IJSPT

CASE REPORT

UTILIZATION OF AUTOREGULATORY PROGRESSIVE

RESISTANCE EXERCISE IN TRANSITIONAL
REHABILITATION PERIODIZATION OF A HIGH
SCHOOL FOOTBALL-PLAYER FOLLOWING ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION: A CASE
REPORT
Aaron D. Horschig, DPT, CSCS, USAW1
Travis E. Neff PT, ATC, CSCS1
Ambrose J. Serrano, MA, CSCS, USAW2

ABSTRACT
Background and Purpose: The Autoregulatory Progressive Resistance Exercise (APRE) model of periodization is an effective form of resistance training programming for short-term training cycles in healthy
athletic populations that has yet to be effectively described in literature in application for rehabilitation
purposes. The purposes of this case report are to: 1) review the periodization concepts outlined in the
APRE model, 2) to detail the use of the APRE periodization programming through the rehabilitation of a
high school football player using the back squat exercise after anterior cruciate ligament reconstruction
(ACLR) and 3), to examine the applicability of this method in the transitional period from skilled rehabilitation to strength and conditioning for which a current disconnect exists.
Case Description: Starting at 20 weeks post-operatively, a 17-year-old male high school football player
recovering from ACLR was able to show a 10 lb daily average increase with the 10 RM protocol, a 6 lb daily
average increase during the 6RM protocol, and a 6.3 lb average increase with the 3RM protocol.
Outcomes: A two-repetition maximum of 390 lbs was performed in the back squat at the conclusion of the
program at 39 weeks post-operatively.
Discussion: The results of this case report strengthen the current limited knowledge regarding periodization during the later phases of rehabilitation and the transition back to sport participation time period,
while at the same time providing new insights for future protocol considerations in rehabilitating athletes.
The APRE method of periodization provides an individualized progressive resistive protocol that can be
used to safely and effectively increase strength in both healthy populations and individuals recovering
from injury during short-term training cycles.
Levels of Evidence: Therapy, Level 4-Case report
Key Words: Back squat, periodization, physical therapy

Boost Physical Therapy & Sports Performance, Lees Summit,

MO, USA
2
Lake Placid Olympic TrainingCenter, Lake Placid, NY, USA

CORRESPONDING AUTHOR
Aaron D. Horschig, DPT, CSCS, USAW
Physical Therapist at Boost Physical
Therapy & Sports Performance
1254 SE Century Drive
Lees Summit, MO 64081
(314) 704-0546
Fax: (816) 524-1445
E-mail: Aaron@boostkc.com

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 691

BACKGROUND AND PURPOSE

The concept of periodization, defined as a systematic
planned variation of program variables in a training
program, has been well established in literature to be
more effective in eliciting strength, body composition improvements and other performance goals than
non-periodized programs both in healthy, injured,
trained, and untrained individuals.1,2,3,4,5,6 Synonymous with phrase Training Organisation, the utilization of periodization is not a recent development,
with many texts on the subject appearing as early as
1917.7 A periodized program optimizes the principles
of specific adaptation to imposed demands (SAID)
and the progressive resistance method (PRE) in
order to more efficiently promote desired outcomes
such as increased strength or muscular hypertrophy
through the continual adaptation responses of the
neuromuscular system.7,8 By introducing progressively overloading stressors to the body, the neuromuscular system will adapt and develop towards
the targeted fitness goals, provided the systematic
progressing load stressors are adequate and do not
exceed the adaptive capabilities of the body.7 However, once the body has adapted to the added stressor,
strength increases are no longer seen.8 Simply stated,
periodization continually changes the type of stressors placed on the neuromuscular system, thereby
avoiding a plateau and promoting continued adaption and strength gains.
An early training programming model used to systematically improve strength was reported in literature in 1945 by DeLorme, who proposed a method
consisting of multiple sets in which patients lifted
their 10 repetition maximum (RM).9 Eventually this
protocol evolved to a three set system of progressing
heavier loads for 10 repetitions; referred to as progressive resistance exercise (PRE).9 This has since
been the starting point for the development and
study of numerous periodization concepts such as
classical linear periodization (LP), which emphasizes
a breakdown of the training program into time periods or training cycles of macrocycles (9-12 months),
mesocycles (3-4 months) and microcycles (1-4
weeks) with ever fluctuating changes in volume and
intensity.8,10,11 Other popular forms of non-linear periodization include undulating models, as described by
Poliquin, in which programming variables such as
volume and intensity are changed more frequently

