Exercise Progression & Rehab Programs

A year or so ago, I put on a CPD evening for our part time staff at the football club discussing exercises and the clinical reasoning behind developing a program (needless to say I got talking about the use of clams for a quite a while – clam blog). In this presentation, I started drawing my reasoning process onto powerpoint using some coloured blocks to help visualise the theory that I was trying to describe.

The theoretical model was recently published in Physical Therapy in Sport and I thought I would use this blog to try and discuss it in a less formal way than the writing style allowed in publication.

 

The model (here) is designed to be fluid and adapted to any individual by any level of clinician. Let me quickly introduce the components:

A theoretical model to describe progressions and regressions for exercise rehabilitation (Blanchard & Glasgow 2014)

 

• The triangular blocks (1) represent the fundamental exercise, the core ingredient that will remain throughout the progression. The arrows running up the side of the triangles represent an ongoing progression throughout the rehab process such as speed, duration, repetition etc. So basically, something that can’t be affected by the stimuli that are added or removed. If you add an unstable surface to an exercise, you can still progress by increasing the duration.
• The coloured blocks represent a stimulus that will help the exercise progress. This can be one of two things;

1. Internal – something that the patient has to focus on intrinsically. A decreased base of support for example, where the patient must focus on the balance element of an exercise.
2. External – the addition of something to the exercise that takes the patients focus away from the movement or action they are performing – adding a ball to a running drill, or a verbal command that initiates a change in direction.

The blocks are interchangeable and can be added / removed at the clinicians discretion.

• Adding a new block, which will progress the exercise, is accompanied by a regression of the “gradient” on the blue triangle. Creating a step-like progression across the model. As you progress with an internal or external stimulus, its important to bring the difficulty levels back down, so reducing repetitions or speed or duration. This allows the pateints to adjust to the new stimuli without fear of re-injury or task failure. When teaching a child to ride a bike with stabilisers, you don’t take them off and ask them to cycle at the same speed you did with them on. For that reason, you wouldn’t get someone going from 30 reps of a hamstring bridge straight into 30 reps on a single leg bridge as a progression. You would decrease base support and reduce reps to allow adaptation.
• Adding a “block” doesn’t mean you have to add something to the exercise. The block represents a step up in their progression. So progressing from two legs to single legs is technically “taking away base of support” but is an addition to the ongoing progression.

 

Lets use an example, recently I started designing a program for a teenage footballer with a proximal adductor strain. New to professional football with no history of conditioning.

In the sub-acute stage, once intial pain had settled, we began looking at his movement patterns and stability and noticed a huge imbalance with his left sided control through sagittal and transverse planes compared to his right. He is left footed, so his plant leg (right) is used to supporting his body weight.

His body awareness and “physical literacy” was so poor we had to regress him right back to basics. The following represents a small proportion of a larger exercise program. I’m not usually an advocate of planks in a multidirectional sport like football, but in this case, his single plane control was so poor that I swallowed my pride and began with basic planks.

When I say basic, we reverted to short lever planks with the knees on the floor – this was the only was we could get him to control the relationship between his trunk and pelvis. Looking at the model, this short lever plank would be the singular blue triangle at the start (1). We built up the duration of the hold from 30 seconds to 90 seconds over time. This would be the arrow running up the gradient of the triangle.

 

The addition of the first block (2) was to increase the length of the lever so that he now has to hold a traditional plank. In doing so, we dropped from 90s hold back down to 30 seconds and over time, built up to 90s. (These are just arbitrary times, based on no real evidence).

 

The next block we added was a rotational element (3), but to ensure the progression wasn’t too sharp, I removed the long lever and returned to a short lever position. I then asked the player to move a light 1.25kg weight from his left side, with his right hand and place it on his right side. Then with his left hand etc etc. The purpose of this was to introduce a transverse task to a sagittal plane activity – as the arm moves from the ground and across the body, the player has to control the rotation through his trunk and avoid rotation at the pelvis. Instead of duration, we built up repetitions over time.

