The human body was designed to move. We are functioning at our very best when we take advantage of the blessing of mobility, and allow ourselves to become any “verb” that strikes our fancy. In fact, none of us would have chosen this particular profession if we were not, at any given moment, able to extoll the virtues of leading a dynamic rather than static lifestyle. What happens, then, when the tide turns against us?
Even something as therapeutic, challenging, fun and restorative as exercise has its share of pitfalls. If we engage in an active, physical lifestyle, chances are fairly good that at some point we’ll be forced on the sidelines due to an injury or unavoidable health crisis.
On an average, the incidence of sports -related injuries nationwide is more than 50% over a 6-month period; and surprisingly, 30-50% of these injuries are actually preventable. As the saying goes “An ounce of prevention is worth a pound of cure”.
How might we prevent these injuries?
By training the body to be durable and resilient, we can put forth our best effort at protecting it…not only from the trauma of difficult and strenuous workouts, but also from unexpected accidents. For an avid athlete, the painful and time-intensive process known as rehabilitation can often seem interminable. What if there was a way to lessen its duration if it is required?
Prehab vs. Rehab
We’re all familiar with rehabilitation, which is when one must seek treatment to recover from a condition or injury. Rehab comes into play only after the damage has already occurred. Prehabilitation, on the other hand, is all about injury prevention. Prehab exercises expose the body and brain to novel positions, thereby enabling an individual to break out of his/her habitual movements. In this fashion, the athlete becomes more adept at knowing how to react when life or sports throw him/her something new. In fact, a 2005 study found that prehab drills could reduce ACL injuries among female soccer players by as much as 88%.
Prehabilitation movements may also help to even out muscular imbalances, resulting in better posture, improved performance, and more efficient pain -free movement throughout the day. As our population ages, there is no reason for cessation of movement to become an eventual necessity. Prehabilitation training has a long-term focus: Embracing these exercises now may pay off 10 or 20 years down the road, when we see that most individuals are becoming inflexible, stiff and frequently succumbing to injury, while others remain agile, flexible and strong.
For a collegiate athlete, whose sports participation occurs for a few months per year and then cycles with an off-season, most trainers and athletic coaches are quick to recognize that prehab training does not begin as the season gets underway. In order to be maximally effective, prehab must be started during the pre-season training. The ideal format of such exercises should be to encompass elements and drills that are specific to the chosen sport, along with strength training and functional stretching exercises.
A well-structured program, tailored to the individual athlete, might target weak or tight muscles as it familiarizes the body with the forthcoming demands of the sport. Increasing strength helps the body withstand impact forces (as in a football tackle); and more flexibility may diminish the rate of ligament strain from overuse. A coach or trainer with an eye on an athlete’s progress will undoubtedly observe and intermittently adjust his/her prehab format as the athlete demonstrates improvements these areas.
Another important aspect of prehab training is sports planning. If a client is preparing his calendar for triathlon season, he may require some guidance in developing a well-balanced training schedule, recovery plans, and meal preparations, while leaving room for real-life setbacks that won’t interfere with his goals. Such prehabilitation training formats may help facilitate this, especially for an athlete who is relatively new to the sport. Some trainers and physical therapists aim to proactively assess the individual before he/she takes on a new activity, such as a race, in an attempt to measure how he/she will progress, and highlight any deficits that may get in the way.
Once the unique issues have been identified, a specific prehab format can be developed.
Here are some prehab suggestions for a competitive Olympic lifter as he enters pre-season training and readies himself for a leg workout:
- Foam roller exercises, which focus on glutes, hamstrings, calves and quads
- Stretching exercises, for hip flexors, ankle mobility and for the lateral rotators of the hips
- Activation exercises, such as thoracic spine wall slides, glute bridges, bodyweight squats, and planks
Probably one of the most important applications of prehabilitation exercises is the benefit to patients who are facing an upcoming orthopedic surgery. Meaningful changes in postoperative functional exercise capacity can be achieved by participation in a prehabilitation program.
What the Docs are Saying
Heather Moore, PT, DPT, CKTP, provides her patients at Total Performance Physical Therapy in eastern Pennsylvania with prehab prior to undergoing surgeries for rotator cuff repair, ACL repair, total knee and total hip replacement. According to Dr. Moore, “Patients initially are skeptical about it, but then they’re amazed by the speed of their recovery compared with that of people they know who didn’t get prehab before the same surgery. That’s when they recognize what a huge difference it made.”
Rob Worth, PT, DPT, MS, ATC/L, OCS, owns a company called Advanced Physical Therapy & Sports Medicine, which operates 8 clinics in the eastern regions of Wisconsin. He characterizes prehabilitation as still being in “the infancy stages,” and says it may take time for this format to become anything close to standard practice within the US health care system.
