Let’s get something clear right off the bat: manual therapy alone is not rehab. Treatment is protocol, rehab is individualized. Don’t get me wrong, I’m not saying it’s not part of rehab. After all, I’m an athletic therapist…I treat! I use manual therapy! I’m just saying that treatment alone won’t get someone back to performance.
Here’s what I see most often in my practice. People seek treatment for a musculoskeletal injury, which can involve manipulation, mobilization, traction and other clinical modalities. Essentially, these are all manual therapy methods. All of these may of course be necessary as part of the protocol for the specific injured tissue or structure. They FEEL better but they don’t GET better.
That’s because they’re not getting rehab. They’re getting treatment. And at best, they are being given one or two generic “rehab” exercises without any specific structure or further modification of their activities. Granted, there are certain exercises that everyone can benefit from. For example, almost everyone with a shoulder issue can benefit from a scapular control exercise. But no one will benefit from ONLY a scapular control exercise or the SAME ONE.
With the current COVID-19 isolation situation, I’m seeing therapy clinics offering online consultations and I’m thinking that’s a great opportunity! An opportunity to give people more individualized exercises, give people structure, get clients involved in their rehab process. At least I hope so! Hopefully it’s not just going through that exercise sheet with the client. You know that photocopied sheet with a bunch of generic rehab exercises that everyone gets…
When I finished my degree in Athletic Therapy in 2001, I was lucky to get a contract at the varsity clinic at Carleton University in Ottawa. I worked with the athletes, life was beautiful. After that contract was over, I came back to Montreal, and got a position in a physio clinic working with the gen pop (active and sedentary clients). They booked me with patients coming in every 30 minutes. By the time you take a history, if you take a good history, your 30 minutes is almost up, you know they’re another client coming. Even if it’s a return patient, 30 mins is not much time to follow up on their progress. So, you do some manual therapy, stick them on TENS, EMS or heat, and on to the next. There’s no time for client-specific exercises, education about proper movement, working through reps to create awareness. No time to even think about structure. So, you pull out the photocopy. I lasted one week. Then I took my practice to the gym. Since then, I do rehab…
You have a job as a therapist, trainer or coach to keep people moving. This means being able to provide a structure within the rehab process so that you can both protect your clients from further injury and expose them to sufficient stress to help with recovery.
A protocol is a detailed plan of treatment. It is the same for everyone. Once we step outside of the clinic, our approach needs to be individualized the same way training is. That is why I say rehab is training.
Rehab is training
In order to be effective at rehabilitation programming from the clinic to the gym, we need to understand that rehab and training are not two different entities but are a continuum. That’s why rehab is training has always been my philosophy. #rehabistraining
The idea behind rehab is training is to consistently select work within a range of effective dose-response that allows for maximal stress to the healthy tissues while still protecting injured tissues.
This is exactly what is lacking with the current generic exercises prescribed in the clinical setting. Let’s take for example a case of rotator cuff tendinopathy. An individual typically goes for treatment and is prescribed a classic side lying external rotation exercise. The objective of this exercise is to activate the rotator cuff. This makes sense, because an injured muscle becomes inhibited. By the way, I talk about these overused and misused exercises in my blog article here.
The problem arises when people are prescribed this and asked to avoid other upper body movements or perform them with very light weight. This is much too vague, and we run the risk of significantly under-loading healthy structures.
Structures and tissues adapt to physical stress, or if we’re speaking in training-specific terms, mechanical load, by a process called mechano-transduction. We are used to utilizing this process for muscles: stress the muscle to stimulate adaptations that promote muscle growth. Although they seem more “passive” than muscles, bones, tendons and ligaments, as well as cartilage are constantly and dynamically trying to adapt to their conditions. Contrary to muscles, meaningful results may take many more months or even years, but they are ongoing, which means they need to be addressed ongoingly as well.
Therefore, to be effective at rehab, we need to:
- identify loads, movements and postures that are pain-triggering to prevent ongoing irritation of sensitive or sensitized structures
- identify pain-free loads, movements and postures to avoid underloading healthy tissues and progressively load the injured tissue
This means finding the balance between protect and expose:
Understanding Rehabilitation
Of course, an understanding of the injury process and of clinical concepts is important for safe and effective rehabilitation:
Understanding the healing process:
It is important to understand the various phases of healing. Anything that is done in a rehabilitation program that interferes with the healing process will delay rehabilitation and progress. Some injuries and/or surgeries come with movement contraindications that also need to be respected to ensure the injured or repaired structure has had the time to adapt. Even without specific contraindications, the stresses of selected exercises must not be so great as to exacerbate the injured structure.
