Chapter 16 - Using Therapeutic Exercises in Rehabilition

Q: When does the rehabilitation process begin, and why is it so important?

• It begins immediately after injury—even during acute management.

• Early, appropriate first aid greatly influences recovery outcome.

• The clinician’s main responsibilities: design, implement, and supervise an individualized rehab plan.

• The “easy part” is designing exercises; the challenge is patient adherence and progressive supervision.

Q: What is the athletic trainer’s overall goal in rehabilitation?

• To return the athlete to participation quickly, safely, and confidently, meeting both physical and psychological readiness criteria.

Q: What are the short-term and long-term goals of a rehabilitation program?

• Short-Term:

  • Control pain and inflammation.

  • Restore or maintain ROM.

  • Regain strength, endurance, and neuromuscular control.

  • Preserve cardiorespiratory fitness.

• Long-Term:

  • Return athlete to full practice and competition without re-injury.

Q: What principle differentiates therapeutic exercise from conditioning exercise?

• Both follow FITT (Frequency, Intensity, Time, Type) principles, but:

  • Therapeutic exercise → used in rehabilitation to restore function after injury.

  • Conditioning exercise → used to enhance performance and prevent injury.

Q: What happens to the body during sudden inactivity or immobilization?

• Physical inactivity causes rapid loss of fitness and function in the injured region (“stress deprivation”).

• Healthy adults can lose 25–33 % of strength in just two weeks.

• The stronger you start, the greater the initial losses.

Q: How does muscle respond to immobilization?

• Atrophy (loss of muscle mass) occurs rapidly, especially in Type I slow-twitch fibers.

• Muscle fibers may convert from slow- to fast-twitch.

• Isometric contractions can reduce atrophy during immobilization.

• Neuromuscular efficiency declines as motor nerves become less responsive—but function returns with retraining.

Q: What happens to joints during immobilization?

• Decreased synovial lubrication and nutrition to cartilage → degeneration.

• Loss of normal compression and motion causes cartilage softening and breakdown.

• Continuous Passive Motion (CPM) or electrical stimulation can help preserve joint health.

Q: How do ligaments and bones respond to immobilization?

• They adapt to normal mechanical stress (Wolff’s Law).

• Without loading, tissue weakens; collagen alignment and bone density decrease.

• Strength can be lost in weeks but may take months to recover

Q: What cardiovascular changes occur during immobilization?

• Resting heart rate rises ≈ 0.5 beat per minute each day.

• Stroke volume and VO₂ max decrease significantly within two weeks—mainly due to reduced stroke volume.

Q: List and describe the major components of rehabilitation.

• Minimize swelling – use P.R.I.C.E. immediately.

• Control pain – through modalities, medication, and activity modification.

• Restore ROM – prevent contractures and stiffness.

• Restore strength, endurance, and power – through progressive resistance.

• Re-establish neuromuscular control – retrain CNS to coordinate movement.

• Restore balance/postural stability.

• Maintain cardiovascular fitness.

• Incorporate functional activity – sport-specific movement.

Q: How is pain defined and categorized?

• Defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”

• Acute: < 6 weeks Subacute: 6–12 weeks Chronic: > 12 weeks.

• Chronic pain prevalence in U.S. adults: 11–40 %.

  • More common in women, older adults, unemployed, low-income, publicly insured, and rural populations.

Q: What are the three types of pain?

• Nociceptive – from actual tissue damage/inflammation.

• Neuropathic – from nerve lesion or disease (e.g., radiculopathy).

• Nociplastic – altered processing of pain without clear tissue injury (often chronic)

Q: What are non-pharmacological options for managing pain in rehab?

• Cryotherapy or thermotherapy, e-stim, massage, relaxation, graded exercise, and cognitive reassurance.

• Medication use (analgesics, NSAIDs) must follow physician supervision—avoid dependency on opioids.

Q: What is the purpose of ROM exercises in rehabilitation?

• Maintain joint mobility and flexibility.

• Prevent contractures and adaptive shortening of muscles or connective tissue.

• Increase circulation and comfort.

• Decrease complications from prolonged immobility.

