Injuries Tend to Happen at Speed

Early in injury rehab it is necessary to respect the healing pathology and prescribe exercises of low loads, done slowly.  These movements can be repeated many times as the muscles don’t fatigue quickly which is good as we are also training a movement pattern.  For example a slow step down or a shoulder external rotation with light theraband.  We PTs are very good at this level of intervention and our knowledge of pathology, healing and loading puts us ahead of the pack.  And if our clients only ever returned to slow and light movments we would have done a brilliant job.  But they don’t.  For reasons only understood by them many clients go back to fast and heavily loaded movement patterns in their jobs and sports.  And again we PTs see this coming and usually prepare them for more vigorous activity.  What about the ‘everyday’ clients?  What about those who may not aspire to fast moving sports or heavy loading at work or recreation?  Do they need more aggressive late stage rehab? I believe so.

Slow and light exercises with reps of 20 or more to fatigue per set do a great job of training slow twitch oxidative muscle fibres.  These fibres are important for posture, slow positional changes, slow movements and static activities.  However, injuries (and re-injuries) happen at speed.  Quads tear during acceleration, hamstrings explode under high speed loading, rotator cuffs tear at speed or under heavy body weight loading.  This last example is a good one – everday cuff tears (degenerative tendons, fatty infiltration, chronic changes then bang!) are easy to rehab slowly: training the slow twitch fibres of the cuff and larger shoulder muscles in the clinic gym and at home to cope with slow and light activity.  Then six or twelve months later something happens – they slip and grab a stair rail; they catch the tip of the 4-iron on a tree root; they quickly reach to catch a falling grand-child; or they try to lift a heavy bag of garden mulch.  In these situations their slow twitch muscle fibres are overwhelmed by the speed or load and their fast-twitch buddies are called into action to make up the necessary torque to complete the action.  If these fast twitch systems haven’t been well trained these clients are exposed to increased risk of re-injury.

So what is the message?  Rehab for the unexpected loading, not just the normal activities of life.  Likewise if you are delivering pre-hab or preventative programs, always include fast, change of direction, altered loading patterns to recruit the fast-twitch system alongside the slow twitch.  In the shoulder this would start with open chain activities such as Body Blade or ball tap, starting bilateral and progressing to unilateral.  Short sharp sets of exercise with rapid change of direction work.  When control is demonstrated, progress to loaded closed chain such as shallow wall falls, heavy punch-bag pushes, wall catch and perhaps even plyoball catch and toss.  Include some heavy lifting drills to build muscle mass and the combination is a potent risk reducer for post traumatic shoulder clients.

I know many of your clients are not trying out for football or hoping to go rock-climbing, but the unpredictable hazards of everyday life can be just as risky.  Remember, they managed to hurt themselve once and that was in their pre-injury state.  We owe them our best professional efforts to make them as ‘life-proof’ as possible before they leave our care.