Principles > Methods – The 6 Key Ingredients of Rehabilitation
The following blog was written by Jarred Boyd (PT, DPT, ATC, SCS, CSCS) and Anthony Iannarino (PT, DPT, PRC, CSCS).
There is not a day that goes by where a clinician, strength coach, personal trainer or other movement-based specialist does not hear “What can I do for insert injury”, “What’s the best exercise for pain in my insert body part”, “What should I do to strengthen insert muscle”.
Truthfully, it depends.
However, with principles in place your “it depends” statement is less random and more pragmatic. Establishing processes and principles can protect you from confirmation bias and emotional alliance, leading to more dialed in reasoning behind the decisions you make. The individual who has an exact method or exercise to specific questions may lose adaptability because they only know one way and thus leave you susceptible to blind spots. This is reflected in the popular adage “If all you have is a hammer, everything looks like a nail”. A flawed interpretation of this adage would suggest to simply acquire more tools. While this can certainly be helpful, a decision-making framework to guide when and why to use these tools is vital. Enter a principle led approach. Aristotle defined first principles as “the first basis from which a thing is known”. In action, we must ask “why” until we get to the lowest level “truth”. In the world of medicine, these “truths” are composed of foundational physics, chemistry, and biology. Principles can serve as the tool box, helping us to organize our methods and guide us to only use our hammer when what we are seeing is most likely a nail.
As human beings we are notoriously biased when attempting to make accurate decisions. We are clouded by current trends, expectations, emotion, fear, and insecurities. We are even susceptible to biological shifts throughout that day that change our thinking from moment to moment, some times with irreversible consequences (i.e. some studies suggest judges may dish out harsher punishments when they are hungry). To compensate for our human flaws and enrich our deeply creative capabilities, we must be grounded in a process that has been constructed on a foundation of principles. The discipline of this principle led process not only allows for more consistent and accurate decision making, it also provides and imbedded framework to analyze successes and failures thus increasing the rate and quality of learning.
The following six principles of rehabilitation are attached to no specific methods or techniques of how manage a rehabilitation process. Instead, the premise is to provide values that remain universal regardless of any specific context.
PRINCIPLE 1: Provide Movement Options
Accommodation and adaptability to an ever-shifting environment makes one more resilient than the one with limited options. Variability is a sign of health in every system in our body. If a patient’s resting heart rate is 90 and max heart rate is 115 their ability to adapt to the fluctuations of a normal day is significantly compromised. This is no different for the movement system. Movement variability can be viewed as letters in a movement alphabet. If one cannot access the full alphabet this will significantly constrain their ability to communicate. For simple tasks (think of a toddler asking for a cookie) we may not even notice the missing letters. However, if you’ve ever read a fifth graders attempt at writing a novel you will see how a harder task revels limitations very quickly. In regards to the movement system, a lack of movement variability may manifest as maladaptive strategies for a given task or environment. The intended movement may present as less efficient, powerful, or creative as one needs to accomplish the required task. Acquiring movement variability ensures the nervous system is effectively responsive in the variation it permits to complete tasks, especially during competition. However, finding the sweet spot for promoting variability is key. Too much or too little, dependent on task, environment and organism, can each create their own set of consequences. This principle simply deems that we must make sure that the client has enough movement options to complete their desired and required movements without restrictions, limitations or impeding constraints.
PRINCIPLE 2: Coordinate Movement Options (Movement Competency)
Coordinating movement options is about teaching the nervous system how to integrate the variability it has acquired to produce a meaningful outcome/output. Manipulating the environment and the task the person must handle encourages the necessary coordination. The control of movement options is fluid as we develop skill. Imagine a baby learning to walk. With flailing limbs and limited control this baby has a great deal of movement variability but a low level of accommodation to challenges. This variability is error based. As the baby gains skill, it will lock joints up limiting movement options to simplify the problem. This is normal during the learning process as a person simplifies the number of options to increase their ability to accommodate to growing challenges. As we progress towards mastery, variability returns, but this time it is purposeful and skill based (i.e. now the 2-year-old can walk with reciprocal arm swing increasing efficiency).
As stated previously, too much variability and we cannot accommodate to the task—too little and we are handcuffed by rigidity and loss of adaptability. Both of these can hinder movement competencies and capacity. Too much threat or difficulty of a movement makes us lose variability, which is why novel movements must be strategically incorporated and monitored. Movements many times should be first acquired in relative safety before dialing up to more complex and unpredictable environments. We can best set the client up for success with strategic periodization to challenges progressively within a given task. Starting with simple movements in a controlled and safe environment before progressing to more complex tasks in chaotic, fluctuating, and reactive environment when nearing readiness to perform.
PRINCIPLE 3: Amplification and Dissipation of Force
The acquisition and coordination of movement options are not meaningful if we do not acquire the ability to manage forces. As humans on planet earth we are constantly managing forces ranging from standing up against gravity all the way to ~6x the force of your body weight when landing from a dunk or sprinting at top end speed. The ability to efficiently convert potential energy into kinetic energy is foundational for all levels of athletics. It all comes down to how well we can distribute forces throughout the body to keep any tissue from being undesirably loaded, which may manifest as a strain, sprain or tendinopathy. In practice this comes down to teaching the ability to dissipate force, produce force, produce force quickly and produce force repeatedly.
These qualities can be garnered through manipulation of biomotor principles ranging from max strength, reactive strength, speed strength, and strength speed. The greater amount of force production and absorption capabilities we can cultivate the larger buffer zone we can build against tissue overload from a biomotor/mechanical perspective. Having no reserve or buffer, whether that is physiologically or metabolically, will put you in a vulnerable position to perform with confidence. Building a buffer beyond what may be necessary will reduce the relative “cost of doing business” and may mitigate susceptibility of injury. Remember this principle is also relative to the task, organism and environment. This is not only for athletes and performance. Geriatric populations likely require more emphasis of this principle than you may realize so those table oriented remedial based exercises aren’t going to cut it.
