Concepts of Rehab
CONCEPTS OF ORTHOPEDIC REHABILITATION
The therapist's primary role in musculoskeletal rehabilitation is to
maximize the ideal conditions for the tissues' own healing capability and
to assist the patient in resuming preinjury activities that are important
to the patient.
Treatment strategies, those methods chosen by the therapist to assist the
patient to recover functional skills, are driven by the occupational
challenge and the physical therapy diagnosis, by the patient's desired
outcome, and by scientific knowledge and rationale.
Occupational therapists and physical therapists must be able to provide
sound rationale to support the interventions they choose for the
rehabilitation of patients with orthopedic problems.
Guiding Principles of Rehabilitation:
Continually Observe, Evaluate, and Critically Think
- Continually Observe, Evaluate, and Critically Think
- Interventions Must Be Patient-centered
- Consider the Dimensions of Rehabilitation (Acute to long term)
- Apply Knowledge of Tissue Healing to Intervention
- Understand and Apply the Concepts of Protection, Rest, and Return to
- Apply Tension to Healing Tissues
- Think Anatomically, Biomechanically and Functionally
- Perform Ongoing Patient and/or Caregiver Education
- Choose Appropriate Frequency of Treatment and Know When to Discharge
- Respect the Injury, but Don't be Intimidated by It
Continually test your Diagnosis / Occupational Performance Dysfunction.
Compare your current measurements to the baseline that you established in
the initial evaluation.
Continually critique your chosen intervention(s) and ask yourself: is this
the best thing for the patient at this time? Always consider the
"progression" of treatment, and continue to challenge the patient,
ultimately preparing the patient for return to activities.
Interventions Must Be Patient-centered
To assist a patient in resuming preinjury activities that are important to
the patient, the therapist must know the patient's desired outcome(s) of
All treatment goals pertain to the patient's desired outcome(s). Any
outcome will relate to one or more of the three areas of activities:
self-care, work, and leisure.
Therapists should have the patient prioritize each desired outcome so that
they know which activities to focus on during treatment. The majority of
patients will rank the importance of their desired outcomes along a
continuum similar to the following:
Patient-centered treatment should end with patients resuming all of the
activities that they have determined are important.
- Regain self-care activities
- regain ability to return to work
- return to performing leisure activities.
Consider the Dimensions of Rehabilitation
As they treat the patient, therapists should ask: "What conditions are
responsible for the dysfunction and are these conditions reversible? If
reversible, what would be the most appropriate means of intervening
therapeutically so as to affect these conditions? If the conditions at
fault appear irreversible, what can be done to optimize residual function?"
It is extremely important for therapists to realize that they cannot "fix"
every person who comes to them with a problem. In addition, just because a
personís problem is not "fixable", this does not mean that the problem
cannot be alleviated through a therapistís intervention.
Rehabilitation can occur in any of the following dimensions that relate to
the patient's problem(s):
Treatment of Pathophysiologic Problems:
- From the pathophysiology perspective
- The impairment perspective
- At the dimension of functional limitation
- The disability perspective >(National Center for Medical
Rehabilitation Research, 1993).
Therapists can employ a number of treatment strategies in the
pathophysiology domain to assist tissue healing, including:
Treatment of inflammation: Pathophysiological interventions should focus on
controlling the acute or chronic inflammatory responses.
Acute Inflammation of Tissue:
Protect: to reduce the chance of further injury to the tissue
Rest: to promote proper healing
Ice: to reduce blood flow, decrease perception of pain
Compression: to prevent and reduce swelling
Elevation: to prevent and reduce swelling and hyperemia
Identify the source of ongoing irritation and eliminate it,
or alter the person's activities so that it no longer has an
adverse impact on the person.
Application of Wolff's Law and Davies' Law to Tissue Healing: a
balance of protecting the tissues and early mobilization; balance of
rest versus exercise.
Treatment of Impairments: includes the following areas:
- Pain: use of modalities, including thermal agents, electrical
- Range of Motion: address restrictions of joint mobility,
strengthening weak muscles, stretching tight ones; addressing
joint capsule tightness; etc. (Goldstein, 1995, p. 55).
