PRINCIPLES OF REHABILITATION
The principle aim of rehabilitation is to restore full function after an injury or a disease. The differences between rehabilitation of the average patient and a sportsman are of degree and specificity. While rehabilitation of the average patient ceases when he can walk without a limp and manage stairs, the rehabilitation of the sportsman must continue not only to a much more advanced level of activity, but it must also be designed to meet the specific demands of his sport. It is for this reason that physiotherapists working in the field of sports medicine must be knowledgeable about the sports with which they are involved, not only about individual techniques such as the different types of strokes in racket games, but also about the tactics of the games. Ideally, the physiotherapist should have participated in the sport in order to more fully appreciate it from a player’s point of view. There should be a close liaison between physiotherapist and coach, in order to have a direct and logical continuation from treatment to early training. Similarly, the coach should know something about the principles of physical treatment so that communication will not be complicated by misinterpretation of jargon.
Rehabilitation should start at the moment of injury, although perhaps the most important thing at that stage is knowing what not to do. Early treatment is dependent upon the nature and severity of the injury and not initially on the type of sport. The essentials of such first aid are simply to ease pain, limit swelling and encourage early movement without over-stressing the injured part. However, when the acute reaction to the injury is diminishing and early repair has started, the rehabilitation programme becomes more specific to the sport. This programme must have the optimum balance of exercises to promote strength, endurance, flexibility, speed and coordination. This balance should not only fit the sport, but in team games should fit each position on the field. Obviously, forwards in soccer or hockey will need running speed and endurance, while a goalkeeper will need more general bodily speed and agility. Similarly, weightlifters will aim mainly to develop power, sprinters will aim for speed, and marathon runners will want to develop endurance.
Whatever programme is designed for an injured sportsman, he must be absolutely clear about what to do, how to do it, when to do it and how many repetitions to do. The programme must be carefully progressed from day to day, always responding to the ‘feedback’ from the previous day’s work, so that the injured part is allowed to take a little more strain at each stage without ever being suddenly overloaded. This type of regime not only builds up muscle, but actively stimulates the repair process, much in the same way as more callus formation is stimulated if the opposing fragments of a fracture are allowed a little movement rather than complete immobility.
Treating the actual injury is only a part of rehabilitation in sport for it is essential to give exercises to all the unaffected parts of the body, so long as the exercises do not jeopardise the injured pan. Such collateral exercises should be strenuous enough to make the patient breathless in order to maintain cardiovascular fitness. With a fairly severe knee injury, for example, exercises to the unaffected parts of the body could include bench press, sit-ups, chinning, curls, press-ups, step-ups with the good leg, etc. The ultimate example of this principle is seen in the Paraplegic Olympic Games.
Although active exercises are the essence of rehabilitation, the physiotherapist in sports medicine requires also the use of other techniques, including electrotherapy and massage. The choice of such supplementary techniques is usually determined not so much by the sport as by the local problems associated with the injury of which the most common are pain, swelling and restricted movement.
It must not be forgotten that while, initially, pain is nature’s warning that damage is occurring, after an injury the pain is often out of proportion to the force producing it. Its effect then is to over-protect an injured part and so prevent the movements which are vital to normal physiological function.
This does not justify the total ablation of pain by local anaesthesia, but it does mean that pain should be reduced sufficiently to allow the player to move the injured part more easily. In most cases, the degree of pain relief afforded by such physical agents as locally applied ice packs and ultrasound is sufficient, although sometimes analgesic medication is necessary. In such cases soluble aspirin is useful because of its additional anti-inflammatory effect, but equally it must be remembered that aspirin is not a trivial drug and it should always be used with great care. Supportive strapping is also useful in the early stages to protect injuries from unnecessary pain or damage.
Ideally, swelling should be prevented by early ice cold compression, elevation and temporary local rest. One of the great skills of the physiotherapist in sports medicine is the recognition on the field or track side of those injuries which are severe enough to develop a swelling. In this context it is helpful to know the individual players, for some players make a fuss over the most minor injuries while others are loathe to admit injury. Similarly, it is useful to feel the ‘pulse of the game’, for an extended interval created by an injury can allow a losing team to sort out its mistakes. When joint injuries are involved it is important to distinguish between a haemarthrosis, which is usually quite severe and swells within minutes, and a synovitis, which may appear initially as a very trivial injury but takes many hours to swell so that the full extent of this injury is evident only the following morning. Clearly there is little or no real structural damage in many so-called injuries which stop football matches, especially in the professional game. It would be pointless to treat every one of these, especially if it meant taking each player off the field, either temporarily or even for the rest of the game.
