#27 - Load Progressions and the Rehab Continuum with Dr. Tom Teter, Part 2

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to consume. to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome, and thanks for listening. Today we finish up part 2 of load progressions and the rehab continuum with Dr. Tom Teeter. In today's episode, we'll discuss the 3 parts of the rehabilitation process, The stages of the rehab continuum and specific interventions within each level of care. We will also talk in detail about what to do with patients who have completed rehab but are not necessarily ready to be discharged from treatment. One thing that I find really brilliant about this particular training is how Dr. Teeter has created a logical organization for the stages of the rehab continuum that still allows for the flexibility and the customization that's required for each individual patient. Dr. Tom Teeter is the owner of Engineering Athletes, a manual therapy and performance enhancement clinic that focuses on integrating movement-based rehab and functional performance training. With more than 15 years of experience in strength and conditioning and clinical practice, Dr. Teeter has treated and trained thousands of athletes at all levels of skills and ability. Dr. Teeter has also become a sought-after expert witness in court cases involving fitness and injury, Due to his expertise in injury prevention, rehabilitation, and performance enhancement training. He's also the developer of Factors Rehab to Fitness, a 25-hour online course that provides a blueprint for fitness programming that bridges the gap between where rehab ends and fitness begins. So without further ado, let's cue the intro music and dive into today's episode.

Our next stage of care in the rehab continuum is motor control. And motor control are things that we're trying to do to get stability around a joint. Now, whereas foundational kinematics and mobility is trying to get afferent input to the brain, we're trying to increase afferents, motor control is trying to increase efferents. We're trying to get the muscles around the joint. We're trying to center the joint and get the muscles to contract in the right amount at the right time. So these are things we could use like positional isometrics. If it's your flavor, you can use developmental positional stabilization or more commonly known as DNS or even something like GRIP, which is in that same ballpark. You could do pails and rails. This is one of my favorite use of force outputs before putting someone back under a body position load is using functional range conditioning or variations of pails and rails. You can also use things like combined loading, eccentric and concentric movement, or even just straight eccentric loading. But notice, combined loading is a different load to the system than just straight eccentrics. And then the last thing you can do is combine this with some type of blood flow restriction, depending on the patient clientele you're working with. So these are all things we could do to increase efferent low threshold force outputs in non-weight-bearing or semi-weight-bearing positions to help increase stability before we put them back under load. You can see here an example on the left is something like DNS, or developmental positional stabilization. You can see at the top we have something like positional isometrics. And then over here at the bottom, we have pails and rails.

Yeah.

