What Does D c to Hep to Continue to Maintain Strength and Mobility Gains Mean in Physical Therapy
Int J Sports Phys Ther. 2011 Sep; 6(3): 241–253.
INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM
Michael P. Reiman
1Duke University Medical Center, Durham, North Carolina, USA
Daniel S. Lorenz
2Providence Medical Center, Kansas City, Kansas, USA
Abstract
Background and Purpose:
Rehabilitation and strength and conditioning are often seen as two separate entities in athletic injury recovery. Traditionally an athlete progresses from the rehabilitation environment under the care of a physical therapist and/or athletic trainer to the strength and conditioning coach for specific return to sport training. These two facets of return to sport are often considered to have separate goals. Initial goals of each are often different due to the timing of their implementation encompassing different stages of post-injury recovery. The initial focus of post injury rehabilitation includes alleviation of dysfunction, enhancement of tissue healing, and provision of a systematic progression of range-of-motion and strength. During the return to function phases, specific return to play goals are paramount. Understanding of specific principles and program parameters is necessary when designing and implementing an athlete's rehabilitation program. Communication and collaboration amongst all individuals caring for the athlete is a must. The purpose of this review is to outline the current evidence supporting utilization of training principles in athletic rehabilitation, as well as provide suggested implementation of such principles throughout different phases of a proposed rehabilitation program.
Evidence Acquisition:
The following electronic databases were used to identify research relevant to this clinical commentary: MEDLINE (from 1950–June 2011) and CINAHL (1982–June 2011), for all relevant journal articles written in English. Additional references were accrued by independent searching of references from relevant articles.
Results:
Currently evidence is lacking in the integration of strength and conditioning principles into the rehabilitation program for the injured athlete. Numerous methods are suggested for possible utilization by the clinician in practice to improve strength, power, speed, endurance, and metabolic capacity.
Conclusion:
Despite abundance of information on the implementation of training principles in the strength and conditioning field, investigation regarding the use of these principles in a properly designed rehabilitation program is lacking.
Keywords: periodization, program design, rehabilitation, strength, training
Background and Purpose
Strength and conditioning is traditionally thought to exist only in the training of the healthy athlete, while rehabilitation is for the athlete who has been injured. Once the athlete completes their post-injury rehabilitation with the athletic trainer and/or sports physical therapist, they often then move onto the strength and conditioning coaches to resume their "weight room workouts" and re-integration with the team. The strength and conditioning coach, in consultation with the athletic trainer and/or sports physical therapist, uses an understanding of the proper technique and application of several types of exercise to develop a program to ready the rehabilitating athlete for competition.
Evidence supporting the implementation of strength and conditioning principles into such a program is currently sparse.1–6 Several authors have investigated both conservative1–4,6 as well as post-surgical interventions.5 While each of these studies have integrated specific strength and conditioning concepts, none have employed the entire spectrum of strength and conditioning as it applies to the rehabilitating athlete. The purpose of this clinical commentary, therefore, is to describe these strength and conditioning principles, and provide a suggested implementation of their use throughout the entire rehabilitation process, not just during the return to sport phase.
Assessment of the Athlete and the Post-Injury Training Program
Proper implementation of a post-injury training program requires assessment of the rehabilitating athlete, their sport, and the defined training program principles themselves (Figure 1). Periodic re-assessment of the athlete, as well as the program and its outcomes can provide the sports physical therapist the necessary information required to manipulate the various training program variables to achieve the desired goals. Specific training principles (Table 1) should be addressed when designing the athlete's program. The sports physical therapist should consider the phase of rehabilitation that the rehabilitating athlete is in when implementing such a program. The specific program parameters of strength, power, endurance, and hypertrophy must also be carefully considered and targeted when planning the program.
Program Design for the Rehabilitation Athlete.
Table 1.