Q: Why can motion loss occur after injury?

• Contracture of connective tissue.

• Resistance to stretch in periarticular structures.

• Adhesion formation from inflammation.

Q: Differentiate between physiologic and accessory movements.

• Physiologic (osteokinematic): voluntary motions like flexion/extension.

• Accessory (arthrokinematic): involuntary joint surface motions—roll, slide/glide, and spin—needed for full ROM.

What are common interventions to restore ROM?

• Stretching for physiologic motion.

• Joint mobilization or capsule stretching for accessory motion.

• Combine with heat or manual therapy as tolerated.

Q: Why is regaining muscular strength critical?

• Prevents re-injury, supports joints, restores performance capacity.

Q: What are isometric exercises and when are they used?

• Static contractions without joint movement.

• Used early in rehab when motion causes pain or instability.

• Benefits: limits atrophy, reduces swelling, increases static strength.

• Limitation: strength gains specific to the joint angle exercised.

Q: What are progressive-resistance exercises (PREs)?

• Concentric and eccentric muscle contractions performed with increasing load.

• Resistance provided by weights, bands, or machines.

• Eccentric work enhances control and deceleration but can cause soreness.

• Machines = safer and more controlled; free weights = recruit stabilizers.

Why is neuromuscular control important in rehab?

• After injury, the brain “forgets” how to coordinate efficient movement.

• Re-education is necessary so movement becomes automatic again.

What elements are key to re-establishing neuromuscular control?

1. Proprioception & Kinesthetic Awareness – joint position and movement sense.

2. Preparatory and Reactive Muscle Characteristics – pre-activation and reflex control.

3. Dynamic Stability – coordinated strength around joints.

4. Functional Motor Patterns – conscious → subconscious movement control.

Improvement occurs through repetition and progressive complexity.

Q: What distinguishes open from closed kinetic chain exercises?

• Open Kinetic Chain (OKC): distal limb free to move (e.g., knee extension, biceps curl); isolates one joint.

• Closed Kinetic Chain (CKC): distal limb fixed on surface (e.g., squat, push-up); multiple joints move; more functional and joint-protective.

Q: Why is balance training vital for athletes?

• Balance depends on proprioception + vision + vestibular input.

• Maintains equilibrium and prevents re-injury.

• Should be integrated into all rehab phases; poor balance increases injury risk.

Q: What did the slides mean by “Your textbook is wrong”?

• Traditional texts over-simplify balance as only proprioception/vision/vestibular.

• New research shows motor and cognitive systems also influence balance and must be trained simultaneously.

Q: How can an athlete maintain cardio fitness during lower-limb injury?

• Engage in alternative low-impact activities such as swimming, cycling, or upper-body ergometry (“use it or lose it” principle).

• Modify as needed to avoid stressing the injured site.

Q: What is a functional progression and why is it important?

• Gradual reintroduction of sport-specific movements to restore confidence and coordination.

• Begin simple → progress to complex; slow → fast; short → long; light → heavy.

• Must mimic actual sport demands while staying pain-free.

Q: What are best practices for implementing functional progressions?

• Monitor for proper form and adverse reactions.

• Integrate early, once goals are met safely.

• Include both physical and psychological readiness.

• Use functional testing (agility runs, figure-8s, vertical jumps, balance tests) to measure return readiness.

Q: What should be understood before creating a rehab plan?

• MOI, anatomical structures involved, and injury grade.

• Healing phase (inflammatory, repair, or remodeling).

• Psychosocial aspects affecting motivation and adherence.

Q: Outline the three phases of healing and their goals.

• Phase I – Acute Inflammatory (Degeneration) Phase

  • Lasts up to 4 days.

  • Control swelling and pain; immobilize for first 1–2 days.

  • Begin early gentle motion to prevent stiffness (“active rest”).

• Phase II – Repair/Regeneration (Fibroblastic) Phase

  • Begins as inflammation subsides; fibroblasts form new collagen.

  • Pain control still essential.

  • Safely add cardiovascular, strengthening, flexibility, and neuromuscular training.

• Phase III – Maturation/Remodeling Phase

  • Longest phase (weeks → months).

