Rehabilitation Principles

Steve Stalzer

John Atkins

Gene Hagerman

In 1977 Dr. Steadman enlightened us (John Atkins and Gene “Topper” Hagerman) with his vision of rehabilitation. This vision has formed the basis of our rehabilitation philosophy—principles and practices—in the care of athletes and others who come to our clinic. As one of the inventors of modern rehabilitation, Dr. Steadman recognized the importance of progressing rehabilitation objectively and preventing the detrimental effects of immobilization, but also protecting the integrity of healing tissue. Dr. Steadman also values teamwork, research-based rehabilitation, and
using rehabilitation guidelines that assure consistency in patient care and outcomes.

While we were working with the U.S. Alpine Ski Team in Squaw Valley, California, Dr. Steadman was practicing orthopaedics in South Lake Tahoe. If an athlete needed rehabilitation, Dr. Steadman would initiate the rehabilitation in his home, monitor and progress the rehabilitation, and analyze the outcomes.

When we were traveling with the ski teams, he was just a phone call away for advice. This communication sealed our bond as a team. In 1984, after the most successful Winter Olympics in Alpine history, we joined Dr. Steadman in South Lake Tahoe, where he invited us to work with all of his patients, including the athletes, no matter what the sport. We joined Dr. Steadman at local and national orthopaedic meetings and the trainers’ conferences. We shared his vision and described our rehabilitation program. We met other orthopaedic surgeons. One orthopaedic surgeon, John A. Feagin, MD, in particular, was as enthusiastic as we were about Dr. Steadman’s rehabilitation practices and philosophy. We were propelled by teamwork, passion, and knowledge. This combination has helped us create one of the most successful rehabilitation programs in the country.

Our rehabilitation team moved together with Dr. Steadman from South Lake Tahoe to Vail, Colorado, in 1990. As the number of patients grew, communication between physician, patient, and therapist became even more important. We designed clear and concise protocols to enable patients to follow our rehabilitation program even if they returned home to continue their rehabilitation. For those patients, we emphasized the importance of keeping in contact by phone calls. We wanted them to know that although we may not be physically involved in their rehabilitation, we were only a phone call away. That was important to us. Keeping in touch with patients, particularly returning their calls, is one practice that shows we care. Everyone associated with Dr. Steadman cares about the patient and the quality of care for each patient.

The rehabilitation team has grown from the 2 of us to almost 50 employees today (2006). Two leaders, Sean McEnroe and Steve Stalzer, joined the team in 1996 and 2001, respectively. They both share our values and work ethic. Together, Sean and Steve have started an extensive mentoring system for our therapists and have expanded our vision. The key to our growth is the wisdom of Dr. Steadman, who continues to guides us, the quality of the new therapists we hire, and always looking ahead and trying to get that much better in the arena of physical therapy, physical fitness, and health.

How do we know we are succeeding? After surgery, the Steadman Hawkins Research Foundation tracks patients and their outcomes. The Foundation has an extensive database on patient satisfaction, return to work, return to sports, and longevity of their lifestyles. We still keep in touch with a remarkable number of patients and continue to tell each patient that we are a lifelong resource for them.

In the following pages, we share the principles of our rehabilitation program and conclude with our vision of the future. What new technology will arrive on the scene? How much of new technology will we incorporate into our program? We will adapt to the technology that is compatible with our philosophy so long as the technology does not eliminate the hands-on approach and the therapist-patient relationship. Our goals and values will never change. We will continue to be the best that we can be and we will aim to become better.

–John and Topper

The Crucial Principles of Rehabilitation

A strong rehabilitation team is an essential part of the successful sports medicine clinic. It is important that the physician and rehabilitation team share common goals, mutual respect, and effective communication. Within the rehabilitation team, the following principles are vital to achieving consistently successful outcomes in rehabilitation.

Teamwork with the physician, therapist, and patient, working toward a common goal, is essential.
The rehabilitation protocol is not a cookbook, but a set of guidelines that assure consistency in patient care, compliance, and outcomes.
The rehabilitation program must be based on current research and evidence-based practice.
Healing tissue should never be overstressed.
The detrimental effects of immobilization must be prevented.
Progression through each stage of rehabilitation must be based on objective criteria.

