Progressive systematic functional

rehabilitation
Ameema,hina,ifra
 Understanding progressive rehabilitation, assessment
and observation

• On initial observation of an injury it is

essential to perform an injury screening.
• two acronyms that provide an effective
method of gathering information relating to
possible trauma are
• SINS (severity, irritability, nature and stage)
• SOAP notes (subjective, objective, assessment
and plan)
• Systematic, functional and progressive
rehabilitation involves the process of carefully
considering the key components of
musculoskeletal trauma.
• This involves adequate management of the
injury in order to prevent further soft tissue
trauma and enable a progressive treatment
protocol to be implemented effectively
• However, during the rehabilitative process it is
imperative to ensure, strengthening is not focused solely
on a specific muscle, this is because during closed kinetic
chain exercises, which simulate functional movement, it
is inaccurate to make judgement stating a specific muscle
is responsible for poor neuromuscular control
• however, fatigue does not occur in a single muscle group
when performing closed kinetic chain exercises
• Similarly, deficits in muscular strength have been shown
to increase the risk of injury
• Therefore, when prescribing exercises during the rehabilitation of an athlete,
it is important to take into account not only strengthening of the effected
region of the body, but also to continue strengthening the entire extremity,
which can prevent muscle imbalances and potential injury concerns.
• Consideration and application of the concept of continual progression is
useful
• as it provides the clinician with the ability to justify why specific exercises
have been prescribed and how best to regress or progress the exercises
depending on the athlete’s development through there rehabilitation
process.
• During the final stages of a rehabilitation programme it is important that the
athlete performs exercises within their functional range
• By ensuring exercises are performed within a functional range, this limits the
possibility of re-injury
• In addition to introducing the athlete to functional
exercise it is important to ensure that movements
simulate the patterns of movement the athlete will
eventually perform in their sport, this needs to include
the relevant muscle actions (concentric, eccentric,
isometric), velocity of movement, force generation,
power output and rate of force development.
• Muscle actions that relate to effective movement
patterns in the athlete’s sport must be implemented
during final stages of rehabilitation
 Inflammation and pain management

• Liebenson (2006) found that the application of

an early stage rehabilitation programme with
restoring full pain-free functional range of
motion as a main objective, is beneficial and
can result in a rapid attainment of pre-set
functional tasks.
• for example cryotherapy can be used in the
acute management of soft tissue injuries.
 Range of motion and flexibility
• Range of motion (ROM) and flexibility are
central to rehabilitation and used not only as
markers of assessment, but more importantly
as techniques for rehabilitation practices
• ROM testing is an essential component of
athlete evaluation and provides the
practitioner with the acquired information
including active and passive ROM
• During initial musculoskeletal evaluation the clinician may have to
take the athlete through active and passive range of motion.
Active range of motion is when the athlete moves the affected
joint through its range without any external influence.
• Passive range of motion occurs when the clinician takes the
affected limb through its range in order to provide information
regarding the integrity of joint or ‘end feel’
• This usually provides important information regarding the
client’s condition and informs the clinician about future action,
assessment and intervention.
• The athlete should not return to full activity until full pain-free
functional range has been established
 Flexibility training
• As flexibility is an expression of range of
motion, knowing when and how to incorporate
flexibility training into range of motion
rehabilitation is important
• Three modalities that are universally employed
during a flexibility programme to obtain an
increase in joint ROM are static stretching,
proprioceptive neuromuscular facilitation
(PNF) and self myofascial release
 Static stretching
• Static stretching involves taking the limb to a position that
produces increases in muscular tension and allows elongation
of a muscle with the aim of enhancing tissue extensibility.
• The proposed neurophysiological process by which this
occurs is termed autogenic inhibition
• As a result of the prolonged period under increased muscular
tension the Golgi tendon organs (GTOs) may be stimulated
and allow for autogenic inhibition to occur, there by resulting
in a decrease in tension and therefore lengthening of the
agonist which enables a prolonged and increased stretch of
the muscles
static stretch for the gastrocnemius
• To initiate the stretch follow these
guidelines:
• 1. facing a wall , place hands out in front
of the body
• 2. place one foot in front of the other
ensuring heels stay in contact with the
ground
• 3. maintaining an upright posture, push
forwards from the hips keeping the head
upright and facing forwards until a stretch
is felt in the gastrocnemius of the back leg.
• Passive stretching at the end of available range
should be avoided for the first 72 hours as a
minimal period and possibly for the first 7–10 days
following injury if more severe

