Functional rehabilitation

Author(s): Haewon Lee, MD and Christopher Plastaras, MD

Originally published:09/20/2014

Last updated:09/06/2018

1. DISEASE/DISORDER:

Definition

Functional rehabilitation is a restoration program that is designed to provide comprehensive treatment of an injury in an athlete.1 In contrast to traditional physical therapy, functional rehabilitation treats with the goal of returning the individual to full participation of the sport, at the prior level of activity. This requires restoration of form as well as function.2 The functional rehabilitation program is designed to progress the athlete from simple activities, such as walking or jogging, to highly complex sport-specific activities that require refined levels of proprioceptive acuity.3 In addition to strength and flexibility, a functional rehabilitation program also incorporates agility and proprioceptive/kinesthetic training.   Without appropriate rehabilitation, injuries frequently result in significant physiological and functional losses which increase the risk for reinjury of the affected area, as well as adjacent tissues and joints.2 While this model has primarily been applied to sports medicine and athletes, it is also appropriate for “industrial athletes”, employees who use their musculoskeletal system to perform their jobs, in order to return the injured worker as quickly as possible without risk of reinjury.4

Epidemiology including risk factors and primary prevention

Injuries are extremely common in sports. According to the CDC, there is an average annual estimate of 8.6 million sports- and recreation-related injury episodes in the United States alone.  Injury rates are higher among males, children aged 5-14 years, and non-Hispanic white persons.5 The rate and severity of injuries can vary widely depending on the sport and level of competition.6,7 Within the collegiate athlete population, there is a variable risk of injury depending on the sport played, the sex of the athlete, and whether the injury occurred during practice or competition.8 See Table 1. Each sport can see a unique distribution of injuries specific to the functional demands on the athlete. Understanding this distribution is critical to developing a training and rehabilitation program that targets and prevents sports-specific injuries.2

TABLE 1. Average annual national estimates of the number of injuries and athlete-exposures, and estimated injury rates, by championship sports
(adapted from National Collegiate Athletic Association Injury Surveillance Program, United States, 5 academic years, 2009–10 through 2013–14)
Season/Sport Event Average annual national estimate of
no. of injuries
Average annual national estimate of no. of athlete-exposures Estimated injury rate per 1,000 athlete-exposures (95% CI)
All sports Competition 76,176 6,472,952 6.0 (5.9–6.0)
Practice 134,498 28,860,299
Overall* 210,674 35,333,250
All men’s sports Competition 51,172 3,387,741 6.5 (6.4–6.6)
Practice 78,829 16,530,517
Overall 130,000 19,918,258
All women’s sports Competition 25,004 3,085,210 5.2 (5.1–5.4)
Practice 55,670 12,329,782
Overall 80,674 15,414,992
Men’s football Competition 19,982 500,698 9.2 (9.0–9.4)
Practice 27,217 4,653,357
Overall 47,199 5,154,055
Women’s field hockey Competition 642 61,240 6.5 (5.8–7.1)
Practice 888 174,943
Overall 1,530 236,183
Men’s soccer Competition 6,458 360,880 8.0 (7.5–8.4)
Practice 6,977 1,323,974
Overall 13,435 1,684,854
Women’s soccer Competition 7,434 432,347 8.4 (8.0–8.8)
Practice 7,679 1,367,650
Overall 15,113 1,799,997
Abbreviation: CI = confidence interval.

* Sums of competition and practice values do not equal overall values because of rounding.

