Rehab Exercises - When to Progress & When to Regress

Musculoskeletal rehabilitation & recovery is rarely, if ever, a linear process.

It's a dynamic process, often marked by fluctuations in a patient's progress.

Pain flares may occur, functional deficits may ebb & flow, frustration may set in, and everything in between.

Today I'm sharing some insights that will improve your confidence regarding your rehabilitation prescription decisions.

Recognising that rehabilitation isn't a linear process and that setbacks are a common occurrence is essential for both clients and clinicians. Here's why:

Variable Healing Rates

Different tissues undergo remodelling and cellular turnover at different rates.

Not to mention the multitude of internal and external variables that exist between individuals that will further influence these rates.

External Factors

Elements such as treatment adherence, health and lifestyle behaviours, as well as occupational and socioeconomic factors will also impact the rehabilitation trajectory.

Psychobehavioural Elements

Somewhat related to the above individual factors, a number of psychobehavioural elements may impact a person's rehabilitation journey.

Some of these elements may arise as a result of a pathology and the person's experience navigating their injury and/or recovery. For example; kinesiophobia, catastrophisation.

However, other psychobehavioural elements may be present prior to the onset of any pathology, and have the potential to greatly influence a person's clinical presentation, prognosis and recovery.

Key Takeaways

• Expect and plan for variability in clinical presentation, functional deficits, treatment response and recovery.

Frameworks > Protocols (read more here)

• Educate and reassure patients early on regarding the non-linear nature of healing, recovery & functional restoration to manage expectations.
• Utilise validated patient-reported outcome measures (PROMS) to monitor progress.
• Assess and address functional deficits, and don't rely purely on pain as an indicator of recovery.

Free Webinar hosted by VALD putting evidence into practice. Individualisation Framework ? PROMS ? Data-Informed Practice (access recording here)

Building strong relationships with your clients and gathering relevant data to measure progress will also provide leverage for clinicians to maintain and/or re-engage motivation if we encounter a setback.

The Importance of Progressive Loading

Many pathologies of chronicity, ie: Achilles tendinopathy, plantar fasciopathy, bone stress injuries etc..., develop as a result of a progressive negative adaptation.

Negative Tissue Environment + Inappropriate Mechanical Load = Pathology

This may arise from "Too Much" load and/or insufficient recovery.

Equally as often and problematic, a pathology may arise from "Too Little" load and/or too long between load exposures.

Progressive loading is the cornerstone of physical rehabilitation and functional restoration.

It involves gradually increasing the load "dosage" in conjunction with sufficient time for adaptation to trigger adaptation.

Positive Tissue Environment + Appropriate Mechanical Load = Positive Adaptation & Recovery

Progression vs Regression: What They Mean

Progression

Progression refers to the advancement of an exercise program by increasing the "dosage", which may encompass load, volume, or complexity of exercises.

Indicators for progression include:

• Reduced Pain and Swelling: The patient reports minimal or no pain during and after exercise.
• Improved Strength and Function: Objective measures such as increased range of motion, strength, and functional capabilities (e.g., hop tests, countermovement jump, star excursion balance test - SEBT).
• Patient Confidence: The patient feels confident and reports feeling ready to take on more challenging exercises.

Regression

Regression involves scaling back the exercise "dosage" when the patient shows signs of overloading or adverse responses.

We may regress the exercise by altering the loading variables, or we may select an entirely different exercise.

Indicators for regression may include:

• Injury "Flare" aka Increased Pain or Swelling: The patient experiences a significant increase in pain or swelling during or after exercises.
• Decreased Performance: The patient shows a decrease in strength, range of motion, or functional performance measures (e.g., countermovement jump).
• Psychological Signs: Increased fear, anxiety, or lack of confidence in performing exercises.

P3 Podcast: Low "Dose" Exercises for Highly Reactive Plantar Fasciopathy - Listen here

P3 Podcast: "Dosing" Rehab WITHOUT Sets & Reps - Listen here

Progression & Regression Tips

1) Always have 3 exercises in mind to accompany your prescribed exercise.

For example, high-load strengthening for Plantar Fasciopathy (b).

A progression (c) for your exercise & dosage.

A regression (a) for your exercise & dosage.

An alternate exercise / movement exposure.

This is where we realise that our understanding of tissue responses to load, types of exercises and dosage variables are essential for developing flexible and responsive functional restoration programs for our clients.

P3 Blog: Dosed Movement Alternatives to "Standard" Rehab Exercises (read here)

2) Understand your dose metrics

There's more to rehab than sets & reps.

Beyond our first variable (ie: the exercise itself), typical strength-based rehabilitation exercises have 9 elements that we can modify.

1. Load
2. Reps
3. Sets
4. Rest
5. Frequency
6. Tempo
7. Range of Movement
8. Joint Angles
9. Complexity

P3 Podcast: 9 Ways to Modify Exercise "Dosage" - Listen here

Couple this with the various running "dose" metrics we are also able to manipulate.

