Michael McGee, EdD, ATC, LAT
After reading this chapter,
the athletic training student should be able to:
- Develop the concept of a functional progression.
- Identify the goals of a functional progression.
- Recognize how and when functional progressions should be used in the rehabilitation process.
- Describe the physical benefits associated with a functional progression.
- Identify and describe the psychological benefits associated with a functional progression.
- Generalize the disadvantages associated with a functional progression.
- Incorporate the components of a functional progression.
- Develop a functional progression for a patient.
- Analyze various functional tests.
- Design a functional test for a patient.
One of the most significant challenges for anyone supervising a rehabilitation program following injury is making sound decisions about when and how to progress the patient toward the long-term goal of safely returning to functional activity while not interfering with the healing process. Rehabilitation of athletic injuries needs to focus on return to preinjury activity levels.35 Function refers to patterns of motion that use multiple joints acting with various axes and in multiple planes.28 Traditional rehabilitation techniques, although vital to the return of function, often stress single joints in single planes of motion. To complement traditional rehabilitation, the athletic trainer can use functional rehabilitation techniques. Functional rehabilitation, along with traditional methods, will ready the patient for activity and competition more successfully than if either method is employed alone.27
THE ROLE OF FUNCTIONAL PROGRESSIONS IN REHABILITATION
Athletic trainers must adapt rehabilitation to the sports-specific demands of each individual sport and playing position. However, rehabilitation programs in a clinical setting cannot predict the ability of the injured part to endure the demands of full competition on the playing field. For example, the complex factors surrounding a solid tackle in competition play cannot be produced in the clinical setting. The role of the functional progression is to improve and complete the clinical rehabilitation process.48 A functional progression is a succession of activities that simulate actual motor and sport skills, enabling the patient to acquire or reacquire the skills needed to perform athletic endeavors safely and effectively.10,16,27 The athletic trainer takes the activities involved in a given sport and breaks them down into individual components. In this way, the patient concentrates on individual parts of the game or activity in a controlled environment before combining them together in an uncontrolled environment as would exist during full competition. The functional progression places stresses and forces on each body system in a well-planned, positive, and progressive fashion, ultimately improving the patient’s overall ability to meet the demands of daily activities as well as sport competition. The functional progression is essential in the rehabilitation process because tissues not subjected to performance-level stresses do not adapt to the sudden return of such stresses with the resumption of full activity. Thus, the functional progression is integrated into the normal rehabilitation scheme as one component of exercise therapy, rather than replacing traditional rehabilitation altogether.16 Clearly, effective progression of exercises can significantly enhance clinical outcomes for all patients regardless of their level of function.6
BENEFITS OF USING FUNCTIONAL PROGRESSIONS
Using a functional progression in a rehabilitation program will help the patient and athletic trainer reach the goals of the entire program. The goals of the functional progression generally include a restoration of joint range of motion (ROM), strength, proprioception, agility, and confidence. Achieving these goals allows the patient to reach the desired level of activity safely and effectively.34 Functional progressions provide both physical and psychological benefits to the injured patient. The physical benefits include improvements in muscular strength and endurance, mobility and flexibility, cardiorespiratory endurance, and neuromuscular coordination, along with an increase in the functional stability of an injured joint.43 Psychologically, the progression can reduce the feelings of anxiety, apprehension, and deprivation commonly observed in the injured patient.10,16,27
Improving Functional Stability
Functional stability is provided by passive restraints of the ligaments, joint geometry, active restraints generated by muscles, and joint compressive forces that occur with activity.33 Stability is maintained by the neuromuscular control mechanisms involved in proprioception and kinesthesia (as discussed in Chapter 5). Functional stability cannot always be determined by examining the patient in the clinic. Therefore, the functional progression can be used to evaluate functional stability both objectively and subjectively. Can the patient complete all tasks with no adverse effects? Does the patient appear to perform at the same level, or close to the same level, as prior to injury? Performance during a functional task can be evaluated for improvement, and functional testing can be incorporated to provide an objective measure of ability.11 The patient can also give important feedback regarding function, pain, and stability while performing the functional tasks.
