Incomplete rehabilitation in athletes, as well as the general fitness population, has led to an unfortunate re-injury epidemic. Should our goal as trainers be to get clients back to training/exercising as quickly as possible, or to help them prevent re-injury?
“Injury Prevention” can be viewed as the dual role of the rehab practitioner and personal trainer/coach. Physical therapy tends to focus on restoring function through a variety of methods and eventually enabling the patient to feel confident enough in the injured area to use it fully. Our role as personal trainers is to facilitate the completion of the rehab process.
However, we often notice a gap between clients possessing the functional capacity to exercise symptom-free and having the strength to perform in the same skillful manner as before the injury.
Slow and Steady Return Can Be Complex
Returning from a serious injury must not be viewed as a quick process. Professionals no longer focus on rehabilitation as the isolation of injured areas, preferring instead to reformat complex movement patterns, or integration. This process may involve substituting and/or slowing the pace of movements until the athlete finds his new comfort zone and goes a long way towards breaking the cycle of what is often referred to as “rehab purgatory”.
Far more strides can be made and successes claimed by smarter training modes that encourage the ultimate return to increased workloads as opposed to the metaphoric placing of a Band-Aid over the injury. By building upon what was developed in PT, striving to continually improve functionality, and ultimately adding strength in the process, athletes can look forward to long-term success even after incurring a serious injury.
Blending Rehab with Personal Training
Programming a client’s workouts after injury can be tricky and time-consuming. The best window of opportunity to optimally complete the process of re-injury prevention lies between rehabilitation and performance training. As trainers, we strive to continue the client’s healing process; but at some point, we also need to re-integrate his or her previous exercises to prepare him for performance re-entry.
A popular strategy is incorporating rehabilitation-type movements with traditional strength movements as supersets, to be performed either as part of a dynamic warm-up or during the training session itself. Pairing rehab exercises with more traditional ones help ease the transition, provided those can be executed effectively without restriction.
Static Stability and Dynamic Stability are strong cohorts in helping an athlete regain proprioception and awareness. By purposefully placing stress near the rehabilitation site on the body, and by challenging other joints to move, the injured area remains static while a dynamic exercise is performed elsewhere.
A great example involves attempting to maintain a neutral ankle. A trainer might instruct his client to begin by executing a single-leg stance on the floor, then moving to the same stance on a padded or slightly unstable surface. The last progression might be maintaining the stance while catching a ball. The client must, therefore, call upon his core and hips while trying to stabilize his ankle.
Part of rehabbing injuries is learning how to move again, and challenging old patterns that may have been executed consistently incorrectly. Rehab workouts typically require a modification of an original movement, and these can be safely incorporated by a professional, well-informed personal trainer.
Re-establishing — and more importantly, maintaining — functional range of motion is the first step when strategizing a path from rehab to strength. We can call this “re-grooving”. Seek to incorporate patterns that restore the client’s ability to move within the ranges required for his specific sport and exercise goals.
The function of a particular move, and how it ultimately serves to improve a client’s sports performance while remaining injury-free, is the trainer’s primary focus. In the case of low back pain, for example, reworking the positioning of a squat can have a tremendous impact on eliminating pain. In cases of upper-body injuries, regaining the rhythm and mobility of the shoulder and scapula becomes important.
Regaining Strength To Prevent Re-Injury
As lengthy of a process as this appears, proper rehab and training skills ultimately prepare the client for beginning to regain strength. Easing into this phase, known as load management, trainers can progressively add weight to those movement patterns that were “re-grooved” in the previous phase of training. To avoid accidental overloading, often a result of an impatient athlete wanting to forge ahead, focus on strength paradigms incorporating high volume hypertrophy work before moving into max strength moves.
In 2016, a panel of experts for the International Olympic Committee covered many of the subtle details involved in load management in a scientific paper entitled “How much is too much?”
Some of the main points covered were as follows:
- Although research in this field is limited, experts remain confident that “load management” serves an important role in preventing re-injury.
- Injury recovery and rehabilitation share many of the same components as recovering and transitioning back to full activity following a serious illness.