Training Program Design Principles.18,22,23,60,64
| Principle | Definition |
|---|---|
| Individuality | Treating the athlete as an individual and designing their training program specifically for them. Several factors should be considered when designing a resistance training program, including age, sex, medical history, previous training background, injury history, overall health, training goals, motivation, and any healing restraints related to the injury or surgery. |
| Progressive overload | States that in order to continue making gains in an exercise program, stress to the system must be progressively overloaded as it becomes capable of producing greater force, power, or endurance. The principle of specificity states that the body makes gains from exercise and training according to the manner in which the body trains. The way the athlete trains is how he or she will function. |
| Specificity | When developing a training program using this principle, one should consider the following: |
| • Energy-source specificity: training the correct energy system | |
| • Muscle action specificity: gains in strength are in part specific to the type of muscle action used in training (e.g., isometric, concentric/eccentric, isokinetic). | |
| • Muscle group specificity: training the muscle group(s) and joint(s) that are involved in the sport. | |
| • Velocity specificity: training gains are specific to the velocities at which exercises are performed. Exercise selection and order of performance specificity | |
| Volume and Intensity | Volume relates to the total amount of weight lifted in a training session. Intensity (or load) is the amount of weight assigned to an exercise set. Volume and intensity are inversely proportional. |
| Frequency | The number of training sessions per specific time-frame (typically enumerated on a weekly basis). |
| Rest period | The length of time for recovery between sets and exercises. Rest period is dependent on the sport the athlete is participating in, the training goal(s) (strength, power, endurance, hypertrophy), load lifted, and the training status of the athlete. |
| Type of resistance | The primary types of resistance available to the athlete are: free weight and elastic resistance (which affords multi-planar, whole body patterns of movement resistance training), machine resistance (provides increased stabilization for isolated muscle strengthening), aquatic resistance (provides multi-planar resistance with fluid resistance/assistance dependent on positioning), and isokinetic resistance (provides accommodating resistance with large amounts of reliable and valid data). |
| Variation/Periodization | The planned manipulation of training variables (load, sets, and repetitions) in order to maximize training adaptations and to prevent the onset of overtraining syndrome.18 |
| ▪ Linear/classical | Linear: This model is characterized by high initial training volume and low intensity. As training progresses, volume decreases and intensity gradually increases based on changing exercise volume and load across several predictable mesocycles. The program over a 12-month period is referred to as a macrocycle, and two subdivisions are the mesocycle (3-4 months) and the microcycle (1-4 weeks). |
| ▪ Non-linear/undulating | Non-linear periodization (NP) is based on the concept that volume and load are altered more frequently (daily, weekly, biweekly) in order to allow the neuromuscular system more frequent periods of recovery. Phases are much shorter providing more frequent changes in stimuli, which may be highly conducive to strength gains.18 |
| ▪ Reverse | Reverse: this model is the inverse of the linear model in which intensity is initially at its highest and volume at its lowest. |
The requirements or demands of any given sport must be ascertained in order to determine how to properly manipulate the training variables throughout the program. For example, training for a football lineman in the latter phases of rehabilitation should emphasize explosive power in activities performed that last 7-10 seconds with 20-60 seconds of recovery time to best replicate the demands of the sport.7,8 In the earlier phases of rehabilitation it may be necessary to correct specific impairments, such as muscle imbalances, that may contribute to injury.9–12 The inability of a rehabilitating athlete to perform a specific task can be identified using various measures (self-report, impairment based, bio-psycho-social, and/or performance based measures). An individual's ability to properly function occurs along a continuum, and therefore should include these multiple measures.13,14 The assessment continuum should include a subjective report of functional ability, observation and examination of impairments, and functional performance testing as appropriate. Functional performance testing has previously been defined as using a variety of physical skills and tests to determine (1) one's ability to participate at the desired level in sport, occupation, recreation, or to return to participation in a safe and timely manner without functional limitations and (2) one's ability to move through as many as three planes of movement. Functional performance is assessed using nontraditional (e.g. beyond manual muscle and range-of-motion) testing that provides qualitative and quantitative information related to specialized motions involved in sport, exercise, and occupations.13 The comprehensive assessment approach can be utilized to not only assess the rehabilitating athlete and their sport demands, but the success of the implemented program as well. If specific program parameter(s) (e.g. functional movement, strength, power, endurance, and/or hypertrophy) are determined to be deficient in the rehabilitating athlete during testing, the program can be modified to correct these deficiencies. Limitations demonstrated in fundamental movement patterns15,16 would require amelioration prior to placing emphasis on power training. Since it has recently been suggested that assessment of an individual's overall functional ability is multifactorial14 complete description of functional assessment is beyond the scope of this clinical commentary. For additional suggestions on the implementation of the assessment of the athlete, the reader is referred elsewhere.13–17
Traditional Training Program Parameters
Specifically training a muscle or group of muscles to achieve the desired goals of increased strength, power, endurance, and hypertrophy is paramount. The reader is advised to consult other sources18–20 for detailed information on training of these parameters, as it is also beyond the scope of this commentary to do so. General parameters will be discussed here.
