The in's and out's of rehabilitation
Take home message
is there a more important time to specifically apply general principles?
For Coaches
As with all programming, thoroughly and systematically apply broad principles to your specific athlete.
For Athletes
As unfortunate as injury is, rehab is an opportunity to learn more about yourself and your individual preparation.
There is a great deal of time and money spent on preventing and rehabilitating injuries. Yet, despite this investment players still get hurt and injuries recur during rehab and playing moments. Rehab is a fascinating area. Where you can be provided with numerous programs for the same injury that all look different, and all work. I find it is one where there is a narrow middle ground between over-simplified and over-complicated. Where practitioners can crave a safe, black and white “follow-this-protocol” strategy, where in fact rehab exists in predominately grey. It is a combination of common sense and art backed, by science (in my opinion) [for an enlightening read on art and science in sport, discover this wonderful discussion paper by Alan Hazlett here. I won’t mind if you leave to read it, it is a wonderful paper. Just promise to come back].
For example, a stronger muscle is more tolerant of load/force and less likely to get injured. Therefore, a simple strategy in rehabilitation is to increase the strength of the muscle to a level higher than what it was prior to injury. Yet, that can be over-simplified. That has not even started to consider movement technique and the complex interaction between muscles and joints of the entire system, not just one muscle working in isolation (which they never do). There are sport, and particularly with injury, incident specific context to consider in a comprehensive rehabilitation program: contraction type, velocity, angles, skill and cognitive aspects (what skill was the player attempting). From simply strengthening the muscle to an encompassing comprehensive rehab program. Fast entering over-complicated.
To help alleviate the “explosion” of variables, there are established protocols for injuries, such as the hamstring, which can assist the rehab design process. Simple and convenient. Over-simple? Consider that the protocol you are basing your program on may have been developed in a sport other than yours (different movement and skill demands) or with a different level of athlete (different training base/age/capacity) or both! Plus, not every hamstring injury is the same (anatomically with three different hamstring muscles and varying levels of tendon involvement, there are many combinations for any injury). All of a sudden, the simple framework to follow is over-simplified to your particular athlete. These are often labelled as “protocols” and not guidelines (as I am sure they were intended), deterring deviation from “evidence-based” practice at your peril.
For every rehab program or protocol that is presented, I feel I can guarantee that at that practice/club/organisation where the protocol/system/advice originates, not every program is exactly the same. It can’t be. Because no two athletes are the same: age, training back ground, injury history, strength and fitness levels, injury site and injury mechanism. This brief list of variables influences the magnitude of program application (how hard or easy a prescribed session is for any athlete) and response of each session for each athlete (how the athlete will adapt to that session). The protocol is altered slightly by the practitioner to get the desired response (based upon their personal understanding of the athlete). I feel the key is to find the common threads among the wonderful options available (as there will be themes) and modify other variables to your context if you can (if you cannot, ask for help. Nothing wrong with that). For coaches fortunate to work at the elite level, consider that your athlete is very likely the outlier that sits outside that general rehab protocol you are following. That subject that is far above the mean of the data collected in a published rehab program. They most definitely respond differently, it’s part of what makes them elite.
Then there is the inverse relationship between return to play time and recurrence and the trade off between risk and reward. If you wish to reduce the chances of recurrence, more time is better. However, that may mean more games missed. So to miss less games, return quicker, but perhaps the player is slightly under-prepared and at higher risk of re-injury. Turning a 3-week injury into 4 with an extra week of rehab to be sure is better than turning a 3-week injury into 6 or 7 because the rehab was done twice. A little more time is always better than less. If available. However, sometimes you have to “roll the dice” as you don’t have the benefit of more time (eg. returning for a qualifying match, or a tournament). Then you play within your limitations and hope for the best.
And everything discussed so far has been physical. There has been no mention of the most important part - the emotional well-being of the injured player! Injuries are terrible. They hurt. They stop players from playing. No player I know likes watching over playing or training, they want to be out there (I want them to be out there!). The rehab process is often slow, sometimes long and players are often admirably impatient wanting to get back out as soon as they can. As a young S&C coach, my program and coaching was all about the physical but now, perhaps like a lot of my coaching, I am making a conscious effort to put the person first and the athlete second. Maybe with experience, the recognition of circumstances and what to do when, is a little more familiar and subconscious allowing focus on other tasks I did not know I needed to be aware of. However, I have not seen too many rehabilitation protocols that include well-being as a variable to include. You see reps, sets, distances, exercises, intensities, but rarely psychology. Perhaps this is the immeasurable art in the science of rehab. I think the mental aspect of the injured athlete drives so much that it should certainly be at the forefront of any rehab program.
Rehab is a necessarily complicated and pressured process. Your job as a coach is to put the person first, consider all the very good rationale from rehab programs available, observe basic fundamental principles of adaptation and science, and apply them as best as you can in your context. To the athlete, I’m sorry you are injured and wish you a speedy recovery. Use this time wisely to learn about yourself as a person and athlete, grow other parts of your life and game whilst being thorough, patient and determined that you will recover.
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Thanks again. BA.