Welcome to the Complete Rehab Framework
🎯 An Integrated Approach
This framework combines three critical domains: capacity assessment (envelope model), force manipulation (cueing strategies), and clinical decision-making (protect/expose framework). Together, these create a comprehensive system for rehabilitation programming and exercise prescription.
🎯 Envelope Model
Nested capacity boundaries - tissue AND system envelopes that dictate what loads are appropriate
⚡ Force Manipulation
Cueing strategies that manipulate impulse, peak force, and ground contact time for tissue protection or challenge
🧩 Clinical Framework
Protect/Expose × Validate/Violate quadrants for matching approach to patient presentation
📚 What This Guide Covers
- Envelope of Function Model: Understanding tissue and system capacity boundaries
- Force Manipulation & Cueing: Absorb, Feel, and Attack strategies for modulating load
- Clinical Decision Framework: Quadrant system for patient-specific approaches
- The 5-Phase Rehab Continuum: From acute injury to performance with LSI benchmarks
- 3 Golden Rules of Exercise Prescription: Biological factors, goals, and preferences
- Interactive Knowledge Quiz: Test your understanding of the complete framework
🎯 The Envelope of Function Model
Think of capacity like nested 'envelopes' - boundaries of what can be handled safely. Movement demands must fit within BOTH tissue AND system envelopes simultaneously.
Force production must respect both boundaries - tissue capacity AND global system capacity
🏥 Tissue Envelope
Local capacity factors:
- Inflammation and healing stage
- Previous injury history
- Tissue conditioning level
- Structural considerations
When tissue envelope is small, use ABSORB cues to minimize peak forces and protect healing tissues.
🧠 System Envelope
Global capacity factors:
- Psychological stress levels
- Sleep quality and quantity
- Cognitive load and demands
- Life circumstances and context
A small system envelope limits tissue capacity even when tissue is healthy. Use protective cues until system improves.
⚠️ Critical Clinical Point
A healthcare worker might have good tissue healing but a small system envelope due to shift work and stress. Treatment must address both levels - tissue rehabilitation alone will be insufficient if system capacity remains compromised. This is why we match cue intensity to BOTH envelopes.
How Envelopes Determine Cue Selection
→ PROTECT approach + ABSORB cues mandatory
"Land soft and slow - your body needs protection right now"
→ FEEL cues with caution, avoid ATTACK
"Feel the load, stay controlled - respect your current stress level"
→ Progress ABSORB → FEEL as tissue improves
"Your mind is ready, now let's progress your tissue capacity gradually"
→ EXPOSE approach + FEEL/ATTACK cues appropriate
"Attack this movement - you have the capacity for explosive force"
⚡ Force Production & Cueing Strategies
Ground Contact Time: ~500ms
ABSORB Strategy
"Land soft and slow"
- Long contact time (500ms+)
- Low peak force
- High total impulse
FEEL Strategy
"Feel ground, then push"
- Moderate contact (300ms)
- Moderate peak force
- Balanced profile
ATTACK Strategy
"Attack and explode"
- Short contact (150ms)
- High peak force
- Low total impulse
💡 Key Integration Principle
These force profiles map directly to envelope assessment. When both tissue and system envelopes are small, ABSORB cues protect tissues by reducing peak forces. As envelopes expand, progress through FEEL to ATTACK cues. The envelope assessment tells you WHICH cues are appropriate for the patient's current capacity.
🧩 Four-Quadrant Clinical Framework
Protect/Expose Axis: Based on objective envelope assessment (tissue + system capacity)
Validate/Violate Axis: Based on whether patient beliefs match reality
🛡️ Protect + Validate
When: Real tissue irritability + Appropriate protective beliefs
Target: Type 1 presentations, appropriate caution
"You're right to be careful - your tissues need protection. Here's how we'll progress safely."
⚠️ Protect + Violate
When: Real tissue irritability + "Push through" beliefs
Target: Type 2a (endurance copers)
"I know you want to tough it out, but that's making things worse. Your tissue genuinely needs rest."
