Principles of Exercise Rehabilitation - Physiopedia

Exercises should also fit patient's physical outcomes when planning a rehabilitation program. Adaptive and progressively challenging exercises allow tissue ... Search Search Search Togglenavigation pPhysiopedia pPhysiopedia About News Contribute Courses Resources Contact Donate Login pPhysiopedia About News Contribute Courses Resources Shop Contact Donate p o + Contents Editors Categories Share Cite Contentsloading... Editorsloading... Categoriesloading... Whenreferingtoevidenceinacademicwriting,youshouldalwaystrytoreferencetheprimary(original)source.Thatisusuallythejournalarticlewheretheinformationwasfirststated.InmostcasesPhysiopediaarticlesareasecondarysourceandsoshouldnotbeusedasreferences.Physiopediaarticlesarebestusedtofindtheoriginalsourcesofinformation(seethereferenceslistatthebottomofthearticle).IfyoubelievethatthisPhysiopediaarticleistheprimarysourcefortheinformationyouarereferingto,youcanusethebuttonbelowtoaccessarelatedcitationstatement.Citearticle PrinciplesofExerciseRehabilitation Jumpto:navigation,search OriginalEditor-MariamHashem TopContributors-MariamHashem,TarinavanderStockt,KimJackson,JessBell,ClaireKnott,Admin,WandavanNiekerkandAmritaPatro  Contents 1Introduction 2PhysicalStressTheory 3MechanotransductionHypothesis 4MobilityandStability 5TheInfluenceofpainonmovementandmotorcontrol 6RehabilitationConsiderations 6.1MotorSkillLearning 6.2Re-loadingRehabilitation 6.3GenerateaNeedsAnalysis[4] 6.4BuildingChronicCapacity 7LoadManagement 7.1IdentifyingLoad[4] 7.1.1Howmuchloadcantheinjuredtissuestolerate?(Safeloads) 7.2Identifyallextraneousloadstotheinjuredtissue.  7.3HowtoMonitorLoad? 7.4ProgressingLoad[4] 7.4.1LoadBalance 7.4.2Frequencyofload[10][11][4] 7.4.3Taskspecifictraining[4] 8AdditionalResources 9References Introduction[edit|editsource] Thegoalofanyrehabilitationistorestorefunctiontothegreatestdegreeintheshortesttime,helpingpeoplereturntotheirfunctionwithminimalriskofre-injury.Whileabsoluterestandoffloadingmayrelievesymptoms,theyareassociatedwithnegativepotentialssuchasdecreasedtissuetoleranceandincreasedtissuevulnerabilityinthefuture. Understandinghowtissuesrespondtophysicalstressandmechanicalloadingishelpfulinachievingabalancebetweenstabilisinganinjuredtissueandavoidingdetraining. PhysicalStressTheory[edit|editsource] AccordingtoMuellerandMaluf[1],biologicaltissuesadapttochangesinthelevelsofappliedstress.Maintainingtissuetoleranceisessentialtopreventatrophy,whereasoverloadingresultsinhypertrophy.Excessivelyhighlevelsofstressleadtotissueinjuryandpotentialpermanentdamage.Themagnitude,time,anddirectionofstressapplicationdeterminethe overalllevelofexposuretophysicalstress.Injurymayoccurduetoahigh-magnitudestressappliedforabriefperiod,alow-magnitudestressappliedforalongduration,and/oramoderate-magnitudestressappliedtothetissuemanytimes. MechanotransductionHypothesis[edit|editsource] Referstotheconversionofmechanicalloadsonthecellularlevelresultinginstructuralchanges.Increasedbonethicknessandwidthinresponsetomechanicalloadingistheclassicalexampleofthishypothesis.Regardlessofthetypeofloading,torsional,compressiveortensile,themechanicalstimulustriggersareleaseofvariouschemicalswhichinturnresultinbuildinguplayersoftissueandimprovesloadtolerance[2]. Thishypothesisisalignedwithasub-principleofWolff'slawthattissuesadapttothespecificappliedloads.Exposuretocompressiveloads,forinstance,willqualifythetissuetotoleratethesametypeofappliedloadsexclusively[3].Thismeansthatbeforeapatientcanreturntotheirsportoractivitytheinjuredtissueneedstobeexposedtothatspecificlevelofload.