And then, here we have eccentric loading. And, on the right, we have an example of blood flow restriction. Now, I don't care. I think blood flow restriction is a new emerging technology that has very far-reaching applications in not only rehab and fitness. I don't care which systematic approach you espouse to, but I think it's something that lends a lot of bridging into fitness where you can start to apply load to tissues in non-weight-bearing positions and get some of the same effects if we were actually using some higher threshold force output. So something you might want to look into. Our next stage of the rehab continuum is functional integration. And this is typically what we would start to classify as fitness, right? We see things— our functional integration is working on strength or general physical preparation. General physical preparation is a hallmark of the foundation you need for any strength and conditioning program. So when we're bridging motor control into— from non-weight-bearing and semi-weight-bearing positions and low threshold force output into these higher threshold force outputs in bodyweight positions, We're going to put people back into fundamental or functional movement patterns. We're going to try to increase their body relative strength, not necessarily maximal strength, but just body relative strength. And we're going to use progressions and regressions of different forms of resistance training in the upper body, trunk and spine, and lower body. And then we're also going to start to work on aerobic endurance. If you look by definition in every strength and conditioning manual, these are the hallmarks of general physical preparation. But they're also part of rehab. If I need someone to be able to squat, I need to put them back under some variation of a squat. Now, in my example, in our course, we talk about we're going to do a TRX squat, we're going to do an unloaded squat, then we're going to do a bodyweight squat, then we're going to progress to a landmine squat, then we might progress to a goblet squat, then we might progress to a barbell front squat or any variation for that particular individual. But now we have a series of progressions that we can put them through That's continuing to increase the application of load while we're getting them through the stages of care to whatever the terminal point is for that individual athlete. So you can see the 7 basic fundamental movement patterns. I usually describe 6. In this diagram, you see squat, lunge, push, pull, bend, twist, and gait. The ones that I think that are more applicable are squatting and hinging, pushing and pulling, which are upper body pushing and pulling. Twisting is another fancy word for core. And then in my mind, locomotion is the last one. But locomotion or gait is a combination of a lunge and a step. So in our class, we talk about push, pull, squat, hinge, twist, and locomote are the 7 basic movement patterns that we want to train. So we can see some examples here of horizontal push in our bench press. You can see at the top right an example of a knee-dominant exercise like a squat. And here at the bottom, we can see a plank or a core stability exercise in the sagittal plane. And This is another thing where what we talk about and what we use in my clinic and in our class is these are all of the progressions and regressions for all the different movement patterns that we just discussed. So these are the things that we use as a progression from rehab into fitness, or if I'm starting someone off right at a fitness program, we're going to start off at baseline and start to work from that. These are things that we all discuss in our course. And lastly, in GPP, you need aerobic endurance. So you could ride your bike, you can walk your dog, etc. Whatever your flavor is, we know that when someone's injured and we're trying to repair tissue, that actually increases in aerobic endurance speeds up the recovery process. So we want to get them back into aerobic endurance as quickly as possible. From there, our next stage in the rehab continuum is progressive kinetics. And if we look at the idea of progressive kinetics, this is all about power and rate of force development or special physical preparation. Now we're starting to become more specific to their sport or activity that we determined in their needs analysis. And we're going to do things like explosive control or recycling control. Explosive control is a one-time high threshold force output, and recycling control is a lower threshold force output done repetitively. And we'll do that through the interventions of sprinting, jumping, and throwing. So you can see here in our practical application, on the bottom left you have sprinting, on the top right you have jumping, and on the bottom right you have throwing. These are all ways to train rate of force development in a very safe and effective way as we're moving through this rehab continuum. If we're working with athletic populations, At some point, they're going to have to sprint, jump, and maybe use upper body ballistic force outputs through throwing. And so these are things we want to include in their rehab program to get them in the right space. And then lastly, on the rehab continuum, we have fundamental capacity. And this is where we're working on special developmental preparation. So this is the most specific we can get to their activity besides competition. And we're working on sport-specific skill.

Okay.