Increased strength is a physical benefit of the functional progression. Strength is the ability of the muscle to produce tension or apply force maximally against resistance. This occurs statically or dynamically, in relation to the imposed demands. Strength increases are possible if the load imposed on a muscle exceeds that to which a muscle is accustomed during exercise. This is commonly referred to as the overload principle and is possible due to increased efficiency in motor unit recruitment and muscle fiber hypertrophy.29 To see these improvements, the muscle must be worked to the point of fatigue both concentrically and eccentrically. The functional progression will develop strength according to the Specific Adaptation to Imposed Demands (SAID) principle. The muscles involved will be strengthened dynamically, under stresses similar to those encountered in competition.
Muscular and cardiorespiratory endurance can both be enhanced using functional progressions. Endurance is necessary for long-duration activity, whether in daily living or in the repeated motor functions found with sport participation. The functional progression will enhance muscular endurance through repetition of activities that create an environment for improving both muscular strength and endurance simultaneously. Cardiorespiratory endurance can be improved through the repetition of movements involved in the progression in the same way as regular fitness levels improve with continuous exercise.
With injury, tissues lose mobility due to immobilization, thus inhibiting normal function. With functional progressions, the injured tissues are stressed within a limited range. This stress should be sufficient to cause the tissue to elongate and return to normal length. Improved mobility and flexibility are crucial to regaining functional movement. Strength and endurance are only functional if the injured body part can move through a full ROM. Tissues also become stronger with consistent stresses, so tissues other than muscle (tendon and fascia) can also be strengthened with the functional progression.29
Relaxation involves the concerted effort to reduce muscle tension. The functional progression can teach an individual to recognize this tension and eventually control or remove it by consciously relaxing the muscles after exercise. The total body relaxation that can ensue relaxes the injured area, helping to relieve the muscle guarding that can inhibit the joint’s full ROM.29
Neuromuscular coordination, agility, and motor skills are complex aspects of normal function that collectively create appropriate contractions at the most opportune time and with the appropriate intensity.29 A patient needs coordination, agility, and motor skills to transform strength, flexibility, and endurance into full-speed performance. This is especially important for an injured patient. If the patient does not regain or improve his or her coordination and agility, performance is hampered and can in itself lead to further injury. Repetition and practice are important to learning motor skills. Regular motions that are consciously controlled develop into automatic reactions via motor learning. This is possible due to the constant repetition and reinforcement of a particular skill.25 To acquire these “automatic reactions,” one needs an intact and functional neuromuscular system. Because this system is disturbed by injury, decreases in performance will occur, increasing the potential for injury. The functional progression can be used to minimize the loss of normal neuromuscular control by providing exercises that stress proprioception, motor-skill integration, and proper timing. The functional progression is indicated for improvement in agility and skill because of the constant repetition of sport-specific motor skills, use of sensory cues, and progressive increases in activity levels. Proprioception can be enhanced by stimulating the intra-articular and intramuscular mechanoreceptors. These are all components of, or general principles for, enhancing neuromuscular coordination.25 The practice variations used with functional progressions allow the patient to relearn the various aspects of his or her sport that the patient might encounter in competition. Rehabilitative exercise programs must stress neuromuscular coordination and agility. Increases in strength, endurance, and flexibility are unquestionably necessary for a safe and effective return to play, but without the neuromuscular coordination to integrate these aspects into proper function, little performance enhancement can occur. For this reason, functional progressions should become an integral part of the long-term rehabilitation stage so that injured patients can maximize their ability to return to competition at their preinjury level.
PSYCHOLOGICAL AND SOCIAL CONSIDERATIONS
Functional progressions can also provide psychological benefits to the patient. Anxiety, apprehension, and feelings of deprivation are all common emotions that occur with injuries. The functional progression can aid the rehabilitation process and facilitate the return to play by diminishing these emotions. Chapter 4 discusses the psychological aspects of the rehabilitative process in more detail. This chapter will focus on the specific contributions of the functional progression.
Uncertainty about the future is a reason many patients give for their feelings of anxiety. Patients experience this insecurity because they have only a vague understanding of the severity of their injury and the length of time it will take for them to fully recover.1 The progression can lessen anxiety because the patient is gradually placed into more demanding situations that allow him or her to experience success and not be concerned as much with failure in the future.
The patient might experience feelings of deprivation after losing direct contact with his or her team and coaches for an extended time. The functional progression can limit such feelings of deprivation because the patient can exercise during regular team practice times at the practice site. By engaging in an activity that can be completed during practice, the patient remains close in proximity and socially feels little loss in team cohesion.1
Apprehension is often listed as an obstacle to performance and many times serves as a precursor to reinjury.1 Functional progressions enable patients to adapt to the imposed demands of their sports in a controlled environment, helping to restore confidence, thus decreasing apprehension. Each success builds on past success, allowing the patient to feel in control as he or she returns to full activity. Figure 16-1 provides a list of the physical and psychological benefits of functional progressions.
