Rehabilitation - restoring back to normal after an injury


In our last article we discussed prehab and noted the difference with rehab.  To recap, by definition, Rehabilitation (according to Oxford dictionary) is "the action of restoring someone to health or normal life through training and therapy after imprisonment, addiction, or illness".  Prehabilitation can be defined as "the process of care, initiated before surgery, whereby patients’ physical, nutritional, medical and mental conditions are strengthened while waiting for surgery in order to face the surgical insult and facilitate postoperative return to preoperative conditions" (McGill perioperative program).  The difference really only is the timing.  Prehab occurs prior to surgery or other intervention, while rehab occurs post surgically or following an injury or chronic illness.  

Rehabilitation as stated above, is the "restoring back to normal".  When there is an injury, there are phases of "restoring back to normal".  Initially, from the treatment stand point, we are first focusing on removing pain and inflammation.  Whether these symptoms are coming from a laceration, a bruise, post-surgical incisions/stitches, burns, tears, or chronic illness, phase 1 in rehab is to heal the damage and reduce the swelling.  In phase 2, we begin restoring range of motion (ROM) and introduce cardiovascular functioning.  Phase 3 involves restoring ROM, improving strength and endurance, proprioception and continued cardiovascular training.  As we meet phase 3 goals, we move into phase 4 where we can continue to build strength while introducing sport specific patterns and the progression of velocity to game speed.  Ultimately, the restoration of strength and function.  Keep in mind that these phases will be discussed from a musculoskeletal injury perspective, but they can definitively be applied to other areas of rehabilitation, i.e chronic illness or depression.  

Phase 1 and 2 (healing the injury and then restoring motion) are the phases that most people know about.  .  We will not focus too much on these phases but put the majority of emphasis on phase 3 and 4. Strength, stability and endurance are often over looked when a professional is not involved in the rehab process.  

Phase 1:  Acute care

Healing of open wounds, reducing inflammation, application of ice, ultrasound, stim, laser, use of NSAIDs (if applicable) are all different modalities of acute care.  This phase can be completed on your own or in the office of a healthcare professional.  The advantages of seeing your healthcare provider during this phase is for the application of modalities that may not be available at home (like laser).  

Phase 2:  Introduction of ROM and cardiovascular training

With any injury, as soon as we can get the part moving, the better the outcome.  This is why you don't stay in the hospital for very long post-surgery.  The longer a body part is immobile, the larger the deficit to the muscles that are immobile.  The introduction of ROM is going to be progressive.  Each day motion continues to improve.  As we move, we help pump blood to the area which provides biochemical components to the area of injury to further help in the healing action.  This is also why introducing some cardiovascular activity is very beneficial.  Keep in mind, you must not do exercises that are contraindicative to the injury.  A stationary bike is great cardiovascular exercise to introduce for multiple injuries to the body, but you have to be able to do it.  

Phase 3:  Restoring ROM, improving strength, endurance, proprioception and continued cardiovascular output.

Part of the restoration of ROM will involve stretching.  During the immobile time, muscles aren't moving how they normally move.  Often there are compensations for ranges that aren't possible due to the injury.  These compensatory muscles then become over worked, they may even get injured themselves, and are often very tight.  Hopefully these tight areas are worked out in earlier phases of rehab, but they may still need to be addressed to fully meet the goals of restored ROM. 

With the introduction of strength post injury, we often start with isometric exercises.  These exercises involve contracting the muscle without changing the length of the muscle.  For example, for the quadriceps muscle, while in a seated position with knee straight, you would squeeze to contract the quads.  You should feel the muscle tighten and then relax as you let the contraction go.  Sometimes we add resistance so you can identify the muscles that need to contract without actually doing the motion of the muscle or group of muscles.  For example, with the cervical flexors try placing your hand on your forehead and push into your hand without actually moving your head (you are performing isometric exercises for the cervical flexors).  Once ROM has improved and isometrics are able to be done without pain, we can add motion to our strengthening (concentric contractions) taking the muscle through its full ROM.  Initially, strengthening will involve individual muscles and then progress as the strength improves to more functional movements involving multiple muscles or muscle groups. 

Proprioception is another component in this phase of rehab that needs to be addressed.  Proprioception is the ability to understand where a joint of the body is positioned in space.  This information is transmitted to the brain via small nerves called proprioceptors.  We have proprioceptors all over the body, the most in our ankles, second in our neck.  We rely on several factors to tell our brain where we are positioned in space, mainly vision, vestibular functioning and proprioception.  When there is an ankle sprain for example, essentially we tear tissue in the ankle, ligments, small capillaries and nerve endings called proprioceptors.  You can retrain these nerve endings to send adequate info back to our brain through various balance exercises.  You can test your proprioception by standing on one leg with eyes open.  Once you can hold this for 10 seconds, close your eyes.  How well is your brain able to keep you balanced?  Do you fall over as soon as you close your eyes?  Or can you hold it for 10 seconds?  With an injury, our rehab needs to also address the proprioceptive component to be able to maintain stability and balance. 

Cardiovascular training in this phase is going to help contribute to some strengthening but also build up endurance to the point where some might think that they are finished rehabilitation.  (but we know that we need to finish with phase 4). 

Phase 4:  Sport specific training, power, game speed performance.

To enter this phase of rehab, full ROM needs to be restored and strength needs to be adequate.  Here we can work on sport specific movements that will prepare for return to play, or for those that are not athletes, movements that were done regularly pre-injury, i.e., lifting weighted objects overhead for someone that does stocking in a grocery store.  For runners, we would incorporate a lot of one-legged stance exercises, cross body motions and changing weight from one side of the body to the opposite.  Football players would need to work on a lot more pivoting and changing direction of the body, reaching and leaping motions if they are receivers or throwing motions if they are quarterbacks.  For any sport, phase 4 means breaking down the motions of that sport, working on those individual motions, then combining them to perform full body movements.  Here we can also introduce power development and speed.  How can we use the body properly to transfer the force development to throw the ball further, swing a bat faster or drive a ball an extra 20 yards.  Force development comes from a combination of muscles, joints and body parts working together in a particular sequence at the right speed and moving at the right time.  Developing power does not have to be a sport specific motion.  A golfer, a runner, a basketball player or a steel worker could all look the same in the gym but you may not be able to identify their specific sport or job.  Power training involves creating a force to move a mass with speed.  Some examples of power training exercises could include vertical jumps, hurdle jumps, medicine ball slams, squat jumps, overhead 2-handed throw, sprints, long jump, and the list goes on.  Another must in any rehab program is developing core strength and proper core contraction.  There are multiple was to do this, however, I believe the best core trainers are Pilates instructors.  Please see the link in our article about Stacey Ziebarth and her Studio Zee Pilates in Hamilton.

 Rehabilitation for a musculoskeletal injury needs to continue through all four phases of rehab to fully “restore normal health”.  We have identified all of the phases of rehab and discussed in detail the aspects that need to be followed.  Injuries can make a big impact on ones’ life and the lives of those around them.  Although some injuries may appear to be completely repaired after phase 2 or 3, the lack of muscle strength and power that should have been rehabbed in phase 4 may present itself with further injuries down the road.  If you or someone you know has been injured, please see a health professional, like Dr. Marnie Mabee D’Andrea, that can take you through these phases of rehab.  Stay tuned in April when we discuss Corrective Exercise, Part 3 in our exercise and movement series.