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Episode 357

357. Live Lecture: Foundations of Rehab

This lecture was delivered live for our Diploma of Clinical Pilates.

You'll also find it as a video on YouTube if you want to see the visuals. Here's the YouTube link: https://youtu.be/UATwStlLVWI

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Transcript
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Let's make a start. We're going to talk about the foundations of rehabilitation.

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Learning outcomes for today. Okay.

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To get stronger over time, you must progressively add either load or reps.

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And we're going to spend, so let me just zoom out for a second here.

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Today's lecture is foundations of rehab and then

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over the next four weeks we're going to look at each of the components of rehab

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in a lot more depth so we're going to look at strength range of motion and control

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and you know a lot of we're going to go deep on how to do each of those how

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to improve each of those things today's an overview of the the whole process,

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right so learning goal number one to

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get stronger over time you must progressively add

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either load or reps rehab is just graded exercise to restore strength range

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of motion and control and by the end of today's session that learning outcome

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number two is going to be engraved on your heart,

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that's my that's my promise to you,

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progress load in line with tissue healing.

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And with load, the dose makes the poison.

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So it's never a question of should I load it, only how much should I load it?

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Finally, we're going to talk about load management, or in other words,

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also known as calm it up, calm it down, then build it back up.

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So this is the high-level overview to just like the quick start guide to rehab.

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All right, so to get stronger over time, you must progressively add either load or reps.

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And this is called the principle of progressive overload, which is really possibly

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the most foundational principle in exercise science when it comes to strength training.

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You have to keep adding load or reps if you want to keep getting stronger.

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Now, we're going to call this graded exercise, but it just means the same thing.

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Over time, make it harder. And you have to make it harder by either adding load or reps.

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Right. So we talked already about how humans are anti-fragile,

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which means that we actually need stress to thrive.

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And here is how graded exercise or progressive overload really sort of is a

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perfect example of that or it really is the essence of that so if we have on the left side here.

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Strength, you know, very strong, not very strong.

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And this is time.

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And at the moment, you've got some level of strength around about here, let's say.

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Well, if we apply a stress in the form of resistance training,

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well, what happens then is, I'll just say you can currently do six push-ups, but you can't do seven.

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Well, if we apply a stress in the form of asking you to do six push-ups,

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well, immediately after you do six push-ups, you can't do six push-ups anymore.

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But then over the next maybe two, three, four days, you'll recover and you'll

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actually do what's called super compensation, which means you'll actually recover

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so that you can do more than six push-ups.

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Now, you might not be able to do seven, you know, after only one session,

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you might be able to do like 6.2 or something, right? You'd just be a little

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bit stronger than you were before you did the workout.

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And if you don't do any more pushups, after a week, maybe 10 days,

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that super compensation will subside and you'll be back to exactly where you started, right?

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So if you did a workout once a month, you would never get any stronger because

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every time you did a workout, you would just get a little bit stronger a couple of days later.

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And then a week or two after that, you would basically return back to where you were at baseline.

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However, if whilst you're in that supercompensation phase, you apply more stress,

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well, guess what happens?

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Well, then you supercompensate again and you get a little bit better.

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Now you can do 6.4 pushups.

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And if we apply more stress whilst you're in the supercompensation phase,

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now you can do 6.8 pushups.

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And now you can do 8 pushups. and now you can do 10 push-ups.

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And that is the fundamental principle of progressive overload is that if we

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reapply a slightly harder stress each time.

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Whilst you're in that phase of supercompensation, we can kind of stair-step your strength.

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And this also applies to flexibility and movement skill.

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At any attribute that we want to improve in exercise, we can use this progressive

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overload model of basically challenging that capacity.

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Like if we want to improve your flexibility, let's challenge your flexibility.

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And then within a couple of days, you'll be just very, very slightly more flexible.

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And if we catch you in that window before that extra capacity subsides back

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to baseline and we challenge you again, Well, we get to build on that supercompensation,

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another supercompensation on top of them. We get to stack them up.

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Thumbs up if this is making sense or if not, ask a question. Okay, great.

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Now, what you may notice here is that these steps get smaller.

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And that is because when you start out, you progress more quickly.

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And as you get closer and closer to your maximum potential capacity for strength

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or flexibility or whatever it might be, you progress more slowly.

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So if you've been doing push-ups four days a week for the last 20 years and

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pushing as hard as you can, you're probably not going to be improving.

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You're like adding five push-ups a week to how many you can do.

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Like you'd be very very close to your maximum potential so you probably you

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know once every three months you can do one extra push-up because you you already

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can do 300 or whatever number,

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right but the first day you do it if you then do push-ups like once a week for

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three weeks you probably double the number of push-ups you can do so there's this kind of you know,

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diminishing point of diminishing returns where if you keep training harder and

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harder for longer and longer, you progress more and more slightly.

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All right, so just to really reiterate that again, to get stronger over time,

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you must progressively add either load or reps.

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Now, if we go back to this graph here,

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and think about, you know, what I experienced a lot of times in the Pilates

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class is we applied a stress in the form of footwork, say,

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on, let's say, you know, three red springs or three full springs or whatever

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you want to call it, okay, and then there was a super compensation,

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okay, and then the person came back and we just applied the same stress again,

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didn't add more springs.

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So then they went down and like that, and then we applied the same stress again,

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and they went down and like that, then we applied the same stress again,

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they went down and like that, and then two and a half years later, guess what?

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Haven't got any stronger because we didn't progressively add load or reps.

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So we have to keep adding load or reps if we want to keep getting stronger.

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Now, this person will get stronger for a short space of time.

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Like, so for a couple of weeks, they'll get stronger, you know,

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each session, but pretty soon they're going to plateau out if we don't,

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uh, keep adding load or progressing the load. Right. So here's an example.

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Mary can do six kneeling pushups. This is Mary.

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She does six push-ups like she really gets she does as many push-ups as she

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can do to the point where the last one is the richard gear officer and a gentleman

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sort of you know really really grinding it out right so she does six push-ups

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and she does that three times a week,

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and monday wednesday and friday first thing before coffee after she goes to

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the bathroom she does six push-ups.

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After a few weeks, six push-ups has become easy, right?

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And so number six is no longer like, oh, I have to really fight for it.

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It's like five and six, right? Now she's doing it a lot easier because she got stronger, right?

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If she keeps doing only six push-ups, she will stop getting stronger at some point.

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And that's going to be relatively early, after two, three, four,

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five weeks, something like that, she's going to stop getting stronger.

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To keep getting stronger she needs to add either load by straightening her knees or do more reps,

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thumbs up if that makes sense or if not ask a question okay all right let's

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see if it made sense what is the principle of progressive overload try not to look at your notes.

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All right. Good answers, but not great answers.

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So I'm saying lots of add load or reps over time, which is correct,

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but it's only half the picture.

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A couple of you have said, if you want to keep getting stronger over time,

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you have to add progressively add load or reps, right?

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So it's not just you have to add load or reps. Like if you don't want to get

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stronger, you don't have to add load or reps.

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It's not a law, but if you want to get stronger, you have to keep adding load

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or reps because that's just how the universe works,

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to get stronger over time you must progressively add either blank or blank.

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Good answers reps or load Ann has been doing footwork on three springs for the

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last two years and has not got any stronger why not?

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Okay good answers she didn't progress the load or the reps no progressive overload

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no strength gains all right so we said to get stronger over time you must progressively

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add either load or reps and this really is it does seem to be just a law of the universe,

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now we're going to see that rehab is just graded exercise so graded exercise

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just means adding load or reps progressively over time.

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Rehab is just graded exercise to restore strength, range of motion, and control.

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Okay, any movement, well, any,

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we can really sort of divide human movement potential into three kind of categories,

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strength, range of motion, and control.

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And uh you know when we say strength

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like these are general categories right

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so strength would include like power speed you

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know explosive force all of the muscle endurance all of those things basically

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muscle fitness what the acsm calls muscle fitness so when you lose capacity

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say you've had a surgery or an injury to some body part, you're going to lose strength.

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You're going to lose range of motion and you're going to lose some degree of

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the ability to control that body part.

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You're going to have less proprioception, less coordination with that body part as well.

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Now, when we work with our clients and we restore their strength,

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we restore their range of motion and we restore their ability to control the

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movement, there's nothing else to restore. That's it. That's all there is.

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Right? So when you've got those three things, you've got everything there is to get.

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There's, that's all there is. Right? So any injury that causes someone to have

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a disability, like they can't do something, they don't have the ability,

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they have a disability, they don't have the ability to do something they want to do. Okay.

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It's some combination of strength, range of motion and control is what they lack. Okay.

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Okay. Like, uh, when I, and, and I, I, I'm going to spend another minute on

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this because I think it's such an important point, although it seems pretty

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kind of obvious possibly to you.

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Most people don't get this. And this really is one of the things that's going

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to make rehab very, very easy and obvious for you and make you give you a lot

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more confidence in your choices.

