Physio Network

[Physio Discussed] Strength & conditioning in rehabilitation: key tips for clinicians with Dr Claire Minshull and Lachlan Wilmot

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In this episode, we dive into the topic of strength and conditioning in rehabilitation. We discuss:

  • Ways to monitor athletes/patients during their rehab
  • Best pieces of S&C equipment for physios to have in the clinic
  • How physios can improve their S&C prescription
  • Challenges with loading in rehab
  • The role of rate of force development in rehab

Want to learn more about strength and conditioning? Dr Claire Minshull recently did a brilliant Masterclass with us called “The Practice-Changing Principles of Strength & Conditioning for Physios” where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial - https://physio.network/masterclass-minshull

Dr Claire Minshull is an internationally respected tutor, researcher, and consultant specialising in musculoskeletal rehabilitation, strength and conditioning and neuromuscular training. She has a PhD in neuromuscular physiology and has worked extensively in academia, clinical practice, and elite sports. She is currently Visiting Professor at Leeds Beckett University and Claire’s expertise lies in bridging the gap between rehabilitation and performance, particularly in optimising muscle function.

Lachlan Wilmot is a leading strength and conditioning coach with over 20 years’ experience working across elite sport and athlete development. He spent 8 years as the Senior Athletic Performance Coach specialising in strength and power at the GWS Giants AFL Club based in Sydney, after previous involvement with the AIS-AFL Academy and NSW/ACT AFL Academy. He is now the Director of Coaching and Performance at Athletes Authority, co-leads performance for the NSW Swifts, and sits on the board of the Australian Strength and Conditioning Association. 

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Our host is @James_Armstrong_Physio from Physio Network

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SPEAKER_01:

What is the best method of monitoring and measuring the rehabilitation of our clients? Strength versus rate of force development. Why does it matter and how do we assess it? We explore these questions and more today, and we're joined by two leaders in the space. Dr. Claire Minchul is a rehabilitation and conditioning specialist, researcher and visiting professor at Leeds Beckett University in the UK. Claire holds a PhD in neuromuscular performance rehabilitation science and has published over 30 papers primarily on strength and conditioning. Claire also runs Get Back to Sport, an education platform helping clinicians apply science in real-world practice. Loughlin Wilmot is the co-founder of Athletes Authority and brings a wealth of experience from elite sport and high performance environments. Known for his practical and progressive approach, Loughlin helps bridge the gap between rehab and performance, with a strong focus on structured loading, testing, and long-term outcomes. In this episode, we dive into how physios can take their rehab programming from good to great, with better testing, better planning, and a clearer understanding of the physical qualities that matter. So let's get into it. I think you're going to love today's episode. I'm Sarah Yule, and this is Physio Disgust. Welcome, Claire, and welcome Lochland. Thank you both for joining us tonight. I'm really excited to sink our teeth into this topic. I think it's a really important topic for the world of physios, osteos, kairos, all of our listeners.

SPEAKER_00:

I appreciate it. Thank you for having us.

SPEAKER_01:

Yeah, absolutely. Yeah, delighted. I should also say SNC coaches as well. So we'll we'll dive straight into it. My first question is what's the best method for monitoring and measuring the rehab of our clients?

SPEAKER_02:

Well, that's a massive area. I don't think there's a single answer to that. I think for me, whenever I'm asked that type of question, it comes back to what is it that you're trying to change? And that is some of the basic, I suppose, principles of strength and conditioning, exercise training, rehabilitation, what indices of performance or what metrics are you trying to change? And then you can start to look for those tools or those metrics that you want to apply to judge progress. So I don't think there's a single uh way of being able to assess that. So it's it's multifactorial, isn't it? That's going to be, you know, if you're thinking about physical performance, where you can easily measure strength, or sometimes we can easily measure strength, and how accurately that's another question. You've got like kind of strength and you've got um some of the later kind of stage stuff, maybe power and stuff like that. Earlier on, maybe you're looking at range of motion, and and then there's also like the psychological component as well, isn't it? How is that athlete feeling? The kind of kinesophobia, that type of thing. So I think for me, the start point is establishing that hierarchy of importance. What type of things do you want to change, or what are all the things that you want to change, and kind of list them in a well, put them in a list and then put them in order. Like what are you gonna focus on first and foremost, then kind of using that periodization principle really, and then what you're gonna move on to. Then start to think about what are the tools that we've got in order to be able to measure progress andor success.

SPEAKER_00:

From my perspective, it's spot on exactly what Claire said. It's such a a huge open clamshell of discussion that you could have, so to speak. But for me, it's the most consistent. At the end of the day, you can you can work in a very high-budgeted, high performance program. You can have you know, Humex, Cybex testing, you can you can have kinematic, you know, Vicon systems set up, and that's fantastic. But if that's what we do do with the gold standard, then yeah, 99% of people have no hope if that's the case. And and we know that's not the case because we we can have some fantastic outcomes from some very basic things. And you know, thanks to people like Vold that now have subscription like model technology, if anything, it's almost the other way. Yeah, people probably have too much access to technology and they don't actually know what they're looking at and they get confused and they feel that they have to keep up with the Joneses and do this and that. And I think as Claire kind of alluded to, let's just start at the beginning and at the end of the day, it's it's it's principles over anything. And if I'm taking rehab and you know, being an SSC coach, I I certainly dabble in, but don't lead that that early stage. But it's okay, well, if it's range of motion, that's that's the overarching principle, range of motion. How we measure that, you can do it with a video, an eyesight, a gyneometra, or you can you can do a 3D motion capture on everything if you want. We're still measuring the same thing, and I think that underpins everything we do. You know, we Claire mentioned power, and power's unbelievable, but you could do a a simple hop, uh a three-hop, and and requires nothing. Or, you know, you can get them on a humac and just get them unleashing, and you can get every data point, you can put them on a 3D capture camera and a force plate measuring every angle, and and you're still getting power, but you know, you're probably giving yourself more opportunity and more things to delve into. And um, I I've seen some of the greatest rehabs done with very little equipment, but just a very good practitioner that knows what they're looking at. And I think there's probably uh a slight bit of, and I know a lot of physios probably can relate to this, that I think we probably need to start a lot of your ventures without the technology to train your eyes a lot more before you get the technology. Coaches and physios that start with tech day one, they probably get a bit lazy, and I probably sound old saying that, but you do you get so used to looking at at data points that get spat out, you you're looking at iPads, you're not watching the person jump, you're letting it tell you things. And that's not to say that it's wrong. It's just probably to say that if you are ever in a field environment where you don't have the tech and stuff like that, you you probably don't have the coach's eye to be able to make decisions on the flyer as well as someone that potentially has done a lot more rehab without all the tech. So probably rambled there a bit, but I think at the end of the day, it's the principles of what you want to chase, as Claire said. And then depending on the environment you're you're in, I don't think there's a better or worse way. It's what's consistent, repeatable, what can you afford? Because if you can only do one HUMAC test, maybe it's not the best option. You're probably better to go back to some grassroots with things that you can repeat six or seven times throughout a rehab length.

SPEAKER_02:

If I could just pick up on a point there, because I think it's current right now, which is on, and I agree violently with you. We've got so many devices available right now, and lots more now in the affordable range for individual um clinicians in clinics. And I think there's also maybe a feeling, a sense of I need this device because I need these numbers. And you know, my teaching has now opened up into the field of assessment and dynamometry and measurement science because I think it's now ready to be received. Because just because you have a number, it doesn't mean anything. You need to know how that number was generated, what's the measurement area associated with that, how often can you take that? Are you testing in exactly the same way each and every time? And if you're not, then that is redundant, that test is redundant. So we shouldn't be chasing the tech, we should be rolling it back to basic principles and thinking about what is it that I really need to change with this person, with these groups of individuals, with my patient populations. And then how can I best achieve that in terms of assessment, which may or may not include dynamometry, tens, hundreds of thousands of pounds worth of kids. Because everything that we do needs to be understood and properly delivered. So as a clinician, and to that point about being able to use your eyes and your yeah, inherently your clinical judgment and your experience, that's invaluable. That will be better than an objective test done poorly. So I think just to say that don't chase the tech because it's needed by ever, you know, we will feel the pressure to have it, by all means, and I'm I'm a great advocate to achieve object measures if they're done well. And let's learn how to use the tools because they can be fantastic in terms of giving you data. But that shouldn't be the thing. It should be what is it that we want to change? How can we seek to evaluate that? What uh experience do I have? What time am I able to invest to learn how to use these tools, techniques, etc.? And again, back to affordability. So a little bit of extra, I guess, points on that.

SPEAKER_01:

I think those are fantastic points. And it probably goes all the way back to your original opening line, Claire, which was about intentionality. I think we we care about what we measure and how much we're measuring, but are we actually measuring exactly what we care about? And just on that, I'm curious because I've noticed we have all of this capacity to measure with Vald and do all of the strength tests. Do you feel like we, because we have that ability, do you think we're measuring at the right time frames after actually allowing a rehab program to have a proper effect before we measure again?

SPEAKER_02:

The critical thing that we really, really want to get that is almost impossible to get is pre-injury data and when that person was flying. So we've established a baseline and we've got a marker that we can aim to get back to or exceed. And that's always going to exist. So that means the earlier we can test, the better. The caveat being quality data capture, standardized test, done well, and we know what we're assessing. So the earliest point that we can obtain quality data enables then some sort of comparison. And I'm not saying it's the thing that we should be aimed for, but it gives just you start to build that picture. As Lackie was saying before, the number of tests then you can obtain, you start to build a profile and an understanding and a and uh, I suppose a picture of how that individual started out and is progressing. So, you know, a single test in a moment of time, even if you're doing like an interlim symmetry test, ratio data doesn't really tell us anything because we lose sight of absolute performance and performance change. So a single test in one moment of time might give us a little bit of information that might feed in a little bit to our clinical decision-making rehab pathways, whether you're returning to play or not. But we need more than a single assessment and we need to start think about assessing over time. And there's many ways you you can do that commensurate with your rehabilitation programming to the start prior to surgery. If there is a surgery, as soon as you see somebody following uh if they're injured, and then if they're in pain or if it's inappropriate to have load heavily the naively injured tissue, then you know you need to rethink that a little bit. Maybe you can get a measure of the non-injured affected side, etc. Again, coming back to that profile of that person and the time frame of rehab and recovery.