Training for muscle performance including strength, power, and endurance, requires different program design and does necessitates variability in exercise prescription (Table 2). Strength training typically involves a load/ intensity of 80-100% of the maximum amount of weight that the individual can lift one repetition (1 RM), utilizing approximately 1 to 6 repetitions.18–23 Power training, on the other hand, requires a primary component of velocity of movement. Therefore, since velocity is inversely proportional to the amount of load lifted, the load will have to be relatively lighter than loads utilized in strength training in order to accomplish the necessary velocity. Power training though does require a foundation of strength.
Table 2.
Repetition Maximum Continuum.18,19,21–23
| Primary Parameter Trained | Repetition Range |
|---|---|
| Strength and Power | 0-6 |
| High Intensity Endurance much greater than Strength and Power | 6-12 |
| Low Intensity Endurance greater than High Intensity Endurance | 12-20 |
| Low Intensity Endurance | 20-30 |
While strength and power training can require similar components of training, endurance training is fairly unique. Endurance training can involve many methods (circuit training, etc.) but the common theme is high repetitions with lighter loads.18–23 The relative work to rest ratio is the lowest amongst the primary three parameters of muscle performance. Endurance training can be a method to achieve hypertrophy training since moderate loads and repetition range of 8-12 is suggested for hypertrophy training.18,22,23
Phases of Injury Rehabilitation
Regardless of the type or region of injury, basic phases of rehabilitation have been described in the literature.3–5,24–34 Dependent on the injury status, whether surgery was involved, and the restrictions associated with the recovery, the duration of these phases will differ. There are some common characteristics, goals, precautions and criteria for progression to the subsequent phase. Described below and in Table 4 is a general outline of the various phases of rehabilitation based on multiple previous protocols, literature sources,3–5,24–34 as well as opinions of the authors. Criteria for progression, goals of each phase, and characteristics of each phase therefore are the authors' opinions based upon available protocols and past literature.
Table 4.
Utilization of Non-Linear Periodization in Different Phases of Rehabilitation.