Any agility or change of direction, and ultimately sport-specific conditioning or work capacity. So you can see here in our representation, you can see on the left we're working on sport-specific skill, on the top right we're working on change of direction, and on the bottom right we're working on work capacity. Now if we go back to this diagram, remember I said when we started, on the top left is the least load to the biological system. Talking about your pain is not very much load to your biology. But work capacity done over the course of an hour and a half, that's a lot of load. So you can see how now we have a way to describe the impact that our interventions have on our biology in each stage of care, and how as each stage of care moves, the load actually increases and gets higher rates. So we also want to keep that in consideration in choosing what interventions we're doing. And you can see here the reason I had to come up with a way to describe why I thought load was increasing. And mainly it was because we're starting to see increased complexity, or we're starting to accumulate complexity with each stage of care that goes on. So for instance, in acute management, all we're worried about is do we have the right joint system or the muscle group that's actually damaged, right? In foundational kinematics, do we not only have the right joint system or muscle group, but now we're trying to get specific range of motion or direction of movement In that joint or muscle system. In motor control, we have the right joint or muscle, we have the right direction of movement and range of motion, and now we want the right timing of muscular contraction to create optimal stabilization. As we increase into functional integration, we want to know that we have the right joint system or muscle group, the right range of motion or direction, the right timing or force production, and now we're starting to work on body relative strength. So we're increasing magnitude. How much force can these tissues produce? And we're going to build that up over a specific amount of time. In progressive kinetics, we use the right joint system, the right range of motion, the right timing, the right magnitude. But now we're trying to work on rate of force production. How quickly can we increase the rate at which these muscles are contracting? That's the definition of power. And then ultimately, we're going to end on fundamental capacity, where we have all of those same elements. But now after rate of force development, we're also working on duration of force production. So you can see over here in acute management, the reason why the load is so low is because there's only one specific item that we're worried about. But when we get over here to fundamental capacity, the reason why the load is so high is because we have an accumulation of progressive complexity, meaning that we have all of these things that start to compound upon each other, which has a much higher rate of effect on the biological organism. And I think for me, when I started to think of it in terms of accumulating complexity, It was really easy for me to understand not only why we're going through these stages of care ultimately, but how it's affecting the biology for that individual athlete. One other thing I wanted to point out as we talk about this is when I talk to clinicians, it's all over the spectrum in the chiropractic profession. I can only speak for chiropractic. I can't speak for physical therapy or athletic training. But average chiropractors that I talk to usually do acute management. They always have some passive therapies they typically use. And a lot of them live in foundational kinematics because the thing that we're taught most in school is joint manipulation. That's what we do. That is our bread and butter. And so good chiropractors live in these first 2 buckets. Great chiropractors also start to integrate some element of motor control. So these are guys that are also doing— a lot of these people are doing like DNS or some element of low threshold force outputs. So if you're an average chiropractor, you're probably doing the first 2. If you're a good chiropractor, you're probably doing some element of motor control. But the top people in their field, at least in our field, are doing all this entire spectrum. And what I also try to point out is in my practice, I do all of these myself. A, because I like it. B, because I have the time to do it. And because the people that I come to have very specific— come to me have very specific goals, and I'm going to make sure that I get them exactly where they need to be. But if you're in a busy practice and you don't have the time, all I ask of you is that you respect these last 3 elements of the rehab continuum enough that you either hire someone to do it for you or you form a relationship with someone that you trust to be able to refer them to as part of their continuum of care to finish out these last 3 things. For instance, if we have a soccer player who has a knee— this magical knee injury we're talking about, and they need to be able to run up and down the soccer field, care doesn't end When the knee pain goes away. To me, care's over when we've restored their function back to whatever their original application was, meaning, can you run up and down the soccer field without pain, with normal range of motion, and with normal capacity? So if you want to be an amazing and outstanding clinician, you have to do all of these things in your rehab continuum. And even if you're not the person doing them, you have to form relationships with other people where you can work together. And the integrated support team around an athletic population and make sure that all of these boxes are checked before you release this person from care.