SPEAKER_00:

From a performance standpoint, and applied to rehab as well, but there's two and a half reasons why you test. One, to influence your program, two, to store data in your back pocket because you know someday they're going to get injured and you're going to use it. So in our in our facility, we have both performance and rehab, and all of our performance athletes, as good as we claim we are, they'll eventually get something. We hope it's little, but they'll eventually get something. And the history of data that we have to be able to look back on to guide their return to play and performance is second to none. And we really value that. As Claire said, it's so hard. You usually get them when they're injured. You wish you could go back and get it. So we kind of, you know, go back in the future and make sure we do collect it. And the half reason is if they've got a combine test or their sport demands something. And sometimes you're just handcuffed and you've got to get them good at that lap that lift because that's what they're going to be judged on. But the caveat to all of that is if you can't repeat it, then does it come back to the gold standard? If I'm running a team and I have all these amazing technology options that I can use and we can do all these tests, but it doesn't really influence my program. Plus, I can't even repeat the thing because it took me two days worth to try and get through all 50 athletes in these tests. Well, I can't repeat it. So it's like, well, the there's really like very few reasons why I would do a test that I can't repeat. And I think that's very similar to the rehab space. The tests you're picking, with the exception of some range of motion ones and sort of clearance stuff, you kind of want this tracked over time because you want to be able to establish that your program is influencing this outcome. And we used it for entry exit criteria, whatever you want to refer to it as. And then you test it again, it's closer and closer. And then, yes, you can layer in some later stage tests as you go. But yeah, as I said, apart from a couple of early stage range of motion things that I might tick off, very few tests will I ever only test once. You've got to have the capacity to do it multiple times. And and I think that guides what tests you use because you can't use 27 because you can't repeat 27. You know, when you have these type of filters, I feel like you you ultimately get handcuffed. It's the same as when you're told, you know, this athlete can train twice a week for 40 minutes. Well, guess what? My choice of options is now handcuffed, and that happens more often than not. And it's uh the same in the rehab space. You you've only got a finite amount of tests or time or whatever it might be. So the the best practitioners get the best bang for your buck options, and they don't they don't convolute everything with a a thousand different things and they test once or twice. Yeah, it sounds cool, but doesn't really apply very well.

SPEAKER_02:

I think that's a really, really important point there. You just said that the best practitioner will give you the best bang for your buck. And that's something I'm really passionate about trying to help clinicians, rehab professionals understand and tool them with that knowledge. Because, as you said before, if there's a gold standard that involves tens, hundred thousand pounds or dollars worth of a kit, then you haven't got, you know, everybody doesn't have that ability. But if you understand, for example, how to develop a repeatable, reliable test of a particular element of performance that you understand the level of measurement error. And measuring an individual is very different to measuring a group of people. So we need even higher levels of measurement precision. If you are understand all of that and you can do that, then you can generate your own tests within your own clinic using your own facilities rather than strive for something that's never going to be achievable. And the value of that is is tremendous because everybody sits in different settings. And it's to have that knowledge and those skills than to develop something that's meaningful for your setting.

SPEAKER_00:

I've always liked the saying to the beginner, there are many options, to the master, there are few. And it fits very perfectly in our world because yeah, the older you get, the more programs you do, the more you realize you go back to the same stuff.

SPEAKER_01:

Fantastic points. I feel like my my saying on that is more is not always more. And it's the art of subtraction that we have to learn, isn't it? What do we remove to distill it into something really potent?

SPEAKER_00:

Especially with social media and everything. I think there's more than enough out there. Dear God. Yeah, that and people jump like I thought I jumped around when I was young at a personal trainer, went to a different conference every weekend, and you learn something new and you change everything. That's just a part of growing up. But now it's like every day there's a whole new method or concept that gets launched out there of people are just they're just swamped in what to do. So I think it's more important than ever.

SPEAKER_01:

Absolutely. Well, I suppose on that and just tying off this question, but what are your both of your thoughts on the best piece of equipment for S and C in a physio clinic?

SPEAKER_00:

Space, turf? It's gonna be an annoying answer for me, but I I think describe athlete's authority. Yeah, well, look, and that's not a great description because we're we're very privileged and very lucky to have uh a lot, a lot of tech and a lot of space. And I say this all the time that we were a performance facility first, turned rehab, which means we already had a lot of space and a lot of equipment. So many rehab spaces are clinics, turned more performance-oriented rehabs. So they're usually in smaller spaces, so I can't just add stuff. We were the other way around. You know, we already had the size, so we just had to find spaces for plits. But if I was in a rehab space and I had to find technology, so to speak, I'll try and yeah, separate these. But first and foremost, I think having a space or an environment that you can do athletic-based testing where it might be a three-hop for distance, these type of things are I would much prefer space over any piece of tech. So these type of things are far more in line with what I would do. If I had no money constraints, probably something like an opto jump, but that is ridiculously expensive. But probably in this day and age, I'd probably be looking at something like a subscription model force plate. I think that's probably my my number one. So pretty inexpensive these days. Um, obviously, Vold are probably the most well known for their whole suite. And again, it's an easy suite to go with from a force frame and a like Nordboard. These things have been pretty commonly used. But yeah, I think a subscription modeled force plate would probably be my number one if I was there, forced to make a decision.

SPEAKER_01:

You're on your desert island, you've got valves. Yeah.

