FUNCTIONAL REHABILITATION

and Kraemer (7) and Wilkinson and Moore (8). Such under- standing of activity-specific physical demands is necessary to ensure thorough rehabilitation and restoration of, for example, tissue integrity and muscle strength, minimising the risk of re-injury on return-to-work or return-to-competi- tion (9).

DEFINING LOWER LIMB FUNCTION With regard to the lower limb, simple clinical observation of ‘normal movement’ demonstrates the lower limb functions in both an open kinetic chain (OKC) and a closed kinetic chain (CKC) situation - the swing phase of gait occurs in an OKC while the stance phase of gait occurs in a CKC (10,11). However since the primary ‘function’ of the lower limb is that of weight-bearing with regard to opposing the force of gravity and movement of the human body from one point- in-space to another (1,11), lower limb force production (Figure 1), force absorption (Figure 2), and stabilisation pre- dominantly occurs in a CKC (9,12). This explains why lower limb proprioceptive acuity is greater in a CKC versus an OKC (13), and why CKC muscle performance demonstrates a stronger relationship to lower limb function defined by hop- ping and jumping than OKC muscle performance (14).

With further regard to lower limb force production, force absorption, and stabilisation, it is important to remember that these functions are ‘multiplanar’ in nature (15) - that is they are performed in the saggital, frontal, and transverse planes simultaneously during the stance phase of gait (15). Therefore, based on the above clinical observations, ‘func- tional rehabilitation’ of the lower limb should involve CKC- biased training programmes which, ideally, are progressed in complexity using multiplanar CKC exercises. Such training programmes are then made ‘specific to the person’s activity or purpose’ by the way in which they are progressed (1,10). For example, considering Table 1, CKC training for a profes- sional rugby player following anterior cruciate ligament injury is clearly a progression of training far beyond that necessary to return an elderly person to activities-of-daily- living following a total knee replacement operation.

ROLE OF TRADITIONAL REHABILITATION Although functional rehabilitation of the lower limb should involve CKC-biased training programmes, some form of phys- iotherapy intervention is required prior to the initiation of CKC training in order to ensure that such training can be safely and effectively performed without the risk of re-injury (9). This is the role of ‘traditional rehabilitation’ (1,2). Traditional rehabilitation predominantly involves minimising pain and swelling, and restoring joint mobility, muscle extensibility (ie. flexibility), and isolated muscle strength (1, 2, 9). Functional rehabilitation predominantly involves restoring neurophysical variables including proprioception, neuromuscular control, balance, and agility in a CKC (1, 2, 16), whilst facilitating the healing of inert tissue (ie. bone, ligament) along the ‘lines of mechanical stress’ unique to CKC function (16, 17). Since normal human movement can- not exist without adequate joint mobility, muscle extensibil- ity, and muscle strength, traditional rehabilitation is a pre- requisite to functional rehabilitation (1, 2, 18), and func-

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Figure 1. Propulsion phase of jumping: lower limb force production in a closed kinetic chain.

tional rehabilitation is a progression of traditional rehabilitation (Figure 3).

COMPONENTS OF LOWER LIMB FUNCTIONAL REHABILITATION Three components form the total concept of lower limb functional reha- bilitation: functional training, functional progression, and functional testing (16). Since the primary function of the lower limb is that of weight-bearing (1,11), force production, force absorption, and stabili- sation in a CKC, are necessary to oppose the effects of gravity and ground reaction forces (9,11,12). Therefore, definitions of functional training, functional progression, and functional testing must consider the ability of the lower limb to produce force, absorb force, and stabilise in a CKC.

Functional training is defined as exercise to improve force production, force absorption, and stabilisation in a CKC. Such exercises include a squat, a step-down, and an isometric single-leg 1/4 squat, respectively.

Functional progression is defined as a clinically-reasoned, goal-ori- ented series of exercises which progressively increase in difficulty and complexity, aimed at enhancing sensorimotor control and the ability of the lower limb to produce force, absorb force, and stabilise in a CKC. Such a progression might involve enhancing lower limb stability by progressing exercises from a stable to unstable base-of-support.

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