LEVELS OF REHABILITATION: PART 2

Natural Movement Progression: Level II

In level II, there are seven (7) objectives or targets that must be obtained in order to progress to any higher level (II–IV). These targets, objectives, or goals are as follows:

1. Pain. Progress to (tolerable level to sustain activity) or near 0–4/10 on VAS.
2. AROM. Progress to (WFL) or near normal range (WNL).
3. Strength. Progress to (good, 4/5 MMT) or near normal at 4+-5/5 MMT.
4. Endurance. Progress to sustain rhythmic continuous activity sans pain for 10 minutes.
5. Balance. Progress to (fair plus) or near good for static and dynamic testing.
6. Gait. Progress to (FIM 5–6; standby assist-modified independent) to near FIM 7 (independent) × 150 feet.
7. Step. Progress to (FIM 5–6) to near FIM 6–7 × 1 flight of stairs (12 steps).

Natural Movement Progression: Level II (Unloaded) and Level III (Loaded/Resisted)

Level II is where the focus is shifted to natural human movement and the seven (7) basic actions that include: bending, squat- ting, lunging, pushing, pulling, twisting, and gait (as well as stepping up/down). Level III also focuses on the seven basic human movement actions except there is now a goal shift toward the development of dynamic strength. In essence, the difference between level II and III is primarily one that progresses from a completion of movement tasks that are natural and basically unencumbered (doing the move- ments naturally free of resistance) in level II to the same class of movement and actions that are more challenging, a.k.a. loaded or resisted, in Level III.

Natural Movement Progression: Level IV

Level IV in our athletic medicine model represents the highest tier on the hierarchy of levels of physical rehabilitation. The performance aspect of level IV activity is more akin to movements that demonstrate athleticism. Movements are based on the seven (7) attributes of athleticism. The natural movement perspective in level IV can be thought of in these actions.

1. Striking: batting, swinging, hitting, punching, chopping, stroking, spiking, and serving (i.e., tennis and volleyball).
2. Throwing: pitching, tossing, passing, flinging, and put- ting; these activities include components requiring accu- racy, velocity, and distance.
3. Kicking: again, components similar to throwing including distance and accuracy.
4. Jumping: includes leaping, hopping, bounding, and thrusting; also involves distance, time, reaction, and speed.
5. Running: sprinting and hurdling; includes direction (i.e., diagonal, backward, and lateral).
6. Catching: a motor skill that requires concentration, timing, and mechanical efficiency as these are at high velocity (i.e., catching in baseball), or during required movement (i.e., receiving a pass in football or basketball).
7. Agility: the ability to instantaneously change direction in negotiating a course of obstacles; the elements of balance, speed, coordination, and motor control are evident.

The culminating principle before we begin to look at exercises and drills for rehabilitation is this: the four levels of rehabilitation comprise the ladder of progression. This ascending the ladder (linear progression) precedes and sets what eventually becomes the cyclical pattern of progression once higher levels of functionality (including muscular force production and capacity) warrant its utilization. The initial linear progression in the rehabilitation exercise system is typical of most programs, allowing the patient/client to move to more challenging exercises (intensity, speed, duration, volume, and position) as functional outcome scores improve.

Resources are always a limiting factor, so based on what your facility has in terms of equipment for rehabilitative exercise will determine what modality you will employ to get the results you want for your patient, client, or yourself.

For detailed lists and templates of protocols, refer to the newly published book by Reid Elam entitled, "REPS (Rehabilitation Exercise Progression System): Volume 1" available in digital format and soft cover through Amazon, Barnes and Noble, Apple iTunes and Google play.