1. Time / Duration
2. Distance / Mileage
3. Intensity (often RPE) &/or heart rate
4. Pace
5. Gradient / Incline - Decline
6. Surface / Terrain
7. Footwear

Lecture: Running Rehab - Understanding "Dose" GFM: Gait | Footwear | Movement - Find Out More here

3) Don't progress too many dose metrics at once!

There are a number of errors often made in progressive rehabilitation.

Common Error #1 - Progressing exercise without adjusting the recovery time to allow positive adaptation to occur. Sufficient time to recover from an applied load is equally important as the load exposure itself.

The greater the load, the greater the recovery requirements.

Remember, what constitutes "high" load vs "low" load will vary from person to person. Keep in mind their recent and long-term movement history.

Using the below example of tendon loading;

Typically, our musculoskeletal system can absorb low-dose movement/load at a high frequency, as the recovery and remodelling requirements for the loaded tissues is lower.

In contrast, higher-dosed movement/load typically requires a greater period of time between load exposure events to allow positive adaptation to occur.

For example; a person may be able to run 10km per day at 6:30min/km pace with no issue. If they were to increase the pace to 4:30min/km, the Achilles tendon & plantar fascia are subject to significantly higher loads.

If we maintain 10km daily and shift from 6:00min/km to 4:30min/km it is highly likely we will see a failed adaptation and pathology begin to develop.

Yes, they will complete the run in a faster time, but the intensity of the bout of work will be significantly higher.

Common Error #2 - Progressing an exercise (e.g., new exercise, higher external load/resistance etc) and not adjusting other dose metrics initially (e.g., reducing reps initially, then gradually building-up).

Using the calf raise as an example;

Typically, if I am progressing someone from a bilateral to a level 2 calf raise (bilateral concentric - unilateral eccentric) or unilateral calf raise, I will ensure that I provide the following education:

"a) By progressing to a new exercise/dose we are increasing the stress on the tissue. So, you may find that you feel;

• That this exercise is a lot harder.
• Like you can't do as many repetitions.
• The Achilles (or whatever the injured tissue is) becomes a little "grumbly" the first few times. Providing the discomfort doesn't move into overt pain or persist for >24hrs, we'll just slowly progress, but can adjust if we need (this is where your regression and alternatives come in handy).
• That your progress is going backwards, it's not. Moving to a harder exercise/more load is the exact opposite.

b) Because we are progressing exercises we may need to drop some of the other dosage variables, so we're not overloading. This means, initially we will;

Reduce the number of sets, reps and days that you are doing the rehab exercises. You've built up to doing 3 sets of 20 each day, which is great!

Bilateral Bodyweight Calf Raise - 3 x 20 - Daily

But now we've progressed, we need to give the body a chance to catch up.

So, whilst we are aiming to build up to 3 x 20 of this new exercise/load, we will follow the traffic light system to guide how many reps per set.

We'll also be moving your exercises from daily to every second day.

Unilateral Bodyweight Calf Raise - 3 x VAS-P - Every Second Day

Eventually, we'll get you up to the goal of 3 x 20, then depending on how your progress is going (e.g., monitoring via TENDINS-A) we may progress again or move your exercises back to daily. "

Free video tutorial "Using the VAS-P For Monitoring Rehabilitation Loads" via P3 for FREE - here.

Common Error #3 - Under-dosing

Again, in the recent webinar I present for VALD Health I demonstrate and discuss how sticking to old protocols can often see our clients falling short of being provided sufficient stimulus to return to their goal activities.

Under-dosing often stems from one or two elements. The first is an uncertainty of how much load is enough. The second is a fear of pain/discomfort.

Remember, fearful clinicians create fearful clients.

If we ensure we know the client's desired capacity, assess their current capacity, and combine this with our understanding of tissue loading & exercise prescription, we're on track to getting great outcomes (if you need a hand or want to learn more about achieving this consistently, click here).

Gathering Information for Rehabilitation Decision-Making

Clinicians must gather comprehensive information to make informed decisions about progression and regression.

Key aspects to monitor include:

• Patient Feedback: Regularly ask patients about their pain levels, confidence, and comfort with exercises.
• Objective Measures: Use tools and assessments to measure range of motion, strength, and functional abilities.
• Clinical Signs: Monitor for signs of inflammation, such as swelling, redness, and increased warmth.

Depending on the pathology you are managing, I highly recommend using a combination of empathetic discussions with your clients, PROMs and relevant functional tests.

By gathering varied information, we are able to develop a multi-dimensional understanding of our patient's recovery journey.

Key Takeaways:

• The rehabilitation journey is never linear; anticipate and plan for variability.
• Progressive loading is crucial for tissue adaptation and functional recovery.
• Progression and regression decisions should be based on patient feedback, objective measures, and clinical signs.

As always, I hope this article has been helpful and I always appreciate the discussions with you all off the back of these articles.

If you've found these insights helpful, leave a comment, send me a DM or share this article with your colleagues.