Ask Mike Reinold

How to Progress Loading Strategies After an Injury

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Have you ever wondered how to progress someone’s exercises or loading strategy after an injury?

This isn’t something that we often learn in school. You probably know how to do it well, but may just need some experience.

Here are some strategies we follow to progress loading in our patients.

To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 249: How to Progress Loading Strategies After an Injury

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Show Notes



Transcript

Student:
So our question today comes from Ryan, from Florida, as a new therapist I really struggle with lower extremity therapy, loading progressions. Do you have any suggestions for taking a patient from injury to walking to more specifically knowing when and how to increase load to help them reach their goals? It was never really covered in detail during PT school. It sounds like a basic thing. So I feel embarrassed, and I don’t understand it better. Thank you for any input.

Mike Reinold:
I’ll start off with this ride, I think many people feel this way. I think we’ve talked about this in past episodes that this isn’t like a huge portion of a lot of programs. I think you should, easy for me to say, I think you should feel motivated to learn this because you have identified this as a knowledge gap that you may have. That’s cool, but man, please don’t feel embarrassed about this. I know again, easy for me to say. It’s not embarrassing that you realize that there’s something you can get better at. I think that’s amazing. So get better at it. Learn that a little bit. Hopefully will teach you a little bit about that. I don’t think I learned it that much in school, either. A lot of it for me was learning by doing, by you in the rehab world, experimenting with loading progressions and how to increase strength in people.

Mike Reinold:
Then I think the second part of that was that the more that I kind of worked on being a strength coach and actually working in a strength and performance environment, that really helped. So let’s start from the beginning though. PT student, early career professional, it sounds like you’re early in your career. Let’s start off with Diwesh maybe, we’re going to go right to the strength and conditioning perspective first, which I think is the good solid background. Somebody coming to you, they just started rehab. They just started anything, an exercise program rehab. How do you determine your loading pattern for that person? What sets and reps, how much weight, where do you start and then how do you start progressing that, Dewey?

Diwesh Poudyal:
Yeah, big thing for me is, first go through an assessment, try to figure out what level they are as far as, in their rehab process or in the performance process. We try to figure out what the entry point to training is. Right? One of my favorite phrases that are picked up kind of along the way is, finding the person’s trainable menu. We kind of start with that. We figure out, what do they have access to currently? Then we figure out, how do we fill in some of these menu items with the patterns that I find are important. Let’s kind of focus on the lower body, because I think the person asked about lower body extremity exercises. We take a look at, we have a squat pattern, we have a hinge pattern, we have a lunge pattern, we have a stepping pattern and then maybe let’s even add in ambulation, the act of walking or running or whatever form of ambulatory exercises.

Diwesh Poudyal:
We figure out, what’s my low hanging fruit. As far as things that I know we’re going to get big bang for our buck through. Then how do we find ways to load it safely and have them continue to make progress? Big things for me are, if we’re talking about a squat pattern, we try to keep it early on to something they can manage staying nice and tall, and being able to kind of bend through ankles, knees and hips and find a good, comfortable position. We might load it with, two sets of 10, three sets of 10, four sets of eight, whatever we have access to that they can actually manage. Then over the course of time, we might progress load, but decrease the volume, meaning, go down in reps.

Diwesh Poudyal:
Then, similarly for let’s say like the lunge pattern, we try to figure out, is a stepping forward lunge, a little too difficult for this person because they might have some compensations and they might struggle with it. All right, great. Let’s do a split squat, keep them in place. We just go up and down on that, on that single leg or split pelvis stance. Then we progress that over the course of time. We treated the same thing, like the squat, we give them higher reps early on to practice it and then as they get a little bit more proficient with the actual movement of the exercise and they show that they can load it a little bit more now, now we introduce a little bit more load, bring the volume down so they can actually manage control of that load and then so on.

Diwesh Poudyal:
You just kind of take that same concept for your hinge. You can even say that same concept for your ambulatory exercises. We might start with easy, moderate loading, sled pushes, if you have access to the sled. Right. Then maybe we kind of turn that into a little bit more like treadmill jogs or then sprints. So there’s definitely ways to kind of progress that we just got to find out what their entry point to training is. Then pick low-hanging fruit that we can get a good training effect out of, while keeping them safe and keeping them progressing.