• Once it is appropriate to begin stretching the

muscle, that is, elongating the tissue beyond its
available range then careful passive stretching can
be performed.
• Each stretch should be held at the end of available
range within the limits of pain.
• Some research suggests passive stretching should
be held for a minimum of 15 seconds with 6–8 sets
per day
Proprioceptive neuromuscular facilitation

• Proprioceptive neuromuscular facilitation is a

form of muscle energy technique (MET)
performed passively with a partner involving
a voluntary isometric contraction followed by
a static stretch phase.
• There are two main PNF techniques; contract-
relax and contract relax-antagonist contract
techniques
• The contract relax method requires a limb
to be move in to a stretched position and then
the agonist undergoes an isometric contraction
for 7–10 seconds.
• Once the isometric contraction ends the ROM
can be increased and the procedure repeated
• Contract relax-antagonist contract
techniques Is performed with a voluntary
isometric contraction of the desired muscle to
be stretched lasting approximately 7–10 sec
followed by an antagonist assisted static stretch
phase
• guidelines to perform hamstring PNF,
• 1. The leg is taken to the initial tissue barrier, with the
opposing leg straight along the floor. Ensure your hand
position is not over the joint.
• 2. Hold for initial period, stretching the raised leg.
• 3. Induce an isometric contraction from the athlete in
the hamstring musculature.
• 4. Rest the hamstring muscles and induce an isometric
contraction of the antagonist muscles (quadriceps).
• 5. Rest and repeat the process.
• 6. Follow the guidelines as stated above for advised
muscle contraction force and length of time contractions
should be held.
 Self myofascial release (SMR)
• Self myofascial release (SMR) is a soft tissue
technique centred on enhancing ROM through the
breakdown of myofascial restrictions in the body’s
fascial system
• SMR is performed by slowly applying a force with the
use of a foam roller to tender spots of the muscle
• The force is maintained for a time period ranging
from 20 to 90 seconds or until a significant reduction
in discomfort is attained.
 Proprioception/neuromuscular control
• neuromuscular control training is important to the
improvements of athletic performance and biomechanical
stability, which in turn reduces the risk of injury.
• Proprioception can be defined as a specialised variation of
the sensory system of touch that encompasses the sensation
of joint movement (kinaesthesia) and joint position (joint
position sense).
• These signals are transmitted to the spinal cord via
afferent(sensory)pathways
• The efferent (motor) response to sensory information is
termed neuromuscular control.
• Two motor control mechanisms are involved
with interpreting afferent information and
coordinating efferent responses feed-forwards
and feedback
• Feed-forward neuromuscular control involves
planning movements based on sensory
information from past experience
• Feed forward mechanisms are for preparatory
muscle activity
• Feedback process continuously regulates muscle
activity through reflex pathways
• feedback processes are associated with reactive
muscle activity.
• There are different proprioceptive states that are important to
consider in the design of a progressive rehabilitation programme.
• Static proprioceptive training involves exercises with the
maintenance of a stable base, while allowing for only minimal
movement
• Dynamic proprioceptive training should only be introduced
when the athlete has demonstrated a sufficient level of balance
and coordination during the static proprioceptive exercise phase
of the neuromuscular control program
• A simple objective test to determine the athlete’s progression
from static to dynamic exercises can include the Romberg test
which assesses the ability to balance
• A more advanced test is the stork stand, which involves the
athlete standing on one leg usually the effected limb and
maintaining the position for a period of at least 30 seconds
without touching the floor with the opposing leg or supporting
themselves with their other limbs
 Basic concepts of application
• Neuromuscular control programme is dependant
on many factors including gender, injury status,
type of sport and level of competition.
• The aim of a proprioceptive training programme is
to promote balance, coordination and agility.
• The athlete must begin first with static exercises
before progressing to dynamic exercises.
• The clinician can alter a range of variables in order to
progress proprioceptive exercises.
• This can involve:
– changing the rate of speed,
– amount of simultaneous activities performed at one time,