  • Collagen realigns along stress lines.

  • Emphasize functional and sport-specific training.

Q: What are signs that rehabilitation is too aggressive?

• Increased swelling or pain.

• Plateau or loss in strength/ROM.

• Exacerbation of symptoms or next-day soreness exceeding expectations.

• In these cases, reduce load and modify exercises.

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Q: What strategies enhance athlete adherence to rehabilitation?

• Provide encouragement and feedback.

• Make sessions creative and enjoyable.

• Involve peers and coaches for support.

• Maintain a positive, goal-oriented attitude.

• Plan for setbacks and normalize them.

• Offer clear written and verbal instructions.

• Keep exercises relatively pain-free and track progress visually.

Q: Why do slides mention “rehabilitation lifestyle intervention”?

• Many chronic conditions (e.g., non-specific low back pain) respond best to behavioral and lifestyle modifications such as posture correction, daily exercise, and stress management—not just acute rehab exercises.

Q: Who makes the final return-to-play decision?

• It’s a group decision involving the sports medicine team, but team physician has ultimate authority.

Q: What factors must be evaluated before RTP clearance?

• Tissue healing status.

• Pain and swelling levels.

• ROM, strength, proprioception, neuromuscular control.

• Cardiovascular fitness.

• Sport-specific demands and protective equipment needs.

• Functional testing results.

• Psychological readiness and confidence.

• Athlete education on prevention and maintenance.

Q: Why are CKC (Closed Kinetic Chain) exercises often preferred in later rehab?

• They more closely replicate functional activities, involve multiple joints, and promote co-contraction for joint stability.

• Common CKC lower-extremity examples: mini-squats, leg press, step-ups, terminal knee extensions, balance work on balls or BOSU.

Q: What is core stabilization training, and why is it essential?

• Focuses on the lumbo-pelvic complex, the foundation for nearly all movement.

• Improves postural control, muscle balance, and functional strength.

• Enhances neuromuscular efficiency for both upper and lower limbs.

What are the benefits of aquatic exercise in rehabilitation?
A:

• Provides buoyant support to reduce joint stress.

• Allows early movement even for limited weight-bearing patients.

• Can be assistive, resistive, or supportive.

• Useful across all healing phases and for sport-specific skill retraining.

Q: What are opioids?

• A class of natural, synthetic, or semi-synthetic chemicals that bind to opioid receptors in the brain and nervous system.

• They reduce the intensity of pain signals and alter perception of pain.

• Also cause sedation, euphoria, and, with misuse, respiratory depression.

Q: Give examples of legal opioids commonly prescribed in medicine.

• Oxycodone (OxyContin)

• Hydrocodone (Vicodin)

• Morphine

• Methadone

Q: Which opioid is both legal and illegal, and how potent is it?

• Fentanyl – a synthetic opioid 50–100× more potent than morphine.

• Used legally for severe pain and anesthesia but also illegally manufactured and sold illicitly.

Q: What is the primary illegal opioid?

• Heroin, derived from morphine. It is illicit and highly addictive.

Q: Define Opioid Use Disorder (OUD).

• A problematic pattern of opioid use leading to clinically significant impairment or distress (e.g., cravings, tolerance, withdrawal, inability to reduce use).

Q: How significant is the U.S. role in global opioid use?

• The United States accounts for ~80 % of all global opioid consumption.

Q: How many opioid prescriptions were written annually in the U.S. by 2017?

• 191 million prescriptions per year.

Q: How many people in the U.S. die from opioid overdose daily?

• Approximately 130 deaths per day from opioids (including legal and illegal).

Q: What percentage of all U.S. drug overdoses involve opioids?

• 69.5 % of all overdose deaths (2018).

Q: What percentage of opioid overdoses involve synthetic opioids?

• 67 % involved synthetics like fentanyl.

Q: What is the national opioid overdose death rate?

• 11.9 deaths per 100,000 individuals.

Q: How significant is orthopedic prescribing in the opioid crisis?

• Orthopedic surgeons are the 4th highest prescribers of opioids, accounting for 7.7 % of the ~80 million prescriptions each year.

