Functional Restoration Program

Functional Performance And Rehabilitation

Fpr is a membership site where Function is the basis for Performance and Rehabilitation. Fpr takes the approach to performance and rehabilitation where sound clinical and evidence based rationale is used for corrective exercise to negate movement impairments and dysfunctions. Fpr looks through a functional pair of lenses at other parts of the body and how those body parts contribute to movement dysfunction. All this is brought to the members through articles, videos, and presentations. Fpr has a mission to collect the newest research articles on performance and rehabilitation topics that members perhaps dont have time to read on their own. Fpr will not only read articles but will develop an application to the learned concepts for allied health professions, coaches, and athletes to utilize. The end result is members training and rehabilitation programs become more functional and efficient. The key to designing any functional rehabilitation or performance program is to first assess what the functional deficits are. With this exercise you get the benefits of core stabilization, glute activation, and lower trap stabilization. You achieve core stabilization by having your patient/client maintain a neutral spine positioning through a flexionextension dynamic movement but you also obtain neutral spine from the glute max activation.

Functional Performance And Rehabilitation Summary


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Functional Restoration

Mayer developed the first functional restoration program for chronic back pain in Dallas (Mayer et al 1985,1987, Mayer & Gatchel 1988). The focus was no longer on diagnosis or treatment but on promoting and maximizing functional abilities in the face of on-going pain (Teasell & Harth 1996). The general view is that these programs essentially ignore the complaint of pain, though Mayer argues that is not entirely true. Improved function often leads to less pain. In contrast, subjective expressions of pain usually do not improve unless there is improved function. Despite that argument, any impact on pain is clearly secondary. Functional restoration programs are usually fulltime for 3-4 weeks. The core is an intensive program of incremented physical activity. The goal is physical reconditioning based on sports medicine principles. Subjective reports of symptoms are ignored, and there are no passive treatment modalities. Assessment of progress and the continued program depend on objective...

The results of functional restoration

The first two studies by Mayer et al (1985, 1987) and Hazard et al (1989) gave return to work rates of 85 and 81711. A review by Cutler et al (1994) concluded that functional restoration was effective. Oland & Tveiten (1991) tried to replicate a functional restoration program in Norway but only 327o returned to work by 6 months. As you might expect, this generated a heated debate. It also led to two proper RCTs (Alaranta et al 1994, Mitchell & Carmen 1994). This study had 98 follow-up at 1 year. At 3 months, the functional restoration patients improved their range of movement, muscle strength, and endurance. However, the gains were greater in men than in women and fell off by 12 months. Self-reports of physical performance and disability improved in males and females and were maintained at 12 months. These improvements in physical performance were similar to those reported by Mayer. Both the treatment and control Initial results of functional restoration in the Workers' Compensation...

Mini Open Repair of Acute Ruptures

It is our belief that the best treatment is an operative one, and we were initially attracted to the method described by Kakiuchi14 combining the advantages of the open and percutaneous techniques. To improve this technique, I developed a new instrument and surgical technique based on a cadaver study and led a prospective multicenter study15 of the first 87 patients consecutively treated in this fashion, which included an early functional rehabilitation program. Following the very good results, we made this procedure our operation of choice for acute Achilles tendon ruptures.

Factors influencing ligament healing

However, the mechanical properties of the MCL midsubstance, i.e. the quality of the healed tissue, were significantly different from intact MCLs. These findings are in agreement with clinical reports which have reported positive outcomes with nonoperative treatment followed by early motion and functional rehabilitation 75 . As a result of scientific studies and clinical experience, it is now generally agreed that the preferred method of treatment for isolated grade III injuries of the MCL 63 is nonoperative (conservative). In the past, immobilization following ligament injury was believed to protect the healing ligament from stress 76 . However, it has been shown in the laboratory that immobilization can result in disorganization of collagen fibrils, decreases in the structural properties of the FMTC, resorption of bone at the ligament insertion sites, and many detrimental effects on the knee joint 77 . Conversely, controlled motion has been shown to be beneficial to the...

