Insights into Rehabilitation in Sport

Original Editor - Wanda van Niekerk based on the course by Ian Gatt

Top Contributors - Wanda van Niekerk, Jess Bell, Kim Jackson and Temitope Olowoyeye  

What is Rehabilitation in Sports?

The World Health Organization defines rehabilitation as: “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” In sports, rehabilitation is often seen as the restoration of the optimal form (anatomy) and function (physiology).

Sports Rehabilitation Aims

Sports injury rehabilitation is a dynamic process with the following aims:

• Restoration of athlete’s functional and performance level
• Return to sport participation in a safe, efficient, and timely manner
• Reduce the risk of re-injury

Considerations in Sports Rehabilitation

Two things to consider in sports rehabilitation are athlete availability and function vs form.

• Athlete availability = Rehabilitation enables individuals to maintain or return to their desired level of activities
• Function vs Form = Rehabilitation enables restoration of optimal function with or without form

Athlete Availability

Zachrisson et al. investigated athlete availability and the incidence of overuse injuries over an athletics season in elite Swedish athletes. They reported the following:

• Monthly injury incidence rates during a season correspond to high training volume periods such as condition phases and training camps
• The low athlete availability (under or just over 80%) reported in this study, both in event groups as well as at an individual level, shows that many athletes in this Swedish cohort may not reach their full athletic potential

Function vs Form

Form = Structure (i.e., an anatomical structure such as muscle, tendon, ligament, joint capsule)

Function = The product of a structure that plays a specific role or the ability of the athlete

There is a close relationship between form (structure) and function. However, if we consider that humans are complex, we can appreciate why the function is not always directly linked to structure. For example, athletes may be participating at a high level, but if they undergo imaging there may be indications of existing pathologies. The imaging may show that the form (structure) is compromised, but the function is not. An example of this is:

• MRI findings were similar in symptomatic and asymptomatic shoulders of young elite swimmers. Asymptomatic shoulders may have many and various abnormalities on MRI that may be radiologically significant, but they are not clinically significant.

Read more about Form vs Function here: Structure vs Function

Planning a Rehabilitation Program

When planning a rehabilitation program, it is important to consider:

• Tissue healing
• Requirements of the sport
• Goals of the athlete
• Psychological aspects and athlete behavior
• Contextual factors such as Competitions and the environment in which athletes find themselves

• Micro planning – short- to mid-term planning
• Macro planning- mid- to long-term planning
• What needs to be achieved with the rehabilitation plan?
  • Healing of a specific structure?
  • Pain reduction?
  • Improve function?
  • Or a mixture of elements?
• Consider muscle properties:
  • Strength vs endurance
  • Is there a link between muscle properties and pain?
  • Will strengthening around the specific area improve pain or is there no relationship between the muscle properties and pain (i.e. pain is still present even after strengthening)?

• Consider the length of session as well as the frequency of sessions needed for an effective rehabilitation plan
• Consider the content of the rehabilitation plan – what are the goals and is there an opportunity?

The rehabilitation plan must consider the fact that the objective of the patient (the athlete) is to return to the same activity and environment in which the injury occurred. Functional capacity after rehabilitation should be the same, if not better, than before the injury. The goal of the rehabilitation process is to limit the extent of the injury, reduce or reverse the impairment and functional loss, and prevent, correct or eliminate the disability.

Rehabilitation is an Opportunity

The goals of sports rehabilitation are to guide the injured tissue healing process, restore function, and help the athlete return to a level of optimal function effectively, safely, and in the quickest amount of time, and to reduce the risk of reinjury. There are various rehabilitation scenarios.

In the case of a first-time injury, rehabilitation will aim to prevent re-injury. With recurring injuries, the aim is to prevent re-injury but also to determine the causative factors and address these. Sometimes athletes complain of niggles and the goal of rehabilitation may be to prevent this niggle from becoming an injury (in other words, the athlete has a medical complaint, but we do not want this complaint to become an injury that can impact training and competition availability).

Rehabilitation provides an ideal opportunity to assess the individual athlete holistically and understand why they are incurring specific injuries.