- Postural alignment and base of support.
- Sensory input: desensitizing areas, retraining proprioception,
etc.(Goldstein, p. 59)
- Mobility and coordination/motor control: can be improved by
altering some of the characteristics of the movement, including
the speed of the movement, the joint ROM, the initial postural
alignment, the sequence of muscle activation (Goldstein, 1995, p.
Treatment Functional Limitations: The most successful treatment
strategies are those that exactly simulate/duplicate the functional
aspects of activities that the person wishes to resume.
Treatment of Disabilities: the therapistís intervention is geared
toward optimizing a patient's function in the various activities of
self-care, work, and leisure. If the conditions causing disability are
irreversible, the therapist must work to optimize the patient's
residual function and help the patient to adapt performance of
A primary concern in any activity adaptation is the patientís ability
to perform those activities that are part of the individualís daily
routine. There are four broad considerations for activity adaptation:
The adaptations used with clients are limited only by the creativity
and imagination of the therapist. The most important criterion of the
adaptations incorporated into activity should be their relevance to
the client (Levine & Brayley, 1991).
- Positive role for the individual: the individual is actively
performing the activity rather than it being done to them.
Through the individualís participation, the individual is
actively adapting to the environment, the situation, or the
activity and, therefore, is actively involved in the therapy
process (Levine & Brayley, 1991).
- Demand of the environment requires adaptation: if individuals
want or need to do something and are obstructed by their own
inabilities, then individuals must learn to adapt themselves to
the environment or adapt the environment to meet their needs
(Levine & Brayley, 1991).
- Adaptation is most efficient when it is organized on the
subcortical level: the focus is on the activity or the outcome,
providing organization of sensory input and motor output to the
subcortical centers where it is handled most efficiently and
adaptively (King, 1978).
- Adaptation is self-reinforcing: each successful adaptation serves
as a stimulus for attempting the next step (King, 1978).
Apply Knowledge of Tissue Healing to Intervention
Tissue healing times depend on the type of tissue, the extent of the
injury, and when/how tension is applied to the tissue. The following
table reflects general time frames when specific tissues may be
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Understand and Apply the Concepts of Protection, Rest, and Return to
To allow tissues to heal, therapists must protect them from continued
trauma by eliminating or reducing loading of the injured structures.
The extent of protection is dependent on the degree of tissue injury.
Low-grade injuries may not require protection, whereas tissues that
are significantly injured and have a slow healing rate may require
Rest does not necessarily mean inactivity. Resting injured tissues can
range from not allowing the patient to perform any activity, to
performance of the activity with certain modifications. Therapists
must be very clear to their patients what constitutes protection,
rest, and return to activity for that patient.
Protect and rest tissues by:
Return the patient to activity by preparing the tissues for the
activity and by gradually resuming the activity.
- Immobilization: casting, splinting, internal fixation.
- Protected Mobilization: Braces, splints, strapping, taping.
- Reduced loading: use of assistive devices, adaptive
- Alteration of activities: maintaining optimal levels of
function while preventing unnecessary loading of the
tissues, example: shortened work time, taking frequent
rests, use of proper body mechanics.
- Alter environment in which activities take place.
* Remove the mechanism of injury, guide tissue healing, prepare the
tissues for return to activity (Gross, 1992, p. 255).
Apply Tension to Healing Tissues
Wolf's Law and Davies' Law:
Long-term exercises cause collagen fibrils to thicken and align
themselves parallel to the direction of force, increasing their
tensile strength (Liu, et al. p.268).
Optimal remodeling of initially formed collagen fibers does not occur
unless the tissue is subjected to physiological loading. Tissues that
do not experience tension will lay down collagen in a disorganized,
nonparallel manner, decreasing their tensile strength (Gross, 1992, p.
When applying Wolf's and Davies' Laws to healing tissues, therapists
Introduction of Tension
- When to introduce tension to the tissues;
- The magnitude and type of tension;
- How to progress the tension such that the tissue can tolerate the
demands of the patient's various activities.
Therapists can use their knowledge of the various healing times of
tissues to assist them in determining when to introduce tension. Many
significantly injured soft tissues are weakest at three to four weeks
post injury, due to the more-rapid absorption of type III collagen and
the slower deposition of Type I collagen.
