REHABILITATION

PRINCIPLES OF

INJURY REHABILITATION

This article seeks to illustrate the basic principles of injury rehabilitation (table 1), explain their importance, and offer examples of their clinical application. However, it is important for clinicians to remember that the principles of rehabil- itation are not necessarily hierarchical – that is, many are implemented concur- rently and not consecutively.

By Nicholas Clark, MSc, MCSP

INTRODUCTION The term ‘injury’ is a medical designation for tissue damage (1,2), which occurs due to both macrotraumatic ‘acute’ injuries (eg. sprained ankle) and microtraumatic ‘overuse’ injuries (eg. patellofemoral pain syndrome) (3). The term ‘rehabilitation’ is defined as “the restoration of an injured person to the level of physical fitness he or she had before the injury” (4), which is necessary to facili- tate optimal tissue healing and ensure that an injured person may safely return-to-work or return-to-sport (3,5).

As such, it is generally accepted that reha- bilitation should be based on sound scien- tific principles alongside specific goals of treatment (3,5,6). Essentially, rehabilita- tion goals should be based on the basic science underlying tissue healing and sen- sorimotor control.

CLINICAL REASONING Clinical reasoning is defined as “the think- ing underlying clinical practice” (8). It involves the organisation of thought processes, the prioritisation of intervention strategies, and the application of clinical skills in the evaluation, diagnosis, and treatment of a patient’s problem (3,8,9).

Clinical reasoning is heavily dependent on TABLE 1. PRINCIPLES OF INJURY REHABILITATION*

■ Clinical reasoning ■ Evaluation-based progression-criteria ■ Assessment of tissue involvement ■ Control pain ■ Control effusion ■ Protect healing tissue

■ Restore joint mobility ■ Restore nerve mobility ■ Restore isolated muscle strength ■ Restore functional muscle strength ■ Maximise proprioceptive stimulation ■ Enhance sensorimotor control

*adapted from: Delforge (3), Harrelson & Leaver-Dunn (5), Denegar et al. (6), Mangine & Kremchek (7). 6

the clinician’s knowledge-base and level of practical experience (8,9) and is critical for safe and effective patient management. Therefore, appropriate clinical reasoning is the prerequisite to any injury rehabilitation process. Consequently, clinicians should continuously reflect on their thought processes and clinical practice with regard to therapeutic objective and efficacy (3,8,9).

EVALUATION-BASED PROGRESSION CRITERIA Historically, many injury rehabilitation pro- grammes have been progressed according to tissue healing time-frames (7). Contemporary clinicians now believe that such rehabilitation programmes were too prescriptive since complications such as disorganised scar formation, major joint stiffness, severe muscle weakness, and pro- longed rehabilitation times were common- place (7).

Furthermore, such rehabilitation pro- grammes made no account for individual physiological differences, that tissue heal- ing is dependent on multiple factors (eg. nutritional status), that different tissues demonstrate different healing times, that a single tissue is rarely injured in isolation, and that different patients demonstrate different levels of compliance with advice and exercise therapy. All of these variables influence the rate and quality of healing, and, in turn, the ‘speed’ with which a patient returns to full function. Consequently, more clinicians are recom- mending rehabilitation programmes based on ‘evaluation-based progression-criteria’ (6,7,10). This means that rehabilitation is progressed as a patient ‘passes’ specific cri- teria. For example, range-of-motion exer- cises are progressed according to decreases

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