👁️ Expose + Validate
When: Capacity exists but fears are present
Target: Type 2b needing graduated exposure
"Your concern makes sense AND you're ready for more. Let's explore this together."
📈 Expose + Violate
When: Capacity far exceeds perceived limits
Target: Type 2b when beliefs don't match reality
"That belief doesn't match what your tests show. Your avoidance is the problem, not your tissue."
🎯 The Integration: Quadrants × Cueing
The Quadrant Model tells you WHICH approach to take based on envelope assessment and beliefs. The Cueing Model tells you HOW to implement that approach through language that modulates force production. Together, they create a complete framework for individualized rehabilitation.
The 5-Phase Rehab Continuum
✅ The 4 Key Questions for Every Phase
- What is the capacity of the tissue now?
- How can I improve capacity now?
- What tolerance levels must they demonstrate to progress?
- What is the final capacity the patient needs?
Phase 1: Early/Acute Phase
Initial ManagementCueing Strategy: PROTECT + VALIDATE + ABSORB cues mandatory
🎯 Primary Focus
- Initial management and symptom modification
- Finding entry point to loading (PRICE, POLICE, PEACE and LOVE)
- Progress through ROM limitations
- Tissue tolerance to stretch (passive, active, active-assisted)
- Muscle activation and control work
⚠️ Common Constraints
- Pain and irritability
- Fear avoidance
- Volume load tolerance limitations
📋 Typical Programming
Low external load, high frequency work: 3 sets a couple of times per day of "go till it burns" theraband or low-level control exercises
✅ Exit Criteria
Can tolerate higher volumes of low external load work
💬 Essential Communication
- "We can see you're tolerating some loading now"
- "Tissues are starting to positively adapt"
- "Will be ready for more effective training soon"
Phase 2: Early → Mid Phase
Tissue Tolerance BuildingCueing Strategy: Continue ABSORB, begin transitioning to FEEL
🎯 Primary Focus
- Continue progressing ROM and tissue tolerance
- Increase training volume gradually
- Begin implementing principles of mechanotransduction
- Focus on tissue remodeling
📋 Typical Programming
Progressive increase in volume and load while maintaining symptom control. Still relatively high frequency, moderate external loads.
✅ Exit Criteria
Ready to progress to hypertrophy-focused training with moderate-high loads
Phase 3: Mid Phase - The Rebuilding Phase
70% LSI TargetCueing Strategy: Progress from ABSORB → FEEL cues
🎯 Primary Focus
Put away the theraband! Load tissues with implements specific to patient's goals.
- Work through hypertrophy training continuum for most volume
- Add low volume, higher load strength work (likely constrained by tempo)
- Include force absorption work
- Consider initial plyometric preparatory work
📋 Typical Programming
Daily loading: 2-3 sets, 8-15 reps, 3 RIR (repetitions in reserve)
- Compound and isolation exercises involving tissue and associated kinetic chain
- Tolerate moderate forces for high volume
- High forces for low volume
✅ Exit Criteria
Greater than 70% LSI on functional assessments
All previous outcomes must be stable or improving
💬 Essential Communication
- "You're tolerating rehab and modified training well"
- "Tissues can safely perform controlled work now"
- "You're around 70% of pre-injury level"
- "Can be involved in low-level skill training, running"
Phase 4: Mid → Late Phase - Sport-Specific Building
90% LSI TargetCueing Strategy: Transition to FEEL and begin introducing ATTACK cues
🎯 Primary Focus
Build up to more specific training for sport/activity. Build toward high-level functional capacity.
⚠️ Critical Checkpoints
You must objectively assess tolerance to:
- Strength loading through ALL contraction types and intensities
- Supra-maximal / yielding strength (e.g., Nordics) - often forgotten!