When swelling has occurred, its dispersal may be aided mechanically by the following methods: 1. The pumping action of isometric exercises. 2. Ultrasound to the periphery of the swelling. 3. Positioning of a limb so that gravity will assist the drainage of swelling away from the distal parts of the body. 4. At a later stage by effleurage massage and heat, especially if an injury has passed into the chronic stage.
The resolution of large swellings may also be aided by the use of proteolytic enzymes, e.g. trypsin and chymotrypsin (Chymoral Forte). It is advisable not to use any form of heat until after about 48 hours, since the reflex vasodilatation may cause further haemor- rhage as blood clots are dislodged. It is safer, therefore, not to prescribe the useful home treatment of contrast bathing until at least the third day.
This problem may be caused by various types of internal joint derangement, but the main causes affecting rehabilitation are protective muscle spasm and joint swelling. Protective muscle spasm is not always accompanied by pain, although it is the patient’s conscious or unconscious attempt to avoid pain. If the patient is helped to move the joint without producing too much discomfort, he will start to get his confidence back. This is obviously achieved by pain relieving methods, particularly cryotherapy, and carefully graded movements. Sometimes this means moving in only a limited part of the joint’s range, or moving in only one plane, in order to get the patient started.
Intra-articular swelling is a special category of swelling, for most cases of synovitis diminish only with rest, and cannot be dispersed with electrotherapy. The classical treatment for a grossly swollen knee is a Robert Jones bandage, the main effect of which is probably simply to splint the joint, although the pressure may help to prevent further swelling of the joint. With such cases the only definitive rehabilitation is a programme of isometric exercises to maintain the tone in those muscles which pass over the affected joint.
Chronic extra-articular swelling can be a stubborn problem, particularly following a fracture of the lower end of the tibia. While this can be dispersed with elevation, massage and electrotherapy, the swelling can sometimes recur over five or six months. It is important in such cases to support the skin with firm bandaging, otherwise the foot and ankle simulates an elastic bag which readily fills up with fluid. The Coban bandage has been found to be ideal for this purpose, and patients may be instructed to wear it whenever the leg cannot be raised, but not to wear it all the time. Usually the problem is overcome when the calf muscles reach their normal strength and there is a full range of ankle movement.
Not all rehabilitation problems begin with an acute injury. Sometimes a sportsman has had an illness and seeks professional advice about early training, or, perhaps, during a tournament, a player develops a mild febrile condition. While always keeping in mind the fact that strenuous activity can be dangerous following acute febrile conditions, especially those of viral origin, the two main parameters to guide rehabilitation are the pulse and temperature. It is advisable also to check respiratory ventilation and blood pressure. Rehabilitation should not begin until the heart rate and body temperature have both returned to their normal resting levels. The resting heart rate of a top athlete is rarely anywhere as high as the average 72 beats per minute. Once it has returned to normal, the player is tested with a little light activity, aimed at not increasing the pulse rate to more than double its resting level. If the heart rate does not return to normal during a period of rest within the two minutes immediately following the activity, or if there is a resultant increase in body temperature within two hours, the patient is not tested again until the next day, and then with proportionately less activity. If the patient passes these tests, he may be tested two or even three times more the same day, with an increase in activity each time, and then even more the following day. It should be emphasised that this system is very much a ‘rule of thumb’ and there is a case for not exercising athletes so soon after febrile conditions because of the danger of myocarditis. Ideally, such athletes should be given an electrocardiograph (ECG) before commencing training. Obviously, if the patient feels worse after such exercise, or does not feel ready to begin rehabilitation, it is probably safer to wait a day or so longer. Patients undergoing this regime are advised to drink large quantities of fluid and to rest in well aerated rooms between exercise sessions, at least during the early stages of the programme.
Another type of problem with no history of injury, is the athlete who develops pain only at high levels of performance, for example during a 100m sprint, or after 10 miles (16km) of cross-country running. It is very difficult to locate any abnormality with the usual repertoire of clinical examination and therefore it may be necessary to accompany the athlete to the gymnasium, track or field in order to let him properly demonstrate the problem. Sometimes electrotherapy is indicated but the really critical treatment is to prescribe the optimum ratio between rest and activity. Basically, the principle is to work the athlete hard at the level just below that which evokes pain, occasionally almost producing the pain for a few seconds. Ice packs may be applied immediately after the work-out in order to diminish any inflammatory response which may occur.
