Editor's Note: Part 1 of this article appeared in the Nov. 15, 2015 issue; part 2 ran in the Jan. 1, 2016 issue.
Once a rehab / fitness program starts, some stiff and/or weak patients seem really good at gaining mobility and strength, while others seem slower than I'd like. If treatment is going slow, I review these possible reasons or mistakes they may be making first.
Why Plans Fail or Fail to Progress
In some cases, patients only do what they like to do or only do exercises or movements that feel easy to them. I have to be the one to tell them what they need. Another reason for stalled results relates to inadequate rest / sleep and inadequate protein intake. I not only mean not getting enough sleep, but also not getting enough time or rest between exercise sessions. Patients need guided, optimal loading, even a little overreaching, followed by periods of lower training stress to allow for muscle adaptation to occur.
Another reason progress may not be being made is that patients are not getting enough variety of movements. I'll give patients specific exercises, but I make sure these are being rotated in and out of the program so we create adaptation, expand the "motor program" and avoid overuse injuries.
A lack of consistent exercise is another reason for poor outcomes. The best exercises (for strength and conditioning programs) are ones patients will do consistently and are sustainable. My home exercise prescription programs include a short mobility warm-up, a little stretching, and specific strength progressions with a load (band, kettlebell, free weight).
What's the Correct Load?
The answer is the heaviest weight with which your patient can perform all of their prescribed reps in a set with perfect form. A beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70-80 percent of 1RM. A beginner can make strength gains on as little as 40-50 percent of their one-rep max.
A load of 70-80 percent of 1RM should cause the lifter to reach fatigue within 8-12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Later, the number moves up to about 85 percent – which would be about a five-rep max for an intermediate lifter.
Of course, 85 percent isn't going to get the job done for very long, either. In a healthy individual, a fast way to build strength is to perform singles at or above 90 percent of one-rep max with regularity. With my rehab patients, I start with body-weight exercises, then progress to continuous-loop bands and other band exercises, and free weights or kettlebell exercises.
The loading parameters are sets, reps, tempo, rest periods and even exercise selection. We can say the total reps x sets x load = volume (qualitatively take exercise selection into account). When two athletes of comparable strength are on the same basic program, the athlete who has the greater volume will be stronger.
There is an inverse relationship between sets and reps. As reps increase, sets decrease and vice versa. The reps performed is just a measure of the total time under tension (TUT). Determine your desired training effect, match it with TUT, and select a weight with which the patient can perform the exercise with perfect form.
You can count the repetitions performed in a set as a measure of the type of outcome you want the patient to achieve:
- 1-20 seconds TUT: strength development
- 20-40 seconds TUT: strength / hypertrophy development
- 40-70 seconds TUT: hypertrophy development
- 70-120 seconds TUT: endurance control development
Let the reps dictate the weight. Remember, if you do not apply overload to the muscles, there is no reason for the body to make any adaptations.
Factors Determining Set Selection
- Time: There appears to be a minimum amount of time the muscles must be stimulated for maximum size and strength gains. Low reps = high sets; high reps = low sets.
- Number of exercises per session: Adding exercises reduces sets.
- Training age: A beginner might start with 1-2 sets. An intermediate / advanced patient (athlete) will do more.
Tempo (Lifting Speed)
Keep in mind load is not the only factor in training – time under tension is the key. The tempo is used to control, prescribe and measure the time of exposure. It is generally written as a three- to four-digit formula. For example, eccentric (lengthening): isometric pause at the bottom; plus concentric (shortening): isometric pause at the top = 3120. Note that one of the pauses should be zero in general.
The tempo is the factor that controls the duration of the rep and therefore the duration of the stimulus. If we don't control tempo, we are sending the message that rep speed is unimportant and never varies. Cutting lifting speed in half has been shown to increase inertial torque 400 percent. This is an indicator of potential joint stress with excessive high-intensity lifting volume.
I usually start with slow-tempo movements, regardless of whether I'm using body-weight, bands or weights, to improve the patient's technique and get them to concentrate on where they should feel the exercise.
Rest Periods
If you adjust the rest period, you adjust the entire program. For the purposes of hypertrophy and fat loss, short rest periods of 30-60 seconds coupled with higher-volume training have been found to cause elevated levels of growth hormone and testosterone. The higher the training intensity and the more deconditioned the patient, the longer the rest period should be.
Other Considerations
I continue to use body composition analysis to emphasize having a plan and goals so the patient knows when rehab is complete. End of treatment is determined by when the physiological process of healing is complete; when their physical performance is reinstated; and when their CNS is satisfied threat levels have reduced and has "turned off" its "surveillance" of the problem that brought the patient in to see me. In other words, they feel better, are doing activities of daily living easier and/or are playing "full out."
In the ACA's rehab diplomate program, participants are taught baseline exercises along with common multiple exercise regressions and progressions. Here's a checklist of positions and movements you can use to create and vary your exercise programming:
- Pick a footprint: Tall kneeling, half-kneeling, scissor stance, lunging, double-leg stance (wide and narrow), single-leg stance.
- Pick a handprint: hands pushing movements, hands pulling movements.
- Incorporate legs moving and core engagement poses. Every movement can be done with assistance from you, a band or some stationary object.
In terms of progressions, I usually start with body-weight only, then use a continuous-loop band, then a kettlebell or free weight. To improve motor patterns, I customize and create exercise prescriptions that use "offset positions" - for example, holding a kettlebell at your side, in the rack position, or over the head, or performing an exercise movement only on one side (unilateral), which is different than holding it on both sides (bilateral). Try experimenting with your fitness / rehab plans to achieve different muscle activation and maximize patient outcomes.
Click here for more information about Jeffrey Tucker, DC, DACRB.