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Functional Training
and Advanced
Rehabilitation
Michael L. Voight, Barbara J. Hoogenboom,
Gray Cook, and Greg Rose
O B JJ E C TTT I VE S
After completion of this chapter, the physical therapist should be able to do the following:
Defi ne and discuss the importance of proprioception in the neuromuscular control process.
Defi ne and discuss the different levels of motor control by the central nervous system and the neural pathways responsible for transmission of afferent and efferent information at each level.
Apply a systematic functional evaluation designed to provoke symptoms.
Demonstrate consistency between functional and clinical testing information (combinatorial power).
Apply a 3-step model designed to promote the practical systematic thinking required for effective therapeutic exercise prescription and progression.
Defi ne and discuss objectives of a functional neuromuscular rehabilitation program.
Develop a rehabilitation program that uses various exercise techniques for development of neuromuscular control.
Function and Functional Rehabilitation
The basic goal in rehabilitation is to restore and enhance function within the environ- ment and to perform specific activities of daily living (ADL). The entire rehabilitation pro- cess should be focused on improving the functional status of the patient. The concept of functional training is not new, nor is it limited to function related to sports. By definition, function means having a purpose or duty. Therefore, functional can be defined as perform- ing a practical or intended function or duty. Function should be considered in terms of a spectrum because ADL encompass many different tasks for many different people. What is functional to one person may not be functional to another. It is widely accepted that to perform a specific activity better, one must practice that activity. Therefore, the functional exercise progression for return to ADL can best be defined as breaking the specific activi- ties down into a hierarchy and then performing them in a sequence that allows acquisition or reacquisition of that skill. It is important to note that although people develop different levels of skill, function, and motor control, certain fundamental tasks are common to nearly all individuals (barring pathologic conditions and disability). Lifestyle, habits, injury, and other factors can erode the fundamental components of movement without obvious altera- tions in higher-level function and skill. Ongoing higher-level function is a testament to the compensatory power of the neurologic system. Imperfect function and skill create stress in other body systems. Fundamental elements can first be observed during the developmental progression of posture and motor control. The sequence of developmental progression can also give insight into the original acquisition of skill. The ability to assess retention or loss of fundamental movement patterns is therefore a way to enhance rehabilitation. The rehabili- tation process starts with a 2-part appraisal that creates perspective by viewing both ends of the functional spectrum:
- Th e current level of function (ADL, work, and sports/recreation) relative to the patient’s needs and goals. - Th e ability to demonstrate the fundamental movement patterns that represent the foundation of function and basic motor control.
Objectives of Functional Rehabilitation
Th e overall objective of a functional exercise program is to return patients to their preinjury level as quickly and as safely as possible by resolving or reducing the measurable dysfunc- tion within fundamental and functional movement patterns. Specific training activities are designed to restore both dynamic joint stability and ADL skills.^1 To accomplish this objec- tive, a basic tenet of exercise physiology is used. The SAID (specific adaptations to imposed demands) principle states that the body will adapt to the stress and strain placed on it. 2 Athletes cannot succeed if they have not been prepared to meet all the demands of their specific activity. 2 Reactive neuromuscular training (RNT) helps bridge the gap from tradi- tional rehabilitation via proprioceptive and balance training to promote a more functional return to activity.^2 The SAID principle provides constructive stress, and RNT creates oppor- tunities for input and integration. The main objective of the RNT program is to facilitate the unconscious process of interpreting and integrating the peripheral sensations received by the central nervous system (CNS) into appropriate motor responses. This approach is enhanced by the unique clinical focus on pathologic orthopedic and neurologic states and their functional representation. This special focus forces the clinician to consider evalu- ation of human movement as a complex multisystem interaction and the logical starting point for exercise prescription. Sometimes this will require a breakdown of the supporting mobility and stability within a pattern. Regardless of the specific nature of the corrective
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Exercise prescription choices must continually represent the specialized training of the clinician through a consistent and centralized focus on human function and consideration of the fundamentals that make function possible. Exercise applied at any given therapeutic level must refine movement, not simply create general exertion in the hope of increased tolerance of movement. 3 Moore and Durstine state, “Unfortunately, exercise training to optimize functional capacity has not been well studied in the context of most chronic dis- eases or disabilities. As a result, many exercise professionals have used clinical experience to develop their own methods for prescribing exercise.”^4 Experience, self-critique, and spe- cialization produce seasoned clinicians with intuitive evaluation abilities and innovations in exercise that are sometimes difficult to follow and even harder to ascertain; however, common characteristics do exist. Clinical experts use parallel (simultaneous) consideration of all factors influencing functional movement. RNT as a treatment philosophy is inclusive and adaptable and has the ability to address a variety of clinical situations. It should also be understood that a clinical philosophy is designed to serve, not to be served. The treat- ment design demonstrates specific attention to the parts (clinical measurements and iso- lated details) with continual consideration of the whole (restoration of function).^3 Moore and Durstine follow their previous statement by acknowledging that “Experience is an acceptable way to guide exercise management, but a systematic approach would be better.”^4 We use the 3 “Rs” as a way to understand the type of treatment phases that a patient will undergo (Table 19-2).