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I you know way back in the 1990s when

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i was in my 20s i used to fix cars for a living this is when cars didn't have

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computers it was just like a motor with a carburettor and you hit it with a

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hammer if it didn't work and then start working and one of the most valuable

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thing probably the most valuable thing i learned from a mentor of mine who taught me how to fix cars was,

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a motor only needs three things to start it

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needs air it needs fuel and it

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needs a spark and if it's got all of those three things it will

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run right so if

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it's not running it's either doesn't have air it doesn't have fuel or it doesn't

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have spark or it doesn't have you know all of the above right but if it's got

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air fuel and spark it will start right so you just test okay is there air is

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there fuel is there a spark off it goes and it's the same with rehab right it really is that simple.

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Strength, range of motion control, that's all there is.

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Thumbs up, if that makes sense. Okay, so if someone can't do a movement,

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right, because of pain or because of any other reason,

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it's just because they lack some combination of strength and slash or range

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of motion and slash or control.

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So all we have to do is go, okay, do they have the strength?

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Yes or no. Do they have the range of motion? Yes or no. Do they have the control? Yes or no.

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If not, we need to build strength. How do we build strength?

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Progressively overload. How do we build flexibility?

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Progressively overload. How do we build control? Progressively overload.

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That's all it is. It really, really is.

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Okay. And progressively overload means start with what you can do and make it

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a little bit harder next time and keep doing that until they get there.

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Thumbs up if this is making sense. Okay, great. All right. So rehab is great at exercise.

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At the start of rehab, someone's just injured themselves. We want to protect

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that injured body part from potential harmful stresses. You know,

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you just wrenched your knee.

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Okay, we don't want to subject that knee to high loads, high forces,

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you know, right now, immediately.

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But rehab is the process of restoring capacity to the body part.

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So, you know, we're not done in our rehab until that knee can tolerate those strong forces again.

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So we have to gradually add load, gradually apply stress to that body part.

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Until towards the end of rehab, we are actually exposing that body part to the

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precise stress that caused the injury, but in a graded, controlled manner.

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So now we're building up a tolerance.

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Example, just say you pulled a calf muscle running up a hill.

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Okay? Well, we have to rehab you so that you can run up a hill without pulling

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a calf muscle, right? The answer is not like never run up a hill again.

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The answer is learn to tolerate running up a hill, right? So it doesn't injure you.

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So we have to first, like day one of rehab, we're not going to run up a hill,

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right? We're going to protect that body part.

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But gradually we apply more load over time, you know, calf raises, stretches,

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get into jumps and hops and plyometrics and standing on wobbly things and all

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of that stuff until you can run up a hill without injuring your calf, right?

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So we have to first protect and then gradually add load until running up a hill is no big deal.

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All right. And there are three phases, broadly speaking, to any rehab process.

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It doesn't matter what body part it is.

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First phase is immobilization. You hurt your calf, we put your foot up on the sofa.

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We protect it. And in this phase, we do things like gentle, slow,

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passive range of motion.

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Passive means you use your hands to gently, or maybe your loved one uses their

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hands, or the physical therapist uses their hands to gently,

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you know, gently move your calf, right?

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Isometrics, you know, tensing the muscle without moving, very low load, no movement.

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Mobilize adjacent joints, right? So if you've hurt your ankle,

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we might wiggle your toes and bend your knee.

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Keep those other joints, the next door joints, the adjacent joints, keep them moving.

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And we maintain fitness in other body parts. So you want to keep working your

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arms and your legs and your back, your other leg and your back and all of that other stuff, right?

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Then the next phase, which corresponds with this kind of graded exercise phase,

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we start with gentle movement, this active movement now.

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So we're doing gentle, active, pain-free range of motion. In the case of an

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ankle, it might, or a calf strain, muscle strain, it might be we start to limp

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around the house on crutches, gently weight-bearing on that.

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Single direction. So we're just moving forwards to backwards.

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Like if we start to get, you know, do some exercises, we won't be doing like

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twisting or anything like that.

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We'll be just doing like really simple, you know, single direction movements with stable loads.

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And we'll be doing some gentle stretching to the, just to the point of discomfort.

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And we'll try and normalize movement patterns over this phase.

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So we'll start by limping on crutches, and then we'll gradually try to limp less and less.

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And by the time we can walk normally, we're at the end of this phase.

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Then the final phase is progressive load through range.

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And this corresponds to sort of meet into late rehab. And so our goal here is

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to achieve full range of motion, right?

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So get that joint back to the same range of motion as the corresponding body

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part on the other side of the body. So if it's the right leg,

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we want to equal the range of motion of that person's left leg,

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whatever their normal is.

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Increase the load and decrease the reps. That's progressive overload,

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right? So heavier load for fewer reps.

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Add in direction change because that's life, right? And we have to be able to tolerate that.

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Increase speed because again, that's life. Even if you are rehabbing your 85-year-old

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grandma and she's got no ambitions to run up a hill,

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well, if she trips and has to put out her leg to save herself,

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that's an explosive deceleration movement.

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So she needs to be able to tolerate that and possibly more than someone 20 years younger.

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So everybody has to go through that phase.

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Decreasing stability, you know, challenge people's balance and movement control.

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All right, now, you don't have to memorize all of this.

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We're going to go through over this so many times until you're rolling your eyes.

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Okay, so don't stress about that.

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All right, what is rehabilitation?

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Ha ha. I just saw an answer someone put in the chat about why didn't Anne increase

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her strength after doing three springs?

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And they said, because she went to a non-breathe education teacher.

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That was good. And of course, rehab is great at exercise to restore strength,

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range of motion and control.

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Uh rachel asked a question so someone

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can get stronger by adding reps or is

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it reps with progressive load uh my understanding was it has to be progressively

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loaded for strength we're going to talk a lot more about this over the next

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two weeks so the next two weeks are all about strength and resistance training

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but the short answer is no you can get stronger by adding reps,

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but because of something called the principle of specificity,

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if your true highest goal is to get stronger, as in not better endurance,

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not better speed, not better power, but just as strong as possible,

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adding load is, there's nothing going to be as good as just adding load, right?

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So if you want to get really strong, you have to move very, very heavy objects.

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That's how to get very strong. but someone who can do 50 push-ups is definitely

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going to be stronger than someone who can only do six push-ups,

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right? That's also true.

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So adding more reps is going to make you stronger, but it's not going to make

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you as much stronger as adding more load.

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They both work. Just load works a bit better in terms of pure strength.

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Let's see if I can get this working again. In early rehab, we blank the injured body part.

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In late rehab, we blank it to potentially harmful stressors.

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Try and do this without looking at your notes.

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And the answer is protect and expose.

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List three features of early rehab exercises. Now, hold it a sec here, hold it a sec here.

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Don't look at your notes, right?

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Think about it. Because this whole program, you're learning to think like somebody

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who's really good at rehab.

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And when you think like someone who's really good at rehab, you are someone

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who's really good at rehab.

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So we want, I just pulled my calf muscle, okay? you want to protect my calf muscle.

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What do we do? Do we do explosive hopping on a BOSU, changing direction all

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the time, right? No, think about it.

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What are going to be some of the features of the program that you're going to

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do to protect my injured part?

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Okay, great answers. Okay, and the answers are like slow movement, single direction,

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gentle passive mobilization, work-adjacent joints,

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gentle isometrics, things like that good answers all

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right what about mid rehab what are we going to be some of the features of mid

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rehab again try not to look at your notes or don't look at your notes think

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about it what makes sense to you right if we started with gentle passive mobilization and isometrics,

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can we're going to end by jumping sideways onto a bosu like what's in between those things.

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Great answers so active pain-free

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movement gradually increase loading you

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know start to introduce direction change start to introduce instability increase

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load decrease an increased range of motion and that's all going to be gradual

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and progressive what about late rehab what are some of the features of late rehab exercise Yes.

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Good answers. Okay, they're going to be like high speed, high load,

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direction change, low stability, high range of motion, all of that stuff, right?

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So it's going to be like really demanding physical tasks that are highly challenging

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to strength and range and control.

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Good answers.

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All right, fill in the blanks. Rehab is blank to restore blank, blank and blank.

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Good answers. Rehab is great at exercise to restore strength,

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range of motion, and control.

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All right, we saw that to get stronger over time, you must progressively add

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either load or reps, and that rehab is just great at exercise,

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which just means progressively adding load or reps to restore strength,

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range of motion, and control.

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Now we're going to see that as we progress, we have to progress in line with tissue healing.

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We can't go faster than the healing tissues.

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All right, progressing in line with tissue healing. So tissue healing has three stages to it.

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It doesn't matter whether you've sprained your ankle, pulled a calf muscle,

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blown a disc out, broken a bone, whatever it might be.

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There are three stages to tissue healing.

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And there's a rough timeline here but

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this is going to vary quite a bit depending on which

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type of tissue you've injured and how severe the injury is and

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also just your general resilience your age your nutrition all of that stuff

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right so take the week since injury with a very large grain of salt so the three

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stages are inflammation that's the first stage of healing so inflammation is

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actually the first stage of the healing process.

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No healing takes place without inflammation.

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Proliferation is the second stage and remodeling is the third stage.