Teamwork

An emphasis on teamwork is the foundation for the successful sports medicine program. The team must share a common goal, mutual respect, and attention to communication. The successful therapist also fulfills the roles of motivating the patient, assuring patient compliance, re-enforcing the physician’s instructions, and managing complications to optimize results.

In 1989, before Dr. Steadman moved to Vail, he asked four individuals (John Atkins, Topper Hagerman, Crystal Adams, and Shirley Carlson) if they would move with him and continue to work as part of his team. To this day, Dr. Steadman insists that he would not have moved if any one member of the team had not been willing to relocate.
Each of these individuals has been a part of his team for more than 20 years.

Goals

The goals of rehabilitation are to return the patient to his or her desired level of activity as quickly and safely as possible. To achieve these goals, the physician, therapist, and patient must work together to determine the best rehabilitation course following injury or surgery. Often, success is measured by how quickly an athlete returns to competition. Although quick return is important, it is vital that the patient’s safety not be compromised as a result. It is equally important that the patient has a long-term successful outcome that includes avoidance of additional injury. Longevity of patient satisfaction and overall health should never be compromised in the return to athletic competition.

Communication

Effective communication among the rehabilitation team members generates and perpetuates successful patient outcomes. The physician and rehabilitation team must communicate clearly about general rehabilitation principles as well as each patient’s plan. We develop postoperative protocols that are fundamental for physician/therapist/patient communication. These protocols are developed through extensive collaboration of all team members including the patient. To assure clear communication, each physician starts his or her day with rounds to see postoperative patients in the rehabilitation clinic with the rehabilitation team. This time is dedicated to establishing each patient’s postoperative rehabilitation course and to clarify individual protocol adjustments. Surgical findings are discussed with the therapist and patient as well as how these findings affect the rehabilitation program. Dedication to communication assures that the patient receives a consistent message from the physician and therapist. Close communication also allows us to respond quickly to any patient problems that arise during rehabilitation.

For the patient who does not live locally, communication is especially important. The patient must clearly understand his or her postoperative rehabilitation program following surgery. A clearly outlined protocol assists in guiding the patient through each phase of rehabilitation. The therapist must maintain adequate contact with the patient to assure that he or she stays on track with the rehabilitation program. Frequent communication allows the therapist to manage complications early and alter the rehabilitation program if needed. It is important to remember that communication does not happen automatically and cannot be taken for granted.

Motivation

Motivation is vital for individuals recovering from an injury, just as it is for optimal athletic performance. Each person is motivated in different ways. Understanding how to motivate each individual is essential for optimizing effectiveness as a rehabilitation provider. The first step in motivating a patient is to establish trust and make a personal connection with each patient.

Take time to get to know patients beyond their current injury.
Find out their interest, activities, sports, and where they are from.
Find out their rehabilitation goals as well personal goals that relate to their health and fitness.

Compliance

Motivation is one key factor in patient compliance, but a well-designed rehabilitation program and the therapist’s professional knowledge are also important. Proper motivation by the therapist leads the patient to be accountable to the rehabilitation program as well as his or her overall health. The patient must understand that his or her role is essential to the success of the rehabilitation program. In addition, a well-designed exercise program is important in achieving patient compliance. The program must be comprehensive, but not overwhelming. Patient compliance improves when the rehabilitation program is limited to the smallest number of exercises that adequately meet the needs of the patient. Patient understanding and knowledge of the rehabilitation program is the final element of compliance. The better the patient understands why each exercise is important, the more likely he or she is to be compliant with the exercise program.

Reinforcement

Because the therapist has the opportunity to see the patient weekly or even daily, it is important that the therapist reinforce key messages to the patient. Reinforcement is unique to each patient and may include weightbearing restriction, bracing, or specific exercises. Compliance must be continually reinforced for optimal patient outcomes.