[4] Physiologicallystressingthetissue,belowthelevelofinjury,withsufficienttimeforadaptationcausescellularresponsethatstrengthenthetissueandimprovesitstolerance. MobilityandStability[edit|editsource] Maintainingmobilitywhilestabilisinganinjuredtissueisrequiredinsuccessfulrehabilitation.Thekeyhereistoavoidrigidity.MuscularrigidityreferstoCo-contraction,occurringinresponsetopainand/orkinesiophobia.Appropriatelevelofco-contractionallowsmobilitytooccuroncestressisminimised. TheInfluenceofpainonmovementandmotorcontrol[edit|editsource] Painhasamassiveinfluenceonourmovementpatterns.Asapainavoidancestrategy,apersonwithinjuredanklemayacquireanantalgicgait.Walkingwithslightplanterflexionandshortstridesmaylaterdeveloptoacompensatoryfootpronation,kneevalgusandhipadductionmoment,thusaffectingtissueloadingpatterns. Individualswhohavelowbackpainhavealsobeenfoundtohavedifferencesintrunkmotorcontrol.[5]Forexample,anindividualmaydevelopaco-contractionoferectorspinaemuscleduetoflexion-relatedLBP.Thisrigidityresultsinexcessivehipmovementtocompensateforthelossoflumbarflexion.Additionally,theexcessivelumbarextensionmaycauseincreasedloadonfacetjointandposteriordiscelements. Thefearofmovementcouldpossiblydeveloptocatastrophisingandcomplicatetheconditions.Therefore,weneedtoconsiderthecentralelementsofpainbyimplementingdesensitizationintherehabilitationprogram. (SeeAdditionalResourcesatthebottomofthepageformoreinformation) RehabilitationConsiderations[edit|editsource] MotorSkillLearning[edit|editsource] Teachingthemovementinvolvesvariouslevelsoflearning:[4] Acquisition/Cognitivestage:deconstructingthefunctionontosimplemovementswithrepetitions. Retention/Associativestage:recallinganddeliveringthetaskafteraperiodofnotpracticingthetask. Transfer/Autonomousstage:theabilitytocarryoutataskwithoutpayingattentiontotactics.Ideally,wewanttodeliverourpatientstothisstagewheretheycanperformasimilar,butdifferenttaskthanoriginallylearnedintheacquisitionstage. [6] Instructingpatientsdependsonthestageoflearning.Inthefirststage,closedskillisusedtoeliminateallexternalinfluencesanddrivesthefocusinternally(Intrinsicfocusedcues)byaskingpatienttoreflectonthepurposeandthemechanismofasimplemovemente.g.singlelegsquat.Repetitionsinthisstageaidscognitionandacquisition.InRetentionandTransferstages,trainingshouldbeexternalorgoalfocused.Forexample,askingpatienttomovetowardsacertaintarget,ordoingataskwhilekeepingtrunkaheadofknees.Theultimateaimofmotorskilllearningistotransfertheskilltoperformanceinsportoractivitiesofdailyliving.Thepatientneedstomovefromclosedskilltasks(samemovementtasksinstablepredictableenvironments)toopenskillwheretasks/movementsareunplanned. Teachingmotorskillcanbedonebyeithertrainingthewholeoronlyasectionofthetask:[4] Wholepracticeiswhentheentiremovementispracticedfromstarttofinish.[7]Fore.g.runningisacontinuestaskwherethedifferentsegments(initialcontact,midstance,andpropulsion)followdirectlyafteroneanotherandthetaskshouldbepracticedasawhole Partpracticeiswhenthemovementissegmentedandspecificareasarefocussedonduringpractice.