The Three-Phase Model for Prescription of Exercise
Th is chapter demonstrates a practical model designed to promote the systematic thinking required for effective prescription of therapeutic exercise and progression at each phase of rehabilitation. 3 The approach is a serial (consecutive) step-by-step method that will, with practice and experience, lead to parallel thinking and multilevel problem solving. The intended purpose of this method is to reduce arbitrary trial-and-error attempts at prescrib- ing effective exercise and lessen protocol-based thinking. It will give the novice clinician a framework that will guide but not confine clinical exercise prescription. It will provide experienced clinicians with a system to observe their particular strengths and weaknesses in dosage and design of exercise. Inexperienced and experienced clinicians alike will
Table 19-2 Three Rs of Treatment Phases
R Description Reset Most problems require resetting of the complete system to break them out of their dysfunctional phase. By just jumping to exercises, the results can be less than optimal. Types of treatments that would be considered a “reset” include joint mobilization, soft-tissue mobilization, and various soft-tissue techniques. Reinforce Once the system has been reset, many dysfunctions will need support or reinforcement while proper patterns are being introduced. Types of reinforcement devices include taping, bracing, orthotics, postural devices, and static and dynamic stretching. Reload The last phase of treatment is the exercise implementation or reload phase, in which the new software is loaded into the central nervous system and a true functional pattern of motion can be reprogrammed.
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develop practical insight by applying the model and observing the interaction of the sys- tems that produce human movement. The focus is specifically geared to orthopedic rehabil- itation and the clinical problem-solving strategies used to develop an exercise prescription through an outcome-based goal-setting process. All considerations for therapeutic exer- cise prescription will give equal importance to conventional orthopedic exercise standards (biomechanical and physiologic parameters) and neurophysiologic strategies (motor learn- ing, proprioceptive feedback, and synergistic recruitment principles). This 3-phase model (Box 19-1) will create a mechanism that necessitates interaction between orthopedic exer- cise approaches and optimal neurophysiologic techniques. It includes a 4-principle foun- dation that demonstrates the hierarchy and interaction of the founding concepts used in rehabilitation (both orthopedic and neurologic). For all practical purposes, these 4 catego- ries help demonstrate the efficient and eff ective continuity necessary for formulation of a treatment plan and prompt the clinician to maintain an inclusive, open-minded clinical approach. Th is chapter is written with the clinic-based practitioner in mind. It will help the clini- cian formulate an exercise philosophy. Some clinicians will discover reasons for success that were intuitive and therefore hard to communicate to other professionals. Others will discover a missing step in the therapeutic exercise design process. Much of the confusion and frustration encountered by rehabilitation specialists is because of the vast variety of treatment options afforded by ever-improving technology and accessibility to emerging research evidence. To effectively use the wealth of current information and what the future has yet to bestow, clinicians must adopt an operational framework or personal philosophy about therapeutic exercise. If a clinical exercise philosophy is based on technology, equip- ment, or protocols, the scope of problem solving is strictly confined. It would continually change because no universal standard or gauge exists. However, a philosophy based solely on the structure and function of the human body will keep the focus (Box 19-2) uncorrupted and centralized. Technologic developments can enhance the effectiveness of exercise only as long as the technology, system, or protocol remains true to a holistic functional stan- dard. Known functional standards should serve as governing factors that improve the clini- cal consistency of the clinician and rehabilitation team for prescription and progression of training methods. The 4 principles for exercise prescription are based on human move- ment and the systems on which it is constructed ( Box 19-2 ). The intent of these 4 distinct categories is to break down and reconstruct the factors that influence functional movement and to stimulate inductive reasoning, deductive reasoning, and the critical thinking needed
Box 19-1 Three-Phase Rehabilitation Model
Box 19-2 Four Principles for Prescription of Exercise
Function and Functional Rehabilitation 517
mechanoreceptors detect change and rates of change, as opposed to steady-state condi- tions.^22 This input is then analyzed in the CNS to determine joint position and movement.^23 The status of the musculoskeletal structures is sent to the CNS so that information about static versus dynamic conditions, equilibrium versus disequilibrium, or biomechanical stress and strain relationships can be evaluated. 24,25^ Once processed and evaluated, this proprioceptive information becomes capable of influencing muscle tone, motor execution programs, and cognitive somatic perceptions or kinesthetic awareness. 26 Proprioceptive information also protects the joint from damage caused by movement exceeding the nor- mal physiologic range of motion (ROM) and helps determine the appropriate balance of synergistic and antagonistic forces. All this information helps in generating a somatosen- sory image within the CNS. Therefore, the soft tissues surrounding a joint serve a double purpose: they provide biomechanical support to the bony partners making up the joint by keeping them in relative anatomic alignment, and through an extensive afferent neurologic network, they provide valuable proprioceptive information.
