We use the three Rs concept in rehabilitation and exercise to create a checklist. Here’s what I mean by that: Imagine that each R has a box next to it—you’ll check off that box before moving to the next R.
Now I’ll tell you what the Rs are: Reset, Reinforce and Reload.
The first time I addressed this concept was to a group of physical therapists in Amsterdam. They were trying to get their heads around the reason we need to look at movement before a lot of other medically condoned breakdown tests.
We’re trying to capture movement dysfunction at the level of the pattern—not just having an assumption the glutes are weak, or measuring a lack of dorsiflexion. My first role is to demonstrate how perhaps glute weakness affects a movement pattern, or how the dorsiflexion limitation may provide a poor foundation and create faulty balance.
We can go through the body with checklist of the many imperfections we all carry, or we could try to discover each individual’s major dysfunctions. We could then work back from those dysfunctions to find what we think are some of the driving forces behind them.
Once we do that, our intervention requires that we do something. What’s the first something we do? Reset.
If you’d prefer to listen instead of read,
here’s a longer audio version of this article,
Episode 21 of Gray Cook Radio
In clinical rehabilitation, we have to make an intervention. We don’t just tell people to do more of an exercise. Usually these people are in pain. If they could do more, they would, but they’re limited by pain or disability… and they can’t.
Many times, we have to use manual therapy to help them climb out of the well. The first order of business is to see if inflammation is driving the system, because if it is, we consider that a chemical problem, not a mechanical problem. As long as you have inflammation on board, you’re going to have inappropriate signals, inappropriate muscle tone and poor movement patterns.
Imagine you hurt an ankle. It’s red, hot, swollen and twice the size of the other ankle. Today is not a good day for squats. As a matter of fact, today’s not even a good day for walking. Today’s a good day to get rid of that inflammation.
We’ve clinically demonstrated that when your joints are swollen or effused, you immediately have reciprocal muscle inhibition. The muscles around that joint are inhibited by the swelling. Pushing your way through joint pain or a swollen or inflamed joint doesn’t make sense on any level, much less on a neurological level.
Let’s say inflammation has been appropriately managed by modalities, medications and behavioral modifications of rest and recovery. We might still see poor motor control or poor movement mechanics. It could be because of the time spent not doing anything, or it could be because of the behaviors associated with limping, bending, twisting and compensation after the injury.
In this example, for all practical purposes there’s no longer a chemical problem because we’ve managed the activity level. We don’t have a lot of inflammation. There are the after-effects of the trauma, but the inflammation is gone.
We still have poor motor control. We could have a certain degree of muscle atrophy. We could have uncoordinated muscle behavior. We could have increased tone. We could have residual trigger points. What we have to do is identify, What are those motor control and movement limitations? What are the problems with mobility and stability?
In rehabilitation, we make a manual intervention. We might hold a joint with our hands and mobilize or manipulate that joint. We do soft tissue work either with our hands or tools, and work deep into the tissue or on the fascia. We might use needles to do a musculoskeletal technique called trigger point dry needling.
We’re going to do something physical to see if we can change motor control or mobility. If you couldn’t bend forward and we saw some stiff vertebral segments, we may want to mobilize those.
Moving those segments completely changes the neuromuscular support around that joint. It may free up some muscle tone and allow you to move through your spine a little bit better. This is still without suggesting an exercise or making you actively do anything.
We did something passively, meaning your role was passive. At the end of that, we should see an appreciable change in something we measured. Did your level of control go up or did mobility improve? If it did, clinically that could be considered a reset.
It’s a window of opportunity.
The first thing we want to do is protect the reset. Having you jump off the table to go play 36 holes of golf is not a real good plan. What I’m going to do is reinforce the change I just made.
There are two ways to do that—Both protective and corrective measures can do that.
Protective measures keep you from getting worse, but may not make you better. Corrective measures actually work toward helping you foster or start the reset process yourself.