PRINCIPLE 4: Enhance Metabolic Capacity
The rationale for the 4th principle, enhancing metabolic capacity, can be defined as the ability to produce energy at an efficient rate and length dependent on the environmental and task demands. The overarching goal is to create fatigue resilience. When we look at fatigue, Noakes’ Central Governor Theory suggests that it can be seen as an emotion constructed by the brain to help self-regulate control of exercise (central governor theory/ Tim Noakes). Like pain, it’s (from a general view) an output from the brain (Explain Pain/ Lorimmer Mosley), designed for protection and frugality of essential resources required for survival. From this viewpoint, fatigue can be seen as another alarm system. But sometimes, especially in athletics and performance, we ignore this alarm system, which may result in less optimal neuromuscular/sensorimotor mechanisms, force production and force dampening capabilities, potentially exposing tissues to higher loads than they can manage. One can moderate the effects and influence fatigue has on the system by ramping up the aerobic systems capacity. The aerobic energy system will prioritize providing long-term supply of energy, improving sustainability of activity and making sure movement options remain available as opposed to detracting options due to threat. When we develop the aerobic energy system we increase efficiency while protecting against the deleterious effects of fatigue.
With increased aerobic properties the onset of fatigue can be delayed and our motor output preserved. The aerobic system also provides an ability to clear out by-products that may be simultaneously produced during anaerobic based training i.e., repetitive sprints with incomplete rest, critical for repeat sprint athletes. Limited aerobic capacity and limited recoverability may result in tissue overload, especially during repeated sprints due to accumulated fatigue and altered biomechanics. It is important to remember that the amount each energy system contributes to the production of energy is dependent upon the intensity and duration of the task, with the aerobic system requiring lower intensity levels with a sustainable output.
PRINCIPLE 5: Expose to Graded Challenges
The next principle is centered around the SAID (Specific Adaptations to Imposed Demands) principle and graded exposure. Simply stated, this can be defined as the ability of the human organism to acquire system tolerance while not exceeding its physiological limits. It is a process by which you slowly and progressively expose yourself to some form of stress, driving adaptations to better handle exposure to similar stressors in the future. In the context of movement, threatening and challenging movements are progressively introduced, in the right dosage and timing, to decrease the perception of pain or improvement in capacity. This can initially be done through novel, non-threatening movements that increase our capacity to move and down regulate the alarm systems threat detection. The big goal with graded exposure is to find the athletes or patients “sweet spot” or “entry point” for loading that will encourage adaptation without going too far past their envelope of function (Scott Dye), or this tissues/systems capacity for stress. These could lead to supraphysiological overload or structural failure not conducive for optimizing performance.
To add to the concept of graded exposure it is important to consider that while an athlete may have the required physicality to perform, they may not have accumulated enough total workload to be able to compete and perform at a high volume and frequency, especially when it comes to practice duration. A high acute (current week) to chronic (previous month) workload ratio may influence susceptibility of future insult/injury due to inability to handle stressors/ demands at a repetitive rate (load management/ Tim Gabbett). Following an injury or surgery our chronic workloads are greatly diminished and we build up stress “debt”. Prior to returning to competition, the goal is to pay off the debt we owe from the injury (healing) and then start saving to accumulate what we have lost. This is accomplished with tactfully periodized challenges, intensity, duration, volume and frequency.
PRINCIPLE 6: Cultivate Self-Optimism/Communication
The last and perhaps most significant principle is to cultivate self-optimism. This can be viewed as the ability to acquire a mentality of robustness and anti-fragility. The purpose is to provide confidence and an internal locus of control, defined as an individual’s belief in their ability to influence events and outcomes through their behaviors. The importance of cultivating an internal locus of control is often overlooked in the healthcare field and sports performance worlds, however, it is probably one of the most influential factors for success. Individuals with external locus of control tend to place blame on outside forces and feel as though they have little control over outcomes and events that transpire. Facilitating an internal locus of control mindset will likely lead to more motivated and success-oriented patients/clients. Encouraging, whether intentionally or not, an external locus on control may instill patients with a mindset of helplessness and even fragility. These patients may become hyper-focused on certain “issues” and search for the magic pill or magic hands to lead them to success.
As we know an injury can lead to a decrease in self-worth. This is where cultivating self-optimism really comes into play. During the process of rehab athletes may become anxious regarding re-injury and apprehensive about performing certain tasks. This makes sense as the brain will place emphasis on the harmed/affected limb or essentially increase the alarm systems strength. This alarm system remains up regulated as long as a person remains nervous and lacks confidence about the injured area. When the brain feels the threat to be decreased (via positive input and thoughts/beliefs) typically the reigns are taken off and less attention on the limb. If this does not occur, will remain locked up and limit movement variability, and thus progress going forward. It is our responsibility, as movement professionals, to instill belief and capability by cultivating a process that provides small wins over time to reveal achievements.
It is important to understand that no methods are inherently right or wrong except in the light of principles and a defined process. When principles are not in place to define the “why” behind the particular methods and a process is not in place to justify the “when” of implementation we are flying blind. Success and failures will not be able to be properly audited and learning will be stunted. With values and core beliefs it is easier to navigate the sea of current, past, and future methods that may deliver sustainable outcomes for clients. It also equips you with the knowledge to avoid emphasis on superfluous, overly complex, and unsubstantiated information when it comes to health, rehabilitation and performance. Principles will always reign supreme over methods when it comes to delivering consistent outcomes.
Written by Jarred Boyd (PT, DPT, ATC, SCS, CSCS) and Anthony Iannarino (PT, DPT, PRC, CSCS).