Disability resulting from injuries and medical conditions are extremely common. Over 50% of Americans over the age of 18 experience a medical condition or injury that could benefit from physical therapy or acute rehabilitation each year. While many of these injuries may seem to heal on their own, they often have lasting effects that can lead to lifelong discomfort or difficulty with daily activities.
Physical rehabilitation is the process of evaluating, treating, and monitoring these injuries with the goal of maximizing the ability of a patient to perform daily and work-related activities. There are six stages in physical rehabilitation. While there is some overlap between these stages, a rehabilitation team will generally go through these steps in order over the course of months to year based on the severity of the injury and the individual patient. The six stages are pain control, range of motion, power and endurance, agility and skill, and monitoring after a return to full activity.
Before rehabilitation and recovery can progress, any ongoing injury must be stopped, and pain must be controlled. These steps often begin during the treatment of a sudden injury or medical condition in the hospital.
There are many medical conditions and injuries that can result in physical deconditioning or disability. With most of these conditions, medical and surgical treatment will be required before rehabilitation starts. Some of the conditions that may lead to a need for rehabilitation are:
Many of these conditions have specific treatments that can both limit ongoing injury and help to control pain. Placement of a cast, splint, or surgery may be required for fractures, joint injuries, and severe tendon/ligament injuries. Medications to help with nerve pain may be needed for patients with spinal cord injury, stroke, and other nerve injuries. Some heart attacks require open heart surgery and a long period of recovery in the hospital. Once these conditions are stabilized, your medical team will likely refer patients to physical therapy for rehabilitation. Even after physical therapy starts, follow-up with these specialists is required to ensure that treatments have been effective.
Pain control is not only the role of other medical specialists. Physical therapists, the key members of the rehabilitation team, have many tools that can reduce and control pain in the setting of physical injuries. This usually begins with wrapping, taping, massage, stretching, and movement exercises for the affected area. This helps to reduce inflammation, swelling, and resistance to movement within the tissues. These measures alone can be more effective than medication in reducing pain.
The second stage of rehabilitation is making sure that the injured area has full range of motion. An excellent example of range of motion is the elbow. A patient with full range of motion in the elbow will be able to fully straighten their arm and bend the elbow enough that they are able to touch their own shoulder on that side of the body.
One of the most common causes of reduced range of motion is treatments for fractures and other injuries. If a patient breaks their elbow and has their arm in a sling for several weeks, the tendons, muscles, and ligaments that connect the elbow joint will become used to the position the arm takes while it is in a sling. When the sling is removed, the arm will have difficulty fully straightening, even if the broken elbow is fully healed, because the arm has not been moved for several weeks.
This loss of range of motion is a perfect example of why physical rehabilitation is so important. Physical therapists can work with injured patients days to weeks after the injury occurs, carefully introducing range of motion exercises while the injury is still healing to prevent any loss in range of motion. Even if an injury is too severe to begin exercises early, physical therapists can monitor for any decrease in range of motion and adjust the position of slings, braces, and splints to minimize decreases in range of motion.
Range of motion exercises take many forms but are typically low-impact stretching and movement drills. These drills are meant to be performed many times a day, slowly stretching the tissues that surround the injured joint. Therapists will have patients perform these exercises many times a day in the hospital or at home and work.
After restoring or preventing the loss of range of motion, the next step is to improve or maintain strength and endurance. Strength is defined as the amount of force that can be produced during a motion, endurance is the ability to continually create that force or repeat it multiple times without becoming too tired to continue.
A practical example of strength and endurance is using a hammer after a severe arm injury. Strength exercises will allow a patient to swing the hammer more intensely. Endurance exercises will allow the patient to swing the hammer multiple times without becoming tired.