[7]E.g.thepowercleanOlympicliftcanbebrokendowninsegmentsandpracticedindividuallybeforecombiningallthesegmentsandpracticethewholemovement Todeterminewhichpracticewouldbeappropriatethetherapistshouldanalysethenumberofsegmentsinamovementandhowthesesegmentsinfluencefurthermovement Feedbackduringmotorlearning:[4] Feedbackcanbeeitherintrinsicorextrinsic.Intrinsicfeedback-seenastheknowledgeofperformancebutincanbelimitingtolearningwheninextreme.Extrinsic(augmented)feedbackcanbefromvisualdemonstrations,usingamirror,verbalinstructionsorguidancethroughtouching. Verbalfeedbackaimsatgivingextrainformationontheknowledgeofperformanceandtheresultsofthetask/movement Findoutfromthepatientwhatstyleoffeedbackworksbestforthem Feedbackcanalsobegiventhroughopenquestionsallowingthepatienttoactivelyproblemsolveregardingthetaskperformance.Itshouldnotonlyjustprovidethemwithinformationoverloadbutshouldchallengethepatient'sbelievesabouttheirskillperformance Timingfeedbackisalsoanotherimportantelement. Constantfeedbackdoesn'tallowthepatienttoreflectandlearn.Feedbackduringtheperformancehelpswiththeimmediatepreventionofaproblembutresearchshowsthatitcanbedetrimentalformotorskilllearningbecausethepatientbecomesdependentonthefeedback Instead,feedbackshouldbegivenattheendofthetrainingsessionoreitherinextremegoodorbadperformance.Keepinmindthatiffeedbackisonlydeliveredposttrainingthepatientmaybecomepassiveinproblemsolving Reducefeedbackastrainingprogresses Summaryfeedbackcanbegivenafterthepatientcompletedanumberofattemptsinsteadofafterindividualattempts Therehabilitationthenshoulddevelopcomplexitytomimictherealityofpatient'soccupationorfunctionalaspirations. RandomSkilltrainingcanbeacquiredinthisstage,bytrainingpatienttodeliverfunctiononvarioussurfaces,withdifferentexternalloadsandtoreacttoexternalstimuli. Re-loadingRehabilitation[edit|editsource] Selectingmeaningfulexercisesthatrelatetopatient'sfunctiontoimproveproprioception.Exercisesshouldalsofitpatient'sphysicaloutcomeswhenplanningarehabilitationprogram.Adaptiveandprogressivelychallengingexercisesallowtissuestresstooccurinaccordancewiththeabovementionedprinciples. Fortasklearningtobecarriedoutsuccessfully,itshouldbebuiltonseveralpillars:flexibility,stability,workcapacity(muscleendurance)andstrength.Theelementsofstrengthstretchbeyondtheabilitytodeliverhighforceagainstrelativelylowrepetitiontoincludegeneratingforcerapidly(acceleration),forceabsorptionandeccentricforcegeneration. GenerateaNeedsAnalysis[4][edit|editsource] Todelivertheappropriatelevelofloading,weneedtoformabaselineofthepatient'sfunctionalcapacity.Communicationisessentialtounderstandthefunctionalneedsandgoalsofourpatients.Thenwewouldperform''PerformanceBackwardsThinking''byhavingacertaingoalinourmindsthengobackinstagestoretrofitthatgoalwiththepatient'slevelofactivity. Firstly,findoutwhattheendgoalis,meaningwhatisthefunctionalactivitythepatientwanttoreturnto. Thendeterminewhatphysicalabilitiesthepatientwillneedtoreachthisgoal.Thesearecomponentsthatshouldbeconsidered: Thepatient'srolewithinanactivityorsport Thetotaldurationofthepatient'swholeperformance.Durationandfrequencyoftrainingsessions Activityduration-isitcontinuousordoesitvaryindurationandintensity Whatactivitiesareinvolved-walking,bending,lifting,carrying,jumping,running,changeofdirection,kicking,throwing Distancecoveredanddirectionofmovement Contact,impactorcollisioninvolvedintheactivity Predominantmusclegroupsandtheiractions ROMandflexibilityneededtoperformtheactions/movements Motorskillrequirements Evaluatingtissuedamage,cardiovascularcapacity,strengthandstabilitycanhelppreventdetraining.Also,oneoftheimportantfactorsistoeliminatetriggersoftissuedamage.Thisincludessourcesthatmaynotbeusuallyconsideredasinjuring.Forexample,anindividualwithanankleinjurywhosleepswithaheavycoverontheirfeet,pushingitintomoreplantarflexion,needtoadaptbyeithersleepingwithsocksorputalightercoverovertheirfeet. BuildingChronicCapacity[edit|editsource] Chroniccapacityistheabilitytodeliverfunctionovermultipleoccasions.Apersonwithhigherchroniccapacityonahigherbaselineabilitytocopewithloadislesslikelytobeaffectedbymassiveincreaseinload[8].Inrehabilitationofaninjuredtissue,specialattentionshouldbegiventobuildingtoleranceandcapacityinmultipledirections.Forexample,directinghamstringspecifictrainingmayleadtoreducedadductorscapacityifnotincludedinthetraining[9].Thegoalistomakesurethatthepatient’schroniccapacityissufficientlyincreasedsothatanyacuteloadincreasewouldnotoverloadthetissue.