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And basically what this is, is we clean up the mess.

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Okay, when there's an injury, there's a mess, there's broken parts,

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dead cells, maybe bacteria, viruses, dirt, whatever floating around, we clean it up.

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Proliferation, we build new tissues.

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Remodeling, we organize the tissue so that it's now strong and pliable.

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Okay? So we clean up the mess, we build new tissue, we organize the tissue.

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Those are the three stages.

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All right, the inflammation stage. So you've got an injury.

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Now, we've got a cut here, but it could be an injury to a tendon or a muscle

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or a ligament or whatever. It doesn't matter. It's the same principle.

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You've damaged cells. You've torn cells. You've crushed cells.

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Okay, there are dead cell parts floating around in your body tissues now.

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So your capillaries, the smallest blood vessels, dilate, which means they open

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up, allowing more blood into the capillaries, and they actually allow,

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they open up, they've got little slip pores, actually, let me get my little

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drawing up here, see if I can draw this for you.

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All right, so you've got a capillary, which is just a blood vessel,

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we should draw that red, shouldn't we?

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Got the capillary, which is a blood vessel, okay, and you've got blood cells

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inside, and actually, funnily enough, red blood cells, this is a red blood cell.

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Oh, my apologies. Here's your capillary, and here's your red blood cell. Okay.

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You can't see it? Oh, hit the wrong button. All right, there you go.

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I've got too many buttons here.

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So this is a capillary, okay, which is just a tiny blood vessel,

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okay, and this is a red blood cell, okay, and this is...

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Seven microns, which means seven one thousandths of a millimeter.

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Right? So if you get, like, if you're in Australia, the five cent piece,

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remember when we used to have cash money, or if you're in the US,

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like a dime is about the same size.

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I'm not sure if you're in a different country, what the currency would be,

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but like a very small coin that is about one millimeter thick.

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Right? Right.

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A red blood cell is seven one thousandths of the thickness of that coin.

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It's so small, you can't possibly see it. The smallest human hair you could

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see with 20-20 vision would be about 60 or 70, one thousandths of a millimeter,

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right? The finest possible human hair, okay?

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So this is like 10 times smaller than the smallest thing you can see with your

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naked eye if you've got perfect 20-20 vision, right?

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So this is your capillary. These are very, very, very small.

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And so a single red blood cell takes up the full diameter of the capillary.

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Now, there are also other things floating around in your capillary, okay?

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And some of them are little immune cells, okay, called macrophages, okay?

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And these are like the little Rottweilers of your immune system.

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And they are attack dogs.

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Okay, they're just roaming around ready to sick onto some invader and just tear the shit out of it.

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And what happens when you have inflammation is your capillary,

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okay, is made of, the wall of the capillary is actually made.

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So if we zoom in on this capillary here, okay,

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the capillary is actually made of...

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These cells, flat kind of pancake cells, end to end.

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That's what the wall of your capillaries are made of. And when you have inflammation,

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your capillaries dilate.

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And what actually happens is these cells open up.

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They're called slit pores, okay? And you've got these big red blood cells in here.

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They're kind of donut-shaped.

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They don't have a hole, but they're kind of broad and round and flat in the

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middle. They're too big. They don't fit out through the slit pores.

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But you've got these little attack dogs in here, the macrophages. They do fit out.

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And so they leak out. So what happens is you have an injury here, right?

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There's some kind of injury to this tissue here, right? You've torn a muscle

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or whatever it might be, right?

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Inflammation happens. The capillaries dilate.

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Attack dogs get set free and they go in and clean up the mess, right?

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So if there's any dead bits of cells or if there's any bacteria or dirt or viruses

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or any other type of thing that's not like your healthy tissue,

::

they just go and chomp, chomp, chomp. They literally eat it, right?

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They've got digestive enzymes inside them and they engulf it and they eat it like they kill.

::

They're your hunter killer cells, right? So your inflammation is the first part

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of tissue healing because we can't rebuild this until we clean up the mess,

::

right? There's all these dead bits of cells floating around and other stuff in there, right?

::

We've got to get rid of that first. So your immune cells go in there.

::

And so that is the first stage of healing. and.

::

All right. Proliferation. The second stage is where we've now cleaned up the

::

mess. Okay. We've killed the viruses.

::

We've cleaned up all the bits of dead cells that were broken,

::

et cetera. Now we'd want to start building new tissue.

::

So we start laying down collagen, which is the main structural protein that builds your tissues.

::

And here's a picture of some collagen under an electron microscope, but it's disorganized.

::

So collagen are long, thin fibers.

::

Think of it like steel cables, right? Collagen are like steel cables.

::

They're proteins. They're not living cells. They're just structural bits that

::

we make our body with, right?

::

So your connective tissue, your muscles, your bones, all of it's made around a frame of collagen.

::

Collagen is what stops us being just liquid and in a puddle on the ground.

::

So we lay down new collagen to form a scar, but the collagen is very disorganized,

::

okay? When I say disorganized, what I mean is think about steel cables, right?

::

So if we wanted to make, you know, we've got like two bits of maybe,

::

you know, here's your muscle.

::

Actually, that's not what I wanted to draw. That's better. Okay. Here's your muscle.

::

Okay. And part of it's torn.

::

Well, we want to lay down collagen to form a scar. Okay.

::

Now think about steel cables. If we were laying down steel cables here to maximize

::

the strength of this structure, we would lay them down like this, right?

::

Lengthways. And that would make it as strong as possible.

::

But when we first lay down the tissue, we're just like, it's all about speed.

::

We want to just get collagen in there as quick as possible, and then we'll organize it later.

::

So we're just kind of getting as much in there as possible. So what we do is

::

we end up laying it down, kind of just whacking it in there,

::

okay, just to get something in there.

::

And it's all disorganized. Like when I say disorganized, it means it's not lined

::

up in the direction of force that it's going to need to transmit.

::

So the steel cables, they're not going to confer a lot of strength at this point.

::

Does that kind of make sense? Thumbs up if it does. Okay, great.

::

So, disorganized collagen fibers are laid down to form a scar,

::

but it's a weak scar because they're not organized yet.

::

And...

::

New blood vessels proliferate because we probably injured blood vessels in there

::

as well, right? So we need new blood vessels.

::

And in proliferation, this is kind of like what it still looks like.

::

Like you're forming a scar, but it's not yet fully like reached its full healing.

::

It's still a bit vulnerable, but it's less vulnerable than when it was newly injured.

::

Then comes the remodeling phase. Okay, we've built the scar. Now we strengthen it.

::

We make it strong and supple. And so basically what happens in this phase is

::

we realign the collagen so that it lines up along the tension lines in the tissue.

::

So, whoops, in this picture here,

::

in the remodeling phase, we get that collagen and we start to line it up so

::

it runs parallel with the lines of force that are transmitted through the tissue.

::

So those steel cables now reinforce the tissue, right, and it becomes very strong. extremely strong.

::

Does that make sense? All right.

::

So we're lining this collagen up with lines along with the lines of force that

::

are transmitted through the tissue.

::

So what if we don't transmit any force through the tissue whilst we're healing?

::

How will the collagen know which way to line up?

::

Well it won't so we have to apply load to the tissue to show the collagen which way to line up.

::

So loading the tissue is actually imperative. It's incredibly important for full healing.

::

After about a year, this scar is going to solidify.

::

It's going to stop being active. We're going to stop laying down collagen.

::

We're going to stop organizing the collagen. It's just like whatever you've got is what you've got.

::

So in that window of like 12 to 18 months, we've got the opportunity to influence

::

the alignment of these collagen fibers, okay,

::

and thus the ultimate strength and flexibility of this new tissue that we created, right?

::

So you've got a window of opportunity to maximize the strength and pliability

::

of that new tissue, and that's rehab, right?

::

So we need to apply load through range because we need this to develop the ability

::

to stretch and elongate, okay, as well as the ability to resist load.

::

So we need to apply load through range in rehab. And that's like the physiology

::

of why that's so important.

::

And that's why we have to go from protecting to exposing.

::

All right, remodeling. So now there are those three phases of tissue healing.

::

And they are inflammation, proliferation, inflammation where the macrophages

::

and the neutrophils escape and they just go to work and clean up all the mess.

::

Then the proliferation where we lay down disorganized collagen and proliferate blood vessels.

::

And then the remodeling where we organize that collagen so it lines up along

::

the lines of force that are transmitted through the tissues.

::

Now, the three stages of rehab that we saw earlier roughly correspond to these

::

three stages of healing, right?

::

So in the inflammation phase, we haven't put down any new tissue yet,

::

right? So it's still a wound.

::

So we want to protect it.

::

This is the protection phase. This is when your foot's up on the sofa.

::

Then as we start to build new tissue, well, we need to start to move that tissue

::

and load it very, very gently because that stimulates blood flow and it stimulates collagen deposition.

::

So that's when we get into the limping around on crutches phase.

::

And then as that collagen is now sort of starting to be laid down and we start

::

to have a scar there, we want to start to line up that collagen,

::

influence the direction and the length of those collagen fibres,

::

well, that's when we need to start to progressively load through range.

