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When is rehab not rehab?

Updated: Mar 30, 2021

This post is for past me.

Specifically, the past-me of a year ago, 8 months post-ACL reconstruction, who had a minor hissy fit one evening because she could "sort of do everything but still just can't do some stuff" and "why has nobody given [her] the exercises to make that happen", who eventually answered her own question mid-tantrum by grumbling "I mean, I suppose I should just keep doing them until they get better, like I'd learn any exercise from scratch, but I used to be able to do them fine, and I'm so much stronger now, and I can do all this other stuff, so I should be able to just do them!".

Maybe I'm the only one who expected that a rehab programme, strictly adhered to, would at some point just unlock all the movements and strength I had had pre-injury. I know how stupid it sounds. Don't think I wasn't aware of how far I had come - in fact, that was the point: I had come so very far, and I was so appreciative, that I just couldn't understand why every possible movement and position hadn't just reappeared all at once.

I knew the answer, even then: I had a new knee. Same leg, roughly speaking. Same kneecap. Same meniscus. But new anterior cruciate ligament, altered hamstring tendon, and who knows what the state of all the rest of the fascia in there was. In the same way my whole body learned to crawl, walk, run, squat, this brand new knee needed to learn those skills again. Learning skills means creating nerve pathways, developing strength, refining the timing: I had the strength for general movements, and my brain knew the finer movements, but somehow my knee just had a rhythm of its own. Movement is about so much more than strength or flexibility or range of motion; it's about resilience, adaptability, reactivity, creativity. Things that can't be bottled and prescribed and methodically practised.

I am not saying that rehab protocols, or the concept of rehab, are flawed. Rather, it is our relationship with them that is flawed.

We live in a very binary world these days: things are good or bad, we are fit or unfit, we are injured or healthy, we are broken or fixed. As such, we expect there to be a point at which we simply are no longer injured; and that means we need a professional who knows the secrets to fixing us (because we don't know how to do it, therefore, in a binary world, somebody else must).

This results in that profession being placed on a pedestal: I have heard a lot of trainers say to their clients who complain of pain or discomfort to go to a physio, whilst avoiding training the entire area. Whilst that can be the right approach, and it's definitely the safer one in terms of covering your back in case of litigation, it promotes this idea that a person can "go to a physio" and come out fixed, or at least with all the answers that will get them fixed. It treats recovering from an injury - a complex process which requires assessment, diagnosis, a treatment plan, education and understanding, some degree of long-term change (obviously you can't keep doing what injured you in the first place, not in the exact same way you did before), and physical effort - as a tick-box exercise. The advice is rarely "see a physio to assess and diagnose the cause of the pain, and then we'll incorporate the exercises into your programme". I realise that's a mouthful, but the point is, "going to the physio" is the very smallest piece of the recovery process. That's like saying your job is going to your workplace each day.

A physiotherapist or osteopath will know more tests to diagnose injuries than a massage therapist, trainer, or coach. But a good coach or manual therapist should have a sound knowledge of muskulosketetal anatomy and physiology, which would allow them to assess a potential injury and make some educated guesses: if you can narrow down the pain to a particular action, you can deduce that the tissues that cause that action are in some way implicated; and depending on where the pain is and how it feels, you may be able to make an educated guess as to what type of structure is injured and how badly. Consequently, assuming the signs and symptoms are not suggestive of a medical emergency, you may still be able to perform a wide variety of movements with the affected area, avoiding the movements that would involve the injured tissues. Sometimes, just moving differently, activating or releasing certain muscles, or practising some self-massage can be enough to make an issue go away. If not, that's when an official diagnosis may be sought. In either scenario, being involved in that exploratory process - "Does this hurt? Can you do this movement? How does it feel when you do this?" - helps you understand your injury and your movement, which is a crucial part of recovering from an injury.

Scope of practice is something I take very seriously, and I will never attempt to diagnose or prescribe rehab for a suspected injury. But it's important to undertand that in many cases, diagnosis and rehab are processes of trial-and-error: match symptoms to a tissue or injury type, suggest exercises that could relieve the pain, and if the pain gets better then your diagnosis was probably right. So in theory, anyone is capable of doing this, but of course the more knowledge you have about what the issue could be, the quicker the process is, and the less likely you are to do something that makes the problem worse (for example, if you were to tell me your knee hurt walking down stairs, I'm not going to ask you to do depth jumps and see how it feels, but I might introduce some controlled, eccentric strength exercises for your quadriceps muscles and see how your body responds to that).

Physiotherapists, osteopaths, and chiropractors are all taught significantly more about the assessment and diagnostic process than trainers, coaches, and massage therapists are - but engaging in the process with someone who doesn't have all the answers can actually help you figure a few things out within your own body, as long as that person has enough of an idea that they're not going to hurt you. On the other side of the coin, there is tremendous pressure on physiotherapists and osteopaths to have all the answers; this pressure can encourage a rushed diagnosis, which doesn't get you better any quicker or give you any faith in the recovery process, nor does it give the therapist professional satisfaction if they realise they made a mistake. So while scope of practice matters deeply, treating the various professions as so utterly distinct (and subject to a hierarchical structure) does nobody any favours.