[4] LoadManagement[edit|editsource] IdentifyingLoad[4][edit|editsource] Howmuchloadcantheinjuredtissuestolerate?(Safeloads)[edit|editsource] Whatforcesaddtoloadandwhichforcesdonotstresstheload Restrictwalking/usewalkingaids/abootforatendonthatcanonlytoleratealowamountofbodyweight/repetitions Reducetherunningdistanceifapatient’stendononlybecomessymptomaticafter8km. Ceasingrunningwillcauseatrophy Determinetheforce-velocityandlength-tensionrelationshipforthemuscle. Fore.g.themuscleneedstogenerateforceatdifferentlengthsandwithdifferenttypesofcontractions. Determinethesamerelationshipsneededfortendonspluswhattypeofloadisneededfore.g.tensile/torsional/compressive Articularandboneinjuriesneedincreasedexposuretocompressive(axial)loadingwhilekeepingtheexposuretotorsionalandshearloadstoaminimal. Foraligamentstartbyavoidingthemoststressfuldirectionofload. Withprogressionmovementcanbefocusedtowardsthestressfuldirection Identifyallextraneousloadstotheinjuredtissue. [edit|editsource] Anynegativeexternalorinternalforces/factorsshouldberemoved. Thiscouldbedonebylettingthepatientuseawalkingaid,tapingorbracing Discontinueorchangeaspectsofthetrainingthatcontributestotheloadontheinjuredtissue Changemovementpatterns HowtoMonitorLoad?[edit|editsource] Itisimportanttoknowwhentoproceedwithgradualstressandwhentotakeastepback.Therearemultipleindicatorsofexcessorlessload:[4] Increasedswellingofthetrainingmusclesindicatesinflammation-overload.Circumferentialmeasures:tobetakenaftertheactivity,inthemorningandintheevening.Ideallyswellingshouldnotincreasebetweendays.Ifitwasincreasedaftertrainingitshoulddecreasebytheevening,ifitisstillswollenbythenextmorningthenthetrainingloadshouldbedecreased. Pain:VAS0-10,ratethescoretoaspecificmovementorexercise.Anychangeinscorethedayaftertraining>1thatdoesnotreducebytheeveningmayindicateoverload Stiffness:especiallyinthemorning,isagoodmarkofinflammation.Linkthestiffnesstoaspecifictaskormovementfore.g.simplyaskthepatientiftheyfinddifficultiesdoingasimplefullsquatinthemorning. Globalloads:technologicalapplicationsandtrackerscouldbehelpfulingivingastartpointtobuildupagradualprogressiverehabilitationprogramwithoutoverloadingordeloading.  ProgressingLoad[4][edit|editsource] LoadBalance[edit|editsource] Itisimportantthattheinitialloadinarehabilitationprogramisnottoohighasitcanleadtoinjury,butifitistoolowitwillleadtoatrophy. Atrophyoccurswithin5-24daysofnoactivity. Itisimportanttounderstandhowthetissuerespondsunderload Painshouldbewellmanagedasitcannegativelyimpacttherehabilitation Frequencyofload[10][11][4][edit|editsource] Acute:chronicloadratioistheamountoftrainingthepatienthascompletedduringtheperiodofrehabilitationcomparedwiththewhatisneededforafulltrainingsession. Acuteloadisthetrainingdonein1weekandchronicloadistheaverageacuteload/trainingdoneinthelast4weeks.Theratiobetweenacuteandchronicshowsiftheacuteworkloadisgreaterorlessthanthetotalworkloadoftheweeksbeforeit Aacute:chronicworkloadof0.5meansthatthepatienttrained/competedhalfofwhatwaspreparedforthe4weeksprior