rehab, strength endurance training, hamstring strengthening programme
Sports injury rehab - Raphael Brandon shares his hands-on experience to offer advice on how to design sports injury rehab regimes based on sound training principles
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In my work as strength and conditioning coach for the English Institute of Sport, I am lucky to work with an excellent sport medical team. One of the main advantages is that the physiotherapists and I work together to design the rehabilitation programmes for our injured athletes. Often this involves my physio colleague initially identifying muscles and movements that need to be strengthened, and suggesting a few exercises to the athlete. The athlete will then work with me in the gym, where my focus is to ensure the exercises are effective for that particular athlete and that the rehab programme is well structured.
Progressive overload
One of the key principles of training is progressive overload. The exercises are set at a specific intensity and volume to start with. Given appropriate recovery time between sessions, this initial training dosage will produce a training response. After a certain time the athlete adapts and the dosage will have to be increased for there to be further increases in fitness. If there is no progression then the athlete’s fitness level will plateau.
This principle is as important when prescribing rehabilitation exercises as when designing strength or endurance workouts. A programme is always much more effective if it progresses over a specified timescale. Table 1 below, for example, gives an eight-week hamstring strengthening programme, using the eccentric hamstring exercise illustrated. Note how the ‘repetitions and sets’ of the exercise change over time.
Table 1 shows a simple volume progression. The goal at the start is to learn the exercises correctly. The trainer must ensure that the athlete performs all rehab exercises with good form and that the right muscles are being recruited effectively during the movements. In this case, the athlete performs only 2 sets x 5 reps twice a week for weeks 1 and 2 because this a difficult exercise and we need to ensure the muscles and tendons of the hamstring are not overloaded too much, too soon. Hopefully, by the end of the four initial sessions, the athlete will be able to lower forward through a good range of motion, as illustrated.
| Week | 1 and 2 | 3 and 4 | 5 and 6 | 7 and 8 |
|---|---|---|---|---|
| Reps and sets | 2 sets x 5 reps | 3 sets x 5 reps | 3 sets x 8 reps | 3 sets x 10 reps |
| Frequency | 2 x per week | 2 x per week | 2 x per week | 2 x per week |
Athlete lowers body forward using eccentric contraction of hamstrings to control the movement. The movement should be kept slow but without strain to the hamstrings. The gluteals are used to keep the hips extended and low back in neutral. The athlete may push themselves back up with their hands, if they do not have the hamstring strength
During weeks 3 and 4 the athlete completes 50% more reps by adding another set (3 x 5). Over the next 4 weeks, the athlete builds up to being able to perform 3 sets x 10 reps, which is three times the original dosage. In this case the programme has targeted the strength endurance of the hamstrings, which is why the emphasis is on building up the number of repetitions over time.
Strength endurance training
Strength endurance is a common goal for many rehabilitation programmes. The aim is to increase a muscle’s ability to withstand repetitive forces or be able to maintain its function for sustained periods. Table 2 gives guidelines for developing strength endurance, which can be used to help you programme effective progressions.
| Repetitions | 10 to 20 |
|---|---|
| Sets | 2 to 4 or 10 to 90 sec holds per set (static positions) |
| Intensity | At a resistance (weight) that results in fatigue during last few reps of each set |
| Rest | 30 to 60 secs between sets |
| Frequency | 2 to 5 x per week |
| Phase duration | 4 to 8 weeks |
It will take 4 to 8 weeks to develop a significant improvement in strength endurance. At the start choose an appropriate resistance or, if it is a bodyweight movement, an appropriate level of position. Once the athlete can do 20 reps (or 90-second holds of a static exercise), it is probably more effective to increase the resistance. Beyond about 20 reps the relative load has now become too low to enable the athlete to continue to develop their strength endurance, so to make the exercise more challenging, greater resistance is needed.
Strength training
Not all exercises in all rehab programmes, however, will be targeting strength endurance. Often strength alone would be more important. For strength training the resistance must be at a level that allows the athlete to perform no more than 10 repetitions per set. Rest periods between sets should be longer: 2 to 3 minutes to allow for the necessary recovery, and the weights progressively increased rather than upping the number of repetitions. But don’t push the weight up too far, too fast: two to three weeks at the same level will be needed.
For example, imagine an athlete has a knee injury and performs quadriceps and hamstring strength tests on an isokinetic machine. The results show that the athlete has left/right strength imbalance in the quadriceps favouring the right, and a poor quadriceps to hamstrings strength ratio (the hamstrings being weak). A rehab programme targeting strength rather than strength endurance will be appropriate to ensure balanced maximum strength levels, as Table 3 shows.
| Single leg press | Leg curls | |
| Week 1 and 2 | ||
|---|---|---|
| Reps and sets | 3 x 10 left; 2 x 10 right | 3 x 10 |
| Frequency | 3 x per week | 3 x per week |
| Weeks 3 to 5: increase resistance | ||
| Reps and sets | 3 x 8 left; 2 x 8 right | 3 x 8 |
| Frequency | 3 x per week | 3 x per week |
| Weeks 6 to 8: increase resistance | ||
| Reps and sets | 4 x 6 left; 2 x 6 right | 4 x 6 |
| Frequency | 3 x per week | 3 x per week |
In general, if you are targeting strength improvements, Table 4 gives guidelines for effective progressions.
| Repetitions | 3 to 10 | |
| Sets | 2 to 5 | |
| Intensity | Heavy weights to produce fatigue within each set | |
| Rest | 2 to 3 min between sets | |
| Frequency | 2 to 3 x per week | |
| Phase duration | 4 to 8 weeks |
It is important not to overload the muscles and tendons too much, too soon, which is why you should start with lighter loads and more reps, and progress to heavier loads and fewer reps. By increasing the number of sets, you can maintain volume when the reps decrease (starting, for instance, with 2 sets x 10 reps and progressing to 4 sets x 5 reps).
So, in terms of effective rehab programme-setting, the key point about progressive overload is that the type of improvement in muscle function must be specific to the goal.
Programme structure
Another area of programme design in which I help my physio colleagues is the overall structure of the rehab programme and how it fits into the athlete’s training week. (This can apply both to work with elite athletes and, more widely, to the health and fitness sector.) It is important to get this prescription right, so that the athlete is left in no doubt about how to achieve their rehab goal. It is the ‘where and when’ of the programme and often involves prioritising the most important exercises to ensure the work gets done.
For example, sometimes therapists give patients very long lists of exercises. All the exercises will be good, but the therapist has not thought about how long the whole programme takes, or when this training is to be done.
Recently, I was working with an athlete who had seen three physios over the last few months. They had all given her lists of exercises to do to achieve various goals, all of which were important for her performance. But she was finding it unmanageable to do all three lists, and was confused as to what was necessary. My job was to integrate all the advice into one cohesive programme.
I added some of the exercises, which required weight machines, to the end of her twice-weekly strength workouts in the gym. For the rest, we determined which of the exercises were the most effective for her and then combined these into a single, relatively short, injury rehab workout which she could perform at home or prior to her training sessions four times a week. She was then clear as to her training priorities, and happy that she could achieve the programme.
I would encourage all therapists or trainers to go through a similar process with their clients. If a busy athlete comes to you with an injury, it is very likely that they will already be struggling to fit in regular workouts, let alone follow a rehabilitation programme. As well as teaching the exercises, it would be advisable to talk through and write down when the exercises can be done.
Check that the patient agrees that the programme you set is realistic and are confident they know how to achieve it. And you will improve their chances of adherence to the exercises if you also set them goals to have achieved by the next time they see you. In essence, you will be applying ‘coaching’ techniques to your work that will raise the quality of results you can get for your clients.