such as on a daily or weekly basis.12 The concept

of Daily undulating periodization (DUP) has been
shown to elicit greater strength gains in short-term
training cycles (12 weeks) when compared to LP
models equated for similar volume and intensity.8,13
Although there is a consensus in the literature on
benefits of periodized vs non-periodized programming when it comes to eliciting the most efficient
strength and performance gains, large inconsistencies remain regarding which type of periodized
model is most efficient. 14 This dilemma is even more
complicated when taking into account the training
level of the subject and time frame allowed for training programming. An even greater gap in evidence
exists in periodization protocols that are specific for
the injured and rehabilitating athlete that facilitate
the most efficient neuromuscular adaptations while
being mindful of the healing processes taking place
at the biological level.15 Most literature on strength
training periodization is based on healthy and not
rehabilitating subjects.15 Current popular protocols
for rehabilitation periodization emphasize the principles of DeLormes PRE through LP and non-linear
protocols.15,16 Complicated with the common inability to assess a patients 1 repetition maximum (1RM)
secondary to rehabilitation contraindications, especially post-operatively, many clinicians are left with
presupposed approaches for determining the appropriate program variables to facilitate maximal efficient performance gains. Even after discharge from
rehabilitation, many practitioners and strength and
conditioning coaches often resort to using a bestguess approach during the transition period where
a subject is no longer injured or in need of skilled
rehabilitation, however, is not yet displaying his or
her pre-injury strength and still re-acquiring strength
through neuromuscular adaptations at a different rate
than healthy subjects. These athletes are many times
blindly thrust back into their prior training programs
with little attention given towards a needed personalized individualized periodized protocol. The quick
return to prior training programs is many times based
on a flawed premise that the athlete, once given the
cleared medical status, is without question ready to
resume their exact high-level prior training regime.
It was not until 1979 when a variant of the DeLorme
system, known as the Daily Adjustable Progressive

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Resistance Exercise (DAPRE) method, was successfully integrated into rehabilitation programming by
Knight.17 This method allowed, for the first time, an
interactive protocol to objectively determine either
the optimal time to increase resistance or the optimal amount of weight to increase the resistance
during a resistance exercise, thus providing a more
efficient way to rehabilitate strength by accounting
for individualized reacquisition of strength.2 A specific autoregulatory program by Siff, derived from the
DAPRE method, expanded on this concept in order
to meet different training goals of hypertrophy and
strength/power, and allow for continual body adaptation through the SAID principle.7 This method,
termed Autoregulatory Progressive Resistance Exercise (APRE), enhances the previous DAPRE method
by introducing training cycles aimed at improving
hypertrophy, strength and power regimes of conditioning. This allows for continual neuromuscular
adaptation to systematically changing program variables thus promoting efficient performance gains.7
To the authors knowledge, only one study has compared the effectiveness of the APRE method to another
periodization model. When compared to a traditional
LP model, the APRE method of periodization has been
shown to be more effective in increasing the strength
and strength-endurance of healthy subjects in both
the bench press and squat over a short period of 6
weeks.14 There is, however, no evidence in literature
supporting or documenting the use or effectiveness of
the APRE concept during the rehabilitation process of
the injured athlete.
The purposes of this case report are to: 1) review the
periodization concepts outlined in the APRE model,
2) to detail the use of the APRE periodization programming through the rehabilitation of a high school
American football player using the back squat exercise after anterior cruciate ligament reconstruction
(ACLR) and 3), to examine the applicability of this
method in the transitional period from skilled rehabilitation to strength and conditioning for which a
current disconnect exists.
Case Description
The patient was an active 17-year-old male American
high school football player with a history of ACLR
of his dominant right lower extremity. Mechanism