A special category of injury, which fortunately is rare, is that which befalls the sportsman who suffers damage to the skull, brain or spinal cord . Initially these patients require emergency medical and surgical treatment which is almost always followed by time in hospital. Such cases may not reach the sports physiotherapist until several weeks or even months after the injury; even then there is much to be done.
One of the main effects of a serious head injury is the extra-dural haemorrhage which can cause pressure on the brain and result in a hemiplegia . The introduction of computerised axial tomography has enabled surgeons to localise cerebral haematomata and thus aid the speed and accuracy of decompression surgery. Even then some patients are left with a hemiparesis and varying degrees of spasticity. Treatment is initially by proprioceptive neuromuscular facilitation techniques (PNF), although patients will be started in the gymnasium as soon as possible. It is surprising how soon they can manage simple manoeuvres from sports activities such as stopping, then hitting a hockey ball, or hitting a shuttlecock. This is usually the most enjoyable part of their treatment and often makes demands on the skills of the physiotherapist who should try to extend the patient further every day, while keeping good control. Injuries to the spinal cord may result in bilateral paralysis with segmental loss of sensation below the level of the injury. Cervical spine lesions result in tetraplegia while cord lesions at lower levels may result in paraplegia of varying severity. The ultimate achievement by patients with spinal cord injuries will depend on the level of the injury, but like most injuries the personal motivation and the design of the rehabilitation programme will play important roles. The basic principle of the rehabilitation is to make those parts of the body above the lesion as strong as possible and often this will be stronger than a healthy person. The latis-simus dorsi muscles with their high level nerve supply and attachment on the iliac crests, are very important and require much attention. This is particularly so with those patients who can be taught to walk with the use of crutches and bracing with calipers. Many paraplegics have achieved world class status in sports such as archery and swimming, as well as becoming competitive in wheelchair basketball and table tennis. Every four years, paraplegics from all over the world meet to take part in the Paralympic Games, which include athletics, lawn bowling, weightlifting, fencing and shooting as well as those sports already mentioned. Many people do not realise that these games are also open to those with cerebral palsy, amputations and who are blind.
Whatever the onset of the problem, whether a sudden acute injury or gradual overuse, or some infectious condition, at some point after treatment and rehabilitation has begun, the fitness of the patient will have to be tested. This is usually done at two levels: 1. between treatment and early training, and 2. between advanced training and competitive play.
The first level
In order to make this first step and commence early training, the injured limb should fulfil the following criteria: 1. It must have at least 50 per cent of its normal power measured with 10RM (according to De Lorme, 1945). 2. It must have at least 80 per cent of its full range of movement. 3. It must have less than 20 per cent of its full potential swelling. 4. It must have virtually normal stability, although this may be supported slightly by strapping at this stage. 5. There should be no pain at rest, nor gradual increase in pain as the work-load increases, although slight pain during or immediately after exercise is acceptable.
The patient continues to have physiotherapy during the period of training, so it is at this point that there must be close liaison between the therapist and the trainer; in addition the therapist must understand what the coach or trainer is trying to achieve and what is demanded not only from the sport but also from the level at which the player will ultimately compete.
The second level
This second stage of fitness testing has to be very demanding, otherwise the player returning to the game will be vulnerable to further injury. The more advanced general criteria are: 1. Absence of pain. 2. No swelling. 3. Full power. 4. Full range of joint movement. 5. Full extensibility of muscles, particularly those which pass over two joints, e.g. the hamstrings. 6. Endurance, e.g. minimum jog of 20 minutes or 2km. 7. Speed, e.g. 100m sprint and shuttle runs.
In addition to these general criteria, there are specific tests depending on the types of skills and situations demanded by the sport. These include, for example, block tackle in soccer, two leg jump in hockey, scrummaging in rugby and lunging in badminton. It is only when a player has passed all these tests that the aim of rehabilitation has been achieved, that is, the attainment of match fitness.
The objectives and methods of rehabilitation in sport have been discussed. What must be emphasised is that the physiotherapist working in this field must have total commitment. His effort should equal that of the sportsman as he fights to achieve physical and mental perfection. Each stage of rehabilitation must be carefully observed and analysed, always making sure that there is a sound reason for every variation in treatment and advice. It is only then that sportsmen can achieve the necessary fitness to overcome the apparent limitations imposed by time, space and gravity. It is only then that physiotherapists may claim a small part in the establishing of new world records or the winning of gold medals.
De Lorme, T. L. (1945). Restoration of muscle power by heavy resistance exercises. Journal of Bone and Joint Surgery, 27, 645-667.