Rehab and prehab are common buzzwords within the manual medicine community, often with vague descriptors attached to them. The Oxford Dictionary of Sports Science and Medicine defines rehabilitation as the “restoration of an injured person to the level of physical fitness he or she had before the injury.” Both rehabilitation and prehabilitation programs are designed to build strength and increase functional capacity, but the timing of their delivery is different. Prehabilitation has traditionally been associated with preparation for surgery; with patients being given physical and/or lifestyle modifications to help improve recovery time and decrease their post-surgery pain levels following surgery. Rehabilitation programs begin after the injury, often in conjunction with treatment, while prehab programs occur prior to treatment being given, often in the form of surgery.
Research has found that those patients who receive a targeted pre-surgical exercise program prior to knee or hip replacement surgery can decrease the odds of needing inpatient rehabilitation by up to 73 per cent, with significant improvements in functional status and muscle strength (Rooks, 2006). An article by Jack, West, and Grocott (2011) discussed the usage of prehab for elderly subjects. The authors found that although there was a “paucity of high-quality clinical trials,” prehabilitation can improve specific fitness measures prior to surgery including levels of physical activity, fatigue, and health related quality of life in cancer patients as well as improved general fitness. More recently, a systematic review by Cabilan, Hines, and Munday (2015) found that “…prehabilitation has no significant post-operative benefits in function, quality of life and pain in patients who have had knee or hip arthroplasty for osteoarthritis; however, there is evidence that prehabilitation may reduce admission to rehabilitation in this population.” Despite the mixed results in the literature, the bulk of the research appears to be favourable for the use of prehabilitation programs.
Considering the needs of the patient
While some patients may be coming in for care in advance of an upcoming surgery, others are looking for traditional treatment and strategies to prevent future occurrences of their pain. Many research studies have shown that traditional treatments offered by chiropractors often perform better when combined with exercise (Leininger et al, 2016; Maiers M et al, 2014; Petersen et al, 2015; Southerst et al, 2015; Walston and Yake, 2016). A study by the National Chiropractic Board of Examiners found that 98 per cent of surveyed chiropractors reported using “corrective and/or therapeutic exercise” as part of their treatment plan. This is where the use of individualized exercise programs directed at either injury rehabilitation or injury prevention can be beneficial. Although pragmatically, it’s important to stress that prehabilitation exercises are best directed at preventing chronic injuries, as traumatic injuries can occur without warning when a load or force too great for the tissues to withstand is applied, causing tissue failure and ultimately injury.
In order to customize a prehabilitation exercise program for a patient, there are three main points that must be addressed:
- Injury history of the patient: this should include the success and failure of previous treatments.
- Movement competency: knowing how well your patient can squat, hip hinge, etc., is important so we can determine where along the exercise continuum to start with their programming.
- Type and level of participation: the type of sport as well as the level of competition will impact the intensity of exercise prescription.
Research by Lauersen (2014) has shown that strength training programs can reduce sport related injuries by nearly two-thirds and overuse injuries by nearly half. However, many factors can contribute to overuse injuries. Giffin and Stanish (1993) found that muscle imbalances, excessive training load, and poor technique could all contribute to the development of chronic overuse injuries. Fortunately these factors are all modifiable once they are identified. The use of a movement assessment tool can be beneficial for identifying muscle imbalances and movement deficiencies to recognize major areas of limitation.
There are several movement assessment tools utilized by manual therapists, with the Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA) among the most commonly used. The FMS was long touted as a screening tool to identify those deemed to be more vulnerable and susceptible to injury (Butler et al, 2013; Cook et al, 2014; Kiesel et al, 2007). Busch et al (2017) have linked the poor scores in the shoulder screens of the FMS and SFMA with increased likelihood of overuse injuries during a baseball season. A recent systematic review by Bonazza et al (2017) in the AJSM found that the FMS had excellent inter-rater and intra-rater reliability. They also found that those with a composite score of <14 had a higher likelihood of sustaining an injury, compared to those with higher scores. Similarly, a critical appraisal of the SFMA from the November 2018 issue of Journal of Sports Rehabilitation found that although some of the studies surrounding the FMS/SFMA were low-quality, the SFMA could correctly identify dysfunctions and limitations, which assisted the clinicians in the creation of an individualized exercise program. Furthermore, research by Baser et al in the Journal of Sports Rehabilitation(2018) found that administering personalized intervention programs based on individual FMS scores was beneficial. This research helps support the usage of a movement assessment tool, such as the FMS or SFMA, to help screen our patients for major deficiencies and asymmetries with movement which can then be used to provide individualized exercise advice.
