The Mess that is "The Middle": Making Sense of the Rehab Process and What is Important for You.

Have you ever watched a crime show where the timeline of events, key players, and relevant information is pinned across a bulletin board for the investigators? A smattering of elements, pieced together to tell a story. Next, think about the assembly of that bulletin board. It takes consideration, time, effort, action, and reflection from the investigators to accumulate this information, consider it, act accordingly, and adjust as needed until the problem (or crime) is solved. That bulletin board is developed in the middle. The middle is messy. The middle is not always clear cut or well defined. The middle requires hard work. In many ways, the middle is a lot like the rehab process.

I’d like for you to consider the investigation bulletin board described above. Consider all the components and information that might be needed to solve the crime. Messy right? In this blog, I’m going to overview components of the rehab process that can make things… messy, but necessary. Rehab following a mild ankle sprain or an ACL tear are familiar to many people, but most of the injuries I see live somewhere in the middle. The middle is not always clear cut or well defined. So, to help, I’m going to divide the middle into three categories: The Basics, The Goals, and The Person.

The Basics: Severity, Complexity, and Pain

Severity

The degree to which structures or tissues are damaged is often categorized by severity. The more severe the injury, the more time needed for tissues to heal, which often increases the time before returning to full activity. The best example of this are lateral ankle sprains or “rolling” your ankle. Grade I ankle sprains result in minor damage and individuals can often return within the week (0-3 days). Comparatively, a grade III sprain results in return to activity windows between five weeks and one year. If your first thought happened to be wow that is a large difference in time… ankle sprains have a high rate of becoming chronic if rehab is not fully progressed and reintegrated back into training.

Complexity

Complexity accounts for the factors that can make a clinician’s decision-making process more difficult and intricate. This can include prior health or surgical history, multiple injuries, and personal factors meaningful to the patient. Two factors I see regularly that increase complexity are time since injury and psychosocial components related to physical health and exercise. The longer individuals wait to address their pain, the more complex the case tends to be, especially once an injury is progressing over weeks to months.  An individual’s relationship with exercise, fitness, and rehab, whether bad, good, or anything in between is important.

Pain

Pain is such a complex topic that it demands its own blog. Consider the previous two components, then read the definition of pain:

an unpleasant sensory and emotional experience, often associated with actual or potential tissue damage, and is a personal experience influenced by biological, psychological, and social factors

I’ll keep this topic simple: pain can be simple, but it is often more complex. It’s a normal part of being a human and our relationship with pain plays a role in the rehab process.

The Goals: Activity, Rehab – Performance Continuum, Longevity

Activity, Exercise, and Sport

The reason so many of us love to engage in sports is because of the association with recreation. The beautiful thing about recreation is that it can mean come in a myriad of ways. I’m very lucky that most of my patients and clients are physically active or involved in sport, but most Americans aren’t moving enough. More than 75% of adults over 18 do not meet weekly physical activity standards. So, here is my clinician plug:

150 minutes of moderate-intensity activity, or 75 minutes of vigorous activity per week

2 days of muscle strengthening activity per week

After that, the more you engage with physical activity, the more deliberate your rehab and training goals should be. But if this proves to be difficult to perform on your own… it might be time to find someone to help.

Rehab – Performance Continuum

“Rehab is training in the presence of injury.” – Phil Glasgow

A common fallacy I observe is the notion that physical therapy needs to look drastically different from our regular workouts and training sessions. Just like the sentiments above, the higher the demands of the activity, the higher the standard for rehab and returning to activity. Regardless of the modality or setting, rehab and training have roots in basic strength and conditioning principles. Our goal is always a return to activity that improves patient / client self-efficacy so they can engage in their own outcomes.

Longevity

Regular and consistent physical activity plays in a positive role in reducing functional and cognitive decline, as well as prevention and management of chronic conditions such as diabetes and cardiovascular disease. Did you read that stat above? It said 75% of Americans over the age of 18 are not meeting physical activity standards, and that number only worsens with age. We know that physical performance indicators such as strength, endurance, and power improve late-life function and quality of life, so what is hindering our ability to be physically active as we age? Often, it’s our ability and determination to engage with physical activity across a lifetime, which alienates us from feeling capable and comfortable in environments that promote physical activity. I’d like to highlight some numbers relating to the effects of physical inactivity:

One year of physical inactivity resulted in:

18.7% decrease in endurance

19.4% decrease in speed

24.5% decrease in strength

Conversely, one year of exercise resulted in:

10.6% increase in endurance

9.2% increase in speed

30.6% increase in strength

My recommendation? Adapt and continue to find ways to stay physical active and engage with your health.

The Person: Honoring the Process, Addressing the Individual

Honoring the Process

Towards the end of 2024 I wrote a blog about the importance of practice in the rehab and fitness fields. And while there are real and positive effects of participating in the process, I also think it’s important to understand the effects of accumulating exercise and training dosages. When we exercise, we stimulate the systems that contribute bodily function and performance, which in turn stimulates a cellular response to bolster those same systems. This is the process of mechanotherapy. In many ways, the consistent effort placed into this process of getting stronger, more fit, more conditioned is more important than the end-result of achieving a specific standard.

Addressing the Individual

If you take away anything from this blog, I’d like it to be this: there are countless ways to go about addressing your pain or injury. Consider all the components outlined above, and how they can complicate or extend your rehab process but also consider how these components can make your care highly individualized when addressing what is most meaningful. At the end of the day, this only needs to work for one person, you. The middle is dynamic, constantly evolving, and yes, messy. Which is why I’ll end with my final piece of advice: dive into the middle, trust your hard work, and try to have some f***ing fun.