Part 1/2 – The Rehab-Training Continuum
In my opinion, everything we do as coaches and clinicians falls somewhere on the rehab-training continuum. Thinking in this way provides guiding principles that can help organize a treatment plan with the end goal in mind.
This model has helped me prioritize what interventions to use and when to use them. It has also clarified why I choose to do what I do. Other goals include:
To guide and direct a logical progression from rehab through to athletic performance.
To orient ourselves towards what we are working on, where we are at and where we hope to get to with an athlete.
To define the variables and targets of the Rehab-Training Continuum.
As we move from left to right on the graph, traditional “rehab” should decrease while traditional “training” should increase. This is represented by the triangle and inverted triangle for rehab and training respectively. It’s important to note that the rehab-training process is a gradient that often has ill-defined borders. If we’re doing it right, we shouldn’t really be able to tell who is rehabbing and who is training, especially as we progress pass the acute stages.
The purpose of the following sections is to define the terms I have used and explain the clinical reasoning behind the proposed framework. Explanations will be following the graph from left to right, so please refer to the images for context.
Additional Considerations:
The human system isn’t as linear as I have laid out – this is a product of the complex domain. I have created this hierarchy to visualize the rehab-training continuum in a systematic way. In reality, things operate more like a heterarchy where there are a confluence of variables contributing to the end-outcome; which means that we can often work on multiple qualities at the same time without interference. A more heterarchical visual will be presented in part 2.
An argument could be made that some interventions satisfy all three targets on the rehab side of the continuum (i.e. variability, efficiency and capacity). Depending on how you coach an exercise, this is completely reasonable. I am flexible and believe that there are multiple paths to pain-free movement.
In many cases, other paradigms work and might be more relevant. I do believe that load-management, pain science education, disease/lifestyle factors and respecting tissue healing are relevant factors. I also believe that sometimes we can “just load it” and get great results. There’s no question that the body is extremely adaptable. The better questions are: to what extent can we adapt? How can we optimize adaptability and athletic development over the long-term? How can we give the human system biomotor qualities that will support the acquisition of subsequent biomotor qualities?
If someone has an acceptable amount of variability and proficient movement skills, building capacity is probably just what they need. If variability isn’t acceptable but bodily constraints have been maximized, it would also make sense to chase subsequent qualities. Just because the categories have been laid out in such a way does not mean that we have to address each quality. Assess, determine what is needed, then apply relevant interventions.
REHAB
In rehab, an athlete’s tolerance is low and is often limited by pain. Graded exposure is used to allow the system to adapt to increasing demands.
I believe that we should target variability, efficiency and capacity in that order to create a greater ceiling of adaptability. Theoretically, we are given more room to adapt by expanding movement options then optimizing movement strategies based on known attractor states. Once we have enough variability and proficient movement skills, it make sense to apply load in order to build further robustness in the tissues and organism as a whole. This systematic and logical approach can applied broadly across different rehab scenarios.
VARIABILITY
DEFINITIONS:
Movement variability – the ability to express as many degrees of freedom as possible keeping specificity in mind.
Coordinative variability – deviation in the path of movement but consistency with the movement outcome.
Position – the relative motions and absolute orientations of the bones. Considers length-tension relationships of myofascia (i.e. concentric/eccentric orientation). Measured through passive range of motion, with the interpretation of these tests acting as proxy measures for axial skeleton position.
Mobility – joint mobility and soft tissue extensibility. Can be neural, myofascial, articular or visceral in origin. Measured directly through passive range of motion and local biomechanical assessment.
Why is variability important in pain management?
In rehabilitation, our intention is to expand total variability of the organism in order to recapture health (1). Movement variability allows the human system the opportunity to choose the best strategy that is dictated by the task and environment. Having options for motion leads to an adaptable system. A loss of movement options results in repeated force vectors, which could lead to overuse injuries and tissue breakdown (2)(3). Variable distribution of force could prevent “pattern overload” and build tolerance in different lines of tissue (2)(3). Expert movers have a high coordinative variability when performing their craft (2)(3). This is a very desirable trait, but only up to a certain point – too little and too much variability is associated with increased injury risk (2)(3).
Injury and pain can also limit movement variability (2)(3). When we have painful structures or patterns, our body has a difficult time accessing certain movements. This becomes problematic over time, especially if we develop rigid movement strategies and are fixed to a limited number of paths. Our nervous system ends up confining us and triggers a perception of threat in unfamiliar ranges or vectors. Ultimately, invariable movement could be both a cause and effect of pain.