Mike Reinold:
I like that, and I like how you started off by not just jumping right into like throwing load on somebody. What you’re trying to do is find which progression or regression of a movement pattern is most applicable to them. So again, say a lunging pattern, we determined you don’t have enough strength or stability or experience with this movement that you don’t do it so well, let’s just do a split squat. Let’s regress the exercise mate and make it basic. I like that. Who else, Dan? What do you do? I thought I saw Dan raise up a little bit. Sorry, obviously you too Dave, but like what do you do in the rehab mode? Somebody comes to you, they have knee pain. I don’t know. Where do you start with them?

Dan Pope:
Yeah, I think that’s a great point. I think this is one of the most powerful things we can do as physical therapists. Learning about this is important. I’m actually doing a whole series of seminars on, I call it stress dosing. I don’t have a good word for it, but that’s essentially what we’re doing. We’re trying to figure out where someone is in terms of their injury. We’re either kind of increasing that dose of stress, decreasing, whatever we need to do. What’s kind of nice is that for certain joints, we can figure out how much stress we’re putting on the joint. Let’s say the knee is a pretty good example. We’ll use example of, let’s say a squat. I know you were talking about walking, but we know from a physics perspective, it’s kind of funny because I took so much physics as I was growing up, but I don’t think I ever had the dots connected well enough from physics to actual physical therapy, but it becomes super important.

Dan Pope:
The deeper I go into a squat, the larger, the moment arm grows from my knee to my center of mass. The more stress goes on my knee. The more my knee comes forward during a squat, the same thing happens, more stress goes through the knee. So if I’m trying to increase stress on knee with something like a squat or a split squat, I can just translate my weight forward, drive that knee forward. I’m increasing the stress in the knee. If I want to decrease that stress a little bit. I just shift my weight backwards. It’s one of the reasons why, if you’re a personal trainer, you have someone with knee pain and you want them to decrease that knee pain and you tell them to squat with the hips back. Usually the knee feels better. I remember back in the day when I was a trainer, I didn’t really understand why, but it’s pretty simple.

Dan Pope:
If you understand those biomechanics, you can decrease some of that stress. So for someone who has knee pain, it’s a little bit different for someone who say post-surgical because for those folks, we have to follow a pretty specific protocol, but you give them whatever they can tolerate at the time. Then pain comes into play, pain for a lot of injuries. Let’s say it’s more of a tendon issue, patellar, tendinopathy, or patellofemoral pain issue. We know we can push through a decent amount of pain. I think part of it is that when we do the evaluation, you have to know a little bit about the pathology. Let’s say it is knee pain, then you try a bunch of movements to see what’s tolerated best and you try and give them pretty much the hardest exercise they can tolerate well and over the course of time as they tolerate more, you just add more and more and more, a couple of easy ways to do this.

Dan Pope:
And Diwesh talked about it as we can increase the load. We can increase the challenge of the movement, so having that knee translate forward a little more deeper into a squat, more knee dominant motions, like a step up as opposed to a single, like a deadlift, and we can increase the speed. So if you’re moving super slowly, it’s less stress through the joint, they move faster, it’s more stress to the joint. There’s so many ways to do this from a program perspective. What we’re trying to do is manipulate some of the stress in whatever way you’d like, low speed, movement, whatever. There’s a lot of options.

Mike Reinold:
Yeah even volume frequency. I mean, all those things actually kind of play into it. So I think that’s a good way of doing it. I like what you kind of said right there, when somebody is in pain, I think the first thing you want to do is you want to determine what’s an acceptable amount of pain. So whatever, let’s say three, four out of 10. You have to establish that and then find what loading strategy does that. I think that’s a great way to start with this. If you’re doing something and they are having no issues with it and they’re breezing through it and they have no discomfort. Some pathology is like a tendinopathy. Maybe you can deal with a two, three, four out of 10 pain. That’s probably a sign you want to load a little bit. Dave, did you have something you wanted to add? I saw you kind of say something.

Dave Tilley:
I mean, my points were kind of summarized pretty well. It’s a funny story because I vividly remember the time that I decided I needed to learn more about this, was actually I flared up somebody’s cuff because I didn’t have a great exercise progression mind. Of course, after that, I need more of this. There’s no worse feeling as a clinician when somebody comes in, they’re like, oh man, I definitely feel crappy. I think we did too much. I’m not getting better. It’s a terrible feeling. It’s what you do with that after like, do you do con. ed or you just keep like blasting ahead and be like nope, I think we’re fine, just keep going. So my 2 cents are, is learn the strength conditioning and learn what exercise progressions.

Dave Tilley:
Dan has some really great graphics about the spectrum of hip dominant versus knee dominant exercises. You can do a high bar back squat with somebody and know that’s more hip dominant and take some pressure off the knees. How do you work up through a trap bar deadlift up to an actual front squat? That’s really important to know, because on the fly, you can adjust those exercises if someone’s having discomfort, but also you can program for them more specifically of what they’re going to have limitations around.