All different, all working in their specific role, but all equally valuable

Once an injury is diagnosed, the thing physiotherapists are possibly most known for is exercise prescription. Their input here is vital, as different injuries require different rest times and different types of loading - but that's not the end of the story for your training/rehab programme. Strength & conditioning coaches know programming. Personal trainers know motivational techniques. Massage therapists know how to make a tight tissue ease. In an ideal world, your physio would tell me (with your consent): "This is what the injury is, I recommend letting it rest until the inflammation dies down, then start eccentric loading for 3 sets of 12". I make sure we are working the right thing, in the right way, whilst incorporating work for surrounding tissues that may not be damaged but that will have been affected by any compensation or guarding. If soft tissue work is needed, I'll know where the tight spots are likely to be, but which tissues to avoid poking and prodding as they heal.

Once any inflammation has died down and tissues have healed, we are left with weakness and/or tightness of the affected area, and possibly surrounding areas (I think most people can relate to having a foot injury and ending up with knee niggles and lower back ache). By incorporating your rehab exercises into a more general programme, some of these issues can be anticipated and prevented. Unfortunately, most of us are so mystified by the concept of "rehab", that we don't dare mess with the formula: if the physio told me to do external shoulder rotation with the Theraband, that's now my routine - no squats, no ab work, no cardio on the exercise bike.

By extension, when we are given the all-clear - whether that included a sound return-to-sport phase or whether it was given when you were able to get through activities of daily living - we forget all about those exercises. I've been there: I suspected that eventually I would get distracted from my leg strengthening routine and get lulled into a false sense of strength by commuting by bike. Despite being well aware of this risk, I did exactly that, and I didn't notice how unstable my knees had become due to not doing any focussed strength and balance work - this, despite being well over a year post-surgery, nearly a year after being cleared by my physio following an incredibly successful rehab programme, with the strongest legs and hips I've ever had. It's not that I'm going to be rehabbing for the rest of my life, and it's not that my knee is compromised post-surgery: it's that my rehab made me so strong, so stable, that backing off that level of effort for a short period of time results in a significant decrease in strength. I have since added some of the exercises back into my routine, and my knees now have the strength they had right at the end of the official rehab process, plus the range of motion I have worked hard to develop since.

In the same way that the definition of injury is a bit blurry, rehab is not a distinct entity from what we commonly think of as training or exercise: the goal in both contexts is to strengthen a particular structure, in order to perform a particular movement. Of course, many of us don't think about training in such a compartmentalised way: we want to get stronger, or fitter, or better at a particular skill, and that usually requires strengthening and conditioning a number of structures and combinations of movements, which all develop simultaneously (well, in theory at least). The difference with rehab is that you - your body, your brain, your mind - can already perform those movements or skills (let's take kicking a ball as an example), so were you to plough ahead and practise kicking a ball without specific rehab for the injured area, one of two things would happen: either you develop a compensation pattern to avoid using the injured tissue, or you reinjure the newly healed or still-healing tissues.

Men playing football

Whilst on the surface of it that may sound like a pretty big difference, and in practice it usually is, I would argue that we could all benefit from using a rehab-like approach to our day-to-day training.

For one, we don't live perfectly balanced, calibrated lives. We repeat similar actions day after day: our eyes are in the front of our bodies, so it's only natural that we would perform most actions in front of us, and we are usually one-side dominant (i.e. right-handed or left-handed), to take the two most obvious habitual "imbalances" (I put that in inverted commas because the word imbalance has negative connotations, and being right-handed or left-handed is not something I consider to be good or bad). Our bodies constantly strive for maximal efficiency, so once a joint gets better at moving in one direction or plane, that's what it will keep doing (so, for example, if we need to move to the side, we will adjust our bodies by turning and stepping forwards in that direction, rather than stepping sideways). In other words, we develop compensation patterns, and if we are just focussed on the goal of the movement (i.e. kicking a ball) rather than what specific actions and sensations are involved in the process, we reinforce these compensation patterns in our training. So if we could dedicate more time to strengthening those smaller, weaker, less active structures, not only could we potentially avoid overuse injuries, but we could make more muscle available for recruitment to perform the action we were training for in the first place.

Or, to flip the relationship the other way around, we might engage more with our rehab process if we moved away from a binary rehab/training mindset. If we saw rehab as training, and incorporated a more rehab-like approach into our training, we might be quicker to see a physiotherapist or osteopath, and more compliant with their advice: I've been told more than once that somebody didn't want to see a physio for a persistent injury because they were scared of being told they couldn't do the stuff they enjoyed. And of course, it is a widely accepted joke/frustration that nobody does their physio exercises. If we could popularise the message that rehab is just exercise - and programme rehab as such - there would be no reason to fear an interruption to a normal training routine, and no room for boredom. Quite the opposite: we should look forward to seeing our therapists so they can suggest ways we can get stronger and better at what we love doing!

Whichever way you are coming at it from, everyone benefits from reframing "rehab" as just a normal component of a training cycle or movement practice. I know I would have needed to learn that sooner.

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