This is an excerpt from Effective Functional Progressions in Sport Rehabilitation by Todd S. Ellenbecker,Mark De Carlo & Carl DeRosa.
Many key components are inherent in a successful functional progression program. Since the program above all else has to be designed for a specific person, following one preset guideline or functional progression cannot be recommended. Therefore, it is important in this chapter to briefly review some of the key components in the rehabilitation process and the process of using and applying functional exercise progressions, and then introduce in the following chapters a detailed series of functional progressions, with supportive evidence and background information in anatomy and biomechanics, to empower the reader to develop his or her own progression for successful applications.
Monitoring Signs and Symptoms
The continued monitoring of the signs and symptoms of the patient during the functional progression is of critical importance for the success of any progression. This forms the basis for the rate and frequency of the progression of the program. Some of the key signs and symptoms are introduced in chapter 1 but are so important that they warrant repeating. For example, the presence of intra-articular swelling is one factor of critical importance in virtually all rehabilitation and functional progressions. Although it may be somewhat joint specific, intra-articular swelling can be palpated and measured or clinically observed in several key joints throughout the body. Swelling about the knee and ankle, for example, is easily monitored and in lower extremity progressions can be an extremely valuable marker for clinical progression. In other joints such as the glenohumeral and coxofemoral joints, swelling is much less noticeable and does not play a major role in the screening process. Progressing exercise and activities in the presence of joint swelling is contraindicated and clearly not recommended.
Other signs and symptoms that often occur with or without swelling are joint pain, significant muscular fatigue or loss of control, and decreased joint motion. The presence of any of these in isolation or combination slows down the functional progression. Using visual analog scales (VAS) or simply asking the person to rate his level of pain, fatigue, or improvement using a scale of 0 to 10 can help put an objective slant on otherwise subjective perceptions of the person's function and feelings during the progression.
Establishing Continuous Progression
The concept of continuous progression is apparent to most, but it is often not adhered to in many suboptimal programs. It is difficult and often encumbering to initially design the functional progression program. Continuing to adjust and progress the program, however, is required to successfully progress the person to optimize gains in strength, motion, and function. Frequent and periodic reevaluations of function as well as consistent monitoring of performance are required to allow continuous progression of the program once initiated. Each of the subsequent chapters on the upper and lower extremities and the trunk will outline specific progressions, complete with information about the methods commonly used and recommended for progressing the program. These form the basic elemental aspects of a functional progression program and can include increases in volume, frequency, duration, and of course exercise intensity.
Using Sport- and Activity-Specific Progression in Addition to Basic Progressions
This key concept highlights the need to balance specific training with the required basic progressions to ensure that optimal baseline strength, coordination, and other important factors remain present throughout the progression. To best illustrate this concept, here is a specific example. When a throwing athlete returns to pitching after rotator cuff tendinitis, baseball-specific progressions are used, including throwing drills that progressively increase the intensity and distance of the throwing motion as well as progress from throwing on flat ground to off the mound. Although this sounds like a very sound progression for a baseball pitcher (and from a throwing perspective, it is), failure to address rotator cuff and scapular strengthening—which for all intents and purposes may appear to be too basic—will likely result in inadequate emphasis on those important muscle groups and lead to muscular imbalance and suboptimal recovery. Additionally, ignoring core stability training and hip strengthening progressions during this return program would also be remiss because these programs (rotator cuff and scapular program, core stability, and hip strengthening) form the basis on which the functionally specific program can progress.
This example highlights the importance of combining sport- or activity-specific programs with more-basic programs to ensure strength development and muscular balance. Other examples include the continued emphasis on quadriceps strength development in the patient while cutting and running drills are concomitantly being progressed to ensure that this important muscle group is continuing to develop during the sport-specific progression. The basic progressions supplied in this book for key muscle groups, and concepts such as core stability, scapular stabilization, and rotator cuff strength, cannot be forgotten or deemphasized once the other sport-specific functional progressions are initiated.
Using Objective and Functional Tests to Guide Progression
Another key factor to consider with respect to functional progression is the integration and use of objective tests and functional tests to guide the progression of the program. The final three chapters of this book list key tests and measures that can help guide the clinician during the progression of a functional program. An example of the application of this type of testing helps support this concept. Frequently, a one-leg stability test or one-leg squat test is used during rehabilitation or preseason physical evaluation of an athlete. For this test, the athlete performs a one-leg squat while the clinician observes the quality of the motion. Often during this movement, the contralateral hip drops downward (termed a positive Trendelenburg sign) as the knee of the stance limb bends (figure 2.1). The presence of this finding indicates weakness of the stance limb's gluteus medius, as it is unable to properly stabilize the pelvis in a level orientation during the descent of the one-leg squat maneuver (Hardcastle and Nade 1985; Kibler, Press, and Sciascia 2006, Chimielewski et al. 2007).
More-detailed interpretation of functional testing has been reported by Piva et al. (2006) for a lower extremity step-down test. Compensatory movements of the arm, dropping of the pelvis, and inward (valgus) angulation of the knee while performing the step-down test can be objectively evaluated and provide key insight into the readiness of a person to return to lower extremity functional activities. The presence of a positive hip drop or Trendelenburg finding in a patient after knee injury indicates the need for more-specific and basic exercise progressions to increase core and gluteus medius strength before introducing more-advanced progressions. This test, then, can become a key part of the reevaluation process to ensure that adequate hip and core stability and pelvic control have been restored before moving on to more-functional and sport-specific programs.
A similar example in the upper extremity is the use and application of clinical tests such as impingement tests (Ellenbecker 2004) and the subluxation relocation test (Hamner, Pink, and Jobe 2000) coupled with isokinetic strength testing to determine readiness of a patient with rotator cuff tendinitis to return to more-advanced throwing progressions. In this example, progressing a patient who has pain in the position of 90° of abduction and 90° of external rotation to a throwing program would be inadvisable based on the findings of that objective test. Similarly, extensive weakness or an imbalance in the rotator cuff musculature identified with an isokinetic shoulder internal and external rotation test is another contraindication for progression. Frequent testing and retesting to gauge improvement not only ensures proper rates of progression in the functional programs but also empowers the person or athlete by demonstrating the effectiveness of the programs being applied to improve baseline function. Functional tests and objective measures of strength, range of motion, and anthropometric girth can form the basis for the thoughtful and educated progression of the programs contained in this book.
The final section of this chapter deals with the importance of evaluating the person's technique as he progresses in the functional program. One of the key concepts in the evaluation of technique involves the kinetic link principle. Clinicians often focus so closely on the injured joint or segment during evaluation that other links and compensations in the kinetic chain are missed and not properly addressed in either the rehabilitation or functional progression program. Many methods can be used to evaluate technique, including simple clinical observation, expert consultation, and video analysis. All three of these methods can prove useful; it is difficult to always rely solely on clinical observation because of the high inherent speeds of human performance. Additionally, the varied sport performance background of the people being worked with often requires expertise beyond the specialty of the primary clinician. Outside exerts with established competence in the sport or activity in question can often offer critically important information relative to the development and implementation of the functional progression program.
Finally, the readily accessible use of digital video recorders and computer software, which allows for manipulation of those images to improve analysis as well as provide feedback to the athlete or person, is exceptionally important in this process. A discussion of the role the kinetic link plays in human performance closes this chapter and prepares the reader for the specific information contained in the second part of this book.
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