Central Nervous System:
Integration of Motor Control
The response of the CNS falls into 3 categories or levels of motor control: spinal reflexes, brainstem processing, and cognitive cerebral cortex program planning. The goal of the rehabilitation process is to retrain the altered afferent pathways and thereby enhance the neuromuscular control system. To accomplish this goal, the objective of the rehabilitation program should be to hyperstimulate the joint and muscle receptors to encourage maximal aff erent discharge to the respective CNS levels.21,27-
First-Level Response: Muscle
When faced with an unexpected load, the first reflexive muscle response is a burst of elec- tromyographic activity that occurs between 30 and 50 milliseconds. The afferent fibers of both the muscle spindle and the Golgi tendon organ mechanoreceptors synapse with the spinal interneurons and produce a reflexive facilitation or inhibition of the motor neurons. 28,30,31^ The monosynaptic stretch reflex is one of the most rapid reflexes under- lying limb control. The stretch reflex occurs at an unconscious level and is not affected by extrinsic factors. These responses can occur simultaneously to control limb position and posture. Because they can occur at the same time, are in parallel, are subconscious, and are not subject to cortical interference, they do not require attention and are thus automatic. At this level of motor control, activities to encourage short-loop reflex joint stabilization should dominate. 15,21,27,30^ These activities are characterized by sudden alterations in joint position that require reflex muscle stabilization. With sudden alterations or perturbations, both the articular and muscular mechanoreceptors will be stimulated to produce reflex sta- bilization. Rhythmic stabilization exercises encourage monosynaptic cocontraction of the musculature, thereby producing dynamic neuromuscular stabilization. 32 These exercises serve to build a foundation for dynamic stability.
Second-Level Response: Brainstem
The second level of motor control interaction is at the level of the brainstem. 25,28,33^ At this level, afferent mechanoreceptors interact with the vestibular system and visual input from the eyes to control or facilitate postural stability and equilibrium of the
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body. 21,25,27-29^ Afferent mechanoreceptor input also works in concert with the muscle spindle complex by inhibiting antagonistic muscle activity under conditions of rapid lengthening and periarticular distortion, both of which accompany postural disrup- tion. 26,30^ In conditions of disequilibrium in which simultaneous neural input exists, a neural pattern is generated that affects the muscular stabilizers and thereby returns equilibrium to the body’s center of gravity. 28 Therefore, balance is influenced by the same peripheral afferent mechanism that mediates joint proprioception and is at least partially dependent on an individual’s inherent ability to integrate joint position sense with neuromuscular control. 34
Clinical Pearl
Balance activities, both with and without visual input, will enhance motor function at the brainstem level.28,
It is important that these activities remain specific to the types of activities or skills that will be required of the athlete on return to sport. 35 Static balance activities should be used as a precursor to more dynamic skill activity. 35 Static balance skills can be initiated when the individual is able to bear weight on the lower extremity. The general progres- sion of static balance activities is to move from bilateral to unilateral and from eyes open to eyes closed. 21,28,35-37^ With balance training, it is important to remember that the sen- sory systems respond to environmental manipulation. To stimulate or facilitate the pro- prioceptive system, vision must be disadvantaged, which can be accomplished in several ways (Box 19-3).
Third-Level Response: Central Nervous System/Cognitive
Appreciation of joint position at the highest or cognitive level needs to be included in an RNT program. These types of activities are initiated on the cognitive level and include pro- gramming motor commands for voluntary movement. Repetitions of these movements will maximally stimulate the conversion of conscious programming to unconscious program- ming.21,25,27-29,38^ The term for this type of training is the forced-use paradigm. By making a task significantly more difficult or asking for multiple tasks, the CNS is bombarded with input. Th e CNS attempts to sort and process this overload information by opening additional neu- ral pathways. When the individual goes back to a basic ADL task, the task becomes easier. This information can then be stored as a central command and ultimately be performed without continuous reference to conscious thought as a triggered response.21,27-29,39^ As with all training, the single greatest obstacle to motor learning is the conscious mind. We must get the conscious mind out of the act!
