Chapter 19

### Objectives

After completion of this chapter, the physical therapist should be able to do the following:

• Define and discuss the importance of proprioception in the neuromuscular control process.

• Define and discuss the different levels of motor control by the central nervous system and the neural pathways responsible for transmission of afferent and efferent information at each level.

• Apply a systematic functional evaluation designed to provoke symptoms.

• Demonstrate consistency between functional and clinical testing information (combinatorial power).

• Apply a 3-step model designed to promote the practical systematic thinking required for effective therapeutic exercise prescription and progression.

• Define and discuss objectives of a functional neuromuscular rehabilitation program.

• Develop a rehabilitation program that uses various exercise techniques for development of neuromuscular control.

### Function and Functional Rehabilitation

The basic goal in rehabilitation is to restore and enhance function within the environment and to perform specific activities of daily living (ADL). The entire rehabilitation process should be focused on improving the functional status of the patient. The concept of functional training is not new, nor is it limited to function related to sports. By definition, function means having a purpose or duty. Therefore, functional can be defined as performing a practical or intended function or duty. Function should be considered in terms of a spectrum because ADL encompass many different tasks for many different people. What is functional to one person may not be functional to another. It is widely accepted that to perform a specific activity better, one must practice that activity. Therefore, the functional exercise progression for return to ADL can best be defined as breaking the specific activities down into a hierarchy and then performing them in a sequence that allows acquisition or reacquisition of that skill. It is important to note that although people develop different levels of skill, function, and motor control, certain fundamental tasks are common to nearly all individuals (barring pathologic conditions and disability). Lifestyle, habits, injury, and other factors can erode the fundamental components of movement without obvious alterations in higher-level function and skill. Ongoing higher-level function is a testament to the compensatory power of the neurologic system. Imperfect function and skill create stress in other body systems. Fundamental elements can first be observed during the developmental progression of posture and motor control. The sequence of developmental progression can also give insight into the original acquisition of skill. The ability to assess retention or loss of fundamental movement patterns is therefore a way to enhance rehabilitation. The rehabilitation process starts with a 2-part appraisal that creates perspective by viewing both ends of the functional spectrum:

• The current level of function (ADL, work, and sports/recreation) relative to the patient’s needs and goals.

• The ability to demonstrate the fundamental movement patterns that represent the foundation of function and basic motor control.

#### Objectives of Functional Rehabilitation

The overall objective of a functional exercise program is to ...

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