This is an excerpt from Therapeutic Exercise for Musculoskeletal Injuries 4th Edition With Online Video by Peggy Houglum.
In the total rehabilitation program, there are two basic elements, therapeutic modalities and therapeutic exercise. Modalities are used to treat and resolve those effects first seen in injury: spasm, pain, and edema. Although modalities are an essential component of a rehabilitation program, they will not be presented in detail in this text. Therapeutic exercise (therex) is an essential and critical factor in returning the patient to sport participation or normal activity. If the therapeutic exercise program is to be effective, however, specific parameters must be addressed sequentially. Each of these parameters must be restored to at least preinjury levels if the patient is to safely resume full sports participation or normal activity. These parameters in their proper sequence are
- flexibility and range of motion,
- strength and muscle endurance,
- balance, coordination, and agility,
- functional activity, and
- performance-specific activity.
Each of these parameters is based on the previous parameter's successful completion, much like a pyramid (figure 1.2), stones placed one on the other, layer by layer until the structure is complete. This concept will become clearer as we discuss each parameter.
Pyramid demonstrating the elements and progression of a rehabilitation program, one parameter advancing from the foundation set by the previous parameter.
At the base of the pyramid is relief of pain and other secondary effects of injury such as joint effusion or edema and muscle spasm. These factors are managed with modalities for the most part. Specific applications of manual therapy and correction of deviations are presented throughout the text. The remaining pyramid levels are addressed using various therapeutic exercise techniques. Flexibility and range of motion must be achieved after pain relief. Once mobility is achieved, gains in strength and muscle endurance are made. As the patient progresses up the pyramid, each step is achieved until the top of the pyramid is reached, where performance-specific exercises that mimic the patient's normal activities are included in the rehabilitation program. Achieving this last level occurs prior to the patient's return to optimal function.
It should be noted that the pyramid's first level includes correction of deviations; this part of the first level is an important aspect of rehabilitation programs that deal with nonacute injuries. This element applies to injuries that occur over time (such as tendinopathies) and are not the result of a sudden trauma. This added first-level pyramid step includes identifying the precipitating factors - etiological factors - that cause the injury to occur. This is a crucial step in rehabilitating chronic or repetitive injuries because if steps are not made to identify the reason the patient developed the condition, the problem will return once the patient resumes normal activities. In these cases, clinicians take on the role of detective to identify the source of pathology and make efforts to correct deviations and causative factors.
Flexibility and Range of Motion
A properly designed therapeutic exercise portion of a rehabilitation program places a priority on regaining lost range of motion and flexibility first. Achieving flexibility early in the therapeutic exercise program is necessary for two important reasons. First, the activities that follow require good mobility of the affected area. To make this point clear, consider how handicapped a hurdler would be if the hamstrings were too tight. Strength and coordination would be of little importance if the flexibility needed to extend the limb over the hurdle was lacking.
The second reason to emphasize regaining range of motion first in the therapeutic exercise program is the impact of the healing process (discussed in chapter 2). As injured tissue heals, scar tissue forms. As scar tissue matures, it contracts and becomes more permanent. These effects are important in eventually minimizing the scar, but they can also be detrimental because as the tissue forms, contracts, and matures, it attaches to and pulls on adjacent tissue and becomes stronger with improved adhesive bonds and its maturation, causing loss of motion of soft tissue structures in the area and of joints when scar tissue crosses a joint.
During healing there is a window of opportunity during which scar tissue mobility can be influenced and changed. Once that time frame has passed, the likelihood of successfully achieving full range of motion is diminished considerably. Although restoration of other parameters is also sought during the first stage of therapy, flexibility must be the primary emphasis.
Strength and Muscular Endurance
As an injured site's healing and mobility progress, achieving normal strength and muscular endurance becomes the priority. With any injury some strength is lost. The amount of strength and muscle endurance lost depends on the area injured, the extent of the injury, and the amount of time the patient has been disabled by the injury.
