Key points to consider planning a rehabilitation program
1. How do we determine the relative amount of resistance for an individual?.
2. How many repetitions should be done?.
3. How much rest period is necessary?.
4. How do we determine the factors limiting exercise performance clinically?.
5.How do we determine which components of rehabilitation are appropriate targets?.
6. Where is the transition between rehabilitation and conditioning?.
7. What is the difference between physiotherapy prescribed exercise and sport rehabilation / fitness instructor?.
8. How do the principals of strength and conditioning apply to rehabilitation?.
9. What do we need to know about the structures we are rehabilitating?.
10. How do we improve exercise compliance?
Selecting variables to modify in a rehabilitation program can prove challenging. Most therapists are familiar with the obvious variables of LOAD & REPETITION but there are numerous other factors that can be manipulated.
- Range of Motion
- Base of Support
- Plane of Motion
Combining different elements of these components allows progression or regression as required. It is essential that therapists are competent in applying these principals in a clinical setting
Click exercise variables to hear the lecture.
Many of you will be familiar with the concept of functional training in rehabilitation, so a brief review of historical aspects will suffice here.
Functional training from a rehabilitation perspective has been used for many decades with the obvious goal of returning an individual to their pre-injury functional status.
The astute reader will note that this implies a degree of individuality and specificity in rehabilitation strategies depending on the individual’s response to the injury in question and the planned functional goals to be achieved. In this discussion we are concerned with a return to playing sport, which has different functional requirements depending on the sport of choice.
Most rehabilitation specialists would agree that the fundamental measure of success is the ability to “perform at maximal function”. The issues of debate usually centre around:
- Whether to use functional exercise as an initial priority.
- Whether to place prerequisite criteria for progressing to functional exercise e.g. base line flexibility measures, stability measures, agility, coordination and power.
- The use of over load / external resistance to achieve progressive increases in power output.
- Key variables to manipulate in exercise progression e.g. load, speed, plane of motion, movement sequence.
Perhaps the biggest source of discussion in this regard is the use of fixed weights / machine systems relative to free weights. In the non-elite athlete there are some attractive aspects to using fixed weights as the machines themselves provide some degree of stability, are relatively safe, allow max or near max loads to be utilised and can be undertaken individually.
Unfortunately the artificial stability provided by machine systems dictates that a critical aspect of functional strength is not trained and therefore of debatable relevance in functional loading. On the other hand free weights use allow mass activation of stability and mobility muscle groups, more closely approximates functional movement patterns and requires higher levels of skill and coordination particularly if technical or explosive lifts are being attempted. Most serious athletes will incorporate some degree of free weights into their training.
The gap between these two approaches can be neatly filled by incorporating batteries of functional tests which explore movement control and coordination in varying combinations of body position, primarily with body weight as the external load, but progressing with small proportional increases in resistance as control allows. It can be reasonably argued that inability to control one’s body weight through a full functional repertoire of positions which are likely to be encountered in the course of the game situation may predispose to injury.
One of the current difficulties related to repeated tests / re-tests of functional measures are the measurement systems used. These tend to be somewhat “low tech”, can sometimes rely on the individuals perception of effort to perform a desired task or require an external examiner’s observation of the quality and sequencing of movement. Needless to say there maybe many hours of debate regarding differences of opinion on these issues!!!
Nonetheless a useful concept in this regard (popularised by American Physiotherapist Gary Gray), utilises the concept of threshold training in which the extreme position which an individual can control is measured relative to that of the other side. Any further change in position produces falling or loss of balance or some compensatory adaptive mechanism – indicating failure.
Components of a total body functional profile.
- Reliability and validity.
- A full spectrum functional testing.
These concepts should be borne in mind when deciding what battery of functional tests to include for an individual or as part of a team training / screening protocol. The other critical point to recognise is that loading is occurring in three planes of motion simultaneously – tri-plane motion.
In clinical practice it is often by combining three planes of motion simultaneously that one can expose weaknesses, which do not appear evident when testing an isolated plane. If one analyses the movement patterns involved in most sports we can see that they can be broken into groups of core functional activities e.g. jogging, running, decelerating, excelerating, twisting, pivoting, jumping and pushing.
Each of these complex movement patterns can be broken down into components and each can be stressed using varying combinations of challenges e.g.
- Range of motion.
- Sequence of motion.
- Eyes opened / closed.
- Corporating simultaneous trunk and limb movement.
- External resistance e.g. elastic tubing, bungee cords or dumbbells.
All allow varying degrees of difficulty to be explored in order to be determine the functional threshold of control.
Gray groups his functional tests under the following categorisations.
- Balance tests.
- Balance reach tests.
- Excursion tests.
- Lunge tests.
- Step up tests.
- Step down tests.
- Jump tests.
- Hop tests.
Functional self-test menu
Below are listed a group of self-test movements which can be administered and the degree of difficulty noted. Please note that there can be many different reasons for an inability to perform complex patterns which could include flexibility, stability, power, endurance or coordination deficits.
1. In- line lunge with body rotation.
Stand in a long stride position with front and rear legs in one line and feet pointing forwards in the same direction. Heels must stay on the ground. Bend front knee and hold leg position still. Add alternating twists of the upper torso to left and right side.
2. Single leg stance with toe touch.
Standing on one leg bend forwards to touch toes with the hand on the same side as your standing leg. Return to upright and reach arm overhead. Focus on maximising hip and knee bend in order to increase the leg stress. Ensure that standing leg does not roll inwards.
3. Kneeling lunge with trunk side bend.
In a kneeling lunge position, with both legs in line, side bend the upper torso from left to right. If toes grip floor strongly, tap floor to prevent fixing.
4. Single leg stance forward / downward leans.
Stand facing a wall, goal post or barrier about 3ft away initially and stand on one leg. Reach forward with the index finger to touch the ground as far out in front to reach the ground if possible. Return to upright and reach with opposite hand.
5. Single leg stance reverse pivot.
Stand on one leg with back to wall or post or barrier. Reach overhead with left and right hands alternately to try and touch behind without falling over. If it is too easy move a further distance from the barrier.
6. Incline lunge with trunk rotation
Lunge at 45° from straight ahead position, holding dumbbell in opposite arm (6 to 10kgs) reach down and across to the outside of the forward foot. Return to upright. Alternate sides.
PS to initially feel the coordination for this drill try work without weights.
There are infinite numbers of variations of these types of drills which can be exciting, fun, challenging and very revealing. We will come back to some of these concepts in the future.