Progression & Regression Framework
Welcome to Part 5, where we will discuss our progression & regression framework to put the finishing touches to this five-part series.
Having a clear thought process relating to appropriate exercise progression & regression during the rehabilitation plan is essential to facilitate adaptation. Exercises are essentially vehicles of physical stress/load application, and having a framework to guide how we are applying that stress/load is crucial.
In Part 4, we briefly discussed the goals behind our rehabilitation. Let’s revisit them briefly here, but refer back to part 4 for more discussion:
- Education
- Exercise / loading / restoring variability (active & manual)
- Symptom modification / resolution
When applying stress/load to the movement system, we need to be clear with the “why” behind the strategies we’re using.
-Are you trying to restore local muscular & joint variability around a local body region?
-Are you trying to improve the coordinative capacity of muscles & joints to share and distribute stress over broader surface areas?
-Or are you trying to influence your clients’ symptoms, which may or may not be related to restoring variability?
We described education in part 4 as an important goal to help explain pain and reframe beliefs, but it’s also important to consider how you’re educating your clients about the goal of your exercise strategies. The narrative you use to describe your loading strategies is essential to drive positive adaptation.
The Framework
Our progression and regression framework mainly focuses on how we can organize our exercise and loading strategies to restore variability. However, it can be used to guide how we can manipulate these strategies when pain/sensitivity is part of the equation, but this needs to be done within the context of unique case situations when you have gathered the appropriate subjective & objective information to guide decision making. Making general claims about how we can influence pain without this unique information is not very helpful to guide rehabilitation.
Our framework guides how you manipulate key variables when applying stress/load to the system. These variables can be categorized into:
1.) Quantitative variables: variables that can be measured.
- Load, duration, speed, frequency, sets/reps etc
Qualitative variables: variables that represent the behavior of muscles & joints.
- Muscular
-
- What contractile behavior are you loading? Concentric, eccentric, isometric?
- Are you loading the muscle in a shortened or lengthened position?
- Are you loading the muscle dynamically or statically?
- Are you concentrating loading into a local muscle or trying to distribute load across multiple muscles?
- Joint / segmental
-
- How are joint segments interacting as you are loading?
- How are joint segments moving as you dynamically load the muscular tissues surrounding them?
- Are you loading a single joint or coordinative multiple joints together?
These do not represent all quantitative & qualitative variables that can be manipulated, but hopefully they give you a general idea of the differences between them. Let’s appreciate them through a mini case example.
Case example:
Client sustained a grade 1 lateral ankle sprain 4 weeks ago and is progressing through rehabilitation with their therapist. One goal in his plan is to increase the load capacity of the ankle plantarflexors, which the therapist is doing by gradually increasing the external load through adding a dumbbell in the clients same side hand during single leg calf raises (quantitative variable).
However, during single leg calf raises (based on their assessment), this client rapidly inverts the calcaneus early in the plantar flexion range, and shifts the load laterally (losing contact with the 1st metatarsal head).
Objectively, the client also has limited dorsiflexion & pronation range of motion.
In this case, the client is unable to maintain load through the medial foot during loaded ankle plantar flexion, and this may be expressed from a number of reasons:
- Perhaps the client is starting the motion with an already-supinated foot, and this may make it challenging to slow down that transition into calcaneal inversion to maintain sagittal ankle plantar flexion.
- Perhaps the client is trying to avoid loading the ankle plantar flexors by reducing the sagittal plane ankle motion and inverting the calcaneus early in the range of motion.
- Perhaps the client has limited big toe extension, and is unable to keep load through the 1st met head as the ankle plantar flexes, so they deviate medially.
Let’s consider this from the perspective of #2.
If they’re expressing this deviation laterally through the foot, do you think by only manipulating the quantitative variables (increasing external load) that we are going to restore muscular & joint variability around the ankle & foot?
In this exercise example, we may have to manipulate muscle & joint behavior (qualitative variable) to bias the foot towards pronation at the beginning of the exercise. This will allow for a slower transition into plantar flexion & supination so that we can increase the time under tension through the ankle plantar flexors.
We may also have to work separately on restoring ankle dorsiflexion & foot pronation to further influence the variability around the foot & ankle.
In this example, you can appreciate that there’s huge overlap between muscle & joint behaviors. In order to plantar flex the ankle under load, we need to concentrate load through the ankle plantar flexors and also, the joint segments need to move into a direction that represents ankle plantar flexion & foot supination. If the client inverts the calcaneus early in the range, and they lose medial foot contact, they are not fully loading the ankle plantar flexors.
As described above, this can be for a number of reasons. But, if the goal of the exercise is to increase the load capacity of the ankle plantar flexors, then we need to manipulate the qualitative behavior of the foot in addition to increasing external load.
What if the client can’t perform this in standing?
If when we facilitate more foot pronation at the beginning of the calf raise, the client really struggles to move dynamically through ankle plantar flexion (even without external load), how can we manipulate these variables to regress?
We can potentially load the muscular tissues isometrically in the standing position to reduce the coordinative demand…
Or, we can reduce the load through the ankle plantar flexors by using a supine wall calf raise (shown here). This reduces the gravitational demand on the ankle plantar flexors and distributes some of the workload into the proximal muscles. It alsoprovides the opportunity for the client to coordinate this slower transition from dorsiflexion & pronation to plantar flexion & supination during the calf raises while under less load.
Because we’re experiencing less load, we can increase the reps & duration of this strategy to add greater challenge.
What are we actually progressing in this example above?
We’re progressing the client towards expressing more movement options (variability) around the ankle & foot while also working towards building greater force production capacity through the plantar flexors. The key here is to understand that we need to consider muscular behavior within the context of joint/segmental behavior. The regression from standing to a supine strategy can be done to make it easier for the client to work on delaying that transition into plantar flexion & supination under less load, but we can still perform the isometric strategy in standing simultaneously.
Of course, this is a very early phase example of how these quantitative & qualitative variables can be manipulated based on the clients assessment, so we would certainly progress the external load, the speed, and impact by eventually transitioning into plyometric strategies to further challenge the ankle & foot.
Progressing and regressing muscle/joint behavior vs exercises
To use this framework, you need to appreciate the behavior of muscles & joints during an exercise. Exercises have many different names, but what’s more important than the name, is being able to describe what’s happening at the muscles & joints. This is what allows you to easily manipulate these quantitative & qualitative variables. As you can appreciate above, not all calf raises are created equal, and this idea can be extended across every region of the body, and it allows us to progress and/or regress exercise strategies in many different ways based on the unique features of the individual we’re working with.
Thanks for reading!
That’s it for this five-part series! Hopefully you enjoyed this information, and if you’d like to learn more, be sure to check out our courses to explore these ideas further.