Rehabilitation Techniques

Rehabilitation Does Not Preclude Hands-On Therapies

Rehabilitation in sports is not always only reliant on exercise therapy. Whichever elements the physiotherapist chooses to apply, these should be evidence-based and applied in the correct context. Some of these approaches can include soft tissue therapy, acupuncture, and electrotherapy, such as shockwave therapy. Health professionals should aim to ensure a good outcome following rehabilitation, but also to empower the athlete and ensure they do not become too dependent on any strategies that the physiotherapist provides. Literature also indicates that the athlete’s and clinician’s skills/expectations about a treatment's mechanism and effect are significant determinants of outcome.

A review of hands-on conservative treatments for pain in recreational and elite athletes investigated current practices and solutions in a sports setting. A summary of the findings of this review can be seen here: Hands-on treatments on pain in athletes

The International Olympic Committee released a consensus statement on pain management in elite athletes. In this statement, the available evidence of several non-pharmacological pain management strategies used by physiotherapists is discussed. These include:

• Modalities and massage
• Movement, strength, and conditioning
• Psychosocial interventions
• Sleep and nutrition
• Surgery

Read the full consensus statement here: International Olympic Committee consensus statement on pain management in elite athletes.

Exercise Prescription

Strength training and conditioning are effective rehabilitation tools after an injury. Muscle strength, endurance, and power are necessary force-producing capabilities to return to sport. Often rehabilitation protocols use suggested timelines for progression to a higher-level exercise, but the rehabilitation health professional needs to ensure that exercise progression is based on functional and objective markers as well.

Athletes need a combination of muscle endurance, strength, and power to perform activities unique to their sport. Thus, when rehabilitating an injury, they should also train with varied speeds and durations of force production throughout the rehabilitation process. The FITT (Frequency, Intensity, Type, and Time) principles of exercise prescription can be applied and varied to suit the appropriate stage of recovery and rehabilitation.

Read more about FITT here: Basic Exercise Principles

See also:

• Principles of Exercise
• Introduction to Therapeutic Exercise

Exercise Prescription – Equipment

When prescribing rehabilitation exercises, the availability of necessary equipment needs to be considered. Many professional athletes are in a centralized location and have access to all necessary equipment, space, and a multidisciplinary team environment. However, other athletes may not have access to all these services while training abroad or traveling for competitions. The availability of equipment, training space, and multidisciplinary support should always be considered when prescribing rehabilitation exercises.

Read more about training during the pandemic to gain insight into the prescription of exercises and equipment here: Training During the COVID-19 Lockdown: Knowledge, Beliefs, and Practices of 12,526 Athletes from 142 Countries and Six Continents

Exercise Prescription – Dosage

• Muscle properties
  • It is important to know what needs to be achieved about muscle properties - e.g., is the goal strength or endurance?
  • Strength
    • Important to determine what percentage of repetition maximum (1 RM) should be achieved.
  • Resistance training is an effective tool to improve muscular adaptations such as endurance, strength and size.
  • The repetition continuum or strength-endurance continuum is usually used to prescribe specific loading recommendations.
    • Muscle strength - low repetitions with heavy loads: 1 - 5 repetitions per set with 80% - 100% of 1 -repetition max (1RM)
    • Muscle hypertrophy – moderate repetitions with moderate loads: 8 - 12 repetitions per set with 60% - 80% of 1RM
    • Muscle endurance – high repetitions with light loads: 15 + repetitions per set with loads below 60% of 1RM
    • Read more: Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum

Exercise Prescription - Pain

Exercise-induced hypoalgesia may be a positive effect of exercise programs. However, it is a complex phenomenon and there are still many unexplained factors (i.e. underlying mechanisms, contextual factors, etc). The evidence for exercise-induced hypoalgesia is currently ambiguous and the methodology and quality of studies need to be improved before reliable and valid recommendations for clinical practice can be made.

Bonello et al. reported inconclusive evidence of exercise-induced hypoalgesia with isometric exercises in people with local musculoskeletal pain. The authors stated that further research is necessary to understand exercise-induced hypoalgesia in different musculoskeletal populations.

Read more: Exercise and Activity in Pain Management

Rehabilitation - Kinetic Chain

Importance of whole kinetic chain rehabilitation

Incorporating the whole kinetic chain into rehabilitation strategies is essential for a good outcome. The term kinetic chain refers to “the sequential task-specific activation of body segments during functional movement patterns.”

An effective kinetic chain will allow appropriate mechanical energy transfer throughout the complete chain and aid in function. Weak links or inefficiency within the whole kinetic chain will influence force transfer to other segments and may cause other segments of the chain to compensate for this energy loss. This has been hypothesized to be a predisposing factor that can increase the risk of injury.