| Training Emphasis | Non-Linear Periodization Phase | Parameter Trained | Training with Team | |
|---|---|---|---|---|
| Phase I Immediate Rehabilitation | ▪ Low intensity endurance of stabilizing muscles | I. Setting foundation with emphasis on muscle endurance | I. Monday: Endurance Wednesday: Hypertrophy Friday: Strength | I. Cardiovascular (CV) endurance training (e.g stationary bike for injured UE or trunk, Upper body ergometer (UBE) for injured LE or trunk) |
| ▪ Training of joint above and/or below for stability and endurance | II. Weight room training of non-injured areas with protection of injured area | |||
| III. Lower-level sport related skills of non-injured areas (e.g. free throws or ball tossing for injured LE; ball passing drills for soccer player with injured UE) | ||||
| Phase II Intermediate Rehabilitation | ▪ Low to high intensity endurance of stabilizing muscles (dependent on their specific function) | I. Emphasis on increasing muscle size and continued strength training | I. Monday: Hypertrophy Wednesday: Strength Friday: Hypertrophy | I. Weight room training of non-injured areas; continue CV endurance, progressing to long duration/lower intensity interval CV activity (bike, UBE, etc) |
| ▪ Progression from low to high intensity strength for muscles responsible for movement of affected area (dependent on contraindications and precautions, etc.) | II. Strength gain emphasis prior to transition to power training | II. Monday: Strength Wednesday: Endurance Friday: Strength | II. Interval CV activity increasing in intensity (decreasing duration) with emphasis on energy system most relevant to athlete's sport. | |
| III. Sport related skills as prior; initiation of sport related skills of injured area (patterns of movement, low-intensity drills, etc.) | ||||
| Phase III Advanced Rehabilitation | ▪ Continued endurance emphasis for stabilizing muscles | I. Strength gain emphasis prior to transition to power training (short duration emphasis) | I. Monday: Strength Wednesday: Endurance Friday: Strength | I. Interval training emphasis on proper energy system and incorporating total body movement patterns |
| ▪ High intensity strengthening progressing | II. Begin transition to power | II. Monday: Strength Wednesday: Power Friday: Strength | II. Sport related skills – progressed to game intensity as per athlete readiness and tolerance | |
| ▪ Low to high intensity power progression of movement muscles (dependent on precautions, etc.) | ||||
| Phase IV Return to Function | ▪ Continued as in phase III; with increased emphasis on clients' functional requirements (i.e. power for jumping athletes; endurance for long distance running athletes, etc.) | I. Continued progression of strength and power phase | I. Monday: Power Wednesday: Strength/Hypertrophy Friday: Power | I. Sport related skills at game intensity progressed to normal practice and eventually return to game competition. |
Phase I, Immediate rehabilitation: Characterized by tissue and/or joint inflammation and pain, disuse, detraining, loss of muscle performance, potential immobilization (dependent on injury), and initiation of tissue repair and/or regeneration. The primary goals to be addressed during this phase are protection of the integrity of the involved tissue, restoration of range-of-motion (ROM) within restrictions; diminishment of pain and inflammation, and prevention of muscular inhibition. Major criteria for progression to Phase II include: minimal pain with all phase I exercises, ROM≥75% of non-involved (NI) side, and proper muscle firing patterns for initial exercises.
Phase II, Intermediate rehabilitation: Characterized by continuation of tissue repair and/or regeneration, increased use of involved body part or region, decreased inflammation, and improved muscle performance. The primary goals to be addressed during phase II include: continued protection of involved tissue(s) or structures and restoration of function of the involved body part or region. Criteria for progression to Phase III include: close to full ROM/muscle length/joint play, and 60% strength of primary involved musculature when compared to the uninjured side.
Phase III, Advanced rehabilitation: Characterized by restoring normal joint kinematics, ROM, and continued improvement of muscle performance. The primary goals to be addressed during this phase are restoration of muscular endurance and strength, cardiovascular endurance, and neuromuscular control/ balance/proprioception. Criteria for progression to phase IV include: strength > 70-80% of non-involved (NI) side and demonstration of initial agility drills with proper form (e.g. avoidance of medial collapse35 of bilateral lower extremities, coordinated and symmetrical movement of all extremities, controlled movement of entire body).
Phase IV: Return to function: Characterized by activities that focus on returning the athlete to full function. The primary goals to be addressed during this phase are successful return to previous functional level in the athlete's preferred activity, and prevention of re-injury.
