Eliminating the Gap Between Rehab and Performance
Why "bridging the gap" isn't enough — and what a full continuum of care actually looks like
I recently came across a post on social media from a prominent education group in the field of musculoskeletal care. This particular group focuses on how to take patients from rehab to performance — a topic I follow closely. The post discussed their approach to rehabilitation strategies for a wide variety of musculoskeletal conditions, and listed techniques they teach to bridge the gap: Dynamic Neuromuscular Stabilization, Functional Movement Screen, Selective Functional Movement Assessment, McKenzie Technique, and Neurodynamics.
On the surface, there is nothing wrong with any of that. But it presents an interesting conundrum — and I think it helps explain exactly why the gap between rehabilitation and performance still exists. Because this is such an important topic, I think we should spend some time talking about it.
Considerations in education
To be clear, the group I’m referencing has a good reputation, and from what I can tell, their material is sound. My comments are not a criticism of their organization. This is a broader observation about the industry as a whole.
Their stated goal is to bridge the gap between rehab and performance by integrating principles that span different disciplines. They acknowledge that musculoskeletal healthcare is notorious for under-loading patients and encouraging fragility and deconditioning. They assert that in order to be resilient, athletes need to be prepared for specific tasks. All of that I agree with entirely.
My issue is with their approach to getting there.
Defining the gap
“Bridging the gap” is a phrase we hear frequently in rehab and performance circles. In practice, it refers to the transitional phase between discharge from therapy — where the goal is to be pain-free — and being fully prepared for the high-intensity, reactive demands of competitive sport. That transition is crucial, and it is almost universally mishandled.
The gap exists for a few distinct reasons. The primary one is the absence of a common language shared across all the professionals involved in human performance. Without a common language, communication between providers breaks down — and when communication breaks down, outcomes become inconsistent.
A second reason is the absence of a unified operating system that takes patients from the table to the field. When every provider is working from their own assessments, their own intervention strategies, and their own metrics for success, things fall through the cracks. In rehabilitation, when things fall through the cracks, patients get re-injured and become stuck in a vicious cycle.
A third reason is a fundamental gap in education around the full rehabilitation process. As I have discussed in previous posts that most of the time we are doing rehabilitation poorly. We are largely defining rehabilitation as the process of getting patients pain-free — not the process of restoring full function. And by function I do not mean the local, isolated function we typically target with treatment strategies. I mean the global function required to perform all the specific tasks necessary for success in a chosen activity or sport. That version of function is defined by the physical qualities required to perform terminal tasks. Rehabilitation, properly understood, is the full continuum of loading interventions that reduces pain and develops those qualities. That second part is where the problem lies.
Getting to the end
The education group I referenced has built their identity around eliminating this gap. But they never get to the end.
Their post highlights assessment and treatment strategies: DNS, FMS, SFMA, MDT, and Neurodynamics. This alphabet soup of acronyms represents the tool illusion I have discussed in previous posts. Breaking them down within my model, DNS (Dynamic Neuromuscular Stabilization) is an intervention used in the motor control stage of care. The FMS (Functional Movement Screen) is a qualitative movement screen used in the client assessment portion of the fitness audit process. The SFMA (Selective Functional Movement Assessment) is a movement assessment that identifies painless dysfunction and is used in the patient examination within the clinical audit process. MDT (McKenzie Technique) and Neurodynamics are interventions used during the foundational kinematics stage of care.
Every single tool they teach lives on the rehab side of the equation. All of them are oriented toward assessment and pain reduction — which is important, but incomplete. Their education model never reaches the performance side.
They never discuss the functional integration stage of care — the use of progressive weight-bearing exercise through resistance training of the lower body, trunk, spine, and upper body. They never discuss the progressive kinetics stage, including power development through sprinting, jumping, throwing, or Olympic lifting. They never address the fundamental capacity stage — sport-specific techniques and tactics, agility, reaction time, change of direction, and work capacity training.
Beyond the six stages of care, they also never address monitoring — the specific acute, subacute, and chronic variables used to quantify load — or the recovery process that follows from it. Sleep, nutrition, hydration, supplementation, active recovery, and regeneration technology are all absent from their model. Monitoring and recovery represent two of the four domains that constitute human performance. If your entire educational identity is built around bridging the gap between rehab and fitness, but you only cover the first three of six stages of care and skip monitoring and recovery entirely, you are not actually getting to performance.
And this is exactly why the gap exists in the first place. Professional education for athletic trainers, chiropractors, and physical therapists stops at acute management, foundational kinematics, and motor control. In order to eliminate the gap, we have to also teach functional integration, progressive kinetics, and fundamental capacity. A group that has “performance” in its name and stops at the halfway point of the rehabilitation continuum is teaching rehab — not performance.
Fixing the problem
To fix this problem, we first have to be able to identify it. The absence of human performance education is at the crux of the issue. Providers in musculoskeletal care are not taught the principles of loading and exercise in their clinical training. I have discussed this over the last two weeks in the posts on the problem with physical therapy — and the same gap exists even more acutely in my own profession of chiropractic. Beyond loading, there is also a widespread lack of understanding of monitoring and recovery strategies, which leaves providers genuinely unprepared to guide the return-to-performance process.
