Resistance Training Guidelines & Exercise Progression in Injury Rehabilitation

Adjusting resistance level of inverted rows (No, that’s not me – notice no bald spot!)

As rehab and fitness professionals, it is crucial that we know why we do what we do. Always be able to answer if someone asks “why?”. One of the awesome things about our profession is that, in rehabilitation and strength training, there are many successful approaches to obtaining great outcomes. Throughout my career I have seen a wide variety of rehabilitative approaches used by the physical therapists and athletic trainers I’ve worked with and known. It is very true that there is no “one way” to obtain positive results with your patients. The art of successful injury rehabilitation is not only “what” you know, but more importantly how you apply what you know (i.e you bridge the gap between knowledge and application). I also believe that, out of fear of increasing pain and setting back the healing process, many times rehab clients may not “pushed” and stressed as much as they could be in terms of developing strength and power (safely, of course, without increasing pain or dysfunction). This concern can be solved by reviewing evidence-based basic resistance training guidelines. I’m going to review an evidence-based approach that I used successfully, specifically in regards to rehabilitating athletes and persons looking to return to the healthy lifestyle they had prior to the injury. Bear in mind, however, that most of these principles are not just appropriate for “athlete” rehab. The four components I wish to discuss are:

  1. Preparing the body for reconditioning (the “dynamic warm up”)
  2. Sequence of Exercise Modes
  3. Work:Rest Ratios
  4. Resistance Training Load Prescription

Preparing the body for reconditioning (the “dynamic warm up”)

Dynamic warm up (DWU) for movement/exercise preparation actively readies the body tissues for the demands about to be placed upon them. In other words, it provides a “wake up” and “rehearsal” for the body. In doing so, you stimulate both a neuromuscular and cardiovascular response. Proper DWU raises core body temperature, increases muscle elasticity, decreases inhibition of antagonist muscles, and stimulates the nervous system. Additionally, especially in the case of athletes, there is an emotional and psychological stimulus for increased levels of activity. There is plenty of research demonstrating the use of a proper DWU:

Rationale:

  • Improves flexibility, coordination, balance, proprioception, and movement speed
  • Decreases chance of injury during training/competition
  • It serves as an excellent tool for concentrating on teaching movement/skill technique (i.e. this is where your “corrective exercises” come in)
  • On the contrary, static stretching has been shown to decrease muscle strength/force production at both slow and fast velocities, anywhere from 10 mins-24 hrs later, as well as plyometric abilities

Gradual progression example in a rehab setting*^:
Low intensity non-impact general warm up (i.e. bike/UBE) → Core/Neuromuscular activation → Joint mobility/dynamic flexibility → Dynamic movement prep → “Build Up” Agilities/Plyometrics (i.e. General linear prep → General multidirectional prep).

*Gradual progression within this from low intensity → high intensity
^ When warranted, modalities and manual therapies are performed prior to starting (as well as when isolated concerns arise during training, i.e. ankle dorsiflexion mobilizations to improve a squat pattern dysfunction)

Sequence of Exercise Modes

In order to obtain the most benefit from utilizing various modes of exercises in rehabilitation, it is important to have an idea of the recommended proper sequence based on research and rationale. If client has 1 or 2 areas (of the distinct areas listed below) of impairment or disability, it is recommended to focus on these areas first, and then supplement “accessory areas” afterwards. If taking a more global approach, a more specific progressive approach as I’ll outline has been shown to be effective in maximizing the cumulative benefits gained through each method of exercise towards the overall goal(s) of your rehabilitation. In other words, you are less likely for one preceeding exercise to have a detrimental or “limiting” affect on a following exercise. Example: you don’t run a long distance workout before performing a plyometric power workout if your goal is to improve power– your power “output” will suck.

Progression guidelines*

*NOTE:  These are after/not including the DWU.  Not all of these areas need to be addressed in every rehabilitation session. This provides a logical sequence to administer therapeutic exercises as appropriate in the event that all were performed in one session.

1) Dynamic Mobility/Warm-up (as outlined above).  For specific example, see here.

2) Agilities
– Motor learning/technique work (i.e. functional agilities such as stops, ladder footwork)
– Linear  (Assisted/BW → Resistance)
– Multi-directional (45 deg COD → 90 deg COD → 135 deg COD → 180 deg COD)
– Assisted/BW → Resistance
– Practical agilities (i.e. real-life movement and situational drills, planned à unplanned               reactions)

3) Resistance exercises/plyometrics for power

4) Resistance exercises for strength
a) Power → Non-power exercises
b) Large muscle areas → Small muscle groups
c) Multi-joint exercises → Single-joint exercises

Muscular Endurance Exercises
a) Large muscle areas → Small muscle groups
b) Multi-joint exercises → Single-joint exercises

5) Balance/Proprioception
– Static → adjust plane of movement → adjust speed of movement → add dynamic external stimulus → change terrain