Box 19-3 Ways to Disadvantage Vision for Stimulation of the Proprioceptive System
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disappear when the individual leans against some type of support before raising the arm. The motor control system recognizes that advance preparation for postural control is not needed when the body is supported against the wall. It is important to remember that most motor tasks are a complex blend of both open- and closed-loop operations. Therefore, both types of control are often at work simultane- ously. Both feed-forward and feedback neuromuscular control can enhance dynamic stability if the sensory and motor pathways are frequently stimulated. 21 Each time a signal passes through a sequence of synapses, the synapses become more capable of transmitting the same signal.14,46^ When these pathways are “facilitated” regularly, memory of that signal is created and can be recalled to program future movements.14,
Conclusion: Relationship to Rehabilitation
A rehabilitation program that addresses the need for restoring normal joint stability and proprioception cannot be constructed until one has total appreciation of both the mechani- cal and sensory functions of the articular structures.^27 Knowledge of the basic physiology of how these muscular and joint mechanoreceptors work together in the production of smooth, controlled coordinated motion is critical in developing a rehabilitation training program. This is because the role of the joint musculature extends well beyond absolute strength and the capacity to resist fatigue. With simple restoration of mechanical restraints or strengthening of the associated muscles, the smooth coordinated neuromuscular con- trolling mechanisms required for joint stability are neglected. 27 The complexity of joint motion necessitates synergy and synchrony of muscle firing patterns, thereby permitting proper joint stabilization, especially during sudden changes in joint position, which is com- mon in functional activities. Understanding of these relationships and functional implica- tions will allow the clinician greater variability and success in returning patients safely back to their playing environment.
Four Principles for
Therapeutic Exercise Prescription
The functional exercise program follows a linear path from basic mobility to basic stability to movement patterns. Corrective exercise falls into one of the 3 basic categories: mobil- ity, stability, and retraining of movement patterns. Mobility exercises focus on joint ROM, tissue length, and muscle flexibility. Stability exercises focus on the basic sequencing of movement. These exercises target postural control of the starting and ending positions within each movement pattern. Movement pattern retraining incorporates the use of fun- damental mobility and stability into specific movement patterns to reinforce coordina- tion and timing. The corrective exercise progression always starts with mobility exercises. Because many poor movement patterns are associated with abnormalities in mobility, restora- tion of movement needs to be addressed first. Mobility exercises should be performed bilaterally to confirm limitation and asymmetry of mobility. Clinicians should never assume that they know the location or side in which mobility is restricted. Rather, both sides should always be checked and mobility cleared before advancing the exercise pro- gram. If the assessment reveals a limitation or asymmetry, it should be the primary focus of the corrective exercise program. Treatments that promote mobility can involve man- ual therapy, such as soft-tissue and joint mobilization and manipulation. Treatments of mobility might also include any modality that improves tissue pliability or freedom of movement. If no change in mobility is appreciated, the clinician should not proceed to
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stability work. Rather, all mobility problems should continue to be worked on until a mea- surable change is noted. Mobility does not need to become full or normal, but improve- ment must be noted before advancing. The clinician can proceed to a stability exercise only if the increased mobility allows the patient to get into the appropriate exercise pos- ture and position. The stability work should reinforce the new mobility, and the new mobility makes improved stabilization possible because the new mobility provides new sensory information. If there is any question about compromised mobility, each exercise session should always return to mobility exercises before moving to stability exercises. This ensures that proper tissue length and joint alignment are available for the stabiliza- tion exercises. When no limitation or asymmetry is present during the mobility corrective exercises, one can move directly to stability corrective exercises. Once mobility has been restored, it needs to be controlled. Stability exercises demand posture, alignment, balance, and control of forces within the newly available range and without the support of compensatory stiff- ness or muscle tone. Stability exercises should be considered as challenges to posture and position, rather than being conventional strength exercises. We propose 4 principles for therapeutic exercise prescription, which we describe as the 4 “Ps” in this section. These principles serve to guide decisions for selecting, advancing, and terminating therapeutic exercise interventions. Application of these 4 principles in the appropriate sequence will allow the clinician to understand the starting point, a consistent progression, and the end point for each exercise prescription. This sequence is achieved by using functional activities and fundamental movement patterns as goals. By proceeding in this fashion, the clinician will have the ability to evaluate the whole before the parts and then discuss the parts as they apply. Table 19-3 lists and describes the principles for thera- peutic exercise prescription.
Table 19-3 Four Principles for Therapeutic Exercise Prescription
Principle Description Functional evaluation and assessment in relation to dysfunction (disability) and impairment
The evaluation must identify a functional problem or limitation resulting in diagnosis of a functional problem. Observation of whole movement patterns tempered by practical knowledge of key stress points and common compensatory patterns will improve the effi ciency of evaluation. Identification and management of motor control
Rehabilitation can be greatly advanced by understanding functional milestones and fundamental movements such as those demonstrated during the positions and postures paramount to growth and development. These milestones serve as key representations of functional mobility and control, as well as play a role in the initial setup and design of the exercise program.