 

Primary prevention of injury should include assessment of static and dynamic equilibrium, structural aspects of the body such as posture, and muscle stability during various sports-related tasks.9 Corrective exercises to address premorbid patterns of dysfunction, sometimes referred to as “prehab”, should be applied during the preventative phase.9 Emotional wellness is also an important factor in injury prevention. Movement efficiency is strongly influenced by emotional states such as anger or anxiety, which can be expressed through impulsive postural maladjustments and mechanical changes.10 Studies suggest that preventative interventions incorporating psychological-based modalities may reduce the rate of injuries in the soccer athlete population.11 Therefore, in addition to physical training, training in emotional coping processes would be beneficial for athletes.10

Patho-anatomy/physiology

Our bodies do not move in a single plane of motion at any one time, yet many methods of training focus on muscle isolation  “strengthen” that muscle. There are certainly cases when it is necessary to isolate a muscle or muscle group to facilitate its activation, but the goal of functional rehabilitation is to train using three-dimensional movement patterns that prepare the entire body for sporting or recreational activities that may involve some unpredictable body movements.

Particularly in sports activities, movements are rarely isolated. As an example, the trunk transmits energy from the lower quarter kinetic chain to the upper — think of a baseball pitcher winding up and throwing the ball or a golfer winding up in a backswing and coming into the follow-through motion. The trunk accomplishes this through diagonal loops and slings which involve the abdominal obliques, gluteal, pectoral and latissimus dorsi muscles.12 See figure 1. The “core” is a key area in this type of program, and consists of the abdominals, paraspinals, gluteal, diaphragm, pelvic floor and hip girdle musculature.13 The pectorals, latissimus dorsi, quadriceps and/or hamstrings are often included as part of the core.

Figure 1: Functional diagonal loops and slings (Please see: Liebenson C. Functional training, part 1: new advances. J Bodywork & Movement Therapies.2002;6(4):248-254.)

Musculoskeletal dysfunction and injury can result in part by poor posture, improper movement patterns, and compromised biomechanics due to musculoskeletal deficiencies.14 Therefore, the integrated model of function, is the basis of functional rehabilitation.

Specific secondary or associated conditions and complications

Restoration of function depends not only on symptomatic relief, but also on the maintenance of strength, return of flexibility and proprioception, as well as restoration of biochemical and biomechanical factors. Unfortunately, localized injury can secondarily result in “detraining” or decreased general fitness and cardiovascular performance due to inactivity. See table 2..

Table 2: Examples of Physiologic Changes Related to Detraining
Cardiac Decline in blood volume

Increase in resting heart rate and heart rate at submaximal exercise

Decline in cardiac stroke volume and cardiac output

Reduction in cardiac mass, specifically of the left ventricle

A higher total peripheral vascular resistance

Sharp decrease in VO2max

 

Pulmonary Rapid deterioration in ventilatory function

 

Metabolic Greater reliance on carbohydrates

Decline in glucose tolerance

Decrease in muscle fiber size

Change in muscle fiber distribution

 

 

A reduced training or cross-training program during the process of rehabilitating an injury can help a patient avoid or delay these metabolic and physiologic changes associated with training cessation, and even improve their overall fitness and performance.15 Psychosocial factors such as life stressor, anxiety, confidence, and associated behaviors have also been seen to influence outcomes of rehabilitation.16 These must also be addressed in order to restore complete function and enable the athlete to return to his/her prior level of activity. Failure to provide full functional restoration may lead to recurrent injury, suboptimal performance or delays in returning to full participation in an activity.

2. ESSENTIALS OF ASSESSMENT

History

Obtaining a history of the patient’s injury, including previous injuries and recovery time, treatment and therapies, training patterns and goals, plans to return to work or sport/activities is a very important initial step in developing a functional rehabilitation program.17 Importantly, information regarding the mechanism of the injury will provide critical information to help determine if the injury is (1) acute, (2) chronic, (3) acute-on-chronic, or a (4) subclinical maladaptation to athletic activity1, which will help the medical provider prescribe the appropriate rehabilitation intervention. Further information elicited in the history, including typical or baseline activities, current level of function, psychological state of the athlete, his/her support system, use of medications or supplements, and what positions, movements or activities reduce or exacerbate pain or impairment, can also facilitate a return to maximum function after injury.

