Bridging The Gap To High Level Rehab – Graded Exposure To Meaningful Movements
The next step straight after the isometrics in part 1 is to get the patient straight up onto their feet and to move in the meaningful ways that we have identified from pillar 1 in understanding the person’s story and what really adds value to their life.
It is important to start the process straight away of getting the patient back on track towards that end goal. We can modify these meaningful movements by using low loads and low speeds to start with until the patient’s confidence starts to grow.
With the meaningful movements, we again want the body to ‘self-organise’ and figure out the movement strategy subconsciously as has to happen in the majority of tasks in the real world rather than focusing on internal cues such as ‘squeeze your glutes’ or ‘pull your belly button in’ etc.
To implement this in the real world, the ‘Go-To’ Therapist will focus the patient’s attention on the outcome of the task rather than specific internal cues, to replicate how movement tasks are executed in the real world.
You will give the person a clear focus and use the outcome of the task to challenge their base of support to provide the body with the ability to self-organize on numerous levels while under perturbatory loads.
Managing unexpected perturbatory loads is a key part of being successful in both sport and life and we need to provide the patient an opportunity to be exposed to these loads and let their nervous system figure it all out.
Now this is not to say we just put them in a position and give them a nudge and say ‘hey, figure this out yourself!’; this part is arguably the piece that therapists fall down on most commonly. There really is an art to progressing a patient without irritating them or causing negative reactions within their system.
The four variables of low load, low speed and high load, high speed and combinations of these become extremely valuable and important to the therapist during the graded exposure process.
So now let’s get back to our groin pain patient and recap their treatment intervention so far.
The patient has had an effective explanation of the true problem (why the groin area is overloading) and the solution (get the posterior lateral hip to share the workload) and understands that the adductor muscles are not the bad guys after all but are just grumpy and letting the patient know they are doing too much work.
They then received some hands-on loading to the lateral hip as the first step in getting the nervous system confident in tolerating load in this direction which in total probably took no more than two minutes.
The therapist uses a key performance indicator such as gross range of motion or motor output in that direction as gauges as to how effective the hands-on treatment intervention was.
Immediately after the hands-on treatment, the patient will perform 6-8 reps of an isometric exercise that gives the nervous system an ability to continue to tolerate load in the direction it received from the hands-on treatment but which now includes the muscle synergists and antagonists to coordinate with the other joints in the limb. They will also be using respiratory desensitisation techniques to further bring the nervous system into ‘rest and digest’ while tolerating loads that previously were associated with having a ‘perceived threat’.
Now we get the patient straight up to their feet after performing 6-8 reps of the exercise chosen in part 1 for the next progression. The total physical treatment/intervention time to date is around 4 minutes.
As you can see in the example below, the reach of the left hand is now driving the pelvis outside the base of support which will cause pre-reflexive and reflexive-like reactions at the local tissues while also showing the nervous system it is safe to load the lateral hip tissues with greater loads placed upon the body.
In this movement, the nervous system has no other option but to decelerate the body weight with the lateral hip tissues.
This is a simple way to get a load through certain tissues if we understand the reactions that happen through the body with certain movements. A physical therapist in the U.S called Gary Gray first coined the term ‘chain reaction’ to describe this.
The ‘Go-To’ Therapist will, however, understand which directions are priorities for the patient at each loading phase through the assessment which will give greater clarity and save time in giving the appropriate stimulus rather than using multiple exercises in the session.
The ‘Go-To’ Therapist once again appreciates the four variables and understands how and when to progress the patient with low load, high load, low speed and high speed variations.
This thought process can be used with any injury.
As you can see here with the other image on the right, if we used this kind of loading it would stress the tissues on the medial side of the hip.
So, for example, in the 2017 Rugby League World Cup, I was using the movement on the left with an MCL injury in week one where we wanted to load the injured tissues a little, but the majority of force was absorbed through the lateral tissues.
In the following week when we wanted to increase load through the MCL tissues to decrease perceived threats and force the medial hamstrings to absorb more load as the tissue healing times are more appropriate, we used the image on the right.
The other great benefit of operating like this is that it is also the start of our exposure to change of direction, so by the time we need the patient to twist and turn at high speeds, the exact same tissues have been experiencing appropriate loads going through them and the higher centres are not perceiving these as threats.
It is this ART of graded exposure where there is clarity in how every exercise movement builds onto the next until it all comes together that I truly believe can cut days and weeks off potential return to play times.
So while some therapists in session 1 are focusing on the site of pain and massaging the area etc., the ‘Go-To’ Therapist is already focusing and working on a graded exposure for the change of direction component of the return to play.
By the time I get patients back to running (if that’s where we need to get the patient back to), the work done in sessions 1 and 2 gives a great foundation and the patient will usually fly when progressing into the graded exposure running progressions.
So now back to our groin pain patient.