Medical imaging techniques such as MRI, CT, x-rays, etc. will provide
information on the exact healing status of tissues.
The cardinal signs of inflammation will help to determine when
therapists can begin to introduce tension to injured tissues.
Reduction of most or all of the cardinal signs of inflammation is a
good indicator of when to begin to mildly stress tissues. The
recurrence of any of the signs following the introduction of tension
usually indicates that the tension applied exceeded the tolerance of
The Magnitude and Type of Tension
The degree of tension is inversely proportional to the extent of
injury. Common sense would dictate that therapists introduce a small
amount of tension initially, evaluate the tissue response, then
proceed as indicated.
Therapists can apply tension in a variety of ways. Tension can be
manual, such as with friction massage, joint mobilization, or
exercise. It can also be provided mechanically by rubber bands,
weights, or other methods of resistance. Regardless, the tissue will
reorganize and begin to align its components in parallel with the
vector(s) of the tension.
When selecting exercises/ activities to apply tension to tissues,
therapists should arrange the functional activities by order of
difficulty/stress to structures (begin with lower level activities,
Think Anatomically, Biomechanically, and Functionally
Occupational therapists and physical therapists must have a solid
foundation in anatomy and biomechanics to develop effective
They should always consider the anatomy of a region and visualize the
various structures that they are rehabilitating.
Therapists should apply biomechanical principles to their treatment.
They should understand and encourage "typical" postures and movements
and be able to discern and influence atypical patterns. They should
consider the forces that the tissues and joints experience, and alter
these as needed.
Treatment should always progress toward the patient performing the
functional activities that they defined as important to them in the
interview. Treatment may begin with simple planar exercises, but
during the course of treatment should progress toward functional
Perform Ongoing Patient and/or Caregiver Education
Patient education is an ongoing part of rehabilitation. It includes
educating the patient and/or caregiver about the problem, teaching
home programs to augment treatment, providing strategies for
performing functional activities, etc. Therapists can augment patient
education with handouts, videotapes, or other educational methods.
Because patient education is an integral part of rehabilitation,
therapists must take the time to perform it properly. Teaching occurs
during therapy. It should not be "tacked on" in the form of a home
program handed to the patient following treatment.
Choose Appropriate Frequency of Treatment and Know When to Discharge
Frequency of treatment depends on many factors. Therapists can use the
following considerations to determine number and duration of patient
Part II of the Hypothesis Oriented Algorithm for Clinicians (HOAC)
provides guidance for when to discharge patients (Echternach &
Rothstein, 1989). Portions of part I of the HOAC are below for
reference, followed by Part II.
- The extent of the injury/length of healing time
- The degree of "skilled" service needed
- See the patient when you need to change the intervention.
- Don't be afraid to schedule a follow-up session soon after you've
changed the treatment program. It is important that therapist's
evaluate the patient's response to the altered treatment.
- Some reimbursors or other parties may try to dictate frequency
and duration of patient visits. Don't be afraid to negotiate with
- Always have the patient's best interest in mind. Work to avoid
falling into a habitual frequency/duration schedule.
- Generate a working hypothesis about the problem(s). Correlate and
interpret findings of the P.E. to determine a P.T Diagnosis or
Occupational Challenge; refer to other practitioner (if therapist
cannot generate a hypothesis)
- Plan reevaluation methodology (schedule dates for reevaluations)
- Plan treatment strategy based on hypothesis, obtain consultation,
- Plan tactics to implement strategy (specifics of treatment plan)
- Implement tactics (perform treatment) and document
Respect the Injury, but Don't be Intimidated by It
- Reassess the patient: Have the goals been met?
Yes. Discharge the patient.
No. Are the treatment strategies being implemented correctly?
No. Improve implementation (go back to step # 8)
If Yes, are the treatment tactics appropriate?
No. Change your strategy (go back to step # 6)
If Yes, is the strategy correct?
Yes. Are the hypotheses viable? (If testing criteria
have been met and goals are not met, new hypotheses are
No. Generate new hypotheses (Go back to step # 4)
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