Why should we prioritize position before mobility?
From a hierarchical perspective, the axial skeleton and pelvis are the foundation for peripheral mechanics. Our first priority should be to normalize the position of our chassis in order to optimize the function of our limbs. If we ignore this logic by working on peripheral mechanics alone, optimizing health and performance may prove difficult.
Optimizing joint position first will give the body an opportunity to express how much mobility it actually has. This will allow us to apply mobility interventions to appropriate areas. Both of these measures are used to indicate the potential for movement variability.
Why should we prioritize position, mobility then motor control?
Limited mobility impacts the quality of sensory input; and sensory input dictates the quality of motor output (4). Clearing mobility issues gives the nervous systems more timely, accurate and complete information which allows for better movement outcomes. Put simply, when feedback loops become distorted, the output lacks quality.
EFFICIENCY
DEFINITIONS:
Efficiency – expressing movement economy through multi-joint coordination and motor control. Energy conservation based on physics and known attractor states.
Movement Economy – gaining mechanical advantage through optimal leverage (i.e. moment arms), joint stacking (i.e. force vectors through axis of joint), summation of forces (ex. kinematic sequence of a throw), positioning COM over BOS, and dispersed over focal loading of tissues.
Attractors – self-organization towards stable, low-energy patterns. Commonalities in the execution of a movement based on movement economy and the principles of physics. Ideally, we jump from one attractor state to another in order to achieve efficient movement. Attractors should be maximized, but movement would be too rigid if this was the only option. (5)
Fluctuators – unstable and high-energy movements that allow for adaptability. Self-organization based on the constraints of the organism and shifting task and environmental demands. Fluctuators should be minimized but are necessary to avoid rigidity. (5)
Motor control – the ability to access and control both the path and outer excursion of movement. The coordination, balance, timing and recruitment patterns associated with movement. Synergies that are easy for the brain to give command to at low and high speeds. (4)(5)
How can we leverage an attractor-fluctuator landscape when rehabilitating movement?
A balance between attractors and fluctuators are needed in order to satisfy movement efficiency while maintaining adaptability (5). This attractor-fluctuator landscape is an example of self-organization: the constraints of the organism, task and environment dictate the movement that is afforded. These concepts can be applied to rehab by changing how we coach movements during low-threshold tasks.
Attractors are seen in the set-up and the end-point of an exercise. If we get the start position right, the rest of the movement will often take care of itself. Visual, verbal and tactile cuing can create a sensory-rich experience that maximizes nervous system inputs while create better movement outcomes. Repetition and load can deepen the attractor wells for fundamental movements, which act as the building blocks that all other movement is derived from. Motor learning allows these attractors to become automatic and universally applicable.
Fluctuators are expressed through the path of motion during an exercise. The athlete will self-organize during this phase based on the constraints of the organism, task and environment. High coordinative variability will allow for fluctuators to be expressed. This functions to improve adaptability as external demands change.
Two visual representations of an attractor-fluctuator landscape from Frans Bosch’s book ‘Strength Training and Coordination’. (5)
CAPACITY
DEFINITIONS:
Capacity – developing physical outputs that match task and environmental demands. The ability to absorb and produce force while tolerating and recovering from loads.
Return-to-Play Progression
1. Isometrics – used for positional strength, time-under-tension and pain modulation.
2. Foundational strength – used to build fundamental patterns through heavy-slow resistance training and tempo work.
3. Absorption/deceleration – used for energy storage capabilities and eccentric control. Introduction to speed qualities – you can only produce what you can absorb.
4. Propulsion/power output – used for power development through fast concentric actions. Longer ground contact times.
5. Elasticity/repeated power – used for repeated power development via the stretch-shortening-cycle. Shorter ground contact times.
Why is it important to build capacity?
Injury occurs when an acute or chronic force exceeds a tissues capacity. To leverage this principle, we must intelligently apply load to the body in order to build robustness in the tissues and organism as a whole. Load should be applied based on a needs analysis of the sport and should replicate force-velocity profiles, force vectors, joint angles and actions, energy system demands and common injury mechanisms.
The capacity phase of rehab should be indistinguishable from traditional training methods. I have therefore categorized this phase under ‘general preparation’ as it seamlessly transition into the accumulation phase of training. Our understanding of exercise progressions and regressions will allow us to scale movements accordingly.
