Tag Archive: rehab

1. 5 Tenets of Sports Injury Rehabilitation

   7th August 2018 1:43 pm Leave a Comment

   Movement is the foundation of sports injury rehabilitation

   Dr Grace Golden gave an insightful presentation on returning to sporting activity at GAIN 2018. I liked her systematic approach which was well illustrated with video examples. She also had a large amount of creativity and fun involved in her rehabilitation sessions.

   Coaching the injured athlete

   Grace “coaches” the rehab sessions, which is different from the experiences of many athletes who are returning from injury. Grace understands the need for skill development and fun in the rehab process. She often works on the sidelines with teams and integrates the rehab with the sport training. This is very important for athlete morale (it also helps remind the coach that the athlete is still alive and kicking).

   Communicating between members of staff is also important. The rehabilitation world uses inconsistent language when working with injured athletes:

   • Return to activity.
   • Return to sport.
   • Return to play.
   • Return to competition.

   What are we trying to do? All of the above are different in intensity, but athletes are often told to “rest for 4 weeks” by a medical professional. There is a difference between graded exercise progressions and competing in a regional tournament.

   Tenet 1 Start simply

   Practise and evaluate locomotor skills in isolation.  This means training in single planes and one direction of movement at the start. Work on the fundamentals before athlete specific and specialised movements.

   “Criterion based rehab” may be a better method than “timeline” based rehab. Grace uses the single leg squat (SLS) as one criterion.  One target is to do 70 sls in a 2 minute span, ideally with a 90degree knee angle, but 70-90 degrees is acceptable. The athlete rests for 2 minutes then repeats, building up to 3 sets total.

   This prepares the athlete for 2 minutes of running or jogging better than “rest”. Having objective criteria improves understanding between athletes, medical staff and coaches.

   Can your athletes do 70 single leg squats in 2 minutes when healthy? Are they fit to play now?

   Tenet 2 Common agility tests should not serve as the primary training stimulus or pathway to progression

   Whilst agility tests like the Illinois agility test, the 3 cone test, or the T-test may have a place in training, they are very simplistic. This means they are quickly learned and the stimulus is redundant after a few attempts.

   Better to think of a variety of exercises using different stimuli. This includes decision making in a controlled fashion.

   Tenet 3 The order we combine locomotor skills influences acceleration or deceleration exposure

   

   Deceleration is loading

   The injured body part is loaded more in deceleration activities than acceleration, Grace trains acceleration early or first and then adds deceleration.

   (See Damaging nature of decelerations)

   Tenet 4 Add discrete skills in transitions for directional and plane changes

   (as long as they have been trained previously).

   Grace broke this into 4 different phases:

   1. Continuous direction and continuous speed.
   2. Continuous direction and multiple planes.
   3. Multiple directions and multiple planes.
   4. Multiple directions and continuous planes (cutting progressions).

   Tenet 5 Be mindful of how what you are doing today is preparing the athlete for what they need later

   Or, “start with the end in mind”. The goal of rehabilitating injured sports people is very different from rehabilitating the normal population. Jogging on a treadmill pain free could be a successful outcome for Joe Public.  That is nowhere near enough for a field/court team sport person, so the rehab process needs to be structured along different lines.

   Summary

   I have barely touched the surface of Grace’s presentation on sports injury rehabilitation. Her presentation was rich with detailed examples of the exercises she uses. Most important for me was how she integrates the work with the coaching staff. It is all too easy to rehabilitate in a clinic room that doubles as a bunker.

   Further reading:

   • Reconditioning athletes
   • Planned Performance Training
   • ACL rehab for sports people

    

2. Reconditioning athletes: Bill Knowles seminar

   10th July 2017 7:12 pm 4 Comments

   “An exercise is something you do a movement is something you feel.”

   

   Bill Knowles

   Was the title of Bill Knowles’ seminar on rehabilitating (reconditioning in his terms) athletes from sports injuries.

   The question he asks himself is “what’s in the best interest of the athlete?” This often means pulling the athlete out of the injured body and getting them to recognise their athletic spirit again.  All too often in rehab settings, the focus of the treatment is on the injured part, rather than on the person (see previous seminar)

   Once you recognise that the entire body is supporting the injured knee then your perspective on getting the athlete back to competition changes.