for original injury was a non-contact deceleration

and pivot movement during a football game. Magnetic resonance imaging (MRI) of the lower extremity revealed a complete anterior cruciate ligament
(ACL) rupture. The patient completed initial conservative rehabilitation and was able to return to finish his season wearing a functional knee brace until
eventually undergoing ACL reconstruction surgery
using a bone patellar tendon bone (BTB) autograft
along with a partial lateral meniscectomy, after the
end of the season. Time from initial injury to date
of surgery was approximately 15 weeks. During his
return to football before ACL reconstruction surgery,
the patient had no reported episodes of giving-way
however reported feeling unstable and weak during
single leg tasks. The patients post-operative rehabilitation process was unremarkable without any
complications utilizing traditional evidence-based
rehabilitation clinical protocol guidelines.18 Criteria
during early phase rehabilitation included restoring
knee active range of motion (AROM), quadriceps
strengthening (both with isometric and closed chain
kinetic exercises, such as mini-squats), restoring
patellar mobility, diminishing swelling and pain, and
restoring safe independent ambulation. Later phases
of rehabilitation continued the trend towards increasing intensity and complexity of functional strengthening while incorporating strength and conditioning
principles such as power development, balance and
proprioception training. He received medical release
to return to running at 16 weeks post-operatively and
was able to return to full athletic participation by 30
weeks. For the purpose of this case report, the details
of his rehabilitation protocol other than the APRE
programming for the back squat exercise, which
began at 20 weeks post-operatively, are not included,
as the entirety of the rehabilitation process is not the
specific focus of this case report. Informed consent
was obtained from the subject indicating approval for
data collection for the purpose of publication.
Clinical Impression #1
It was determined that the patient was a good choice
to utilize the APRE intervention secondary to the need
to return to his prior high level of strength in an efficient manner. Because he was a high school football
player he would be required to perform high intensity
squats during team strength and conditioning sessions

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 693

and up until this point he had only performed very

light intensity squats during rehabilitation exercises
with higher repetitions. Prior to the start of the APRE
periodization, the patient had been progressing from
squats while holding a weighted kettle bell (45 lbs)
for 3-5 sets of 15-20 repetitions and had transitioned
to using the weightlifting bar for back squats of light
intensity (135 lbs) for 3-5 sets of 10 repetitions. For
this reason an efficient method of strength periodization was needed in order to help the patient return to
higher intensity squatting.
Examination
At 20 weeks post-operatively the patient was able
to meet the developed criteria for initiation of the
APRE program, including observed lower extremity
symmetry within 90% (ACLR compared to opposite
lower extremity) using the 1) Star Excursion Balance
Test (SEBT) and 2) a lateral step down excursion
test.19,20 The SEBT has been shown to be an effective
test in analyzing postural and lower extremity control deficits.20 The patient also had to demonstrate
correct technique in the barbell back squat.21 It is
important to note that any lower extremity symmetry of less than 90% compared to the opposite lower
extremity would prohibit the start of the APRE program for the reason that a considerable amount of
skilled therapy to enhance neuromuscular control
would still be needed before progressing to a protocol that emphasizes strength/power.
The back squat method utilized during the protocol
was a high bar technique with shoulder width stance.
The athlete was given verbal and tactile cues to slowly
descend to a parallel position where the hip and knee
joints were even, and then extending the hips and
knees simultaneously during the ascension phase without leaning forward or showing unwanted hip rotation.
The athlete wore only standard cross-training shoes
and did not wear any additional supporting equipment
during any of the squatting sessions such as belts, lifting suits, knee wraps, or weightlifting shoes.
Clinical Impression #2
Based on the patients ability to show sufficient lower
extremity symmetry on all examination testing previously discussed, it was determined that he met the
requirements to start the APRE periodization for the
back squat exercise at 20 weeks post operative.