TRAINING
In training, our intent is to build capacity based on a needs analysis of the sport. Progressive overload is used to allow the system to adapt to increasing demands.
This side of the continuum is biased towards long-term athletic development. Early phases aim to develop a foundation that will support the acquisition of specific qualities later on. The general trend over a macrocycle is for volume and variability to decrease as intensity and specificity increases. That being said, it’s important to maintain enough movement variability throughout all phases to ensure adaptability and proper execution of sport skills.
ACCUMULATION
DEFINITIONS:
Accumulation – building volume and hypertrophy that supports strength development in later phases.
General Preparation:
Strength training: should include a vast array of movements focusing on fundamental patterns. The following movement categories are relevant:
Squat, hinge, step and lunge patterns. Bilateral, asymmetrical bilateral, split and single leg stances.
Push (horizontal/vertical), pull (horizontal/vertical) and single arm movements
Loaded carries, locomotion and ground work
Anti-rotation, anti-extension, anti-flexion and anti-lateral flexion movements
Movements in 3 planes of motion keeping specificity in mind
Conditioning: building an aerobic base to assist with the development of anaerobic fitness. Developing the foundation that supports our ability to recover. Keep in mind work:rest ratio’s for sport as supported by the literature.
What is the goal of the ‘accumulation’ phase?
Accumulating volume allows us to build athletic qualities that will to assist with strength development later on. This phase also functions to re-apply basic patterns that are lost during over-specialization.
INTENSIFICATION
DEFINITIONS:
Intensification – building strength with moderate specificity. Supports skill acquisition with sport-specific tasks.
General preparation transitioning into special strength:
Strength training: fundamental patterns and some special strength exercises.
Conditioning: starting to more closely mimic work:rest ratio’s for sport as supported by the literature.
What is the goal of the ‘intensification’ phase?
The goal is to build strength related to the demands of the sport. Load should be applied based on a needs analysis of the sport and should replicate force-velocity profiles, force vectors, joint angles and actions, energy system demands and common injury mechanisms.
REALIZATION
DEFINITIONS:
Realization – sport-specific strength training with the intent of maximal transfer.
Special Strength:
Special strength training: exercises aimed at transferring directly to sport performance. Should rely heavily on specificity and the needs of the sport, position and individual. Exercises could be followed up by the full execution of a skill in order to re-stabilize the pattern.
Conditioning: direct match to work:rest ratio’s for sport as supported by the literature.
How can we leverage an attractor-fluctuator landscape when coaching movement?
As mentioned previously, the human system self-organizes itself by balancing attractors and fluctuators. These concepts can be applied to training by changing how we coach movements during high-threshold tasks.
Attractor states are seen in the set-up and the end-point of gym movements. Sport skills are often more complex and therefore have more attractors throughout the movements. For example, there are various ‘checkpoints’ in the kinematic sequence of a baseball swing that are desirable in order to execute the skill efficiently.
Fluctuators are expressed through the path of a movement, both in the gym and with sport skills. There should be variation between individuals and between repetitions executed by the same individual. Fluctuators are innate to the athlete and therefore do not require coaching. For example, we see variable execution in the movement between ‘checkpoints’ of a baseball swing based on the individuals physics and anthopometry.
Using a baseball swing as an example of an attractor-fluctuator landscape in a sport skill. (5)
What is the goal of the ‘realization’ phase?
The goal is to peak for the competitive phase of sport. Programming should directly correspond to a needs analysis of the sport and should replicate force-velocity profiles, force vectors, joint angles and actions, energy system demands and common injury mechanisms.
In part two, I’ll be applying this model to case studies and creating athlete specific profiles using the variables above. Tune in next week for more!
References:
1. Hartman B. The Intensive IX. Presentation presented at IFAST; 2019.
2. Hamill J, Palmer C, Van Emmerik R. Coordinative variability and overuse injury. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2012;4(1).
3. Stergiou N, Decker L. Human movement variability, nonlinear dynamics, and pathology: Is there a connection?. Human Movement Science. 2011;30(5):869-888.
4. Cook G, Burton L, Kiesel K, Bryant M, Torine J. Movement. Aptos, CA: On Target Publications; 2015.
5. Bosch F. Strength Training and Coordination: An Integrative Approach. 2010Publishers; 2015.