rehabilitation training

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:

research shows gastroc-soleus strength is associated with reduced Achilles tendinitis risk
quadriceps strength, particularly in the vastus medialis, is associated with reduced risk of patellofemoral pain and is essential for successful rehabilitation from knee ligament injuries
back extensor (erector spinae group) strength endurance is associated with a reduced likelihood of getting low back pain
and it is essential to regain – safely – shoulder joint strength after a joint sprain or fracture.

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.

Training principles

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.

Intensity

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.

1RM is the maximum weight that the individual can lift, as they will only be able to manage a single lift at that weight
8-12 RM is considered a suitable intensity of training for gaining general strength and building muscle mass
15-20 RM is considered suitable for strength endurance benefits.

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.

Volume and frequency

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.

Progression

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.

Table 1: Rate of perceived exertion (RPE)
RPE	Difficulty	Decision
<5	Too easy	Significantly increase the reps or the load
6-7	Quite easy	Increase reps, sets or load – progress to next level
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 exercise

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.

Specificity

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.

Closed v open chain

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.

The exercises

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.

Group 1: Quadriceps

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.

Table 2: Quadriceps series
Exercise	Start sets x reps (each leg)	Target sets x reps (each leg)
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:

Quadriceps
Gluteus maximus

Stabiliser muscles and secondary muscles involved:

Gluteus medius
Obliques
Erector spinae
Adductors Hamstrings

Suitable for rehab in:

Knee ligament sprain
Patellofemoral pain
Post-operative knee procedures

Techniques:

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.

1. Split squat (split lunge)

Start position:

Stand with good posture, feet hipwidth apart, and take a big step forward (about 1m).
Hips will be in the centrally planted above feet.
Shoulders are above hips, to prevent any forward lean.
Feet remain hip-width apart.
Hips are square to the front and pelvis is in neutral (seen from the side).

Descent:

Bend the front knee and lower hips straight down.
Keep trunk upright during the lowering.
Keep the front knee aligned with front foot as the knee bends (aim the knee to track over the little toe).
Do not allow the front knee to advance beyond the toes (seen from the side).
Finish when front knee is at a 90- degree angle. Do not let the back knee touch the floor.
If the knee joint is painful, reduce the range of the dip. Do not progress to the next exercise until full range can be performed pain-free.

Ascent:

Push down into the floor with front leg and straighten knee.
Keep front knee aligned with front toes.
Raise hips straight up, keeping trunk upright.
The pelvis should remain square to the front and neutral throughout the movement.

Rationale:

This is a relatively easy movement, with most adults being able to perform 10-20 reps without difficulty. This makes it a good start point for injury rehab.
The front leg does most of the work, but significant weight is taken on the back leg, reducing the overall load on the front.
The knee position is controlled, with limited dorsiflexion, thereby reducing tibio-femoral joint forces. This means the gluteus maximus contributes significantly to the movement.
Reducing the range of motion on the front leg will make the exercise less stressful if required, and it is easy for the patient to reproduce this limited range unsupervised.

Split squat (split lunge)

2. Rear lunges

Start position:

Stand with good posture, feet hip-width apart.
Hips are square to the front; pelvis is in neutral (seen from the side).

Decent:

Lift the left leg off the floor slightly.
Bend the right knee and lower hips down and backwards.
Control this descent using the right quadriceps and gluteals for as long as possible.
During the lowering, reach back with left foot (about 1m) and place it on the floor.
Aim to keep most of the weight on the right.
Keep trunk upright during lowering.
Keep front knee aligned with front foot (aim the knee to track over the little toe) as the knee bends.
Do not allow the front knee to advance beyond the toes (seen from the side).
Finish with right knee at 90 degrees and left knee bent beneath hips.

Ascent:

Push down into the floor with the right leg and begin to straighten knee, standing up and forward.
Lift left leg off the floor as soon as possible and complete the ascent using only the right leg.
Keep front knee aligned with front toes.
Finish standing upright, two feet on the floor.
Pelvis should remain square to the front throughout the movement.
The pelvis should return to the neutral position at the top of the ascent.

Repeat for the other leg.

Rationale:

This is more demanding than the split squat because during some of the movement all the weight is supported on the working leg.
The support leg takes the weight only during the second half of the descent and the first half of the ascent, where the knee bend and quadriceps force is greatest.
Again the knee position is controlled, with limited dorsiflexion, thereby reducing tibio-femoral joint forces. This means the gluteus maximus contributes significantly to the movement.
90-degree knee position must be attained during this exercise otherwise it will not be a significant progression from the split squat.

Single leg squat, toe tap for balance

Start position:

Stand with good posture, feet hipwidth apart.
Hips are square to the front and pelvis is in neutral (seen from the side).
Point left foot downwards, place the big toe on the floor, allowing the right leg to take virtually all the weight.
Let arms hang down each side for balance.

Decent:

Bend right knee and squat down. The left knee will also bend, but the work is done with the right side.
Allow the trunk to lean forward slightly during the squat down.
Also, allow the ankle to flex and knee to move ahead of toes slightly during the squat down. This allows a full range of movement.
Keep front knee aligned with front foot as the knee bends (aim the knee to track over the little toe).
Finish with right knee at 90 degrees.

Ascent:

Push down into the floor with right leg and stand up.
Keep front knee aligned with front toes.
Finish standing upright, left big toe remaining in contact with the floor, weight on the right.
Pelvis should remain square to the front throughout the movement.
Back remains straight, despite a forward lean going down.
Pelvis should return to the neutral position at the top of the ascent.

Complete one set on the right and then one set on the left.

Rationale:

This is more demanding than the lunge as virtually all the weight is taken on one leg throughout the full range of movement.
The toe-tap position enables the patient to keep balanced throughout the full range of motion, allowing the complete movement to be performed well.
Contrary to popular myth, allowing the knee to flex forward beyond the toe-line is correct squatting technique. Although it increases the tibio-femoral forces, it also promotes increased quadriceps force, thereby increasing the strength benefit for the quadriceps. If the knee is fixed at the toe-line during the squat, hips and low back will produce more force relative to the quadriceps.
A 90-degree knee position must be attained during this exercise otherwise it will not be a significant progression from the lunge. Shortening the range makes the exercise easy.

One leg squat

Technique:

As above, but with all weight on one leg and no toe tap for balance.
Allow the free leg to bend slightly. This exercise can be performed on a step, with the free leg off the side.
Hips must stay square to the front and pelvis level (seen from the rear) as the movement is performed.

Rationale:

Full range of motion with full bodyweight placed on one leg, plus the increased balance challenge makes this even more difficult.
This is an excellent exercise demanding advanced hip stability as well as excellent quadriceps strength.
Any adult who can perform three sets of 15 reps on one leg with perfect balance, alignment and range of motion down to a 90- degree knee angle each rep has developed good functional strength.
Elite athletes, however, may need to be stronger.

One leg squat

One leg squat with dumbbells

Technique:

As above but with a 5kg dumbbell held upon each shoulder with arms flexed.
The weights on the shoulders increases bodyweight, and therefore the load on the leg.
Wearing a rucksack evenly weighted eg, with sand, would achieve the same effect.

Rationale:

Just about qualifying as minimal equipment, the addition of dumbbells or weighted rucksack allows further progression.
The dumbbells, held close to the body, increase the load on the quadriceps significantly, and also the balance challenge of the exercise (less so with rucksack).
If the weight is held out in front, the increase in force is produced in the hips and low back rather than the quadriceps.

Part II will cover exercises for calf and back; part III will deal with shoulder strengthening.

Raphael Brandon