An article I read in the PhysioSA journal from February has provided the inspiration for my first blog. The main theme of the article was a call for physiotherapists to improve our treatments using more optimal load management strategies. This is due to our profession being under threat by other qualified exercise-based professions. It was a bit of a ‘light-bulb’ moment for me where a lot of my frustrations within the physiotherapy industry thus far were put into words. So often we hear of physiotherapists just doing the bare minimum, or using age old treatment methods that no longer have evidence to support their use. I quote from the published article, “Physiotherapist are great at selling bull%$#@ treatments and we are at risk of losing our competitive edge to other professions due to this.” In the modern world of sports medicine, patient and injury management has evolved into an integrated system of role players, which involves many different health professionals that can adequately provide services to satisfy these needs. In a sporting setup where there is access to different professionals, such as a professional sports team, it is important for each health professional to know their unique role in this system for the end goal of achieving full recovery of the patient. I am fortunate enough to working in an environment where there is access to multiple professionals, each with different skill-sets, and we use this system to the advantage of all our patients.
Something that the physiotherapy industry has lost in recent years, in my opinion, is our role in rehabilitation. We are highly trained medical and rehabilitation professionals, yet time and time again I feel we are neglecting this important part of patient management. We generally use the term ‘therapeutic exercise’ which is “the systematic performance of planned physical movements, postures, or activities, intended to enable the patient to 1) remediate/prevent impairments, 2) enhance function, 3) reduce risks, 4) optimize health, and 5) enhance fitness and well-being.”
These sorts of exercise programs differ from traditional exercise program models because they have different outcome measurements that need to be achieved. We should definitely not neglect our manual therapy and hands-on skills for restoring movement and tissue function, but we should looking to ‘muscle-up’ our rehab skills.
First off, a quick review some of the basic principles in exercise prescription:
· We should always adjust the intensity, duration, frequency, mode, volume, and specificity of the activities in each session to see new elevated levels of adaption.
· The Specific Adaption to Induced Demands (SAID) principle is one that is still relevant to rehabilitation. This principle was formed on Wolff’s Law (which states that form follows function), and the physical stress theory (which states that biological tissue has five responses to physical stress placed on it i.e. decreased stress tolerance/atrophy, maintenance, increased stress tolerance/hypertrophy, injury, or death).
· Adaption to tissue stress should be integrated into functional retraining before commencing a RTP program. The main reason is that movement patterns become dysfunctional after injury or operation, and this needs to be ‘retrained in the brain.’
Incorporating a more traditional exercise program model:
To integrate the physiotherapy rehab process into more traditional exercise programs, we need to understand how these programs are built. Most (not all) exercise programs are based on a periodization program, which refers to the progressive adaption process used to develop fitness in a body system. The founding principle of training is that a stressor disrupts the homeostasis of the internal body systems, and the body tries to recover from this to restore homeostasis. With repeated bouts of this process, the body adapts and can recover quicker, and can sustain for longer periods before homeostasis is disrupted again. By regularly changing the stress and external inputs applied to tissue, you begin to see a phenomenon described as supercompensation, where the tissue is in a higher state of learning than before. This General Adaption Syndrome (GAS) can be divided into three different stages. Stage 1 is an alarm stage, with a disruption in homeostasis. Stage 2 is resistance stage where the stressor is advantageous and the body adapts. Stage 3 is exhaustion, where the stressor exceeds the body’s ability to adapt and the stressor becomes chronic or negative. Training and rehabilitation should fluctuate between stages 1 and 2. If we think from a physio rehabilitation perspective, after an injury or operation, we need to stress the tissue adequately to get into stage 1 and progress to stage 2, whilst avoid stage 3.
