General Principles of Exercise Rehabilitation

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Top Contributors - Wanda van Niekerk, Kim Jackson and Jess Bell  

Introduction

In order for clinicians to design an effective rehabilitation programme, they need to understand what the specific performance needs of the athlete or individual are. What are the athlete's goals, but also what is their current status? Identifying an athlete's current status will also identify the athlete's current constraints, and most often these constraints are around tissue injury. Implementation of the rehabilitation programme can only start if these factors are in place. The rehabilitation plan is made up out of a loading plan with a clear set of intervention intents. This results in adaptations that lead the athlete from their current status to their performance goals. An important consideration is monitoring and reviewing the interventions and also monitoring against the intended outcome.

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Performance Backward Thinking

• Performing a performance needs analysis with the athlete
  • What is the athlete's performance goal or end goal?
  • What is required to reach this goal?
  • What physical qualities underpin these?
  • What are the current capabilities?
  • What are the barriers and facilitators?

Components of a Performance Needs Analysis

Consider the following in an activity-specific needs analysis:

• Sport, role, position
  • What is the athlete’s role within the activity or sport
• Performance duration
  • Total duration of the athlete’s whole performance
  • What is the duration and frequency of training sessions?
• Activity duration
  • Continuous activity or does it require bursts of varying intensity and duration
• Activities
  • What is involved?
    • Jumping, landing, sprinting, change of direction, kicking, throwing, lifting, carrying?
• Impact sport/Collision sport/Contact sport
• Distances covered and directions moved in
• Endurance and capacity-based requirements
• Strength requirements
• Predominant muscle groups
• Predominant muscle actions
• Flexibility and range of movement demands
• Motor skill requirements

A Paradigm for Needs Analysis and Rehabilitation

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• Performance requirements can include level of strength, level of mobility, level of endurance, coordination tasks
• With an injury, the current status of the injured tissue as well as the athlete’s holistic status needs to be assessed.
  • Reliable and sensitive assessments are necessary to assess the current tissue status
    • What can the injured tissue tolerate at this moment in time?
    • What can the individual do in relation to the injured tissue at this current time with injury?
    • Consider dichotomised versus graded assessment approaches
      • Dichotomised assessment:
        • "Specific structure is painful, therefor it is injured"
        • Simple test with a yes or no answer or yes the structure is injured or no, the structure is not injured.
      • Graded assessment
        • Graded exposure of the tissue to load to see how much load the injured tissue can tolerate.
    • The assumption is often that an acute muscle/ligament/tendon injury will have zero load tolerance when the structure is injured, but often these injured structures can still tolerate a level of load even if it is very little.
      • Examples:
        • If an injured tendon can only tolerate low repetitions of body weight load, then activities such as walking can be restricted, or the relative load reduced by utilising walking aids. However, if the tendon only becomes painful or irritated after running for 10 km, it would be unsuitable to restrict the athlete from running altogether as this will most likely lead to tissue atrophy.
        • If an athlete can lift a 5 kg weight without pain or symptoms, then this would be the starting loading point.
      • Muscle Testing examples:
        • Muscle or tendon: test for the ability to tolerate load with an isometric make-test in mid-range.
        • If the athlete passes the test, then a break-test can be performed where the tissue is eccentrically loaded.
        • Following that, the muscle can be tested in outer range or elongated position, and so forth.
        • In this manner, the tissue load is determined through a graded assessment and a clearer understanding is achieved of the current status of the injured tissue.
      • The level of load an injured tissue can tolerate needs to be clearly identified
        • Note that significant muscle atrophy can occur within 5 -14 days of inactivity (Wall et al 2013). It is, therefore, crucial to determine the minimum activity an injured athlete can perform to reduce the occurrence of atrophy due to underactivity.
        • Once the gaps have been identified and a starting point for loading has been identified, that can be seen as the establishment of a stable baseline.

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A certain amount of micro failure is allowed when loading the tissue as this brings on physiological changes, which leads to tissue adaptation, and this strengthens the tissue. If we consider the load-deformation curve and sub-optimally load tissue (loading in the left-hand side of the micro failure, this will lead to tissue atrophy and the tissue will weaken to the level of the loads applied. Similarly, if the tissue is overloaded (loading to the right-hand side of the micro failure zone, this can lead to irreparable damage).

Therefore, it is imperative to apply the maximum load the specific tissue can tolerate.

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