“Prehab” wasn’t a word that anyone used when Dr. Worth became a PT more than 20 years ago. At that time, physical therapy might have been suggested as a last-ditch effort to avoid surgery, but it wasn’t seen or even considered to be a viable pre-surgical tool. “What we’ve learned in the past 20 years,” Worth says, “is that when surgery is imminent, there are things PTs can do to ensure the best possible patient outcomes. We can work to optimize range of motion, strength, and function, thereby placing the patient in front of the starting line when he or she undergoes surgery and has a head start afterward.”
Patient education is a big part of prehabilitation, says John Mishock, PT, DPT, DC, owner of Mishock Physical Therapy & Associates in eastern Pennsylvania. Patients who are scheduled for an operation and who choose to participate in prehab training are educated on what to expect and do before and after surgery, in order to maximize healing, range of motion, strength, and overall recovery. Beforehand, he says, “Patients are educated on their specific impairments and functional deficits, so they can begin to work on those deficits prior to surgery. Immediately following surgery, “Because patients know from their education that the new joint is stable, they quickly begin the early-activation process of movement that helps reduce swelling, initiates muscle contraction, increases range of motion, and reduces pain.”
Another benefit of prehabilitation formats, Worth observes, is that “knowing the patient’s range of motion, strength, and function preoperatively, through clinical examination and direct observation, allows the patient and PT to more accurately set realistic postoperative goals.” For example,” he says, “if the patient has 20° knee flexion contracture prior to replacement surgery, full knee extension may not necessarily be an attainable postoperative goal.”
What Research Says
A recent report published in the Journal of Bone & Joint Surgery found that physical therapy before total hip or total knee replacement surgery can help reduce the need for post-operative care by nearly 30 percent, saving the patient an average of $1,215. A typical prehab program begins about six weeks prior to the scheduled orthopedic surgery, and includes cardiovascular conditioning, strengthening of key muscle groups, balance/posture assessment and training in addition to patient education. With prehab, patients have been found to experience the following benefits:
- Enhanced muscle strength, which helps the surrounding muscles, which often need to compensate for a lack of full function during recovery.
- Better body mechanics, balance and mobility, which helps patients as they re-learn movements like getting out of bed or climbing stairs.
- Less pain after surgery, which makes physical rehabilitation easier and improves quality of life.
- Greater stamina, confidence and motivation to recover.
While prehab isn’t meant to replace a post-surgical rehabilitation, it does carry with it the ability to help individuals get the most out of their rehab program.
The field of orthopedic surgery is not on a solo mission to incorporate prehabilitation into its pre-surgical protocols. Preliminary research shows promise of prehab exercises improving patients’ abilities to tolerate chemotherapy and return to normal physical functioning more quickly. In one randomized controlled trial of 77 individuals awaiting surgery for colorectal cancer, patients were divided into 2 random groups. While all participated in a program consisting of exercise, relaxation and nutritional counseling, half of the trial subjects went through the program in the 4 weeks prior to surgery; the other half participated in the same process 8 weeks following their operations.
At the end of 8 weeks, 84 percent of the patients who had engaged in prehab exercises performance had recovered to or improved their baseline measurements during a six-minute walking test. In contrast, only 62 percent of rehab patients demonstrated similar statistics. The study was published last year in the medical journal Anesthesiology.
“Prehab could be a relatively cheap way to get people ready for cancer treatment and surgery, both of them stressors,” says Dr. Francesco Carli, a Professor of Anesthesiology at McGill University in Montreal who co-authored the study.
The health care service Kaiser Health published a news release about prehabilitation for patients with cancer who are about to undergo surgery, chemotherapy, or radiation. The Kaiser Health piece, which was reported by the Washington Post and other media sources, attempted to be clear about both the promise and the challenges of broadening the practice of prehabilitation.”It seems intuitive that people’s health during and after invasive surgery or a toxic course of chemo or radiation can be improved by being as physically and psychologically fit as possible going into it,” the news release noted. It cautioned, “Research to examine the impact of prehab is in the beginning stages.” The piece also quoted an American Cancer Society official as saying, “There are some physiatrists who don’t believe in prehab. They feel like the science isn’t there.”
For oncology patients, a much more positive outlook comes from Cheryl Guarna, PT, MPT, CLT, STAR/C, owner of Oncology Rehab and Wellness Resources in Ashburn, Virginia. It is her strong belief that prehab affords “a sense of control at a time in their lives when they otherwise may feel helpless and overwhelmed. They’re taking an active role in their treatment,” she notes, “which makes them feel more positive about their experience. Various studies have shown that positive thinking can play a role in improving patient outcomes.”
Use Warm-Up as Your Weapon
For the average personal trainer working in the average fitness facility, how might we best incorporate these findings for our clients? We can start with the basic warm-up, gearing it specifically to the workout ahead. If a client happens to be a competitive athlete, include sports-specific moves to awaken the muscles that will soon be called upon to perform. Even with our average daily clients, we can heed the “ounce of prevention/pound of cure” adage!