Progressive Overload: A Strength Training Model for The Rehab Professional


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By Teddy Wilsey, DPT, CSCS

It is well known that the body must be broken down in order to build up. This is the fundamental principle of exercise: stress adaptation occurs in order to strengthen our bones, condition our cardiovascular system, maintain our joint range of motion, and optimize our muscular function. If you don’t use it, you will lose it. This idea of invoking stress is an area that rehabilitation professionals often fall short in. The physical therapy curriculum is designed to prepare a generalist who can work with all levels of patients including pediatrics, hospital work, and neurological rehab. These are all very important aspects of healthcare, however, the major downfall of a generalized therapist degree is a lack of knowledge in sports rehab and basic strength and conditioning. This article will touch on the need to stress the system in orthopedic rehabilitation and the idea of progressive overload within a linear periodization rehabilitation model.

Performance is a relative term, as the performance ceiling for a 75 year old recovering from a knee replacement is vastly different than that of a college basketball player recovering from an ACL rupture and patellar tendon autograft. Either way, they are both knee injuries and the principles remain the same. Regaining quadriceps strength will be an integral part of both of their programs, and the exercises might be very similar at the beginning phases. As mentioned in the introduction, physiological adaptation and increases in performance require stress to the system. It’s important to understand that stress is relative. An exercise or weight load that might cause stress and elicit strength and gains for the 75 year old would probably not be of the same benefit for the college basketball player. This same weight could even create negative adaptations over time if it is not sufficient to stimulate the system. For example, if a 400 lb. squater is only doing goblet squats with 25 lb., they will actually get weaker while working with you.

The therapist’s job is help their patients increase function. From an orthopedic recovery standpoint, therapists must cause some amount of stress in order to help their patients improve function. Most therapists typically see their patients for 2-6 months at the most, depending on the injury. Although linear progress is not a long term solution to training, it lends itself well to this shorter time period and rehabilitation type of recovery where exercise selection is constantly being progressed. Strength and conditioning periodization models are helpful to understand from a theoretical standpoint, but are typically more complex than we need for therapy. In the simplest of terms: just make sure your patient is doing more than they were two weeks ago.

To examine progressive overload, stress, and a linear model, let’s look at integrating the squat into rehabilitation for both of these patients. Outside of gait, the squat is arguably the most functional movement that exists. Standing up is an essential skill for nearly everyone. To start with the 75 year old patient s/p total knee, their sit to stand would likely begin with an upper extremity assist and a very short range of motion to a high box. Loading the knee will assist in gradually restoring range of motion and alleviating stiffness. Manual therapy, stretching, and other passive modalities can help with managing pain and improving range of motion as well. This patient’s knee will likely be stiff, and the soft tissue structures surrounding the knee may be weak and shortened as well. The typical arthritic knee experiences months to years of progressive weakening and range of motion loss prior to surgery. Rehabilitation prior to surgery should focus on maintaining and regaining full range of motion and improving strength to tolerance.

The first day or two after surgery for these two patients might look very similar. The college basketball player ACL repair will also start a squat with a TRX. After the second or third PT session, the college athlete will require much more challenge to make progress. They might be more comfortable achieving parallel depth sooner, as their tissue was supple prior to surgery. In this patient, there will also be a need to be emphasize slowly increasing the stretch across the patellar tendon. This is due to the patellar tendon autograft. The squat will start with a vertical tibia, and the therapist will gradually cue the patient and modify exercises to allow more dorsiflexion and knee flexion over time in order to rebuild the surgical site and increase patellar loading.

By 6-8 weeks, both of these patients should be squatting with weight. The total knee might be nothing more than 10-20 lb. goblet squat, or it could be up to a 50 or 60 lb. goblet squat, depending on their prior function. The basketball player might be in that 40-60 lb. range for a goblet, or even back squatting 135 lb. or more. Again, this depends on prior strength levels.  Both of these patients should be exposed to similar relative stressors. They should both feel muscular soreness at times. They might both even feel some increased knee soreness during periods of introducing new movements or taking big steps forward. That’s usually OK. The important distinction here is that the stress for a college athlete’s rehab needs to be significantly higher than that of a knee replacement patient in order to evoke adaptation.

Rehabilitation professionals often fall short in is creating enough stress and adaptation for their higher level athletes. The typical outpatient therapist’s caseload is probably only 10-20% athletes, at the most. Hence, the potential blind spot and need for a greater understanding of how to help challenge athletes. The concepts are the same across the board, but there needs to be a greater understanding of the nuances of higher level and more challenging exercise and movement. Remember, without stress and progressive overload, there is very minimal adaptation.

To learn more about how to challenge athletes and what exercises to use, check out my instagram at @strengthcoachtherapy.

Healthy-Baller-Teddy-300x300Dr. Teddy Willsey, DPT, CSCS, is the director of sports medicine at Healthy Baller, a sports performance gym located in Rockville, MD, a suburb of Washington D.C. In addition to his daily practice, Teddy writes, speaks, and posts on social media regularly with the goal of educating therapists, fitness professionals, and recreational exercises on practical approaches to exercise and rehabilitation with a sports medicine and performance focus. Teddy’s work can be found on Instagram: @strengthcoachtherapy

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