Today's episode of The Factor Podcast is sponsored by Rehab to Fitness. Rehab to Fitness is a course for healthcare providers and fitness professionals to learn how to progress clients and patients from rehab into a functional fitness program. In this virtual course offering, Dr. Tom Teeter takes complex physiological concepts and makes them easy to implement. From the basics of fitness to advanced programming techniques, participants leave this course with a specific and practical blueprint that they can begin applying immediately in practice. The information included in this class has helped both general fitness clients and high-level athletes achieve their peak physical potential and remain injury-free. If you are truly interested in integrating fitness into your current systems, then this class is for you. To learn more about this 25-hour online course offering, visit our virtual learning platform at online.sports-seminars.com, or visit the link in our show notes to take 10% off of your registration using promo code PODCAST. That's P-O-D-C-A-S-T. And be sure to visit the website at online.sports-seminars.com. Now, back to the show.

I think that's super important. Now, like I said, I do it all myself, but I also have a lot of colleagues who they do the first 3 and they work with people on their team or work with other people that actually finish out the rest of the care. So the other thing that I want to touch upon, in my mind, the only reason we perform rehab is to open up neurological windows of opportunity to load tissue. The only way we can make long-term change to tissue is through application of load. And so what we do in rehab is just opening up these neurological windows to put us in positions to make loading tissue successful. So the end goal for every person that comes in my office is fitness, and I'm pretty successful in integrating that into almost 80% of my client populations. Also, we have to think about placing load into biological organisms is the only way we can create long-term physiological adaptation. And then everything we do in our clinic ultimately comes down to the application of force. Now, the big question that I want you to try to answer with what we talked about today is why do we need to work through these stages of the rehab continuum? And the answer has to be patient care is not terminated until the patient has had their normal function restored. And this is individual and context-specific. Again, just because the soccer player's knee pain is gone doesn't mean that care is over. Care is over when their normal function is back to equilibrium, meaning can you run up and down the field like you did before you were injured? Yes or no? And if the answer is no, care's not over yet. You might not be the one in charge of that patient at that time, but they're still going through that rehabilitation continuum. The last thing I want to talk about is this idea of a functional continuum. And if we go back to the specific needs that we talked about in our universal truths, what are the things that Homo sapiens were designed to do? These are the main things that we've determined from an aspect of function. And the first thing we talk about is, can you breathe properly? Now remember, we talked about breathing and that falls into acute management. Do you have proper mobility? Yes or no? If you don't, we need to stop and work on it. Mobility falls under foundational kinematics. Nextly would be, do you have proper motor control or stability? Well, if you don't, probably need to work on it. So that falls under our stage of care and motor control. If we get down here where it says general strength and conditioning, the first box would be, do you have the ability to control your body weight through fundamental patterns of movement? Push, pull, squat, hinge, twist, and locomote. If the answer is no, probably need to work on it. But fundamental movement patterns and aerobic endurance all fall under functional integration. If once you have fundamental movement patterns and aerobic endurance, then we can start to specify into either specific developmental preparation through progressive kinetics, You can see here we have speed and power, the next stage of our rehabilitation continuum, and then ultimately into sport-specific skill and work capacity, which is our last stage in fundamental capacity. So you can see that the functional continuum, the things that Homo sapiens were designed to do from a biological perspective, and the rehab continuum match up perfectly, which tells me that our idea that we're tying everything back into load and biology were meant to be a synergistic partnership. And so when we go through this with our clients, what you have to do is find the right landing point in stage of care and start to work them forward from there. So we always want to consider the functional continuum and how that relates to their specific hierarchy needs from a biological perspective. Now, that being said, where do you start with treatment when there's already known tissue damage with chronic pain, like a knee with multiple surgeries? If it's acutely painful, I would start in acute management. If it's not acutely painful, then I would start where— and that's the other thing maybe I should touch on is if you use the right assessment model, if you use this kind of idea of the clinical audit process, your assessment will tell you exactly where you need to go. If someone comes in and has had multiple knee surgeries, or I had a patient this morning that has that knee replacement, but it was 4 or 5 years ago. Okay, well, we're not starting in acute management. My assessment has led us that we are starting with foundational kinematics. So your assessment, depending on which one you use, will guide you to the right stage of rehabilitation. Normally with acute conditions, you're talking about less than 5 days. Like, this happened less than a week ago. Anything else past 7 days-ish is not necessarily acute. So your assessment should lead you specifically to what stage of intervention you need to start. Dakota asked, Do you actually use AUs to establish tissue adaptation or load quantification? Or when motor control now acquires the proprioceptive to handle the load capacity? I'm not sure exactly, Dakota, what you're trying to ask there. In the first part, do you use and express to the patient the 2 phases of care? So what I do is I have these stages of care, that poster that you saw on my wall in my treatment room, and I will Literally just walk them through that. My assessment leads that the reason why you're having knee pain is because your ankle's not moving. So the thing that we need to start with is to get that ankle moving to make your knee pain go away. And so we're going to start with foundational kinematics. And the thing that I probably feel like is the most optimal to get your ankle moving might be joint mobilization. And so I'll just show them where that is on the chart. And I go, remember in your activity intolerance where you told me that you wanted to be able to run a marathon? Well, running a marathon's way over here in our fundamental capacity or specific developmental preparation. So we've got to work our way all the way through these stages, and we have specific benchmarks along the way so that I feel comfortable when you're running a marathon that your knee pain is not going to flare up again. I