Consider the type of sport the athlete participates in (water-based vs land-based, extreme sports) and the ability of the athlete (for example a wheelchair-based Paralympic athlete) when incorporating the whole kinetic chain into the rehabilitation plan.

• Examples of whole kinetic chain involvement
  • Tennis – leg and trunk generate 50% - 55% of total kinetic energy necessary for the serve
  • Baseball – important requirements for an efficient baseball pitch are shoulder external rotation range of movement and control as well as lumbopelvic hip stability and gluteal muscle activation
  • Throwing athletes with reduced hip abduction strength and hip range of motion may have an increased risk of shoulder and elbow injuries

Multidisciplinary Team

Athletes of all levels aim for performance and to improve performance. Many variables influence this quest for performance such as:

• Recovery
• Rest
• Training
• Emotional control
• Nutritional control
• Injury management

These factors need specific knowledge and expertise from professionals trained in these areas such as:

• Physiotherapists
• Sports physicians
• Psychologists
• Strength and conditioning coaches
• Biokinetics
• Sports scientists
• Dietitians
• Coaches
• Performance analysts

Using boxing as an example: The Great Britain Boxing organization co-ordinates and integrates the various members of the multidisciplinary team through Individual Athlete Planning (IAP), where the complete rehabilitation of an athlete is planned, and all members involved are aware of the plan. Often, the role of the physiotherapist in this process is to provide guidelines about what coordinates and strives to bring the multidisciplinary team together.

Read more:

• The multidisciplinary team in sports: a narrative review
• ‘How’ a multidisciplinary team worked effectively to reduce injury in a professional sports environment
• Taking the lead towards healthy performance: the requirement of leadership to elevate the health and performance teams in elite sports

Improving Athlete Expectations

Carroll et al. explored what recovery meant to participants after a musculoskeletal injury and if they expected to recover. In this qualitative study, the following points were highlighted:

• Recovery can be summarized as:
• Complete symptom cessation, with the pain-free function”
• Return to function despite residual pain”
• Expectations were driven by:

• A desire for a clear diagnosis
• Belief (or disbelief) in the clinician’s prognosis
• Previous experiences
• Experiences and attitudes of other people
• Other information sources such as the internet
• A sense of self as resilient

Expectations seem to be set in relation to hopes and fears. It is, therefore, recommended that clinicians consider both when negotiating realistic goals for the client and providing education to the client about their injury and rehabilitation. This approach is recommended for people with non-specific musculoskeletal pain, where there is no clear diagnosis and treatment may not completely improve pain.

Read the complete article: How well do you expect to recover, and what does recovery mean, anyway? Qualitative study of expectations after a musculoskeletal injury.

Adherence to Rehabilitation

Following a sports injury, athletes’ compliance with a rehabilitation program is a significant consideration. This adherence or compliance has an influence on the rehabilitation process. Motivational factors that contribute to an athlete’s adherence to the rehabilitation process include:

• Social support
• Having goals during rehabilitation
• Internal and external pressures

In the study by Hildingsson et al., the following were also important for athletes:

• The desire to achieve personal goals
• Passion for their sport
• Strong athletic identity
• Importance of relatedness with the team
• Maintaining their physique

Athletes want to make autonomous decisions and be in control of their own lives. Athlete-centered approaches and rehabilitation need to be relevant and physiotherapists are uniquely placed to empower athletes and help them achieve their goals.

Read the complete article:Perceived motivational factors for female football players during rehabilitation after sports injury–a qualitative interview study.

Strategies to Enhance Adherence

Gledhill et al. provides clinicians with four strategies to enhance patient’s adherence to rehabilitation. These strategies are:

• Form strong relationships and provide high quality social support
  • Provide the athlete with clear, honest and understandable information
• Encourage patients to maintain the social side of sport
  • Clinicians can do this by scheduling rehabilitation sessions within the team environment (i.e. pitch side while team is training on the field)
• Support the patient’s autonomy
  • Encourage the athlete to be autonomous
• Use goal setting techniques with athletes
  • Goal setting will facilitate improved adherence as the athlete will become more self-efficient and more focused.

Read the editorial here: ‘I’m asking you to believe—not in my ability to create change, but in yours’: four strategies to enhance patients’ rehabilitation adherence

Adherence to Rehabilitation in Sports

Christakou and Lavallee listed three theoretical approaches on which adherence to sport injury rehabilitation is based. These are:

• Protection motivation theory
  • Two cognitive approaches, the threat appraisal process and the coping appraisal process, are involved in decision-making to adopt protective health behaviors.