Identification and management of osteokinematic and arthrokinematic limitations
The skills and techniques of orthopedic manual therapy are beneficial in identifying specific arthrokinematic restrictions that would limit movement or impede the motor- learning process. Management of myofascial and capsular structures will improve osteokinematic movement, as well as allow balanced muscle tone between the agonist and antagonist. It will also help the clinician understand the dynamics of the impairment. Identification of current movement patterns followed by facilitation and integration of synergistic movement patterns
Once restrictions and limitations are managed and gross motion is restored, application of proprioceptive neuromuscular facilitation-type patterning will further improve neuromuscular function and control. Consideration of synergistic movement is the final step in restoration of function by focusing on coordination, timing, and motor learning.
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Pain
Aristotle said, “We cannot learn without pain,” which is very wise because pain is usually life’s most power- ful teacher. However, pain is simply the brain’s inter- pretation of a neurologic signal normally associated with trauma, dysfunction, and instant and continu- ing damage. Pain affects motor control and greatly reduces the effectiveness of even the best corrective exercise technique.
Purpose
The word purpose is simply a cue to be used dur- ing both the evaluation process and the exercise prescription process to keep the clinician intently focused on the greatest single factor limiting func- tion. The primary questions to ask for this principle appear in Table 19-4. It is not uncommon for clini- cians to attempt to resolve multiple problems with the initial exercise prescription. However, the prac- tice of identifying the single greatest limiting factor will reduce frustration and also not overwhelm the patient. Other factors may have been identified in the evaluation, but a major limiting factor or a single weak link should stand out and be the focus of the initial therapeutic exercise interven- tion. Alterations in the limiting factor may produce positive changes elsewhere, which can be identified and considered before the next exercise progression. The functional evaluation process should take on 3 distinct layers or levels (Table 19-5). Each of the 3 levels should involve qualitative observations followed by quantitative documentation when possible. Normative data are helpful, but bilateral comparison is also effective and demonstrates the functional problem to the patient at each level. Many patients think that the problem is simply symptomatic and structural in nature and have no example of dysfunction outside of pain with movement. Moffroid and Zimny suggest that “Muscle strength of the right and left sides is more similar in the proximal muscles whereas we accept a 10% to 15% difference in strength of the distal muscles.... With joint flexibility, we accept a 5% difference between goniometric mea- surements of the right and left sides.” 48 The functional activity assessment involves a reproduction of combined movements common to the patient’s lifestyle and occupation. These movements usually fit the defini- tion of a general or specific skill. The clinician must have the patient demonstrate a variety of positions and not just positions that correspond to the reproduction of symptoms.^49 Static postural assessment is included, as well as assessment of dynamic activity. The quality of control and movement is assessed. Specific measurement of bilateral differences is difficult, but demonstration and observation are helpful for the patient. The clinician should note the positions and activities that provoke symptoms, as well as the activities that illustrate poor body mechanics, poor alignment, right-left asymmetries, and inappropriate weight shifting. When the clinician has observed gross movement quality, it may be necessary to also quan- tify movement performance. Repetition of the activity for evaluation of endurance, repro- duction of symptoms, or demonstration of rapidly declining quality will create a functional baseline for bilateral comparison and documentation. Next is the functional or fundamental movement assessment. The clinician must take what is learned through the observation of functional movements and break the
Table 19-5 Three Levels of Functional Evaluation
Level Name Description I Functional activity assessment
Combined movements common to the patient’s lifestyle and occupation are reproduced. They usually fit the definition of a general or specific skill. II Functional or fundamental movement assessment
The clinician takes what is learned through the observation of functional movements and breaks the movements down to the static and transitional postures seen in the normal developmental sequence. III Specific clinical measurement
Clinical measurements are used to identify and quantify specific problems that contribute to limitations in motion or control.
