Learn how to provide cost-efficient, three-phase individualized rehabilitative care that gets positive results

Rehabilitative care should not be viewed as a one-size-fits-all program. The human body passes through several stages after an injury and each stage requires a specific exercise regimen. An effective rehab program should be tailored to both the individual’s current needs and the goal of restoring as much strength and functional ability as possible.

Appropriate care for patients with musculoskeletal injuries usually includes an effort to rehabilitate. Progressive exercising will allow a quicker return to routine activities and help avoid reinjury. The benefits of early, progressive rehabilitation exercise include decreased neural inhibition, quicker recovery of muscle function, restoration of range of motion (ROM), less pain, and better performance in activities of daily living.¹

In a majority of cases, the process of rehabilitation for musculoskeletal injuries can be undertaken in three distinct phases: 1) acute care; 2) recovery of movement; and 3) functional conditioning.² A comprehensive rehabilitation plan will include different types of exercises that are useful for each of the healing phases.

Acute Care
Once an injury has occurred, the patient will experience varying amounts of pain and swelling, as well as weakness, diminished ROM, and decreased performance of routine activities. Pain and swelling are indicators of inflammation due to tissue damage, and require immediate attention. Reducing further damage is an important goal during the acute care phase. Therefore, protection of injured areas and the surrounding healthy tissue is crucial. Frequent cooling of the damaged tissue will help prevent additional bleeding and swelling and help to control pain.

Controlled, active exercises to prevent atrophy should begin as soon as pain is under control and inflammation begins to subside. Since isometric training results in muscle strength gains mainly at the joint angle used,³ controlled motion (dynamic) exercises in a pain-free range should be initiated as soon as they can be tolerated. Initially, no resistance/load motion progresses to a minimal external load (such as exercise tubing). This can be carefully progressed based on the pain levels and tolerance of the patient. Electrical stimulation can be helpful in motor unit recruitment in this stage, while it helps to control excessive pain.⁴

Figure 1. Exercises to regain normal flexibility and full range of motion of injured points should be a part of the rehabilitation program in the early recovery phase.

Recovery of Movement
Return to normal activities is compromised without full ROM; therefore, exercises to regain normal flexibility (Figure 1) of injured joints are important in the early recovery phase.

Stretching is one accepted method for increasing the flexibility of tight muscles in patients with musculoskeletal conditions.⁵ For maximum benefit, stretching exercises must be done two or three times a day, with a minimum of three repetitions of approximately 30 to 60 seconds for each muscle group. Stretching should be performed after the involved tissues have been heated above resting body temperature—either following an active warm-up, or by passive, external heating (such as a heating pad or hot tub). Early morning stretching may be counterproductive.

To avoid atrophy and ensure a rapid return to regular activities, daily dynamic resistance exercises to increase strength can be initiated as soon as they are tolerated. Both concentric and eccentric muscle actions should be worked, with a gradual increase of ROM and resistance.⁶ Muscle endurance must be addressed by stimulating a higher level of oxygen uptake for a sustained effort to prevent deconditioning. Elastic exercise tubing is a safe, effective method of providing progressive resistance exercises with an aerobic component.⁷

Figure 2: Exercises at the functional conditioning stage should simulate activities of daily living. Incorporate motions and activities that re-educates and coordinates specific muscle actions and reactions for performance of normal movements and duties.

Functional Conditioning
This phase prepares the injured patient to return to regular lifestyle and job-performance activities. Exercises at this stage are more functionally oriented, to simulate the demands of the patient’s activities of daily living. Conditioning training incorporates motions and activities that re-educate and coordinate the specific muscle actions and reactions that the patient needs for his or her performance of normal movements (Figure 2) and duties.

Phase to Phase
Physical rehabilitation should be planned to take place simultaneously with the biological healing of the injured tissues. Current rehabilitation concepts emphasize functional activities and retraining of normal loading and movement patterns. Appropriate and progressive rehab programs should be started early in the treatment of all patients with musculoskeletal injuries. Expensive rehab equipment is usually not required. Simple strength retraining programs utilizing elastic exercise tubing are readily available and effective. CP

Kim D. Christensen, DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Wash. He has participated as team chiropractor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, past-president of the ACA Rehab Council, and a lecturer and author of many musculoskeletal rehabilitation texts. Christensen can be reached via email: kchristensen@peacehealth.org.

References
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