Chapter 16
Extended Lecture Outline
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The Athletic Trainers Approach to Rehabilitation
o Process of rehabilitation begins immediately after injury
o Competitive nature of athletics necessitates an aggressive approach to rehabilitation
o Goal is for the athlete to return to activity as soon as safely possible
o Decisions to alter and advance programs should be based within the framework of the healing
process
o The use of rehabilitation recipes is discouraged, each person is different
Therapeutic Exercise Versus Conditioning Exercise
Sudden Physical Inactivity and Injury Immobilization
o Effects of General Inactivity
o Effects of Immobilization
 Muscle and Immobilization
o Adverse muscle changes can occur in 24 hours
 Atrophy and fiber-type conversion
o Disuse leads to loss of muscle mass
o Greatest atrophy occurs in Type I (slow-twitch) fibers
o When activity is resumed, normal protein synthesis is reestablished
 Decreased neuromuscular efficiency
o Immobilization causes motor nerves to become less efficient in
recruiting and stimulating individual muscle fibers
o Once immobilization ends – original motor discharge returns in about 1
week
 Joints and Immobilization
 Causes loss of normal compression, leading to decrease in lubrication within the
joint causing degeneration
 Ligament and Bone and Immobilization
 Ligament and bone become weaker when stress is eliminated or decreased
 Full remodeling of ligaments after immobilization may take as long as twelve
months or more
 Cardiorespiratory System and Immobilization
 Resting heart rate increases approximately one-half beat per minute each day of
immobilization
 Stroke volume, max oxygen uptake and vital capacity decrease
Major Components of a Rehabilitation Program
o Minimizing Initial Swelling
o Controlling Pain
o Reestablishing Neuromuscular Control
 Neuromuscular control: the mind’s attempt to teach the body conscious control
of a specific movement
 Four critical elements: proprioceptive and kinesthetic awareness, dynamic
stability, preparatory and reactive muscle characteristics, and conscious and
unconscious functional motor patterns
 Proprioception: the ability to determine the position of a joint in space
 Kinesthesia: the ability to detect movement
 Ability to sense the position of a joint in space is mediated by mechanoreceptors
found in both muscle and joints and by cutaneous, visual and vestibular input
 Joint Mechanoreceptors
 Ruffini’s corpuscles
 Pacinian corpuscles
 Merkel’s corpuscles
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 Meissner’s corpuscles
 Free nerve endings
 Muscle Mechanoreceptors
 Muscle spindles and golgi tendon organs
o Establishing and Enhancing Core Stability
 Core is defined as the lumbo-pelvic-hip complex, where the center of gravity is and
where all movement begins
 Key muscles include transversospinalis group, erector spinae, quadratus lumborum and
latissimus dorsi, rectus abdominus, external oblique, internal oblique and transverse
abdominus, gluteus maximus, gluteus medius and psoas
o Regaining or Improving Range of Motion
 Physiological versus Accessory Movements
 Physiological movements result from an active muscle contraction that moves
an extremity through flexion, extension, abduction, adduction and rotation
 Accessory motions refer to the manner in which one articulating joint surface
moves relative to another (spin, roll and glide)
 Normal accessory motions must occur for full-range physiological movement to
take place
 If physiological movements are restricted – one should engage in stretching
activities to improve flexibility
 If accessory motions are restricted – incorporate mobilization techniques into
treatment program
o Restoring or Increasing Muscular Strength and Endurance
 Isometric Exercise
 Progressive Resistance Exercise
 Concentric and eccentric muscle contraction
 Isokinetic Exercise
 Testing Strength, Endurance and Power
o Regaining Balance and Postural Control
 Balance involves the complex integration of muscular forces, neurological sensory
information received from the mechanoreceptors, and biomechanical information
 Achieving postural stability involves positioning the body’s center of gravity within the
base of support
 Primary mechanisms for controlling postural stability occur in the joints of the lower
extremity
o Maintaining Cardiorespiratory Fitness
o Incorporating Functional Progressions
 Functional Testing
Developing a Rehabilitation Plan
o Setting Long-term and Short-term Goals
o Exercise Phases
 Preoperative Exercise Phase
 Phase 1: The acute inflammatory response phase
o Begins immediately and may last as long as 4 days
o Focus of rehab is to control swelling and to modulate pain by using
rest, ice, compression, and elevation
 Phase 2: The fibroblastic repair phase
o This stage may begin as early as four days after injury and may last for
