Programming From Rehabilitation to Performance

David Joyce

Introduction

One of the basic aims of spinal rehabilitation is to progress the client from the acute injury phase to a state of full function. The specific demands of the full-function state will vary dependent on the individual and the needs of their occupation, whether they range from elite sport to military action, from office work to parenting duties. All have their specific physical demands and the rehabilitation process should commence with a clear understanding of these demands, in much the same way that a sporting coach will have a clear understanding of the performance they want from their athlete at the end of a training program (Table 23.1).

Unfortunately, rehabilitation programs are very rarely planned in such strategic detail, leaving the client at best short of peak performance, and at worst open to further injury. This is because many rehabilitation programs pay no heed to the fluctuations in physical loading required to maximize the performance outcome, instead adding progressively more load. This may work for a short-term rehabilitation, but for anything longer than 6 weeks, the retraining program needs to be appropriately periodized.

The aims of this chapter are to:

Introduce the concept of periodized rehabilitation;
Explain its utility especially in light of emerging evidence of the deleterious effects of poorly planned rehabilitation loading;
Propose an effective model of periodized spinal injury retraining.

Table 23.1 Examples of the Different Demands a Spine May Encounter According to the Demands of the Individual’s Occupation

Occupation	Demands
Elite sport	Collisions, extremes of motion, heavy and repetitive training loads
Military	Long marches, carrying heavy equipment
Office work	Prolonged sitting
Parenting	Bending over a cot or change table Carrying a wriggling toddler

The Importance of Capacity Building

Injuries occur when the load imposed on a body part exceeds that part’s capacity to tolerate the load. This is true regardless of whether the load is a sudden acute force, or repetitive, subthreshold loading over a protracted period of time.

When load > tolerance ⇒ injury

Much injury rehabilitation literature centers around decreasing the mechanical stress on injured tissue. This works on the first part of the above equation, and essentially centers on the reduction of threat. This is, of course, good sensible practice for a repairing body part. It does not, however, provide enough comfort for the practitioner when returning their client to their chosen field of endeavor, because it is not working on the second part of the equation, namely increasing the capacity of the organism to tolerate forces (increasing margin of safety). Really, this capacity building should be the central tenet of all rehabilitation programs.

Failure to do this means an undue reliance is placed on chance when returning a client to their tasks. There can be a world of difference between the client being pain free, and the client being ready to return to performance. The first part is often a consequence of considering the first part of the injury equation (reduction of threat), whereas the second part is contingent upon the individual having being appropriately conditioned to withstand the functional demands (increasing margin of safety). Examples of these parts of the equation can be seen in Table 23.2. We should, however, be not simply looking at injury prevention as an outcome measure. Although we could rearrange the equation to say:

When tolerance > load ⇒ injury prevention,

we need to shift our thinking toward performance optimization. When tolerance is too far in excess of load, one could mount the argument that the individual is under loaded. As it is a dynamic organism, the human body will adapt downward quite quickly to adjust to this load-under-threshold. Eventually, in its quest to find equilibrium, the body will reduce its threshold to meet the load, through dynamic tissue adaptation (e.g., muscle-tendon unit atrophy or bone stock amelioration). The art of the practitioner, therefore, is to assess exactly where this so-called “performance line” is, so that the client is neither under, nor over, loaded.
We should always have building capacity, or tolerance, as our primary goal of rehabilitation.

Table 23.2 Examples of Methods That Can Be Used to Reduce Threat, and Increase the Margin of Safety

Injury

Methods of Reducing Threat

Methods of Increasing Safety Margin

Chronic neck pain

Reduction in or removal of injurious load

Reassurance and education about pain physiology

Gentle mobility exercises

Active exercise therapy

Maintenance of cardiovascular fitness

Progressive neck stability and strengthening exercises

Shoulder girdle strengthening

Trampolining

Graduated reintroduction to function

Acute low back pain

Reduction in or removal of injurious load

Reassurance and education about pain physiology

Gentle mobility exercises

Acupuncture

Active exercise therapy

Maintenance of cardiovascular fitness

Progressive lumbar stability and strengthening exercises

Lower limb strengthening

Hula-hooping

Graduated reintroduction to function

It is important, however, that when we consider “capacity building,” we should not limit ourselves to thinking solely in terms of the mechanical strength of the injured tissue. The rehabilitation specialist should have a holistic view of capacity that encompasses such domains of:

Tissue health of the injured structure as well as all interrelated structures (strength, power, compliance/flexibility, endurance)
Motor control (motor unit recruitment and sequencing, motor program selection)
Cardiovascular health (both aerobic and anaerobic systems)
Emotional and immune health (graded exposure to “threatening” tasks)

As can be seen, therefore, the rehabilitation program needs to take the individual out of the injury, and look at all the things they can do, as opposed to simply the things they cannot do. This is somewhat of a paradigm shift for many rehabilitation professionals. It encourages a move from a medical-based model of injury to a performance-based model of retraining. Many physical therapists still are very focused on the cannot do part.

