaded without core activation surface training reduced the proprioceptive deficit. squat. The first objective that should be addressed The use of unstable ­surfaces allows the clinician to use posi- in the RNT program is restoration of proprioception. the first set of exercises following a change in mobil. Rhythmic Using this as a corrective exercise base. decrease the difficulty. ­spinal cord and thus produce a reflex response. poorly pated joint load occurs. a smaller can also provide additional proprioceptive information by stimu- base of support. The patient can perform the compressive force. Between 15 and 30 repetitions. observe the response joint or the size of the perturbation (Tables 23-8 and 23-9). The to the next set. ment pattern moving to a quadruped exercise.75 At the same time. stressful.53.78 Figures  23-7 ­pattern is usually indicated to increase the difficulty. and coordination. ­sensitivity of the secondary peripheral afferents.

RI. extension. pos. Flex. RS. PNF. showed that postural control improved after 6 weeks of training progression of activities must be goal oriented and specific to the when performed 15 minutes per day. Konradsen and Ravin81 initiated into the overall rehabilitation program after adequate also suggested from their work that afferent input from the calf healing and dynamic stability have been achieved. rhythmic stabilization.54 whose tasks that will be expected of the athlete. RI 90°/90 ER at end range ER Conc/Ecc Side-lying RS. SRH. SRH ER/IR Conc/Ecc Weight-bearing RS. The key musculature was responsible for dynamic protection against sud. ER. ­controlled to uncontrolled activities. Bernier and Perrin. OTIS. Concentric. Initially. slow reversal hold. satisfactorily completing the activities that are considered pre- formed three to five times a week. Pinstaar et al82 reported that ­postural Progression of these activities is predicated on the athlete sway was restored after 8 weeks of ankle disk training when per. Tropp and Odenrick39 also requisites for the activity being considered. . den ankle inversion stress. SRH. oscillating techniques for isometric stabilization. and from each of these training programs do have some differences. reciprocal isometrics. flexion. Ecc. from low-force to high-force activities. external rotation. They concluded that the changes Neuromuscular Control would be supported by the concept of reciprocal Ia inhibition via Dynamic reactive neuromuscular control activities should be the mechanoreceptors in the muscles. UE.518 Physical Rehabilitation of the Injured Athlete Table 23-8 Upper Extremity Neuromuscular Exercises Phase I: Proprioception Phase III: Reactive and Kinesthesia Phase II: Dynamic Stabilization Neuromuscular Control Goals Normalize motion Enhance dynamic functional stability Improve reactive neuromuscular abilities Restore proprioception and kinesthesia Reestablish neuromuscular control Enhance dynamic stability Establish muscular balance Restore muscular balance Improve power and endurance Diminish pain and inflammation Maintain normalized motion Gradual return to sport/throwing Stability Exercises Joint repositioning PNF D2 Flex/Ext PNF D2 Flex/Ext Movement awareness Supine RS with T-band RS Side lying Perturbation RS RI Seated Perturbation RS—eyes closed SRH Standing 90°/90° PNF D2 Flex/Ext PNF D2 Flex/Ext at end range ER at end-range RS PNF D2 Flex/Ext RS. also found that ­reactive neuromuscular control is from slow-speed to ­fast-speed postural sway was improved after 6 weeks of training. ­ emonstrated changes in healthy adults in patterns of contrac- d tion of the inversion and eversion musculature before and after Phase III: Restore Reactive training on an unstable surface. upper extremity. internal rotation. RI Scapular strengthening ER Conc/Ecc RS Weight bearing (axial compression) Scapular PNF—RS. Ext. RI ER/IR at 90° abduction—eyes closed ER/IR Conc/Ecc RS Standing while leaning on hands PNF D2 Flex/Ext—eyes closed Eyes closed Quadruped position Balance beam Standing on one leg Tripod position PNF D2 Flex/Ext—balance beam Reactive plyoballs Biped position Slide board—side to side Push-ups on unstable surface Axial compression with ball on wall Slide board push-ups UE plyometrics OTIS Axial compression—side to side Two-handed overhead throw Axial compression—unstable surfaces Side-to-side overhead throw Plyometrics—two handed (light and easy) One-handed baseball throw Two-handed chest throw Endurance Two-handed underhand throw Wall dribble Wall baseball throw Axial compression circles Axial compression—side/side Sports-specific Underweighted throwing Overweighted throwing Oscillating devices Boing Body Blade Conc. should evoke a balance reaction or weight shift in the lower ing in subjects with functional instability of the ankle. proprioceptive neuromuscular facilitation. objective is to initiate reflex muscular stabilization. IR. these exercises tural control improved after 6 to 8 weeks of proprioceptive train. extremities and ultimately progress to a movement pattern. SRH. eccentric. With this in mind. program consisted of balance exercises progressing from simple to The general progression of activities to develop dynamic complex sessions (3 times a week for 10 minutes). Although activities.

