As one on the frontlines for 20 years the concept of “flags” was useful to provide a strategy for integrating multiple elements into patient management strategies. Unfortunately , much like pain management programs recognition has driven a hands off strategy of patient management on the basis that “manual therapy” is either ineffective or creates dependance in this patient group.

The converse view is that manual therapy and functionally specific rehabilitation can be used directly as a cognitive-behavioural strategy to address specific patient complaints / functional impairments. As physiotherapists we need to recognise that any interactions we have with patients have cognitive / emotive connotations and there is no practical reason why physical means cannot be used to facilitate this approach as an adjunct or an alternative to psychotherapy techniques

Those who attended the “Decade of the Flags” conference in Keel university at the end of 2007 will know that primary care clinicians can now no longer hide behind professional boundaries as an excuse not to challenge patients distorted beliefs or facilitate rehabilitation programs which are tailored to their needs.

This obviously poses clinical challenges but the facts won’t go away by passing the buck.

What do you find the most challenging aspects of of this situation?

Key points to consider planning a rehabilitation program

1. How do we determine the relative amount of resistance for an individual?.

2. How many repetitions should be done?.

3. How much rest period is necessary?.

4. How do we determine the factors limiting exercise performance clinically?.

5.How do we determine which components of rehabilitation are appropriate targets?.

6. Where is the transition between rehabilitation and conditioning?.

7. What is the difference between physiotherapy prescribed exercise and sport rehabilation / fitness instructor?.

8. How do the principals of strength and conditioning apply to rehabilitation?.

9. What do we need to know about the structures we are rehabilitating?.

10. How do we improve exercise compliance?

Selecting variables to modify in a rehabilitation program can prove challenging. Most therapists are familiar with the obvious variables of LOAD & REPETITION but there are numerous other factors that can be manipulated.

Speed

Range of Motion

Base of Support

Plane of Motion

Combining different elements of these components allows progression or regression as required. It is essential that therapists are competent in applying these principals in a clinical setting

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Click exercise variables to hear the lecture.

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Many of you will be familiar with the concept of functional training in rehabilitation, so a brief review of historical aspects will suffice here.

Functional training from a rehabilitation perspective has been used for many decades with the obvious goal of returning an individual to their pre-injury functional status. The astute reader will note that this implies a degree of individuality and specificity in rehabilitation strategies depending on the individual’s response to the injury in question and the planned functional goals to be achieved. In this discussion we are concerned with a return to playing sport, which has different functional requirements depending on the sport of choice. Most rehabilitation specialists would agree that the fundamental measure of success is the ability to “perform at maximal function”. The issues of debate usually centre around:

1. Whether to use functional exercise as an initial priority.

2. Whether to place prerequisite criteria for progressing to functional exercise e.g. base line flexibility measures, stability measures, agility, coordination and power.

3. The use of over load / external resistance to achieve progressive increases in power output.

4. Key variables to manipulate in exercise progression e.g. load, speed, plane of motion, movement sequence.

Perhaps the biggest source of discussion in this regard is the use of fixed weights / machine systems relative to free weights. In the non-elite athlete there are some attractive aspects to using fixed weights as the machines themselves provide some degree of stability, are relatively safe, allow max or near max loads to be utilised and can be undertaken individually. Unfortunately the artificial stability provided by machine systems dictates that a critical aspect of functional strength is not trained and therefore of debatable relevance in functional loading. On the other hand free weights use allow mass activation of stability and mobility muscle groups, more closely approximates functional movement patterns and requires higher levels of skill and coordination particularly if technical or explosive lifts are being attempted. Most serious athletes will incorporate some degree of free weights into their training.

The gap between these two approaches can be neatly filled by incorporating batteries of functional tests which explore movement control and coordination in varying combinations of body position, primarily with body weight as the external load, but progressing with small proportional increases in resistance as control allows. It can be reasonably argued that inability to control one’s body weight through a full functional repertoire of positions which are likely to be encountered in the course of the game situation may predispose to injury. One of the current difficulties related to repeated tests / re-tests of functional measures are the measurement systems used. These tend to be somewhat “low tech”, can sometimes rely on the individuals perception of effort to perform a desired task or require an external examiner’s observation of the quality and sequencing of movement. Needless to say there maybe many hours of debate regarding differences of opinion on these issues!!!

Nonetheless a useful concept in this regard (popularised by American Physiotherapist Gary Gray), utilises the concept of threshold training in which the extreme position which an individual can control is measured relative to that of the other side. Any further change in position produces falling or loss of balance or some compensatory adaptive mechanism – indicating failure.

Components of a total body functional profile.

1. Safety.
2. Measurability.
3. Reliability and validity.
4. Simplicity.
5. Meaningful.
6. A full spectrum functional testing.

These concepts should be borne in mind when deciding what battery of functional tests to include for an individual or as part of a team training / screening protocol. The other critical point to recognise is that loading is occurring in three planes of motion simultaneously – tri-plane motion. In clinical practice it is often by combining three planes of motion simultaneously that one can expose weaknesses, which do not appear evident when testing an isolated plane. If one analyses the movement patterns involved in most sports we can see that they can be broken into groups of core functional activities e.g. jogging, running, decelerating, excelerating, twisting, pivoting, jumping and pushing.

