Exercise prescription in injury rehabilitation

Injury rehabilitation is a diverse topic to discuss. We have written about it before, and here we would like to go back to some core foundational beliefs we believe to stand true regarding rehabilitation prescription. There is real gap in the physiotherapy profession when it comes to prescribing exercise for the purpose of rehabilitation. The science is pointing more and more to exercise as medicine, so I strongly feel our profession needs to beef up on our knowledge and understanding of this topic. This article focuses on a practical application for getting the right exercise principles across for injury rehab and sporting performance.

The core beliefs that I like to use when prescribing exercise are as follows:

  1. Specificity – the exercise/s given should specifically address the key issue presented and must translate into the specific function or movement required for the athlete.
  2. Progression – the exercise/s should be progressed to increase the capacity of the tissue to handle more load.
  3. Overload – the exercise/s given should be difficult enough to stimulate a supercompensation response in the tissue.
  4. Individualisation – the exercise/s must be modified to suit the athlete’s characteristics and goals.
  5. FITT principles should be used – frequency (how often), intensity (how hard), time (how long), and type (goal specific movements)

On top of these basic principles, I think every practitioner and coach should have developed or be in the process of developing their own method. This should be based on science, with clinical and practical experience adding the individual touch that makes it unique. My method is based on basic strength and conditioning principles. I will briefly discuss some of these below.

Periodisation: this is where a rehab or exercise block is broken up into different components. This should always be time limited (e.g. 8 weeks), and should include recovery weeks. Components that can and should be worked on are strength endurance, maximum strength, power, plyometrics, and mobility.

Training load (TL): this is essentially a fancy name for how much work was done. Training load is complex and can be measured in various ways. Sessional load is an easy way to measure this, using the following formula: [TL= volume x intensity]. For example, if an athlete has to do 3 sets of 15 reps of 20kg resisted knee extensions, their load for that exercise would be:

[TL= volume (3×15) x intensity (20kg)] … TL= 45 x 20 … TL= 900

This would then be calculated for each exercise given and a total sessional load would be obtained.  

Another way to use sessional load when variables such as weight and reps/sets are not available (like running training) is to use time as the volume component and ask the athlete to rate the session intensity using the Rate of Perceived Exertion (RPE) scale. For example, if an athlete does 10 reps of 30sec runs at a hard effort, and they rate the session afterwards as 8/10 on the RPE scale, there sessional load would look like this:

[TL= volume (10×30) x intensity (8)] … TL= 300 x 8 … TL=2400

Obviously, there are no predetermined numbers to reach with using this sort of training load measure. As long as the load is gradually progressed (or regressed if symptoms flare up) and is measured against the individual’s initial assessments. Essentially, you need to be tracking some form of data, otherwise you are guessing.

A major principle I like to use in prescribing exercise is the type of movements. Complex, multi-joint, and multiplanar movements have shown to be more useful than isolated joint movements (within context of the injury at hand). My go-to movements are:

  1. squat variations
  2. lunge variations
  3. deadlift variations
  4. single leg variations

Altering the ROM, reps, sets, weight, and speed of these same movements will allow for variation in the program according to the specific goals. There is no need for circus tricks. Keep it simple. Keep it challenging. Keep it progressing.

One final thought. The dosage for exercise prescription has always been higher reps with lighter weight for endurance, and lower reps with heavier weight for strength. Recently there has been emerging evidence where reps until failure can produces similar results regardless of the weight. I think the most important thing to remember is that the tissue needs to be stimulated in order to change. I like to use the time-under-tension principle, where the longer a muscle is undergoing forces, the more it will be stimulated to adapt. This is where eccentric (or negative) training and slow heavy loading can be implemented.

To end off, I think any practitioner or coach should always stick to basic principles and add their own flavour along the way. The goal should always be to leave the athlete in a better condition than when they first came for treatment. Prescribing exercise is one way of definitely achieving this goal.

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