Strengthening exercises have obvious importance for the rehab programmes that sports therapists design for clients or patients. In recent years rehabilitation knowledge has focused on core stability and the importance of correcting muscle imbalances.
Usually this means concentrating on the smaller ‘stabiliser’ muscles. Exercises for these muscle groups are commonly (although not exclusively) performed without weights or using simple resistance bands, which enables professionals conveniently to be able to prescribe home-based and minimal-equipment exercise regimes.
Lest we forget, however, strength in the large ‘mobiliser’ muscles is also important to rehabilitate many common injuries. For example:
The modern gym, equipped with machines for all muscle groups and free weights, is the ideal place to develop strength. It gives sports therapists a wide choice of exercises and an easy, regulated means of progression. Resistance machines, with their numbered and graduated weight stacks, make prescriptions for a progressive programme straightforward and safe.
But what do you do when the client or patient has no ready access to a fitness facility and they are limited to bodyweight exercises for their rehab? In this case, rather than simply moving the pin on a weight-stack, it will be necessary to introduce a shift of body position or a new exercise in order to achieve progression.
The aim of this short series of articles is to provide sports therapists with guidelines for safe and effective home-based rehab programmes using minimal equipment, starting with the principles of exercise planning and moving on to practical advice for key mobiliser muscle groups.
Different goals require different ‘doses’ of exercise training. A dose of training comprises three main components: intensity (weight), volume (set and reps) and frequency (sessions per week).
Rehabilitation training tends to focus on developing general strength and strength endurance. This is for three perfectly sound reasons. First, chronic injuries are usually related to repeated stresses and the ability of the muscle-tendon unit to tolerate accumulated forces. Secondly patients recovering from sprains, fractures or operations need to rebuild muscle mass lost during a period of immobility. Thirdly maximal strength training requires very high intensity (at least 80% of maximum force), which could be counter-productive for rehabilitation purposes. If maximal strength training is to be part of a recovery programme, it must be built in at the end of the rehab progression, after general strength and muscle mass have been rebuilt.
The term repetition maximum (rep max or RM) refers to the maximum number of times one can perform a movement at a specific weight, and is the standard method for defining the intensity of strength training.
For rehab purposes, parameters within the 8-20 RM range will provide appropriate intensity. If the same exercise can be performed for more than 20 repetitions without rest, the training benefit for strength or strength endurance will be small: in effect the exercise level is too easy. The support professional needs to evaluate intensity for each exercise against the desired rehab goal, which is relatively simple when you have a weight stack to play with, but much harder with minimal or no equipment.
For bodyweight-only exercises, the individual’s own mass and body position relative to the moving limbs and gravity define the amount of ‘weight’. The only way to change the load is to change either the position or the movement. This is why the range of movement performed is key to the difficulty of the exercise. As an exercise is performed, the working muscles are subject to different levels of force, depending upon the joint angle and the distance of the point of load from the pivot point. In all the exercises outlined in this series, it is necessary to maintain the range of movement as the difficulty of the exercises increase, in order to progress properly.
Where resistance bands are being used, apart from range of movement, the length and thickness of the band are the two main variables of intensity and should be monitored carefully accordingly.
In general two to four sets of 8-20 reps is considered sufficient volume for each exercise. A rest of 60 to 90 seconds is recommended between sets; the patient should run out of effort in the final set. For example, using a 15 RM weight, a patient would probably be able to perform three sets of 12 repetitions with 60 seconds rest between each set. The last set would be very difficult, in order to achieve the ‘overload’ which produces training benefit. In some cases it will be appropriate to begin with only one set of an exercise, as this will achieve sufficient training benefit in the earliest stage of rehab.
Large muscle groups can be trained two to three times per week with at least 48 hours’ rest between training sessions. Once a week may be enough to maintain strength but will not develop it. More than three sessions may not allow sufficient recovery for the muscle-tendon adaptations to occur. Smaller muscle groups can be trained four to five times per week, if you are pursuing an aggressive rehab programme, but three times is probably enough for most people’s needs.
Training benefit comes from overloading the muscles, thereby forcing them to strengthen. So once a muscle has responded to the initial ‘dose’ of training, the dose has to be increased to gain further improvements. As seen above, intensity and volume are the two main variables by which exercises can be progressed. For rehab programmes I am in favour of first increasing volume, keeping the weight constant. Then, once the patient can competently perform a certain number of sets and reps, the load should be increased. This is a cautious and safe way to progress.
