Physical rehabilitation

Rehabilitation is an umbrella term for a combination of activities that promote the restoration of optimal form and function. Both of these components are important. Form is about the anatomical structure, function is about the physiological processes. Regardless of the type of injury, the main goals of ‘rehab’ are to limit the trauma, reverse or reduce any loss of function, eliminate the disability, and prevent recurrence. 

In the case of an injured athlete, there may be a whole team of people that oversee their rehab. This can include physicians, physiotherapists, soft tissue therapists, coaches, personal trainers, nutritionists, psychologists and other practitioners. Communication between all involved healthcare practitioners is essential in order to ensure the approach is integrated and effective.
 
The key principles of rehabilitation have been summarised with the mnemonic: ATC IS IT
 

• A – avoid aggravation – The approach must address the injured person’s needs in the most effective way while eliminating the likelihood of worsening of the condition.
• T – timing – Following from the first principle, therapeutic exercise must begin as soon as possible without worsening the condition.
• C – compliance – It is crucial to educate and motivate the patient to ensure that they adhere to the designed recovery protocol.

 

• I – individualisation – The physiological and anatomical uniqueness of the individual needs to be considered, so that the approach can be tailored accordingly.
• S – specific sequencing – The overall approach needs to follow a logical continuity adapted to the healing response and pace of the individual.

 

• I – intensity – It is essential to find the delicate balance between challenging the recovering system or body part without aggravating it.
• T – total patient – This principle is about working holistically to ensure that the whole body and beyond it, the mind and heart of the person are also engaged and cared for during rehab.

 
Components
 
Regardless of the particular type of trauma, the following would usually be included as part of the rehab programme.
 
Pain management. Reducing the pain as far as possible with natural techniques and with the need of medication as a last resort is an essential part of the rehab. 

Passive movements (or passive range of motion (ROM) may be the only type of motion possible at the site of injury. With this type, the therapist would manually take a limb through its range of motion without the patient’s muscles being activated. For example, with the patient lying supine, the therapist may slowly lift the patient’s arm to 90 degrees while supporting the elbow to complete flexion and mobilise the shoulder joint. 

The advantage of this technique is that the joint can be mobilised even if muscular activation is too uncomfortable or impossible for the patient. It can also help the nervous system to a degree to maintain the neural pathways for accomplishing the movement. Passive movements, however, will not preserve bone or muscle because there is no voluntary contraction or lengthening of the muscle and no tension on the bone.
 
Active movements are initiated and controlled by the patient themselves. The muscles are activated in order to move the joint though its achievable range of motion at the time. 
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These movements can be active range of motion (ROM) like moving or stretching your injured arm by using your healthy one.
 
General exercise where you simply move your legs for example is the other type of active movement.
 
And finally, active assisted movements, rely on some the therapist’s assistance in order to complete the entire range of movement.
 
These movements have a number of benefits. They increase movement in the joint and hence promote better function of the area or the whole limb. The can also improve movement efficiency, decrease pain, increase the independence of the patient, and maintain or even improve joint integrity.
 
A variety of rehab scenarios can be improved with active movements. Arthritic joints, joints with a foreign object in them or recovering from a surgery can benefit. Active movements are also essential for resolving ligament sprains, muscle strains, and in some instances even acute injury with swelling.
 
For example, a patient with an injured shoulder, may perform an active shoulder adduction in side-lying position. They will start their arm initially resting on the hip and will gently and slowly raise it up towards the ceiling and then continue moving it above their head to take the shoulder through its whole range of motion. It is important to work within a tolerable level of discomfort, and discontinue the movement if there is pain.
 
Resistive movements or strengthening exercises are designed to maintain or increase muscle strength and/or size and bone density. They challenge the muscle to the point of fatigue. This overload promotes adaptation that increases the muscle’s strength. 

Resistive movements may include a variety of exercises targeting individual muscles or entire muscle groups. Usually, the resistance is increased as the patient’s strength builds up. The form of resistance may be gravity, water, a resistance band, one’s bodyweight, or external weight. In order to be effective, these exercises must progressively increase the demand on the muscle.
 
Some of the benefits of this type of movements include improved strength, injury prevention, improved function, increased muscular efficiency, better quality of movement, activation and improvement in neural functioning, and prevention of arthritic conditions. Perhaps most importantly, in the context of a rehab these movements help the patient re-built their confidence in relying on the recovering physical structure.
 
Resistive movement can be beneficial in arthritic conditions, pre- and post-surgery, post injury, and following periods of immobilisation. Additionally, they can be applied to correct dysfunctional movements by strengthening specific muscles and to improve posture by balancing opposing muscles.
 
In a patient recovering from a quadriceps strain, an example of resistive movement against gravity would be to straighten their leg while sitting on the side of a treatment couch.
 
Functional movements must be an integral part of any rehab programme in order to reproduce the types of motions and activities that are habitual for the patient or recovering athlete. Their primary objective is to return the person to optimum function. 

Their biggest advantage is that they tend to be easy to remember and adhere to because they ask the patient to replicate familiar movements. A well-designed functional programme would progress the person from simple to more complex movements until complete match with their functional needs is accomplished. Being able to perform the movements in good form without assistance would be an indication that the functional rehab has been effective for the patient and it is now complete.
 
Functional training can include angle-specific strengthening for the joint, closed kinetic chain exercises, refining neuromuscular control, and velocity-specific muscle activity. In more simple terms, a functional movement would be to re-educate a person to squat on their own after a hip surgery so that they can get up from the toilet seat in their everyday life.
 
Proprioceptive exercises challenge and develop once special awareness of their body. Decreased proprioception increases the likelihood of injury or recurrence of trauma during the recovery phase. Injury or immobility also tend to decrease proprioception. 

Like with strengthening movements, an effective proprioceptive rehab programme would be progressive. It will be designed in a way that introduces increasingly more complex movement patterns to help the person regain and develop their awareness of their body in space.
 
A holistic proprioceptive rehab programme would feature initial assessment in order to establish a baseline. There will also be a way of measuring progress against an outcome. The individual components may include exercises to improve reaction time, balance and strength. Functional dynamic exercises modified to the particular range where there is instability are also used frequently.
 
The benefits of this type of exercises during rehab is that they reduce the risk of re-injury, improve joint stability and position, and help improve confidence. The have the added advantage of improving mobility and reducing muscle compensations.
 
Proprioceptive exercises are applied with good success in cases of recurrent injuries, like ankle sprains, or when there is pain or swelling in a joint that may be reducing the proprioceptive feedback. Post-surgical and ligament or tendon damage scenarios also benefit from this type of training as it helps recover the damaged proprioceptive receptors.
 
An example of proprioceptive balance exercise after an ankle sprain would include the use of a wobble or balance board. The unpredictable movements are helpful in teaching the body once again to respond quickly to the changes with little or no deliberate thinking. In other words, the proprioceptive receptors themselves are re-educated to do their job properly.