What psychological factors are important in the management of chronic pain

Several psychological systems are potentially at work in the patient with chronic spinal pain. These include the traditional Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) categories, cognitive-behavioral factors, and character traits. In one functional restoration program, 59 of patients with chronic back pain had active psychopathology, which included major depression in 45 , substance abuse disorder in 19 , and anxiety disorder in 17 . Although there were psychological illnesses present before the spinal pain began, most of the disorders developed after the spinal injury. Cognitive-behavioral factors commonly observed include fear, fear-avoidant behavior, and poor coping abilities.

Rehabilitation Protocol

We instituted an early functional rehabilitation program, carefully supervised by a physical therapist, which is divided into four distinct stages. For the first 2 weeks, patients are allowed partial weight bearing (30 to 45 pounds) and maintained in the splint, full-time. Then gentle ankle range of motion (flexion and extension) is begun, as well as thigh muscle exercises and the use of a stationary bicycle. The goal is to reach a neutral ankle position by the end of the third week. After 3 weeks, full weight bearing is allowed with continuous use of the protective splint. At the end of 8 weeks, the splint is discontinued and weight bearing is allowed without any external support. A more intensive program of ankle range of motion, stretching, isometric, and proprioceptive

Of the Achilles Tendon

Postoperative regimens after Achilles tendon rupture can be broadly categorized as delayed rehabilitation or early functional rehabilitation. Delayed rehabilitation utilizes cast treatment to immobilize the tendon. This common postoperative practice after open Achilles repair includes a 4- to 6-week period in a non-weight bearing, short leg cast that begins in equinus and is gradually brought to neutral. Full weight bearing is typically permitted at 4 to 6 weeks in a short leg cast, after which the cast is removed and physio therapy is begun.1-6

Achillon Surgical Repair

Functional rehabilitation protocol following surgical repair of an acute Achilles tendon rupture Table 9.2. Functional rehabilitation protocol following surgical repair of an acute Achilles tendon rupture A primary concern following percutaneous repair is the strength of the fixation and its effect on postoperative rehabilitation and outcome. Buchgraber and Passler21 performed a retrospective review of 48 patients who had undergone percutaneous repair utilizing a 1.2-mm PDS cord. Postoperatively, patients were treated with casting (18 patients) for 6 weeks or functional rehabilitation (30 patients). Functional rehabilitation consisted of an anterior splint in 10 to 20 degrees of plantarflexion for a mean of 2.7 days, which was then converted to a special shoe (Adimed-Stabil Ortotech, Gauting, Germany) with a 3-cm heel lift. Patients were allowed to weight bear immediately after obtaining the shoe, and isometric muscle exercises began. An isokinetic regimen started at 4...

Insertional Achilles Rupture

A less common condition is that associated with an Achilles sleeve avulsion, or insertional rupture of the Achilles tendon. This type of rupture is almost always associated with chronic inflammation and degeneration at the Achilles insertion.26 This type of rupture does not have sufficient distal soft tissue to facilitate a direct tendon-to-tendon repair. The degeneration and poor quality of the distal stump of the Achilles along with the less secure fixation of the tendon to the calcaneus either with transosseous suture or suture anchors require a modification of the functional rehabilitation protocol in order to prevent reruptures, as in the following case study.

Neuromuscular disorders

The above-mentioned randomized clinical trial did also include 29 participants with hereditary motor and sensory neuropathy, and after the 24 weeks of training three times a week with weights adapted to their force, a moderate increase in strength and leg-related functional performance was found 44 -

Relationships between denaturationinteractions of the whey proteins in heated milk and the functional properties of

When milk is heated, there are numerous changes to the milk system, including changes to the proteins, the milk salts (including mineral equilibria between the colloidal and serum phases) and lactose many of the changes can involve more than one of the milk constituents (International Dairy Federation, 1995). The changes can be irreversible or reversible to various extents depending on the changes being monitored and the conditions of the heat treatment. Although the changes to the protein system are an important determinant of the functional properties of milk products, all other changes to the milk system should also be considered to obtain a full understanding of the relationship between heat treatments, interactions and functional performance. However, there are limited examples of changes to components other than the proteins and the functional behavior of milk products, and therefore this review is restricted to some examples of the relationships between the changes in the milk...