You might be thinking — that’s not my job. And in some narrow sense, that may be true. But if you want your patients and athletes to be performance-ready, you have to understand what performance readiness actually requires. You may not be the person implementing the performance programming, but you need to understand it well enough to communicate it clearly to the other members of an integrated support team. You need to understand what comes after the work you do. There will be situations where you are either guiding the entire process yourself, or collaborating to build a return-to-sport plan. That is impossible if you don’t understand the performance side of the equation.
Eliminating the gap
The question then becomes: how do we fix this problem? I think this is a multifaceted issue, so it needs a multifaceted solution. But first it has to start with education. To begin, we need education that stops centering individual tools and methods, and starts teaching an overarching unified operating system. Systems establish the overarching structure, interconnected parts, and rules of a framework. Methods are the specific, actionable steps used to execute or achieve results within that framework. Together they represent the interplay between broad organizational design (systems) and daily operational tactics (methods). Systems represent the underlying structure that automates processes and produces long-term, consistent behavior. Methods are the specific tactics or processes used to yield answers and solve problems within the system. Understanding how the two interact is essential for sustainable progress.
To teach this system of human performance, we need a model that places load as the language of human performance. Since a lack of loading and exercise education is a problem I have previously identified, and sits at the apex of this conversation, we need to teach a system that utilizes load as its common language. Imparting load onto our patients is how we create short-term and long-term changes to physiological function. We need load to progress away from pain and move into the development of physical qualities. Load is the language, and the systematic model of human performance is how it is expressed. We need our system to express the lifecycle of load across multiple domains.
I have discussed these four domains previously in my post titled “What the Periodic Table Taught Me About Human Performance.” These domains are the Audit Elements, the Intervention Elements, the Monitoring Elements, and the Recovery Elements. The Periodic Table of Performance Elements expresses the lifecycle of load within the human performance model. The Audit Elements demonstrate the patient’s constraints and the individual’s load tolerances. The Intervention Elements are the specific methods by which we utilize load to achieve a specific therapeutic or training goal. The Monitoring Elements are how we quantify the loads we are applying during the Intervention Elements, and the Recovery Elements are how we put deposits back into the system in order to bring the individual back toward homeostasis. This is the lifecycle of load, and this is what providers need to learn.
After we have learned a unified operating system that centers load as the common language of human performance, we need to ultimately get to the topics relative to performance. As I stated, these topics should include different progressions and regressions of resistance training in the lower body, trunk and spine, and upper body. They should also include the development of power through the use of sprinting, jumping, throwing, or Olympic lifting. And any conversation regarding performance has to include sport-specific skill, techniques and tactics of sport, agility and change of direction, as well as work capacity for conditioning. This discussion on performance should also include sport exposure progressions during the re-introduction of practice leading back to competition and return to play. These are the things we need to be learning related to performance.
It is only when we have an understanding of a unified operating system — with load as the language — that demonstrates the lifecycle of load as it moves through a human performance model, that we can begin to eliminate the gap that exists. The goal should not be to just bridge the gap, but to eliminate it entirely. In order to do this we need to make sure that there is one continuous continuum of care, with no separations or silos. This can only be accomplished through proper education, and we need to have a sound understanding of performance in order to do this.
Practical knowledge
To tie this together: eliminating the gap requires education that contains the following:
A unified operating system — the lifecycle of load
The clinical audit process — for patients seeking rehabilitation for pain
The fitness audit process — for individuals seeking training to improve performance
Defined stages of care — from the table to the field
The monitoring filter — quantification of load variables
The recovery pyramid — restoration of homeostasis
The operational algorithm — order of operations
Sport exposure progressions — structured return to sport
The gap between rehab and performance isn’t going to close because we teach more assessments, add another certification, or memorize another acronym. It closes when we stop treating rehab and performance as two separate worlds that need to be bridged, and start treating them as one continuum with a single, shared language: load.
Every provider touching an athlete’s care — whether managing acute pain or programming sprint work — needs to understand where their piece fits in that continuum, what came before it, and what comes after.
That means a real understanding of the clinical and fitness audit processes, the defined stages of care, the monitoring filter, the recovery pyramid, the operational algorithm, and sport exposure progressions. Not just the first three stages of care that most clinicians are comfortable living in.
You don’t need to become a strength coach or sport scientist overnight. But you do need to understand performance well enough to guide it, communicate about it, and hand off your patient without a gap in the plan. That is the standard our field should be held to.
Not bridging the gap. Eliminating it entirely.
If you want to see what the full continuum looks like — from the clinical audit process through sport exposure progressions — the Language of Human Performance guide walks through the entire model. Find it here.
When you hand a patient off at the end of your scope of care, how confident are you that whoever receives them next understands what stage of the continuum they're entering?