I have worked in sports medicine and rehabilitation for nearly 25 years – treating athletes at the highest level of competition, the average person with a minor sprained ankle, and even combat veterans coming back from war with an incomplete spinal cord injury. I have summarized what I have learned into a few concepts of rehab that patients should expect with any injury.
Pain during rehabilitation is okay. Rehabilitative therapy should not be pain-free, as some pain is fine and expected. Any pain above a 5/10 is counterproductive. The key to pain is not how you feel right after therapy, but how you feel 24-48 hours later. If the pain is a 5/10 during rehab, but a 2/10 the next day, we are making productive progress. After years of coaching wrestling, I have learned to explain the difference between being “hurt” versus being “injured.” I can help you recover if you are hurt, but I will cause more harm than good if you recently endured an injury.
Movement is key. There is not a single injury in which movement does not provide a benefit. Move as much as possible within tolerable limits. Movement activates the following:
Nervous system, reducing the effects of atrophy
Endocrine system, regulating hormones to aid the body’s healing process
Cardiovascular system, increasing blood flow to expedite the healing process
Lymphatic system, aiding the immune system to help fight off infection.
Therapy must remain consistent. Chronic injuries do not develop overnight, and they will not be healed overnight. One rehabilitation session will not fix any injury; however, one session can make it worse if progression is too swift. Therapy is not a race. Just because a patient can tolerate an exercise, it does not equate to being beneficial. If therapy progresses too quickly, it exceeds the capacity for the tissue to recover and delays healing.
Improvements in range-of-motion (ROM) can only be improved under load. Although there is a major benefit to static stretching as it relates to muscle inhibition, it will not improve motion. Muscle tissue needs to be active in a dynamic manner through a full range of motion to restore function and motion.
The “placebo effect” is very real. If a patient believes a treatment is beneficial to them, then the therapy will be successful – positive thoughts bring about positive results. Rehabilitation and healthcare professionals should not discourage any treatment protocol unless it will reduce the healing process or worsen the injury. Individualized therapy is paramount to addressing the interconnected nature of any injury.
Improving strength can fix everything. There has never been a single circumstance in which improving overall strength and power has ever shown to be detrimental to the recovery process – actually, the opposite is true, improving strength around the joint and beyond always proves to be beneficial. Improving overall strength should be one main goal for any rehabilitation protocol.
Rehabilitative therapy sessions should emulate an individualized exercise prescription. Aside from the very early acute phase where an injury is isolated, all rehabilitation should look like a traditional exercise session. Some exercises will need to be modified to protect (inhibit) certain muscles, while other exercises will be modified to stimulate (activate) other muscles, but the overall exercise prescription should not vary dramatically.
Muscle tissues need to be exposed to many various forces. The goal of rehabilitation should prepare the tissue for the future demands that will be placed upon it. Exercise choices should be individualized to each specific patient, as exercise history (motor unit synchronization), type and severity of the injury, and patient’s needs and goals determine the rehabilitative treatment required for long-term quality of life.
Diagnosis is not always the most important information when designing a treatment protocol. There are thousands of special essays for the shoulder, whereas a positive or negative result does not matter all that much. The determination of therapy prescription should ask: What are the patient’s limitations? How can we fix these limitations? Therapists tend to develop “tunnel vision” when developing a treatment protocol, being over-concerned with exactly “what hurts” when it will not change the rehabilitation and the interconnectedness within adjacent joint structures.
Systems matter more than any specific injury. The human body works within a framework of several systems being interconnected and reliant upon one another – consequently, rehabilitation should be focused on how one region of the body directly or indirectly impacts another (known as the regional interdependence model). An example of this would be found in how we address an ankle sprain versus an achilles strain, whereas rehabilitation therapies are virtually identical in joint strength and mobility – the focus should be rehabilitating the joint, not the injury.
A patient’s mobility is more important than flexibility. Many young clinicians become overly obsessed with range-of-motion essays and measurements. The argument: “The patient needs to have the ‘textbook’ 140 degrees of hip flexion as the primary goal.” In my contrary opinion, I believe the goal should focus on the patient being able to perform all of their activities of daily living and exercise pain-free. Movement is life – if a patient can perform all overall movements pain-free, the degree of hip flexion now has no practical relevance.
Joint stability improves through strength exercises. If rehabilitative therapy can improve force development (motor unit synchronization and recruitment), there will be a notable increase in overall stability within the joint via the co-contraction of synergistic and stabilizing muscles. It is imperative for rehabilitation protocols to focus on stimulating muscles and performing joint movements in an unstable environment – if there is a decrease in demand placed upon the region, there will be a dramatic decrease in strength gains to stabilize the joint.
Unilateral exercises used throughout the rehabilitation will consistently fix muscle imbalances. By increasing the use of single-arm and single-leg exercises, weaknesses will be exposed that typically would not be seen with traditional bilateral movements. Whether an imbalance or injury, unilateral movements will overcome compensations through greater motor unit recruitment and synchronization demanded to perform quality movement patterns.
Focus on changing only one variable at a time. A rehabilitative therapy prescription should not only be individualized but should also have a clearly laid out plan of progression. How patients respond to various therapies and which type of therapy is most beneficial is unique to each person. If the therapy progression modifies too many variables at once, the therapist and patient are unable to determine which modality of therapy was truly beneficial in treatment.
All rehabilitation sessions are about evaluation. Virtually every therapist uses their first rehabilitation session as an evaluation, as it is the most important metric in establishing an individualized, safe and effective therapy prescription. Within the initial assessment, countless essays can be performed, which provides an insurmountable log of data, however, most of the information will not inform the therapist what daily tasks a patient can or cannot perform, whereas the therapist cannot determine the root cause of dysfunction. A therapist needs to get their patient moving within the initial session, which leads to a swift conclusion in finding patient limitations and determining which therapy would be most beneficial. Additionally, each therapy session should be used as an opportunity to reevaluate how well the rehab prescription is progressing, and whether to modify any therapies.
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