Designing a Training Program with Consideration for the Injured Athlete Needs Analysis of Training Program
In order to properly design a patient and sports specific rehabilitation program, a needs analysis should be performed.36 Performing a comprehensive analysis (Recall Figure 1), investigating such factors as the physiological and biomechanical requirements of a sport is required when designing the program. Components of a needs analysis include a general biomechanical analysis of the sport which rehabilitating athlete participates in, an analysis of the energy sources utilized in the sport, and an analysis of the common injury sites and patterns for the sport.36 Furthermore, an appropriate physiological analysis allows the clinician to devise a program that addresses specific strength, range of motion, flexibility, power, endurance, and speed requirements for any given sport. For example, an American football player needs more muscle size and strength than a cross-country athlete or a soccer player. Only by addressing these requirements specifically will an athlete be successful in returning to their sport or activity. Next, a biomechanical analysis is required to choose training activities that develop the athlete in a manner most specific to the sport. Specificity of training is a foundation of both functional and resistance training programs.18 It is the authors opinion that the sports physical therapist should be well-versed on injury patterns that are present in the sport in which the rehabilitating athlete is participating to ensure that prevention strategies are included. For example, female soccer and basketball players have demonstrated a higher risk for anterior cruciate ligament ruptures than athletes who participate in other sports.37–41 Likewise, American football lineman and gymnasts are at an increased risk for spondylolysis and spondylolisthesis compared to athletes in other sports.42–45 Each of these examples shows how training programs for the rehabilitating athlete should be specifically designed to accommodate each individual athlete's needs to maximize performance and avoid subsequent injury. The reader is directed to Table 5 for an illustration of these concepts.
Table 5.
Needs Analysis Comparison for a Male Football Player versus Female Soccer Player Recovering from ACL Reconstruction Surgery.
| SPORT | Football | Soccer |
|---|---|---|
| Biomechanical Analysis | - Multi-directional, multi-joint, explosive movements that vary with position | - Multi-directional movements with varying degrees of intensity, often requiring simulataneous manipulation of a ball |
| - Requires multiple stops/starts | - Eye-foot coordination | |
| - Asymmetry of stance and kick leg | ||
| Energy requirements Physiological Analysis | Primarily ATP | Primarily aerobic |
| - Maximal power and strength, flexibility, balance | - strength, endurance, flexibility, balance | |
| - One game per week | - Possibly several games in a week | |
| - Environmental acclimatization | - Female athlete triad considerations | |
| - Environmental acclimatization | ||
| Injury patterns | - Soft tissue injuries including ligament sprains, muscle strains | - Females have high risk of ACL injury in soccer |
| - Soft tissue injuries including sprains and strains | ||
| -Increased incidence of spondylolisthesis in linemen | - Overuse tendinopathies | |
| -Concussion | - Spondylolysis |
Assessment of Rehabilitating Athlete's Strengths and Weaknesses
Assessment of each rehabilitating athlete's strengths and weaknesses can be a complex undertaking. As previously mentioned, proper assessment of an athlete's functional capacity is multi-factorial, involving multiple variables.14 Along with the assessment of the rehabilitating athlete's strengths and weaknesses, knowledge of their training history/status, injury history/status, and basic physical characteristics is warranted. Training status may depend on numerous factors, including length of time playing the sport, length of time specializing in the sport (or position within a sport), and the level of competition at which the athlete is accustomed to participating.
Training Program Design Principles
Once the clinician has determined the rehabilitating athlete's needs, the next step in designing the rehabilitation program is manipulation of the program principles. As previously mentioned, it is beyond the scope of this article to discuss all the necessities of program design; however some discussion of these principles is warranted especially in light of the paucity of literature regarding their implementation in the rehabilitating athlete The program principles of interest to the sports physical therapist for manipulation include: exercise selection, training equipment availability, training frequency, exercise order, rest interval and resistance/training load.
