Therapy Education Systems - Orthopedics II

TIS

Chapter 9
Function-Based Rehabilitation - Principles And Techniques

Introduction
- "functional" is a very abused term
- concept is good, but overgeneralizations have occurred
- too often accept any closed chain activity in the LE as "functional"
- something we should have been doing years ago: listening to the patient
- both a philosophy and a practice
- is not an "either-or" situation relative to "traditional rehabilitation"; a well-balanced program contains components of both, with the goal being the thorough and expedient rehabilitation of the patient
- be cautious of those who feel that there is only one way to design a rehabilitation program
- a "functional progression" is simply an extension of a traditional PRE program

Rationale for "function-based" program
1. Wolff's Law - bone remodels according to the stresses placed upon it; bone will be laid down where stresses are the greatest, and thin where loads are diminished
2. Wolff's Law of soft tissue - this law has been extended to include soft tissue remodeling; healing collagen fibers will orient along the lines of stress via a peizoelectric effect, resulting in a stronger tissue than if no load had been imposed
3. SAID - Specific Adaptations to Imposed Demands; the body will adapt to demands placed upon it; the therapist must determine the timing, magnitude and direction of demands placed upon the healing tissue; initially, the therapist should control these variables, with gradual relinquishing of these variables to the patient; however, the therapist must first assess the demands placed on the patient; variables may include:
  - time
  - repetitions
  - speed
  - ROM
  - force/load
  - open vs. closed chain
  - concentric, eccentric or isometric muscle contraction
  - acceleration/deceleration
  - weight bearing
  - triplane motion
  - externally applied forces; i.e. getting hit, carrying loads, uneven surfaces, etc.
4. Joint receptor stimulation: with injury, effusion, position sense is diminished; this may account for the large number of reinjuries despite full strength and mobility; simple immobilization without injury decreases position sense; all the strength in the world won't save your ankle if you land in an inverted position
  - Ruffini endings (capsular stretch, proximal joints) slow adapting
  - Pacinian corpuscles (sensitive to accel and high velocity changes in joint position) fast adapting
  - Golgi-Mazzoni corpuscles (sensitive to compression of joint capsule in plane perpendicular to its surface) slow adapting
  - Golgi ligament endings (sensitive to tension or stretch on ligaments) slow adapting

Components of program

highly variable; depends upon activity

(Gary Gray)	Closed Chain	Open Chain

End segment	Fixed	open
Axis of motion	distal & proximal to axis	distal to axis
Muscle contraction	primarily concentric isometric	combination: concen, eccen,
Movement	predomination of some ms. grps w/o isolation	single, isolated plane of movement predictable
Loads	normal loading in normal environ	artificial loading in artificial enviro
Velocity	variable, controllable	predetermined or influenced
Stress & strain	consistent stress & strain on soft tissue	artificial means
Stabilization	normal postural mechanisms	inconsistent
Planes	triplane	single plane
Proprioception	normal proprio & high degree of carryover to normal activity	erroneous feedback & little carryover
Techniques	unlimited	limited by equipment
Reaction	reaction + action	action alone

Precautions with program
- be sure of indications; is joint compression warranted? (i.e. DJD) not all problems are best-treated with closed chain activities
- many activities will produce gluteus medius soreness; approach any new activities slowly and incorporate appropriate stretching
- avoid overworking; because many of these exercises mimick functional activities, the patient will have a tendency to overwork

Basic principles of proprioception/balance program
- start with joint compression, and vertical loading over the base of support
- gradually move off base of support in various planes of motion
- continue to progress; a balance board alone does not make a proprioception program
- program must be progressed and tasks made increasingly difficult
- patients learn very quickly
- continue to train the nervous system in addition to the muscular system
- PERTUBATION is the key word as the program progresses
- goal is to teach the patient how to LEARN; we cannot teach them finite skills, but teach their nervous system how to adapt to new activities
Examples:
- single leg standing with/without support
- toe raises on a single leg with/without support
- single leg squats with/without support
- lateral step-ups in varying directions
- 4-way hip or Inertial exercise system standing on involved leg
- balance beam
- BAPS board
- rocker/balance board
- add speed, resistance, additional activities
- many of these activities can be initiated in a pool and progressed to dry land

Other closed kinetic chain activities
- wall slides
- mini-squats (sitting squats)
- leg press
- stairmaster - unilateral or bilateral
- kinetron
- snowbounder
- Fitter
- Shuttle
- mini-tramp
- treadmill

Putting it together I: Optimal Loading

* You must know the stage of healing of the tissue you are dealing with!

Curwin & Stanish Classification:
Level I: no pain
Level II: pain with extreme exertion which disappears when the activity is stopped
Level III: pain with exertion which remains 1-2 hours after the activity is stopped
Level IV: pain with activity which alters function. Pain may last 4-6 hours after activity and/or may increase during activity
Level V: pain begins as soon as activity begins and causes withdrawal from activity
Level VI: pain with ADL, unable to participate in sport or rehabilitation activity

* These levels do NOT refer only to sports! They refer to rehabilitation as well! Use these as a guide to help your patient understand how much exercise is appropriate.

Optimal loading: the key to determining the appropriate level of activity is finding the patient's baseline; this is their level of optimal loading; any more overworks and any less underworks; if the patient overworks on a given day, they should return to their baseline and build back up
- The loads placed on the patient should build up to approximate those demands that will be placed on them when they return to their activity
- the goal is to optimally stress the healing tissue so it responds via Wolff's Law

Putting it together II: Planes of Motion
- the athlete should be progressed into the specific planes of motion that stress the healing tissue - this is the SAID principle
- for example, a patient with a MCL sprain should eventually be trained in the frontal plane to impose specific functional demands upon the ligament; these demands are different from those placed upon it in a sagittal plane

Putting it together III: The Functional Progression

Definition: planned activities that progress a patient through a series of increasingly difficult functional tasks. It is an extension of the PRE program.

Benefits: both physical and psychological
1. specific stressing of healing tissue
2. neuromuscular coordination
3. activity specific strength & endurance training
4. confidence in return to activity
Principles of Program Design:
1. same as a PRE program - sets, reps, intensity, SAID
2. overload
Considerations:
1. Evaluate functional task
  - CV demands
  - MS demands
2. Evaluate environment
3. Formulate a plan based on these
Prerequisites:
1. Strength/endurance - consider testing when tired
2. ROM
3. swelling
4. WB status
Precautions:
1. Motor ability can fool you
2. Physical and psychological readiness
Program Examples:
1. Work hardening
2. Sports
  - running program
    must complete an impact loading progression prior to return to activity
  - initially therapist controls variables
  - gradually variables are relinquished to the patient to control
  - teach patient classification scheme to understand how to monitor program

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