– limiting the amount of sight during training
– and adapting exercises that are more functional with sport
specific movements.
• This may not only enhance performance potential in a
competitive sporting environment, but further play a
significant role in injury prevention.
• It may also be more beneficial to the athlete
to perform proprioceptive exercises during the
beginning of a rehabilitation session or before
a training routine.
• REASON:
• Exercise induces fatigue on the
mechanoreceptors that are situated in the
musculature surrounding the joint .
Practical implementation of unstable surface
training
• The importance of unstable surface training (UST)
has been shown to be beneficial in enhancing
proprioceptive input, enabling neuromuscular
adaptations to commence during the early stage
rehabilitation process
• The majority of sporting movements in the upper
extremity occur in an open chain manner; therefore
it may be more beneficial to incorporate unstable
surface based exercises under these circumstances,
rather than in the lower extremity.
• As a result of proprioceptive training,
receptors in soft tissue structures and joint
complexes are trained to perform coherent
actions, able to initiate dynamic, functional
movements.
Strength endurance and maximal strength
• It is imperative to ensure athletes progress through the
rehabilitation process establishing an adequate level of muscular
endurance and then strength.
• Isometric strength training needs to be considered in the initial
rehabilitation phase, and is often implemented 3–7 days post
injury .
• Frequency, duration and intensity are limited by the patients’ pain.
Some therapists advocate three sets of 10 repetitions using 5–10
second holds to begin with at intensity within pain tolerance.
• These then are undertaken at multiple angles, beginning in mid
range then progressing to inner range(shortened position) then
outer range (lengthened position).
• Early phase strengthening exercises, involve an isometric
contraction of the agonist muscle with no movement at
the joint.
• Once an athlete is able to perform isometric muscle
contractions at various joints without the onset of pain, it
may then be advisable to progress the athlete onto
dynamic exercises.
• During isotonic exercise the athlete must provide a force
powerful enough to initiate concentric and eccentric
muscle actions, whilst coping with a constant external
load.
• Initially the athlete should perform slow and
controlled movements in order to allow for
increased neural response to the working muscles
and the continued development of neuromuscular
control.
• Once the athlete is able to control the exercise
effectively the continual progression to sports
specific, functional activity coupled with changes in
velocity, increased load and use of different planes
of motion, should be considered.
 General adaptation syndrome (GAS)
• Through training, the body’s systems and tissues
adapt in direct response to the stresses imposed
on the body during each training session.
• Three primary phases:
• The alarm phase : occurs following the
introduction of a new stimulus, can lead to the
onset of delayed onset muscular soreness
(DOMS), joint stiffness and a general feeling of
discomfort following a training session.
• The resistance phase: is when training
adaptations occur and the muscles are able to
respond effectively to the physiological
changes within the body.
• Exhaustion phase: If however, training
continues without the appropriate
introduction of a new stimulus the exhaustion
phase is emphasised.
 Plyometric training
• Plyometric training is a form of resistance training that
involves high-velocity based exercises characterised by
quick eccentric (lengthened) muscle contractions followed
by rapid concentric (shortened) muscle contractions.
• All sports and athletic movements require the optimum
functioning of active muscles to produce muscular forces at
varying speeds through multiple planes of motion.
• These exercises enhance power production by increasing
motor-unit recruitment, rate of muscle firing and sensitivity
and excitability of the neuromuscular system, thereby
promoting optimum neuromuscular efficiency.
• Plyometric training focuses on increasing the strength and
efficiency of the fast-twitch fibers.
•  The goal is to train for maximum force production in the
smallest period of time, so reps are kept low and the
intensity and effort is high.
• It is also worth noting that plyometrics can be effectively
performed in water , thereby reducing the impact forces
and stress on the muscular system.
• and allowing plyometric training to be introduced to
athletes at an earlier stage in their
development/rehabilitation.