Application into physio rehabilitation:
Using these principles described above allows us to progress a patient through a broader rehab process even if they do not have periodization in their training. The late stages of any rehab process are a more functional focused phase. In this phase, there is a lot of exercise based training and movement retraining that needs to be done, but it is here where I feel we as physiotherapists are becoming ‘slack’ (for a lack of a better word). Different phases of a periodization program will require certain athletic capabilities, and it is our responsibility to ensure that the patient is ready for this type of loading in training before returning to their sport. A good understanding of metabolic, neurological, motor and physiological requirement for the patient’s return to their sport should drive our progression of rehabilitation in all our patients. Generally (and there are various models out there that use different training strategies), a rehab progression should follow the linear progression model of exercise training…
stability and activation – strength endurance – maximum strength – power – maintenance
Understanding where in this progression the patient should be from a fitness perspective will align the rehab goals better. For example, if in a maximum strength phase, we would need to ensure that the we incorporate a lot of strength based work at the right dosages. Or for a power phase, our rehab would need to ensure that the tissue that was injured has been adapted to handle the eccentric, high velocity, and quick turnover rate of forces associated with training in these phases. We should also always look for ways (as far as possible) to incorporate exercises that can maintain the patient within the desired mesocycle/microcycle phase of their training, such as alternative forms of cardiovascular and/or strength training.
Loading is a word widely used in modern day sports medicine, and for good reason. Load is simply a progressive management program of the stress applied to tissue, aimed to rehabilitate a patient from injury to return to play (RTP). Load management should be progressive, sports specific, and aimed at restoring function and preventing injury. Loading tissue refers to the specific stress from the rehabilitation exercises such as increasing reps or adding weight or changing the speed of movement. It also refers to functional loading activities, such as progressive running programs. These principles don’t only apply to sports. For example, the rehabilitation for a manual laborer with back pain should not stop at some basic ‘core’ exercises in the physio room, but rather move into more complex movement and exercise for health and well-being. As the old mantra goes, prevention is better than cure.
The take home message is that injury management is moving towards a more outcome based method. I strongly believe that we as physiotherapist are adequately equipped to dive into the deep-end of rehabilitation and RTP functional training with our patients to achieve these desired outcomes. It is merely a matter of taking the time to think outside the box and move beyond the four corners of the physio cubicle. I do believe that we serve our patients as part of a bigger system along with other health professionals, but we should not limit ourselves to bed work because of this. We should rather integrate our methods and beliefs into other methods for the total benefit of recovery from an injury. We need to think about rehab as more than just a set of exercise; but rather as an opportunity for the body to learn and adapt to new challenges. Just as we learnt to read and write at a young age, so we should learn to move after injury. This change in mindset will change your view of how you prescribe your ‘home exercises’ tremendously.
Some practical tips for muscling-up the rehab process:
Prescribe home exercises with the goal of learning and adapting to tissue stress.
To learn new movement patterns, the body systems need to be challenged with just the right amount of stimulus and feedback to see adaption.
Think about injury recovery from a load management perspective.
Remember [load= volume x intensity]. Adapt both variables for proper load management.
Consider the patients requirements for their sport and training phase of periodization they should be in.
Commit to the cause- meet your patients at the fields and go through those running programs you prescribe.
Don’t be scared to prescribe ‘gym based’ exercises…it’s part of the bigger picture for RTP
Use standardised outcome measures to monitor progress.
Blanchard, S., & Glasgow, P. (2014). A theoretical model to describe progressions and regressions for exercise rehabilitation. Phys Ther Sport, 15(3), 131-135. doi:10.1016/j.ptsp.2014.05.001
Brody, L. T. (2012). Effective therapeutic exercise prescription: the right exercise at the right dose. J Hand Ther, 25(2), 220-231; quiz 232. doi:10.1016/j.jht.2011.09.009
Hoover, D. L., VanWye, W. R., & Judge, L. W. (2016). Periodization and physical therapy: Bridging the gap between training and rehabilitation. Phys Ther Sport, 18, 1-20. doi:10.1016/j.ptsp.2015.08.00\
*Darryn is a physiotherapist, currently completing his MSc Sports and Exercise dissertation in Training Loads/Illness in IronMan triathletes. He is an accomplished athlete himself, having played varsity rugby at UCT and completing IronMan based through a self designed training program. He is running a website, aimed at creating dialogue around sports and exercise medicine, and is a good friend and colleague, and we fully support his new venture!