Chapter 9
Function-Based Rehabilitation - Principles And Techniques

  1. Introduction

  2. Rationale for "function-based" program
    1. Wolff's Law - bone remodels according to the stresses placed upon it; bone will be laid down where stresses are the greatest, and thin where loads are diminished
    2. Wolff's Law of soft tissue - this law has been extended to include soft tissue remodeling; healing collagen fibers will orient along the lines of stress via a peizoelectric effect, resulting in a stronger tissue than if no load had been imposed
    3. SAID - Specific Adaptations to Imposed Demands; the body will adapt to demands placed upon it; the therapist must determine the timing, magnitude and direction of demands placed upon the healing tissue; initially, the therapist should control these variables, with gradual relinquishing of these variables to the patient; however, the therapist must first assess the demands placed on the patient; variables may include:
      • time
      • repetitions
      • speed
      • ROM
      • force/load
      • open vs. closed chain
      • concentric, eccentric or isometric muscle contraction
      • acceleration/deceleration
      • weight bearing
      • triplane motion
      • externally applied forces; i.e. getting hit, carrying loads, uneven surfaces, etc.
    4. Joint receptor stimulation: with injury, effusion, position sense is diminished; this may account for the large number of reinjuries despite full strength and mobility; simple immobilization without injury decreases position sense; all the strength in the world won't save your ankle if you land in an inverted position
      • Ruffini endings (capsular stretch, proximal joints) slow adapting
      • Pacinian corpuscles (sensitive to accel and high velocity changes in joint position) fast adapting
      • Golgi-Mazzoni corpuscles (sensitive to compression of joint capsule in plane perpendicular to its surface) slow adapting
      • Golgi ligament endings (sensitive to tension or stretch on ligaments) slow adapting

  3. Components of program
    (Gary Gray)
    Closed Chain
    Open Chain
    End segment
    Fixed open
    Axis of motion
    distal & proximal to axis
    distal to axis
    Muscle contraction
    primarily concentric isometric
    combination: concen, eccen,
    predomination of some ms. grps w/o isolation
    single, isolated plane of movement predictable
    Loads normal loading in normal environ artificial loading in artificial enviro
    variable, controllable
    predetermined or influenced
    Stress & strain
    consistent stress & strain on soft tissue
    artificial means
    normal postural mechanisms
    Planes triplane single plane
    normal proprio & high degree of carryover to normal activity
    erroneous feedback & little carryover
    limited by equipment
    Reaction reaction + action action alone

  4. Precautions with program

  5. Basic principles of proprioception/balance program

  6. Other closed kinetic chain activities

  7. Putting it together I: Optimal Loading

    * You must know the stage of healing of the tissue you are dealing with!

    Curwin & Stanish Classification:
    Level I: no pain
    Level II: pain with extreme exertion which disappears when the activity is stopped
    Level III: pain with exertion which remains 1-2 hours after the activity is stopped
    Level IV: pain with activity which alters function. Pain may last 4-6 hours after activity and/or may increase during activity
    Level V: pain begins as soon as activity begins and causes withdrawal from activity
    Level VI: pain with ADL, unable to participate in sport or rehabilitation activity

    * These levels do NOT refer only to sports! They refer to rehabilitation as well! Use these as a guide to help your patient understand how much exercise is appropriate.

    Optimal loading: the key to determining the appropriate level of activity is finding the patient's baseline; this is their level of optimal loading; any more overworks and any less underworks; if the patient overworks on a given day, they should return to their baseline and build back up

  8. Putting it together II: Planes of Motion

  9. Putting it together III: The Functional Progression

    Definition: planned activities that progress a patient through a series of increasingly difficult functional tasks. It is an extension of the PRE program.

    Benefits: both physical and psychological
    1. specific stressing of healing tissue
    2. neuromuscular coordination
    3. activity specific strength & endurance training
    4. confidence in return to activity

    Principles of Program Design:
    1. same as a PRE program - sets, reps, intensity, SAID
    2. overload

    1. Evaluate functional task
      • CV demands
      • MS demands
          strength & endurance
          open/closed chain
          length of time
    2. Evaluate environment
    3. Formulate a plan based on these

    1. Strength/endurance - consider testing when tired
    2. ROM
    3. swelling
    4. WB status

    1. Motor ability can fool you
    2. Physical and psychological readiness

    Program Examples:
    1. Work hardening
    2. Sports
      • running program
        must complete an impact loading progression prior to return to activity
      • initially therapist controls variables
      • gradually variables are relinquished to the patient to control
      • teach patient classification scheme to understand how to monitor program

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