Functional Progressions & Functional Testingin Rehabilitation

Chapter 16

How do you move forward in Rehab?

• Function in rehab = patterns of motion that use multiple joints acting with various axes & in multiple planes– Essential part of rehab that places tissues under stresses that

return tissues to levels of full activity

– Places stresses & forces on each body system

• Traditional rehab techniques often stress only single joints in single planes of motion

• To complement traditional rehab, you can use functional rehab to ready your patient for activity

Functional Progression• Functional progression = succession of activities

that simulate actual motor & sport skills– Enables the patient to acquire or reacquire the skills

needed to perform activity– Must be able to adapt rehab to the sport-specific

demands & specific position

• The clinician breaks down the activities into individual components.– The patient can focus on each specific part of an

activity.

Benefits for Using Functional Progression

• Helps patient reach goals of entire program

• Goals of functional progression:– Restoration of joint ROM– Restoration of strength– Restoration of proprioception– Restoration of agility– Restoration of confidence

• Provides both physiological & psychological benefits to the patient

Benefits for Using Functional Progression

• Improves functional stability

• Muscular strength – SAID principle

• Endurance – muscular & cardiorespiratory

• Flexibility – elongating tissue to proper length

• Muscle relaxation – reduce muscle tension

• Motor skills – coordination & agility, automatic reactions

Psychological & Social Considerations

• Anxiety – uncertain about future

• Deprivation – losing contact with team & coaches

• Apprehension – precursor to re-injury

• Success of activity gives confidence & motivates to attain the next goal

Components of a Functional Progression

• Phase 1 – Acute Injury Phase– Focus on restoring joint ROM, muscular strength, &

muscular endurance

• Phase 2 – Repair Phase– Focus on incorporating proprioception & agility exercises

• Phase 3 – Remodeling Phase – Focus on restoring everything to pre-injury status

• Progression should allow for planned sequential activities that challenge the athlete while allowing for success

Activity Considerations• Principles for activity selection

– Individuality of athlete, sport and injury– Should be positive (no increase in symptoms should

occur)– Orderly progressive program should be utilized– Variety – avoid monotony, but don’t cause confusion

• Vary exercise techniques used

• Alter the program at regular intervals

• Maintain fitness base to avoid re-injury with return to play

• Set achievable goals, reevaluate, & modify regularly

• Use clinical, home, & on-field programs to vary activity

Activity Considerations• Make sure the patient understands the rehab

process

• You need to emphasize the importance of sport-specific activities to enhance the patient’s return– Incorporate the inherent demands of the sport

• Physical & athletic fitness should be merged to maximize athlete response & return to previous levels

Designing a Functional Progression• No cookbook method

• You are only limited by creativity

• Should be initiated early in progression

• Guidelines– Evaluate the patient’s current status– Review expectations of the patient and physician

• Do they work together?

– Understand demands of sport and position played• May require incorporation of athlete, coach and other athletic trainers

– Analyze demands that will be placed on athlete (rank order)– Set goals and means to assess levels of function and progress– Set parameters for return to play criteria

Components of Physical Fitness & Athletic Fitness

Full Return to Play• Decision requires full evaluation of athlete’s condition

– Objective observation and subjective evaluation

• Athlete should feel ready physically and mentally• Controlled return

– Added stress to injury can slow healing and result long and painful recovery or re-injury

• Criteria– Physician’s release

– Pain free, no swelling

– Normal ROM, strength

– Completion of functional testing minus adverse effects

Functional Testing

• Patient performs certain tasks appropriate to the stage in the rehab process in order to isolate and address specific deficits

• Purpose for functional testing• Determines risk of injury due to limb asymmetry • Provides objective measures of progress• Measures ability of individual to tolerate forces• Used as an indirect measure of strength and power

• Functional tests serve as good correlation to functional ability• Utilize valid and reliable tests

• Should look at both unilateral & bilateral function– Allows clinician to determine if athlete is compensating

• Must consider stage of healing, appropriate rest & self-evaluation

Functional Testing

• Limitations of functional testing – Might be limited due to lack of availability of normative

values or pre-injury baseline values for comparison - subjective decisions must be made based on test results

• E.g.: BESS

– If normative data/pre-injury status is available objective decisions can be made