Outcome
The APRE method employs a 10 RM scheme for
hypertrophy, a 6 RM scheme for strength/hypertrophy, and finally a 3 RM scheme for strength/power.7
All routines are based on the DeLorme method of
PRE and consist of 4 sets of different load and repetition requirements (Table 1).7 The 10 RM regime will
be described here as it was the first periodization
scheme employed for this case report for the back
squat exercise. After the performance of a general
warm up including 10 minutes cycling on a recumbent bike followed by 5 minutes of self-myofascial
release using foam rolling to the anterior and lateral
lower extremities, the first set consisted of 12 repetitions at 50% of the estimated 10 RM (also labeled the
working set as the first two sets are percentages taken
from set 3). After a minimum 2-minute rest period,
the first set was followed by 10 repetitions at 75%
of the same-estimated 10 RM. During the third set,
the anticipated 10 RM was lifted until failure. Due to
this programming being used for rehabilitation and
transition purposes, failure was not only seen as the
inability to complete another repetition, but also the
inability to continue with good technique secondary
to lower extremity compensations or the presence
of pain. For this reason, the clinician overseeing
the performance at times made subjective decisions
to end the set secondary to technique deficits that
began to appear. The number of repetitions reached
during this maximal effort third set was then used to
adjust the intensity for the fourth and last set (Table
2). Again, repetitions during the fourth set were performed to maximum effort, and the number of repetitions reached was used similarly after the previous
third set in order to determine the anticipated 10 RM
working set for the next training session by adding
or subtracting loads (Table 2). This allows subjects to

Table 1. Adjusted Progressive Resistance Exercise Training

Routines.
Set
0
1

3 RM Routine
Warm-up
6 reps (50% of 3 RM)

6 RM Routine
Warm-up
10 reps (50% of 6 RM)

10 RM Routine
Warm-up
12 reps (50% of 10
RM)
2
3 reps (75% of 3 RM)
6 reps (75% of 6 RM)
10 reps (75% of 10
RM)
3
Reps to failure (3 RM)
Reps to failure (6 RM)
Reps to failure (10
RM)
4
Adjusted reps to failure*
Adjusted reps to failure* Adjusted reps to
failure*
*Denotes that the training load must be adjusted according to Table 2

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 694

Table 2. Example Adjustments for APRE Protocols.

Adjustments for 3 RM
Repetitions Set 4
1-2
Decrease 510 lbs
3-4
Same
5-6
7+

Adjustments for 6 RM
Repetitions Set 4
0-2
Decrease 510 lbs
3-4
Decrease 05 lbs
5-7
Same

Increase 510 lbs

Increase 10- 8-12
15 lbs
13+

Increase 510 lbs

Increase
10-15 lbs

Adjustments for 10 RM
Repetitions Set 4
4-6
Decrease 510 lbs
7-8
Decrease 05 lbs
9-11
Same
12-16
17+

Increase 510 lbs

Increase
10-15 lbs

exercise near their optimal capacity for strength during each training session allowing for individualized
progression of strength redevelopment.2 It should be
noted that rest periods between sets are subjective
based on the patients perceived fatigue. It is recommended by the authors that a minimum 2 minutes
of rest, maximum of 5 minutes, be utilized between
the maximum repetition sets.
The 10 RM scheme was used during 6 training days
over a 3-week period, each spaced at least 2 days
apart for adequate recovery. For the purpose of
this case report, strength changes seen during the
APRE protocol are reported as the performance
changes seen between the first and last day of each
separate repetition protocol (Figure 3). After the
3-week protocol was complete, a de-loading week
was employed consisting of 3 sets of 10 repetitions
at 75% of the last estimated 10RM for two training sessions. The 6RM protocol was then initiated
for a 3-week period, again consisting of 6 training
periods spaced at least 2 days apart. The second