several weeks
o Incorporate activities to maintain cardiorespiratory fitness, restore full
range of motion, restore or increase strength and reestablish
neuromuscular control
o Modalities to control pain and swelling and improve strength/range of
motion
 Phase 3: The maturation-remodeling phase
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May last for several years, depending upon the severity of the injury
Ultimate goal of this stage is to return to activity – focus should be on
regaining sport-specific skills
o Adherence to a Rehabilitative Program
o Criteria for Full Return to Activity
Additional Approaches to Therapeutic Exercise in Rehabilitation
o Open Versus Closed Kinetic Chain Exercises
 CKC exercises have become rehab treatment of choice because they are more functional
than open chain exercises
 CKC exercises use varying combinations of isometric, concentric, and eccentric
contractions which must occur simultaneously in different muscle groups
o Aquatic Exercise
 Three uses of water’s buoyancy (Assistive, supportive and resistive)
o Proprioceptive Neuromuscular Facilitation Techniques
 Techniques of PNF
 Used for purposes of facilitating strength and increasing range of motion
 Flexibility increased with contract-relax, hold-relax, and slow-reversal-holdrelax
 Strengthening can be facilitated by repeated contraction and the slow-reversal,
rhythmic initiation and rhythmic stabilization techniques
 Strengthening Techniques
 Rhythmic initiation
 Repeated contraction
 Slow reversal
 Slow-reversal-hold
 Rhythmic stabilization
 Stretching Techniques
 Contract-relax
 Hold-relax
 Slow-reversal-hold-relax
 Basic Principles for Using PNF Techniques
 PNF Patterns
 Involve three component movements: flexion-extension, abduction-adduction
and internal-external rotation
 Involve distinct diagonal and rotational movements
 Exercise patterns are initiated with muscle groups in lengthened or stretched
positions
o Muscle Energy Techniques
 Manually applied stretching techniques that use principles of neurophysiology to relax
overactive muscles and/or stretch chronically shortened muscles
 Manual therapy technique that is variation of PNF contract-relax, and hold-relax
techniques
 Technique begins by locating a point of resistance to stretch (resistance barrier)
o Joint Mobilization and Traction
 Mobilization Techniques
 Used to increase accessory motions about a joint by use of glides within a
specific part of the range of motion
 Maitland – Five grades
o Grade I – Small amplitude at beginning ROM
o Grade II – Large amplitude glide within the midrange of motion
o Grade III – Large amplitude glide up to the pathological limit of ROM
o Grade IV – Small amplitude glide at end range of movement
o Grade V – Small amplitude, quick thrust delivered at the end range of
motion (manipulation)
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Traction: Technique in which one articulating segment is pulled to produce
some separation of the two joint surfaces
o Mulligan Technique
 Combines passive accessory joint mobilization applied with an active
physiological movement by the patient for the purpose of correcting positional
faults and returning the patient to normal pain-free function
 Mobilizations with movement (MWM’s) for treating extremities, and sustained
natural apophyseal glides (SNAG’s) for treating the spine
 Principles of treatment
o Myofascial Release
 Group of techniques used for the purpose of relieving soft tissue from the abnormal grip
of tight fascia – form of stretching
 Myofascial treatment based on localizing the restriction and moving into the direction of
the restriction
o Graston Technique
o Strain/Counterstrain
 Approach to decreasing muscle tension and guarding that may be used to normalize
muscle function
 Passive technique that places the body in a position of greatest comfort , thereby relieving
pain
 Explained by stretch reflex
o Positional Release Therapy
 Based on strain/counterstrain techniques – primary difference is the use of facilitating
force (compression) to enhance the effect of the positioning
 Active Release Technique
 Developed to correct soft tissue problems in muscle, tendon, and fascia caused by the
formation of fibrotic adhesions as a result of acute injury, repetitive or overuse injuries or
constant pressure or tension injuries
 Fibrotic adhesions disrupt the normal muscle function, which affects the biomechanics of
the joint – leading to pain and dysfunction
 Deep tissue technique used for breaking down scar tissue/adhesions and restoring
function and movement
o Soft-Tissue Mobilization
o Biofeedback
 Used as a tool to help a patient develop greater voluntary control for purpose of
enhancing either neuromuscular relaxation or muscle reeducation following injury
Purchasing and Maintaining Therapeutic Exercise Equipment