Bridging the Gap from Rehab to Performance – Part 5

Part 4 of this series from Bridging the Gap from Rehab to Performance continued an exploration of the first segments of an organizational system to care for patients/clients from table to field: Pain Generator, Motion Segment, Psychomotor Control, and Somatosensory Control, then moving from clinical to the functional and performance related segments.

In this post, we’ll conclude the topic of PERFORMANCE – SEGMENTS OF THE ORGANIZATIONAL SYSTEM.

Shifting between a Medical and a Performance Model
This is one of the most difficult concepts to present. There is no single defining point where an athlete is doing rehab and then making the transition to performance training. Our athletes may be rehabbing an upper-extremity injury and at the same time be performing lower-body performance training to minimize atrophy and maintain the ability to produce power in the legs while still protecting the injury.

Although the bridging-the-gap model seems like a continuum, it is actually more of a checklist. Your athletes do not need to pass one stage before moving to the next. These elements do not have to happen in a certain order, with the exception of addressing the pain generator if there is one. Pain will affect all aspects of the biopsychosocial model and needs to be dealt with immediately. With that exception, everything else may be worked on at any point in the process of returning to play, but these all need to be addressed at some point prior to returning an injured athlete to the field.

However, there are plenty of athletes playing while in pain. While the bridging-the-gap model acknowledges that pain should be dealt with immediately, this idealistic suggestion may not be a realistic expression of what occurs every day in sport. People participate while they are in pain—they do it all the time. Hence, this model is not a true continuum, but more of an ideal, theoretical progression that recognizes the need for flexibility toward a given athlete at a given time.

The first four categories of Pain Generator, Motion Segment, Psychomotor Control, and Somatosensory Control live under the medical model. We typically address these areas under the supervision of a health care provider with a focus on improving pain, normalizing a system, and preparing for the higher-level activities of the performance model. These four areas deal with the fundamental building blocks of performance.

Somatosensory Control, Fundamental Performance, Fundamental Advancement, and Advanced Performance are part of the performance model. These typically build and fine-tune an athletic body after laying the foundation.

The overlap of the two models comes from the nervous systems. Somatosensory control—the afferent nervous system—is the underlying key to everything. It will be difficult to build total-body strength and power, athletic movement, and athletic skill in a person who is in pain, lacks proper mobility and stability, and has poor body control.

Athletes always want to be in the performance model. Athletes will come to you with goals such as “I want to improve my first-step quickness,” yet have horrible hip mobility and cannot get into the fundamental athletic positions needed to improve first-step quickness. Restoring the motion segment might be necessary in the immediate stages of intervention. Once the motion segment is improved, first-step quickness improves because you have addressed the weakest link in the system.

Philosophies and techniques that are more on the medical model side of the continuum improve the performance model without doing anything related to performance.

Think of the medical model as the foundation for a new house and the performance model as the actual house to be built upon that foundation. Can you build a house on a bad foundation? Of course you can. However, you will be limited as to how many stories the house can have, how big the house can be, and how long the house will be able to withstand the elements. You can build a house on a bad foundation, but it is not advisable.

Likewise, building performance on an injured, broken system is possible, but it is not advisable.

Creating a Return-to-Play Timeline
People in our fields often work without a plan. Could you imagine getting on a flight and having the pilot not follow the preflight checklist and executing the flight plan? Alternatively, imagine trying to build a house without plans. Plans direct us where to go. They force us to go through the systematic processes to ensure we do not skip a fundamental step that may be nearly impossible to fix later. Creating long-term goals with short-term goals to be met along the way will ensure that you give your client ample time to adapt, and these allow everyone to see the roadmap they will be traveling along. If anything veers off course, the end result will change.

Let us use a soccer player returning to the field after a knee injury, whom we would like to have back on the field in a game in three months. We need to look at the schedule and see if there is time to set up a simulated game or a friendly game that may not have much at stake. We aim for some type of lower-intensity, full game activity one week prior to the athlete’s real return to see how well the action of a simulated game is tolerated.