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movements down into the static and transitional postures seen in the normal develop- mental sequence. This breakdown will reduce activities to the many underlying mobi- lizing and stabilizing actions and reactions that constitute the functional activity. More simply stated, the activity is broken down into a sequence of primary movements that can be observed independently. It must be noted that these movements still involve multiple joints and muscles. 49 Assessment of individual joints and muscle groups will be performed during clinical measurements. Martin notes, “The developmental sequence has provided the most consistent base for almost all approaches used by physical therapists.” 48 This is a powerful statement, and because true qualitative measurements of normal movement in adult populations are limited, the clinician must look for universal similarities in move- ment. Changes in fundamental movements can effect significant and prompt changes in function and must therefore be considered functional as well. Because the movement pat- terns of most adults are habitual and specific and thus are not representative of a full or optimal movement spectrum, the clinician must first consider the nonspecific basic move- ment patterns common to all individuals during growth and development. The develop- mental sequence is predictable and universal in the first 2 years of life, 50 with individual differences seen in the rate and quality of the progression. The differences are minimal in comparison to the variations seen in the adult population with their many habits, occu- pations, and lifestyles. In addition to diverse movement patterns, the adult population has the consequential complicating factor of a previous medical and injury history. Each medical problem or injury has had some degree of influence on activity and movement. Thus, evaluation of functional activities alone may hide many uneconomical movement patterns, compensations, and asymmetries that when integrated into functional activi- ties, are not readily obvious to the clinician. By using the fundamental movements of the developmental progression, the clinician can view mobility and static and dynamic stabil- ity problems in a more isolated setting. Although enormous variations in functional move- ment quality and quantity are seen in specific adult patient populations, most individuals have the developmental sequence in common. 50 The movements used in normal motor development are the building blocks of skill and function. 50 Many of these building blocks can be lost while the skill is maintained or retained at some level (though rarely optimal). We will refer to these movement building blocks as fundamental movements and consider them precursors to higher function. Bilateral comparison is helpful when the clinician identifies qualitative differences between the right and left sides. These movements (like functional activities) can be compared quantitatively as well. Finally, clinical measurements will be used to identify and quantify specific prob- lems that are contributing to limitation of motion or limitation of control. Clinical mea- surements will first classify a patient through qualitative assessment. The parameters that define that classification must then be quantified to reveal impairment. These classifica- tions are called hypermobility and hypomobility and help create guides for treatment that consider the functional status, anatomic structures, and the severity of symptoms. The clinician should not proceed into exercise prescription without proper identification of one of these general categories. The success or failure of a particular exercise treatment regimen probably depends more on this classification than on the choice of exercise tech- nique or protocol. Once the appropriate clinical classification is determined, specific quantitative mea- surements will define the level of involvement within the classification and set a baseline for exercise treatment. Periodic reassessment may identify a different major limiting factor or a weak link that may require reclassification, followed by specific measurement. The new problem or limitation would then be inserted as the purpose for a new exercise interven- tion. A simple diagram (Figure 19-1) will help the clinician separate the different levels of function so that intervention and purpose will always be at the appropriate level and assist in the clinical decision making related to exercise prescription.^51
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to manage the impairment and produce some level of function that is usually viewed as dys- function. It should be considered a natural and appropriate response of the body reacting to limitation or symptoms. The body will sacrifice quality of movement to maintain a degree of quantity of movement. Taking this into consideration, 2 distinct needs are presented.
Posture for Protection and Inhibition The clinician must restrict or inhibit the inap-
propriate motor program. In the case of a control or stability problem, the patient must have some form of support, protection, or facilitation. Otherwise, the inappropriate pro- gram will take over in an attempt to protect and respond to the postural demand. Although most adult patients function at the necessary skill level, on evaluation, many qualitative problems are noted. Inappropriate joint loading and locking, poor tonic responses, or even tonic holding can be observed with simple activities. Some joint movements are used exces- sively, whereas others are unconsciously avoided. Many primary stability problems exist when underlying secondary mobility problems are present. Moreover, in some patients, the mobility problem precedes the stability problem. This is a common explanation for micro- traumatic and overuse injuries. It is also why bilateral comparison and assessment of proxi- mal and distal structures are mandatory in the evaluative process. With a mobility problem, a joint is not used appropriately because of weakness or restriction. The primary mobility problem may be the result of compromised stability elsewhere. Motor programs have been created to allow a patient to push on despite the mobility or stability problem. The prob- lems can be managed by mechanical consideration of the mobility and stability status of the patient in the fundamental postures. For primary stability problems, mechanical support or other assistance must be pro- vided. This can be done simply by partial or complete reduction of stress, which may include non–weight bearing or partial weight bearing of the spine and extremities or tem- porary bracing. If the stability problem is only in a particular range of movement, that move- ment must be managed. If an underlying mobility problem is present, it must be managed and temporarily taken out of the initial exercise movement. The alteration in posture can effectively limit complete or partial motion with little need for active control by the patient. Th e patient must be trained to deal with the stability problem independently of the mobil- ity problem or be at a great mechanical advantage to avoid compensation. The secondary mobility problem, once managed, should be reintroduced in a nonstressful manner so that the previous compensatory pattern is not activated. Manual articular and soft-tissue techniques, when appropriate, can be used for the pri- mary mobility problem, followed by movement to integrate any improved range and benefit from more appropriate tone. If the limitation in mobility seems to be the result of weakness, one should make sure that the proximal structures have the requisite amount of stability before strengthening and then proceed with strengthening or endurance activities with a focus on recruitment, relaxation, timing, coordination, and reproducibility. Note that the word resistance was not used initially. Resistance is not synonymous with strengthening and is only 1 of many techniques used to improve functional movement in early move- ment reeducation. However, the later sections on position and pattern address resistance in greater detail. Posture should be used to mechanically block or restrict substitution of stronger segments and improve quality at the segment being exercised.
