Chapter 16: Using Therapeutic Exercise in Rehabilitation

Athletic TrainerΉs Approach to Rehabilitation

€Begins immediately after injury

€Initial first aid has a substantial impact on the injury

€One of ATCΉs primary responsibilities is to design, implement and supervise rehab plans

€Design programs based on short and long term goals


Short term goals


Long term goals



Due to competitive nature of sports, rehab must be aggressive


Therapeutic Exercise Versus Conditioning Exercise


Effects of General Inactivity


Effects of Immobilization


Atrophy and fiber conversion



Decreased neuromuscular efficiency


Joints and Immobilization


Ligaments and Bone and Immobilization



Full remodeling of ligament can take 12 months or more following immobilization


Cardiorespiratory System and Immobilization

Resting heart

Stroke volume, maximum oxygen uptake and vital


Key Components of Rehabilitation

€Controlling Pain

€Restoring Range of Motion

€Restoring Muscular Strength, Endurance and Power

Must work through a full pain free range of motion when working on strength





Progressive Resistance Exercise (PRE)


Traditionally focus on concentric exercises

€Eccentrics involved in deceleration of limbs

€Facilitate concentric contractions for plyometrics & incorporated w/ functional PNF strengthening exercises

€Both forms are contraction can be created using a variety of equipment

€Machines tend to limit movement in functional planes

€Machines and free weights are difficult to operate at functional speeds w/out injury





Isokinetic Exercise

Incorporated in later stage of rehabilitation process

Uses fixed speeds w/ accommodating resistance to provide maximal resistance throughout ROM

Isokinetic units allow for calculation of torque, force, average power, and work ratios which can be used by the clinician diagnostically

Allows for work at more functional speeds

Work at higher speeds tends to reduce joint compressive forces

Can be used to develop neuromuscular pattern for functional speed and movements


Testing Strength, Endurance and Power




Re-establishing Neuromuscular Control, Proprioception, Kinesthesia and Joint Position Sense

€Following injury, body forgets how to integrate information coming in from multiple biological sources

€Neuromuscular control is mindΉs attempt to teach the body conscious control of a specific movement

€Re-establishing neuromuscular control requires repetition of same movement, step by step until it becomes automatic (progression from simple to difficult task)

€Closed kinetic chain (CKC) exercises are essential for re-establishing control but can be difficult

Closed kinetic chain = foot or hand is weight bearing


Joint Mechanoreceptors

Found in ligaments, capsules, menisci, labra, and fat pads

Sensitive to changes in shape of structure and rate/direction of movement

Most active at end of ranges of motion


Muscle Mechanoreceptors

Muscle spindles - sensitive to changes in length of muscle

Golgi tendon organs - sensitive to changes in tissue tension


Regaining Balance


Maintaining Cardiorespiratory Fitness



Functional Testing

Uses functional progression drills for the purpose of assessing the athleteΉs ability to perform a specific activity

Entails a single maximal effort to gauge how close the athlete is to full return

Variety of tests

€Shuttle runs                                     -Vertical jumps

€Agility runs                                     -Balance

€Figure 8Ήs                                          -Hopping for distance

€Cariocca tests       -Co-contraction test


Preoperative Exercise Phase (PREHAB)

Only applies to those requiring injury

Exercise may be used as a means to improve outcome

By allowing inflammation to subside, increasing strength, flexibility, cardiovascular fitness and neuromuscular control the athlete may be better prepared to continue rehab after surgery


Phase I - Acute Inflammatory Response Phase




Phase 2: Repair Phase




Phase 3: The Maturation/Remodeling Phase

Longest of 3 phases

Pain is minimal (none to the touch) and collagen must be realigned according to tensile strength applied to them during functional activities

Focus is on regaining sport-specific skills

Functional training - repeated performance of athletic skill for purpose of perfecting that skill

Strengthening exercises should be used to place athlete under stresses and strains normally associated w/ athletic participation

Plyometrics can be used to improve power and explosiveness

Functional testing should be done to determine specific skill weaknesses that need to be addressed

Thermal modalities should be used to enhance tissue environment (reduce spasm, increase circulation, waste removal and reduce pain)


Criteria for Full Return to Activity



Open kinetic chain exists when foot or hand is not in contact w/ ground or other surface

Closed kinetic chain = foot or hand is weight bearing


Forces begin at ground and work their way up -- forces must be absorbed by various tissues and structures, rather than just dissipating


Most activities involve some degree of weight bearing, therefore CKC exercise are more functional than open chain activities

Isolation exercise typically make use of one specific muscular contraction to produce or control movement

CKC exercises integrate a combination of contractions in different muscle groups w/in the chain

There are a variety of popular exercises

€Mini-squats, leg presses, step-ups, terminal knee extension w/ tubing, push-ups and weight shifting exercises on a medicine ball


Core Stabilization Training


Core Stabilization Exercises


Aquatic Exercise



Proprioceptive Neuromuscular Facilitation Technique

€Exercise that uses proprioceptive, cutaneous, and auditory input to produce functional improvement in motor output

€Used to increase strength, flexibility and coordination

€Based on the physiological properties of the stretch reflex


Basic Principles for Using PNF Technique



PNF Patterns

€Involves 3 components



Internal/External rotation



Joint Mobilization and Traction

Used to improve joint mobility or decrease pain by restoring accessory motion -allowing for non-restricted pain free ROM



Mobilization may be used to

Reduce pain

Decrease muscle guarding

Stretch or lengthen tissue surrounding a joint

Produce reflexogenic effects that either inhibit or facilitate muscle tone or stretch reflex

For proprioceptive effects that improve postural and kinesthetic awareness



Mobilization based on concave-convex rule

€Mobilization can also be used in conjunction w/ traction


Pull articulating segments apart (joint separation)

Occurs in perpendicular treatment plane

Used to treat pain or joint hypomobility

Treatment Planes

Joint Mobilization Techniques


Myofascial Release



Locate restriction and move into the direction of the restriction

More subjective and relies heavily on experience of the clinician

Focuses on large areas

Can have a significant impact on joint mobility

Progression, working from superficial to deep restrictions

As extensibility increases in tissue should be stretched

Strengthening should also occur to enhance neuromuscular reeducation to promote new more efficient movement patterns

Acute cases resolve in a few treatments, while longer conditions take longer to resolve

Sometimes treatments result in dramatic results

Recommended that treatment occur 3 times/wk



€Technique used to decrease muscle tension and normalize muscle function

€Passive technique that places body in a position of comfort - thereby relieving pain

Locate tender points (tense, tender, edematous spots, <1cm in diameter, may run few centimeters long in muscle, may fall w/in a line, or have multiple points for one specific joint)

Tender points monitored as athlete placed in position of comfort (shorten muscle)

When position is found, tender point is no longer tense

After being held for 90 seconds, point should be clear

Patient should then be returned to neutral position


Positional Release Therapy

Active Release Therapy

€ART is relatively new type of therapy used to correct soft tissue problems caused by formation of fibrotic adhesions

Result of acute injury and repetitive overuse injuries or constant pressure/tension

Disrupt normal muscle function affecting biomechanics of  joint complex leading to pain and dysfunction

Way to diagnose and treat underlying causes of cumulative trauma disorders


Deep tissue technique used for breaking down scarring and adhesions   

Locate point and trap affected muscle by applying pressure over lesion

Athlete actively moves body part to elongate muscle

Repeat 3-5 times/treatment

Uncomfortable treatment but will gradually soften and stretch scar tissue, increase ROM, strength, and improve circulation, optimizing healing

Must follow up w/ activity modification, stretching and exercise

Active Release Therapy