In part 1 I discussed the foundations of exercise prescription and introduced the concept of autoregulatory periodization. The following is my interpretation of a practical application of these concepts to rehabilitation. There have been many who influenced my views on this, but Mel Siff’s, Matt Perryman’s, and recently Mladen Jovanovic’s writings on this topic have played some role in my thought process.

As discussed previously, the first step is to determine what the goals of the session are and choose a set/rep/rest scheme that will drive this. Reiman and Lorenz have an excellent paper on the topic of integrating strength and conditioning principals into rehabilitation that can help with making these decisions.⁶ The basic rep schemes laid out in Siff’s APRE model very easily fit into a zone-based trainings approach. I prefer a zone based approach as it’s doubtful that specific rep schemes matter to any significant degree since the intensity and taking the sets to appropriate levels of fatigue seems to be more significant – especially when discussing rehabilitation where loading schemes are targeting detrained or untrained individuals.^7-9

There are two initial determinations that need to be made:

1. Rep ranges
2. Intensity levels

It’s also important to determine which aspect will drive the other. If the rep range is the constant, then load is the independent variable and RPE will be the dependent variable. Alternatively, RPE can be the constant and either load and/or repetitions will be manipulated to reach the desired RPE. For practical purposes, programming can be approached using the same general zones that Siff described with the possible addition of a higher rep zone (15+) for situations where higher loading is contraindicated but strength and hypertrophy is still the goal. Looking at the chart below (figure 1) we can see that there are three main approaches that can be used. Figure 2 shows how these three variables can interact.

RPE-Driven Approach

Begin the exercise with acclimation sets hitting the determined rep zone. Keep adding load until the desired RPE is reached. With a heavier load, more warm-up sets may be needed and with lower intensities, one or two may be enough to get to the working load. In this approach, the load is manipulated to achieve the desired intensity at a set zone. The number of sets necessary to reach this goal will vary session to session based on readiness level. Once the goal RPE is reached within the set zone a working max has been established.

For example, with a goal of strength/hypertrophy and with the deadlift as the selected exercise, a target rep scheme of 5-7 may be selected with an intensity of 7-8 for the RPE. The bar is loaded with a weight that you are confident the patient can perform well over 5-7 times and 6 reps are performed. An RPE is recorded and informs the loading for the next set. This process is repeated until a RPE of 7-8 is reported in the 5-7 rep range. This will be the working load for that day off of which intensity can be calculated.

 Zone-Driven Approach

In this approach, a load and a goal RPE is determined initially. The set weight is lifted for as many reps as it takes to achieve the desired RPE. This approach lends itself to lighter loading with patients who may not tolerate higher loads.

For example, in a post-op total knee patient working on squats, bodyweight may be the set load with a desired RPE of 7-8. The patient performs 12 repetitions the first set before hitting a 7 RPE. Consecutive sets of 10, 8, and 6 are performed hitting a RPE of 7-8 on each set.

Load-Driven Approach

This approach can work well with a patient who can tolerate loading and needs to spend some time at higher intensities. Start with load that puts the exercise at a predetermined RPE within the selected rep zone. As the patient fatigues, consecutive sets will be performed at a lower load maintaining the same repetition range and RPE.

Taking the previous patient who is still working on squatting strength a few weeks later, a moderate zone at 7-8 RPE is selected. They start by squatting to parallel with additional weight and get 8 reps before achieving a 7 RPE. The next set is done with bodyweight getting 7 reps with and RPE of 8. The final set is done to a slightly higher chair and the patient gets 10 reps before stopping.

Conclusion

At this point, the options for moving forward are very open. The above guidelines give some very broad guidelines that can easily be manipulated to adapt to any individual. These approaches can easily be combined within a session as well. For instance, with a compound multi-joint exercise may start the session and the RPE driven approach is used. This may be followed up with a few accessory exercises done with either a load or zone-driven approach to target specific identified weaknesses. This also allows HEP intensities to be prescribed. Once the patient understands the concept it is easy to assign a range and a RPE goal. Unlike a number of other programs I have used Medbridge’s HEP program actually allows you to type in a range for the reps, which makes this very simple.

The main concept here is that there is a need for an approach that can integrate feedback into the daily programming. This ensures that appropriate intensity levels are reached while respecting the individual’s readiness.

The outlined methods above are obviously not the only way to achieve this. It does, however, give you as a clinician the ability to begin factoring exercise intensity back into exercise prescription. And, as the APTA has indicated, this is something that is sorely needed.

Origionally posted on Medbridge

References:

1. Cardinale M, Newton R, Nosaka K. Strength and Conditioning. Wiley; 2011.
2. Day ML, McGuigan MR, Brice G, Foster C. Monitoring exercise intensity during resistance training using the session RPE scale. Journal of Strength and Conditioning Research. 2004;18(2):353–358. doi:10.1519/R-13113.1.
3. Verkhoshansky YV, Siff MC. Supertraining. Verkhoshansky.com; 2009.
4. Knight KL. Knee rehabilitation by the daily adjustable progressive resistive exercise technique. Am J Sports Med. 1979;7(6):336–337.
5. Mann JB, Thyfault JP, Ivey PA, Sayers SP. The effect of autoregulatory progressive resistance exercise vs. linear periodization on strength improvement in college athletes. J Strength Cond Res. 2010;24(7):1718–1723. doi:10.1519/JSC.0b013e3181def4a6.
6. Reiman MP, Lorenz DS. INTEGRATION OF STRENGTH AND CONDITIONING PRINCIPLES INTO A REHABILITATION PROGRAM. Int J Sports Phys Ther. 2011;6(3):241.
7. Mitchell CJ, Churchward-Venne TA, West DWD, et al. Resistance exercise load does not determine training-mediated hypertrophic gains in young men. Journal of Applied Physiology. 2012;113(1):71–77. doi:10.1152/japplphysiol.00307.2012.
8. Burd NA, Mitchell CJ, Churchward-Venne TA, Phillips SM. Bigger weights may not beget bigger muscles: evidence from acute muscle protein synthetic responses after resistance exercise. Appl Physiol Nutr Metab. 2012;37(3):551–554. doi:10.1139/h2012-022.
9. Burd NA, West DWD, Staples AW, et al. Low-Load High Volume Resistance Exercise Stimulates Muscle Protein Synthesis More Than High-Load Low Volume Resistance Exercise in Young Men. Lucia A, ed. PLoS ONE. 2010;5(8):e12033. doi:10.1371/journal.pone.0012033.t003.
10. Baechle T, Earle R. Essentials of Strength Training and Conditioning. 2nd ed. Human Kinetics Publishers; 2008.