The exercise progression may finish session 1 and so their rehab programme between sessions is simply the isometric variation from the previous part 1 and the standing progression from this part.
Ideally when leaving after session 1, the patient has restored full physiological joint range of motion and can tolerate loading in each of the 8 directions for the lower limb or the 4 directions for the upper limb etc.
So in the groin pain patient’s example, we would ideally want to have restored full hip flexion and the motor output at 40% MVC in all 8 directions of both limbs.
When the patient returns for session 2, the ‘Go-To’ Therapist will recheck the key performance indicators such as the 1-2 objective assessment movements and also the direction of force testing from pillar 5.
Ideally when the patient returns they will still be able to display a good motor output in all 8 directions. This would be a great sign that they have maintained the tolerance load between sessions and are ready to further progress in the graded exposure ladder.
If the patient came in and they were back to how they were pre-treatment in session 1, there would be a conversation then mapping out step-by-step what they did between when they left after session 1 and now, to find out exactly why they have regressed again.
Usually if they have regressed it can be due to the exercises being too high load for this point (which is rare); the patient doing the exercises incorrectly or not following instructions; or the patient feeling a bit better and pushing ahead with activities that are too high level, in which case we would need to review the effective explanation section again as we did not do a good enough job communicating the plan.
For the sake of our groin pain patient, we are going to assume that you have done a great job with your effective explanation and with your hands-on treatment and rehab choices for session 1 and the KPIs you are working with are going to plan. When your patient next comes in, you need to progress them onto the next step of the graded exposure plan.
Progressively Loading The Movement And Outcomes
When the patient returns, we would make sure the KPIs are all going in the right direction including the patient’s symptoms. The KPIs for this patient would be their hip flexion passive assessment and also their motor output in the direction of the posterolateral hip. The other KPI you might be interested in would be the adductor squeeze scores which may have been painful and/or weak.
At this point in the rehab, sessions 2-3, the patient will usually be feeling pretty good and asking when they can run again, for example. The problem is, up to this point I have absolutely NO IDEA if they can tolerate higher ground reaction forces, especially in the directions we’ve identified in pillar 5.
The big question is whether with these higher demands, they will be able to tolerate loads through these paths or go back to old movement habits and load excessively in the areas where the symptoms were first experienced.
It is also worth noting that you have only stressed these tissues to date at low loads and low speeds.
To avoid guessing if the patient is ready to run, part 1 is all about progressively loading the tissue identified and increasing the demands on the patient’s nervous system through a graded exposure at higher loads and higher speeds of movement.
It is very common for the patient to be looking really good at lower speeds and loads but once we speed the movement up, they revert back to older movement habits.
Remember: A NEW LEVEL OF LOADING, A NEW PROBLEM FOR THE NERVOUS SYSTEM TO FIGURE OUT.
We can expose the patient’s nervous system to these loads by increasing the speed of movements or by other means via single leg loading which will continue to change the base of support further.
You can also further threaten the nervous system by repeating the single leg variation but on a box or height.
Think about walking along a two x four plank of wood on the floor and then repeating this on a small height in the playground versus the same plank but between two skyscraper buildings.
The height variable further increases the perceived threat to the nervous system and hence the patient will tend to go towards ‘fight or flight’, change their breathing strategy and usually decrease their movement variability. We can use this knowledge to our advantage when prescribing rehab exercise progressions in the real world.
You will be watching the patient’s reactions closely to understand if he/she is ready to progress further or needs to regress. You can access a free bonus training on this using the link below:
The progressions for the groin pain patient in sessions 2 and 3 may start with a lunge movement with the perturbatory load applied as the foot hits the floor at higher speeds and then progress to a single leg variation in session 3 as shown in the image below.
As you can see by the reach of the arm, we can continue to load the lateral hip tissues effortlessly (the left side in this image) with more challenges for the nervous system to overcome, such as the box height, to name but one.
It is worth noting that as you progress your patient to higher loads, new problems may become evident, specific to their story and injury history that did not flag up on your basis assessment.
These loading exercises are also used as assessments now and it is worth putting these levels of load across all directions for the limb quickly in the session to screen for any ‘energy inefficiencies’ at certain loads or speeds of movement that our basic lower level assessments in session 1 and 2 may have missed.
Remember, A NEW LEVEL OF LOADING, A NEW PROBLEM FOR THE NERVOUS SYSTEM TO FIGURE OUT and this is why at each level going forwards, we will check all planes of movement for any ‘energy inefficiencies’.
These inefficiencies will usually be related to the person’s story and may require some hands-on treatment to help desensitise further and a week spent on tolerating loads at this level and speed, before progressing to higher loads and speeds in the graded exposure plan.
If the patient is OK with these loads and has no negative reactions to the KPIs, then it is time to progress to pillar 7 and higher-level rehab.