Quality of life issues

As mentioned previously, survival has not improved significantly over the past 20 years and one of the main treatment goals is to improve the quality of life for oral cancer patients. The problem is how to measure quality of life. This is now being resolved with questionnaires to try to assess this aspect of treatment. These questionnaires look at psychological and social aspects of patients' lives as well as functional performance. The two questionnaires usually used are The European Organisation for Recognition and Treatment of Cancer (EORTC) and The University of Washington Quality of Life Questionnaire (UW-QOL). The EORTC contains general questionnaires for all cancers and a head and neck module specifically for cancer in that region, whereas the UW-QOL is a head-and-neck-specific questionnaire. With the use of these questionnaires it is becoming easier to recognise which treatments help or adversely affect quality of life. This area of cancer management is still in its infancy,...

Standardised assessment

Occupational therapists have a vast array of standardised assessments and screening tools available to them which can be used to contribute to the assessment of cognitive functions. Standardised, impairment-based assessments aim to provide valid and reliable assessments of performance skills, that is, specific cognitive components. They should not be used in isolation, but in combination with observational clinical assessment and clinical reasoning to ascertain to what extent the cognitive impairment impacts on occupational performance. It is advisable to be fully familiar with the test manual and validation processes to understand the extent of the remit for each test. Many of these assessments are impairment based and caution is advised when interpreting the results as they may not necessarily be clinically meaningful or relate to a person's functional performance.

Outpatient Rehabilitation

Functional performance improves significantly during inpatient rehabilitation, but patients generally continue to improve for at least another 3 to 6 months, especially in mobility and compensatory techniques for ADLs. Follow-up studies of patients discharged to outpatient care or to no formal therapy vary greatly. For example, trials differ in the time from onset of stroke to discharge, in the residual impairments and disabilities of the patients, in the level of available psychosocial support, and perhaps most important, in the style, intensity, and duration of therapies.

Trials of Schools of Therapy

Mine whether a particular technique improves functional performance. Small randomized trials during inpatient or outpatient therapy revealed no significant differences between conventional therapy and proprioceptive neu-romuscular facilitation (PNF),204 conventional exercise and Bobath's technique,205 conventional exercise versus Bobath and Rood,206 conventional versus PNF versus Bobath,207 electromyographic biofeedback (EMG BFB) versus Bobath technique,208 sensorimotor integration versus functional treatment in occupational therapy,209 and, in an alternating treatment design, Bobath compared to the Brunnstrom method.210 One of Johnstone's neurophysiologic techniques applies an air splint to the extended upper extremity and aims for the subject to push back with the affected proximal arm as a rocking chair leans the subject forward. A half-hour treatment for 30 days was compared to passive rocking in a well-designed trial with 100 subjects who had an acute stroke.211 The Fugl-Meyer...

Padrenergic Receptor Signaling In The Failing Heart

The nature and extent of heart failure associated with the MLP- - mouse and that rescued by the PARKct have been examined in vivo using a pressure-volume analysis and Ca++ i signaling using patch-clamp methods and confocal Ca++ imaging (Esposito et al. 2000). In order to examine the murine myocardial contractile state in vivo, a method was developed to measure the intrinsic myocardial contractility in mice (Fig. 3). Using two pairs of endocardial implanted piezoelectric crystals (Fig. 3) and a high-fidelity micromanometer in the LV, in vivo pressure-volume (PV) relationships were obtained. These PV relationships were obtained in the presence and absence of PAR stimulation and showed that in the MLP- - pARKct animals, end-diastolic and end-systolic cardiac volumes became near normal, and the slope of the end-systolic pressure volume relation (indicating contractile state) was similar to that observed in wild-type animals (Esposito et al. 2000). Furthermore, there was functional...