• Personal investment theory
  • Personal incentives, sense of self-belief and perceived options will determine motivation in specific situations.

• Cognitive appraisal model
  • This model considers that post-injury behavior is influenced by emotional responses to injury. These emotional responses are believed to occur because of the interaction between personal and situational factors.

Enhancing Adherence to Rehabilitation

For successful rehabilitation, there needs to be a partnership and collaborative effort between the rehabilitation professional and the athlete. Athletes sometimes have trouble adhering to a rehabilitation plan because of cognitive issues (understanding the nature of the injury, the treatment goals and prognosis), emotional issues (issues such as anxiety, anger, etc) and behavioural issues (athletes feel that they need to do something about their injury). Sports rehabilitation professionals are under pressure to not only apply their rehabilitation skills to such situations, but to also address issues such as athlete anxiety and the potential outcome of rehabilitation. Christakou and Lavallee suggest some practical strategies that may enhance adherence to rehabilitation:

• Education
  • A crucial step in the rehabilitation process is to ensure that athletes have good knowledge and are educated about their injury. This will have a positive impact on their adherence and personal goals, and will enhance their belief in the efficacy of the rehabilitation approach.
• Communication (Listening – Active)
  • Roberts et al. measured verbal communication in initial physical therapy encounters and reported that in their study sample, physiotherapists spoke for 49.8% of the session and patients for 33.1%. Physiotherapists provide lots of information to patients; 12.5% of this information is advice or suggestions during the initial encounter.
  • In a follow-up study measuring the prevalence and nature of verbal interruptions during back pain consultations, Roberts and Burrows highlighted that “clinicians were 7 times more likely to interrupt than patients.” The main reason for interruption by clinicians was to “seek” or “give” additional information.
  • Learn more:
    • Communication skills
    • Skills to Enhance Communication
    • Listening

• Thought Stoppage
  • "Athletes who have negative cognitive appraisals of an injury tend to have negative thoughts that can lead to emotional disturbance, and subsequently possible non-compliance to rehabilitation program.”
  • Physiotherapists can encourage athletes to recognize negative thoughts about their injuries and highlight that this is a normal reaction. The aim is to turn these negative thoughts into positive feelings using pragmatic statements. Some examples of these statements are:
    • I am going to complete the recovery process
    • I am improving, I am going to return to sport
    • I want to return to play again this season
    • This injury is just a minor threat to my career in sport
    • I am going to start winning medals again
    • I am going to have full strength

• Enhancing Athlete’s Beliefs
  • Beliefs about the meaning of the rehabilitation process can determine adherence towards rehabilitation. It is important to explain to athletes the meaning or link between what they are doing and what it will achieve. This also improves overall coping strategies.
  • Share information that is linked to progression such as: "Your range of motion is improving."

• Using Short-Term Goals (Objective Measures)
  • Goal setting provides a motivational strategy to influence the amount of effort put in towards achieving a goal. It increases the focus of attention and enhances perseverance.
  • Attainable and quantifiable measures are needed to support this process. (e.g. range of motion, strength, balance)

• Enhancing Pain Tolerance
  • It is important to remember that pain is an emotional and sensory experience, which is very subjective.
  • Athletes may stop adhering to their rehabilitation if they believe that any pain felt at the time or after a session will be harmful to their recovery or simply because they cannot tolerate the pain.
  • Coping strategies can be enhanced through proper pain education by clinicians.

• Social Support
  • Social support from coaches, friends, and parents can enhance an athlete’s adherence to a rehabilitation program.
  • Having discussions with teammates about their previous injuries and return to success provides an opportunity for increased rehabilitation adherence and sporting success.

General Guidelines

• Purpose of rehabilitation
  • What will the outcome be?
  • Definition of success

• Adherence to rehabilitation
• Planning and structure
  • Properly explained to all parties involved
  • What types of intervention

• Collaboration between multi-disciplinary team

• Consider the kinetic chain with rehabilitation, but also the person and ensure proper support
• Judicious use of evidence-based adjunctive therapies where needed
• Focus on empowerment of the athlete, educate the athlete and be clear and honest when providing information

Resources

• Rehabilitation in Sport
• Principles of Rehabilitation
• Components of Rehabilitation
• Stages of Rehabilitation