Aratioof2.0meansthepatientdidtwiceasmuch,anythingmorethan1.5isseenasaspikeintrainingandcouldbeseenasaninjuryrisk. E.g.apatientwithaadductorstrainwouldaftertimeofftorecoverhaveanincreasedriskofinjuryeventhoughthepatientmightbeabletorunpainfree. E.g.apatientwithhip/kneeosteoarthritiswhowereinbedwithfluwillhaveanincreasedriskofacute:chronicloadratiowhenreturningtofullactivity.Taskspecifictraining(example-dependingonthepatientandtheload) Taskspecifictraining[4][edit|editsource] Avoidglobaldetraining,asitwillcompromisethepatient’sfitnesstoreturntothesport Startwithcontrolledexerciseslikeclosed-chainexercisesdependingontheloadthepatientcantake(squats,singlelegsquats,lunges,stepupsetc) Progresstoincreasingtheloadandchangethesurfacetochallengethepatient’sstability Whenthepatientisabletoacceptloadontheaffectedsideundermultidirectionalloadsthenprogresstoloadacceptanceinbilateralandunilaterallandingactivitiesmovingtowardsrunning. Thenprogresstheseactivitiesoverbarriersandthentodifferentdirections. Itisimportanttoreloadthepatienttofulfilintheneedsoftheirsportortheactivitiesthatareimportant Increasethepatient’schroniccapacitysufficientlysothatanyacuteloadincreasewouldnotoverloadthetissue AdditionalResources[edit|editsource] [12] References[edit|editsource] ↑MuellerMJ,MalufKS.Tissueadaptationtophysicalstress:aproposed“PhysicalStressTheory”toguidephysicaltherapistpractice,education,andresearch.Physicaltherapy.2002Apr1;82(4):383-403. ↑KhanKM,ScottA.Mechanotherapy:howphysicaltherapists’prescriptionofexercisepromotestissuerepair.Britishjournalofsportsmedicine.2009Apr1;43(4):247-52. ↑FrostHM.Wolff'sLawandbone'sstructuraladaptationstomechanicalusage:anoverviewforclinicians.TheAngleOrthodontist.1994Jun;64(3):175-88. ↑4.004.014.024.034.044.054.064.074.084.094.10Chapter10.PrinciplesofExerciseRehabilitation. PhysicalExamination,in:PettyNJ.Neuromusculoskeletalexaminationandassessment:ahandbookfortherapists.ElsevierHealthSciences;2011Jan27. ↑vanDieënJH,ReevesNP,KawchukG,vanDillenLR,HodgesPW.MotorControlChangesinLowBackPain:DivergenceinPresentationsandMechanisms.JOrthopSportsPhysTher.2019;49(6):370-9. ↑Threestagesoflearningmovement.Availablefrom:https://www.youtube.com/watch?v=OHGE68ZS8g4 ↑7.07.1SattelmayerM,ElsigS,HilfikerR,BaerG.Asystematicreviewandmeta-analysisofselectedmotorlearningprinciplesinphysiotherapyandmedicaleducation.BMCMedEduc.2016;16(15).  ↑Gabbett TJ.Thetraining—injurypreventionparadox:shouldathletesbetrainingsmarter and harder?BritishJournalofSportsMedicine 2016;50:273-80. ↑CookJL,DockingSI.“Rehabilitationwillincreasethe‘capacity’ofyour…insertmusculoskeletaltissuehere….”Defining‘tissuecapacity’:acoreconceptforclinicians.BrJSportsMed. 2015Dec;49(23):1484-5 ↑BlanchP,GabbettTJ. Hastheathletetrainedenoughtoreturntoplaysafely?Theacute:chronicworkloadratiopermitsclinicianstoquantifyaplayer'sriskofsubsequentinjury. BrJSportsMed.2016Jan8:bjsports-2015[Accessed11July2018] ↑BowenL,GrossAS,GimpelM,LiFX.Accumulatedworkloadsandtheacute:chronicworkloadratiorelatetoinjuryriskineliteyouthfootballplayers.BrJSportsMed.2017;51(5):452-9. ↑UnderstandingFear-AvoidanceBeliefsandChronicPain.Availablefrom:https://www.youtube.com/watch?v=UzyTvyQfXK0 Retrievedfrom"https://www.physio-pedia.com/index.php?title=Principles_of_Exercise_Rehabilitation&oldid=315864" Categories:RehabilitationFoundationsExerciseTherapySportsMedicineOccupationalHealth GetTopTipsTuesdayandTheLatestPhysiopediaupdates EmailAddress IgivemyconsenttoPhysiopediatobeintouchwithmeviaemailusingtheinformationIhaveprovidedinthisformforthepurposeofnews,updatesandmarketing. 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