Rehab & Training Part 1 - The Importance of Adherence.

A Little History.

There is a long history - dating back to the 19th Century - of using exercise and physical training as a conservative approach to rehabilitation. (Roth, 1860). Exercises were developed to assist with many health challenges including conditions such as scoliosis, other orthopaedic deformities and neurological conditions. There was no pretence that this was some “cure all” but a recognition that health and fitness had to be earned and a programme of exercise could be helpful for many conditions

Exercise is medicine?

Throughout history exercise has been recognised as a form of exercise. Remedial Gymnastics proved effective in developing fitness and rehabilitation in armed services personnel in the 1940’s. This activity was practiced as a professional activity until the 1980’s when Remedial Gymnasts were absorbed into the physiotherapy profession.

Once upon a time there were Remedial Gymnasts. Like many developments in medicine, the remedial gymnastics profession had its origin in times of war. In the Second World War, special rehabilitation units were created in the UK to deal with both unfit recruits to the armed forces and with the numbers of injured personnel who needed to be returned quickly to active duty. These units especially stressed a modified form of physical training which proved to be very successful.

After the war, the then Ministries of Labour and Health took action to ensure this process continued in civilian life and a course was created at Pinderfields General Hospital (as it then was) in Wakefield, as a school of remedial gymnastics. Originally this operated as a conversion course for ex-military physical training instructors. This was the origin of a profession, which became one of those covered by the provisions of the 1960, Professions Supplementary to Medicine Act.

The profession was always small compared with those of physiotherapy and occupational therapy. Over time, changes in the activities and clinical practice of remedial gymnastics brought it into closer alignment with the practice of physiotherapy, and a merger between the two professions was eventually achieved in November 1985.

Training and exercise applied to rehabilitation has received a lot of attention in recent years - due perhaps to the growing recognition of neuroplasticity, neurogenesis and technology designed to exploit it. This is all very positive and brings hope to those striving to recover from a neurological condition. Although many aspects of neuroplasticity still need to be researched, the “essential” ingredients are often stated as a need for frequent, intense and specific active and passive movements or exercise. This hints as a form of training or re-learning - encouraging recovery of function by performing a movement (with or without assistance) many times.

A number of facilities now offer intensive therapy programmes that promise to foster a degree of recovery for programme participants. We have clients who use technology to at least maintain a level of fitness at home and thereby reduce the risk of longer term health complications. We have seen clients make great progress by following these intensive programmes and others fail to make much progress. The problem is trying to unpick the factors that lead to success or to failure. It is not simple because so much depends on the client’s ability to “stick to” the programme.

Let’s explore this topic and think about it in the way an athlete thinks about training for a goal.

The Difference Between Exercise and Training.

Rehabilitation progress provoked by exercise will always tend to have plateaus. Let’s imagine that you have attended an intensive therapy “holiday” to provoke some physical recovery over a concentrated period. It might be a week - it might be a bit longer. Let’s say that you loved it and made some useful functional goals that met your expectations. What happens now though? Will you hang on to these gains?

If you think about it for a moment, you will need to commit to some form of ongoing exercise or training practice to maintain anything you have gained. Otherwise the benefits of that effort will almost certainly evaporate over time.

Non of us, disabled or not, can expect to exercise just once in a while and keep the strength and fitness we have gained for a lifetime.

The body’s “use it or lose it” principle kicks in. The body always adapts to the demands placed upon it - that is good news when the demand is created by regular exercise but not so good when our body adapts to a sedentary lifestyle.

Let’s distinguish between the terms ‘exercise’ and ‘training’ as they are often confused and then look at some principles that are likely to shape how effective exercise-based therapy is likely to be.

Exercise and training are actually separate concepts that are often used interchangeably. Exercise is physical activity that is performed for the effect it has today. Exercise is physical activity done for its own sake and for its value right now, and may well involve doing the same activities at the same intensity day after day. You could argue that this is what most people going to a gym will seem to do. There is nothing inherently wrong with this, and in fact may be necessary and sufficient to reduce the risk of secondary complications following a spinal cord injury for example. The participant experiences a particular level of fitness, probably enjoys themselves and may be content with that.

Training is directed toward achieving a particular improved performance goal in the future. Athletes will train with some future goal in mind and must follow a systematic process for a long time. This is a process that aims to stimulate the body systems that then adapt over time to the particular stimulus provided. The specific nature of the process matters if results are to be achieved. Someone training for a marathon will not use the same training process as the weightlifter. We can train to gain cardiovascular fitness and strength, or particular skills in movement coordination and muscle size for example, but the specific nature of the training programme will always have to vary depending on the goals. Just as in rehabilitation, athletes look to hone what they do to achieve a specific result.