Examples of the relationships between whey protein denaturation and the functional properties of milk

Yogourt And Denaturation

Some of the most detailed studies on the relationship between the functional performance of milk and the heat treatment conditions or whey protein denaturation levels have been reported for acid gel or yoghurt systems. Parnell-Clunies et al. (1986) showed correlations between the level of whey protein denaturation and the firmness and apparent viscosity of yoghurt, regardless of the method used to heat the milk (batch 85 C , high-temperature short-time 98 C and UHT 140 C heating systems for different holding times). However, other properties, such as water-holding capacity syneresis, were more dependent on the heating system used and it was concluded that high levels of whey protein denaturation in milk were not necessarily associated with an improved water-holding capacity in yoghurt. In extensive studies, Dannenberg and Kessler (1988a, 1988b) examined the relationship between the denaturation level of whey proteins in milk and the functional performance (firmness, flow properties...

Principles of rehabilitation of sports injuries

The optimal restoration of function in a timely manner. By far the most common error which results in a setback or re-injury is when the athlete returns to sports participation too early. In this context it is paramount to teach the athlete to distinguish between that pain perceived as 'good pain' associated with training, i.e. that which is related to muscular exertion, and the pain which may be associated with too great a loading of the affected tissue which is detrimental to the healing process. Following an injury, general cardiovascular fitness, muscular strength, balance and coordination are affected, and the rehabilitation program should address all of these areas besides the actual injury. Finally, the rehabilitation process following an athletic injury should progress into a training program aimed at maintaining function and preventing re-injury. Prevention of injury is at times particularly important since some injuries, like muscle-tendon strains, are associated with a high...

Procedures For Pain Relief

Monitoring of chronic pain requires pain relief but also the patient's well-being, functional restoration, work-status restoration, and global outcome. These considerations may be very complex, because each case may be managed with multimodal analgesia techniques1 3 ( Table 12-5 ).

Surgical Treatment Options

If symptomatic instability persists despite an adequate functional rehabilitation program and bracing, lateral ligament reconstruction is indicated. More than 80 surgical procedures have been described to reconstruct the lateral ankle ligaments. These procedures can be grouped into either anatomic repair or non-anatomic repair. Anatomic repair is preferred as it preserves the natural biomechanics of the ankle. Nonanatomic biotenode-sis techniques are used in select cases obesity, poor soft tissue (revision procedures or connective tissue disorder generalized

Medial Gastrocnemius Strain Tennis

Loading failure at the musculotendinous junction. This muscle spans both the knee and the ankle. It is so named tennis leg because it is commonly encountered in a middle-aged individual during the push-off phase while playing tennis.28 Swelling and sometimes ecchymosis are seen. Seldom is a major defect palpated, but often there may be acute or chronic slight muscle mass loss in that area. Concomitant acute compartment syndrome has been reported.29 As with other muscular strains, the phases of injury, inflammatory healing, and remodeling occur as a rehabilitation course is undertaken. Resolution of symptoms and no significant loss in functional performance are the typical course.

What about the patient whose pain becomes chronic and disabling

Other factors contributing to the pain must be identified. There has been a large movement toward treating benign or nonmalignant pain problems with opioid medications and various injections, disc dissolution techniques, device insertion (spinal stimulators, intrathecal drug delivery systems), and surgery. However, these are unlikely to treat the entire problem. In addition, these treatments are invasive, associated with high complication rates, and unlikely to resolve disabling pain or restore functional ability. When the etiology of the pain is not clearly defined and there are multiple inorganic signs, treatment is directed at the functional loss and disability. This type of patient is best served by an interdisciplinary team (not multidisciplinary) approach, such as a functional restoration program. This approach uses cognitive-behavioral methods together with physical methods and is guided by a biopsychosocial approach to the patient's pain and disability. Acceptance of pain and...