::

Does that make sense to you?

::

So if we start to load through range here, all we're going to do is tear that muscle further, right?

::

But if we immobilize here, we're actually going to prevent the scar from reaching

::

anything like its full strength or flexibility, right?

::

So we must, you know, respect the phases of tissue healing and apply the appropriate

::

amount of load at each stage, right?

::

And it's not zero load here. it's gentle slow passive range of motion isometric

::

like very gentle you know small range,

::

you know light movements here slow but there is some like because we're gonna

::

promote blood flow and all of that other good stuff that happens you know when

::

we um you know activate an area so does this kind of make sense to you thumbs up if it does.

::

Great. All right. So, Marie asks, what about bone tissue?

::

Well, bone is also predominantly made of collagen. Bone itself is mineralized collagen.

::

But unlike muscle, tendon, ligament, joint capsules, or sort of the rest of

::

the connective tissue, bone actually doesn't form scars. It actually just regenerates.

::

So, when you tear a muscle, the tissue that you use to repair that isn't muscle tissue.

::

You don't build new muscle tissue, you just build a scar. So now you've got

::

like a muscle with a little bit of the muscle that's not muscle anymore. It's now a scar.

::

Right? So that healed muscle is never going to be like 100% as strong as the

::

pre-injured muscle because you've replaced a bit of contractile tissue with a bit of inert scar.

::

With bone, however we actually regenerate new bone right so healed bone is literally the same as,

::

bone that's never been injured uh and uh because bone has no uh sort of contractile

::

properties to it it's much and it's not very elastic like tendons and ligaments are somewhat elastic,

::

bone doesn't benefit from being moved whilst it's healing so that's why we immobilize

::

it in a cast for six to eight weeks.

::

But at the end of that six to eight weeks when it comes out of the cast,

::

bone does respond to load by getting stronger. And so we do need to load that

::

bone after we come out of the cast.

::

So it's just with bone, the amabilization phase is a bit longer typically than

::

with, say, a pulled calf muscle. Basically the same principle.

::

Great. Yeah, some really great comments in here. With muscles and ligaments,

::

is that why there's a tendency to repeat injury?

::

So biggest risk for a second ACL,

::

anterior cruciate ligament injury in the knee, is previous ACL injury.

::

So probably, now we don't know exactly why, right?

::

But my guess would be whatever predisposed that person to injuring their ACL

::

in the first place is probably still the case.

::

So just say it's like being female or being a certain age or being a certain

::

body mass or having certain, you know, tendon, a ligament position within the knee or whatever.

::

So those factors are still there. So whoever injured it first time is more likely

::

to injure it the second time.

::

The second massive factor is people don't get rehabbed properly, right?

::

They do a couple of knee extensions and then go back to doing whatever it was

::

that they injured their knee doing.

::

And they haven't actually gone through that process where now their knee is

::

actually stronger than it was before they injured it because it's like,

::

well, if it's just as strong as it was before you injured it,

::

that's not good because it wasn't strong enough to resist the force and it got injured, right?

::

So it has to be actually stronger than it was before it's injured.

::

So we need to be able to tolerate those hopping, direction change,

::

explosive movements, instability, all of that stuff.

::

That's why it's so important to rehab people right up to the end point where

::

they can hop on and off of BOSU sideways and stuff if they've got, say, a knee injury.

::

And likewise, in the shoulder, they have to be able to throw and press and put

::

their hand behind their back between their shoulder blades and do all of those

::

things because that's what people have to do in life.

::

So we have to build them up to be able to tolerate those things. All right.

::

So, tissue healing times. So, like I said, though, take those weeks with a grain

::

of salt. Muscle generally heals in three to six weeks.

::

Bone, six to eight weeks. And connective tissue, which is pretty much everything else.

::

Now, bone is actually technically connective tissue, but it's kind of a special

::

type of connective tissue because of the reasons I just said.

::

So, things like discs, ligaments, tendons, joint capsules, these are all connective tissue.

::

Okay, and they're 12 to 18 months to heal. So if you rupture an Achilles tendon,

::

how long is the rehab process?

::

12 to 18 months. Okay. If you tear a calf muscle, how long is the rehab process?

::

About three to six weeks.

::

And if you want to read the citations on this, they're there.

::

All right. So we're going to look at the case study now, which is a 51-year-old

::

male, double right shoulder surgery, February 2022, I think.

::

I think that was it. That was me.

::

And my goal was to get back to bench pressing. So I had a biceps tendon desis

::

and a massive rotator cuff tear repaired in January or February 2022.

::

And so this was my rehab. So one day post-surgery, what phase are we in?

::

Don't look at your notes.

::

Immobilization, right? So like 23 hours and 50 minutes a day, I'm in a sling.

::

And then I'll come out, you know, a couple of times for gentle passive range

::

of motion, gentle isometrics, you know, all of those things we said, okay?

::

Inflammation phase, immobilization with gentle passive mobilization,

::

extremely small range of motion. This is one day post-surgery.

::

Take it away, Raph.

::

So it's a passive movement. I'm rocking my body back and forth and the shoulder

::

muscles, I'm trying to get my shoulder relaxed, right?

::

And just let gravity and the inertia of my body movements move.

::

And that is my full range of motion, right? I've probably got,

::

what, 10 degrees of range of motion there.

::

Okay, so I've lost a lot of strength. I've lost a lot of range of motion.

::

I've probably lost a lot of control as well, right? So that is an example of

::

what you do. Now, this is not your job.

::

This is the job of the physical therapist, right? So we take over at that second

::

phase when they come out of the sling or the cast or the boot or the,

::

you know, whatever it might be.

::

Okay. So we start in phase two, four weeks post-surgery, right?

::

So now I'm out of the sling or starting to come out of the sling and we're starting

::

again at this gentle movement phase. Okay. So the macrophages have done their work.

::

I'm starting to lay down scar tissue in there. It's starting to become stronger.

::

Okay but it's still quite vulnerable so i'm doing gentle active pain-free range,

::

stretching to the point of discomfort normalizing movement patterns right trying

::

not to hike my shoulder up or protect you know guard that shoulder right so

::

i'm doing my goal is to get back to bench press so what exercise do i do bench

::

press can't do 100 kilos so i start with what i can do, which is a broomstick.

::

Basically zero load. And can you notice here, there are these safety straps.

::

I'm not actually getting all the way to the strap, but I don't have the ability

::

to go through that full range yet.

::

I'm moving pretty slow, okay? And I'm trying to move both ends of the pole at

::

the same speed, right? Because that's the control aspect.

::

So this is what rehab looks like. And I'm going to play you the full,

::

like, 60 seconds of this clip because it's freaking boring, right?

::

When you're rehabbing someone, your job is to sit and watch them do this and

::

say, you're doing awesome. That's great.

::

This is the grind. This is rehab. This is what it looks like.

::

Raph, that's awesome did you just touch that safety strap there? that's great.

::

Daisy says am I getting to the point of not being able to do more here?

::

No so I want to be very gentle stop way before I reach that point of near failure

::

or whatever so I can't remember how many reps I did but it's basically to the

::

point of mild discomfort,

::

So like, this is not sexy, right? This is just like, just doing the boring work,

::

putting, literally putting in the reps.

::

And this is what you're going to, your job is, you know, as you rehab.

::

Now you might not be watching someone bench press, you might be watching them

::

do some other movement, but like, it's going to be as boring as that.

::

Okay. Four weeks post-surgery. Eight weeks post-surgery, I'm now in the remodeling phase.

::

Okay. So I'm starting to add load through range, progressive load through range.

::

Going for full range of motion, okay, same as the uninjured side,

::

gradually increasing load, decreasing reps, adding indirection change,

::

increasing speed and decreasing stability.

::

Now, I'm not doing all of those things in this one exercise,

::

and I don't think you should do all of the things in one exercise.

::

It's not, don't go from like stable, low load, slow speed, bilateral,

::

all of a sudden balancing on a unicycle, on a BOSU, juggling a cat and a chainsaw

::

and a raw egg or something.

::

Like they have to increase the load, but keep the stability the same or increase

::

the instability, but keep the load the same, right? We progress a little by little by little.

::

So here is 20 kilos, right?

::

So I've gone from basically zero to 20 kilos load, which is a five kilo per

::

week increase, right? Now that's not a rule.

::

The rule is not like increase five kilos per week. The rule is increase what you can per week, right?

::

Because our goal in that middle phase, okay, is gentle, active,

::

pain-free ROM, stretching to the point of mild discomfort, right?

::

So if I added five kilos and I was like, that really hurts, it's like,

::

well, that was too much then.

::

Okay, if I add five kilos, I'm like, yeah, I can do that, right?

::

Then it's not too much. Does that make sense?

::

Do you have any questions about how to figure out how much load to add in this particular situation?

::

All right. So here is eight weeks post-surgery. Notice it's the same exercise.

::

It's just the same exercise, right? All I've done is give me a heavier thing, right?

::

And can you notice I'm going full range now? The bar's hitting the safety straps.