 

Now that we were confident he could hold a plank, and control rotation in a short lever plank, we could combine the two blocks as the next progression. Now in a long lever plank with a rotational element.

 

The next progression was to add an unstable surface (4). To do this, the player performed a plank with his thighs on a gym ball. This in itself was quite easy so we instantly added a rotational component with an unstable surface, gym ball pelvic rotations (see video here). So now on the model, we have the basic “plank” triangle at the top, a block underneath to symbolise the long lever, another block to symbolise rotational control and a third block to symbolise an unstable surface.

 

“The length of time required by an individual to master a task has

been described as a linear function that begins quite rapidly with

the introduction of a new task and then plateaus or slows over time

as practice continues (Gentile, 1998).”

 

 

This is a very simplistic example of how the model works, but hopefully it demonstrates the fluidity that is intended with it and how the blocks are interchangeable and can work independently or as part of a more complex progression. Every program you write will be individual and the progressions will be different, therefor every model will look different. Some will continue longer than others, some may be shorter than the one I’ve described here. Some will end up with taller columns due to the number of progressions. The width of one column compared to its neighbour may be different size due to the length of time it takes for the patient to master. And so on and so on. If I continued, hopefully I could have ended up with the player doing this:

But whats the use of that defending a counter attack?

 

Like many conversations I begin or poor jokes I tell, this may be one of those things that only makes sense in my head, but I would love to hear if it makes sense to others – if you think it works and examples of doing so.

 

Yours in Sport

 

Sam

 

 

Podcast Review: Tendons

I wonder if anyone else does this, subscribe to podcast channels and store them on your phone in an attempt to convince yourself that you’re doing CPD, but never get round to listening to them? I’ve also been known to do this with articles, printing them out then cluttering mine & my colleagues desks but never reading them.

Well I decided to catch up on a few podcasts and start listening to them in the car on the way to work. Flicking through the different channels I subscribe to, I saw 2 separate discussions about tendons. So I thought I would listen to both in succession and see what similarities or differences the experts had. These aren’t necessarily the only podcasts to talk about tendons, just 2 I had on my phone:

1) Physioedge #23: Lower Limb Tendinopathies with Dr Peter Malliaris (here)

2) The PhysioMatters Podcast session 6: Achilles Tendons with Seth O’Neil (here)

 

Revision time: 

Before we start, a quick opportunity to revise some key topics discussed below. Figure 1 demonstrates Cook & Purdhams continuum of tendinopathies.

Figure 1: Cook & Purdhams Tendinopathy Continuum (click image for article)

 

Difference between Achilles and Patella Tendon:

A particularly interesting theme throughout the podcasts was the difference between Achilles and Patella tendon pathologies. None of the podcasts openly said “lets start addressing different tendons with different management” but they pretty much edged that way.

Malliaris was careful not to align himself with any particular “recipe” for tendon treatment, but did say that if he were to prescribe a protocol, he would use a different one for Achilles than he would Patella tendons. Later in the podcast, he explains his theory on not loading the patella tendon beyond 70 – 80 degrees knee flexion, explaining that there is no benefit to heavy loading into the end range for tendons… except the achilles tendon. This makes sense, if we understand that tendinopathies are a reaction to a combination of tensile and compressive loads. For the patella tendon to be lengthened, with the knee in full flexion, the patella will be acting as a fulcrum on the tendon tissues. However, when loading the achilles in a lengthened position the calcaneous doesn’t cause as much compression on the tendon (excluding Haglund’s deformity).

A quick cameo from a third podcast (BJSM Apophyseal injuries in children and adolescents with Dr Mattheiu Sailly, here) but interestingly discusses different processes between Osgood-Schlatters and Severs disease, with less tendon involvement seen in Severs. Could this paediatric presentation be similar in adult tendinopathies?

 

Is there a benefit to deep squats with a tendinopathy?

Exercise management:

While on the topic of lengthening tendons and putting them under load, it seems apt to discuss the one exercise method that goes hand in hand with tendons, Eccentrics.