Once we determine the day, we know to plan short games first, playing with a full team of 11 on each side but with a shortened field so there is less running. We might want that to happen one or two weeks prior to a full pitch, simulated game. Prior to that, we could schedule a game with shorter distances on the pitch and with fewer players on the field to focus more on offensive or defensive plays. We want that to happen a week prior to playing with a full team on each side.

Prior to this, we would plan offensive or defensive drills with some light contact and before that drills without the possibility of contact. Earlier, we would have used drills that do not require critical thinking—just movement execution—and before that, we would use multi-directional movement skills specific to soccer while using a ball.

Before that, the athlete needs multi-directional movement skills specific to soccer but without a ball. Prior to that, we would plan linear movement with and without a ball. Before performing linear movement, we need to see full strength and the ability to develop power.

To do this, an athlete needs full mobility and stability throughout the motion segment with good psychomotor control and somatosensory control.

Prior to all of this, our athlete needs to be free of pain.

By the time you work backward through that entire scenario, giving the athlete plenty of time to adapt to the new stresses, you may find that three months is not enough time to return the person to play. If you were to attempt it, the progressions would have to be extremely aggressive, and there is no room for issues in the process. If there is an increase in pain or swelling at any point, you would need to take a step backward, and the long-term goal of returning to the field would be delayed.

Reaching your short-term goals will culminate in achieving your long-term goal. You cannot achieve long-term goals without covering the short-term goals along the way.

From a clinical standpoint, we have to make our findings and explanation of dysfunctions meaningful. When we are evaluating a patient and decide we see a weak glute medius . . . truly, who cares? Why should anyone care that the glute med is weak? Well, a weak glute med will result in poor hip mechanics, possibly resulting in synergistic dominance of the TFL and decreased power production at the hip, overloading the lumbar spine or knee. Once we relate the objective dysfunction to a functional limitation, we can create a goal: improve glute med strength. Once we have a goal, we can create a plan. The plan should include glute med strengthening exercises.

Every objective dysfunction should have a functional limitation along with a short-term or long-term goal with a plan to achieve the goal.

To be sure, I always tie an objective dysfunction with meaningful information (I include this in the chart found in Appendix Two of Bridging the Gap from Rehab to Performance.) This keeps me honest in making sure every objective finding has a plan for improvement as well as making sure every dysfunction is attached to a meaningful functional impairment.

Don’t identify dysfunction for the sake of identifying dysfunction. What does the dysfunction mean? How does it affect the patient’s life, and how are you going to fix it?

Clinical Pearl

  • Identify an Objective Dysfunction,
  • Attach It to a Functional Limitation,
  • Determine a Short- or Long-Term Goal for Improvement, and
  • Create a Plan to Fix It.

Create realistic timelines for your athletes to adapt to the new stresses you are introducing, and build in some recovery days to allow for rest. Work backward from the long-term goal to give you, the athlete, and the coach a realistic timeline for return to play.

Bridging the gap from rehab to performance does not follow a linear continuum. If we wait for all football players to have perfect fundamental performance and somatosensory control, we would all be staring at a blank television on Sundays. Nor are the sports medicine and sports-performance elements of athletic rehab going to be perfect progressions. We might be working in several of these phases at the same time and might have to regress certain exercises to ensure quality movement patterns. The organization of the bridging-the-gap model should help you and your team understand where each intervention fits and that this will not necessarily be a linear progression.

It is your job to figure out the best way to combine your education in the most effective and efficient ways possible to get your athletes back onto the field. I hope the material presented in Bridging the Gap from Rehab to Performance will help you do exactly that. That is the beauty of this system.

You do not have to choose one person to follow or need to follow a specific system. If it had been proven that just one system worked, we would all be doing it. Everything fits. Everything has its place. Your choice in each instance is dependent upon the individual athlete in your care.

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