When someone has prospects for rehabilitation and functional gains then they need to think of what they are doing as a training process with a goal rather than exercise. Goal setting in rehabilitation is not easy though and even clinicians dont always know what is possible. Let’s assume that training is at least going to be safe and worth trying, what additional actors should be considered?

The Training Process.

If we were to consider a hierarchy of ingredients of any training process it might be something like this (Helms, 2019).

What makes up a good training programme?

In order of priority are the following components. Helms described this as a pyramid with the items of the most importance at the base supporting the others. As we will discuss, Adherence is absolutely fundamental and we will discuss this below. The additional items we will describe across a series of articles.

1. Adherence

2. Volume, intensity and frequency of training

3. Progression

4. Exercise selection

5. Rest and recovery

6. Tempo

Spanning and supporting each of these components is the concept of ‘periodisation’ and we will get to discuss this too in a later article.

If we think about what we have learned about neuroplasticity, the parameters we seem to have to influence in rehabilitation are fairly similar to those listed above. In simple terms, this is the intentional manipulation of training variables over time to achieve specific goals. Training for physical rehabilitation depends on tapping into the body’s natural ability to respond and adapt to an applied stimulus.

The “task specific, intensive and frequent” mantra is often used to describe the necessary approach to make gains in rehabilitation. Well, periodisation is how a strength and conditioning professional expresses how training should be structured to allow the body to adapt and grow fitter or stronger over time.

Before spending time thinking about the nuts and bolts of a training programme to recover function, we need to deal with this fundamental issue of adherence.

Adherence to Exercise.

As we mentioned above, there is no point in committing to an intensive therapy period without also recognising that training to achieve a functional goal is a journey that must be continued consistently for a period of time to produce meaningful results. A potential problem with this in the state of the art is that clients may not have the time or money to be able to commit to a programme long enough to get results. No one I met ever complained that they got too much rehabilitation. However, I have met clients who found striving for recovery to be exhausting and the most demanding thing they have ever attempted. What is going to help these clients stick at a programme long enough to get results?

Adherence is the foundation of everything in training and basically we humans are only likely to stick at something if certain conditions are met. There is no point designing a programme that the client cannot commit too. The basic conditions are

1) Is the training plan realistic? - You might have a particular functional improvement in mind but you will need to have the time and resources to commit to this training otherwise you are not going to be successful. Is the training facility miles away and expensive to attend? If it is, the plan may not get off the ground.

2) Is it likely to be enjoyable? - Some people I know are “hard core” and are able to focus on a distant, abstract goal and keep going until they achieve it. This is typical of athletes and sports oriented people who are comfortable with working hard toward achieving a goal even when the odds seem to be stacked against them. The majority of us are not like that and have to work at finding the passion to keep going. A realistic appraisal of your ability to work towards a goal might be important to how you can commit to a particular training plan. Do you work best in a one-to-one situation with a trainer or would you thrive in a group environment, for example? I have seen people training in Andrew Galbraith’s Prime Physio that thrive on the community and sense of purpose of the group. This group training energy can be great for some people but may not suit others. When a therapist can act as an effective coach this can be extremely valuable.

3) Is the plan flexible? - As you are likely to need to work at improvement for the long term there will be times when life gets in the way. No one wants to spend their life in therapy all the time. Does the plan allow for the unexpected? What happens if your energy levels are low one day?

What. It. Takes.

The fact is, training needs to become a habit if goals are to be achieved. We have to be able to make the behaviour something we just “do” - otherwise results are not going to be forthcoming.

We can feel inspired to attend that intensive therapy session but unfortunately inspiration can be very short lived. We can be inspired by the words and deeds of others but that won’t last unless we see results for ourselves. We can hope to find motivation if we sense progress is being made but motivation is hard to sustain for the long term. A coach (therapist) can help provide this to some extent and we can certainly all “feel” motivated but sooner or later this will not be enough.

We can use inspiration and motivation to find the discipline we need to make training a habit. It’s doing the work long enough that we just do what we need to do without always needing that flash of inspiration or motivation. The world class athlete and the person recovering from a neurological condtion must make training a habit to succeed in achieving their goals.

We have some great technology available to assist rehabilitation and our knowledge of how to deploy it is improving all the time. However, It is easy to forget the fundamentals. No matter how special the technology we should recognise the principles of training still apply.

In the next article, we will examine the issues of volume, frequency and intensity of training.

References.

Helms, E; Morgan, A; Valdez, A. (2019) “The muscle and strength pyramid” ISBN 9781090912824

Roth, Mathias (1860) “Notes on the movement cure, or remedial gymnastics, the diseases in which it is used, and on scientific educational gymnastics. Original Publication - Groombridge & Sons. 1860. Persistent URL https://wellcomecollection.org/works/aum6e3tu