This chapter provides rehabilitation specialists with a resource that will help them use appropriate evidence-based therapeutic exercises as they relate to specific orthopaedic protocols. Evidence from systematic reviews indicates that the use of appropriate therapeutic exercise has been the foundation for most successful rehabilitation programs for the majority of musculoskeletal impairments.
Historically, exercise strategies and techniques have varied in their scope and effectiveness. The goals of this chapter are to present and outline therapeutic exercises that have been validated through research and the consensus of treating clinicians and to provide this information in a practical and applicable manner. Whether or not rehabilitation specialists use these practices, this chapter provides a resource, practical guide, and rationale for the inclusion of a number of these exercises in the rehabilitation arsenal.
Rehabilitation Concepts for the Application of Therapeutic Exercise
To provide the necessary framework for the clinician, the rehabilitation concepts for the application of therapeutic exercise are first outlined and discussed. These concepts are then applied to specific rehabilitation programs for the shoulder, elbow, knee, and foot/ankle.
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The application of therapeutic exercises must be based on a thorough and continual clinical evaluation.
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The treating clinician should be acutely aware of which tissues are affected, whether through injury or surgical intervention.
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Each joint in the body has a specific function and is prone to specific, predictable levels of dysfunction. As a result, each joint has specific training needs. This situation leads to the simple but profound concept that our efforts in rehabilitation and performance enhancement are to effectively restore the optimal movement patterns for which the body was designed. Table 37-1 outlines the general and overriding function of each joint.
TABLE 37-1
GENERAL AND OVERRIDING FUNCTIONS OF EACH JOINT
Joint
Primary Function and Training Needs
Ankle
Mobility
Knee
Stability
Hip
Mobility and stability
Lumbar spine
Stability
Thoracic spine
Mobility
Scapulothoracic
Stability
Glenohumeral
Mobility and stability
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The rehabilitation specialist should follow a continuum of therapeutic exercise application. The acronym “AIR” can be used to help outline this approach to rehabilitation and training.
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Activate (A): Initially, therapeutic exercises are designed to isolate, activate, and strengthen weak muscles.
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Integrate (I): Once these weak muscles are “activated” and strengthened in isolation, exercises are then provided that integrate the muscles via movements in more functional patterns, such as pushing, pulling, squatting, and lunging.
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Reinforce (R): Finally, therapeutic exercises are provided that reinforce the proper motor pattern throughout the functional and sport-specific needs of the individual.
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Proper therapeutic exercise form and motor control should never be compromised.
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An appropriate amount of variety should be provided in the therapeutic exercise prescription.
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It is important to stick to the basics. In most cases a core group of exercises should be adhered to and built upon when designing a rehabilitative and/or strength and conditioning program. These exercises have been established in research and in clinical settings.
Language of Therapeutic Exercise
Before proceeding, some of the terms typically applied to various components and concepts of therapeutic exercise are broadly defined.
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Therapeutic modalities. Modalities such as cryotherapy, forms of electric stimulation, moist heat, whirlpool, ultrasound, iontophoresis, and phonophoresis are all potential contributors that are available to the rehabilitation specialist, particularly during the acute phases of rehabilitation. Modalities may aid in controlling or eliminating the inflammatory process, lessening pain, and enhancing the healing environment. However, if a person has continued pain and inflammation, it is important to evaluate and more appropriately address the underlying causes. Modalities such as neuromuscular electric stimulation may also be used to help reeducate and enhance muscular activations when necessary.
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Kinetic chain. According to Steindler, a closed kinetic chain state occurs when the distal body segment meets considerable resistance, as it does with a pull-up or squat. In contrast, the open chain state occurs when the peripheral extremity is able to move freely, such as when waving the hand or in the swing phase of the gait pattern. However, considerable ambiguity exists when describing various exercises by open and closed chain definitions. We prefer a more simple and precise description, noting that an activity may be weight-bearing or non–weight-bearing. For further clarity, we note the activity’s relationship to a given anatomic structure. Research has offered conclusive evidence regarding the relative stresses that are placed on the body’s joint structures during both open and closed chain exercises.
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Neuromuscular activation. As noted previously, therapeutic exercises are usually initially designed to activate weak and/or inhibited muscles. These particular activities have been appropriately termed neuromuscular activation exercises.
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Neuromuscular control. Neuromuscular control is defined as a person’s ability to physically respond to a given stimulus correctly. Sufficient neuromuscular control is coordinated by one’s proprioceptive and kinesthetic awareness. Proprioception refers to the sense of where a given joint segment is at a given time. In contrast, kinesthesia refers to one’s ability to perceive details about a given joint’s motion at a particular moment.
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Dynamic stability. Dynamic stability is one’s ability to control and stabilize a joint during a functional activity.