find that with a lot of this stuff, it's all about how you explain it. If you just start with one particular stage and you're not telling them why, It's not necessarily something that they're going to follow through with. And there are— look, there's— I'm not going to lie to you, there are some patients that will come in and be like, yo, I just want my knee pain to go away. I don't really care about all the other stuff. I just don't want it to hurt. I go, okay, well then here's what I think we have to do. But in my practice, since it's a lot of really high-level athletes, or I work with a lot of athletic and even university teams, look, they need to get back to full function. And if they don't have it, The number one risk factor for injury is previous injury, and the second risk factor is right-to-left asymmetries. All of those fall under things that fit within this model. So if I don't get them back to full function, they're highly likely that they're going to get injured again. Does that answer your question, Dakota? Hopefully. Anybody else have any questions? Okay, well, if no one else has any questions, I would like to thank all of you for listening to presentation. I feel very passionately about this stuff because I think As chiropractic's trying to expand its reach within the healthcare marketplace, I think our scope of practice allows us to do a lot of things that other people can't. And because of that, we have the opportunity to reach a whole lot more people. So, oh, we have a question. Dakota, do you use Move2Perform? So that's a great question. Let me answer that real quick. Move2Perform, I actually just found out, is no longer operational. They're folding Move2Perform, the algorithm, into the FMS Pro app. So I'm getting, as an example, I'm getting ready next Friday to test 150 football players at a local university. And so we're going to use the Move2Perform app for part of our report of findings part. But we're also, we have come up with one of the things we talk about in our classes. We've come up with a different scoring system for the FMS. We're using their scoring system and interpret the data differently to make it more specific. So I would say we are going to be using the FMS Pro app, formerly known as Move2Perform. For part of it, and then we're going to use our scoring system for the interpretation of data. I will say for someone like Dakota, you took the class when it was the first version. We're on version 5, so we have a lot of updated information. And so we didn't necessarily talk about the new scoring system in the class that you were in, but obviously we're using that now. We found great success in using that to reduce injury. Caesar asked, do you train compensatory patterns if there's a structural or irreversible lack of function? If I'm understanding that right, let's say someone has a structural pathology that can't be changed. So maybe, for instance, someone has pins and screws in a joint where it doesn't allow it to function. So will I still train that? I will train it to its tolerable limit. So I will modify certain movements if I feel like we can get around it, or I'll eliminate certain movements. So maybe if I give you an example, I have a patient who I've trained for 15 years now who has— now has bone on bone in one of his shoulders. He needs a shoulder replacement. But he's just putting it off getting one until the pain gets bad enough because he just doesn't want to do it yet. So when we train, I will still train that shoulder, but I'll stop anything past about, I don't know, eye level. We don't do— so I've eliminated or gotten rid of those ranges of motion where I know he's going to be painful or compensate. And we'll only train and we modify how we train in our horizontal pulling pattern. So I will train if there's a lack of Structural pathology or a lack of function. It's all about modification or elimination, if that answers the question. Does anybody else have any questions? I'm happy to answer. Like I said, thanks for coming. Just a little shameless plug, if you found this interesting and you'd like to learn more, we are hosting a lot of Rehab to Fitness courses over the fall, God willing, if everything cooperates. We have one in Columbia in August, we have one in October in Tennessee, and one in November in Florida. But I also will tell you that we're making a nice shift to our model where in January we're going to do an updated course where we're going to a 16-week cohort model where you sign up for a 16-week course and we have 2 to 3 hours of material every week over a particular topic that's related to the Rehab to Fitness course. And then we do an hour Zoom call or Q&A with myself answering questions or other industry professionals that have an expertise in that area that we're discussing. I found in teaching the Rehab to Fitness course that when I'm trying to work with clinicians to get them up to speed on this stuff, that 16 hours over a weekend just wasn't enough. And we want this information out to young students and clinicians to— so we can have a bigger reach. And so we're going to make our model more robust by going to a 16-week online cohort. And at the end, when you're through with the 16 weeks, we're going to have our 2-day live course where we get to come in person and practice all the progressions and regressions and do this live in real time. So if you have any interest, stay tuned for that in January. We'd love to see you in some of our courses in the fall. If you have any questions, please feel free to reach out. If you want to reach me personally, you can send me a message on Facebook. It's Peter Jr., my personal page. You can go to Rehab to Fitness as a page, or my personal business page is Engineering Athletes. Or if you want to send me an email, you can send me an email. My personal email is peterjr@yahoo.com. As some of you who know me, I'm happy to answer questions at any time of day. And hopefully you found this information helpful. So thank you all for coming, and hopefully we'll see you at a class sometime in the fall. Everybody take care.

That's it for today's episode. Be sure to join us for episode 28, where we shift our focus away from clinical treatment onto something that's incredibly important when building a successful practice. The patient journey. In this 2-part training with Dr. Jeff Langmaid, we will discuss how you can seamlessly guide your patient's journey from potential patient to active patient, and finally to proactive advocate for your practice. We will also discuss tactical steps you can take to effortlessly attract, engage, and retain more of your ideal patients. You won't want to miss it! Episode 28 drops in 2 weeks, or 1 week for our Patreon subscribers. In the near future, we're also planning a few special Q&A episodes with our past instructors. So please be sure to click on the Q&A link in our show notes and ask any burning questions you may have. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Please give us a 5-star rating to help us grow the show. Every little bit helps. And last but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, as well as learn about any special offers that Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on FACTOR Rehab System course scheduled for the fall. And if you're interested in learning more about the FACTOR Rehab System, Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.