One of the biggest mistakes I see people make when trying to rehab an injury is compartmentalizing difficult, progressive training and rehab.
I understand this difficulty because it can seem like there's a massive gap between what your soft tissue may permit you to do and what "needs" to be done to progress your training towards your goals. It's part of what creates this dichotomy in our brains of "training" versus "rehab." But they aren't mutually exclusive.
If you want to bridge the gap between training and rehab, especially as an advanced athlete or motivated athlete tired of the boring "three sets of eight to ten reps of rehab movement," there are plenty of ways to break the mold.
RECENT: Feel Your Back Again with the Seated Prone Row Bench
The massive caveat to this is that you still need to be addressing the overall environment that your tissue lives in. Look at things like movement quality and overall mobility.
For most of us, bringing up tissue integrity and resilience has to be done in a way that matches how we train: It has to be able to withstand challenge.
Implementation of intensity techniques and extended sets has been one of my favorite ways to allow my clients to get back to training. It has allowed me to gain confidence back in my own tissues' ability to push a set hard (and rebuild trust) after injury.
What is an Intensity Technique?
Suppose we define intensity as "proximity to failure," either mechanical or technical. In that case, an intensity technique essentially drives more reps closer to that failure point with a systematic approach that is trackable, progressive, and qualitative.
Anyone who's been injured knows there comes the point where learning to trust your body again is a bit of an art. Trusting it to stay put together when fatigued (intra-set) or straining through a hard rep is a bit of a lost art in the rehabilitative context.
It's important to define intensity (with regards to proximity to failure) before utilizing an intensity technique. Failure can be a pure mechanical failure (as in, the muscle cannot produce enough force to complete the rep) or a technical failure. How you standardize your training will depend on your injury, training block/history, training goals, and even movement selection.
You can use the Rate of Perceived Exertion (RPE) or Reps in Reserve (RIR) system to determine proximity to failure– in general, MOST people don't actually take their training to "1 RIR" as often as they think, but a smattering of literature will tell you that's okay, and that there's change that occurs within reps even further away from failure. As a good rule of thumb, I prefer stable implements (like a machine) where external stability is provided for a movement I want to take to pure muscular failure. Movements with more degrees of freedom of movement or requiring a high skill component should be kept within the "technical failure" (where technique breaks down) realm.
A good example of this might be a leg press versus a smith machine. With a smith machine, there's a greater amount of joint movement as well as stability (if you consider all the joints of the spine, for example) compared to the leg press, where you're locked in AND have a frame of reference for stability (the back pad).
Favorite Intensity Techniques
My favorite intensity techniques when bridging the gap from rehab to training are:
- Cluster Sets
- Myoreps
- Rest-Pause Work
- Partials
Each of these needs to be considered with the following variables:
- What joints are you trying to load?
- Where is the most limited portion of the movement, from a strength standpoint?
- How easy is setup for multiple sets in a row?
- What is the intent with regards to a more or less stable implement?
There is a time for both. Early in a block, you may want to use a more stable implement to gain confidence and tissue resilience. As a transition between a stable implement and a barbell, a less stable movement can serve as a go-between. Movement selection becomes an important detail with regard to intent.
Rest-Pause Work
Within a spectrum of "reps accumulated in proximity to failure," there are nuances. For example, most people in a traditional bodybuilding setup will approach rest-pause work with true failure points. From a rehab standpoint, you could modify this to stay within 2 RIR, allowing gradual load exposure and linear progression. Strength athletes use cluster sets to condense training. Bodybuilders will often use them to gain work density and condense total workload. Cluster sets can also be used for rehab for quality work to be done under a fatigued state.
While muscle rounds can be torturous for bodybuilders, they can improve tissue capacity and cellular changes (think physiological adaptation like improved vascularity and mitochondrial density if the sets last long enough) that promote an environment that improves recoverability and conditioning. For strength athletes, it tends to be a weak point.
Which type of intensity technique you use should be based loosely on ease of setup, desired proximity to failure or failure points (rest-pause versus myoreps, for example), and total desired volume. You also have to consider total work:rest ratio.
Cluster Sets
I'm a huge fan of cluster sets on an implement like the leg press for lower body training. It allows quality work to be done at a threshold where the "weakest link" doesn't limit the set so much as overall conditioning.
Sets of smaller numbers of reps (say five) allow technical perfection, allowing focus to remain high. The overall volume can be monitored week to week (6x4) and allow the work:rest ratio to be monitored simultaneously (5x5 is "roughly" the same number of reps as a 6x4, but the work:rest ratio is modified). They're easily and objectively tracked and measured with standardized rest times, and most athletes can modify a movement to perform the clusters independently for five sets. Usually, someone can unrack a leg press four to five times.
Upper body training provides a different situation for something like a machine-loaded shoulder press. The biggest limiting factor here is often setup—clearing the first rep can be problematic. A 5x5 cluster (or even 12/4/4/4 myoreps) may be more limiting as someone will need to basically "start" the set (the hardest point in the movement) five separate times.
Moreover, I tend to find that most people have an easier time gauging true failure points with upper than lower body. You'll see someone hit an actual 1 RIR on upper body training more often than 1 RIR on lower body training (where it might feel like your eyes are bleeding, but on video, you had three to four reps in the tank). Something like a rest-pause set that takes you closer to multiple failure points may be more appropriate, especially if Week 1, you keep two reps in the tank. It leaves you room to progress linearly over the next few weeks and set yourself up for success.
Conclusion
There's a LOT of nuance in the application. Still, while way too many of us continue to compartmentalize our training into "rehab" or "hard training," it's important that coaches, athletes, and clinicians start to think differently about how we can go about carving a different path.
We need to think about tissue tolerance, cellular/physiologic changes that occur with training, and taking sets closer to failure in a stable environment to provide nervous system input that downregulates threat perception. When I'm working with an athlete, these are three of the most common themes that need to be addressed. If we can do that while also permitting a sense of self-efficacy/allowing the athlete to train, it's a win all around.
Dani is a Doctor of Physical therapy, CSCS, nationally qualified women’s physique competitor, and elite level powerlifter in the 123 class. She's the first to admit she pushes the envelope with training, which uniquely allows her to blend principles of rehab with a love for all things iron. Creativity, relationships, and trust drive her to empower coaches and athletes with tools and education from a PT who understands training demands. Visit MERGE Performance to learn more (remote PT services, consults, and training).