- Full power continuum
- Full plyometrics continuum
📋 Typical Programming
2-3 times per week: 2-5 sets, 2-7 reps, 2-3 RIR
- Open chain and closed chain strength work
- Power and plyometrics work as appropriate
- Sport-specific movement patterns
- Progressive intensity and complexity
✅ Exit Criteria
Greater than 90% LSI on prior assessments PLUS high-level functional tests
All clinical assessments must remain stable
💬 Essential Communication
- "You're around 70-90+% of pre-injury level"
- "Should be involved in more 'normal' training at moderate intensities"
- "Low or no level of chaos yet"
- "I need to objectively see tolerance to ensure duty of care"
Phase 5: Late Phase / Performance - Return to Sport
95% LSI TargetCueing Strategy: Full ATTACK cues appropriate for performance demands
🎯 Primary Focus
Patient predominantly involved in normal training routine. Ramp up from controlled to chaotic environments.
- Team sports: Small-sided games → Full team training
- Fitness sports: Weight lifting → Met-cons
- Targeted extra rehab work to catch up to peers/unaffected side
📋 Key Assessments
Must demonstrate tolerance to extra volume of higher-level power and maximal loads:
- Pre-injury numbers on all affected lifts
- Jumping performance normalized
- Running speeds, volumes, accelerations, decelerations restored
- Sport-specific training tolerance
✅ Exit Criteria
Greater than 95% LSI on all testing + tolerance to agreed training sessions
💬 Essential Communication
- "You're around 95%+ of pre-injury level"
- "Acute tissue re-injury risk is LOW"
- "Risk from relative skill deconditioning in chaotic environments is HIGH until decent volume of full training"
- "Don't be afraid to suggest rest days if signs of increasing irritability"
- "Book follow-up appointments to reassess even if doing fine"
📊 LSI Summary Table
| Phase | LSI Target | Activity Level |
|---|---|---|
| Phase 1-2 | N/A | Symptom management, ROM |
| Phase 3 (Mid) | >70% LSI | Low-level skill, running |
| Phase 4 (Mid→Late) | >90% LSI | Normal training, moderate intensity |
| Phase 5 (Performance) | >95% LSI | Full training, competition clearance |
The 3 Golden Rules of Exercise Prescription
🎯 Core Philosophy
"Our ongoing clinical success is in the ability to guide our patients to participate in the most relevant physical activity for their current and future contexts."
These 3 rules apply to everyone from recreational athletes to elite performers, and from acute injuries to chronic conditions.
📚 Essential Exercise Science Nomenclature
- Tempo: Speed at which movement is performed
- Time Under Tension (TUT): Reps × tempo
- Volume: Proxy for work in a session (sets × reps × load)
- Load: External (kg, %RM) or internal (RPE, VAS, HR, VO₂)
- SAID Principle: Specific Adaptations to Imposed Demands
- Progressive Overload: Increasing work to drive adaptation
Rule 1: Know Your Biological Factors Brutally Well
This is how you reason what the exercise is doing to the tissues
Rule 2: Know the Goals - Make Sure They Match!
Don't butcher the SAID principle. Match person AND task
Rule 3: Know Your Patient's Personal Preferences
Exercise only works if they actually DO it!
Rule 1: Know Your Biological Factors Brutally Well
🔧 A. Biomechanics
Arthrokinematics / Kinetics
Your expert knowledge of modifying body positions to solve movement problems.
Example Problem: Anterior knee pain at certain load in squat
Solution: Sit back into hips to decrease external flexion moment on knee (within tissue capacity), transferring increased moment to hip
Pro Tip: Manipulate exercise selection / range of motion to adjust arthrokinematics
Whole System Kinetics
Forces acting on the whole system - play with tempo, TUT, reps, and load to modify total system kinetics without changing the movement.
Example: Same squat problem, different solution
Solution: Don't change exercise - change HOW it's done to decrease total system GRF and impulse within knee joint capacity
Pro Tip: Think isometrics and heavy slow resistance for tendinopathy
Summary: Change the way the movement LOOKS to deload a sensitive tissue, OR change the way the whole system is LOADED to deload a sensitive tissue.
