Take Sam. She is an amateur runner who’s done a calf on a longer than usual run. Sam now waits for a period of time for it to settle and a week later goes again for another run. It goes again.
Sam decides to rest a bit longer this time, and might even do a bit of stretching. 10 days later she goes for another run, and sure enough the calf goes again. Sam is now getting a bit worried, thinking the calf needs more rest time. So this time she waits 2.5 weeks, uses some heat and ice. Sam thinks she surely should be ready now, but still is a bit worried going for another run on this day. She really doesn’t know what to expect. So off she goes, feeling quite good half way in, Sam tries to pick up her pace and, sadly for her, the calf goes again. She limps home upset, frustrated and really worried.
Sam reads on the web that soft tissue injuries need 4-6 weeks to heal, so that’s what she does and stays off it for 5 weeks- Stretches it, heats it and cools it. Worried concerned and expecting the worst, Sam goes for another run after 5 weeks…and BANG! she does it again.
Sound familiar? This is the classic story of the unsupervised rehabilitation cycle of re-injury.
The principle of load progression and adaptation ensures that your musculoskeletal, neuromuscular and central nervous systems (CNS) can adapt to the changes imparted onto it so that it can accept new levels of load and appropriate level of confidence is achieved.
We have understood for a long time that the musculoskeletal and neuromuscular systems need time to adapt to accept increasing load ie muscle strength, bone density etc etc. This is easily understood in a simple bench press exercise. You can’t lift 25kg until you have lifted 30kg; You can’t lift 35kg until you have lifted 30kg; You can’t lift 40kg until you can lift 35kg and so on. If you were to try and lift 40kg straight away, you would fail because your musculoskeletal and neuromuscular systems have not adapted to the load.
We now also know that the CNS plays a big part in adaptation and also needs time to adapt. Simplistically speaking, if your brain can cognitively rationalise that it can achieve a level of activity, then your body will achieve, and risk of failure is significantly reduced.
A stepped up and gradual approach to increasing the body’s ability to deal with load ticks all boxes and looks after all the systems involved in adaptation.
A stepped up approach (blue line below) is needed in your approach to rehabilitation. It is important to slowly and steadily increase the load and demand placed on the body so that the body will adapt. This allows for the following;
- the physical capability of your body to adapt ie strength and proprioception
- your CNS will adapt and develop confidence in the next level of increase which will allow for success. If your brain thinks it is reasonable and logical to achieve the next level of increase, then you are more likely to succeed. If you are weary, unsure and have a lack confidence at a certain level of increase, you are more likely to fail.
- if you fail a certain level of increase, then you can continue at the previous/lower level of success until the body has fully adapted, to allow you to try the next increase again and succeed, and move forward.
The saw tooth approach (red line below) is a very common approach to unsupervised rehabilitation and will guarantee failure and prolonged recovery. This illustrates Sam’s story. This approach;
- does not allow for physical, neural and CNS adaptation
- does not allow for central nervous confidence to develop so you are setting yourself up for failure
- when you have a failure your activity reduces to zero and progression ceases.
- the brain is unable to reasonably expect what will happen next time you perform setting the body up for failure.
This stepped up approach can be taken for all activities in your rehab program, whether it be for a simple calf raise, or a balance activity or a return to run program. Anytime you are wanting to progress your level, this approach needs to be taken to maximise success.
In rehabilitation typically you can increase load by a number of variables. Commonly these are;
When progressing a part of your rehab activity it is important to increase only one variable at a time.
For example, this could be an approach on a Straight Line running activity;
- Start with 20m straight line run throughs at 50% intensity.
- If this level is achieved, then increase distance to 30m.
- If this is achieved then increase to 40m.
- If this level is achieved you may want to increase intensity to 75%, but ensure you drop the distance down to 20m again.
- then increase distance to 30m, then to 40m.
- You may now want to increase distance to 60m, but drop the intensity back again down to 50%.
As you can see you can juggle the variables to increase the load requirements on the body and to allow for adaptation and prpgression.
Looking at this example, if there is some failure at a level, lets say 30m at 75%, then you would drop down to the previous level, 20m at 75%, until adaption and confidence has been achieved before trying that level again.
It is always best to consult your therapist to get clear goals and guidelines to help you progress through your rehab successfully, but hopefully these basic principles will help guide you through your rehab program.