Functional Progressions Functional Testing in Rehabilitation

1. Functional Progressions & Functional Testingin Rehabilitation

2. How do you move forward in Rehab? Functional activities are an 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

3. Terminology Functional Exercises – Activities that advance a patient to a safe return to full participation as soon as possible Functional Evaluation – Assessment of the patient’s ability to perform an exercise or skill drill safely & accurately before allowed to advance to the next level

4. Goals of Functional Exercise Attain full functional levels of flexibility, strength, endurance & coordination Achieve full functional ability so that normal speed, power, control & agility are restored Restore the patient’s self-confidence in own performance as well as injured body part Return patient to full participation safely & efficiently at a level at least equivalent to pre-injury performance

5. 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 Activities are broken into individual components. Focus can be placed on each specific part of an activity.

6. 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

7. 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

8. 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

9. 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

10. Activity Considerations/Precautions 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

11. Activity Considerations/Precautions Make sure the patient understands the rehab process – explain, explain, explain! 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

12. Activity Considerations/Precautions Avoid swelling & pain Understand tissue integrity Know the patient’s confidence level Be aware of progression tolerance Introduce activities at low speed, intensity, & difficulty

13. Designing a Functional Progression Workout 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

14. Components of Physical Fitness & Athletic Fitness

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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 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)

27. 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)

28. 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 (See handout) Subjective Evaluations Incorporation of subjective questionnaires or numeric scales to assess function

29. Final Thoughts! Basic functional exercise progression Flexibility Strength Endurance Proprioception Advanced functional exercise progression Force & Intensity Speed Distance Complexity Support