🧬 B. Biochemistry / Cellular Biology
Pragmatic knowledge of cellular processes allows you to get the most bang for your buck and minimize disuse atrophy in rehab.
The 3 Mechanisms of Mechanotransduction
1️⃣ Mechanical Tension
Muscle cells detect stretch via special proteins → triggers muscle protein synthesis
- More growth with full ROM vs. isometric for same volume
- Pro Tip: Train through full ROM with higher external loads
2️⃣ Muscle Damage
High volumes (especially eccentric) → tissue breakdown → satellite cell recruitment → more muscle tissue
- Subsequent stress spread across more tissue
- Pro Tip: Increase total volume load and eccentric load
3️⃣ Metabolic Stress / Accumulation
High volume + reduced rest → metabolic by-products accumulate → chemoreceptors detect disruption → hormonal cascade → muscle protein synthesis
- Think "the burn" from high rep or isometric exercises
- Pro Tip: Increase TUT, minimize rest, work at/above lactate threshold
⚠️ Critical Application: Post-Operative Rehab
Problem: Limited by GRF or shear/compression forces → can't apply much mechanical tension or create moderate muscle damage (low external load, decreased ROM, low training volumes)
Solution: Maximize metabolic stress to maintain anabolic stimulus:
- Lower load
- Decreased ROM
- High TUT
- Low inter-set recovery periods
Summary: In most circumstances, patients can't use 1 or 2 of these mechanisms due to injury or pain. You better know how to maximize the one they CAN use to minimize effects of deloading!
Rule 2: Know the Goals - Make Sure They Match!
Don't butcher the SAID principle.
Specificity Relates to the PERSON, Not Just the Tasks
Your analysis should include traits like:
- Resilience
- Adherence
- Kinesiophobia
- Graded exposure needs
Sometimes people need exposure to tough things to build psychological resilience. Sometimes they need exercise to be flowing, melodic, relaxing because they're already in high stress mode.
⚠️ Common Challenge: Training Around an Injury
Problem: How do we keep training the athlete who can't tolerate closed-chain knee dominant exercises with high enough loads to be protective against further injury?
If we fail: Focusing JUST on low-level rehab leads to:
- Local tissue deconditioning
- Systemic deconditioning relative to peers
- Higher risk of subsequent injury on RTS
- Longer times in rehab
Solution: Find the most specific exercise on the spectrum that you can still train with relatively high external loads to maintain:
- Training tolerance in local tissue
- Total systemic training load response
Remember: There are many ways to vary an exercise to suit the individual. There's no one right way to squat, deadlift, press, etc. Find solutions, not problems. Remove barriers by finding techniques that suit the patient in their context.
Rule 3: Know Your Patient's Personal Preferences
"Saying exercise does or doesn't work is like saying food does or doesn't work."
Food only works if the person eats it. Exercise only works if the person actually does it.
Dr. Robert Sapolsky's 4-Point Checklist for Maximum Buy-In
1. Some Level of Control / Autonomy
- Likes and dislikes
- Ability to "feel" the movement
- Tolerance levels
- Exercises described and collaborated vs. dictated
2. A Sense of Belonging
- Shared patient-centered journey
- Not going it alone
3. Some Sense of Predictability
- Rough prognosis
- What if they do the intervention vs. don't
- Acceptable pain levels
- Barometers for improvement
- Progressions and regressions
4. An Outlet from Life's Stress
- Program should fit into patient's life
- Not add undue stress
📝 The 3 Rules in Shorthand
- Know the biological impacts of exercise and how the body adapts
- Know the goals of your patient and your exercise prescription
- Know the personal preferences of the person in front of you
🎓 The Bottom Line
For physiotherapists working with active populations, knowledge of S&C principles and how they affect tissue rehabilitation allows for clear communication around goals, timelines, and expectations. Knowing how to program ensures you can perform your duty of functional capacity assessment and risk mitigation - leaving no room for doubt in your decision-making.