When most people think of strength training, they think of weightlifting. Weightlifting is a valuable tool in rehabilitation, especially for athletes with sports-related injuries. However, for many patients in rehabilitation, weightlifting can be too intense, leading to a risk of worsening injury. There are many exercises that physical therapists use to introduce strength training to patients gently; these include:
In some cases, endurance and strength go hand-in-hand. Many patients will have an excellent increase in endurance with the strength training methods listed above. Some patients with injuries or medical conditions that have led to a long period of bed rest, severe weakness of the lower extremities, or damage to a large amount of the body will require additional steps to restore their endurance.
Countless exercises count as endurance exercises. The best endurance exercises can be performed for at least 60 seconds at a time, are repeated often, and can be safely performed without injury. Choosing safe and effective endurance exercises is one of the most important roles of a physical therapist.
Balance is the ability of the legs and pelvis to keep the body in an appropriate position when standing, walking, running, and moving around. Coordination is the ability of the arms and upper body to move in a way that the patient wants in order to accomplish a desired task or action. Balance and coordination are close cousins of strength and endurance. They rely on each other; without one, the others are useless.
Similar to how strength and endurance can be trained by a range of motion exercises, balance and coordination will improve with strength and endurance exercises. Once a patient has enough strength to move themselves and objects in their environment around, work can begin to help them perform these actions more precisely.
An example of balance training is the use of a “rough walk,” an area of ground with uneven obstacles that are meant to be stepped on and over. By walking over this uneven terrain, patients activate small muscles in the legs, stress ligaments that connect the joints, and train the nervous system to sense obstacles and abnormalities through touch alone. These changes together help with walking on all types of uneven surfaces, reducing the risk of falls and other injuries.
Training coordination is typically focused on using the hands and arms in a variety of situations. These situations usually mirror real-life tasks such as using tools, utensils, writing instruments, and manipulating switches, knobs, and screens in the environment. Just like balance, these coordination exercises help to train the nerves and small muscles in the hands and arms, allowing them to work in unison.
Finally, the last step in the acute process of rehabilitation after an injury is training agility and skill. This step is most complicated in patients who have highly physical jobs, are athletic, or are very young. Agility is the ability to perform a task or exercise quickly without injury. Skill in the setting of rehabilitation is a complex task that may be specific to one patient or a small group of patients which requires specific training and repetition to master.
Training agility and skill is extremely specific. No two patients are alike when they reach this step. A good example is a shoulder injury in a baseball player. Even if two patients have the same injury and play at the same level, they will have different areas of weakness after their injury. They will need specific exercises designed for them to target these areas of weakness.
After rehabilitation is complete and a patient progresses through all of the steps above, the adventure is still not over! Even after returning to full activity, good follow-up is critical. Returning to full activity can reveal minor injuries and complications that were missed during the rehabilitation process. Other patients may experience a gradual return of their injury or condition that required them to seek rehabilitation in the first place. A good follow-up plan with the patient’s doctor is critical to discover and treat these small problems before they become major ones.
Rehabilitation is a complex process that cannot be easily summarized into any one article. Each of the steps of rehabilitation are unique for every patient and increase in complexity as a patient progresses through them. One way to speed up the process of rehabilitation is to ensure excellent communication between members of the medical and therapy teams. Sierra Care provides rehabilitation services with a focus on team-based care. Our physical therapists work closely with occupational therapists, nurses, and medical specialists in multiple fields. This collaborative approach ensures that patients receive the best possible care. We specialize in treating patients with catastrophic injuries, traumatic brain injury, spinal cord injury, stroke, and any medical illness leading to disability. For more information on Sierra Care’s services or if you know a patient who could benefit from our services, please contact us.
Carreño L, Thomasma E, Mason J, Pitt W, Crowell M. Comprehensive Rehabilitation of the Athlete: A Specific and Purposeful Approach. Sports Med Arthrosc Rev. 2021;29(4):e57-e64.
English B. Phases of rehabilitation. Foot Ankle Clin. 2013;18(2):357-367.
Montagnini M, Javier NM. Physical therapy and other rehabilitation issues in the palliative care setting. Post TW, ed. UpToDate. UpToDate Inc. Accessed November 13, 2023.