COMPONENTS OF A FUNCTIONAL PROGRESSION
Functional progressions can begin early postinjury. In general, the early focus of phase 1 in the progression is on restoration of joint ROM, muscular strength, and muscle endurance. The next phase of the progression focuses on incorporating proprioception and agility exercises into the program. These phases can be 2 separate phases or, as is often the case, they may overlap. By including proprioception and agility exercises into the program, the injured area is positively stressed to improve the neurovascular, neurosensory, and kinetic functions.34
The functional progression should allow for planned sequential activities that challenge the patient while allowing for success. The success will give the patient confidence in his or her ability to complete tasks and motivate the patient to attain the next goal. Neglecting to plan and use a simple progression can lead to reinjury, pain, effusion, tendinitis, or a plateau in performance. To plan appropriately, each decision for a patient should be based on individual results and performance rather than solely on time factors.34
Several factors must be addressed to provide a safe and effective return to play with the use of functional progressions. First, what are the physician’s expectations for the patient’s return to activity? Second, what are the patient’s expectations for his or her return to activity? Third, what is the total disability of the patient? And fourth, what are the parameters of physical fitness for this patient? Keeping the total well-being of the injured patient in perspective is a significant factor.10
Exercise can be viewed from 2 perspectives. From one perspective, exercise is a single activity involving simple motor skills. From the second perspective, exercise involves the training and conditioning effect of repetitive activity.25 It is well accepted that preinjury status can be regained only if appropriate activities of sufficient intensity are used to train and condition the patient. To provide the patient with these activities, 4 principles must be observed. First, the individuality of the patient, the sport, and the injury must be addressed. Second, the activities should be positive, not negative; no increased signs and symptoms should occur. Third, an orderly progressive program should be used. Fourth, the program should be varied to avoid monotony.29 Steps to minimize monotony include the following:
- Vary exercise techniques used.
- Alter the program at regular intervals.
- Maintain fitness base to avoid reinjury with return to play.
- Set achievable goals, reevaluate, and modify regularly.
- Use clinical, home, and on-field programs to vary the activity.25
Patients are continually exposed to situations that make reinjury likely, so every effort should be made to understand and incorporate the inherent demands of the sport into the rehabilitation program. The athletic trainer can emphasize the importance of sport-specific activities to enhance the patient’s return to activity, rather than simply concentrating on traditional rehabilitation methods involving only weight machines and analgesics.
The components of fitness are listed in Figure 16-2. There are 2 distinct components in this model. The physical fitness items used in more traditional rehabilitation programs should be merged with the athletic fitness items of functional progressions to maximize the patient’s chance to regain preinjury fitness levels.
The components of a functional progression should aim to incorporate all the factors listed in Figure 16-2 under athletic fitness items.
DESIGNING A FUNCTIONAL PROGRESSION
Athletic trainers should consider all aspects of a patient’s situation when designing a functional progression. There is no “cookbook” method that meets the needs of all patients. Athletic trainers should use their creativity when it comes to developing progressions for the patient. As previously stressed, functional progressions should start early in the rehabilitation process and then culminate in a full return to participation. The following guidelines are suggestions for designing functional progressions that can meet the needs of various injury situations.
As with any rehabilitation program, the patient’s current state should be evaluated first. This step may include a review of the patient’s medical history, physician notes and/or rehabilitation protocols, a physical exam or injury evaluation, diagnostic testing, and functional testing. Once the status of the patient is established, planning for proper progression may occur. Planning will involve reviewing the expectations of the patient and the physician. What are the rehabilitation goals and parameters? At this point, the athletic trainer must determine whether the injury situation, patient’s goals, and physician’s expectations will work together. If not, the athletic trainer must work to bring the 3 together. The athletic trainer will also need to understand the demands of the sport and the position played by the patient. The patient, parents, coaches, and other athletic trainers may serve as valuable resources for successful completion of this step.