Understanding pathomechanics
When a joint or muscle is injured, normal function is compromised. Being able to assess and recognize compensation is key to re-establishing function. A solid understanding of biomechanics and functional anatomy is also essential in selecting and prescribing exercises that respect contraindications, limitations or restrictions throughout the rehab process. For example, understanding how different positions, grips, levers, etc. can impact movement so that at all times you can minimize compensation and maximize performance.
The Movement Optimization Strategy for Rehab
If you have been following me for a while, you know by now that I program using a Mobilization-Activation-Integration strategy. If you didn’t know about it, this is the strategy I teach in the Movement Optimization for Prehab and Performance Level 1 course, that by the way, is now being offered online so that you can learn from the comfort of your home!
The Movement Optimization Strategy and its application in the rehab process is essentially premised on the idea that there is a movement adaptation to pain. It has been shown that pain alters movement, although the underlying mechanisms of this behavior are not quite fully understood. While some aspects of motor adaptation to pain are consistent, changes in behavior are unique to the individual and possibly to the muscles and/or tasks.
In response to pain, the body changes the way it moves. This is a natural and quite effective protective strategy. However, it comes with consequences if it lasts for too long. Studies have shown that adaptation to pain involves a redistribution of activity within and between muscles which can lead to decreased movement variability, increased rigidity and stiffness, and altered behavior due to the threat or anticipation of pain. Here is a particularly good article on this topic: Pain and motor control: From the laboratory to rehabilitation.
An efficient rehab strategy needs to address all of these factors.
Mobilization
The objective of the Mobilization sequence is to create space or to remove any barriers to movement. In the clinic, this would involve mobilizations, traction, soft-tissue release, etc. Following injury, the redistribution of activity between muscles and consequent changes in mechanics result in modified (limited) movement and stiffness as the body’s normal protective mechanism. However, beyond the acute phase, this stiffness becomes detrimental. The Mobilization sequence helps restore movement and decrease rigidity. I always give my clients self-management tools to do this themselves, as what they can do more frequently will always provide better results than what I can once a week clinically. In our rotator cuff example, this might mean utilizing methods to down-regulate the upper traps or the levator scapula, which may become hypertonic. It might also involve gentle stretching.
Activation
The objective of the Activation sequence is to create awareness or address factors that can improve movement. Joint or muscle injury may result in inhibition of muscles or muscle fibers. The Activation sequence serves to isolate and recruit specific muscles using exercise like a classic rotator cuff exercise, for example.
Activation exercises are specifically concerned with restoring normal function following injury. Exercises to create precise and conscious correction of movement lead to improvements in motor control and can also be part of the Activation sequence.
Integration
The Integration sequence serves to create behavior (or avoid un-wanted behavior such as compensation). Pain apprehension and decreased movement variability maintain the individual within the constraints of a compensatory movement strategy. The Integration sequence reintroduces movement that is apprehensive. In our shoulder example, this might be selecting exercises to progress an individual back towards partial overhead movement.
This is also where rehab is training finds its way, that is, we need to find ways to maintain load so that we can maintain strength in the continuum of care. The Integration sequence essentially includes everything you are going to change within the training regimen so that you can keep safely loading tissue. It is where you constantly seek to find that balance between protect and expose.
Strength is everything
Strength is everything. Without strength, resilience is decreased. Rehabilitative exercises are specifically concerned with restoring normal function following injury, but strength exercises should also be included and individualized to avoid underloading the system/surrounding tissues. All exercises are tools, and the exercises you select, as they fit the needs of the rehab plan, become rehab. This is why rehab is training, and rehab is individualized.
As you can see, there is much more to rehab than manual therapy. There exists a gap between the clinic and the setting in which a client performs, whatever that relative performance may be. As a therapist or trainer, you should aim to bridge that gap.
The Movement Optimization Strategy is an approach that helps address the many different pieces of the rehab process. Best of all, it involves your client in the process, giving them control and ownership of their rehabilitation under your guidance and supervision.
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Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
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