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Preventing MSK injury with exercise
Another excellent example of directed exercise to help prevent musculoskeletal injury is the FIFA 11+ program. This is a program developed to help reduce injuries in youth soccer teams using a standardized warm-up, which was designed by “an international group of experts based on their practical experience with different injury prevention programmes for amateur players aged 14 or older” and should replace the usual warm-up prior to training. A study from the British Medical Journal in 2008 found that when teams performed these exercises at least twice a week, there were 37 per cent fewer training injuries, 29 per cent fewer match injuries, and almost 50 per cent fewer severe injuries. One of the exercises included in the FIFA 11+ is the Nordic hamstring exercise. A 2017 systematic review and meta-analysis by Attar et al found that injury prevention programs that include the use of the Nordic hamstring exercise decrease the risk of hamstring injuries among soccer players. Further research is needed to link specific injuries with exercises; for example, Attar et al mention a possible connection between the reverse Nordic hamstring exercise and quadriceps strain. Similarly, it has been theorized that the Bunkie test might be a tool to identify weaknesses and imbalances in the kinetic chain of athletes. Although whether these restrictions and limitations result in an increased injury occurrence has not yet been shown (DeGennaro and Swogger, 2015; Van Pletzen, 2010).
Similar to the Bunkie protocol, Dr. Stuart McGill has found a correlation between core endurance testing and lower back pain. In his research, McGill has found core endurance tests to be decreased in those who suffer from nonspecific lower back pain compared to healthy controls. Previous research has shown that workers who reported lower back pain had decreased trunk extensor endurance, and Biering-Sorenson (1984) found that a lack of endurance appears to be a predictor of future occurrences of LBP. Research from Abdelraouf and Abdel-Aziem (2016), suggests the use of these exercises to help prevent lower back pain in collegiate athletes. Many chiropractors are familiar with McGill’s “Big Three” exercises: the bird dog, the modified curl-up, and the plank. These tend to be the hallmark exercises of many lower back and core rehabilitation exercises, although they may also be appropriate for prehabilitation programs in those concerned about future bouts of nonspecific LBP.
As with any exercise program, it is important for prehabilitation exercise programs to be progressive. An article in the Journal of Strength and Conditioning Research in 2015 found that individuals suffering from mechanical lower back pain who had acceptable levels of lower back endurance could benefit from performing a more complicated exercise, such as the deadlift. Similarly, Welch et al (2015) found that free-weight based resistance training including deadlifts and squats improved strength, motor control, and other physiological aspects such as increased cross sectional area in individuals with chronic LBP. Berglund (2016) found that deadlifts may be beneficial for subjects with mechanical low back pain, as they provide clinically relevant points of education including hip hinge patterning, and motor control strategies.
These research studies highlight the need for patients to be coached and cued to perform exercises correctly, particularly as the difficulty increases. Although time consuming, being present to instruct your patients in the performance of their exercises can be very helpful. Otherwise, building a referral network with knowledgeable personal trainers, strength coaches, and other rehabilitation professionals including kinesiologists and athletic therapists can be helpful for both your practice and your patients.
From a practical perspective, we can build upon the work established above to develop a solid exercise regimen for our patients. Knowing your patient’s injury history, their personal goals, and previous levels of activity can all be beneficial for prescribing an adequately challenging program. Moreover, a movement evaluation such as the FMS or SFMA is a good starting point to try and identify areas of improvement. Marrying these findings with the research surrounding overuse injuries common to an individual’s sports and other daily activities, as well as their relevant injury history can help to offer a truly individualized prehabilitation exercise program. Although we may not be able to prevent all musculoskeletal injuries, offering our patients a thorough and individualized exercise regime may help them build capacity for their activities.
Overall, there are numerous positive effects associated with exercise including: improving muscular strength and endurance, increased blood flow to affected tissues, maintaining adequate range of motion, neuromuscular retraining, improved aerobic capacity, patient empowerment including increased self-reliance and decreased fear avoidance, exercise-induced analgesia, and much more. While the research may be lacking in terms of definitive answers to preventing musculoskeletal injuries, there is no denying the benefits of exercise.
Many patients entering a chiropractic office can benefit from the gradual and guided introduction to exercise, particularly when it is individualized to their specific concerns. At the end of the day, exercise is medicine.
Dr. Brett P. Guist graduated from CMCC in 2015 and is a chiropractor practicing in Burlington, Ont., with a focus on rehabilitation. In addition to his role as a chiropractor, he also teaches and conducts research and has been published in several peer-reviewed journals.
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