“Eccentrics are not essential – Dr Peter Malliaris”

Malliaris comes across as a big fan of eccentrics. They are a useful method of increasing time under tension (TUT) and applying a heavy load, however they do not have to be a part of every program!

If a patient is unable to perform an isometric exercise, don’t even bother attempting an eccentric exercise as they will lack the quality throughout the movement. Another example would be a program designed for a player in mid-season. In these circumstances, it could be better to provide high load isometric exercises. O’Neill supports this theory for mid-season. While we accept that eccentric exercises will help the tendon, remember that they will also fatigue the muscle and therefor could impact on performance.

It is also important to recognise the stage of tendinopathy (see Figure 1). While a degenerative tendon can be treated quite aggressively in order to increase stiffness, however most athletes are likely to present with a reactive tendinopathy. In these cases, the cellular matrix is generally intact so the management can afford to be less aggressive. In these cases, activity modification to acutely lower the load would be beneficial and combined with isometrics, which Malliaris believes have an analgesic effect.

With any program for tendons, it is important to continuously monitor pain responses. A short duration of pain following activity suggests a stable tendon, however pain for a couple days suggests a very reactive and unstable presentation. O’Neill quotes a theory based on Delayed Onset Muscle Soreness (DOMS) as the characteristics of tendon pain and DOMS are strikingly similar. He explains that fascia seems to be a source of pain as opposed to the contractile tissues. The paratenum contains most of the nerves and the structures here will suffer from the delayed onset soreness. Much like actual DOMS, the tendons respond well to loading. O’Neill uses the analogy of going for a gentle jog when you have DOMS in your legs, and feeling a bit better afterwards.Over time, changes in both central and peripheral sensititsation may cause the heightened peripheral sensitisation we see with chronic loading – hence part of our management is activity modification.

Moving on from mid-season management, Malliaris discusses the off-season and the tendency of athletes to put their feet up for a few weeks after a gruelling season. This would be detrimental to a problematic tendon and as soon as they resume intense pre-season training you will spend the whole pre-season fighting fires with a reactive tendon. Therefore prescribe off-season tendon programs that include jumping, hopping, running drills to maintain control of the tendon.

 

“True tendon problems tend to be aggravated by a Stretch Shortening Cycle – Seth O’Neill”

 

In his exercise programs, Malliaris ensures that the Stretch Shortening Cycle (SSC) is as long as the “slower exercise” phases. However, these do not have to be done in simaltenous blocks. The SSC exercises should be incorporated as early as possible, providing the movement patterns are fluid and symptoms are under control (again, its important to understand and recognise a reactive or degenerative phase tendinopathy).

 

“Patella tendinopathies love intensity and loves load”

 

Summary:

Tendon management remains a complex and daunting task for physiotherapists, yet in an age where we promote individualised management of injuries we still seem keen to follow a “recipe” for tendon management. Both podcasts discuss the importance of treating the individual, with reference given to their demands and tailoring programs to suit them. However, we seem happy to discuss “tendons” as a whole. Hamstring management has its own niche, at the same time we don’t treat all ligament injuries like an ACL. Should we start discussing individual tendons separately? As mentioned at the top, Malliaris changes his stance on loading through range when managing Patella tendons and Achilles tendons. We have only discussed these two tendons, without any reference to the rotator cuff, the hamstring tendons, flexor and extensor complexes in the forearm – all of which have different roles and demands.

What is exciting is the amount of research going into tendons and our understanding is evolving very quickly. Since my short time of being a physio, we have dropped “itis” and introduced “opathy”; eccentrics fell out of favour recently and Alfredssons protocol has been dissected and critiqued to death, yet now, with the support of Malliaris and O’Neill (amongst others) we feel comfortable using eccentrics again, but as part of a bigger program.

I highly recommend listening to the above podcasts and subscribing to their channels, they are a hugely resourceful… resource!

 

Yours in sport

Sam