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Power. In terms of physics, power is defined as how fast one is able to perform work. Practically, power is said to be like a “burst of strength,” referring to how well a person can quickly and forcefully perform a movement.
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Plyometrics. Plyometric exercises, such as jumping and throwing, use a prestretch movement in a quick and powerful manner. A plyometric jump training program for persons rehabilitating from knee injuries and medicine ball/Plyoball throwing for persons after upper extremity injuries are common in rehabilitation settings.
Before we provide outlines for specific therapeutic exercise protocols, a general overview of important basic rehabilitation principles is necessary. Wilk et al. have outlined in detail a four-phase approach to rehabilitation. The phases are progressive and sequential in nature and should be implemented as such to safely and most effectively help the person return to his/her activities. Table 37-2 briefly details the phases and general goals for each phase in a rehabilitating setting.
| Phase | Goals | Focus of Training |
|---|---|---|
| Acute phase |
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| Intermediate phase |
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| Advanced strengthening phase |
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| Return-to-activity phase |
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Rehabilitation Protocols for the Shoulder Complex
Rehabilitation protocols for the shoulder complex involve a multiphasic approach that is both progressive and sequential. The protocol is always based on appropriately treating the specifically involved structures and the underlying primary cause. Each phase of the rehabilitation protocols represents a progression in which the exercises become more aggressive and demanding, with the inherent shoulder complex stresses becoming gradually greater. For this text, the discussion of rehabilitation progressions is related to rotator cuff repairs, superior labral anterior to posterior (SLAP) lesion repairs, anterior stabilization procedures, and posterior stabilization procedures. When available, clinical rationales are based on evidence provided through systematic reviews, clinical practice guidelines, and consensus statements.
Acute Phase or Immediate Postoperative Phase
In the acute phase or immediate postoperative rehabilitation phase, the emphasis is on protecting the healing tissues, negating the effects of possible immobilization, and controling pain and inflammation. A rational approach to therapy involves early, safe motion to allow optimal tissue healing. This goal is accomplished by introducing passive and active assisted exercises to aid in reestablishing range of motion (ROM). Submaximal and pain-free isometric training of the rotator cuff and scapulothoracic muscles are prescribed to help promote scapulothoracic and glenohumeral muscular activations. Therapeutic prescription in this phase is often very protocol and physician specific.
Subacute or Intermediate Strengthening Phase
In the subacute or intermediate phase, the exercise emphasis is on improving strength and neuromuscular control of the glenohumeral and scapulothoracic muscles. A person who is performing rehabilitation for a nonoperative condition would likely begin in this phase. The purpose of the movements in this phase, which are mostly performed in isolation, is to correct problems such as muscle imbalances or specifically weak points. Remember the acronym “AIR,” because this phase typically calls for the activation of inhibited and weak periscapular and rotator cuff muscles. Scapular- and rotator cuff–isolating exercises with arms below shoulder level in pain-free and safe ranges are first prescribed.
Advanced or Dynamic Strengthening Phase
In the advanced or dynamic strengthening phase, the objective of the exercise protocol is to improve strength, power, and muscular endurance. These parameters need to be reestablished in parallel with the functional activities to which the person will return. Therapeutic exercises are provided to further enhance and integrate targeted rotator cuff, deltoid, and scapular muscles. For overhead throwing athletes, the clinician can advance the exercises to include more functional sport-specific ranges.
Return-to-Activity Phase
The final phase in the rehabilitation program is the return to activity phase. The objective of the therapeutic exercise outline during this period is to progressively implement functional demands on the shoulder complex and help the person return to full participation in sport or work activities. Typically, the previously prescribed exercises are advanced in intensity through alterations in resistance and volume. The strength, power, endurance, and functional stability must continually be advanced as sport or work activities are introduced.
In the following sections, details regarding various surgical procedures are discussed as they apply to rehabilitation protocols for the shoulder.
Rotator Cuff Repairs
Ideally, the rehabilitation specialist therapist will have excellent communication with the treating surgeon and treatment options will be determined based on the patient’s age, the size and chronicity of the tear, the surgical approach, and the fixation method. Of primary importance after rotator cuff repair surgery is avoiding the development of shoulder stiffness through initiation of early shoulder mobility without possibly compromising the repair. The safest approach to facilitating passive mobility to the shoulder is for the rehabilitation therapist to perform the exercises with the patient in a supine position and then progress to active assisted ROM exercise once adequate tissue healing occurs. In most cases, the goal is to restore full passive ROM by the sixth week after surgical repair of the rotator cuff. Therapeutic exercise selections remain gradual and progressive as discussed earlier. Typically, more advanced training is begun during the fourth postoperative month.