When fatigue patient by using visual or proprioceptive input. WS. Therefore. partial-arc controlled exercise. Anterior weight shift. biomechanical ankle platform system.. or both. running. These reac. closed chain kinetic. LWS. posterior weight shift.g. . A  sudden alteration in joint position induced by either the (oscillating techniques for isometric stabilization) and other ­clinician or the athlete may decrease the response time and serve devices (e. the clinician must be concerned with the requiring explosive acceleration. they are specifically designed to facilitate neuromuscular movement or as complex as a dynamic plyometric response ­reactions. or visual obstacles). Develop static control and posture jumping. or change in kinesthetic input and quality of the movement patterns rather ­direction. weight shift. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 519 Table 23-9 Lower Extremity Neuromuscular Exercises Phase I: Proprioception and Phase III: Reactive Kinesthesia Phase II: Dynamic Stabilization Neuromuscular Control Goals Normalize motion Enhance dynamic functional stability Improve reactive neuromuscular abilities Restore proprioception and kinesthesia Reestablish neuromuscular control Enhance dynamic stability Establish muscular balance Restore muscular balance Improve power and endurance Diminish pain and inflammation Maintain normalized motion Gradual return to activities. CKC. PACE. PWS. cutting Stability Exercises Bilateral to unilateral Oscillating techniques for isometric Squats Eyes open to eyes closed stabilization (OTIS) Assisted Stable to unstable surfaces AWS AWS Level surfaces PWS PWS Foam pad MWS MWS Controlled to uncontrolled LWS LWS PNF Chops/lifts Chops/lifts Rhythmic stabilization ITIS Lunges (front and lateral) Rhythmic isometrics PACE AWS Slow reversal hold PNF PWS Rhythmic stabilization MWS Rhythmic isometrics LWS Slow reversal hold Stationary walking with unidirectional WS Stable to unstable surface Stationary running Rocker board PWS Wobble board MWS BAPS LWS Balance beam AWS Foam rollers Mountain climber Dyna-disc CKC side to side Fitter Slide board Plyometrics Jumps in place Standing jumps Bounding Multiple hops and bounds Hops with rotation Bounds with rotation Resisted lateral bounds Box jumps Depth jumps Multidirectional training Lunges Rock wall Clock drill Step-tos Four-square Agility training AWS. foam rolls. PNF. to develop reactive strategies to unexpected events. Although these exercises will improve physiologic param- tions can be as simple as static control with little or no ­visible eters. deceleration. impulse techniques for isometric stabilization. proprioceptive neuromuscular facilitation. motor control becomes poor and all training effects are lost. via tubing occurs. medial weight shift. MWS. The exercises will allow the clinician to challenge the than the particular number of sets and repetitions. lateral weight shift. ITIS. medicine balls. BAPS.

articular loading and unloading. Therefore. Fi g u re  2 3 . during the exercise progression. The progression should be from straight plane to multiplane movement patterns. ADL move- ment does not occur along a single joint or plane of movement.7 Rhythmic stabilization. The most important factor to consider during rehabilita- tion of patients is that they should be performing functional activities that ­simulate their ADL requirements. This rule applies not only to the specific joints involved but also to the speed and amplitude of movement required in ADLs.520 Physical Rehabilitation of the Injured Athlete Fi gure  2 3 . be placed on ­progression from simple to complex neuromotor . controlled acceleration and deceleration. the focus of the neuromuscular rehabilitation pro- gram is to restore ADL and sport-specific skills. all aspects of normal ­function should be observed. balance control during weight shifting and changes in direction. Exercise and ­training drills that will refine the physiologic parameters required for return to preinjury ­levels of function should be incorporated into the program. and ­eccentric muscle control. Therefore. exercise for the kinetic chain must involve all three planes simultaneously. and demonstration of both conscious and unconscious control (see Tables 23-8 and 23-9). It is essential that the exercise program be specific to the patient's needs. Emphasis in the RNT program must Figure 23-9 Single-leg balance on an unstable (foam) base.1 0 Single-leg balance with oscillating techniques for isometric stabilization. Box 23-6 Balance Variables That Can Be Manipulated in the ­­Dynamic Stability Phase to Produce a Sensory Response Bilateral to unilateral stance Eyes open to eyes closed Stable to unstable surfaces Figure 23-8 Quadruped position with manual perturbations. When dynamic stability and reflex stabilization have been achieved. including ­isometric. Figures  23-13 through 23-15 are examples of exercises that can be implemented in this phase. concentric.

before advanced conditioning and skill acquisition. CHA P TER 2 3     F u n c t i o n a l Tr a i n i n g a n d Ad v a n c e d R e h a b i l i t a t i o n 521 Figure 23-11 Plyoback. Fi gure  23. resistance. Fi g u re  2 3 . ­including prop. Just being great at a technique is requiring refined ­neuromuscular ­mechanisms. not good enough.12 Lunging movement. Unexpected activities ­during ADLs are down into its component parts so that they can be performed in by nature unstable. forward with sport cord Figure 23-14 Dynamic training. and then progress to highly complex motor skills based in a systematic approach. The more patients rehearse in this type of a sequence that allows acquisition or reacquisition of the activ. and plan effectively because corrective exercises will evolve and ing program should begin with simple activities. Body Blade–low position. prioritize. the better they will react under ­unrehearsed con- ity. . two-handed upper extremity chest pass. The rioceptive and ­kinesthetic awareness. A significant amount of controlled chaos should be during ­function. The clinician's professional skill must be ing/running. patterns that are specific to the demands placed on the patient s­ tabilization. which provides reflex joint clinician should not worry. such as walk. Body Blade–elevated position. The clinician needs to learn how to categorize. The train.1 3 Dynamic training. equipment will change. Technical aspects of exercise will change. ­environment. Basic conditioning and skill acquisition must be achieved ditions. The functional progression breaks an activity included in the program. This system is not based on exercise.

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