SPEAKER_02:

Well, that's my answer, right? My answer is so I I teach a lot of physios and and rehab professionals just kind of getting into this. What do I need? You need resistance, you need kit to generate an overload that's greater than that individual is accustomed to. Whatever that looks like, it can look really flashy, and you can spend loads on you know, kind of gym-based kits, and there's loads of different add-ons now that you can get with you know, kind of make it look even fancier. But the basics is it needs to be heavy enough to challenge the index that you want to you want to change. So, strength, we know we need to push really, really, really heavy just for a few repetitions, and to create that, certainly for the lower limb, can be quite, quite challenging. Um, we need some significant mass to do that. So some resistance kit is really important. And again, where I sit is can we introduce some of these principles that we're looking at when that athlete is less impaired, less in pain, or uh the tissue's more resilient? Can we look at some of those principles earlier on? So if we've got somebody who is blood compromised, does that mean we can't train strength with them? Well, no, it doesn't immediately. Let's think about that as a as a problem to solve. What can we do? Can we adapt exercise, etc.? But if we're talking about kit, thinking like blood flow restriction kit. It's not for everybody and but for the right patient. It can be a real pardon the pun, leg up to to get into doing some uh resistance base exercise, a much lower load that can instill some strength adaptation and hypertrophic changes much earlier on in the rehab pathway than if we didn't have that. And that's just one option that involves kids. We can do it in different different ways. Yeah, so that's just a couple couple of things from me. Resistance, definitely number one. And then are there some adjuncts that we could maybe um use to accelerate some of these outcomes or could do some of this stuff earlier on where individuals are load compromised? So that could include things like blood flow restriction.

SPEAKER_00:

You bring up a good point. I think for anyone out there that either runs a clinic now or is looking to set something up, understand what your framework and system is first, and that will dictate what you get. Uh, as an example, we certainly pride ourselves on if an athlete comes in, injured, sore, pain, we will overload them somehow, somewhere, which means things like a leg extension, uh a hamstring curl machine, a leg press, pendulum squat, belt squat, all these things that are almost bodybuilding like, we prioritize because we know the amount of times that we can't do a lot of stuff with an athlete in season. They've just got to, you know, I hate saying it, but it's it's tick the box. Sometimes you do. You just got to keep some sort of stimulus in them. And machines are great. Yeah, so many people have these things against them, but they're brilliant. They isolate, they control, they overload, everything you want to do in a compromised athlete. Uh, so understanding your rehab process, looking at someone else and and what they have and what's shiny and what's new, if it doesn't actually align with how you rehab, then you get you're gonna hit a wall pretty quickly. So understand what do you prioritize in your rehab process and when, and make sure you've got it because you you don't want to be sending athletes or any type of patients that you're working with, even general pops, down the road to do stuff that that you kind of should be doing with them at your facility.

SPEAKER_01:

Fantastic points. And I'm actually gonna use the repeated concept of overloading and underloading into the next question, which may be now a very lead-in question, but where do you think we go wrong with SNC in our rehab?

SPEAKER_02:

I've got an issue with that with that because I never say anybody's doing anything wrong unless they're hurting somebody. I don't ever want to be gonna, I suppose, tarnished with being critical because it's incredibly difficult to work with humans. I'm kind of one and I know I'm difficult, and I'm actually rehabilitating at the moment. So my team I may be a little bit exasperated. So not only is it really difficult to work with individuals, then in this type of setting, you've got to know what's the best way physiologically changing indices of performance strength, but rate force development, power, what else, tissue compliance, blah, you know, all of these different things. So we need to know the best way to design exercise to do that, and know the dose response. Then those individuals are gonna be in some level of discomfort or have clinical restrictions. So then you need to go, can I still deliver this and solve that equation? And then you've got to go, that's an individual. Can I get them to buy in? Now, if you're working with athletes, usually it's a little bit easier than general populations, but not all the time. So, in terms of wrong, I think those individuals may have not had the right type of training or the had that level of understanding, or the there's a gap in knowledge that we can help to redeem, to fill commensurate with their own setting. And if there's anything that I know that can help people's rehabilitation practice, then it's absolutely my pleasure and blessing to be able to aid that. So I think there's ways in which we can improve, and I can improve, but in terms of wrong, and that's not to pick on you for the question, but it's often said within this arena and within loads on social media, and I just grates on me a little bit because it's a phenomenally difficult job.

SPEAKER_00:

Yeah, yeah. Sometimes wrong does have the context that they're doing it on purpose, but you're right. It's very contextual, and I'll always anything I've done, do or say is always, and typically from the context of a team sport environment, it is a different environment to say your Olympic institute one-on-one environments or your general population clinic environments and things like that. But if I had to, if I had to put it on the spear type of thing, I I think the biggest misconception is probably a bit too harsh, but the biggest thing I see a lot of rehab go maybe a little bit too slow and blocked is people have this assumption that everything happens one step at a time, i.e., we return range, we should get pain free, we then load, then we load with range, and this type of almost just absolute beautiful unicorn type setup that never happens because of that. And in a team environment where a lot of people are very, very happy to say these days, you know, timelines are out the window. It's all about entry and exit criteria. And I'm all for that. But when you've got a head coach asking what game are they returning, guess what? Your timeline is straight back in there. It doesn't matter. You can't just be like, oh, well, we'll see if they get there quickly, or yeah, we'll just see how they go each phase. You can't do that. You've got to tell them. You may be able to pat it out and you'll still treat them with each phase and hopefully speed them up. But the timelines are a real thing, they exist. And whether they're an athlete that has a coach asking or they're asking, they want to know when they're back. And that's where a lot of the stuff that I've done in the rehab space is okay, well, it's still painful in this range. So we can chase heavier loads in this movement in this range, but we'll also change and chase range of motion with no load in this range, and then we'll try and put some ISOs or we might use some complex work or BFR and in this range with this. And there's always a handful of things that need to be done before you you technically load everything, but there's a lot that you can do when someone's still in pain and still doesn't have great range that is actually going to accelerate them at the back end once it returns. And I think the ability to work around pain a little bit more with good loading is probably missed a lot. People probably feel like I can't load anything until this is pain-free. And I think with the push of tendons and and the popularity of trying to return people with tendon pain and how we can load that is hopefully shifting that a little bit. I think a lot of people are getting far more comfortable to accept a little bit of pain and good load and stuff like that. And even in the calf space, you mentioned Claire about stimulus. Like I think every week it goes up by one body weight or something that you need to pump into the calf like you're protected. Like it's just getting almost out of reach for most people these days. But that's a perfect example. Like so many people now talk up to eight times, nine times body weight on a bloody Smith machine in a seated position that you've got to tolerate. Like that's a lot of weight. These type of things, I think, uh probably the more advanced side of it that I think potentially people that have worked in environments that don't need to get an athlete back on a day ready to perform, that often they probably haven't been forced to try and load outside the norm. And I think that's probably what's becoming more popular now, even in your just typical clinical settings. I think people are starting to understand that hang on, load, load is good when it's appropriately done. And we know that we can't accelerate it at the end. We have to have started doing something leading into that. And that's a very overarching sort of thing, I know. But um, that's probably the thing that I see is probably that the bigger gap at the moment, that people can probably load a lot of ranges, angles, joints, muscles earlier in a rehab space than then potentially they do.

SPEAKER_02:

I agree. I agree entirely. And it's what I teach. The fundamentals of pretty much every course that I teach is all about this. Can you solve the equation? Can you change your range? And we've got evidence that suggests or clearly shows that, you know, isometric, for example, doing isometric training. Now, this isn't isometric 60-second holes, this is high load, go for maximal contraction at a particular joint angle, will give you a strength adaptation at that joint angle. Now, if you do it at long muscle lengths, you might actually get a transfer across to shorter muscle lengths as well. So, you know, there's loads of different ways. And if you understand a little bit the human physiology, some of the literature in this space, then you've got a multitude, maybe five different options without buying any kit to influence, for example, strength adaptation. And if you think about injuries, when injuries happen, we're rather than looking to perhaps recoup strength, we're looking to attenuate loss, certainly in that early phase. So if after all of the adaptations that you've thought of, you still can't do it, you can still train the opposite side. The cross-education effect is so powerful, and that means strength training one side for the benefit of the other that is not strength training. If you never heard it before, it sounds very weird, very profound. But human body is amazing. We've known about this since something like 1894. Well, not me personally, because I've been doing something else, but in healthy populations, it can generate a strength adaptation. In those injured populations, particularly at the early phase, it can attenuate loss. And we've done studies in this space, and just for a little bit of extra time, no extra money, a heavy load resistance training program on the non-affected side can attenuate the loss on the affected side, which again gives you ability to perhaps go a little quicker or have a better outcome at the end of that time point because you've got as far or as long or as much change to make in that time frame. And even in non-athletic situations where you've got this, I need my athlete back on this date, for example, NHS, national health service practice in this country, you still have a time frame. You might only see somebody like two or three times. What's the biggest bang for your book that you can get uh in those sessions? How can you you can space them out if you've got the luxury of doing that? You might only get to see them in a six-week block. What changes can you make? What losses can you attenuate? The point about thinking about the environment as equation and maybe not going like he was saying linearly. We need to get eliminate pain. Now you think about I do a lot of work. My passion now is OA, osteoparthritis, particularly with a knee. Those individuals are in pain no matter what you've got to do with them, right? So if you're gonna wait for them to become pain-free, you're gonna have a pretty long wait. And they probably won't be very responsive when you start with them. You need to think about some of these challenges, and as a, I guess, as well, and a fear when you think about patients, individuals who are in pain or who have injuries, there is an inherent fear about I don't want to make them worse. So I understand completely where it comes from. Do no harm, don't want to get them worse, and particularly with older populations as well. But in actual fact, if you think about this as a physiologic problem to solve, how can we, for example, reinstate strength? Well, it's high loads, kind of low repetitions, ideally for an optimal prescription. But essentially, if they're doing nothing, any amount of loads to start with is going to challenge that. So we we do need to start to load these populations. Swimming's not really gonna do it, you know. Certainly if you look at Linda Beck's amazing work in the Lithmore trial and series beyond that, you're thinking about osteopenia, osteoporosis, what's going to solve or help remedy the kind of uh bone mineral density changes? Again, it's not low load. So we've got to fear, we don't want to load these people because they're fragile. But actually, if you look at it from a physiologic perspective, we need to load that tissue to cause it to adapt. So, how can I look at that situation and solve that equation such that it's clinically appropriate to do, but still I've got a chance to get some of these important stimuli in for the high load. If you look at it from that perspective, then it's pretty powerful.