Physical examination

An in-depth physical examination is the foundation of a functional rehabilitation program. In addition to neurological assessment, including muscle stretch reflexes and manual muscle testing, a functional physical examination should evaluate posture, balance, gait, muscle control and body stabilization, including symmetry of landmarks such as shoulder height, iliac crests, greater trochanters and positioning of each calcaneus. Three-dimensional or multi-planar range of motion, both passive and active, of major joints is also important, as is the assessment of the quantity and quality of movement.18 Static and dynamic body stability,neuromuscular control andproprioception are elements that are often not included in standard rehabilitation assessments but are integral to functional rehabilitation.18 Examples include the patient’s ability to perform single leg squats, box jumps, and planks. The assessment should be based on the patient’s presenting injury, but also evaluating for pre-existing deficiencies that may have contributed to the injury, as well as muscle imbalances or biomechanical deficits that may inhibit full recovery.  This type of assessment in the physical examination is essentially looking for the “rusty links” in the kinetic chain.  Examples include assessing for pes planus or weak hip abductors, poor transversus abdominis activation, and leg length discrepancies. See figure 2. This initial assessment will be critical to starting the rehabilitation program in the right direction, but re-evaluation throughout the course of the program is also essential to ensuring successful completion of the program and preventing delays in recovery.

Figure 2: Effect of overpronation of the foot on the kinetic chain (Please see: https://athleticlab.com/importance-lumbopelvic-hip-complex-1/kinetic-chain/)

Functional assessment

Functional assessment should incorporate identification of the tissue injury complex, clinical symptom complex, functional biomechanical deficits, the functional adaptation complex and the tissue overload complex.19 The first of these is the actual site of the tissue injury, while the second may include the site of injury or the location of referred pain symptoms. Functional biomechanical deficits arise as a result of the body’s malcompensation to the injury and related pain and range of motion (ROM) limitations (ie,weak or inhibited muscles in one area or tightness in others, such as in lower crossed syndrome; see figure 3). The functional adaptation complex is a series of changes that develop as a result of the functional biomechanical deficits and can be seen either distal or proximal to the tissue injury complex. The tissue overload complex is defined by increased stress placed on adjacent or biomechanically-related structures. As an example, in sacroiliac joint (SIJ) dysfunction, the tissue overload complex would include increased stress across the lower lumbar and lumbosacral zygapophyseal joints and contralateral SIJ, hip joints and even the knee.19

Therefore, a functional assessment should incorporate an examination of the entire kinetic chain in order to reveal those biomechanical deficits caused by injury or resulting from deconditioning. Muscular imbalances and limitations in flexibility should be documented as these have been implicated as risk factors for injury, as well as complication from injury.6 As such, a rehabilitation program that focuses on treating muscles in isolation will often be inadequate in returning athletes, particularly high-level athletes, to their prior level of performance.1

Another key component to a successful functional rehabilitation program is how the athlete performs the prescribed exercise or activity.  Correct form is crucial to successful rehabilitation. Incorrect performance of a movement or exercise may lead to additional injury or a prolonged recovery time. Ensuring that an athlete is performing a prescribed movement or exercise properly while reviewing the athlete’s technique for warm up, training or cool down exercises will aid the individual in achieving a successful outcome.

Figure 3: Lower-Crossed Syndrome: Joint dysfunction is created by imbalance between tightness in thoracolumbar extensors, the iliopsoas, and rectus femoris, and weakness of the deep abdominal muscles gluteus maximus and medius. Please see: http://muscleimbalancesyndromes.com/janda-syndromes/lower-crossed-syndrome/

Imaging

Accurate diagnosis is important to facilitate proper rehabilitation. While functional rehabilitation lends itself to functional diagnostic methods, imaging can be helpful to clarify specific pathologies. X-ray and CT are most useful in imaging ossified or calcified structures, while MRI provides high resolution imaging of soft tissue structures without ionizing radiation. Ultrasonography is being used more frequently to assess the neuromusculoskeletal system due to its availability, safety and low cost.20 It also allows dynamic assessment of joint and muscle structures that is not currently possible with XR, CT or MRI. Ultrasound can be used to assess activation of deeper muscular structures, such as the transversus abdominis, and can be used as biofeedback to aid in rehabilitation.