Of all the parameters of therapeutic exercise, strength is probably the most obvious and most frequently sought to restore after an injury. It is obvious because it is easily understood that a weightlifter with a sprained knee cannot return to competition until full knee strength is achieved. It is just as obvious that an auto mechanic must have normal shoulder strength to return to work after suffering a dislocation.
The need for muscle endurance and the relationship between muscle strength and endurance are sometimes not considered, however. If a baseball pitcher has good rotator cuff strength but no endurance beyond 10 repetitions, how will he be able to pitch more than a couple of innings in a game? If a UPS driver can leg press 225 kg (496 lb) but can climb only one flight of stairs, will she be able to deliver heavy packages for an entire shift?
Muscular strength and endurance are two dimensions within a continuum of muscle resistance. Essential concepts of muscle strength and endurance are presented in chapter 7.
Balance, Coordination, and Agility
Balance, coordination, and agility are often omitted in a therex program. It is too often assumed that because range of motion and strength are restored, the patient is ready to resume full sport participation or normal activity. This is not the case at all. Impaired balance and coordination - either from injury to the structures controlling these parameters or from lack of practice in a specific skill - increases risk of injury.41
A variety of factors affect a patient's balance, coordination, and agility. A number of factors in turn are affected by these elements, including muscular power, skill execution, and performance. (The factors that affect and are affected by balance, coordination, and agility are discussed in chapter 6.) Adequate flexibility and strength must be achieved before appropriate balance and coordination skills can be developed. Coordination and agility are based on the patient's having enough flexibility to perform the skill through an appropriate range of motion and enough strength, endurance, and power to perform it repeatedly, rapidly, and correctly. This is why balance, coordination, and agility are presented later in rehabilitation: they are based on the foundation of good flexibility, strength, and even muscle endurance.
Although not all health care professionals emphasize this parameter, a total rehabilitation program must include the recovery of balance, coordination, and agility. Consider a tennis player who has suffered a back injury that has kept him out of competition for 2 months. The timing of his serve, the coordination of his response to his opponent's serve, and the agility of his feet in sudden lateral movements on the court may all be impaired. In a normal rehabilitation program, simple balance exercises are introduced early in the therapeutic exercise program, but coordination and agility are not emphasized until after strength and range of motion are achieved.
Functional and Performance-Specific Activity
Specific skill performance is the last step before a patient's return to optimal function and participation. Accurate execution of functional and performance-specific skills requires attainment of all previous parameters first. Sometimes it is difficult to determine when agility exercises end and functional exercises begin. This difficulty occurs because some agility exercises could be considered functional exercises. Likewise, some functional exercises could be thought of as performance-specific exercises for some sports or job tasks. For example, an agility exercise may be jumping side to side over hurdles or cones, but that could also be a functional exercise for someone who is a soccer goalie or a football defender. Jumping side to side may also be a performance-specific exercise for a tennis player. How these exercises are labeled is based primarily on when in the program they occur and what the goal is for the specific exercise. If the goal is to increase speed of motion, then it is likely an agility exercise, but if the goal is to improve lateral motion accuracy, it is likely a functional exercise. It becomes a performance-specific exercise if the patient is on the field or court and performing a specific sport skill that involves side-to-side movement.
There is an evolution of exercises in the last half of the rehabilitation program that moves from an emphasis on balance and coordination to an ability to execute normal drills that mimic the patient's actual activities. The last step before returning to normal activities involves the execution of these performance-specific activities. In this final stage patients regain the confidence they need to perform at their prior activity level. Concepts and examples from this phase of rehabilitation are discussed in chapter 9. When the patient can achieve specific goals established for these activities, the rehabilitation clinician can be assured that the final long-term goal of fully rehabilitating the patient has been achieved.
Therapeutic exercise must address the following physiological parameters in proper order: first, flexibility and range of motion; second, muscle strength and endurance; third, balance, coordination, and agility; fourth, functional performance; and fifth, performance-specific activities.