   A few key considerations on rehabilitation

   Bill outlined some of his principles that underpin his approach to reconditioning.

   • Rate of force acceptance (deceleration) vs rate of force development (acceleration). The latter is much talked about and measured, the former is where injuries often occur.
   • Rehabilitation (medical model) vs reconditioning (performance model)

   We are looking to get back to performance so we need to think about this from the onset (I will use the term reconditioning from herein).

   • “We have to stay professionally stimulated” as improving the journey helps athletes. (It’s hard to stay professionally stimulated if you are handing out photocopied sheets of paper with “3 sets of 10” for each exercise for every person who walks into your clinic).

   This then encourages us to think of more athletic ways to train. A good way to start improving the journey is through a movement that is familiar to the athlete. Bill showed a video clip of an athlete very soon post injury, who was walking in water with a knee brace and even did some low level bouncing).

    The restoration of athletic normal

   

   Interlinked

   We are looking to prepare the athlete for return to play whilst also addressing their injury.

   Physical literacy, athletic development and athletic normal are all linked and form part of a “training based prevention”.

   Compare that to a medical intervention led prevention strategy with exercises which mean they are “just doing stuff”.

   “Training is through movement, not simplistic exercises.”

   Our aim is “The ability to move efficiently in an athletic environment with precision style and grace.” We can “start encouraging biological healing through movement.”This exercise has the added benefit of encouraging sleeping which of course is a great healer.

   If you just look at things from as sports medicine perspective, you might be satisfied with an injury that is healed. However, “just because you are biologically healed, does not mean you are athletically prepared.”

   Bill then quoted Carol Welch: “movement is medicine for creating change in a person’s physical, emotional and mental states”.

   Followed by Plato: “Lack of activity destroys the good condition”.

   The athlete must not forget what is natural and simple (to them) so this must be incorporated into their reconditioning programme.

   A “protection mindset” contributes to complexity. This is unnatural and may add no enhanced healing quality if it compromises movement quality.

   Rebuilding the formula one car

   

   Formula one ferrari

   Bill used a great analogy when looking at reconditioning. If your Ferrari formula one car is broken into pieces, you can attempt to rebuild it and end up with a red porsche. You have ended up with a fast red car, but it isn’t a formula one car.

   You have to know what the athlete looks like at the end. “I’m not interested in restoration of jogging, I’m interested in the restoration of acceleration, deceleration and change of direction.”

   

   Porsche

   Movement is so simple and yet so complex. Many clinicians prescribe exercises and restrict on other movements because they are uncomfortable with movement.

   (I know one physio whose end stage acl rehab was chatting to a footballer who was jogging on a treadmill! That was his “return to play” assessment).

   I have seen Bill present many times now since 2011 with several practical workshops too. He has given me the confidence to both discuss sports injury with clinicians and also work with athletes on reconditioning their serious injuries.

   (It helps that I can share ideas with my wife Sarah who is a Chartered Physiotherapist who has developed her knowledge of movement by becoming a level 1 strength and conditioning coach).

   

   Bill, Vern and Nick Folker at breakfast

   Bill is a fine example of the GAIN faculty and attendees who learn from the different people and return to their settings to apply, innovate and develop their knowledge in order to help their athletes.

   I also spent an hour discussing ACL reconditioning and using the 4Dpro with athletes over dinner with Bill. This was very enlightening and will help the athletes I work with here in Devon: thanks Bill!

   Further Reading:

   • Dr Mike Joyner on Sports Science: Servant or Master?
   • Bill Knowles on Planned Performance Training

3. Planned Performance Training: Bill Knowles

   21st September 2015 9:11 am 5 Comments

   “Having nothing enhanced my career”

   Bill Knowles doesn’t have any magic answers or quick fix exercises.  His approach to injury rehabilitation based on good coaching and insisting on excellence in every exercise means injured athletes getting back to competition readiness sooner.

