Loading & Rehabilitation Features

Welcome to Part 4, where we will explore some of the key features that guide our thought process when beginning the loading & rehab process. 

What’s your goal?

Once you have gathered information from the assessment, we need to use this information to establish an entry point to rehab (which we’ll discuss in the next section below), but we also need to be clear with the intention behind the strategies we’re using. To simplify things, we split these intentions into three separate categories:

1.) Education

• Explaining pain in simple terms (sensitivity vs damage)
• Reframing beliefs, reducing fear, increasing confidence

2.) Exercise / loading / restoring variability (active & manual)

1. • Graded physical stress application to muscles & joints in a step by step manner
   • Using our variability framework to guide muscular & joint loading
   • Graded exposure to meaningful activities

3.) Symptom modification / resolution

1. • Using symptoms (e.g., pain) to guide rehab strategies
   • Based on contributing factors identified in the assessment
   • Can overlap with strategies to restore variability, but not always

Why separate them like this? When working with individuals experiencing pain and/or movement limitations, we find it important to not only use pain as a variable to guide our rehabilitation strategies. There are many contributing factors to someone’s pain experience, and while it is important to use pain (& other relevant symptoms) to guide the how, why, and when behind your rehab strategies, it’s important to use other variables to guide your thought process too.

This brings us back to our variability framework discussed in Part 2, where we explore how we use the behavior of muscles & joints/segments to help paint a picture of how the movement system is handling forces/loads. 

It’s important to not mix these two up, but this, unfortunately, happens all the time when we see therapists trying to pin the cause of someone’s pain on a specific muscle and/or joint behavior.

E.g., “you’ve got anterior shoulder pain because your scapula is stuck in depression and can’t elevate & upwardly rotate.” Or, “you’ve got low back pain because your pelvis is stuck in an anterior tilt.”

The problem with these statements above, is that it ignores the complexity of pain. But, we’re also not saying that influencing the variability of the scapula or pelvis in these examples can’t have an effect on the pain experience, because it certainly can. We just don’t think that you can honestly attribute the cause of pain to the position/behavior of one segment.

Can the lack of variability of the scapula or pelvis contribute to the individual’s pain/sensitivity? Of course it can. 

However, research shows time & time again why we can’t only use biomechanics to guide pain rehabilitation. The reason is because even when individuals have experienced pain relief using a biomechanical approach, it was often shown that the biomechanics didn’t actually change after the intervention.

E.g., using the scapular example above (and this is an example often shown in the research) – we can change the scapular position according to what we think is “normal” alignment (does not exist), load them there, and we may see a change in pain. But, when we re-check the position of the scapula, it hasn’t changed…

What does this tell us? It means we can’t say that the cause of their pain was secondary to the position of the scapula, and that it doesn’t have to change to influence pain.

But, remember, from our perspective, we’re not loading muscles & joints with the intention of “correcting faulty mechanics,” but more so to restore variability. This means that we can still give the nervous system the experience of load while the scapula & associated muscular tissues experience load, but it doesn’t mean that the scapula has to sit back into a made-up “correct” alignment for there to be a positive change.

Overall, It tells us that biomechanics don’t necessarily need to change to influence pain, but they can certainly help to guide our thought process when selecting loading strategies to use. It also tells us that there’s a difference between addressing pain/modifying symptoms, and restoring muscular & joint variability.

So, we can use education, exercises, and other loading strategies to influence the movement system, but we need to be clear about whether we’re using pain to guide our strategies, or the current variability of the muscles & joints. In reality, you will be using both, i.e., we can load muscles around the scapula with the intention of improving variability & reducing sensitivity, but we also need to be open to the idea that there may be many other contributing factors to the pain experience.

In a nutshell: we can’t only use biomechanics to influence pain, but we can certainly use it to restore muscular & joint variability

Establishing an entry point

After an assessment, it can seem overwhelming when you have identified multiple potential contributing factors to an individual’s main concern/problem.

In Part 3, we discussed some of the key subjective & objective features that will help to guide this entry point. Let’s recap some of the objective features below within the context of these loading & rehabilitation features:

1.) Local muscular variability

1. • Do we need to influence the local contractile behaviors surrounding the individual’s main problem?
   • E.g., an individual with persistent low back pain struggles to flex their lumbar spine. Do we need to restore the local lengthening/eccentric capacity through the lumbar extensors? 

2.) Local joint / segmental variability

1. • How can we use the local segments to guide how we load muscular tissues?
   • E.g., using the same case example above – can they flex their rib cage & extend their pelvis to enable a lengthening of the lumbar extensors? How are the rib cage & pelvis interacting in other planes?

3.) Global coordinative capacities (intermuscular & interjoint variability)

1. • How are muscles & segments interacting across the rest of the midline and across the lower limb?
   • E.g., can the individual manage & distribute forces well across the lower limb well? If not, might this be influencing the level of muscle activity proximally at the lumbar spine?

4.) Sensitivity (are those movements painful / uncomfortable / sensitive?)

1. • What are the other potential drivers of pain/sensitivity?
   • E.g., what if flexion is limited and also painful/sensitive? How might this influence the strategies we use to improve flexion?
   • What if the individual is avoiding flexion because they were told by someone that it is dangerous and that they need to keep their spine straight? Think about education here.
   • Key point: there are LOTS of ways to reduce pain/sensitivity, but they often don’t share the same intention of restoring variability. We need to integrate both.
   • E.g., they might feel better when they get manual therapy on the lumbar extensors, but manual therapy does not necessarily improve the capacity of the lumbar spine to flex.

So, where do we start? Using the low back pain example above…

Do we target the local muscles and joints/segments around the lumbar spine with exercise/loading strategies?

Do we target things more from a coordinative perspective, and begin loading the lower limb with the intention of reducing muscle activity / restoring variability proximally at the lumbar spine? 

Do we address other drivers of sensitivity (other potential aggravating movements or behaviors)?

The key to establishing the most appropriate entry point is discussing your thoughts with the client and engaging in a shared decision as to where to start. Let them become an active & engaged participant in the process.

Also, you don’t only have to choose one driver of a lack of variability or a potential driver of pain/sensitivity – you can integrate more than one during the initial session.

How are you monitoring progress & progressively loading?

Once we establish a plan & begin using a combination of strategies to influence beliefs, restore variability, and influence the individual’s symptoms…how are monitoring their progress and what are we using to guide progressive loading to ensure we’re building greater adaptability?

To monitor progress, we need to establish feedback markers or key performance indicators to help guide the individual’s response to our interventions. These feedback markers may consist of aggravating movements, muscle & joint variability, and even their own perception of progress based on how they are functioning in the real world.

To progressively load their movement system to facilitate greater adaptation, we need a framework to guide our loading strategies. 

How can we make an exercise/loading strategy more challenging to facilitate greater local muscular & joint variability?

How might we regress it if it’s too coordinatively challenging for the individual?

How might we challenge the coordinative capacity of the muscles & joints to improve their ability to share and distribute forces?

We do this by manipulating quantitative & qualitative variables throughout the rehab plan, and this ensures that we can constantly push for progress and consistently work towards facilitating greater capacities to handle forces.

Check back for Part 5 where we will explore this progression & regression framework more.