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How to Develop Clinical Confidence in Rehabilitation and Athletic Development: Understanding the Hierarchy

Feeling confident in your treatment plan is crucial for any physical therapist or athletic trainer. But with so many factors to consider and a vast range of potential injuries, navigating the rehabilitation process can sometimes feel overwhelming. In fact, if you ask any experienced clinician how long it took them to finally feel fully confident in their ability to tackle any clinical case, they will tell you about 5-6 years.

The Hierarchy of Rehabilitation and Athletic Development (The Rehab Hierarchy) can be a game-changer for clinicians, providing a clear roadmap to follow and boosting your confidence in creating effective treatment plans.


Understanding the Rehab Hierarchy

Based on the work by strength and conditioning coach Al Vermeil, and adapted by physical therapist Rob Panariello, MS, PT, ATC, CSCS, the Hierarchy breaks down the rehab process into a step-by-step pyramid. Each level builds upon the one below, ensuring a logical and progressive approach. The hierarchy was most recently further enhanced by the work of Robert Shapiro DPT, COMT, NKT and Donis Gil, ATC by adding simplified evaluation classifications and considerations for the inflammatory response.


Here's a simplified breakdown:

  • Foundation: Evaluation and Classification - This initial stage involves thoroughly assessing the client's condition and classifying it based on factors like impairment type and healing stage.

  • Building Blocks: Inflammation Management, Mobility, Motor Control, Strength - Here, the focus is on addressing pain and inflammation, restoring proper movement patterns, retraining the nervous system, and building foundational strength.

  • Powerhouse: Power, Elastic Strength, and Speed - Once a solid base is established, power, elastic strength and speed training can be introduced sequentially in order to enhance athletic performance.

  • Putting it All Together: Skill assimilation - The final stage integrates all the previously trained aspects into functional movements specific to the client's sport or activity.


Confidence Through Structure

The Rehab Hierarchy's beauty lies in its structure. By following this organized framework, clinicians can feel assured they're not missing crucial steps. It eliminates the guesswork and ensures a logical progression from addressing core issues to building athletic performance.


Benefits for Clinicians

  • Enhanced decision-making: The Rehab Hierarchy provides a clear framework for treatment plan development, making it easier to choose appropriate interventions at each stage.

  • Improved communication: The hierarchical structure facilitates communication with patients and athletes. You can explain the rationale behind each step and set realistic expectations for progress.

  • Stronger patient outcomes: By ensuring all aspects of rehabilitation are addressed systematically, the Rehab Hierarchy promotes faster recovery times and a lower risk of re-injury.

  • Boosted confidence: Following a proven framework empowers you to approach each case with a sense of direction and control. Seeing positive patient outcomes further strengthens your confidence in your abilities.


The Hierarchy of Rehabilitation and Athletic Development is not a rigid recipe, but rather a flexible guide. Experienced clinicians can adapt it based on individual needs. However, for new practitioners or those facing complex cases, the hierarchy offers a valuable roadmap to navigate the rehabilitation journey with confidence.

In conclusion, the Hierarchy of Rehabilitation and Athletic Development is more than just a theoretical concept. By incorporating this framework into your practice, you can not only improve patient outcomes but also build your own confidence as a clinician.


If you would like to learn more about the Hierarchy of Rehabilitation and Athletic Development you can watch this video where Robert Shapiro, DPT, COMT, NKT, provides a more in-depth overview of this intuitive approach:




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