de-load week was employed after finishing the 6RM

protocol, this time consisting of 3 sets of 5 repetitions at 75% of the last 6RM estimate. The last 3RM
scheme of the APRE used a 3-week cycle with 5
training sessions. Overall, the APRE program was
able to emphasize 3 distinct phases of hypertrophy,
strength/hypertrophy, and strength/power (Table
4). At no time during the protocol did the athlete
experience pain, which would have limited his ability to perform continued repetitions.
Table 3 contains tabulated results for the back squat
performance changes seen with the APRE. Through
the 10RM protocol, a 50 lb increase in strength was
shown (21.3% improvement) in a 3-week period
consisting of 6 workouts. A daily average increase of
10 lbs was seen (4.3% improvement) with a weekly
average increase of 17.5 lbs with the 10 RM protocol.
During the 6RM protocol, a 30 lb increase was seen
(9.7% improvement) in a 3-week period consisting
of 6 workouts. A daily average increase of 6 lbs (1.9%
improvement) was shown with a weekly average
increase of 12.5 lbs (4% improvement). During the
3 last weeks of the APRE program, the 3RM protocol
yielded a 25 lb increase (6.9% improvement) over
5 workouts. A 6.3 lb daily average increase (1.7%
improvement) was shown with a 13.8 lb weekly
average increase (3.8% increase). The last day the
patient was able to perform a 390 lb back squat for
2 repetitions 32 weeks post-op ACLR. This weight of
390 lbs was only 100 lbs less than his prior 1 repetition maximum prior to tearing his ACL.

Table 3. APRE Repetition and loads for Subject.

APRE
Rep
Scheme

Number
of
Sessions

First Day

Last Day

Strength Increases (4th Set)

3rd
Set

4th Change
Set (%)

Daily
Average
(lbs)

Change
(%)*

Weekly
Average
(lbs)

Change
(%)*

10

4.3

17.5

7.4

1.9

12.5

6.3

1.7

13.9

3.8

4th
Set

10 RM
6
Weight (lbs)
225 235 285 21.3
Repetitions
15 10
10
6 RM
6
Weight (lbs)
300 310 340
9.7
Repetitions
10
6
5
3 RM
5
Weight (lbs)
370 365 390
6.8
Repetitions
2
0
2
*Denotes change from the irst day weight lifted

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 695

Table 4. Overall APRE Training Program with associated

phase empahsis

APRE Rep
Active Weeks Emphasis of Phase
Scheme
10 RM
1,2,3,4*
Hypertrophy
6 RM
5,6,7,8*
Strength/Hypertrophy
3 RM
9,10
Strength/Power
* Weeks 4 & 8 were de-load weeks, but still performed
the repetitions designated in the speciic phase

DISCUSSION
The concept of periodization, defined as a systematic planned variation of program variables in a
training program, has been well established in literature to be more effective in eliciting strength, body
composition improvements and other performance
goals than non-periodized programs both in healthy,
injured, trained or untrained individuals.1,2,3,4,5,6
There is abundant literature on periodization protocols and their effectiveness in healthy trained and
untrained subjects as it relates to all aspects of fitness,
not only strength. However a paucity of evidence can
be found in relation to rehabilitation protocols, especially when searching for protocols for effective and
safe ways to return an athlete to a high level of sport
and resistance training performance post-operatively.
Consistency in descriptions of specific programming variables is lacking amongst clinical protocols
in which effective rehabilitation can be carried out
while still being mindful of individual differences in
biological and neuromuscular healing processes.15,22
Rehabilitation periodization protocols exist outlining
both linear and non-linear programming approaches,
which make good recommendations for exercise
selection and even volume, however, they lack in
specifics for exercise intensity.15 For example, with
the linear periodization following ACL reconstruction
proposed by Lorenz et al, the protocol load requirements are generally vague per volume requirements,
and may not be as effective for that reason in promoting the reacquisition of strength in power athletes
that need to return to high intensity resistance exercises such as the back squat.15
The DeLorme protocol of PRE was the first reported
periodization model in research literature to detail
a systematic model for increasing strength both in
healthy and injured populations.9 The DAPRE method