::

And can you also see that I'm struggling with the control a bit,

::

like both ends of the bar are not hitting the strap at the same time,

::

right? I'm struggling to get both of those ends of the bar moving at the same

::

speed. So that's the control aspect.

::

Um, Marie says, so you didn't go from broomstick to Olympic bar, but in five kilo steps.

::

Yes, that's what I did. So I've got a, like, I've got a five kilo bar and a

::

10 kilo bar and a 15 kilo bar.

::

And I just bought those on eBay. They're like $10 each.

::

Uh, Sarah says, could you change all of those things in a session,

::

but not in the same exercise? So you could do, yes, you could do one exercise

::

with a bit more load, but the same stability. and then you could do a different

::

exercise with the same load and a bit less stability.

::

So you could challenge each of those things separately and I think that's a good idea to do that.

::

This particular exercise has more load and more instability because a heavier,

::

long, unwieldy bar is actually more unstable than a broomstick. It's more wobbly.

::

Louise says 24-hour rule. Yes, we're going to get to that. All right,

::

so this is eight weeks post-surgery.

::

This is your job. watch someone do the same exercise you've already been watching

::

them do for eight weeks and just keep watching them do it and go, that's awesome.

::

You're doing 20 kilos and you're going full range.

::

That's great. I bet that makes you feel good. All right.

::

26 weeks post-surgery, six months of doing this same freaking exercise. Okay.

::

100 kilos, that's about a four and a half kilo increase per week, okay, for 26 weeks,

::

full range, increased speed, okay, and again, it's just like,

::

this is session number, you know, 257, and just the same exercise,

::

a little bit harder, progressive overload.

::

It's going all the way hitting my chest, moving faster, and it's heavier.

::

And because it's heavier and it's long and unwieldy, it's also more unstable.

::

It's just simple, right? It's not complicated is the point here, right?

::

It's like just start with doing the thing, make it so easy that you can do it,

::

and then gradually make it a bit harder and keep doing that until you can do what you want to do.

::

Maurice says, ad load every week. I was pretty much adding load every session,

::

but it's not a rule that you add load every session, week, second session, whatever.

::

It's like you add load when you can, right? So I can do 10 reps.

::

Now I can do 12 reps. Oh, let's add more load. So I can only do 10 reps again.

::

And what I found was because I was very regular and consistent with doing those

::

workouts, I could add load every week, right?

::

But if I come back next week and I can still only do 10 reps,

::

well, don't add more load because I haven't got stronger yet.

::

Good question all right name the three phases of tissue healing now the actual

::

names are not important but the gist of what happens in each phase is important

::

so if you forget the name but you like you remember what happens just say that.

::

What's each phase about what's the focus in each phase Yes.

::

Beautiful. I love these answers. Early is we're just protecting slash immobilizing.

::

Second phase is gentle movement slash scattering the collagen, whoever said that.

::

And the third phase is lining up the collagen, progressively loading through range, exposing.

::

Okay, all of those things are correct. Good job.

::

Rehab is blank to restore blank, blank, and blank.

::

Okay, and rehab is great at exercise to restore strength, range of motion, and control.

::

Now, why are we just belaboring this to the point where hopefully you're already

::

starting to roll your eyes?

::

Because almost everyone way, way overcomplicates this.

::

Like, it's not true that more complicated approaches to rehab work better.

::

Simple works best. Now, that's not always true. Like if you're a nuclear physicist,

::

there are probably lots of complexities that you have to deal with,

::

right? And sometimes complex things work better than simple things.

::

But in the case of rehab, it really is that simple.

::

And anything we do to make it more complicated makes it work less well, right?

::

So the thing I really want you to take away from this lecture and from this

::

program is like, don't overthink it.

::

Just start with what they can do and gradually make it harder over time until

::

you get to what they want to be able to do that's it right rehab exercises are

::

just regular exercises with the right amount of load range and control that's all,

::

true or false rehab needs to be complex.

::

And the answer is false what is rehab.

::

The answer is rehab is great at exercise to restore strength,

::

range of motion, and control.

::

Now, I don't apologize, but I'm just going to have a little meta moment here

::

about the whole eye roll thing, okay?

::

Because it really is a very deliberate strategy here.

::

And if you think about something that most of you probably feel anxious about,

::

say, public speaking, right?

::

Imagine you have to get up in front of a crowd of people you don't know,

::

or maybe people you do know, and present on a topic, right, for half an hour, right?

::

For most people, that's like heart palpitations, right?

::

And imagine I said you can't have any notes or slides or anything.

::

You just have to do it off the cuff or from memory, right?

::

Well, imagine if, now let's change that and say, all right, what I want you

::

to do is recite the alphabet in front of that group. of people with no notes

::

and no slides. Well, could you do that?

::

Because you know it so well, right?

::

It's very hard to be nervous about doing something you've done 50,000 times

::

before, right? It's just so, so easy because you know it so well,

::

because you've done it so many times, okay?

::

So that's where we want to get you to with all of this stuff like,

::

oops, client walks in, they've got, oh, I've got this terrible shoulder thing.

::

And instead of you being like, oh, my God, panic, it's like,

::

oh, we're going to need to restore strength, range of motion and control.

::

We start with what you can do and build you up from there.

::

Easy peasy, right? Done this 50,000 times before.

::

So we're just trying to get in as many reps as possible in this program.

::

So by the time you get to the end of the program, you've already done it 10,000

::

times and you're 10,000 reps closer to being like you're on board,

::

you know, just another shoulder rehab. Okay, let's get started.

::

So it's a very important strategy and to be confident you need to almost be

::

bored by the thing, right? Because you just know it so well.

::

You know what's going to happen before it happens, right? Because you've just done it so many times.

::

So that's why we're here. All right.

::

True or false? Rehab exercises are just exercises.

::

And the answer is true. All right, we saw that to get stronger over time,

::

you must progressively add either load or reps.

::

And that rehab is just graded exercise, which just means progressively adding

::

load or reps to restore strength, range of motion, and control.

::

And we saw that you have to progress load in time with tissue healing.

::

We saw an example of that in my shoulder rehab.

::

Now we're going to look at the idea that with load, the dose makes the poison.

::

And what this means, the dose makes the poison. Who's heard of that saying,

::

the dose makes the poison?

::

Okay, great. So it's true of almost everything, right?

::

So we think about something that is extremely toxic, like arsenic, right?

::

It's in apple seeds. Eat an apple seed. Have you ever eaten an apple seed? You didn't die, right?

::

Because there's such a tiny amount in there that your body can process it.

::

It's not a problem. It's not poisonous. But if you had enough of it, it would kill you.

::

Same with things that we normally think of as not toxic, like water.

::

Have a glass of water. It's good for you.

::

Have 15 liters of water. You'll die. You get something called hyponatremia.

::

So you dilute your body fluid you don't have enough sodium and

::

potassium floating around in your body fluid it's too diluted now

::

so you can't send nerve impulses and your

::

muscles can't contract your heart stops beating you die right so

::

too much water people get people die of hyponatremia after like marathons where

::

they just drink way too much water and stuff and then you know it's very rare

::

okay but water in a high enough dose just drinking water can kill you right

::

the dose makes the poison.

::

So is water a poison? Well, if you have enough of it, yes, but generally no, right?

::

Is arsenic a poison? If you have enough of it, yes.

::

If you have less than that, no, right? Is load dangerous? Can it injure you?

::

Yes, if there's enough of it in a short space of time.

::

And if there's just the right amount, it actually protects you from injury, right?

::

If you don't have any water, what happens? You die, right

::

so not enough and too much

::

are equally not good right it's the goldilocks amount

::

they're just right not too little not too much that's what we want

::

right with water and the same with load so the dose makes the poison too little

::

load leaves the body weak and prone to injury so how do you get injured well

::

too little for too long right followed by too much too soon that's how you get change it.

::

For example, low strength in a single leg bridge increases your risk of hamstring injury, right?

::

So if you've got weak hamstrings, you're more likely to have a hamstring injury.

::

Too much too soon after too little for too long increases injury risk.

::

And so it's not high levels of activity, as we said previously, that risk injury.

::

It's big changes in levels of activity that predict injury.

::

So if you're deconditioned from not doing much for a long time,

::

and then all of a sudden you do a lot and your body tissues can't tolerate it,

::

that's when you increase your risk for injury.

::

So this is a study on the running mileage and the training volume of elite rugby players in Australia.

::

And they looked at how many miles they ran each week and how many training sessions

::

they did, and they correlated that with who got injured.

::

And what they found was people who had consistently high levels of running didn't

::

get injured, But people who had low levels and then had a high level,

::

they got injured much more often.

::

So it's the change in workload, not the workload.

::

So if you double your training volume or intensity in a week,

::

you increase your risk of injury significantly there.

::

So you should increase relatively slowly, no more than, let's say, roughly 20% a week.

::

And so this is not the same principle, but it's a different study.

::

Actually, sorry, it's the same study. So those that had the highest mileage

::

consistently actually had the fewest injuries because they were the strongest.

