Programming Methods for Injured Athletes

Background

Managing your clients’ pain and injuries can be a difficult task. Individuals will vary greatly in their response to these situations. Some will experience immense lows and negative thoughts associated with their pain, such as how long will this deter me from training or how much of a setback will this cost me? While others will understand this is a part of the training process and know that in a relatively short time they will be back to what they love.

Regardless of the disposition of the individual, getting out of pain is frustrating for everyone. People will respond differently to different messages from coaches and clinicians, respond differently to various types of treatments, training styles, and communication styles. I can understand how this is probably disappointing to those analytical types who want a blueprint and step-by-step process to follow. It is just not how humans  adapt and overcome pain. What they need is a combination of graded exposure, realistic outcomes, and a training plan that helps build bridges from baseline exercises to their goal.

Strategies, Part 1

The Theory

Graded Exposure

In its simplest form, graded exposure is taking the smallest stimulus that does not evoke pain but resembles an activity that is pain producing, then increasing the stimulus over time. The increase in stimulus could be exposure to specific positions, movements, loads, volumes, frequency, intensities, or time domains. This is very similar to the concept of progressive overload, or over-stimulus, used in strength and conditioning, except on a smaller scale in terms of where the progression begins and how you navigate the response.

Load Management

This is understanding the current threshold of the client relative to their current capacity. Load management encapsules all stressors from training, such as load, volume, and density. Individuals who are experiencing pain will have a lowered threshold relative to their capacity, being able to navigate that is imperative to helping guide your athlete back to pain-free training. To start, you’ll use a conservative amount of load relative to the individual and the injury/pain they’re experiencing. From there, make small incremental progressions around 3-5% of total load per session. Although depending on what the client is experiencing, there may be periods of time you use the same load and the exposure is the progression. Not every session needs to be progressed from week-to-week. You need to give the client time to adapt and to ensure the stimulus you provided them does not increase pain. 

Planned/Reactive Deloads

For individuals who are already in pain or dealing with an injury, using planned deloads as a way to navigate the training load can help mitigate training stressors that could affect them negatively. There are no set structures of deloads that your clients will need, though classic literature suggests some sort of deload every 3-4 weeks. A deload can be a change or removal of a specific exercise, reduction in loading, or a reduction in total training volume. Reactive deloads can be used in a similar manner as planned deloads, except they are based on the immediate feedback of the client. This can be a useful method of managing training stress of the client when you’re uncertain about their current threshold. This style of programming requires more communication as to when a deload is needed and how to execute it. You can use reactive deloads with everyone, but they are more effective with individuals who have a longer training age and know themselves better.

Improve Movement Options

In the TTT Movement course, we spoke about the FIVES (freedom, intensity, variability, endurance, and self-mastery) model as a way to view movement. For people dealing with pain and injury, they begin to lose movement options as their body attempts to protect itself and restrict movement options. This is obvious when you see people experiencing bouts of low back pain and how stiff they become. They no longer allow themselves to bend, flex, or rotate their spine whether in fear of movement or due to pain. For these individuals, you want to start by improving their freedom and variability. Freedom refers to the ability of the client to move their body in any way they want to and variability refers to possessing a number of different movement options to complete a specific task. Freedom training is analogous to mobility training, static stretching, loaded stretching, and other forms of integrated isolation training that helps develop new ranges of motions. Variability training is using the freedom you’ve developed to build new ways of performing movements, such as being able to squat in different stances.

Strategies, Part 2

The Tools

Breathing

The control of breath can be an effective way to help clients get out of pain. From this perspective, there are two major processes that using your breath can assist with: 1. Regulating the nervous system to bring it from a sympathetic state to a parasympathetic state, and 2. The capacity to help change movement patterns (i.e expanding areas that have been compressed or restricted). If an individual is spending more time in a sympathetic state, or a heightened state of arousal, this could affect their experience of pain and how other sensory inputs affect their body. As a part of one of the TTT Movement course iterations, Max put out an entire series on breathing and different techniques. You can view that here to learn more about how to effectively use breath work for your clients.

Isometrics

This is one of the first entry points to return to strength training that you can use with individuals who are experiencing pain. In the TTT Strength course, we discussed different styles of isometrics, overcoming and yielding, and the usefulness of each one. Most often in the initial stages of helping your client out of pain, you’ll lean more towards yielding isometrics as the force requirements are lower. This can allow you to load irritated tissues in a way that is tolerable to the client, then begin to build on those positions with other strength training tools.

Studies have shown that using long duration isometrics can actually dampen pain signals for a short term effect. This could be a useful tool that you could use as a way to develop capacity in any painful movements. An example of this could be low back pain while squatting, you can use a long duration front loaded wall sit followed by goblet box squats to parallel in order to develop tolerance to loaded hip flexion.

Something that you have to keep in mind while navigating this process is you don’t want to fight tension with tension. This is the counter to using isometrics, or solely relying on isometrics. Many of your clients will begin to reduce their movement options due to pain in certain positions. If these individuals are already taking the ability to move freely away, then using isometrics is reinforcing those behaviors. In those situations, we need to restore motion to those individuals instead of layering on more tension.

Build and Develop End Range Capacity

With the loss of movement options comes the loss of the ability to access the end range of motions needed for your client’s sport, as well as the ability to be strong and stable in those positions. It is important to reestablish those positions so athletes can be confident when they are in competition. In order to bridge the gap between where they are now to where they want to be you can use isometrics and movement variability to navigate the process. It is important to note that you do not need to rush people into their end ranges, but rather think about this as a gradual introduction process. Train and use the motion they currently have available to them and over time allow those positions to redevelop. Movement systems like Functional Range Conditioning (FRC) can be useful in these situations as they use low to no external loading and solely rely on the body’s internal loading ability. The TTT Movement course goes over joint rotations, PAILs and RAILs, and end range lift offs in the methods section to provide you with details on how to program these exercises for your clients.

Find The Hardest Thing They Can Do Well

Depending on the severity of the injury, much of the rehabilitation process will be performed by a medical provider leaving you with restricted options, or at the minimum what can feel like restricted options. This is where the art of coaching can make an impact on your clients training while they work through pain and injury. Your ability to be creative and provide them with goals that allow them to feel challenged, make meaningful progress towards things they care about, and help calm their anxieties around their injury and pain will be imperative. This can be simple things like picking upper body exercises to make progress in when dealing with a lower body injury, or using endurance tests as a marker of improvement when dealing with pains associated with load intolerance. Sometimes this may even look like spending more time outside of the gym to remove excessive stressors, like doing some easy hikes. The ultimate goal is finding the hardest thing an individual can do and exploiting that to continue to give them meaning and purpose.

Conclusion

This is a brief introduction to many concepts that physical therapists and other rehabilitation specialists use in order to help their patients get back to function. Entire books, courses, and companies have been created in the name of a majority of these concepts. Expecting to know the in’s-and-out’s of any of these subjects from this blog would be misleading. My hope is that one of these topics resonates with you and you follow that pathway down to understand it at a deeper level so you can better serve those you work with.