Exercise Selection
Exercise selection is a critical program principle for which the clinician should account. Multi-joint exercises are exercises that involve many muscle groups in one exercise.18 Examples of multi-joint exercises include squats, deadlifts, cleans, bench presses, and push jerks. Typically, these exercises are done first in the training session because they are the most fatiguing, but also because they are recommended most for increasing muscle and bone strength.18 The other type of exercise is known as supplementary, or isolation exercises. Examples of isolation exercises include front raises, lateral raises, and knee extensions. Since these isolation exercises are primarily single joint-single plane exercises, they are a good choice for the untrained or inexperienced athlete.18 Ultimately, though, the experienced athlete will require several multi-joint exercises in their program in order to be successful.
Progression to multi-joint exercises involves more instruction and greater time to practice in order for the athlete to establish the necessary coordination to properly execute the exercise safely and effectively. Performing large muscle mass, multi-joint exercises early in the workout has been shown to produce significant elevations in anabolic hormones.46–48 This type of an anabolic response may potentially expose smaller muscles (such as those in the affected area) to a greater anabolic response than that resulting from only performing small muscle exercises.47,48
Availability of Training Equipment
A lack of certain equipment necessitates changes or does not allow the performance of some exercises.36 In the context of free weights, lack of floor or ceiling space may hamper lifts that could involve dropped weights or pushing weights overhead. For example, many Olympic lifts performed overhead (i.e. snatch, jerks) are performed with bumper plates that bounce on the ground to promote athlete safety if a lift is missed, or if maximal lifts are attempted. In any of these cases, the bar is often dropped to the floor where it bounces and could potentially injure others. Some machines may not be multi-dimensional enough to be sport-specific for the rehabilitating athlete,36 so the clinician will need to supplement training programs with appropriate exercises. For example, when the rehabilitating athlete needs to perform a chest press motion, it may be more appropriate to use the dumbbell or barbell bench press than a weight machine. These lifts, although utilizing the same musculature, require the athlete to make adjustments to complete the lift given that the axis of movement is not fixed and may follow an unpredictable course compared to a seated chest press using a weight machine which only has one axis of movement.
Training Frequency
Training frequency ultimately depends on the volume and load of exercises, the type of movement (multi vs. single joint) that prevails throughout the workout, the training level of the athlete, the goals of training, and the health status of the athlete.36 Traditionally, resistance training on alternating days is encouraged in the early stages of training to ensure recovery,36 but frequency may increase with increased training experience. Previous authors have demonstrated insignificant differences in strength gains observed between training 1, 2, 3, or 5 days per week if the volume was kept constant.18 When near maximal resistances are used, more recovery time is advocated.18,19,22,23
The sports physical therapist must also consider other concurrent training in which the athlete is involved. A young pitcher may not only be in season, but may also be working with a pitching coach once or twice a week in addition to resistance training. The frequency of training may need to be reduced to accommodate the athlete's schedule of training in order to ensure that proper rest and recovery is achieved. Similarly, an increase in training frequency may be warranted if the athlete appears to be reaching a plateau or making minimal gains in one or more of the training parameters (e.g. strength, power, endurance).
Exercise Order
The ability to perform the desired load and volume of each exercise is dependent on proper order of exercise.36 Proper coordination of the integration of multi-joint and isolated strengthening exercises requires careful planning on part of the sports physical therapist. Each individual athletes physical condition, as well as the their particular strengths and weaknesses will require consideration when designing the training program.36 Various methods of utilization of exercise order will be described.
Because multi-joint exercises require the most coordination, skill, and proper levels of energy, it is encouraged that they are performed first in the training session. For example, the bench press should be performed prior to tricep extensions. Since multi-joint lifts are the most fatiguing, the athlete is unlikely to obtain the maximum benefit of these exercises if the smaller muscle groups are fatigued from previous exercises. Pre-exhaustion is a training technique is a training technique in which a muscle is fatigued in a single-joint, isolated movement prior to performing a multi-joint exercise involving the same muscle.36 An example of pre-exhaustion training is performing leg curls or leg extensions prior to a back squat or deadlift. The sports physical therapist may utilize this technique if they feel that the multi-joint movements are not completely developing the muscles in question or to help alleviate the effects of training boredom. To the author's knowledge, no studies exist utilizing pre-exhaustion as a training technique.