by Knight, modified from the original DeLorme PRE,

allowed for the first time an interactive protocol for
objectively determining either the optimal time to
increase resistance or the optimal amount of weight
to increase the resistance during an exercise, thus providing a more efficient way to rehabilitate strength in
an individualized and safe manner.2 The APRE used
in the present case report, varies only slightly from
the DAPRE in that it provides multiple training protocols within itself based on specific desired outcomes.
There is a 10 RM scheme provided for improving
hypertrophy, a 6 RM scheme for addressing strength/
hypertrophy, and finally a 3 RM scheme for development of strength/power.7 In a rehabilitation setting or
in a strength and conditioning setting for the transition
athlete who has been discharged from a traditional
rehabilitation setting however has not yet returned
to pre-injury strength levels, this allows for continual
neuromuscular adaptation to systematically changing
program variables thus promoting efficient performance gains.7 Where as the DAPRE method has only
been shown in literature with non-functional seated
knee extension strengthening exercises after knee
injury, the APRE method has been shown in healthy
populations to be an effective periodization method
when used with functional strengthening exercises
such as the back squat compared to LP programming
during short (6 week) training programs.2,14
Mann et al was able to show significant improvements in 1RM bench press, number of repetitions
performed with a weight of 225 lbs in the bench press
(strength/endurance) and in estimated 1RM back
squat (APRE: 43.3 +/- 23.2 lbs vs LP 8.4 +/- 34.8
lbs, p = 0.05) compared to a LP group over a 6-week
training period.14 The results of this case report are
consistent with the findings of Mann et al, showing significant changes in estimate RM back squat
strength using the APRE protocol in a short training cycle (Table 3).14 The APRE protocol used in this
case report allowed for weeks of de-loading between
the three stages. This principle of using de-loading
weeks, called the fluctuating overload system, has
been used to facilitate recovery and growth between
stages of increased loading of a microcycle.7
It has been recommend that if maintaining a LP program model during the rehabilitation after ACLR,
strength training should be the emphasis between the

The International Journal of Sports Physical Therapy | Volume 9, Number 5 | October 2014 | Page 696

12th to 16th week before employing the power phase in

the later weeks of the rehabilitation process.15 For the
authors purposes, the APRE programming regime for
the back squat was not incorporated into the rehabilitation protocol until the 20th week post-operatively. The
20th post-operative week was deemed, in the authors
opinion, to be an important transitional period when
the patient had been medically released to return to
partial participation in athletics and weight training,
yet had not re-acquired strength levels prior to ACLR.
The athlete had been utilizing numerous forms of
resisted squatting exercises in the rehabilitation protocol such as hand-held kettle bell squats and band
resistance squats up until the point when the APRE
was initialized. It is important to note some physician
post-operative protocols restrict strengthening of the
involved lower extremity for many weeks, thus, the initiation of the APRE protocol would need to be delayed
until proper prerequisites for the start were met.
There are several limitations to this case report; one
being that the results are only based on the strength
increases of one patient during the rehabilitation
process. More research should be performed with
patients rehabilitating from similar injuries with a
control group of athletes using other LP or DUP programs in order to fully assess the effectiveness of
each protocol. The results of this case report do not
suggest that the APRE protocol is superior to LP or
DUP programming, however show that strength can
be gained in a healthy individual and re-acquired
during rehabilitation and in the transition phase
after formal rehabilitation in a quick and safe manner during short-term training cycles.
Conclusion
During the transition period after skilled physical
rehabilitation, athletes may find themselves returning to resistance training with strength deficits compared to pre-injury levels. This results of this case
report demonstrate the outcomes following the use of
a detailed, individualized periodized protocol that was
used safely and effectively for this athlete in a rehabilitation and transition period in order to increase
his back squat performance in a short time period.
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