Electrodiagnostic medicine (electromyography and nerve conduction studies) may also be helpful in arriving to an accurate diagnosis and in some cases prognosticating time to recovery.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Once the injury type has been determined and an accurate diagnosis made, a rehabilitation plan with consideration of specific adaptation to imposed demand (SAID) should be developed.1 As the human body adapts to biomechanical demands, the desired training effect must drive the exercise protocol that is prescribed. The basic components of an exercise program include intensity, duration, frequency, and mode. Specification of these components is important to achieving optimal rehabilitation, mind-body rest, avoiding overtraining, and ensuring that sport-specific training is incorporated in the program.

Overall, progression with the rehabilitation protocol will depend on the injury, healing process and the sequential steps of the components. The program itself should take into account the individual athlete, psychological aspects of the injury and recovery, the phases of healing, and the rehabilitation progression.

Practice recommendations for functional rehabilitation remain limited by the lack of strong evidence-based studies and are currently guided by expert opinion. Keeping this limitation in mind, some of the current recommendations are as follows:

Anderson et al. describe a four-phase program, beginning with controlling inflammation, progressing to restoration of motion, then developing muscular strength, power and endurance, and finally return to sport-specific activity.21 Each phase of the functional progression program builds off the previous one.

Herring and Kibler provide additional information on these phases.1 The initial or acute stage of rehabilitation focuses on the clinical symptom complex and tissue injury complex. It incorporates rest and/or immobilization, physical modalities, medications, manual therapy, initial exercise or perhaps surgical intervention. In order to advance to the next stage, there needs to be adequate pain control and tissue healing, near-normal range of motion (ROM) and tolerance for strengthening. The recovery stage of rehabilitation focuses on the tissue overload complex and functional biomechanical deficit complex. It may also utilize manual therapy, flexibility training, proprioception and neuromuscular control training and specific, progressive exercise. Criteria for advancement include: no pain, complete tissue healing, essentially full pain-free ROM, good flexibility, 75-80% or greater strength, as compared with uninjured side, and good strength balance. Their final stage of rehabilitation is the functional stage. The focus here is on the functional biomechanical deficit complex and subclinical adaptation complex. This stage uses power and endurance exercises, a sports or activity-specific functional progression and technique/skills instruction. As long as the participant remains pain-free, with full pain-free ROM, demonstrates normal strength and balance, normal sports mechanics and can demonstrate sports-specific skills, he/she can return to play. Afterward, the athlete continues to work on an ongoing injury prevention program.

Clark describes a seven-phase continuum of rehabilitation. This concept begins with corrective exercise training including manual therapies, stretching and “grooving” or re-training the motion and motor patterns.22 The second stage involves integrated stabilization training to build stability and strength. Stage three is stabilization equivalent training to build strength and endurance, including proprioception-rich exercises on stable and unstable surfaces. Muscular development training is stage four, promoting muscle hypertrophy through higher volumes of exercises. Stage five is maximum strength training with higher exercise intensity. In stage 6, the maximum strength obtained in stage 5 is used to develop power, which is defined as the strength or force produced over a unit of time; developing this power is necessary for quick agile movements in sports performance.The final stage is maximum power training, using power exercises such as rapid lunges with dynamic 3D medicine ball throws to generate optimum force.

Biagioli simplifies the recovery from acute sports injury into three major phases while acknowledging that physical therapy protocols may divide these phases further for precise therapy implementation.9 See Table 3.

