PRINCIPLES OF REHABILITATION

prolonged periods (eg. isometric neck strengthening for a motorcyclist). Basic body weight exercises may also be helpful in increasing strength and mobility during the recovery phase and may include unweighted knee extension following a knee injury or press-ups against a wall for early shoulder rehabilitation.

As the capacity of the injured tissues to withstand force increases, additional resistance must be added to stimulate further strength gains. This may be achieved through the use of more advanced body weight exercises or through the application of external resistance. When designing a strengthening programme as part of rehabilitation, it is important to consider a number of factors such as site of injury, the importance and type of strength most relevant to the athlete's sport, age, current level of competition and the previous experience of strength training.

It is also important to be aware of the strength training principles of progressive overload, variability and specificity. An intelligently designed programme that has the correct combina- tion of contraction type (eg. concentric, eccentric, isometric or isokinetic), exercise choice (eg. free weights versus. machine weights) load, number of sets, repetitions, speed of contraction and frequency of training can significantly enhance the benefits of training. For example, there is considerable evidence to support the use of eccentric strengthening in the management and prevention of injuries

affecting the muscle-tendon complex (e.g. hamstring (27), patellar (28) and Achilles tendinopathy (29)).

Considerable research has been carried out examining different combinations of intensity, volume and frequency of training. However, very few studies have examined the use of such programmes in the rehabilitation environment. As a result, care must be taken when implementing programmes for rehabilitation that have been designed for fully fit athletes, many of whom often have a long history of weight training. Historically, physiother- apists have used protocols based upon the Oxford technique, which like the Delorme and Watkins model was developed for rehabilitation in the 1950s. This approach recommended completing three sets of ten repetitions of various percentages (50%, 75% and 100%) of the ten repetition maximum (10RM). Although now over fifty years old, the general guideline of perform- ing three sets of ten repetitions with a weight between 50 and 100% of the 10RM, two to three times per week is still a useful starting point during the early phase of rehabilitation. Once strength training of this kind has been completed and three sets of the initial 10RM can be comfortably performed, more advanced strength training programmes may be implemented.

It is also important when designing more advanced strength training programmes that their content should reflect the demands of the athlete's sport. It is essential that the physiotherapist takes into account key muscle groups involved, predominant energy systems used, and the relative importance of power, speed and absolute strength.

Figure 2: Correct overhead squat 14

The careful manipulation of training load, volume and frequency can achieve sport- specific performance benefits such as increased muscular endurance, running speed or throwing distance, as well as pro- tection from recurrence. For example, a programme to increase absolute leg strength in a rugby union prop-forward may be involve 3 sets of 3 reps of squats and dead lifts using a weight equal to 70% 1RM with a three minute rest between sets. In contrast, a sprinter for whom explosive power is more important may perform a similar number of sets and reps of ballistic jump squats using a much lighter load of 30% 1RM.

RANGE OF MOTION ENHANCEMENT The ability to move part or parts of the body through a wide range of purposeful movements during a sporting event can have a significant influence on athletic performance and the potential for (re)injury. Small limitations in ROM can have profound effects on technique and biomechanical efficiency resulting in altered proprioceptive input and adoption of aberrant motor patterns. Consequently, restoration of or improvement in normal preinjury ROM is central to any rehabilita- tion programme (30). Loss of ROM may be due to any one or a combination of factors such as joint capsule stiffness, muscle length changes, increased muscle tone and connective tissue thickening.

When designing a programme to address ROM dysfunction, it is essential that any intervention is directed towards the appro- priate tissues and that techniques adopt- ed, such as manual mobilisation or passive stretching, specifically target the limiting structures. It is important to establish whether the limitation in movement is due a reduction in passive or dynamic ROM. This can be assessed using clinical and functional tests. Functional movement testing is an effective way of identifying functional limitations in ROM. For example, the inability of an athlete to perform an overhead squat correctly can quickly reveal reduced shoulder and thoracic spine ROM (figure 2).

Reduction in passive ROM is usually best addressed using static stretching exercises that direct overpressure for a set period of time to the limited tissues. Reduction in dynamic ROM on the other hand is man- aged by the careful repetition of technical- ly correct movements throughout full avail- able pain free range with the application of a small amount of overpressure.

FITNESS/ENDURANCE TRAINING The importance of adequate fitness in the prevention of injury has been highlighted by Willems et al (31) who identified dimin- ished cardiorespiratory endurance as a sig- nificant risk factor for inversion ankle sprains in male subjects. Periods of inac- tivity due to injury can result in a signifi- cant reduction in cardiorespiratory and muscular endurance; as a result, rehabilita- tion programmes must include specific

sportEX medicine 2007;32(Apr):10-16