Managing Complications

An awareness and proper management of potential complications is essential for consistently successful outcomes. Attention to joint effusion, joint pain, and tendonitis are all elements the therapist and the patient watch for during the rehabilitation program. Early treatment of complications can be the difference between a minor adjustment to the rehabilitation program and a major setback. The patient should also be properly instructed to watch for swelling and pain, particularly when advancements are made in the rehabilitation program. Close communication between the therapist and physician allows for expedited treatment of complications.

Optimizing Results

Optimal results are achieved when effective teamwork, communication, and patient compliance are combined with a sound rehabilitation program. Several key elements exist in optimizing the results of rehabilitation. The first key is to understand and follow the fundamental principles of rehabilitation. The second element is the “art” of progressing each patient appropriately through the rehabilitation
program. It is equally important that the therapist understand when to accelerate and when to decelerate the patient’s rehabilitation. Focusing on overall fitness is another key element of optimizing results. Working on cardiovascular fitness, core strength, and upper body strength all aid in improved fitness. The last element in optimizing results is accomplished by working on performance enhancement during the final stage of rehabilitation.

By initially building endurance, strength, and then power, the athlete has built a solid foundation for advanced sport specific training and plyometrics. Form running, speed training, and agility drills can push the athlete to be quicker, faster, and stronger than before injury.

Finally, accountability leads to improved compliance with the rehabilitation program and thus leads to improved outcomes and optimal results. Compliance also improves when the patient understands the rationale for the rehabilitation program. It is the role of the therapist to re-inforce patient compliance and to keep the patients motivated as they progress through each phase of rehabilitation. The successful therapist understands that motivation is essential for consistently successful outcomes.

Rehabilitation Protocols

The rehabilitation protocol is not a cookbook, but a set of guidelines that assure consistent patient care, improved compliance, and improved outcomes. Consistent patient care is achieved when all patients follow a consistent rehabilitation philosophy. The rehabilitation protocol assures that the nonlocal patient will continue to follow the same philosophy after returning home. Improved compliance is achieved by providing the patient with a comprehensive protocol that provides the patient with knowledge of the rehabilitation program. The combination of consistent patient care and improved compliance results in improved outcomes and allows for analysis of outcomes. An additional benefit of protocols is that they provide an avenue for communication with other rehabilitation providers. The rehabilitation program or protocol should be based on fundamental rehabilitation principles. The protocol should be comprehensive yet simple enough to enhance patient compliance. It is a key element for patient, therapist, and physician communication and has allowed us to maintain consistent care with patients who complete their therapy in all parts of the world.

Healing Tissue Should Never Be Overstressed

The management of knee injuries has evolved significantly in recent years with the advancement of arthroscopic techniques and rehabilitation knowledge. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in both recreational and elite athletes.¹ The dilemma in rehabilitation is that the rates of healing must be balanced with rehabilitation that stresses these injured, repaired, or reconstructed elements of the knee.² Rehabilitation involves restoration of normal range of motion, gait, proprioception, and strength to allow return to functional activity. In the recreational or professional athlete, the rehabilitation program must also focus on restoration of power, speed, and agility for optimal return to competition.

The need for return to activity as quickly as possible is clear, but the time at which safe return is possible is less clear.³,⁴ If neuromuscular coordination, strength, or endurance is inadequate, static elements of joint stability share greater loads and the normal bone, cartilage, or ligaments may fail putting the repair or reconstruction at risk.²,⁵,⁶ The dilemma in rehabilitation is that rates of healing must be balanced with coordination that stresses injured, repaired, or reconstructed elements of the knee. Delay in initiating physical conditioning lengthens the time for return to preinjury activity level and may encourage some patients to resume activity when healing is maximized, but conditioning is not optimal.² We do understand that healing tissue should not be overstressed.

Communication among the physician, therapist, and patient is essential in understanding the constraints of tissue healing related to the patient’s injury, repair, or reconstruction. The physician and therapist must also stay abreast of current research related to time constraints of tissue healing. We have seen a trend for success to be measured by how fast a patient returns to sports. Although the time for return to competition is important, it is equally important that safety is not compromised. A truly successful outcome is measured by longevity of patient satisfaction and a long-term healthy, asymptomatic knee.