Table 3: The three major phases of functional rehabilitation
Acute phase: May last from 24 hours post-injury to approximately one week. Ends when symptoms have subsided enough for athlete to tolerate basic non-athletic activities.
·         Focus on protection of injured tissue, minimizing pain, minimizing inflammation

·         Early physical therapy with gentle and conservative maneuvers can be initiated

·         Early, complete, accurate diagnosis during this time is essential

Intermediate phase: Begins when acute symptoms have improved and athlete is able to tolerate non-athletic activities
·         Focus is placed on slow, graded advancements in strength, flexibility, endurance

·         Precautions such as aggressive stretching may need to be implemented

·         Rehabilitative activities may be largely directed at particular simple physical measures, rather than sport-specific functional tasks

·         Modifiable elements potentially contributing to injury should be addressed (i.e., incorrect biomechanics, antagonist muscle group imbalances, inflexibility, poor proprioception)

·         Optimizing kinetic chain should begin in this phase

Sport phase: A critical period, which begins following return of normal strength, flexibility, and other basic performance parameters
·         Focus is placed on developing functional movement patterns through sport-specific drills and integrated training

·         Continue to emphasize corrective strategies

·         Caution against the belief that the athlete is ready for full competition as athlete continues to be at risk of reinjury at this point

 

Coordination of care

Functional rehabilitation is best provided with a team approach, involving physiatrists, physical therapists, athletic trainers and strength and conditioning coaches. The role of each team member must be clearly defined to facilitate a cohesive program for the athlete or patient.9 In addition to providing a timely and accurate diagnosis as well as managing the medical aspect of treatment, it is the responsibility of the physician to determine when a patient is able to return-to-play.23 Return-to-play essentially means that the patient is ready to resume full participation in a sport and competition. The decision to return a player should be made using objective data provided by the care team.9

In practice, returning to a sport typically involves gradual increased degrees of physical activity, from the strictest precautions to unrestricted competitive performance.9 It is of great importance that the care team, particularly coaches and athletic trainers, are made aware of proper practices, including the graded approach to return to play, preventing reinjury, and the impact that an injury will have on a competitive athlete’s season.9

Patient & family education

Patients and patients’ families need to be educated in the training required to restore full function and avoid re-injury. Often treatment failure or re-injury are due to returning to competition too soon. Conversely, failing to advance training when appropriate can lead to loss of valuable time, which for an athlete, can result in deconditioning and lost opportunities9, whereas for the “industrial athlete”, unnecessarily prolonged periods away from work can place the patient at risk of unemployment, result in loss of wages, and hinder return to daily activities.

Emerging/unique Interventions

Successful outcomes can be demonstrated with return to work or sport at a previous level.

Physicians should be aware of an increase in the commercialization of internet-based exercise programs with varying emphasis on sports medicine principles such as functional movement and stability, or meditative and modified yoga practices. These programs, developed by the fitness industry and popular on social media, cater to a broad group including non-athletes with musculoskeletal pain, the lay athlete and to high-performing competitors. Patients may ask their physicians about the value of these programs and may benefit from further education. Greater physician awareness of these types of programs can help physiatrists understand the options available to patients outside of formal physical therapy.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Physicians should add functional diagnostic methods to their evaluation of patients and incorporate functional rehabilitation strategies into their rehab prescriptions. This approach can be helpful not only for athletes, but for geriatric and disabled populations. Functional rehabilitation builds upon traditional therapy models. It should be stated that an overly progressive approach that de-emphasizes classic exercises and techniques may be detrimental to rehabilitation. Indeed, many classic exercises and techniques are critical to success in sports training and should be included.9

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

While this concept may be new to those familiar only with approaches that focus solely on reduction of pain and movement limitations, for many physiatrists and rehabilitation professionals, “functional rehabilitation” is the only approach to recovery from an injury. Taking the time to educate patients that pain-free does not indicate full recovery may aid their complete recovery and prevent recurrence. Caution should also be expressed to those trying to start a high-intensity exercise/fitness program, regarding the potential risks of beginning at too-high of an activity level or increasing too rapidly without appropriate preparation.