A complete analysis of the demands that will be placed on the patient and the injured body part once return to play is achieved must be completed. All of the tasks involved in the activity should be ranked on a continuum from simple to difficult. Simple tasks may involve isolated joints, assisted techniques, or low-impact activities, whereas difficult tasks often group simple tasks together into one activity and involve higher-impact, activity-related skills. Primary concerns should include the intention of the activity, what activities should be included, and the order in which the activities should occur.50
It is imperative that the athletic trainer assess the patient periodically throughout the progression prior to moving to the next level in the progression. Assessment of present functional status of the injury should serve as a guide to a safe progression.29 The assessment should be based on traditional assessment methods, such as goniometry, along with knowledge of the healing process and the patient’s response to activity, functional testing, and subjective evaluation. Aggressive activities that cause pain, effusion, or patient anxiety can be replaced with less-aggressive activities. Achieving a certain skill level in a functional progression occurs when the skill can be completed at functional speed with high repetitions and no associated increase in pain or effusion or decrease in ROM. The athletic trainer and the patient should realize, however, that setbacks will occur and are common. Sometimes, it takes 2 steps forward and 1 step back to achieve the needed level of improvement.
EXAMPLES OF FUNCTIONAL PROGRESSIONS
The shoulder joint serves as a template for upper extremity rehabilitation and functional progressions. A functional progression for the throwing shoulder should include the following steps. First, the patient must be instructed in and complete a proper warm-up. During the warm-up, the patient should practice the throwing motion at a slow velocity and with low stress. The activity can then progress through increasingly difficult stages, as indicated in Table 16-1 and in more detail in Chapter 17. Table 16-2 provides an example of a functional progression for hitting a golf ball, and Table 16-3 provides a program for return to hitting a tennis ball. Any upper extremity injury can benefit from one of these programs or can be exercised in similar fashion using any sport equipment needed for that sport.41
Many of the activities for the shoulder are equally effective for rehabilitation of the elbow, wrist, and hand. Other activities that can be used for upper extremity rehabilitation may focus more on the elbow or wrist/hand. An excellent example of functional elbow rehabilitation can be found with Uhl, Gould, and Gieck’s work with a football lineman.52 The progression started with simulated lineman drills for the upper extremity in the pool. The patient then progressed to proprioception and endurance work using a basketball bounced against a wall and progressed to a medicine ball thrown against a plyoback.35 Both athletic trainer and patient satisfaction as well as no report of pain indicated successful completion.52 This is a great example of how the athletic training staff used sport-specific tasks to determine the functional level of the patient.
The typical progression begins early in the rehabilitation process as the patient becomes partially weightbearing. Full weightbearing should be started when ambulation is performed without a limp.
Running may begin as soon as ambulation is pain free. Pain-free hopping on the affected side may also be a guideline for determining when running is appropriate. Exercising in a pool allows for early running. The patient is placed in the pool in a swim vest that supports the body in water. The patient then runs in place without touching the bottom of the pool. Proper running form should be stressed. Eventually, the patient is moved into shallow water so that more weight is placed on the ankle. The patient then progresses to running on a smooth, flat surface—ideally, a track. Initially, the patient should jog the straights and walk the curves and then progress to jogging the entire track. Speed may be increased to a sprint in a straight line. The cutting sequence should begin with circles of diminishing diameter. Cones may be set up for the patient to run figure 8s as the next cutting progression. The crossover or sidestep is next. The patient sprints to a predesignated spot and cuts or sidesteps abruptly. When this progressions is accomplished, the cut should be done without warning on the command of another person. Jumping and hopping exercises should be started on both legs simultaneously and gradually reduced to only the injured side.
The patient may perform at different levels for each of these functional sequences. One functional sequence may be done at half speed, whereas another is done at full speed. For example, a patient may run full speed on straights of the track but do figure 8s at only half speed. Once the upper levels of all the sequences are reached, the patient may return to limited practice, which may include early training and fundamental drills. An example of a functional progression for the lower extremity is found in Table 16-4.