Each of these complex movement patterns can be broken down into components and each can be stressed using varying combinations of challenges e.g.

1. Range of motion.
2. Sequence of motion.
3. Eyes opened / closed.
4. Corporating simultaneous trunk and limb movement.
5. External resistance e.g. elastic tubing, bungee cords or dumbbells.

All allow varying degrees of difficulty to be explored in order to be determine the functional threshold of control.

Gray groups his functional tests under the following categorisations.

1. Balance tests.
2. Balance reach tests.
3. Excursion tests.
4. Lunge tests.
5. Step up tests.
6. Step down tests.
7. Jump tests.
8. Hop tests.

Functional self-test menu

Below are listed a group of self-test movements which can be administered and the degree of difficulty noted. Please note that there can be many different reasons for an inability to perform complex patterns which could include flexibility, stability, power, endurance or coordination deficits.

1. In- line lunge with body rotation.

Stand in a long stride position with front and rear legs in one line and feet pointing forwards in the same direction. Heels must stay on the ground. Bend front knee and hold leg position still. Add alternating twists of the upper torso to left and right side.

1. Single leg stance with toe touch.

Standing on one leg bend forwards to touch toes with the hand on the same side as your standing leg. Return to upright and reach arm overhead. Focus on maximising hip and knee bend in order to increase the leg stress. Ensure that standing leg does not roll inwards.

1. Kneeling lunge with trunk side bend.

In a kneeling lunge position, with both legs in line, side bend the upper torso from left to right. If toes grip floor strongly, tap floor to prevent fixing.

1. Single leg stance forward / downward leans.

Stand facing a wall, goal post or barrier about 3ft away initially and stand on one leg. Reach forward with the index finger to touch the ground as far out in front to reach the ground if possible. Return to upright and reach with opposite hand.

1. Single leg stance reverse pivot.

Stand on one leg with back to wall or post or barrier. Reach overhead with left and right hands alternately to try and touch behind without falling over. If it is too easy move a further distance from the barrier.

1. Incline lunge with trunk rotation

Lunge at 45° from straight ahead position, holding dumbbell in opposite arm (6 to 10kgs) reach down and across to the outside of the forward foot. Return to upright. Alternate sides.

PS to initially feel the coordination for this drill try work without weights.

There are infinite numbers of variations of these types of drills which can be exciting, fun, challenging and very revealing. We will come back to some of these concepts in the future.

No doubt many of you are aware of the competition amongst health professionals for the the mantle of key exercise prescribers.

Many therapists feel that their undergraduate training is insufficient.

Some feel that the boundaries of practise are at best “blurred” which creates confusion with the public regarding choice of therapist.

This has led to an explosion of interest in “functional training” - which is fast becomming a by-word for strength and conditioning. Understandably, physiotherapists core training does not provide these skills. This can make physiotherapists feel “inadequate” but we need to consider the type of caseload we see and whether strength & conditioning principals are the nesessary tools or whether other parameters are more relevant.

What do you think? Post your comments

David

Given the multifactorial nature of shoulder impingement pain how can we determine the dominant mechanism to plan intervention?
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1 Mobility defecit?

2 Postural mal-alignment?

3 Scapular control defecit?

4. Rotator cuff control defecit

5 Structural pathology

6. Anatomical anomaly

Post your thoughts and questions.
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Some folks have asked for a list of references.
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click here to download
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As promised here is the link to the accompanying slide presentation from last week’s audio download

 http://www.physioseminars.com/public/presentations/shoulder-impingement-slides/player.html

Instructions for use:

1 Double click on link

2 Slides will play automatically

3. Pause, forward, rewind from the control panel at the bottom of the player screen.

4, Can skip to slides from the left hand side slide menu.

5 Suggestion - if you downloaded the audio previously you can use your MP3 player whilst viewing the slideshow.

Hope you enjoy

David

Welcome to all of you who were at the sports rehabilitation seminar in UCD, Dublin on Saturday 29 th March. As I mentioned after my presentation I have now made the Audio of this lecture available as a free MP3 download for attendees. Many thanks to Garrett Coughlan and his team at Sports Managment Ireland for organising the event and inviting me to speak. I hope you got some useful clinical information - the ultimate objective of the day!! I will post the slides I used on the day shortly but in the meantime you can listen/download the audio to playback on your PC or iPod as you prefer. (click here to download) This is a big file and will take time depending on your internet connection speed.

Key Points

Mechanisms of Impingement

Clinical Algorithm’s

Testing

Differential Diagnosis

Treatment Selection

(click here to download) This is a big file and will take time depending on your internet connection speed.

Alternatively, to play the audio now click on the play arrow below.

Are you happy with the differential diagnosis around the groin?

Clinically the extent of overlap between pathologies reduces diagnostic certainty.

Frequently, by a process of elimination, surgical pathologies are excluded and the rest are left to time, steroid infiltration and a miriad of pallative measures.

What do you think are the most effective rehabilitation tools to employ with chronic groin dysfunction?