Clinical Approach to Periodization

by Mitch Hauschildt, MA, ATC, CSCS

I have long described myself as a strength coach who happens to be an athletic trainer, and my rehab philosophy has always fallen in line with that mindset.  I have always pushed the limits for my athletes to get them moving very quickly after an injury and integrate movement patterns that many clinicians would describe as “aggressive.”  My approach has served me well I believe for several reasons:

• We are designed to move well and move often.  The body likes to move, so the earlier we can do it, the better.
• Most people are injured because of poor motor patterns (even many contact injuries can be linked back to poor movement in some capacity), thus correcting them aids in the rehab process.
• Cardiovascular fitness is important for tissue healing, thus movement aids in the healing process.
• Mentally, patients respond well to movement because it is encouraging for them to return to activities that they performed regularly prior to getting injured.

One way that I believe that my strength and conditioning background has helped me tremendously is by integrating periodization strategies into my rehab programming.  This is especially true of longer term rehab patients, but isn’t limited just to them.  Unfortunately, most athletic training and physical therapy programs don’t do a good job of teaching periodization.  Thus, most clinicians working in the rehab setting get stuck in the “3 sets of 10 reps” mode, which doesn’t do our patients justice.  It is boring and doesn’t aid in the physical improvement of their body.

Before we jump into using periodization within your rehab programs, it is important that we define periodization:

Periodization is a systematic type of resistance training that involves specific training phases that alternate different levels of intensity, volume and frequency of workouts to maximize performance outcomes.  

There are a large number of different periodization models out there, including linear, undulating, conjugate, triphasic and block, to name a few.  Most experienced strength coaches utilize a hybrid of several of these depending upon their team, sport, training age, time, facilities, time and so on.  My goal for this post, isn’t to influence you to use one specific model or approach.  Rather, my goal is to provide you with solid reasoning for using periodization and encourage you to find an approach that works well for you and your setting.

Let’s go through some basics here that hold true for most periodization models and discuss how they fit into the rehab setting.

• There is a distinct correlation between work capacity and strength gains.  The vast majority of periodization models that exist encourage work capacity training early on.  They may have other words for it, such as accumulation or hypertrophy, but they are all getting at the same thing…in order to build strength and power the human body desires fitness and endurance.  This usually occurs through relatively high volume with low load.
• The human body thrives when it has constant variation.  Periodization is really just a simple form of evolution.  You give the body stimulus and watch it react.  If you give it the right stimulus, you get what you want.  If you don’t give it the right stimulus, you get something else.  But, the human body is very accommodating.  Every minute of every day, it is wired for survival.  It wants to find a way to accomplish today’s tasks tomorrow by putting forth less effort.  This is why you see people on the same elliptical machine day after day at the gym who haven’t changed a bit.  Their body has adapted to the training and is no longer improving.  Periodization constantly changes stressors to the body, thus helping it improve.
• After the body has a certain level of work capacity and fitness, strength and power can be trained through higher intensity, lower volume training.  While I do understand that most people reading this post don’t work specifically with athletes, I do believe that everyone needs some level of strength and power.  It’s what helps us climb a flight of stairs, play a round of golf or even push a shopping cart around an uneven parking lot.
• Quality is more important than quantity.  Only on rare occasions do I find that it works well to push through suspect movement patterns in order to accomplish a patient’s goals.  Thus, we need to make sure that regardless of what we are trying to accomplish, we don’t allow poor movement patterns to creep in.

Clinical Applications

When I approach the rehab patient, I look at several key periodization strategies to maximize my time with them and improve their overall outcomes.

• After reducing pain and swelling, move to improving a patient’s work capacity.  An injured patient will naturally have a significant reduction in their fitness levels and overall work capacity.  This can be accomplished with general fitness training around an injury (i.e. using battling ropes for conditioning a patient with a lower extremity injury) or through local muscular endurance work via specific movements.  In many periodization models, they suggest high volume in the area of 10-15 reps for multiple sets.  Understand that with injured patients, this may be impossible because the patient likely won’t tolerate the high loads of sets and reps.  We can combat this several ways:
  1. Start with lower sets and reps in order build the needed work capacity needed to be able to introduce an accumulation phase of training (prior to reducing the volume in a strength and power strategy).
  2. Give the patient a total number of reps that they need to perform and allow them to break the reps up into smaller sets in order to accomplish the task.  Many times I’ll tell my patients that they need to perform 25 total reps (as an example) and they can break it up however they want to.  This ensures that they are performing quality reps and also ensures that I’m getting the total amount of work done that I want, but also allows them to keep it tolerable.
  3. Start with less complex movement patterns and help them to progress to more complex, multi-joint movements.  This is a great way to build tolerable work capacity.
• Provide constant stress.  This is usually accomplished by varying the sets, reps, load and exercise selection.  In our busy days in the clinic, it is often way too easy to keep repeating the same workouts every time they come in.  It may be easy on both you and the patient, but just because it is easy doesn’t make it good.  Make an effort to change up exercise progressions, load and/or volumes every time your patient comes in.
• Set up a generalized weekly programming model for your patients.  My athletes know that after they have moved past the initial phase of their therapy and they are moving fairly well, that their week will usually involve moderate intensity strength and movement training early in the week, recovery mid week and they will get smoked on Friday as they leave our training room with a couple of days of recovery to look forward to.  This standardized approach gives the patient the stimulus that they need and also keeps you relatively sane and lets the patient know what to expect when they walk in the door so they have appropriate expectations as to their workload.
• Plan ahead.  Whenever I start any rehab patient, and especially my long term rehabs, I make a long term plan for their programming.  This gives me goals to shoot for and allows me to organize my thoughts so I don’t all of the sudden look up one day and find myself completely off track.  I have to understand that my plans are likely going to change based on how the patient is progressing, but the better I plan, the better the overall outcome is for my patients.

Once you succeed in implementing some of these very basic strategies, then move on to incorporating some of the more advanced periodization strategies for your longer term rehab patients.  Doing so will pay valuable dividends for both you and your patient.

Looking for more help?  Schedule a consultation today!