Functional testing involves having the patient perform certain tasks appropriate to his or her stage in the rehabilitation process to isolate and address specific deficits.12 As a result, the athletic trainer is able to determine the patient’s current functional level and set functional goals.37 According to Harter, functional testing is an indirect measure of muscular strength and power.24 Function is “quantified” using maximal performance of an activity.24 Harter describes 3 purposes of functional testing as follows24:
- Determine risk of injury due to limb asymmetry
- Provide objective measure of progress during a treatment or rehabilitation program
- Measure the ability of the individual to tolerate forces24
1. Functional activity can begin early in the rehabilitation process with:
○ Assisted PNF techniques
○ Nonweightbearing Biomechanical Ankle Platform System (BAPS; Spectrum Therapy Products) board or BOSU Balance exercises
○ Partial weightbearing BAPS board or BOSU Balance exercises
○ Full weightbearing BAPS board or BOSU Balance exercises (Figure 16-7)
○ Walking normal; heel; toe; sidestep/shuffle; slides (Figure 16-8)
○ Sagittal, frontal, and transverse planes (Figure 16-9)
○ 90-degree pivot with weight or increased speed
○ 180-degree pivot with weight or increased speed
○ Forward step-up, 50% to 75% max speed (Figure 16-10A)
○ Lateral step-up, 50% to 75% max speed (Figure 16-10B)
○ Straight-away on track; jog in turns (goal = 2 miles)
○ Complete oval of track (goal = 2 to 4 miles)
○ 100-yd “S” course 75% to 100% max speed with gradual increase in number of curves (Figure 16-11)
○ 100-yd “8” course 75% to 100% max speed with gradual decrease in size of “8” to fit 5 × 10 yd (Figure 16-15)
○ 100-yd “Z” course 75% to 100% max speed with gradual increase in number of “Z”s (Figure 16-12)
○ Sidestep/shuffle slides
○ 10 yd × 10
○ 20 yd × 10
○ 40 yd × 10
○ Acceleration/deceleration; 50 yd × 10 (Figure 16-13)
○ “W” sprints × 10 (Figure 16-14)
6. Box runs:
○ 10-yd clockwise/counterclockwise × 10 (Figure 16-16)
○ Barrow Zig Zag Test (Figure 16-17)
7. Shuttle runs—“suicides” (Figure 16-18)
8. Carioca runs (Figure 16-19):
○ 30 yd × 5 right lead-off; 30 yd × 5 left lead-off
9. Jumping (Figure 16-20):
○ Boxes, balls, etc
10. Hopping (Figure 16-21):
○ Two feet
○ One foot
11. Vertical jump using a Vertec (Sports Imports; Figure 16-22)
12. Cocontraction semicircular test (Figure 16-23)
13. Cutting, jumping, hopping on command
14. Sport drills used for preseason or in-season practice
Functional testing can provide the athletic trainer with objective data for review.44 Traditional rehabilitation programs and improvements in strength and ROM do not always correlate with functional ability.26 Functional testing should have a better correlation with functional ability.
When contemplating the use of a functional test or battery of tests, the athletic trainer must evaluate the test(s) chosen. Validity and reliability must be considered. A test should measure what it intends to measure (validity) and should consistently provide similar results (reliability) regardless of the evaluator.44 Other factors must be considered before releasing a patient to full activity. These include a subjective evaluation of the injury, performance on functional tests, presence or absence of signs and symptoms, other recognized clinical tests (isokinetic testing, special tests, etc), and the physician’s approval.44 Functional testing should attempt to look at unilateral function and bilateral function in an attempt to determine whether the patient is compensating with the uninjured limb.12 Other considerations should include the stage of healing for the patient, appropriate rest time, and self-evaluation.37
Functional testing might be limited if the athletic trainer does not have normative values or preinjury baseline values for comparison.44 Obviously, a patient who cannot complete the test(s) is not ready for a return to play. However, what happens to the patient who can complete the test(s) but has no preinjury data available for comparison? The athletic trainer has to make a subjective decision based on the test results. If the normative data or preinjury data are available, the athletic trainer can make an objective decision. If a soccer player is able to complete a sprint test with a mean of 20 seconds but her preinjury time was 16 seconds, then she is only 85% functional. Without the preinjury data, the athletic trainer might be unable to determine the patient’s functional level. Of course, the athletic trainer can always compare to the mean functional level of the uninjured team members to aid in the decision making. Other methods that will aid in objective decision making include limb symmetry and error scores. Limb symmetry can include strength, ROM, and other traditional measurements; however, in this case, limb symmetry refers to the functional ability of the limbs. For example, a single-leg hop that compares the ipsilateral limb with the contralateral limb uses the following formula:
(ipsilateral limb/contralateral limb) × 100 = limb symmetry percentage
Functional testing should be an easy task for athletic trainers and should be equally simple for patients to understand. Cost efficiency, time demands, and space demands are important concepts when considering the tests to use.
Clinical Decision-Making Exercise 16-1
A soccer midfielder is recovering from a grade 2 medial collateral ligament sprain and has been cleared for sport-specific training. What types of activities could you use for this patient?