One of my biggest bugbears in the rehabilitation industry is that patients who get given a rehab program tend to be given a shopping list of exercises with minimal thought process behind the implementation of the prescribed program. Something which doesn’t help the situation is that these programs tend to be either scribbled onto a piece of paper in the last 5 minutes of a consultation (how the hell are you as a practitioner supposed to design an effective program in that time), or in the digital age of 2021 the software platforms that practices gravitate towards for exercise programs are often incredibly poorly designed.
Having a structure towards how you build your sessions is not only important from a patient outcomes perspective, but also from a systemisation of development point of view. I used to spend hours writing programs for my clients because I had absolutely no system that directed me towards funnelling specific components into particular areas!
In order to understand how you can best structure your session it’s important to consider the 8 acute variables of resistance training that you can manipulate in your programs. These are:
- The exercise
- The sets
- The reps
- The prescribed resistance
- The order of exercises
- The speed of the exercise
- The rest periods between reps and sets
- The periodisation across different weeks
When creating an exercise rehabilitation program, the variable that is most manipulated by practitioners is the exercise, delivering new rehab exercises during each appointment has almost become a rite of passage in order to keep athletes interested in the process.
The rest of this blog will be focused on and expanding on point number 5! Being able to categorise our exercises into particular ‘blocks’ that have a specific focus/goal will make sure that you as the rehab professional are ticking off all your goals for the athlete in each session.
Once you have outlined your exercises and order of completion it will set the tone for being able to focus on the other variables, and that’s where being specific in your training prescription will assist in overcoming targeted injury deficits.
The structure/order that I utilise for my athletes is as follows:
Prep work has been given a bad rap namely because historically it has been filled solely with passive treatments such as stretching and foam rolling prior to a strength session, however there are many useful avenues you can utilise at the very beginning of a session to set your athletes up for success.
Any immediate preconditioning that may assist in facilitating loading throughout the rest of the session, this may be isometric modalities for neural drive or pain relief (see video below); ROM work; BFR training for pre-fatigue, and/or any kind of soft tissue therapy or mobility drills that you may want to prescribe the athlete should be performed in this block.
The important point to note is that this work should have a specific purpose so that the athlete can get more out of their proceeding blocks. This is particularly helpful for athletes in the earlier stages of their rehabilitation journey where they may suffer from neuromuscular inhibition as a result of pain and/or swelling.
Video – SB Knee Extension Isometric – aimed at promoting high neural drive to the quadriceps through a maximal voluntary isometric contraction.
Gait Mechanics Block
For lower limb injuries, the foundations of running mechanics should begin from the day that the athlete can fully weight bear, whether that be on or off crutches. Setting the foundation for good running postures will make life easier when you return the athlete to the field, as they will have gradually built themselves up to the demands of linear running in lower load, safe environments.
This component of the session is placed first in order to maximise the freshness of the athlete and will also assist in acting as a central nervous system stimulus that would traditionally be present at the end of a performance-based warm up.
Video – Wall Drill: Acceleration Load & Lift – used primarily in a load introduction phase to develop knee flexion and extension control whilst going from triple flexion into triple extension.
This block should be focused on prescriptions based around where the athlete sits on the plyometric continuum. For athletes in the early stages of rehab there may be no velocity block at all or the prescribed exercise(s) may be mundane and repetitive, but the point of this is to promote the foundational learning of positions that will later be exposed to more complex and chaotic environments. Developing the capacity to tolerate ground contacts will aid in an uncomplicated return to running and will build confidence in the athlete.
Video – Countermovement Jump – performed in a load introduction or strength accumulation phase to develop the stretch shortening cycle.
This block is the primary focus of the session and should take up the bulk of the session. For a lower limb injury I typically target either a knee dominant or hip dominant day bias, and all prescriptions should reflect their stage of rehab. Remember this is a rehabilitation program first and a performance program second, so if the athlete is suffering from a foot or ankle injury you want more stimuli specific to that tissue than global strength lifts.
Describing the breakdown of the strength session could be an entire blog in itself, but this should be the most demanding block of the program from an energy expenditure perspective.
Video – GHD Bosch Hold – utilised in a strength accumulation phase in order to build isometric strength at length of the distal hamstrings.
The final component of the session (if needed), this is where any extra stimulus that the injured limb / area of the body needs should be prescribed. Once the athlete has finished their rehabilitation journey the resilience block is a good place to position ongoing rehab ‘top up’ work or injury prevention-based exercises that are specific to the athlete’s sport, i.e. for field sport athletes a suitable option may be to put hamstring or adductor based top ups in here (see video).
Video – Adductor Hold (Short Lever) – used from a strength accumulation phase onwards targeting isometric strength of the adductor musculature.
Well there you have it! My structure for creating a rehabilitation session from start to finish. I hope you found this useful and remember, systemising program design is a fundamental process in not only saving you time, but also in ensuring you are getting optimal outcomes for your athletes.