Table 1 below details a method of evaluating load levels and overall difficulty of an exercise. It is a version of the 0-10 RPE (Rate of Perceived Exertion) scale. RPE is a useful rehab tool, giving subjective feedback that can help the therapist to assess more accurately when and how to progress the programme. It is also a very important way of helping the patient learn to evaluate their body’s response to being challenged.
|<5||Too easy||Significantly increase the reps or the load|
|6-7||Quite easy||Increase reps, sets or load – progress to
|8-9||Working well||Suitable level for rehabilitation training.
Keep reps and loads the same
|9.5-10||Max effort||Very difficult. Arguably too hard for rehab,
so reduce load, sets/reps or change the
For weight training, use RPE in this way. After the client has completed the required number of sets (assuming they can do this successfully), ask: ‘On a scale of 0-10, how difficult was the last set?’ Use Table 1 to help you decide whether and when to make changes to that exercise. Remember, the last set needs to be tough for training benefit to occur.
Tip: if the client replies: ‘it was OK’, which they often do, repeat the question and make them specify a number! One warning, however. The RPE feedback system is a tool, not a rule to govern all progression. Use your judgement to ensure you do not rush your patients. When increasing the load, keep in mind that tendon strength takes longer to develop than muscle strength. This is why I recommend increasing the repetitions at a particular load up to a target level before stepping up the weights.
The final training principle important for rehab programmes is the specificity of the exercise movement.
Research has shown that the range and speed of movement, and the type of contraction performed in training all result in specific improvements. For example, isometric contractions of the quadriceps at a 90 degree knee angle will greatly improve static strength in this position but not significantly improve dynamic strength across the whole range of knee motion.
The specificity argument is especially important when thinking about the transfer of strength capabilities into daily life or sporting movements. It sounds obvious, but the goal of the rehab programme is to enable the patient to be pain-free while they run, play sport, work or do the housework. The goal of rehab is not to enable the patient simply to excel at a selection of exercises. The exercise prescription is the means to the end.
Numerous research studies have shown that exercises using free weights – which involve multiple joints and force the body to provide its own support – have greater ‘mechanical correspondence’ to ergonomic and sporting movements. In contrast, machine-based strength exercises tend to involve single muscles, with the machine providing the support. Therefore the transfer of a training effect to real life is considered superior from programmes based on free weights.
This logic extends well to minimal equipment rehab programmes, as bodyweight exercises are indeed ‘free weight’ movements, minus the additional load provided by barbell, dumbbells etc.
The relative merits of closed versus open kinetic chain exercises have also been researched and argued over extensively over the past 10 years.
Closed-chain exercises are movements where the end of the limb being exercised is in contact with the floor or a fixed object. They are often multi-joint movements, and tend to be free-weight movements such as squats (although some machines, such as the leg press, are closed-chain exercises).
Open-chain exercises are movements where the end of the limb moves freely and the joint is fixed. These movements are typically single-joint and single-muscle movements, often performed on machines, for example the leg extension and leg curl.
The general consensus among researchers and clinicians is that closed-chain exercises are more effective for rehabilitation purposes. These movements involve the mobiliser as well as co-contraction of the stabiliser muscle groups. They have greater proprioception benefits than open-chain movements. The strength gained using the closedchain exercises can be more readily transferred to sport or daily life movements and so are more purposeful in rehab.
We begin the exercises with the quadriceps series, moving on to the calf, back and shoulders in future issues. For each muscle group, the exercises described will begin with light movements or positions and progress to heavy ones, showing how it is possible to continue to gain strength without weights machines.
This exercise progression is for patients needing to increase quadriceps strength. Closed-chain knee exercises produce superior EMG ratios of vastus medialis:vastus lateralis to open-chain exercises. Note, also, the large number of muscle groups involved in the movements. Begin with the first exercise alone, at the start level of sets and reps. Progress to the target level sets and reps. Once this can be accomplished at an RPE of 6-7 out of 10 (see Table 1), move on to the next exercise.
|Exercise||Start sets x reps
|Target sets x reps
|Split squat (split lunge)||3 x 10||3 x 15|
|Rear lunge||3 x 8||3 x 15|
|Single leg squat, toe tap for balance||3 x 10||3 x 15|
|Single leg squat||3 x 10||3 x 15|
|Single leg squat with dumbbell||3 x 8||3 x 15|
Main muscles trained:
Suitable for rehab in:
Knee ligament sprain
Post-operative knee procedures
I urge you to pay attention to the details, particularly those defining the range of motion required (see comments above). If a constant approach to range of motion is not maintained, the series does not work as a progression.
Repeat for the other leg.
Complete one set on the right and then one set on the left.
Part II will cover exercises for calf and back; part III will deal with shoulder strengthening.