SPEAKER_00:

I feel like there's two things that people probably don't give enough credit for because they don't see it early on. It's only until the later stage of rehab that you can appreciate it is one, really good pre-surgery training to be able to go under the knife with very little swelling, good strength, good movement. You speak to any surgeon and they open up someone that's been training leading into it, it's like a dream. That and then loading early, because it's not like you necessarily, like if you get anterior knee pain in an ACL rehab, it's not like this eliminates it magically. It's not like it magically makes that first three months easy. But what it does do is it sets you up for the next block where you've already established this loading. We've just said you can't just throw 100 kilos on someone's back out of nowhere. But you can if they've been building up load for all this time and you don't actually get the monies back until after. So I've seen and heard a lot of people say, Oh, I did this, tried this, but I didn't really think it didn't really accelerate the rehab. Well, it doesn't accelerate the rehab, it's not like they suddenly go quicker. You still have to go through the same issues. You still get faced with random things that pop up. It's not like a magic vix, but just time and time again, I see in that that back end. Obviously, depending on the rehab, we use an ACL, it's probably the easiest one to uh extrapolate out over a longer time. But you know, that four, five, six month mark is where the money starts to come back because you're like, holy crap, like we're in this time where a lot of people are reintroducing stuff and we can actually really push someone, and it's a great feeling. And you get them back again, not necessarily super quicker, but in a far better environment. They they can actually return to performance and it's not just return pain-free, which there's a fair difference. And I think that's where you make your money. So um, anyone listening, don't be shy because you're like, oh, it hasn't magically sped up the first two phases. In my experience, you still suffer the same things. You still get random bouts of pain. They still get every now and then something just swells, and you're like, why the hell did it swell? Like, yeah, these things happen, but yeah, I feel like it breeds a far better, robust individual once they get into the harder stuff if they've been doing this type of loading earlier.

SPEAKER_01:

I think those are fantastic points. So it's starting with the end in mind. And Claire, I think building onto your point, there's certainly what I'm hearing is the relevance to consider those, that physiological and anatomical knowledge in what tissue we're loading and how that feeds into the pain and performance picture, how chondral surfaces, how bone loads, how tendon loads, and how that might change our adaptations to the programming as we go.

SPEAKER_02:

Well, I think, you know, if you think about the issues that you're faced with that would challenge your loading full stop. And if there's a clear clinical reason, absolutely, I'm not saying kind of ignore all your training and your clinical reasoning. But if there's a way in which you can, you know, joints love load, joints like loading. You take away a load, your tissues adapt in the same way that you would load them, except in the negative way. So we need it becomes proportionately more important as we age to introduce, if we're not already doing it, some sort of resistance training, some sort of heavy training, because our lives are becoming more and more sedentary. So we're not getting it in everyday life. I think, you know, if you even if you carry a shopping home, we want that to be easy, not to be your like farmer's carry of the day. What is it that's challenging your thoughts about loading? And then how can you you solve that? And then clearly, you know, if you're doing a tendonopathy rehab, it might be slightly different in terms of exercise selection than who's maybe a runner versus an older person who wants to be able to walk on unstable ground with OA with their dog. The exercise selections will be different commensurate with the the individual and their baseline status and with the, I suppose, a tissue that you're looking to engage and load, but the principles remain the same. So I say everybody is an athlete. Let's treat everybody with the same level of knowledge that we have about athletic elite performance to that general population. The principles are the same, it's just the way in which we deliver them. And if you think about yourself, how do you train yourself? Do you go to the gym, right? So if you go to the gym and do you strength train, how do you approach that? Now, if you go back into your clinic or your rehob environment, do you switch that? And if you do, why? If you know there's a better way to instill strength adaptation or rapidity of muscle force production, if you know there's a better way to do it, why are you almost withholding that from your patient? And I say that it's a little bit provocative, but if we take a step back from the thing that that causes the fear and the hesitancy and look at that objectively without emotion, is there a way we can work around that to do what I know is best? That's the empowerment, and that's what's going to be the start to improve maybe those touch points, the input-output equation with you, your patient, and the patient with those exercises now.

SPEAKER_00:

Yeah, our old red head of rehab, Justin Richardson, used to always say a great Warren Buffett quote, which is that the best way to make money is to first not lose money. And it is very appropriate to rehab. The best way to get strong, powerful, progress is first of all, don't lose it. So whatever they've got at the time when they say just maintain to start. That's the first in the box. Make sure they don't go backwards.

SPEAKER_01:

Fantastic advice from you both. I like it. Moving into the sort of the strength versus rate of force development, why does it matter and how do we assess it? Claire, I know you've done a fantastic post on it as well that I was reading the other day too. So if you're happy to answer.

