Table 2

Integrating S&C in UK Defence Rehabilitation: challenges and solutions related to clinical delivery

Commonly cited challenges	Proposed solutions
Clinical delivery
1. Within the MDT, how do we establish role leadership for the design and implementation of the patient’s S&C programme?	The existence of role overlap is inevitable within the UK Defence Rehabilitation care setting, and we believe this is to the benefit of the patient. However, while overlap between disciplines working towards a shared treatment goal is to be encouraged, duplication or poor training load management is actively discouraged. In fostering an effective MDT, clinical leadership, role clarity and treatment boundaries must be well established. Ensuring there are agreed goals on commencement of treatment and effective communication between team members throughout the patients care pathway is recommended. Standardising the approach taken to assess determinants of S&C-related performance and physical performance tests would provide consistent and unambiguous feedback from all therapists involved in the patient care pathway. While ordinarily the clinical team leader would allocate individual responsibilities to implement such solutions, the very nature of an MDT promotes shared decision making across all team members.
2. The availability of an objective performance based-outcome measure that specifically informs the effect of therapeutic S&C interventions.	The recently updated British Armed Forces PES provide an objective measuring tool that can identify the current physical and functional status of military personnel with MSK injury. The PES are well understood by military rehabilitation practitioners; therefore, referring to a patients current physical status against these physical assessment measures may provide an occupational specific means of monitoring strength gains/improvements across the entire rehabilitation care pathway. For example, progress of the patient could be assessed against their capacity to perform exercise on a force–velocity curve (see figure 3) and their functional performance against PES/SCR (see online supplemental file).
3. When administering a concurrent training programme (with multiple competing treatment aims) in Defence Rehabilitation, how do we optimise physical function while avoiding an interference effect?	Concerns related to the interference effect of concurrent training are primarily a concern at the later stages of rehabilitation (figure 2, phase II). This is when greater consideration of exercise selection, course timetabling/programme design and monitoring are required to meet specific areas for improvement identified via clinical and/or performance-based physical assessments. Understanding the physical requirements of a patient (PES) is therefore vital to ensure strength programmes can be designed to accelerate rehabilitation care. Furthermore, careful scrutiny of group-based exercise classes is vital to ensure the principles of therapeutic S&C are being correctly incorporated or modified to meet the needs of the individual.
4. How do we achieve morphological changes in muscle tissue size and strength while following the traditional 3-week period of residential rehabilitation?	It is becoming increasingly recognised that the patient’s preintervention expectations will influence postintervention satisfaction.21 Typically, to achieve significant morphological changes in muscle tissue requires a 8 to 12 weeks strength training programme, with early increases in muscle strength primarily explained by neurological adaptations.22 Therefore, it may be unrealistic to expect significant physiological adaptation to strength training within 3 weeks and for patient expectations of recovery to be met. An alternative approach may involve an emphasis on education, coaching and personalised mentorship in order to empower the patient to self-manage rehabilitation using a home-based programme over a longer duration (eg, 3 months). This would provide a realistic timescale to gain a physiological adaptation thereby aligning patient expectations with known timescales for physiological recovery. Some evidence supporting this approach to rehabilitation care is provided by the existing 1-week hip and groin education programme with 3-month follow-up, which is increasingly showing promising physical, functional and occupational outcomes.23 This approach would also complement the growing popularity and evidence for the use of telemedicine/telehealth among clinical populations to promote health outcomes and quality of life.24
5. How can we integrate the principles of S&C in the presence of acute or persistent pain?	Progressive exposure to painful movements without adverse experience is essential to the desensitisation of non-nociceptive or neuropathic MSK pain.25 The principles of modifying movement patterns, manipulating training variables, and dynamically adjusting training programme load are available to clinicians (see Table 1). Using training load monitoring methods such as session rate of perceived exertion may also prove clinically useful.26 27 However, conventional training principles were developed using healthy adults (Figure 1). Incorporating the principles of S&C into MSK rehabilitation where pain is the primary limiting factor to progress remains a considerable challenge. This is an area worthy future research effort.

MDT, multidisciplinary team; MSK, musculoskeletal; PES, physical employment standard; S&C, strength and conditioning; SCR, soldier conditioning review.