Posture for Recruitment and Facilitation The clinician must facilitate or stimulate the
correct motor program, coordination, and sequence of movement. Although verbal and visual feedback is helpful through demonstration and cueing, kinesthetic feedback is para- mount to motor learning. 56 Correct body position or posture will improve feedback. The posture and movement that occur early in the developmental sequence require a less com- plex motor task and activate a more basic motor program. This creates positive feedback and reinforcement and marks the point (posture) at which appropriate and inappropriate
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actions and reactions meet. From this point, the clini- cian can manipulate frequency, intensity, and duration, or advance to a more difficult posture in the appropri- ate sequence. The clinician must also consider developmental biomechanics by dividing movement ability into 2 cat- egories: internal forces and external forces. Internal forces include the center of gravity, base of support, and line of gravity. External forces include gravity, inertia of the body segment, and ground reaction forces. Accord- ingly, the clinician should evaluate the patient’s abilities in the same manner by first observing management of the mass of the body over the particular base provided by the posture. The clinician then advances the patient toward more external stresses such as inertia, gravity, and ground reaction forces. This interaction requires various degrees of acceleration production, deceleration control, anticipatory weight shift- ing, and increased proprioception. Resistance and movement can stress static and dynamic postures, but the clinician should also understand that resistance and movement could be used to refine movement and stimulate appropriate reactions.^56 Postures must be chosen that reduce compensation and allow the patient to exercise below the level at which the impairment hinders movement or control. This is easily accomplished by creating “self- limited” exercises.^3 Such exercises require passive or active “locking” by limiting movement of the area that the patient will most likely use to substitute or “cheat” with during exercise. To review, posture identifies the fundamental movements used in growth and develop- ment. Th ese movements serve as steps toward the acquisition of skill and are also helpful in the presence of skill when quality is questionable. Figures 19-2 through 19-5 illustrate a few examples of these types of movements. By following this natural sequence of movement, the clinician can observe the point at which a mobility or stability problem will first limit the quality of a whole movement pat- tern. The specific posture of the body is as important as the movement that is introduced onto that posture. Clinicians may already know the movement pattern that they want to train, but they also need to consider the posture of the body as the fundamental neuro- muscular platform when making a corrective exercise choice. The posture is the soil and the movement is the seed. A chop pattern with the arms can be performed while supine, seated, half kneeling, tall kneeling, and standing. Each posture will require different levels of stability and motor control. When stability and motor control are the primary problems, a posture must be selected to start the corrective exercise process. A patient with a mild knee sprain or even a total knee replacement may demonstrate segmental rolling to one side, but “logroll” to the other simply to avoid using a flexion-adduction–medial rotation movement pattern with the involved lower extremity. The clinician has now identified where success and failure meet in the develop- mental sequence. The knee problem creates a dynamic stability problem in the developmental sequence long before partial or full weight bearing is an issue. Conse- quently, it must be addressed at that level. The patient is provided with an example of how limited knee mobility can greatly affect movement patterns (such as rolling) that seem to require little of the knee. However, by restor- ing the bilateral segmental rolling function, measurable
Figure 19-2 Supine bridging movement
Figure 19-3 Rolling to prone
Four Principles for Therapeutic Exercise Prescription 529
thirds, this exercise would involve only the extension third of movement. The flexion third and middle third of movement are not needed because no impairment was identified in those respective ranges. Not only was the hip in extension, but the knee was also in flexion. This is important because the hamstring muscle will try to assist hip extension in the end range of movement when gluteal strength is not optimal. However, the hamstrings cannot assist hip extension to any significant degree because of “active insufficiency.” Likewise, the lumbar extensors cannot assist the extension pattern because of the passive stretch placed on them via maximal passive hip flexion. Hip extension proprioception is now void of any inappro- priate patterning or compensation from the hamstrings or spinal erectors through the positional use of active and passive insufficiency.^57 Qualitative measures will provide specific informa- tion about exercise start and finish position, movement speed and direction, open- and closed-chain considerations, and the need for cueing and feedback. Close observation of the osteokinematic and arthrokinematic relationships for movement and bilateral comparison is the obvious starting point. Specific identification of the structure and position represents mobility observed by selective tension (active, passive, and resisted movements), and the end feel of the joint structures would provide specific information about the mechanical nature of the limitations and symptoms.