Rehab Process and Objectivity
If we view the rehab process as an opportunity, weather that be a developmental, robustness and/or performance based. Once we gain this view point we can widen our approach to the player or individual and instead of treating the injury site we then treat the whole system. This approach is of course easier and simpler during long term rehab when compared to short term. With long term injuries we have the chance to do a deeper dive and wider needs analysis as naturally we have a longer time with the athlete, more time to plan and develop a strategy even change tactics if required. With this being said, if we go after to many aims or objectives the process can become over complex. If this happens we can get conflicting ideologies and strategies that not only confuse us as the practitioner but ultimately the athlete that can lead to less buy in, over stimulation and decrease the outcome.
There are two ways we can look to counter this, finding common objectivity that forms the core of our rehab which we can base themes, plans and content which runs from start to finish. Or we can choose to focus on stages or periods of rehab that last a limited time with one or two outcomes at the end. Here that certain stage will be fully engaged to develop the objectivity you have chosen before moving on to another objective, usually a higher stimulus. Both strategies have pro’s and con’s with the former being more simplistic in its approach but give you the ability to complete a deeper dive whereas the latter gives more complexity but allows development within a number of facets of individuals performance or development outcomes. However, we could combine these strategies whereby we chose one or two main objectives that remain stable or are our primary objectives with our secondary and tertiary objectives changing with the type of training or rehab the individual is being subjected to. This is and should be heavily dependent on who and what the players individual and performance aims have been identified as.
Objectivity should form the mainstay of your process that helps set targets and forms the metaphorical walls of which aids your planning and content. As you hit your objective targets your walls expand, you’ll find that your content grows alongside. The development of technology alongside sports science and sports medicine means we have a much clearer picture on how the individual or injury is performing. In my opinion this is a massive boost to how we operate. We no longer need to be beholden to tissue healing times in our progressions or time frames to return from injury. We can also leave subjective assessments, such as tissue tone or the way a player looks or feels like as background information to help inform our decisions rather than be based on. Thus, helping gain a more rounded and fuller picture on athlete and tissue health. As technologies advance and become more widely available we will gain further insight into how objectivity with the supports of subjective data can assist with decision making. It’s important to note that time frames and tissue healing times are still important. Progression in rehab through objectivity must be proven and errant with selected markers still adhered to and hit.
What is objectivity and what should I look out for?
Objectivity can come in many forms, strength, power, speed etc this is because we can put numbers to this information, and it is easily measurable. For example, increase in strength therefore we see an increase in force measured in Newtons. This form of information is paramount when it comes to injury as we gain an understanding as to how much tensile strength the tissue can tolerate or how much force the joint can withstand. This then gives the green light to proceed to the next stage of rehab or if the tissue still requires a period to develop. We can now see how this helps to aid our decisions through the process.
Testing through rehab can be easy to complete as we usually have more time with the athlete during this period, but it can be difficult to know when to complete this. We must understand there is a difference between long term rehab, where a player has potentially had surgery and short to medium term. For example, after ACL surgery I will wait for the post-surgical management period to have elapsed and for a period of introduction movement patterning rehab to commence before I think about performance-based objectives. This is to allow for any inflammation period to have decreased and allowed for normal knee function to resume.
During short to medium term rehab, usually defined as 6 weeks or less where time and planning is critical. Here, the first round of testing we may we have some symptoms present, usually pain, soreness or tightness and this is often termed ‘P1’. For me this is vital information as I have taken to the tissue to its current limitation while gaining important objectivity that will guide my rehab in the coming days and weeks. This objectivity will give what we call an ‘LSI’ or limb symmetry index number as well as a figure we can compare to more arbitrary information. However, we must take care and caution when using the ever-popular LSI as this compares the injured limb to the non-injured limb. What is the athlete has injured their dominant side or is going through a development or upskilling phase by which both injured and non-injured limbs need a form of intervention? Therefore, we must use LSI in connection with pre-season, current cohort and/or arbitrary data that is known to us. Then gaining a deeper understanding of what the individual’s needs from an injury and development point of view.
Understanding what to look out for and what that means for either progression or regression is vital to taking a step in the right direction for your athlete. There is a plethora of evidence that supports this. The likes of VALD and Hawkins Dynamics can give detailed evidence in what we should be aiming towards. From Isometric squat and mid-thigh pull to counter movement jump, drop jump and now rebound jumps to help guide us and our athletes through the process. It’s then up to the practitioner what to use and specifically what metric to go after.
If we take a look and put this into practice through some typical and widely used metrics.
So, what do we know?
In terms of LSI, we ideally aim for within 5-10%. However, this can take time and ultimately, we have players that are one sided dominant so may naturally have up to a 10% difference between each limb. So, during rehab for progression to a higher stimulus I look for a 15-20% LSI. It must be noted that if a player is at 20% caution will be taken on what I expose them to, what intensities and how much. This then gives me the opportunity to run a concurrent program where the nuances of each session will be heavily dependent on daily aims and objectives and what has happened on the previous days.
My experience in working with LSI’s is anecdotal and learnt through experience and is very much on a case-by-case sicario. Given more time with an athlete I would prefer to be more within 10% but working in professional sports we do not always get the luxury of time.
As stated before I use LSI’s as a secondary aim, we have other more widely researched objectivity we can aim for. See the table below for some widely used tests and what we should be aiming for within rehab.
We know that within upright running at sprinting speed can generate up to 9x body weight of forces. However, we know that within a gym setting is near on impossible to get near this exposure. So, what is the minimum requirement? This has been set at 4-4.4x body weight by Alex Natera and team with the support of VALD. Therefore, we must prepare our injured athlete to this level of either tensile strength or and/or forces.
