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One of the biggest disparities I see between performance based programming and rehabilitation based programming is that a performance based program is largely centred around macro planning whilst rehabilitation based programming could be considered to have more of a micro planning focus. This can be furthered by outlining that performance programs gravitate towards what I consider a 'bottoms up' approach whilst rehabilitation programs gravitate towards a 'top down' approach.
Whilst there are inherent advantages and disadvantages to each particular model and that elements of both need to be adopted when creating a rehabilitation plan for an athlete, I feel too often in the rehab world that practitioners weight their programs too heavily towards a top down approach without considering the overall context of where their interventions sit in the overall timeline of the athletes journey.
I understand that the rigidity that a bottoms up approach will not fit practically into an athletes rehabilitation journey as there are many variabilities in regards to tissue healing time, athlete compliance and health variability that may affect an athletes ability to progress or stick to the proposed timeline. These create consequences that are not present in a performance based program where if an athlete is progressed simply because their 'designated training blocks' have finished then they may enter phases of rehab that they are not suitable for. Yet I believe that too many practitioners create too much variability of their rehab programs by changing interventions without allowing adequate time for physiological adaptation to occur. Furthermore, this creates a fixation with what exercises an athlete is doing and a detachment from arguably a more important component... How an athlete actually performs their exercises.
The benefits that a bottoms up approach to rehabilitation can provide is that it can create context to then mould your training blocks, sessions and interventions based upon outcome goals.
For Example:
Outcome Goal: Tissue Healing & Restoration of Biomechanics
Expected Timeline: 3-6 Weeks
Exit Criteria: Full ROM, Nil Effusion, Normal Gait Patterns
Interventions: ROM work, Gait Retraining, Muscle Activation Strategies, Swelling Management Strategies
Suddenly you have created yourself a phase of rehab, have outlined an expected prognosis to keep your clinical reasoning accountable and then have themes for your intervention choices. This will allow you as the practitioner to trim the fat away from your programs and ensure that you are only prescribing interventions that match the goals that you have outlined for your athlete at that point in time.
Now the important point to consider here is that phases of rehab don't act in isolation. They should be directly influenced by what the outcome goals are of the proceeding phase of rehab. Thus we are now directed to reverse engineer the process; decide what a fully rehabilitated athlete looks to us and then break it down into smaller bite sized chunks with outcome focused goals.
I've attached an example template of what you may consider when creating a timeline for an athlete. There are no right or wrong ways to create different phases of rehab and an overall journey, as long as you are considering key pillars of:
Tissue Healing
Load Introduction
Reconditioning
Return to Training
Return to Play
Factors that you may consider when creating your timeline and phases of rehab include the following:
Focus - What are the outcome goals of this phase of rehab?
Weeks - How long is the expected phase of rehab?
Block - How do I split my expected weeks of the phase into periodised training blocks?
Goals - Physical goals relating to the athletes morbidity level of their injury i.e. Increase ROM, Restore gait patterns, Increase hypertrophy etc
Strength - What is the focus of the strength training? Are they modified in any particular way?
Off-Feet Conditioning - What modalities can / should an athlete be using? If any?
Running - What element of a Gait Mechanics continuum is an athlete up to in their journey to return to run. I challenge all practitioners that they can be doing running mechanics work the moment the athlete is allowed to weight bare
Skills - How can I implement tactical skills safely into the athlete program? What are they doing?
Contact - Where does the athlete sit in regards to a return to contact continuum?
This is a non-exhaustive list of options that you may consider when creating an overall timeline and furthermore, phases of rehab. It is important that whatever system you create resonates with your practice and strengths. Hopefully reading this today has made you consider more than just 'the rehab exercises' that you are prescribing your athletes and that long term sports rehabilitation should be planned from start to finish so you always know where you are, where you came from and where you are going.