SLAP Repairs
The primary rehabilitative concern after a repair of a SLAP lesion is to appropriately control all forces and loads on the repaired biceps-labrum complex. Therefore persons undergoing a SLAP lesion repair must be educated to avoid all isolated biceps contractions throughout the initial phases of their rehabilitation. Gradual ROM in a protective range is performed for the first 4 weeks. Initial passive elevation is kept below 90 degrees to avoid strain on the labral repair, and progressions in external rotation are performed cautiously to minimize strain on the labrum through the peel-back mechanism. The goal is to gradually restore full ROM by 8 weeks and then progress to full thrower’s motion by the twelfth week.
Within the rehabilitation outline, isolated biceps strengthening is not performed until after the eighth week after surgical repair. Also, because of the resultant posterior shear forces, all closed kinetic upper extremity exercises are withheld until the eighth postoperative week as well. Performance of internal and external rotation ROM activities may be advanced to 90 degrees of shoulder abduction during the fourth postoperative week.
Anterior Capsulolabral Stabilization Procedures
Of utmost importance in the rehabilitation protocols after surgery to stabilize the anterior shoulder are balancing the restoration of motion and function while maintaining an appropriately taut capsulolabral complex. A standard anterior capsulolabral repair, addressing attenuation of the anterior inferior capsule, is most directly stressed by external rotation, particularly above 90 degrees of abduction. In a cadaveric model, Itoi et al. demonstrated that with the arm by the side, external rotation up to 30 degrees could safely be applied to the shoulder without separating a simulated Bankart lesion. As such, external rotation is held less than 30 degrees for the initial 3 weeks and then progressed to 45 degrees by the sixth postoperative week. Considering resultant stresses to the inferior capsule, flexion is limited to less than 90 degrees until 3 weeks after surgery, then flexion is gradually increased to 135 degrees through postoperative week 6. The goal is to achieve full ROM in all planes at 12 weeks after surgery.
Even though the rotator cuff does not require specific protection after arthroscopic stabilization procedures, shoulder active ROM and rotator cuff strengthening is purposefully withheld during this early postoperative phase because of the potentially detrimental effect to the healing tissues. The strengthening program should integrate the appropriate ROM progression, while increasing muscular activity levels allow for dynamic stabilization in progressively more dynamic environments.
Posterior Capsulolabral Stabilization Procedures
To protect the anatomic capsulolabral reconstruction of the posterior capsule, which is much less robust than the anterior capsule, extreme care is taken to avoid posterior glenohumeral shear forces by avoiding all internal rotation and adduction shoulder motions for the initial 6 weeks. In most cases, a longer period of immobilization is used after these procedures to sufficiently protect the shoulder. Full internal rotation and horizontal adduction ROMs are very gradually progressed, with full motion sought at 12 weeks after surgery. Considering therapeutic exercise applications, resisted internal rotation, combined flexion and internal rotation, and horizontal adduction strengthening are not used until 6 to 10 weeks after surgery. Closed kinetic upper extremity exercises also are withheld until the eighth to twelfth postoperative week.
Tables 37-3 through 37-7 illustrate therapeutic exercises for the intermediate and advanced phases of shoulder rehabilitation. These exercises, as previously mentioned and described, are outlined into a number of categories. These categories are listed and defined below in an outline for a comprehensive therapeutic exercise rehabilitation program for the shoulder. This outline is provided in such a way that the clinician can easily create a thorough, effective, and successful rehabilitation program. References for the inclusion of the particular exercises are provided. These studies are primarily from electromyographic research. Note that these exercises allow for heightened activation of the muscles addressed.
- A.
Dumbbell routine (choose one routine). These routines group together related dumbbell shoulder complex exercises that activate a large number of the rotator cuff and scapular muscles.
- B.
Rotator cuff–specific exercises (choose the appropriate exercise[s]). These exercises are designed to isolate and strengthen specific rotator cuff muscles as necessary.
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Scapular-specific retraction, downward rotation exercises (choose one exercise) . These exercises are designed to train the scapular-stabilizing muscles that aid in functional pulling movements and act to isometrically hold the scapulae when the arm is dynamically moving.
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Scapular-specific protraction, upward rotation exercises (choose one exercise) . These exercises are intended to assist the shoulder complex in functional pushing motions and help maintain proper scapulohumeral rhythm with active elevation of the arm.
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Dynamic shoulder complex training (choose one or two exercises) . These advanced training exercises for the shoulder complex are performed in functional and sport-specific movement patterns.
| Exercise Component | Scapular Specific Protraction, Upward Rotation (Choose One Exercise) |
|---|---|
| Targeted muscles | Serratus anterior |
| Intermediate strengthening | Push-up (+), A, press-up, protraction; B, dynamic hug ; C, D1 PNF    |
| Advanced strengthening | A, Stability ball; B, unstable surface push-ups; C, closed chain UE step variations    Bench press progressions: A, DB floor press; B, BB floor press; C, DB bench press; D, BB bench press with foam roller    
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