Q: What are opioid overdose death rates (per 100,000) by county in Delaware?

• New Castle: 42.2

• Kent: 24.6

• Sussex: 49.2

What percentage of patients prescribed opioids for chronic pain misuse them?
A:

• Between 21–29 %.

Q: What percentage develop Opioid Use Disorder (OUD)?

• About 8–12 % of those prescribed opioids.

Q: What percentage of people who misuse prescription opioids eventually use heroin?

• 4–6 % transition from prescription misuse to heroin.

Q: What percentage of heroin users first misused prescription opioids?

• Roughly 80 %.

Q: Why is opioid prescribing particularly relevant in orthopedics?

• Orthopedic procedures often involve moderate to severe postoperative pain (e.g., fractures, joint surgeries).

• High risk of overprescribing, prolonged use, and diversion of unused pills into the community.

What is the risk of prolonged opioid use after arthroscopic shoulder surgery?

• 8.3 % of patients continue opioids long-term after surgery.

List predictors of prolonged opioid use after orthopedic surgery.

1. Higher total opioid dose before/after surgery (Odds Ratio = 2.0).

2. History of suicide or self-harm disorder (OR = 2.0).

3. History of alcohol dependence/abuse (OR = 1.6).

4. Mood disorder (OR = 1.3).

5. Opioid prescription filled within 30 days pre-op (OR = 1.3).

6. Female sex (OR = 1.3).

7. Anxiety disorder (OR = 1.2).

8. Pre-existing chronic pain diagnosis (OR = 1.2).

What other risk does opioid use pose in older adults?

It increases fall risk by 1.4–2.7× due to sedation and dizziness.

What do studies show about opioid prescriptions for ankle sprains in emergency departments?

34.6 % of patients with ankle sprains (LAS) were prescribed opioids, with an average duration of 3 days—often unnecessary.

What was the trend in post-ACL surgery opioid prescriptions by 2024?
A:

• A ~24 % reduction in total prescribed opioids, showing progress toward safer pain management.

What were the findings on opioid use after knee arthroscopic surgery?

• Patients were prescribed ~20 tablets, but actually took only 4 tablets on average for 2.7 days.

• This left 16 unused tablets per patient circulating in the community—potential for misuse or diversion.

Did limiting opioid prescriptions change pain outcomes?

• No difference in pain between patients given full vs. limited prescriptions.

• Optional or reduced-dose groups had fewer leftover opioids and equal pain control.

How did non-opioid pain management compare after ACL surgery?

• The non-opioid group reported lower self-reported pain and faster recovery than those prescribed opioids.

Q: How does the timing of physical therapy affect opioid use?

• Delayed initiation of PT increases the likelihood and duration of opioid use—even in those not previously on opioids.

• Early movement and PT significantly reduce dependence.

Q: Why is “reducing, not eliminating” opioid use emphasized?

• Some individuals with chronic or high-impact pain still require opioids for quality of life.

• The goal is to balance adequate pain control with addiction prevention.

What percentage of U.S. adults have chronic pain vs. high-impact chronic pain?

• Chronic pain: 20.4 % of adults.

• High-impact chronic pain: 8 % (pain limiting major life activities).

Q: What are the three key questions posed by the CDC regarding opioid management?

• When should opioids be initiated or continued for chronic pain?

• How should opioids be selected, dosed, monitored, and discontinued?

• How should clinicians assess risk and address harms of opioid therapy?

What are examples of non-opioid treatments for pain management?

• NSAIDs (e.g., ibuprofen, naproxen).

• Acetaminophen.

• Local anesthetics and nerve blocks.

• Physical therapy and early mobilization.

• Cryotherapy, thermotherapy, and e-stim.

• Cognitive and behavioral approaches (mindfulness, relaxation).

Q: What is the CDC’s overall guidance on opioids in pain management?

• Opioids should not be first-line therapy for most pain conditions.

• Use the lowest effective dose for the shortest duration possible.

• Reevaluate benefits and harms frequently.

• Combine with non-opioid and non-pharmacologic therapies whenever possible.