^58 Assessment of positional static and dynamic control will reveal limitations in stability and provide a more specific starting point for exercise. Quantitative measures will reveal a degree of deficit, which can be recorded in the form of a percentage through bilateral comparison and compared with normative data when possible. ROM, strength, endurance, and recovery time should be considered, along with many other (quantitative) clinical parameters, to describe isolated or positional function. This will provide clear communication and specific documentation for goals, as well as be a tracking device for the effectiveness of treatment, information that will help define the base- line for initial exercise considerations. As stated earlier, any limitation in mobility or stabil- ity requires bilateral comparison, in addition to clearing of the joints above and below. The proximal and distal structures must also be compared with their contralateral counterparts. This central point of physical examination is often overlooked. Cyriax 58 noted, “Positive signs must always be balanced by corroborative negative signs. If a lesion appears to lie at or near one joint, this region must be examined for signs identifying its site. It is equally essen- tial for the adjacent joints and the structures around them to be examined so that, by con- trast, their normality can be established. These negative findings then reinforce the positive fi ndings emanating elsewhere; then only can the diagnosis be regarded and established.” After position and movement options are established, a trial exercise session should be used to observe and quantify performance before prescription of exercise. Variables, including intensity and duration, can be used to establish strength or endurance base- lines. Bilateral comparison should be used to document a deficit in performance, which is also recorded as a percentage. A maximum repetition test (with or without resistance) to fatigue, onset of symptoms, or loss of exercise quality is a common example. This will allow close tracking of home exercise compliance and help to establish a rate of improve- ment. If all other factors are addressed, the rate of improvement should be quite large. This is the benefit of correct dosage in prescription of exercise position and appropriate work- load. Most of the significant improvement is not a result of training volume, tissue metabo- lism, or muscle hypertrophy, but of the efficient adaptive response of neural factors. 59 These
Figure 19-6 Single-leg bridge
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factors can include motor recruitment efficiency, improved timing, increased proprio- ceptive awareness, improved agonist/antagonist coordination, appropriate phasic/tonic response to activity, task familiarity, and motor learning, as well as psychological factors. Usually, greater deficits are associated with more drastic improvement. Treatments should be geared to stimulate these changes whenever possible.
Pattern
The primary questions to ask for the pattern principle appear in Table 19-4. The word pattern serves as a cue to the clinician to continually consider the functional movements of the human body occurring in unified patterns that occupy 3-dimensional space and cross 3 planes (frontal, sagittal, and transverse).^3 Sometimes this is not easily ascertained by observing the design and use of fixed-axis exercise equipment and the movement patterns suggested in some rehabilitation protocols. The basic patterns of proprioceptive neuromus- cular facilitation (PNF), for both the extremities and the spine, are excellent examples of how the brain groups movement. Muscles of the trunk and extremities are recruited in the most advantageous sequence (proprioception) to create movement (mobility) or control (stability) movement. Not only does this provide efficient and economical function, but it also effectively protects the respective joints and muscles from undue stress and strain. Voss et al^60 clearly and eloquently stated, “The mass movement patterns of facilitation are spiral and diagonal in character and closely resemble the movements used in sports and work activities. The spiral and diagonal character is in keeping with the spiral rotatory char- acteristics of the skeletal system of bones and joints and the ligamentous structures. This type of motion is also in harmony with the topographical alignment of the muscles from origin to insertion and with the structural characteristics of the individual muscles.” When a structure within the sequence is limited by impairment, the entire pattern is limited in some way. The clinician should document the limited pattern, as well as the isolated segment causing the pattern to be limited. The isolated segment is usually identified in the evalu- ation process and outlined in the “position” considerations. The resultant effect on one or more movement patterns must also be investigated. A review of the basic PNF patterns can be beneficial to the rehabilitation specialist. Once a structure is evaluated, one should look at the basic PNF patterns involving that structure. Multiple patterns can be limited in some way, but usually one pattern in particular will demonstrate significantly reduced function. Obviously, poor function in a muscle group or joint can limit the strength, endurance, and ROM of an entire PNF pattern to some degree. However, the clinician must not simply view reduced function of a PNF pattern as an output problem. It should be equally viewed as an input problem. When muscle and joint functions are not optimal, mechanoreceptor and muscle spindle functions are not optimal. This can create an input or proprioceptive prob- lem and greatly distort joint position and muscle tension information, which distorts the initial information (before movement is initiated), as well as feedback (once movement is in progress). Therefore, the clinician cannot consider only functional output. Altered pro- prioception, if not properly identified and outlined, can unintentionally become part of the recommended exercises and therefore be reinforced. The clinician must focus on synergis- tic and integrated function at all levels of rehabilitation. An orthopedic outpatient cannot aff ord to have a problem simply isolated 3 times a week for 30 minutes only to reintegrate the same problem at a subconscious level during necessary daily activities throughout the remaining week. PNF-style movement pattern exercise can often be taught as easily as an isolated movement and will produce a significantly greater benefit. Therapeutic exercise is no longer limited by sets as repetitions of the same activity. Successive intervals of increas- ing difficulty (although not physically stressful) that build on the accomplishment of an ear- lier task will reinforce one level of function and continually be a challenge for the next. A simple movement set focused on isolation of a problem can quickly be followed by a pattern that will improve integration. The integration can be followed by a familiar fundamental
532 Chapter 19 Functional Training and Advanced Rehabilitation