Role of functional imaging in stroke patients

For the analysis of the relationship between disturbed function and altered brain activity studies can be designed in several ways measurement at rest, comparing location and extent to deficit and outcome (eventually with follow-up) measurement during activation tasks, comparing changes in activation patterns to functional performance and measurement at rest and during activation tasks early and later in the course of disease (e.g. after stroke) to demonstrate recruiting and compensatory mechanisms in the functional network responsible for complete or partial recovery of disturbed functions. Only a few studies have been performed applying this last and most complete design together with extensive testing for the evaluation of the quality of performance finally achieved.

Rehabilitation and Quality of Life

In spite of improved reconstructive techniques, the cosmetic and functional rehabilitation of most major postsurgical facial deformities is far from optimal. It is easy to underestimate the value of a skillfully fabricated facial prosthesis in this era of sophisticated free microvascular transfer, however the services of an expert maxillofacial prosthetist can be invaluable. The psychologic, physical and social impact of major cosmetic disfigurement and functional disability, especially in young individuals, can be devastating and the treatment team must be able to provide comprehensive support to these patients. Advances in speech and swallowing therapy, physical therapy and nursing have been vital in improving outcome after major head and neck surgery and it is crucial for the treating surgeon to involve these experts in the management of the patient as early as possible preferably before the resection.

Maxillary Defects and Obturators

Fabricating a functional obturator follows use of conventional principles of removable prosthetics retention, stability and support. The remaining teeth, therefore, are valuable for optimal functional rehabilitation. The head and neck surgeon can improve the prosthetic prognosis by considering the following principles or modifications at the time of ablative surgery 23


Other authors have had less favorable results after the percutaneous repair, with major complications involving sural nerve entrapment. Klein et al.32 reported on 38 patients with a 38 incidence of nerve entrapment, including the necessity for a second operative procedure to remove the offending suture and free the nerve. Nerve entrapment has also been reported by Rowley and Scotland,31 Steele et al.,33 and Aracil et al.34 FitzGibbons et al. 35 reported on two sural nerve injuries, one complete, among 14 patients. Buchgraber and Passler36 reported on 59 patients treated with a percutaneous technique. The patients were divided into two groups, one undergoing functional rehabilitation and the other cast immobilization. The authors noted sensory impairment in the territory of the sural nerve in almost one quarter of their 59 patients treated with a percutaneous technique. Although a major reason behind the percutaneous technique is its lower incidence of wound problems, the same authors...

Open Surgical Repair

Mandelbaum et al.24 studied 29 patients who underwent open Achilles repair after acute rupture followed by early functional rehabilitation. Postoperatively at 48 to 72 hours, the patients' intraoperative dressings were converted to removable posterior splints that allowed the institution of early range-of-motion exercises. Patients were encouraged to perform 10 to 20 degrees of dorsi-flexion and plantarflexion four to five times a day. At 2 weeks, patients were placed into a hinged walking brace that allowed full plantarflexion while blocking dorsiflexion at 10 degrees of equinus. Partial weight bearing was initiated at 2 weeks, with progression to full weight bearing at 4 weeks with the boot in neutral or with a cowboy boot. All patients returned to full sports activity by 12 months. Cybex dynamometer testing showed a mean functional deficit of only 2.9 in strength and 2.3 in power compared to the uninjured

Case Study

A 21-year-old collegiate football player felt an acute pop in his right lower extremity during practice. Physical examination was consistent with an acute midsubstance Achilles tendon rupture. To decrease the risk of wound complications in a high-level athlete and to decrease the risk of reruptures, operative intervention was performed with the Achillon system. A 1-cm transverse incision at the level of the rupture was utilized along with No. 1 nonabsorb-able polyfilament for fixation. Postoperatively, the patient was placed in a splint in 20 degrees of plantarflexion in order to maximize skin perfusion over the Achilles.31 The patient underwent functional rehabilitation as outlined for patients who have undergone open repair however, the splint was discontinued at 1 week, and earlier range-of-motion therapy begun, because of a minimal


Functional rehabilitation offers the advantages associated with early range of motion following tendon repair, with increased strength of the healed tendon, minimal skin necrosis, and lack of arthrofibrosis.8' 19 24,29 There has not been an associated increase in rerupture with early range-of-motion protocols compared to immobilized patients.8' 192429 Following functional rehabilitation, patients have been able to perform nearly symmetric strength and power testing, in contrast to a 10 to 20 deficit with cast immoblization.4' 8' 17-1924 The overall superiority with respect to outcome without a significant rerupture rate supports the use of functional rehabilitation over cast immobilization after open repair.