- Load management requires a delicate balance, as both too much, as well as insufficient, load has the propensity to increase the risk of both re-injury and setbacks in illness recovery. Dynamic load changes — increasing intensity up or down too rapidly — pose much bigger risks than absolute load.
- In general, elite athletes are relatively immune to the risks of overload. However, our everyday clients definitely need us to practice prudent load management in their workouts.
Getting Client’s Head Back in the Game
“Load” can also refer to non-physical yet still vitally important aspects of training. Mental fortitude does matter, whether it interferes with effective training in the form of an athlete’s self-doubt, lack of confidence, or overall fear of a serious re-injury.
Even after completion of the PT program, many recreational athletes find that they do not yet have the strength and/or mental fortitude to pick up where they left off prior to the injury. If this seems to be a problem area, you may suggest visualization techniques, where the client sees him or herself as 100% successful. Tapping into the mental aspects of excelling in a sport will allow athletes to master those last few steps of a total rehabilitation process in the gym.
Fear of reinjury after a sports injury, as a client transitions from rehab movements to actual sports-specific actions, can negatively impact an athlete’s recovery, thereby preventing a successful and complete return to competitive sports. As trainers, we may wish to educate ourselves in the application of psychologically informed practice. This methodology provides interventions to reduce fear of reinjury, thereby optimizing rehabilitation outcomes.
Healing Mind And Body
Currently, attention tends to focus on the inclusion of psychological interventions during sport injury rehabilitation. Many rehabilitation paradigms have begun integrating these steps, thereby expediting both physical and psychological recovery from injury. Among the myriad of techniques available, a client/patient may learn relaxation, mindfulness, imagery, goal setting, and stress management.
Studies consistently reveal how such psychological interventions help diminish negative consequences, improve coping skills, and reduce re-injury anxiety. Consequently, recovery periods shorten, and injured athletes frequently return to their sport sooner than anticipated. Although few controlled outcome studies have been published, anecdotal evidence continues to support psychological interventions as powerful tools in decreasing negative healing consequences while increasing confidence in former movement patterns.
As mindful as trainers are in terms of formatting a recovery program, encouraging clients to maintain their PT exercises on training off-days is always a good practice. This helps the client know that a “safety net” supports him as he moves toward a return to full movement. Many athletes favor an injury longer than necessary, most likely out of fear of re-injury or even of “testing” the affected area. If a trainer does not feel comfortable addressing the psychological component of recovery and prevention, seeking out other, more specific professional resources on a client’s behalf will always be appreciated.
Recognizing the Role of Rest
Fatigue contributes significantly in any injury recovery program. Sleep deprivation, a seriously underestimated problem, often leads to the development of chronic pain. Training regularly in a fatigued state not only impairs athletic performance, but negatively impacts the rate of injury recovery.
The risk of collateral injury is a significant factor in many cases of chronic pain. This term refers to the idea that when an athlete incurs an injury, he places himself at higher risk for all manners of other injuries. A seemingly minor setback in terms of re-injury can thwart the healing process and ultimately lead to a lifetime of chronic discomfort.
For decades, athletes have been encouraged to “get back in the game” following an injury, often by professional trainers and coaches who place a higher value on a team’s success than in addressing a potentially serious risk. Physical therapy previously supported the practice of “mobilizing injuries” as rapidly as an athlete’s pain level would allow. As a result, serious sprains were rarely casted, despite the fact that a sprain can in some cases be worse than a fracture.
A 2009 study published in the Lancet presented clear evidence that a full cast for a severe ankle sprain facilitates healing far better than using either braces or tubular compression bandages. Sadly, we learn that re-injury avoidance has not always been a top priority.
The Total Package
Keeping an ethical perspective on our scope of practice, personal trainers can safely utilize their knowledge to help recreational or high-level clients make a full return to their chosen sport following injury. Feel encouraged to contact the referring physical therapist, and discuss a client’s past exercises when necessary. A combined professional effort is what clients deserve, and we now have the ability to create successful outcomes.