• Functional test should be easily understood by athletic trainer & patient

• Must consider cost efficiency, time and space demands

Examples of Functional Progression & Testing The Upper Extremity

• Possible functional activities that can enhance upper extremity performance– PNF, swimming, pulley machines, rubber tubing – All can be used to simulate sports activity

• Must focus on proprioception & neuromuscular control– Awareness of proprioception– Dynamic stabilization restoration– Preparatory and reactive muscle facilitation– Replication of functional activities

• Kinesthesia training can use similar activities– Requires removal of external cues

• Promotion of joint position sense– Activities that can be used

• Isokinetic exercise• Proprioception testing devices• Goniometry• Electromagnetic motion analysis

– Can be practiced with visual cue progressing to no cues– Activities can be active or passive– Can also work to reproduce specific paths of motion to

increase functional component of activity– Must stress joint at both ends of ROM and at mid-range

• Results in capsuloligamentous afferents & musculotendinous mechanoreceptors, respectively

• Dynamic stability– Stresses the training of force couples provided by scapula

stabilizers & muscles of the glenohumeral joint– CKC exercises enhance co-activation

• Preparation and Reaction– Incorporates rhythmic stabilization activities along with

CKC exercises• Rhythmic stabilization prepares athlete for motion and improves

muscle stiffness while training for reaction

– Plyometrics are an excellent alternative activity

• Functional Activities– Stress sports specific skills

– PNF patterns can be used as early alternative to sports specific activity (more function, less stress)

• Program should focus on core, scapulothoracic stabilizers and the glenohumeral joint– Quadruped position allows athlete to work muscles of

trunk/core and upper extremity

• While most activities are OKC oriented, CKC activities are important for restoration of proper function

• Throwing Progression– Instruct athlete in complete an appropriate warm-up

• Should incorporate throwing motion practice (slow velocity with low stress)

– Progress through increasingly difficult stages• Shoulder serves as template for upper extremity

rehabilitation and progression– Many of the activities for the shoulder are equally effective

for the elbow, wrist and hand

Functional Testing for the Upper Extremity

• Timed performance is simplest & most common means used for testing

• Velocity• Controlled environment (indoors to decrease effect of weather)

• Set up a standard pitching distance (60’6”)

• Have athlete use a wind-up motion

• Measure a maximum of 5 throws measured in mph with radar gun (if no radar gun – use stop watch)

• Compute the mean and compare to pretest values

• CKC Upper Extremity Stability Test• Use sports specific drill to assess performance &

readiness

Progression for the Lower Extremity

• Utilizes same basic pattern as upper extremity

• Can use sprint times, agility runs for time, hopping (height and distance), co-contraction tests, carioca runs and shuttle runs

• Sprint test– Set distance

– Run the distance for time

– 3-5 sprints should be completed and the mean computed

– Pre-test and post-test measures are compared

• Agility test– Same premise as sprint test– Difference involves the course

• Not just straight ahead running• Incorporates changes in direction, acceleration, deceleration, starts &

stops

– Other agility tests• Box runs• Zigzag runs• Cutting maneuvers• Figure 8 runs• Back pedaling drills

– Changes in shape and size can make drills more difficult

• Vertical Jump– Record height athlete is able to jumps (3-5 trials)– Test can also be varied

• Bilateral jump vs. Single leg jump• Countermovement vs. static squat start• Approach step vs. stationary start• Upper extremity use for propulsion vs. restricted use

• Co-Contraction Semicircular Test– Athlete moves about a semicircular pattern while

tethered to taut Theraband using a forward facing shuffle

– Athlete will complete 3 trials of 5 repetition for time– Provides a dynamics pivot shift for the ACL

insufficient knee

• Hopping Test– Single leg hop for distance– Timed hop test (ability to hop 6 meters for time)– Triple hop for distance (distance covered in 3 consecutive

hops– Crossover hop (distance covered in 3 hops)

• Carioca Test– Run performed for time– Run a total of 80 feet, 40 feet to the right and 40 feet to the

left, both facing the same direction– Record 3 trials and calculate a mean

• Shuttle Run– Four 20 feet sprints (with 3 direction changes)– Suicide sprints – sprint, touch mark and return to starting

position (total time to complete drill)

• Balance Test– Helps determine deficits in proprioception and balance

– Single leg stance (hold position for time)• Can incorporate different surfaces, and eye condition

• May also incorporate sports skills into test

• Functional Hop Test

• Subjective Evaluations– Incorporation of subjective questionnaires or numeric

scales to assess function