Ligamentous Injuries

Treatment is based on the severity of the injury. Nonsurgi-cal treatment with protected weight bearing and protected ROM early for a few weeks is recommended for isolated grade 1 or 2 LCL grade 1 is an opening of the lateral joint line less than 5 mm, and grade 2 is an opening of 6 to 10 mm. Progressive ROM and functional rehabilitation are initiated. Return to sports can be expected in 6 to 8 weeks. Surgical indications are recommended for isolated grade 3 LCL injuries ( 10 mm gapping) and any rotator instability of the posterolateral corner. Acute surgery has more favorable outcomes, and early referral to an orthopedic surgeon is recommended. injury is based on the posterior drawer test and the relationship of the proximal tibia to the femoral condyles. In grade I PCL injuries, the tibial plateau is slightly anterior to the femoral condyles in grade II, plateau and condyles sit flush at the same level and in grade III the tibia is posterior to the level. Treatment of a PCL injury is...

Contusion Injury

I, limitation of hemorrhage phase II, restoration of pain-free motion and phase III, functional rehabilitation of strength and endurance. Severe contusions require bed rest with hip and knee flexion to tolerance. In military cadets, this is accomplished with admission to the hospital outside the military, this may be achieved with bed rest at home with excuse from classes or work. Mild and moderate contusions are managed similarly however, the strict call for bed rest is not indicated. This initial period of treatment progresses to the second phase when thigh girth is stable and the patient is pain free at rest. Phase I typically is 24 to 48 hours in length. Phase II initiates motion and for severe contusions begins with continuous passive motion until painless passive range of motion is achieved from 0 to 90 degrees, and then continues phase II exercises for the outpatient condition using supine and prone active flexion and well-leg gravity-assisted motion with a stationary bike. All...

Low back pain

Often those who seek advice have tried to continue for weeks despite significant pain, and therefore present with a chronic problem. At this stage, an understanding of differential diagnosis, careful history and physical examination is obligatory to pinpoint the problem. Based on this evaluation, simple advice or a functional rehabilitation program will help most athletes to return to their sport. Imaging procedures are only supplementary and cannot replace the clinical examination. Sensitive procedures like MRI may describe abnormalities that are not specific because of their high prevalence in the asymptomatic population. In adults radiologic spondylolysis spondylolisthesis correlates poorly with low back pain. In young athletes, an isthmic stress fracture may explain acute low back pain. Low back pain and walking difficulties in the elderly that are relieved by forward bending suggest spinal stenosis alternatively, coxarthrosis or cardiovascular disease may give similar symptoms...


To direct suture repair when compared with a nonoperative approach that involved a structured rehabilitation program. In a subsequent article, the senior author and colleagues19 showed that this conservative approach was successful, even for the highly competitive athlete who returned to contact sports. In 1993, Reider et al20 reported excellent results in 35 athletes who had undergone conservative management of MCL tears with functional rehabilitation and been monitored for more than 5 years.


Cates that it may be possible to reduce the incidence rate of ACL injuries in soccer 83 , but the results of this single study has to be verified further. The prevention of ACL injuries in female players is particularly important, since females have a higher incidence of this injury, get injured earlier in life and, in addition, have a greater risk of knee OA even when injuries are excluded. The increased popularity of female soccer, not least at high-school level, shows a clear path towards a problematic situation some years ahead. Knee injuries occurring at 18 years of age, with radiographic OA in the early thirties and onset of symptoms perhaps a few years later or even before, may result in patients requiring OA surgery in their early forties. A study of injury risk factors in female soccer revealed that neither physical capacity, functional performance, nor muscle strength correlated to injuries 84 . In that study increased joint laxity was the only significant risk factor.