::

They had the strongest hamstrings.

::

They got the fewest injuries. So load applied gradually prevents injury.

::

Strength training reduces ACL and hamstring injuries.

::

Stronger hamstrings, fewer injuries. Stronger ACLs, fewer injuries.

::

10% increase in strength training volume, reducing injury risk by 4%.

::

So doing more means less injury risk.

::

Athletes with stronger squats have fewer lower limb injuries.

::

So male athletes who can squat greater than 2.2 times body weight,

::

which is freaking humongous.

::

And female athletes who can squat greater than 1.6 times body weight,

::

which is also humongous.

::

We're talking like elite level squatting here.

::

Have fewer low body injuries, right? So strong legs equals fewer leg injuries.

::

That kind of makes sense.

::

And so I think this is the fundamental misconception that we talked about recently

::

in relation to kind of wear and tear, right? Because humans are not machines. We don't wear out.

::

Instead, we respond to stress in an anti-fragile manner.

::

If the stress is applied gradually, we actually become more resilient as a result of stress, right?

::

It doesn't wear us down, It actually builds us up, right?

::

So hence, you know, this little post I did a little while ago,

::

keeping safe increases your injury risk.

::

Gradually building load, impact,

::

and range over time is how you build tolerance and reduce injury risk.

::

Avoiding heavy weights, impact, and end range leaves you weak and vulnerable,

::

increasing long-term injury risk.

::

So the dose makes the poison. Go too much too soon after too little for too long, causes injury.

::

Gradually building up to a high level over time, reduces injury.

::

All right. What does it mean to say that with load, the dose makes the poison?

::

Great answers. Okay. Okay, so too little and too much are both bad,

::

and the right amount at the right time is protective.

::

Too much too soon after blank for blank increases injury risk.

::

And the answer is too little too long. True or false? Training hard over a long

::

period of time increases injury risk because of wear and tear.

::

The answer is false.

::

True or false, humans are anti-fragile. We get stronger in response to stress.

::

When the stress is applied gradually.

::

And the answer is true if you want to minimize injury risk how should you train.

::

Great answers, team. Consistently, progressively overload. Love it.

::

You're already smarter than about 60% of personal trainers, exercise physiologists,

::

and physical therapists.

::

All right, we saw that to get stronger over time, you must progressively add either load or reps.

::

And that rehab is just adding load or reps to restore strength,

::

range of motion, and control.

::

That we need to progress load in line with tissue healing. We can't exceed the

::

speed of tissue healing. We have to respect that.

::

And that with load, the dose makes the poison.

::

Too little is no good. Too much is no good. The right amount is good.

::

Now we're going to talk about load management, which is, in other words,

::

calm it down, then build it back up.

::

So this is what to do if you do load it too much too soon, right?

::

So just say you're rehabbing my shoulder and we add five kilos and you're Marie,

::

and then I come back the next session and I say, Marie, my shoulder has been

::

really sore and inflamed for the last five days since the last session. What do you do?

::

A, panic, hide under the bed, or B, say, no, that's cool.

::

All right, it looks like we overdid it a little bit. Let's drop the weight back

::

a bit until it calms down and then gradually build it back up again,

::

but a bit more slowly this time.

::

And the answer is B. Okay, so that's load management.

::

All right, load management. In other words, calm it down, then build it back up.

::

All right, so we've already met the cup of resilience, okay,

::

and we saw that the stressors we can pour into the cup, you know,

::

could be, for example, tissue changes. Maybe there's been a surgery, okay?

::

Maybe there's a tear or a strain or a sprain or a bruise or something like that, okay?

::

Systemic inflammation. Maybe we're stressed or overweight or got a bad diet

::

or underslept, right? Causing that systemic inflammation.

::

Poor mental health.

::

Worry. And another stressor we can pour into that cup, believe it or not,

::

is training load, exercise.

::

Exercise is a stressor, right? If we pour too much training load in there, we can cause injury.

::

Okay? Because training load is a stressor. Like we've said that many times,

::

exercise is the process of systematically applying stress to the body in order

::

to elicit a training response to get stronger or more flexible.

::

So if we do too much training load on top of all of those other things,

::

we can actually cause injury.

::

So how do we choose the right amount?

::

All right, well, I'm going to divert a little bit for a moment here.

::

So chronic short sleep, here's something we can pour into the cup,

::

right? Not enough sleep.

::

Chronic short sleep is associated with a significantly increased risk of injury.

::

So if I come into my training session with Marie and Marie's like,

::

how have you been, Raph? And I'm like, oh, I've been sleeping terrible.

::

The baby's been keeping me up all night or whatever, right?

::

Then Marie might say, well, why don't we take it a bit easier today,

::

okay, and not add any more weight?

::

Now if we add a big increase in training load on top

::

of poor sleep that even further increases

::

injury risk right so we can see how the cup of resilience kind of works you

::

know this metaphor really does work with how the human body works and reduced

::

sub-maximal running speed is associated with higher injury risk so what does

::

what does this mean well if i'm not running as fast as i normally run, why not?

::

Well, because I'm run down and fatigued and, you know, haven't been eating properly

::

or sleeping properly or whatever.

::

It's like, well, all of those things leave me vulnerable to injury, right?

::

So if I'm not performing as well, if I come in and I'm doing my warmup set and

::

I'm like, oh, this is really heavy, it's still heavier than usual, right?

::

Or maybe Marie says, okay, well, let's not add any more weight today.

::

Let's go a bit easy, right?

::

She's reading the warning signs.

::

Niggles, which I learned recently is not a word that people in the US use,

::

okay? And it means unusual aches and pains.

::

I think it's a British, Australian and New Zealand term.

::

But if I come in and Marie says, how are you going? I'm like,

::

oh, I've just got this weird pain in my neck today, right?

::

Well, Marie says, why don't we take it a bit easier, okay? and just do a medium

::

session today, not a full-on session.

::

Because she's seeing or interpreting this and going, huh, I think your cup's pretty full right now.

::

Is this making sense? Thumbs up if yes.

::

Okay, great. So here we get to the famous 24-hour rule.

::

And this came out of research by Peter Maliaris and Jill Cook and Ebony Rio in tendinopathy.

::

And what this says is if symptoms are elevated after a session for more than 24 hours then.

::

Reduce how much and how intensely you work out at the next session and keep

::

it low, keep reduced intensity and duration until the symptoms settle,

::

but just do less until the symptoms settle and then gradually increase the duration

::

intensity again, but just a bit slower this time, right?

::

Or in other words, calm it down, then build it back up.

::

All right, now, So I want to, I want to just spend another moment thinking about this.

::

So if, if I, if I'm in say the third stage of rehab, right.

::

The progressive load through range, right. So in the early phase,

::

the goal is to keep it relatively pain free, right.

::

So if I'm doing my stretch, you know, three weeks post-surgery and I'm like,

::

oh, this really freaking hurts.

::

Well, I'd need to back it off. That's too, that's too intense.

::

Cause the goal is to keep it relatively pain free in that early stage.

::

Cause we're in the protect phase.

::

Okay. But once we get to the expose phase, the progressive load through range

::

phase, okay, if it hurts during, if I'm doing the bench press and I'm like,

::

okay, I'm doing 40 kilos here, this kind of hurts a lot,

::

Marie can have the confidence to say, don't worry, that's fine, keep going.

::

Or if she's stretching my shoulder and I'm like, oh my God, this is 11 out of

::

10 pain, okay, she'd be like, well, you're tough, you can take it,

::

okay, take your medicine. Okay.

::

Pain during is perfectly safe. Doesn't indicate you're doing any damage.

::

It's a normal part of the rehab process.

::

Anyone ever done rehab for after a joint surgery or injury? Right. It hurts, right?

::

It hurts, right? It hurts when you stretch, you're literally stretching your tissues longer.

::

Right. It hurts. If it doesn't hurt, you're not doing it hard enough.

::

But if it still hurts like two days later, you went too hard, right?

::

So it should hurt a bit in the during part, right?

::

But it should settle within a day afterwards, right?

::

If it doesn't settle, it means you did too much, okay?

::

And this is really, you know, the best way I know to gauge how much intensity

::

you should be working with your client, right?

::

You can only know in hindsight, right?

::

Because what we need to do, you know, is we need to provide enough stimulus

::

that we stimulate a strengthening response or an increasing range of motion, okay?

::

But a little enough stimulus that we don't cause tissue damage, right?

::

So it needs to be enough to provide a training response, but not too much to

::

cause damage. So there's some like Goldilocks amount, right?

::

Dose makes the poison, okay? And the thing is that amount changes because as

::

I get stronger, I need a bigger dose to keep getting stronger,

::

progressive overload, right?

::

And as my tissues heal, they have more capacity, right? So it's a moving target.

::

So just because you got it right last week doesn't mean you're going to get it right this week.

::

If you do the exact same thing, it might be different. Plus,

::

I might've had a shit sleep or had a fight with my wife or, you know, whatever it might be.

::

And my cup might be almost full, right?

::

So you will get it wrong from time to time. A hundred percent for sure,

::

definitely you will get it wrong from time to time, right?

