15 Minute Rehabilitation: It’s Time to Unplug

While working as an athletic trainer I was frustrated and furious with the constant flow of athletes ‘needing’ certain treatment. I was tired of students and support staff hooking athletes up to every biophysical modality in the athletic training room. Why? They had no clue – it felt good to the athlete, it ‘worked’, it was easy, the coach said to – my blood beginning to boil.

It seemed every injury for all athletes was treated by the wonderful benefits of electrical stimulation. After a quick evaluation the injured body part is surrounded by electrodes and covered with a comfy hot or cold pack. For 20 minutes the athlete sat there with a special tingly, prickly feeling that gives those in pain a warm fuzzy feeling. As a health care provider there is nothing easier than slapping on a few electrodes and walking away for 20 minutes; it’s easy and clients love it. I must admit that I have fallen victim to the persuasive effect of e-stim as both an athlete and health care provider. But it was time to unplug. The overuse of modalities coupled with the under usage of manual therapy and rehabilitation was sickening. So what did I do?

I unplugged it all. I took all of the modalities and put them in one room with one table. It was not to be used unless a valid reason existed to do so. Holy s***, did I make some people mad. Instantly, coaches and athletes, became health care experts saying it was needed. But for the fellow athletic trainers – they understood. It made them learn reasons why to use modalities. It also help them look at the treatment of injuries in another way. This method also enhanced their ability to identify and correct common human movement dysfunction than causes pain.

Before I go further and before those in support of  modality usage start throwing data at me, stop. E-Stim (along with the other biophyscial modalities) is a versatile modality, has few contraindications and is a quick easy way to reduce pain in most clients. For this reason e-stim is often the first tool of choice.  The effectiveness and subsequent overuse of e-stim, is secondary to pain relief. A structure called the substantia gelatinosa (SG), lies in the IV Laminae of the dorsal horn in the spinal cord. This structure is where nociceptive (pain) fibers terminate and decisions with regards to how pain should be handled are determined. Also terminating in the SG are A Delta fibers (sensory fibers). E-stim has several modulations, but the most common is for a theory called “Gate Control Theory”. Essentially, electrical impulses from e-stim therapy bombard the SG through the A Delta Sensory fibers and over-ride the nociceptive fibers and ‘turn-off’ pain. The pain relief can last from minutes to several hours.

Unfortunately, all too often, athletic trainers try to control pain rather than fix the problem. Rather than spending 20 minutes turning off pain, why not allocate the time to long-term pain relief and correcting dysfunction? Why not spend 20 minutes correcting a muscle imbalance, which will lead to lifelong change and keep athletes out of your athletic training room? All you are doing is putting a band-aid on a problem, unfortunately you have to keep putting that band-aid on everyday for the entire season. I said it before and will say it again – Athletic Trainers need to transition from triage to rehabilitation and optimizing functional movement. However, I understand the problem: it is a time crunch. Athletic training rooms are vastly understaffed – making it difficult to dedicate 20 minutes of rehabilitation time to one athlete, when 3oo are lined up at the door. So we have a time crunch, but there is a solution…

Almost all injuries we see in the athletic training room are a result of:  altered length tension relationships, altered arthrokinematics, altered neuromuscular recruitment. Collectively, these issues are what makes up human movement dysfunction. You name the injury – tendonitis, ACL tears, PFPS, fasciitis, MTSS, impingement, rotator cuff pathologies, you get the point – can be linked back to human movement dysfunction. The good is that human movement dysfunction is identifiable, preventable and correctable. The better is that the strategies to correct human movement dysfunction can be done in less than 15 minutes per day.

Yes, I said it – you can perform a 15 minute rehabilitation session. I presented on this topic at the NATA District 10 and District 2 conference and even did a few customized workshops. A colleague presented on the topic at the June 2012, NATA conference. Imagine correcting a problem, preventing injury, or rehabilitating an athlete in 15 minutes per day. That would be better than slapping on a pair of electrodes and setting up hi-frequency biphasic sensory-level stimulation. You will fix the problem and reduce pain. How you ask?

As I said above, human movement dysfunction is often composed of three problems, all which are identifiable during human movement assessments. The assessments will indicate where human movement impairments exist. But lets say for example we have a patient with patellar tendonitis, we would likely see functional impairments somewhere along the lower extremity. Below is a sample program I would do in 15 minutes.

Decrease neurological drive to hypertonic tissue – 3 minutes 

Exercise: Self-Myofascial Release or Manual therapy

• Gastrocnemius/Soleus – 60 seconds
• Adductors – 60 sec
• TFL/IT-band – 60 sec

Lengthen hypertonic muscle or joint tissue – 3 minutes

Exercise: Static stretch or joint mobilization

• Gastrocnemius/Soleus Stretch – 1 set @ 30 sec
• Kneeling Hip Flexor Stretch – 1 set @ 30 sec
• Adductor stretch – 1 set @ 30 sec
• Posterior joint mobilizations at the ankle – 90 seconds

Increase neurological drive to hypotonic tissue – ~ 6 minutes

Exercise: Isolated Strengthening or positional isometrics

• Resisted Ankle Dorsiflexion – 2 sets x 15 reps (slow) (2 minutes)
• Resisted Hip Abduction and External Rotation- 2 sets x 15 reps (slow) (2 minutes)
• Resisted Hip Extension – 2 sets x 15 reps (slow)  (2 minutes)

Integrated Dynamic Functional Motion – ~ 3 minutes

Exercise: Integrated movements

•  Ball Squats w/Resistance Band Around Knees – 2 sets x 15 reps (slow)

Note this is just a sample program. In the above instance I assumed the client had limited ankle dorsiflexion and muscle imbalance at the hip musculature. The specific human movement impairment will be client and injury dependent. That said, you can follow the same formula and perform rehab in the same amount of time that it takes to perform e-stim. Too often we use the time crunch as an excuse for our failure to perform due diligence as health care practitioner. We have a job – that is to keep athletes healthy. Let’s choose the path that works – not the band-aid.