“Prehabilitation” or “prehab”, which traditionally referred to a period of physical therapy prior to a surgical procedure in order to improve the functional capacity of the patient,23 has recently gained greater visibility and mainstream interest for injury prevention outside the surgical context. “Prehabilitation”, or pre-rehabilitation, in sports medicine focuses on injury prevention through targeted therapies, and can include strength training and identification and correction of anatomical or kinesiologic factors that may predispose an athlete to injury.24,25 While prehab is distinct from functional rehabilitation, incorporation of a prehab protocol in a recovered athlete can effectively prevent reinjury or new injuries and should be considered in a comprehensive approach in the management of athletes.26

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

There is limited evidence demonstrating the clear benefit of functional rehabilitation over other types of rehabilitation programs. There are many studies to demonstrate the benefits of rehabilitation for musculoskeletal injuries and for returning someone to activity after injury, but there are no comparative studies currently available. As revealed in a recent systematic review of exercise interventions for the treatment of shoulder pathology in the overhead athlete, evidence for a global treatment approach consistent with functional rehabilitation principles is largely based on grade D expert opinion.27 The dearth of strong evidence for the incorporation of global and sports-specific exercises has been attributed to the focus of studies on the acute stages of recovery, the lack of reporting of reproducible interventions, and the lack of reporting of functional outcomes and return to play.27 The challenge of reporting outcomes in musculoskeletal research is widely acknowledged and is hypothesized to be due in part to bias phenomenon of outcome measures; low treatment fidelity; the presence of common mediators among different treatment arms, impeding the ability to demonstrate differences between specific mechanisms; and non-specific influencers inherent in certain treatment modalities.28

With greater evidenced-based recommendations in the future, increasing advocacy efforts to allow for longer and broader insurance coverage for full functional recovery will also aid the promotion of functional rehabilitation. Additional research on the specific benefits of functional rehabilitation will not only benefit our patients and our profession, but is sorely needed.

REFERENCES

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  7. Koutures, Chris G.,Gregory, Andrew J. M. (2010 February). Injuries in Youth Soccer. Retrieved from http://pediatrics.aappublications.org/content/125/2/410.long.
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  9. Biagioli, Brian. Advanced Concepts of Strength and Conditioning. Coral Gables, FL: National Council on Strength and Fitness; 2015.
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  18. Geraci MC. Rehabilitation of the hip, pelvis and thigh. In: Kibler WB, Herring SA, Press JM, eds.Functional Rehabilitation of Sports and Musculoskeletal Injuries. Aspen, CO: 1998; 224-226.
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  21. Clark M. The seven phase continuum of rehabilitation. 3rd International Symposium on Functional Rehabilitation. Calabasas, CA:NASM: 2004.
  22. P.A. Houglum, Therapeutic Exercise for Musculoskeletal Injuries (4nd ed.), Human Kinetics, Champaign, IL. 2016. Accessed on Google Books. April 27, 2018.
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  24. Kibler, W., Chandler, T., & Stracener, E. (1992). Musculoskeletal adaptations and injuries due to overtraining. Exercise and sport sciences reviews., 20, 99–126.
  25. Meir R, Diesel W, Archer E. Developing a Prehabilitation Programme in a Collision Sport: A Model Developed within English Premiership Rugby Union Football. NSCA 2007, 29;3 p.50–62
  26. Wright, A., Hegedus, E., Tarara, D., Ray, S., & Dischiavi, S. (n.d.). Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis. British journal of sports medicine., 52(4), 231–237. doi:10.1136/bjsports-2016-096915
  27. Cook CE, George SZ, Keefe F. Br J Sports Med. Epub ahead of print: [April 25, 2018]. doi:10.1136/bjsports-2017-098978

Original Version of the Topic:

Adam P. Cugalj, DO. Functional Rehabilitation. 9/20/2018

Author Disclosure

Haewon Lee, MD
Nothing to Disclose

Christopher Plastaras, MD
Nothing to Disclose

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