::

And you'll know you got it wrong because your client will come back and say,

::

oh, I've been really sore since the last session.

::

Right? Three days ago or whatever. And you say, oh my God, pedic, I've broken you.

::

No, you say, that's, you know, I'm sorry your body part is sore.

::

It just means we overdid it a little bit last time. Let's pull it back today

::

and we'll keep you at a reduced intensity and volume until it settles.

::

Okay. And then we'll gradually build you up at a bit slower again this time.

::

Right? So how much do you reduce it? You reduce it so it settles,

::

right? So if you do 10% less and it feels fine, great.

::

If you do 10% less and it still hurts, do 20%, 30%, 50%, 80%, 90% less.

::

Just keep making it less until it settles.

::

Thumbs up if that makes sense.

::

Okay, great. So don't panic. Just keep doing less until it feels okay and then do that.

::

And then once it feels fine for a couple of days, gradually build it back up

::

again. All right, so that's the 24-hour rule.

::

What does calm it down and build it back up mean,

::

okay great means reduce it to the

::

point where if if it's uh set you know if it's

::

inflamed irritated aggravated for more than a

::

day after a session reduce the

::

load to the to where it's not irritated and

::

that might mean taking a couple of days off or it might mean

::

doing a couple of days of just gentle stretching okay or it might mean just

::

reducing you know the weight on the bar by

::

five kilos or just doing three reps fewer right it might be only very small

::

change or it might be very big reduction that's required depending on how irritated

::

it is and then you gradually build it back up again explain the cup of resilience

::

metaphor in relation to injury risk so we talked about it in relation to pain before,

::

explain it in relation to injury risk.

::

Okay, great answers. So basically, if your cup is full of other stuff,

::

like poor sleep and stressors, well, one of the things we pour in can be training load.

::

So we can actually manage the training load proactively when we're aware of

::

all these other stressors, we can proactively reduce the training load to prevent injury.

::

So we can adjust it up and down as needs be.

::

If your rehab client has increased pain that lasts more than 24 hours after

::

a session, should you A, panic and catastrophize, or B,

::

do something else, and if so, what?

::

And the answer is B, calm it down, then build it back up again.

::

And this is very much like turbulence in an aircraft, right?

::

It's a completely normal thing for you to overdo it at some point.

::

Like it's basically inevitable that you will overdo it at some point with almost

::

every client, right? I can pretty much guarantee that.

::

So you should prepare the client for that in advance. Hey, look,

::

it's going to be a moving target here.

::

We've got to give you enough load to stimulate strengthening,

::

but not too much to actually cause you to aggravate. Don't say to injure you,

::

say to aggravate your injury, right?

::

So it's going to be a moving target. We've got to give you just enough, but not too much, right?

::

So I'm going to be conservative here and we're going to err on the side of caution.

::

We're going to gradually build you up, but inevitably we'll get it wrong at

::

some point because it's a moving target.

::

As you get stronger, we need to build it up, right? And also sometimes if you

::

don't sleep properly or you're stressed or you haven't been eating well or whatever,

::

your resilience can be down. And the same thing that you could tolerate last

::

week, you can't tolerate today, right?

::

So we probably will get it wrong at some point.

::

And we'll know we got it wrong because you'll have this kind of like sore shoulder

::

or sore back or sore knee or whatever body part, okay?

::

And it'll feel kind of inflamed and irritated and sore. And you'll probably

::

be wondering, oh my goodness, oh, have I injured myself again?

::

And what I want to tell you in advance is no, you haven't, okay?

::

That's a normal part of rehab. Just means we irritated those tissues and they're a bit inflamed, okay?

::

There's no harm done. but it does tell us that we need to do less at the next session.

::

And so when that happens, if that happens, we'll just reduce the amount of work

::

that we're doing and then gradually build you back up again.

::

So if you prepare your client in advance for this, it's very,

::

very easy when it does happen.

::

All right, what is the 24-hour rule?

::

Great answers, all right. So if they've got pain during a session,

::

if they're in the strength through range phase, it's perfectly fine and safe

::

and probably even necessary.

::

But if the pain doesn't settle within 24 hours, probably means you did too much.

::

So you should calm it down, then build it back up.

::

All right, putting it all together.

::

So we have these sort of load and tissue healing sort of progression.

::

And bear in mind that this is, you know, the timeline here is rough because

::

it depends which tissue type you're dealing with. So I'm going to be slower, some faster.

::

And it doesn't just apply to strength training because stretching is load too.

::

So we can use this exact same template for stretching, right?

::

So we've been talking a lot about strength, but the same thing applies for flexibility.

::

And we'll talk a lot more about flexibility in a couple of weeks.

::

All right. And so stage one, gentle, slow passage ROM.

::

Stage two, gentle, active, pain-free ROM. So we're talking about stretching

::

now. And static stretching to the point of discomfort.

::

And then in that third stage, progressive load through range.

::

So the stretching and the strengthening kind of join together in that third

::

phase. And we're doing load through range.

::

All right. So just a quick overview of my rehab journey to illustrate that.

::

So we saw this as a stage one. this is passive range of

::

motion okay i won't play the whole thing for you because you already saw it

::

but that's like stage one okay this is a weak post right and you can see bigger

::

range of motion right still pretty passive but a bigger range of motion there,

::

um 28 days got the broomstick out okay so this is a range of motion and control

::

and you know very very mild strength exercise.

::

And then same time as the broomstick is static stretching to the point of moderate discomfort.

::

This was like moderately excruciating.

::

Same. This is my maximum shoulder flexion at that point.

::

But this was like, ouch, in this point. Oh, there it is. Ouch.

::

Then mid to late rehab. Okay. Progressive load through range.

::

Now, this exercise is much more unstable and much heavier load and much bigger

::

range than the previous ones. So it combines those pec stretches I was doing

::

with the bench press and the load.

::

And so now we've got progressive load through range, right? So this is late

::

stage rehab. Now, your clients don't have to do one-arm push-ups.

::

This is my particular journey, right? And my goal was to get back to high-level,

::

you know, bench pressing, right?

::

But this is 32 weeks. So this is like seven, eight months post-surgery, right?

::

So the other thing that I think most rehab professionals get wrong is they are

::

way too cautious, way too conservative.

::

Eight months after rehab, they're still doing the lightest flex band,

::

where the tissues can tolerate a much heavier load.

::

And remember, we've got that one-year window to realign those collagen fibers

::

by putting maximum load and stretch on them to stimulate them to be as strong

::

and flexible as possible, right?

::

Now, of course, we'd need to respect the tissue healing times,

::

but I think most people are way too much on the side of too much respect, okay?

::

And we need to be, you know, need to push it a fair bit harder in most cases.

::

And we've got the 24-hour rule and all those things about niggles and all of

::

that to guide us into how much, you know, is the right amount.

::

All right. So here's just like the 60 second, you know, summary of that whole thing.

::

And it's like, I just did like a bazillion reps of each of these exercises.

::

This is basically my entire set of exercises that I did for rehab.

::

Like there weren't other special exercises I did.

::

This was it. This was like literally what I did, you know, six days a week for a year.

::

And just when you do it more and more and more, you get better and better and better at it.

::

And can you see how that's just a progression it's just the same thing done,

::

harder right and it's just really really simple it's like literally like three exercises,

::

all right so we've got our three stages to

::

sum up and in this early stage we want gentle slow passive range of motion gentle

::

active pain free range and static stretching to the point of discomfort and

::

then progressive load through range and big take-home message.

::

Rehab is just great at exercise.

::

In our early stage, here's our gentle, slow, passive range of motion.

::

In the middle stage, here's our gentle, active, pain-free range.

::

Here's our static stretching to the point of discomfort.

::

It and here's our progressive low through range okay

::

that's what rehab is it's literally just doing bench press and push-ups and

::

pec stretches if your shoulder's been operated on okay and if it was my leg

::

it would be squats and lunges right and if it was my back it would be forward bends and backbends.

::

It's just your standard basic exercises with graded exposure.

::

All right, final self-test. True or false?

::

Rehab is graded exercise to restore strength, range of motion, and control.

::

And the answer is true. True or false? Rehab exercises are just exercises.

::

And the answer is true. True or false? Rehab needs to be complicated.

::

The answer is false.

::

What do you do if your client feels sore after a session?

::

And the answer is 24-hour rule. Good job.

::

So if they just feel sore like two hours after a session, I would say just wait

::

and see how they feel tomorrow.

::

But if they feel sore a couple of days later, yeah, calm it down.

::

Rehab is blank to restore blank, blank, and blank.

::

And the answer is rehab is graded exercise to restore strength,

::

range of motion, and control. All right.

::

We saw that to get stronger over time, you must progressively add either load or reps,

::

that rehab is just graded exercise to restore strength, range,

::

and control, and that we need to progress load in line with tissue healing,

::

that with load, the dose makes the poison, so it's never the question of should

::

we load it, but rather how much should we load it.

::

And load management, in other words, calm it down, then build it back up.