SPEAKER_02:

So rate of force development refers to the ability for us to produce force quickly. And if we're looking at assessing that through some of the amazing kit that Lackey's got, what we'd look at is the force time curve. So you say like a force production over time and then the removal of force. And it's the gradient of that force time curve. It's often used interchangeably with muscle power. These rate of force, RFD, and muscle power, same thing. They're not actually the same thing because muscle power, if you think about how you assess muscle power, it's usually with, you know, if we're thinking about a very simple test of power, a broad jump. Okay. So you could have very poor power, session one, session two, but in session two, you can go further because you've lost 20 pounds in weight. Okay. So the thing is we're looking to change the contractile properties of the musculature. And then again, coming back to basic physiology, that will translate, as long as you don't put on weight, into better power performance if we're measuring it in that way. The other thing to say, rate of force development is not just something that's important for athletic populations. It is super important in sprint speed, in vertical jump height, in rapid changes of direction. Of course, it absolutely is. But it's not only there. If you think about general populations and you think about injury incidents and you think about time course of injury incidence, you know, it takes less than half a second to fall over, right? So we need rapidity of muscle force production. If you're standing up out of a chair and you trip, and you know that that older person trips over their handbag tortoise partner, I don't know, whatever's there, you need a fast acceleration of that lower limb to help prevent the fall, but also then accommodate their mass as they plant the foot, which again is rapid muscle contraction. So it's first to say it's really, really important in in all populations. And there's data that show deficits and loss in OANEs, in phtalofemoral pain, as well as ACL, injured and rehabilitated populations. Maybe it's proportionally more important. But the way in which we um and Blackie probably can say some really great points on this, how you specifically train for that, it's you need a different approach to it. So you do something new with somebody, they'll get a multitude of adaptations. But thereafter, you need to start to get really specific if you want to change strength, you want to change rate of force development, the contract properties of the musculature. The key thing, and there there are different ways we can focus on this. If we want to go really granular, we can chop up that force time curve and think about the early phase, the first hundred milliseconds. And yes, we are talking in very small time frames. But if I told you that it takes less than half a second, maybe less than a third of a second to fall, then these small time frames are really, really important. So we can focus on that early phase and then latterly the late phase, and we can get into that if you want to. But the key difference between training strength and training rate of force development is the intent, the intent to be explosive. And that is the critical thing. Now you can play around with mass and load and resistance and exercise type, but there has to be that explosive intent to really focus on a maximal speed of muscle activation, which is different to if you think about strength training and strength-based training, you just need to lift the thing off the floor or push push the thing, and there's no real kind of time parameter that we're evoking here. The key thing, and indeed when you assess rate of force development as well, if you kind of get into that, it's the as fast as you can, and and the emphasis is placed on the speed of contraction. They are different, strength and rate of force development are different, both are important in many populations, and all populations actually. And the way to distinguish is strength is maximal force, rate of force development is rapidity of force of production.

SPEAKER_00:

I agree with all. I have a small gripe with RFD as a whole, just because I think it's the Arkham's razor of the fact that it is amazing, but it's also the most sensitive and hardest thing to test. To actually put someone, it doesn't matter what you're doing. Let's take an IM like an isometric mid thigh pull on force plates, which again, 90% of physios don't use grip straps. So that's another recommendation. If you're doing an isometric mid thigh pull and you don't have a grip grip straps on, then you're just testing someone's grip strength. So always wear straps. Next part is to teach someone how to contract at the right time with the right intent to be able to measure accurate RFD is very tough. And it during a rehab process isn't probably the best time to teach someone. So this is where you you've got to quantify, qualify, probably as a better word, your individual you're working with and what's going to be the bang for their buck. Because RFD is very important. It's just getting an accurate measurement is the is the tough part. Me personally, I'm I'm a massive lover of impulse, which is to throw another word at everyone. But when working with with athletes, you want to get them more forceful, but you want to get them to do it quicker. And then they get more forceful, they get slower. And then you okay, we'll get them a little bit quicker with doing it, and then their force drops. It's just this ebb and flow that is the entire life of a strength editioning coach, robbing Peter to pay Paul and trying to give it back and trying to find that growth. And impulse is the best way to think about it of that area under the curve where we've actually made an entire change where you don't want someone super good at RFD, but have very low max force. Same as you don't want someone really good with max force, but then have, yeah, it takes four hours to get there. Now, obviously, positionally, it's different. You can certainly, it is weighted. You know, if you're working in rugby, it's a big prop forward. Doesn't matter if it takes them half an hour to get there. As long as they can get there, that's that's the key thing. Obviously, there's still arguments to say that it's important, but impulse for me describes the relationship of both of these actually improving, or at least one remaining and the other one getting better, because it means that we're actually chasing both. And the way you do that is, I don't want to say art form, but but it is. It Claire said it right. Everyone's human. So if we even completely remove ourselves from a rehab space, you're working with a very healthy high-end athlete, same sport, same background, same ethnicity, they respond differently. It's magic. It's everyone is very different. So you've got to have a lot of methods uh in the back to work out things. And and that's why our industry is flooded with all these different methods that like people aren't wrong. Like, people don't advertise this because they haven't gotten anyone better. Maybe there's one or two. But ultimately, everything's worked for someone somehow. It just depends how it's been applied and what their physiological response has been at that time they're loading, what what sport they're playing, but define adjustment of trying to get someone stronger, then you're kind of like, Well, you're strong enough. Now let's try and apply more force at a quicker rate. But then we start to look at contact time and say, Well, you spend four hours on the ground to do this, we need to get contact time quicker. But then if we go too quick with contact time, you're not putting enough force into the ground. And you know, there's a lot of different methods to trick the body into doing that and adjusting. But this is the nature of a return to performance. And I think if you're not having these discussions, then again, you're probably doing a return to play, you know, not return to performance, because this is the echelon of discussion, I think, at that end stage rehab that good rehab physios, as they they get more experience, want to start to have the discussions about, start to work out, okay, well, how do we improve their ability to apply force? But also now, how do we do it at a greater rate? And this comes back to what's the best tech? What should I have in my facility? Well, if that's what you value, then what are you going to use? Are we now looking at, say, a gym aware unit where you can measure the velocity of different movements? Is this where you're getting contact mats or opti jump where you're measuring contact time of plyometric options and whether or not you do need to load them up with a jump to slow down their contact time, but in turn put more force into the ground to then remove that and speed them up again? And it is a four-day discussion on how you improve RFD impulse and max force. But it's probably the the biggest takeaway I can say is that one, they're all very important, and then the interrelationship of them is very important to decide what you prioritize in a lot of your high speed movements and your jump selection, whether you load it, whether you don't load it, what type of rep ranges you want to use and and how you want to track even the descent of velocity. You know, are you actually worrying about the load or are you just tracking how many reps above 1.1 meters a second? And once it drops, that's the set done. Like this is where we start to chase that higher end. And as Claire mentioned, like the funny thing is that this type of stuff's the most important for, I will, again, without offending, probably say the most basic of populations where it's just an older person who is starting to degrade. You know, you think high-end elite million dollar athlete with this type of stuff, but it's as important for the other age group. Because as Claire said, like when they fall, they fall hard. And the only way to stop yourself from falling is a rapid contraction of a muscle, a huge rate of force development to be able to stop you. And there's there's plenty of studies coming out, and plenty of EPs or exosphysiologists and physios that are working in the space that are chasing power. And it might be as simple as seated leg extension done at a higher rate, but at least it's starting to lend that gap of, well, actually, this power training per se is not the peak. This power training is actually sometimes the foundation of just human movement and making sure everyone's doing it. The elite athlete level, you're probably you know putting the magnifying glass on all the results a little bit closer. If you're a physio and you're not having the discussions, I think that's something that is certainly an area for development. Yeah.

