How to Implement Periodization In Rehabilitation

In December 2019 (before the COVID madness took off) I had the privilege of attending Greg Lehman’s “Reconciling Biomechanics With Pain Science” course (1).

Greg talked about the potential of using a client’s goal activity (in his case gymnastics) as the main component of a rehab program. He discussed how, in some cases, it can be helpful for some and counterproductive for others. In his example, he found that continuing to work on aggressive gymnastics flips aggravated an abdominal strain.

This, and an editorial paper made me think “when can we use a concurrent approach to rehab and when do we need a phasic approach to rehab?” (2). We talk a lot about periodization in strength training – particularly in the course of the past decade when it seems like everyone was using phasic (i.e. linear, block) periodization or concurrent periodization – but it gets less attention when designing a rehab plan. This blog aims to shed some light on the different approaches in rehabilitation. If you want to learn more detail about periodization for athletes, check out Amy Arundale’s Masterclass on Return to Play.

But first, let’s define some terms.

What is periodization?

Periodization in strength training refers to the process of organizing training so that your performance is maximized on the day(s) that matter (i.e. a track meet, powerlifting meet, marathon run, or playoff game) and so you avoid burnout. Some people define periodization simply as “a plan.”

What is concurrent periodization?

Concurrent periodization means training all attributes concurrently (strength, speed/power, and hypertrophy) within a training session or a training week.

The most well known example of this is the conjugate training method popularized by the powerlifters at Westside Barbell which consists of 2 days a week where the powerlifts are trained in a heavy (max effort method) fashion and 2 days a week where the powerlifts are trained in an explosive (dynamic effort method) fashion. The powerlifting movement of the day is then followed by higher rep (repetition effort method) accessory exercises to build muscle.

Another (less popular) example is the system used by Mike Boyle Strength & Conditioning where a single training session will often consist of power, strength, hypertrophy and conditioning exercise all in the same session.

When is concurrent periodization appropriate in rehab?

A concurrent approach can be used when all desired attributes (e.g. strength, ROM, power, individual goals) can be worked on concurrently and safely without (long-term) worsening symptoms.

An example of this could be a young athlete with achilles tendinopathy who starts to get pain halfway through a basketball game. We must assume that his strength, ROM, ambulatory ability and gait aren’t too bad as he can get through half a game of basketball without pain. In this case you can work on all of these attributes and progress the athlete’s basketball endurance at the same time.

For the purpose of this article and simplification I’m mainly using athletic populations – but it can be applied to general populations and even senior populations as well. Power loss is one of the biggest issues that can affect seniors. As long as they can safely weight bear, balance and ambulate without gait aids (and have no medical precautions), power/strength can be developed through resistance/body weight exercises done with a fast concentric (performed safely) in conjunction with balance, range of motion and endurance exercise.

What is phasic periodization?

Phasic periodization, in strength training terms, is where training is broken down into phases (weeks-months in length) that focus on specific attributes. Examples of this in training are linear and block periodization where training transitions from a phase of high reps with lower weights (hypertrophy or accumulation) to a phase with moderate reps with moderate weights (strength or transmutation) to a phase with high weights and low reps (peaking or realization).

Side note – If you are interested in learning more about periodization for strength training and athletics, I highly recommend the following resources:

• The Periodization Bible by Dave Tate (3)
• Advances In Functional Training by Mike Boylen (4)
• Training = Rehab 3 By Charlie Weingroff (5)

When is phasic periodization appropriate in rehab?

A phasic structure to rehab is more appropriate than a concurrent structure in two scenarios:

Scenario 1:

When certain prerequisites (i.e. weight bearing status, ROM, strength, psychosocial factors, time since procedure) must be met before progressing to further activities.

A simple example of this is someone who’s had rotator cuff surgery. Based on Canadian protocols – they will likely be in a sling for 6 weeks, cleared to do active movement of the arm at 6 weeks, and then cleared to do strengthening at 8-12 weeks post-surgery. Obviously, in these cases you can’t work on separate attributes together and have to reach certain prerequisites before the next.

Another example could be someone with severe bilateral knee OA who’s dependent on gait aids and has limited mobility. They may need to develop a base level of strength, ROM, and weight bearing ability before progressing to more advanced strengthening, balancing, and power exercises.

A third example, could be someone who’s highly fear-avoidant with activity and has high psychosocial factors. In this case, you may need to (potentially in conjunction with mental health professionals) work to reduce those factors in order to get them to a point where they can start participating more in active therapy.

Scenario 2:

When the goal activities may be exacerbating and increasing symptoms in the long term.

I see this a lot in my powerlifting friends who continue to push through the main movements even though they may be continuously exacerbating their symptoms and regressing their rehab. In these cases, regressions may need to be made in terms of load (i.e. lowering the weight and/or decreasing training volume), ROM (i.e. switching from full ROM squats to box squats) or even regressing exercises (i.e. switching from barbell to goblet squats) to allow the affected areas to desensitize.

Wrapping Up

Periodization or planning a rehab or training program involves many factors and isn’t always as simple or black and white as this article portrays. I hope this provides some insight into when to use a concurrent or phasic approach. If you liked this blog then I highly recommend checking out Amy Arundale’s’ Masterclass on Return to Play in athletes for further periodization strategies. Thanks for reading!