::

If you cause a problem, don't panic, just do a bit less until it settles and

::

then gradually build it back up again.

::

Okay. Thanks for staying with me. Sorry we went a couple of minutes over time.

::

And hopefully the rest of your life, now you won't be able to ever unsee those words.

::

Rehab is just great at exercise to restore strength, range of motion and control.

::

And it really is that simple.

::

Any questions?

::

You can hear me? Hi, Raph. Yeah. Hi, Ramsey. Hi.

::

Happy New Year. Thank you. Same to you. Thank you.

::

While we were in class, I've been in touch with a friend who's very,

::

very close for years. She dances with me, everything.

::

Anyway, she's had a wrist injury since a car accident going on three years.

::

And because I'm with Breathe and I mentioned you and everybody,

::

now she's listening to what I said.

::

So what you said in class today, I texted her. And I said, your wrist should

::

be stronger now than before the injury and not just as bad, if not worse.

::

She wasn't rehabbed correctly. So that was great.

::

She believes me now. She listens because I'm with you.

::

So I was able to give her that standout takeaway that her wrist should be stronger

::

now. Appeal to higher authority. Love it.

::

Nicely done. Nicely played.

::

You can also do that without appealing to me. I'm fine if you do that.

::

I read in the American College of Sports Medicine guidelines.

::

I said this is all science-based evidence. I said that with many,

::

many papers of research, and I'm paying $5,000 for it. I got a lot of great trainers.

::

Because of you and Breathe, now she's listening to me where I've been saying sort of these things.

::

But now she's receiving it, so that's a great, great plus.

::

And it stands out the way you all present when you present.

::

It just jumps out what are our takeaways. So it was real clear.

::

I heard it right away, and I had to text her because we were just talking about it the other day.

::

That's great. And I think it might also be, I suspect it is also, or maybe exclusively,

::

not that she knows or cares who I am,

::

but the fact that you are so confident

::

now in your knowledge that that comes across to

::

her maybe that's that's which is what

::

i said to you about doing our um mini essay over the same thing we had at the

::

beginning even though i said some of the same things i just felt so much more

::

confident i was able to add some of the uh the terminologies that we've covered

::

in our take takeaways so in my many essays.

::

So I said that to you, that it was a good idea to do that because it made you

::

feel much stronger and more confident with what we were saying from, say, September.

::

Great. Well, you're just doing progressive overload with learning how to rehab

::

people, right? You're just doing the reps and gradually doing more.

::

It doesn't have to be complicated to always keep it as simple as it is.

::

It's almost like it's the difference between honesty and complication,

::

which the medical field does. and even keeps the information away from people.

::

Yeah, thank you. Anna?

::

Hi, Raph. Well, I wanted to ask you maybe about like a case,

::

if it's possible, of a client, because it's like all together what you have

::

been talking in those weeks, especially about a whole person framework.

::

Like I've gotten a client uh who

::

who joined my Pilates math lessons group

::

all and she three years ago she had this bulge she had surgery and after that

::

she had rehab she's green of rehab and she heard from her physio that she could

::

do Pilates right so she started new lessons with me but she's fearful about

::

her spine and all the pain that she's still having and everything.

::

And I just, you know, encouraged her that we will keep moving and we'll give

::

it little by little, you know, little challenges.

::

And it was going okay. But last week she just said that, you know,

::

she thinks that she has had like too much pain in her leg and that maybe it

::

was a little bit too much for her and her back, you know.

::

I'm like thinking, you know, because maybe she's catastrophizing a lot about

::

her back and her spine and it's a big deal, you know. Or would it be that it's

::

more like that emotional phase?

::

Maybe it was too much because she is coming back as a beginner.

::

Should I even pay attention to that or just come back to see what she got into in the lesson?

::

Because it's difficult then from there, you know, to really want to keep on exposing.

::

So the 24-hour rule applies here, right? So if you've aggravated her symptoms.

::

You haven't done any damage.

::

But you know if our symptoms are aggravated for more than a day afterwards we need to do less and then,

::

gradually build her up again. And in specific, and we'll cover this in a lot

::

more depth in the spine module, but just to kind of peek ahead at that,

::

the things that are going to typically,

::

aggravate sciatica, so pain down the leg that's related to the back,

::

are going to be to do with spinal bending.

::

So now it's not always the case that bending forward is worse and bending backward

::

is better. Sometimes it's the opposite.

::

But often people find that bending in one direction makes it worse and bending

::

the other direction makes it better.

::

So, uh, so it could be a combination of just like how much she did,

::

but I would think probably more how much bending she did.

::

So, um, what I would do with her is something called directional test for directional

::

preference, which is a very simple test.

::

Just ask her to come in like five minutes before class one time or stay five minutes after one time.

::

Uh, and you just literally have her stand there and do like 20 forward beans

::

in a row. So I could literally just like.

::

Touch your toes, you know, it doesn't matter if she can't reach her toes,

::

just like, just fold forward, right?

::

Don't worry about technique, it's just like bend, okay?

::

Do that 20 times in a row, then stand back up.

::

How's your leg pain? Better, worse or same?

::

Right? If it's worse, then you know that forward bending aggravates her leg

::

pain, so just do less of that, right? If it's better, you know that forward

::

bending alleviates her back pain, so do more of that, right?

::

And if it makes no difference, well, forward bending probably doesn't affect

::

her leg pain, then do backward bending, right?

::

Lie her on her tummy, get her to push up into like a swan.

::

Again, no technique, don't tell her to activate this or that or just like bend,

::

okay? Do 20 of those, okay?

::

Stand up again, how's your leg pain? Better, worse, same, okay?

::

If it's better, backbending makes her better so do more backbending anytime

::

she gets pain let's jump down on the floor and do 10 or 15 quick backbends that

::

should alleviate your symptoms,

::

if it's worse then backbending aggravates her symptoms so let's do less backbending does that make sense?

::

Right. So most people, it's something like 60 or 70% of people find that they

::

do have a directional preference with sciatica and that's so either back bending

::

or forward bending will make it better.

::

Okay. And often the other one makes it worse. So just do that test.

::

If you find one that makes it worse, just say, great, we'll just do less of

::

that or maybe even none of that and we'll do more of the one that makes it better

::

and you can just keep doing everything else in class and you'll be fine. Right.

::

If neither of them makes it better or worse, right

::

it's probably just the amount that she did right

::

so just less you know just tell her to take a break drop

::

to her knees in the push-ups you know all that kind of stuff okay so

::

i can estimate that anyhow even over the healing times it can still happen this

::

kind of right so so sciatica sciatica pain in the leg is uh due to an irritation

::

of a nerve root in the low back and that can be a combination of disc bulge.

::

You don't even need like anything pressing on the nerve. It can just be inflammation

::

in there, which can result from, you know, a whole bunch of different things.

::

Could be disc degeneration, could be systemic inflammation, you know,

::

lots of different things.

::

Also, there could be osteophytes. So there's like so many different reasons

::

why she might have sciatica that, and for most people, sciatica goes away after

::

like two to three years, right? So she's in that period where it's probably

::

going to go away within the next 12 months.

::

But for some people it doesn't. Okay. And, uh, in any event you can probably,

::

you know, if, if she's lucky to be one of those, like 60 or 70% of people who

::

do have a directional preference,

::

you can probably manage it by just doing less of the direction that aggravates

::

and more of the direction that alleviates.

::

Okay. And if she doesn't have a directional preference, we just got to manage the load, right?

::

So just do less total work, less total intensity until it settles.

::

And then gradually build her up over time. Okay, thank you so much. No worries.

::

Sophia.

::

Hi, Raph. I'm curious about DOMS. I understand the 24-hour rule.

::

With DOMS, it'd be a different pain.

::

They get, my head is trying to think, is it delayed? I'm just going to say,

::

can that happen later than 24 hours?

::

Or can the pain be easily distinguished or because it's different?

::

Typically, yeah, good question. So typically, DOMS actually onsets 24 hours

::

after the session. So you, you

::

know, typically don't feel any pain in the first day after the session.

::

And then it's the next day when you, you start to get really sore.

::

So that what we're talking about here in relation to the 24 hour rule is when

::

it's painful during and then it's still painful after and it doesn't settle.

::

But whereas DOMS, it may or may not be painful during, often you can get DOMS,

::

you're just doing a workout, feels fine.

::

And then the next day you're like, holy crap, that was, I'm really sore now.

::

Right so doms may or may not be

::

painful during and it doesn't feel like inflamed it's

::

like sore muscles i mean you've we've all had doms right

::

so we know it's it's in the muscle right whereas

::

if you've had like a shoulder surgery you doms

::

won't be like in your shoulder joint here right but if you overstretch it like

::

you will feel the shoulder joint will feel inflamed and irritated and you know

::

stiff and all of that stuff same if you've had a back surgery or a knee surgery

::

or whatever it'll be like in the joint you know as opposed to muscular pain which is DOMS.

::

Okay looks like we're done almost anyone else got anything you want to ask or share,

::

great job enjoy your week if you've got a question in uh in slack i'll see you in there ciao.

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