Too often, we get caught up when telling our clients about the need to not sit, or bend, or lift. This no doubt stems from the wish to do no further damage and is admirable in its intent. It does, however, place the injury and not the person at the center of the model, and it neglects all the other aspects of the individual that can be loaded. For example, it is amazing how much better low back pain often feels after a pool session with some carefully designed flexibility and reaction work.

Commence With the End in Mind

When planning the spinal rehabilitation program, the clinician should have a clear understanding of the demands of the task the individual needs to return to. This may include (but is not limited to) any or a combination of:

Running (total volume, high speed running, change of direction, acceleration, deceleration)
Lifting (type, frequency, mass, object)
Movement (plane, combined, resisted, frequency)
Landing (height of descent, single leg, double leg, surface)

Perhaps the best way to do this is to determine the most “risky” features of the tasks that the individual needs to return to. For a gymnast with a lumbar spine pars stress reaction, it would be wise to have an understanding of the spinal extension demands of a full training week. For a rower with thoracic spine pain or rib stress fractures, it is necessary to have a very clear appreciation of both the on-water and off-water demands on the athlete. For the client with neck pain who works on a building site, it is necessary to gain a full understanding of the intensity and frequency of vibration forces imposed by operating the machinery
necessary to fully perform their work duties. Once this has been done, the rehabilitation process can be planned appropriately, and stepwise, progressive graded exposure to these tasks can be accounted for.

In the sport of Australian Rules Football, for example, players are exposed to loaded flexed spinal postures when gathering the ball. It is a game involving 360-degree contact, and thus the players must be competent to:

Achieve these postures
Absorb impacts and perturbation applied from any point on the compass
Rapidly return to an upright position in order to distribute the ball to a teammate.

Videos demonstrate an example of a progression from regaining full range of spinal flexion through to bending to pick up a ball under laterally applied collision pressure. In this instance, an analysis of the sporting demands was made, and then pared back to ensure that competency milestones were appropriately selected and placed in the rehabilitation program.

These videos highlight the need to “start with the end in mind,” and sequentially apply stress to the body in such a way that the athlete is not just competent, but fully confident to go back into the competitive environment following and injury.

Considerations When Planning a Rehabilitation Program

The human body provides a remarkable example of how adaptation follows stimulus, and this construct provides the central plank upon which training and rehabilitation programs are designed. The aim of (re)training is to provide the correct environment,^* whereby an accumulation of cell signaling, hormonal, neural, and immune responses lead to the neuroendocrine-immuno-musculoskeletal adaptations required for functional enhancement.¹

This enhancement, also known as a supercompensation response, provides the rehabilitation specialist with the underpinning objective for every program that needs to be designed. Supercompensation is the term used to describe an adaptive performance improvement following a period where training stresses are summated over time with appropriate recovery. It is the reason why athletes train. We can apply it in the rehabilitation setting to mean a functional improvement following a period of retraining.

As with all training programs, however, the accumulation of these stresses cannot be haphazard. If the overall volume of rehabilitation load, its intensity, frequency, or type of stress is too great or inappropriate for the tissue or its healing stage, the individual will move past the positive adaptive state, to one of maladaptation where the risk of injury, illness, or poor performance is elevated.²

As such, the accumulation of these loading stimuli needs to be coordinated in an appropriate manner, through a process known as periodization.

When one examines the scientific literature, the topic of periodization is replete with research examining the practice of manipulating physical adaptive stimuli in order to progress performance toward a predefined competitive peak.³ It is based on the premise that to progress the physical performance of an individual, training loads must fluctuate in volume and intensity; they cannot inexorably increase with impunity due to the sequelae of performance blunting, overfatigue, illness, or injury, all symptoms of the overtraining syndrome.⁴

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