SPEAKER_02:

A really good illustration of how granular it can get and how important these things are when you've got the time, capacity, resources, and you're dealing with those really high-profile athletes. And, you know, I concur with with everything that that Lackey said. I think if I put myself in a clinician's shoes who might be feeling somewhat overwhelmed by this, I'd just like to roll it back and say there is relevance in this and don't worry about the volume of information that's just been imparted on you. Absolutely true. But in terms of measuring rate of force development, I'd say it's a futile exercise unless you're going to really practice and become experts at it and have the right type of equipment. I've written several measurement science papers on rate of force development. It's an inherently variable index. And that's due to you, it's due to your kit, and it's due to the individual being able to perform explosively, repeatedly, and habitually. But just because you might not be able to measure it, it doesn't mean you shouldn't necessarily train it. And the best way, again, illustrated really nicely, it does not have to be highly complex moves, potentiation complexes with X, Y, and Z and 70% of this and but think about strength as the fuel tank, the maximal force that that individual is able to generate. Then think about the ability to express that quickly. So if you move, once you've got somebody strong, then you could almost do exactly the same exercise, lower the weight to maybe something like 50% of what they were doing, 70% of what they're doing, just to make this simple and do it explosively. And explosively is the key, right? It's often called explosive strength in the literature as well, right? Of thought development, because it's been explosive and you can do it isometrically, you can do it in machines, you can do it kind of bodyweight stuff, you can do it in very complex ways, but it doesn't have to be complex. So we're now talking about power openia in the literature versus sarcopenia and power maybe having more or greater influence on quality of life, all cause mortality disease, like strength has. I'm not sure we're quite there yet, but it's certainly important. And if you're going to integrate it into your practice, I'd strongly encourage you to do. Just think about the movements, the exercise prescriptions that you're doing for strength, and just drop the road a little bit. As long as it's safe to do it explosively, and it can be, that's your starting point. It doesn't have to involve all the really important things that we're talking about before when you're dealing with high-level athletes. And clearly there's a really, really strong remit for all of this, and there's maybe a lot of money at stake as well. But if we're saying it's really important for general populations, that might be just a nice way to start out.

SPEAKER_00:

100%. And to be honest, to that point, I'd even go further and say you don't actually need to be that strong. I think the concept of people needing to be really strong to do it is probably sometimes holds people back because we know, yeah, greater strength usually indicates greater coordination, they're better at it, usually get more out of it. But if you're a physio standing there trying to do that and not go, oh well, are they strong enough? Don't overthink it. As I said, if we go back to that leg extension example, if they've got enough plates that you can reduce it by a few plates and they can do it comfortably at speed and they look like they can control it, then that's a good start. Like don't overthink, oh, they're not strong enough yet and keep delaying. No doubt the stronger someone is, the better outcomes you can usually have with velocity work, but it's certainly not a door in my mind that just because they're not super strong, they can't start some things at velocity.

SPEAKER_01:

I think there's some fantastic clinical gems and some really tangible takeaways from both of you there. So thank you very much, and a huge thank you to I suppose helping us explore all things S and C and rehab and performance and hopefully navigate it more confidently in the clinic and hopefully consider ways that we can optimize what we do with our patients. So thank you. Absolutely my pleasure. Thanks for having us.

SPEAKER_00:

We'll go to chat when quick.