If I thought sleeping on your stomach might be complicating your neck problems, I might give you some advice on lifestyle. I might give you a brace or an orthotic, but I might also use some leukotape or kinesiotape to hopefully facilitate better activity or enhance the feedback when you move. This reinforcement doesn’t push you farther along; it keeps you from backsliding between therapy sessions.
The reloading is where we actually teach exercise and look for a pattern or a part of a pattern to reinstate motor control. It would be futile to try to reload something if we didn’t have good reinforcement. We’d continually be taking two steps forward and three steps backward.
It would also be inappropriate to expect you to fix it yourself when part of this vicious loop of moving poorly and not sensing enough information to self-correct will perpetuate itself.
The reset is a largely passive activity on the patient’s part.
The reinforcement is where we do lifestyle management and offer conservative advice.
The reloading is therapeutic exercise.
You have no idea how many people come to our workshops, dispense with some of the advice we give, attempt a corrective maneuver on somebody who probably needs some manual intervention and some lifestyle critique, and hope that half-kneeling for four minutes a day will correct all the ailments discovered on a movement assessment.
I just gave you a medical scenario. However, I can completely turn these three Rs into corrective strategy used both in fitness and performance enhancement when people have movement dysfunction not complicated by pain.
The corrective strategy we impose may be foam rolling. It may be stretching. It may be static stability. It may be dynamic stability. But if we’re doing it right, the reset can demonstrate how the movement has changed.
How do we know the movement has changed? We’ve done a movement screen.
What are some of the things we can do to reinforce the corrective strategy? We may have to temporarily delete some activities. If we think your attention to detail in your kettlebell swings is sloppy, we may have to pull you back from that to get you moving. This will give you a better platform to have more attention to detail in your swings the next time out.
I didn’t say you couldn’t deadlift. I didn’t say you couldn’t work on your presses. I just said, ‘Your swings are not too good right now.’
Part of what I’m going to do to reinforce you not backsliding in your program is to temporarily delete an exercise.
I often have to do this for runners. Compounding a stride or gait pattern with more mileage probably isn’t going to get them any faster or make them a better runners. A lot of runners have gotten better by cutting back their running. A lot of lifters have gotten better by deleting a lift they weren’t doing correctly until they’re doing it better.
Reloading is also about programming. Programming could mean using a corrective strategy blended with some conditioning work, such as using supersets to establish better hip hinging and then doing deadlifts, and then maybe add some swings. We cover that in our forthcoming DVD, The Future of Exercise Program Design, due out in October.
This whole reset, reinforce and reload can be applied to both rehabilitation and exercise. In rehabilitation, we’re dealing with both pain and dysfunction. In exercise professions if people are acting as they should, we’re only really dealing with dysfunction.
If you identify pain, it’s not a fitness problem anymore. It’s a health problem. Let somebody who is licensed in healthcare deal with it or you’ll be banging your head against the wall looking for a new exercise for something that’s not a fitness problem.
Reset, reinforce and reload is a pretty simple concept, but don’t just do it and assume success. The way for you to know you did a reset is to see that you changed something, and you changed it without a lot of programming. You changed it in a very short session—often in a single session.
Then think what you can do to reinforce that, both by deleting things—being protective—and maybe by adding behaviors, which is being corrective.
For example, you might say, “I want you to superset this movement with a flexibility move every time you do it. I never want you working on your squat without doing squat mobility work first.”
One reinforces the other.
Then the reloading is the programming that maintains and supports the gains you’ve made.
But remember this: The three Rs don’t work if you don’t have a baseline.
If you have a baseline for movement, you can tell yourself whether you have permission to go from one box to the next because you’ll know you changed something. A couple of weeks down the road you’ll know if you have maintained something and reinforced it, and you’ll know if your programming is efficient.
It’s a mouthful, but I’ll tell you what: If you check those reset, reinforce and reload boxes, it might real hard. But it’ll make you better.