Knee joint effusion and the subsequent capsular distention can cause major alterations in the normal gait cycle and can be considered a causative factor promoting the acquisition of quadriceps avoidance gait patterns.⁷ Weightbearing restrictions are surgery-specific, but crutches should not be discontinued until the patient is able to demonstrate a pain-free, normal gait pattern. We typically instruct patients in partial weightbearing with crutches for a minimum of 1 week to assist in decreased knee stress and joint effusion.

Preventing the Detrimental Effects of Immobilization

The effects of joint immobilization are dramatic and include muscle atrophy, articular cartilage degeneration, ligament strength loss, and excessive adverse collagen formation.¹,⁸ ⁹ ¹⁰ ¹¹ ¹² ¹³ ¹⁴ ¹⁵ ¹⁶ ¹⁷ Experimental studies in cat and rabbit knees show that the earliest changes with immobilization take
place at about 15 days and include subsynovial intracapsular connective tissue proliferation in the infrapatellar and intercondylar regions. By 30 days, fibrofatty tissue enveloping the cruciate ligaments completely filled the notch, extending from the patellar tendon posteriorly to articular surfaces not in contact. The tissue density increased daily and was mature within 1 month. Adhesions forming over articular cartilage were present at 15 days and the cartilage surface was noted to lose definition with progressive loss of the tangential cell layer.¹⁸

Biochemically, the intra-articular and periarticular connective tissue shows a steady decrease in glycosaminoglycans and water. Collagen remains more stable with a half-life of 300 to 500 days and as a result forms random cross links. New, altered collagen is deposited in small amounts in a nonaligned fashion.¹ Immobility inevitably results in localized areas of articular cartilage that are subject to compression during a sustained period. Decreased cellular activity, loss of chondrocytes, and neovascularization results. Loss of chondroitin sulfate rapidly accelerates with time and the immobilized joint begins to resemble a degenerative joint by 4 weeks.¹⁶ Clinically, the patellofemoral joint is at great risk.² Scarring of the anterior interval, the interval between the patellar tendon fat pad and the tibia, is a common reason for stiffness in the anterior cruciate ligament (ACL) reconstruction patient.¹⁹ These adhesions can cause significant alterations in patellofemoral and tibiofemoral kinematics and contact, and reduce the knee extension force.²⁰

Avoiding adhesion formation is accomplished by joint motion and preventing localized compressive forces. Joint motion is accomplished with the use of a continuous passive motion machine, passive range of motion (ROM) exercise, and patellar mobilization. The primary effects of continuous passive motion are increased synovial fluid movement, intermittent compression, and soft tissue tension in the knee. This results in more rapid clearing of hemarthroses, prevention of adhesion formation, and stress-induced connective tissue healing.¹¹ Passive ROM exercise and patellar mobilization exercises are performed three to four times daily. We instruct each patient to perform a total of 10 to 15 minutes of inferior-superior and medial-lateral patella glides as well as medial-lateral patellar tendon glides three times each day for up to 6 weeks following surgery.

Immobilization can also have detrimental effects on joint proprioception. It has been demonstrated that proprioceptive afferents conduct more rapidly than A-delta and C fibers. Thus, the proprioceptive afferents allow immediate reflex control of joint position.²¹ ²² ²³ ²⁴ Lack of tonic input through functional stimulation at the spinal level may act to imbalance the normal spinal tonic efferent output completely.²⁵ Alterations in tonic stimulus by immobilization and nonweightbearing may uncouple “learned” reflexes and require relearning to achieve preinjury levels of activity.²⁶ This first link of the kinetic chain is extremely important in achieving a high degree of coordination, agility, and dynamic joint stability.² Salter et al.¹¹ have shown that early rehabilitation with continuous passive motion may, in fact, alter perception of pain by proprioceptive input using these reflex arcs, and this may ultimately help to keep these arcs functional.

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