6) Static Stretches

Work:Rest Ratios

Newsflash:  3 x 10 with 30 second rests, all the time/every session does not cut it. Please read that 3 x 10 times today. Your client will not gain muscle strength and functional power with this approach, setting them up for future re-injury. We need to recondition strength and power, not just muscle hypertrophy and endurance. Proper reps, set, and rest period prescription can have a huge impact on successful outcomes. It is important to remember that rest periods differ based on your training goal (i.e. strength/power vs. muscle endurance). Typically, rest periods are inversely related to load: heavy load = longer rest period. I’ve heard the argument that “I don’t want my patient just sitting around that long between sets – I have to maximize their time in the session”. Well, I agree. That’s why we prescribe “accessory” exercises to perform using different body regions/neuromuscular systems to serve as “active rest”. Superset that . An example would be using a single-leg Romanian deadlift coupled with a plank variation, or a balance/proprioception exercise between shoulder strengthening sets. Treat the body, not just the body part

Rest Period Length Based on the Training Goal
Training Goal Rest Period Length b/t Sets*
Strength 2-5 minutes
Power 2-5 minutes
Hypertrophy 30 – 90 seconds
Muscular Endurance 30 seconds or less

* Multi-joint requires longer rest than single-joint

Training Specific Energy Systems
% of Max Power Primary Energy System Stressed Typical Exercise Time Work:Rest Ratios
90-100 Phosphogen 5-10 sec 1:12 to 1:20
75-90 Fast Glycolysis 15-30 sec 1:3 to 1:5
30-75 Fast Glycolysis and Oxidative 1-3 min 1:3 to 1:4
20-35 Oxidative > 3 min 1:1 to 1:3

In terms of day-to-day rest, here are some recovery guidelines*. When performing plyometrics, lower intensity drills can be performed 3-4x/week (minimum 24 hrs recovery time; example = technique drills or jumping rope). Moderate intensity plyometric drills can be performed 2-3x/week (36-48 hrs recovery time; example = medicine ball throws or band resisted exercises).  Higher intensity, high shock drills should be performed no more often than 2x/week (72 hours recovery time; ex: high box jumps or max effort bounding). *Disclaimer – it’d be fine to do upper extremity plyos one day and lower extremity the next day – rest times are referring to a specific muscle group/body region being stressed). With regard to resistance training, training for strength should be performed on non-consecutive days for muscle group. When training for balance, proprioception, core stability, and muscular endurance, it is typically fine to perform these on a daily basis without concern for overtraining.

Resistance Training Load Prescription

In addition to proper rest periods, variation and progression of load is also key to successful outcomes. This is especially important when the client is strength training on a regular basis.  Every day should not be a “heavy stress” day (100% of the load). In order to avoid overtraining and plateaus, it is important to mix in some “medium stress” days (90 % of the load) and “light stress” days (80% or less of the load). In terms of progression of the training load, I typically follow the “2-for-2” progression rule. Let’s use this example: goal is 3 sets of 8 reps for a dumbbell bench press. I will increase resistance load when patient demonstrates the ability to perform 10 reps on the third set for 2 consecutive instances.

There is also some debate about the use of multiple sets vs single sets. Single sets may be more appropriate for untrained individuals and when performing a muscular endurance/high rep set. Multiple sets are more appropriate for intermediate/advanced persons, showing better long-term gains. Studies have also shown that multi-set without failure tends to be more effective over time vs. single set to failure.

Load and Repetition Assignments Based on Training Goal
Training Goal Load (% 1RM) Goal Repetitions
Strength 85+ < 6
Power:        Single-effort eventMultiple effort event 80-9075-85 1-23-5
Hypertrophy 67-85 6-12
Muscular Endurance < 67 > 12

Repetition Max Continuum (Baechle & Earle, 2000)

rep max continuum

One of my most common recommendations I make to athletic trainers and physical therapists is for them to take a portion of their annual CEUs through courses geared towards fitness/performance training. I’ve personally learned a ton this way, much of which I have worked in cohesively with my sports medicine/rehab background to improve my outcomes! Challenge yourself by questioning the rationale behind your approach. This is the best way to continually improve!

P.S. I apologize for the length of time between this and my last post.  Baby #3 joined the family recently, so I’ve been both sleep deprived and busy 🙂

Thanks for reading!
Ryan

RStevensATC@gmail.com

References:

  • Annaccone AR.  Balance of Power.  Adv for Dir Rehab.  21-24; Aug 2007.
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  • Groner C.  Stretching…Out?  Biomechanics.  Oct 2004.
  • Howard RL.  Plyometric Concepts Reinvent Lower Extremity Rehabilitation.  Biomechanics.  Sept 2004.
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  • Myer GD, Paterno MV, Hewett TE.  Back in the Game.  Rehab Management.  Oct. 2004.
  • NSCA Certification Commision.  Essentials of Strength Training and Conditioning. 2005.
  • Pitney WA, Bunton EE.  The Integrated Dynamic Exercise Advancement System
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