Dave Tilley:
Two is, I think you mentioned it Mike, there’s some good studies that show that under a three out of a 10 out of pain is maybe a tolerable limit depending on the pathology. I think the important thing is educating people about you’re probably going to feel some discomfort here, as long as your pain is not worse the next day after significantly, and it goes away within 24 hours or reduces back to its baseline, we’re probably okay, a yellow light system. I think that that’s really important for us to educate people on what what’s that tolerable level, because most people, we’ve talked about before, just have disuse or discomfort associated with exercising. That’s a normal response and they think it’s pain from their injury.

Mike Reinold:
Yeah. I love that. That’s great. Lisa, what else?

Lisa Russell:
I’ll say this is one of the biggest things I feel like I’m continuously learning from all of you. I’m still working on this, I don’t feel comfortable with this for the most part. I mean, unless I feel like I’ve already been there with somebody, but I feel this is one of the things that, when I’m thinking of something I want to do with someone, I either kind of check in with one of you guys or create that conversation because it’s tricky and I’m definitely still learning that. So you guys are my resources there for sure.

Mike Reinold:
You’re right though. A lot of this, we learn through experience. There isn’t a magic course you can take necessarily, I do think there’s some con. ed. You can study up in the strength and conditioning literature, exercise fizz, maybe sit for your CSCS. I think that’ll be helpful. Dewey, did you have something on that?

Diwesh Poudyal:
Yeah the last thing that popped into my head that could definitely be helpful, and it’s something that I preach to our interns all the time. It’s just having two things, one having a really good system that organizes all your patterns and tells you kind of all the things that are available from a movement standpoint. Then second, having an enormous exercise library so that you can kind of manipulate modified positions. It’s similar to what Dan was saying about shifting the levers and kind of figure out how to create a different type of stress in a certain area. Having that giant exercise library can really help you slide in and out of that scale of where is this particular athlete and what’s appropriate for this one. I know we use it a ton in the performance end of things, too. So I can definitely see that applying to physical therapy as well.

Mike Reinold:
Yeah. It’s like a systems approach, right? That was great. You guys gave some great answers. You guys are wicked smart. I mean, very smart answers. I’m actually impressed with the answers. I think you guys answered it, super macro and super amazing. I’m going to give you a micro answer and just a quick little answer. I think honestly, you may need this too a little bit. You guys were so advanced and so awesome with your answers. How about this? Look there’s room for, there’s a little gray hair, but keep this in mind. You got one exercise you want to start with someone. You want to know where to load. Start with two sets of 10, that’s what we started with. This is what I do at least. I start with two sets of 10 and then as they’re going through it, I immediately say, how’s that? Is that easy? Is that moderate? Is that hard?

Mike Reinold:
Then based on their feedback, based on what I’m seeing, I’ll adjust the weight that day. Hopefully that day I will try to figure out a decent weight for them to use. It might take a session or two. A lot of people don’t understand intent and they don’t understand how to lift things heavy. They think they’re struggling a little bit, but then when you quiz them, you’re like hey, was that easy, moderate, hard? They’re usually oh, that was moderate. We’re like great, let’s go up. Until somebody says oh, that was pretty hard and they look like they’re struggling a little bit with the last few reps we go up and they’re going to be surprised at how strong they get, in one session because they start lifting more weight.

Mike Reinold:
So same exercise, two sets of 10 find that weight, easy, moderate, hard. What do you do from here? I would probably slowly increase their load, linear loading, just ease each session until we start to get to a plateau, I would keep them two to three sets of 10 and let them load, load, load until they keep going up. At some point when they start to plateau, especially with somebody that’s new to these exercises. That’s when we start manipulating the sets and the reps. That’s when we start going down with reps up and weight, start doing some other variables. I think in most physical therapy settings, the concept of linear load, which is keep the set and reps the same, but then slowly increase load is very valuable for most people. If you have an advanced trainee, a super aggressive athlete, somebody later down the road, you have to learn more about this, but starting off, you can keep it simple and do a lot of damage.

Mike Reinold:
That would be my advice and then take everything that all these smarter people than me just said and put it all together. Then that’s some pretty advanced loading strategies or stress strategies, as Dan said, too. That’s pretty cool. Hopefully that helps. If you have questions like that, head to mikereinold.com, click on that podcast link, you can fill out the form to ask us more questions and be sure to rate, review us, iTunes, Spotify, and we will see you on the next episode. Thanks again.

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