There are various methods of pairing exercises to challenge the athlete, alleviate boredom, and emphasize muscle endurance and hypertrophy. Super setting involves alternating agonists and antagonists with minimal rests between exercises. For example, a bench press followed by a seated row or a bicep curl followed by a triceps pushdown would be examples of super sets. Compound setting is performing two different exercises of the same muscle group in alternating fashion with little to no rest between exercises. Anterior lunges followed by squats or barbell bicep curls followed by alternating dumbbell curls are both examples of compound setting. Athletes in poor physical condition may find super setting, compound setting, or pre-exhaustion techniques too strenuous in the early stages of training.36
Other methods to manipulate exercise order are to have an athlete perform upper and lower body exercises in an alternating fashion. The clinician can also have the athlete perform upper body push and lower body pull exercises alternatively, or vice versa. Lastly, the athlete can perform a "push-pull" routine. Here, the athlete can perform a front squat followed by a deadlift. Push-pull may involve agonists and antagonists, but may also include an upper body "push" exercise coupled with a lower body "pull", or vice versa. Collectively, these methods allow more exercises to be completed within a session and allow greater intensity of each exercise due to extended recovery of the each muscle group being worked. Plus, these methods help promote balance and symmetry of agonist-antagonist training.
Rest Period & Resistance/Training Load
Manipulation of all of the above training variables are applicable to the rehabilitating athlete, but it will require the sports physical therapist to design athlete specific programs, keeping the above principles in mind. Regardless of injury, it is advised that the athlete have at least 24 hours of recovery between sessions, and 48 hours in between sessions working the same muscle group.18,21,22 For a rehabilitating athlete who is seen only 1-2 times per week, a total body routine is advocated to maximize training balance. If training is done 4-5 days per week, a split routine is advocated by the authors of this review to allow proper recovery between muscle groups used. Regarding the athlete who is rehabilitating 3-5 days per week, the authors suggest activities on "off days" might include flexibility training, yoga, balance and proprioceptive exercises, or core/abdominal training.
Determining the training load and rest ratios requires careful consideration of the rehabilitating athlete's sport and the body part or region to be trained. For example, muscles of the trunk are primarily slow twitch, type I muscle fibers49–51 that necessitate high repetition, low load endurance based training. Other, more explosive muscles that are prime movers, utilized in jumping (e.g. quadriceps and gastrocnemius) require strength based training programs, progressing to lower loads at explosive speeds, and plyometric type training for development of power.
Training load is usually determined with 1 RM testing in strength and conditioning. The use of 1 RM testing is often disadvantageous for the rehabilitating athlete as it requires a systematic progressive increase in maximum load lifting capability. Although this method is the most advantageous and accurate method of determining 1 RM, the use of estimating 1 RM and training load charts is advisable for these athletes. Other methods for determining training load include the DeLorme technique, the Daily Adjusted Progressive Resistance Exercise (DAPRE) technique, the OMNI-RES, or the Oddvar Holten method.52–55 These tables are intended to be used as a guide until the athlete has developed the neuromuscular capabilities that will allow them to safely and effectively test with heavier loads to more accurately determine their 1 RM.18 The use of such tables is but one method of determining load, as other methods have proven effective.55 Training volume is typically prescribed in terms of the number of repetitions per set, number of sets per session, and the number of sessions per week.56 The importance of training volume for maximal strength and hypertrophy gains during early phases of resistance training has previously been demonstrated.57–59 Untrained, normal individuals were shown to experience maximal strength gains with a mean training intensity of ≈12 RM, while trained individuals demonstrated these gains with a mean training intensity of ≈8 RM.59
The length of the rest period is dependent on the training goal, the relative load lifted, the sport in which the athlete participates, and the training status of the athlete. The rest period is a primary determinant of the overall intensity of a workout, as rest period length is strongly related to the load lifted.18,21,60 The rest period length not only determines how much of the adenosine triphosphate-phosphocreatine (ATP-PCr) energy source is recovered,60 but also how high post exercise lactate concentrations become in the blood.47,61–63
Other training principles were outlined and defined in Table 1. Additionally, Tables 2 and 3 provided descriptions of training load and rest period suggestions. Utilization of concepts and suggestions given in these tables, as well as the outline provided in Figure 1 will provide the sports physical therapist the necessary framework to design a proper training program for the rehabilitating athlete. Integration of these principles into a specific program is the next step.
