Most individuals, be they athletes or general population patients, understand that exercise is the most important factor in the rehabilitation of most musculoskeletal disorders. However, different types of exercises serve different purposes in the rehabilitation process, and we as health care providers (myself included) often fail to fully explain these purposes.


Within our model, we talk about different types of load that can contribute to an injury and that need to be addressed in rehabilitation. Our assessment of these different types of load will dictate how we go about our exercise prescription.


  1. Direct, tissue-specific load. This is where we are applying load directly to the injured tissue. Say for example an athlete has a hamstring strain. A hamstring curl, involving direct contraction of the injured tissue, would be an example of an exercise for direct, tissues specific loading. These are the exercises that are often confusing to patients, as many individuals assume that an injured structure requires rest, and sometimes (depending on the type of structure involved) these exercises will cause pain during and/or after exercise.. However in order for a structure to increase its tolerance to the stress of whatever activity we are aiming to return to, we need to develop the load tolerance in a graded manner. 
  2. Indirect load. With these types of exercises we are addressing potential causative factors, or improving/maintaining capacity in uninjured areas. In the same example above of a hamstring strain, this might be strengthening the glutes to help offload the hamstrings in a movement involving hip extension.
  3. Systemic load. These are exercises that target areas unrelated to the injured area. An example might be performing training the opposite leg to maintain strength in the affected limb via the cross education phenomenon. Or we might want to performing something like swimming to maintain cardiovascular fitness, or simply capitalise on the analgesic effects of general exercise.


These exercises may look similar from the outside, but have very different purposes and therefore should be prescribed and progressed in different ways. 


#rehabilitation #patienteducation 

About the author

Sam Gilbert

Sam Gilbert is a registered physiotherapist with the Australian Physiotherapy Association (APA) and certified strength and conditioning specialist (CSCS) with the National Strength and Conditioning Association (NSCA). He holds a bachelor’s degree in Physiotherapy from Latrobe university (Melbourne, Australia) and a master’s degree in Exercise Science (Strength and Conditioning) from Edith Cowan University (Perth, Australia).

A 3rd Dan black belt in Shinkyokushinkai Karate under the World Karate Organisation (WKO), Sam participated for over 20 years in full contact competition, winning multiple state and national titles, and culminating in a 4th place in the heavyweight division of the Shinkyokushinkai World Cup in 2009.

As the co-founder and clinical director of Club 360, the premier multi-disciplinary health and fitness center in Tokyo, Japan, Sam has combined his practical experience with an in-depth study of sports performance in relation to combat sports, and strives to help other combat athletes reach their full competitive potential, whilst at the same time decreasing injury risk and increasing competition and training potential.

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By Sam Gilbert