REHABILITATION PRINCIPLES TABLE 3. CLINICAL APPLICATIONS OF INJURY REHABILITATION

■ Clinicians should continuously reflect on the level of knowledge and thought process- es underlying their clinical reasoning

■ Evaluation-based progression-criteria should be used when deciding whether to progress from one stage of rehabilitation to the next

■ Assessment of all structures in the vicinity of the injury site ensures an awareness of all the tissue-types involved and minimises the risk of prolonged rehabilitation

■ Adequate pain control is critical for optimising patient comfort, minimising abnormal sensorimotor control, and expediting the rehabilitation process

■ Effective effusion control is critical for minimising proprioceptive loss and muscle inhibition

■ Healing tissue should be protected using taping, bracing, etc. ■ Joint mobility should be restored to ensure adequate range-of-motion and normal afferent feedback to the CNS

■ Nerve mobility should be restored to reduce perineural muscle overactivity and reduce the risk of injury to perineural muscles

■ Single joint (ie. OKC) strength training is always indicated to reverse isolated muscle weakness

■ CKC muscle strength training is indicated to restore functional muscle strength of the lower limb

■ CKC exercise is critical for maximising proprioceptive stimulation ■ Balance exercises alter inter-muscular co-ordination to optimise normal human movement and functional joint stability.

limb sensorimotor control and the specifici- ty of muscle training (13), once isolated muscle weakness has been reversed with single-joint (ie. OKC) strength training, multi-joint (ie. CKC) strength training should be implemented to restore function- al muscle strength and enhance inter-joint sensorimotor control (13).

MAXIMISE PROPRIOCEPTIVE STIMULATION There are at least nine ‘theories’ of motor control (46), the majority of which operate on a ‘sensory-motor’ basis (46). This means that before an appropriate motor output can be performed, sensory input is required (46,47). This illustrates the need for intact proprioception since mechanoreceptor feed-back induces and modifies motor output at all three levels (ie. spinal cord, brainstem, cortex) of motor control (47). Consequently, once pain and effusion have been controlled, and once isolated muscle strength has been restored, since CKC exer- cise demonstrates greater proprioceptive acuity than OKC exercise (48), CKC exercise should be implemented as soon as possible following injury to maximize sensory input to the CNS in an attempt to ‘normalise’ limb sensorimotor control.

ENHANCE SENSORIMOTOR CONTROL Normal human movement and functional

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joint stability depend on ‘normal’ sensori- motor control (13,46,47). As such, sensori- motor control has both ‘sensory’, ‘process- ing’ and ‘motor’ components (46,47). The sensory component refers to proprioceptive input to the CNS (46), while the processing component refers to neural processing by the CNS (46) and the motor component refers to motor output in the form of muscle activity (46). With regard to injury, once isolated and functional muscle strength have been restored (49), sensori- motor control can be enhanced further by retraining inter-muscular co-ordination using balance, agility, and plyometric exercises (49). In fact, since sensorimotor control of joint stability refers to the co-ordination of different muscle groups to control the movement and posture (ie. alignment) of a joint (13), specific research has shown that balance and perturbation exercise enhances inter-muscular co- ordination to optimise muscle synergies. This facilitates functional joint stability of the lower limb following injury (50,51).

SUMMARY Injury rehabilitation should be based on sound, scientific principles with respect to tissue healing, sensorimotor control and goal-setting. In order to administer a safe and effective injury rehabilitation pro- gramme, the clinician should have a good knowledge and understanding of the basic

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