Table 3.
Rest Period Continuum.18,19,21–23,63
| Primary Parameter Trained | Rest Period |
|---|---|
| Muscular Power | 5-8 minutes |
| Maximal Muscular Strength | 3-5 minutes |
| Muscular Hypertrophy | 1-2 minutes |
| Muscular Endurance | 30-60 seconds |
Integration of Training Principles and Parameters into a Rehabilitation Program for the Injured Athlete
The previous sections offered suggestions regarding multiple parameters and the opportunities for their manipulation of these training principles for the rehabilitating athlete, based on current evidence and principles used with normal (uninjured) athletes. Additionally, Table 1 defines periodization, as well as the difference between linear and non-linear periodization. The rehabilitating athlete may need to be considered similar to the untrained category initially with respect to the injured body part. Therefore, as outlined in Table 4 the initial non-linear periodization phase for the injured body part or region should be an emphasis on higher repetitions and muscle endurance/hypertrophy with a later initiation of strength-based training. As the patient progresses further in their rehabilitation, additional progression into more aggressive strength training and power training should be incorporated. Unlike linear periodization, where the emphasis is on only one parameter (endurance, hypertrophy, strength, endurance), non-linear periodization allows the clinician the ability to train more than one of these parameters at a time, while still emphasizing one of them in a particular phase. Although the literature is lacking regarding the utilization of types of periodization with the rehabilitating athlete, the opinion of the authors of this review is that the non-linear form of periodization would most likely fit the rehab process in most instances. Additionally, it is the authors' suggestion that the rehabilitating athlete continue with some form of training with their team. Table 4 also offers ideas on how to integrate the rehabilitating athlete into team training components. This is a general framework upon which the reader can build and individualize a program specific to the needs of each rehabilitating athlete.
As an alternative to non-linear periodization previously described, a rehabilitation program could be constructed using short duration linear periodization. Utilizing a short duration linear program would require initial emphasis on high volume and low intensity (endurance and/or hypertrophy phase). Progression into the strength/power phase and eventually to the power phase at end stage rehabilitation would then occur. Once again, the authors of this commentary assert that non-linear periodization may prove to be a more advantageous method of program design for the rehabilitating athlete as it affords implementation of multiple variables into the different phases throughout the rehab program.
CONCLUSION
Strength and conditioning principles and training parameters are a necessary component of the decision making and tailoring of any rehabilitation program. This is especially important in the rehabilitation and full return to function of an injured athlete. The sports physical therapist implementing such programs should be cognizant of each the components and variables for the rehabilitation program of an athlete. Currently the literature has little to offer regarding of the integration of strength and conditioning concepts into the rehabilitation of the injured athlete. The benefit of integration of these training principles during the rehabilitation of an injured athlete, although intuitive for best practice, remains elusive. Future studies should investigate the extent of the relationship between strength and conditioning principles and their integration into a rehabilitation program for the rehabilitating athlete. Determining how integral a role these training principles play for athletic rehabilitation is long overdue.
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Articles from International Journal of Sports Physical Therapy are provided here courtesy of North American Sports Medicine Institute
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164002/
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