Creating a specific rehab plan for each patient is key in order to obtain the best possible treatment outcomes. The use of basic strength & conditioning principles is very important, but many physios either don’t know about them or don’t know how to apply them. As a result, many patients are given a generalized, underdosed exercise program that doesn’t really improve their symptoms.

This blog is based on the excellent Masterclass from Dr. Claire Minshull The practice-changing principles of strength & conditioning for physios. Make sure to watch this one if you want to know more about the topic.

Training principles

A good exercise program should be based on the 3 principles of training: specificity, overload and progression. The last two are where it often goes wrong. An individual’s training regimen should always have a greater intensity than the individual is used to to achieve the desired outcome. A school teacher that does triathlons in her free-time needs a different kind of training than a sedentary school teacher. Secondly, the training should progressively get harder each week. The best, most specific, individually tailored training programs evolve as the individual gets stronger. Otherwise, progress will flatline.

Strength first

A good rehab program should include strength as a base, as it is a baseline for many other rehab variables, like power, muscular endurance etc. It is no longer a secret that lack of muscle strength is associated with all-cause mortality and has a negative effect on many aspects of life. Stronger people typically live longer, suffer less from pain and have a better quality of life than weaker individuals.

This is why integrating strength in any rehab program is a must! Proper strength training means heavy loads, is very high in intensity, has very few repetitions and a rather long period of rest in-between sets (1). Unfortunately, the reality is that many “strength training” programs are merely resistance training. If your patient can still comfortably have a chat with you while performing his/her exercises, then it’s not strength training.

Ref: Masterclass Claire Minshull, research by Baechle & Earle (2008) and Fleck & Kraemer (1987)

If you really want to target strength, then training at 5RM intensity is optimal (1,2). This is a lot less than the classic 3×10 repetitions many physios use! Recent studies show that doing 5-9 sets per week, over a period of 8-12 weeks at 5RM results in a 61% strength gain, while training 5-10+ sets per week, over the same period at 8-12RM intensity only improved strength by 23%. This is a huge difference! And if you do the math, the first option will take less time than the latter, as you need to do less repetitions each week to get better results! (3)

Exercise adaptation for pain

I can already hear many of you thinking “Sounds great, but there’s no way you can do this with patients, as many of them are in pain or are restricted in ROM etc.”

There’s no denying that, but there are multiple ways in which we can regress exercises. Sadly, load is often the primary regression option when patients are in pain, but deloading often means loss in specificity. Other possible adaptations to consider before manipulating load are bracing, an extended warm-up, analgesia and of course: exercise adaptation! In my opinion, this is the most important one, as it is quite easy to adapt exercises while keeping the load and specificity. We can try to manipulate the mode of muscle activation (think isometric, concentric, eccentric), speed, angle or ROM, kinetic chain etc.

In most cases, when one or more of these variables are changed, patients are able to train under high loads without being in pain. So next time you catch yourself decreasing loads, it might be good to try out one of these other options.

When patients are really limited (think post-op, a lot of pain, little ROM), isometric training can really be a game-changer. It is often very underestimated, as most of us have learned that it only increases strength in the specific angle you’re training at. This turns out to be incorrect!

Recent studies show that, when you’re training at longer muscle lengths at a high enough intensity (>75% of the Maximum Voluntary Isometric Contraction (=MVIC)), there is an increase in concentric strength and a transfer of strength gain across ranges (4,5).

Let’s clarify this with an example: performing an isometric knee-extension movement at 90° knee flexion (a position in which the quads are already quite lengthened) at >75% of the MVIC, will not only improve knee extension strength in this angle, but in all other angles, as well as increase concentric strength. Can you imagine how many opportunities this brings? Unfortunately, it doesn’t work the other way around, as training at shorter positions doesn’t transfer strength to longer lengths.

Changing from closed to open kinetic chain or compound to isolation exercises is also an easy way to regress exercises, as compound movements like leg press or back squats are often less tolerated than isolated open kinetic chain movements like leg extensions.

Periodization

Of course strength usually isn’t the only thing we need to work on when treating patients. That’s why optimizing periodization is very important. Periodization is basically dividing a large training period into smaller blocks in order to optimize progressive adaptation of specific rehab outcomes (6).

There is always a certain hierarchy of importance during rehab. While strength, ROM and sensori-motor abilities like proprioception are important to integrate from the start, their importance does decrease towards the end, where variables like power and performance or sport specific sensori-motor abilities become more important.

Ref: Minschull et al. 2020

Sometimes, you can’t do everything at once. If for some reason, your patient can commit to only 1 rehab session per week, it is better to stick to one or two parameters (like strength & proprioception) and do them well instead of trying to target everything!

Wrapping up

I hope this gave you some insights on how to improve your exercise plan. Always keep specificity, overload and progression in mind and try to keep the load high by changing other exercise variables instead of simply decreasing the weight.

Check out Dr Claire Minshull’s Masterclass The practice-changing principles of strength & conditioning for physios here if you want to go more in depth, I’ve no doubt it will add to your rehab quality.

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Supercharge Your Patient’s Recovery:The Practice-Changing Principles of Strength & Conditioning