   Knowles delivered a quite extensive review of his methods and some research on “Return to competition strategies for the load compromised athlete”. This included video clips of his athletes working and also his ideas on creating the right environment and team for athletes to excel within.

   He started out having to work with big groups of people and not much kit, so he had to innovate and adapt right from the beginning.

   Planned Performance Reconditioning (PPR) not injury rehabilitation

   Knowles started with talking about why he doesn’t use terms like “prehab” or “rehab”. These imply start and end points and a medical based model. The athlete would then walk back on to the pitch, start competition and get reinjured.

   Instead, the PPR should be an opportunity to get the athlete better and to ensure that they are stretched, challenged and engaged throughout the process. “Ultimately injury is an opportunity to become a better soccer playing athlete and potentially a better soccer player”.

   In high performance sports you should STRIVE for a better soccer player.

   In order to evaluate and plan what you are doing you need to combine Evidence Based Medicine (Science) with Experience Based Evidence (Art).

   The coaching of the rehab process was emphasised time and again, the athlete and the exercise must be coached well. “Exercise is something you do, movement is something you feel” get the athlete out of the injury and remember who they are”.

    A Joint Compromised Athlete is a Load Compromised Athlete

   JCA            LCA

   The joint is not to be trained in isolation, it is part of the whole body and the loading has been compromised too.

   Once you are a LCA you are always an LCA. That is why you need an “Athlete Sustainability Programme”. This is something that is included throughout the year to prevent lapses.

   This is a Performance based model, compared to a Physio or Medical based model: they are not experts in planning performance training.

   This was a theme that came up several times over the conference (And Rob Newton mentioned this at the RFU conference too about Australian sport) where teams are now letting physios lead training sessions with “Pilates” or “core” and wondering why they are not performing on the pitch!

    “It’s a brain injury dude”

   Knowles explained something called “Arthrogenic Muscle Inhibition” (AMI) which is the change of the sensory receptors due to injury. This results in an inability to completely contract a muscle.

   This is a bilateral situation: Quadricep activation deficits of 7-26% in the unaffected limb have been measured. After an ACL injury the athlete is more likely to tear the opposite knee, and more likely to get reinjured than the non injured athlete.

   The AMI is severe in the short term, plateaus at about 6 months, and slowly declines over the next 18-33 months! So, training the rest of the body is important to prevent that getting weaker too. This must be continued for nearly 3 years!

   The brain has to be worked and rehabbed too: so lots of new challenges, games and activities must be included to ensure the athlete is ready to play and compete.

   “The knee bone is connected to the head bone”.

   The Central Nervous System has been affected, so this must be trained too: “It is not a race to get them back, it is a process to get them better” Gambetta.

   Envelope of healing

   The upper limit of the envelope is for the elite athlete, but too much work leads to inflammation. Too little work is safer, but it is not causing enough adaptability.

   There are no time frames for the rehab procedures, instead criteria based progressions are needed. Function leads to the next stage. For example, biologically running might be right after 8 weeks, but mechanically the loading ability isn’t ready.

   The LTAD process gets interrupted by an injury, so other areas need to be worked on during the recovery. Contact sports players need to be “toughened up” to prepare for training, others can develop volume, load or skill ability. It can be a time to “increase the player’s bandwidth” of exercise competency.

   There are so many things that can be done to “stop the bleeding of skills and mindset” when injured.  Knowles gave great examples of working with golfers and soccer players on using limited skills, or slower actions with severely injured players very early on in the rehab process.

   Summary

   It was great to see how a World Class expert in rehab works, and how he is passionate about coaching athletes.  The videos we watched and practical demonstrations we saw and did later really opened my eyes. (Physiotherapist Sarah and I discussed this when doing the rebounder exercises).

   The “Progression, Variety and Precision” that Ed Thomas talked about were very apparent in Knowles’s work.

   One of the good things about GAIN is the interaction between different professions. Everyone was learning from each other and recognising the transfer across areas.

   Come to our clinic

   If you want your sports injury rehabilitated, then you can come to our physiotherapy clinic based in Willand, Devon. Physiotherapist Sarah Marshall and myself have helped many athletes return to competition from injury.