Fitness vs Rehab: Prescribing a Patient's Home Exercise Program

Welcome back to our next blog, a commentary provided by Joseph LaVacca, on the idea of fitness vs rehab, and how it applies to our current practices and areas of opportunity in the healthcare field.  

When I came out of school I was obsessed with treatment, like I am sure most of us were.   It wasn't that important for me to know anything else.  We had a "diagnosis" and we had some research on how to treat it - even if the person in front of me was never actually a part of said research.  Achilles tendinosis?  Eccentrics will take care of that!  Patellofemoral pain?  Sidelying leg raises and clamshells for you!  If I mixed in things the patient liked, made them break a sweat and came up with a few cool new exercises everything would be good.  Right?  What about figuring out what caused the issue in the first place?  It seemed like I was treating the “what” and not the “why”.  

What I found, after some reflection, was myself (and a lot of colleagues) didn't have time for anything else.   We were seeing patients every 15 minutes, we had to write notes, maintain the facility,  schedule, fill out insurance paperwork oh and make sure we were still delivering quality care.  We needed exercise to "fill" the time we were not able to spend with our patients.  This included the obligatory hot and cold packs (to everyone regardless of diagnosis), electrical stim (regardless of pain level) not to mention the use of ineffective ultrasound treatments.  “Warm Ups” of the bike/elliptical/treadmill started the treatments (NOT that this is always a bad thing) instead of placing our hands on them and evaluating changes in tissue/range of motion/strength or pain.  10+ exercises later we were prescribing more exercise to people in pain then we performing in a regular 60 minute workout ourselves.  The problem was specificity - our solution for someone who couldn't stand on one leg with their eyes open for 10 seconds was to challenge them on unstable surfaces, perform dynamic movements and try to make things "cool".  

 

Some exercises are “cooler” then others.  But before we get there have we broken down the parts?    

Some exercises are “cooler” then others.  But before we get there have we broken down the parts?

 

 

Even worse was that SOME people were seemingly getting better so it did not seem all that pressing to change. We settled for mediocrity, after all there was always surgery/needles and pills to help fix your pain.  Or worse seeing that patient in the street and asking them how they were doing with the reply of "Fine, as long as I do not run or squat anymore."  What I felt was missing was empowering patients to return to their desired activities, while reducing the likelihood of the same people from coming back with the same condition (or a new one) a few months later.  I began to reevaluate myself and the people around me and what I quickly saw was consistent: 10 minutes of "Hands on" treatment, and 40+ minutes of "therex". Hardly any Neuro muscular re-ed, gait training, therapeutic activities (at least not in the sense where it was categorized appropriately).  It seemed as if I was in a world of fitness - we diluted ourselves down to a level of personal training "around pain" and this was the norm.  No wonder why trainers never seemed to like us in my experiences.  We moved in on their territory and most of the time prescribing exercises incorrectly while simultaneously doing a poorer job on progressions.  How much exercise is to much?  How little is not enough?  What is the perception/expectations of patients coming to PT and the doctors referring them?  These would be all questions I would wrestle with.

Enter FMS/SFMA/NKT/RockTape/FRR and a lot of people who are smarter than myself to introduce the power of WHY.  As I began to focus on dysfunctional movement patterns, figuring out that local pain did not mean a local problem, and emphasizing pain education and "proper" movement I was able to target the patients complaints and make global changes on movement and symptoms (some times without touching the area in pain).  Deliberate HEP (10-15 mins MAX) linked to the "patient specific test" resulted in renewed commitment to PT in patients and faster results.  My expectation became to analyze why the patient was in pain, determine if the primary limitation was a mobility/stability/or motor control deficit and develop individualized treatment plans accordingly while placing responsibility on the patient to do their HEP - that meant NOT watching someone do 10 sets of straight leg raises every single session.  

We need to do less not more. We need to spend time perfecting skill, not "familiarizing" ourselves with several and placing our own interpretations on systems that exist, and work, for a reason.  Trust your skillset, empower your patients and hold them accountable - I am sure you will be happy with the results.  

 

Let us know what you think!  What do you think about exercise prescription?  Is it getting out of hand?  How do you hold yourself/staff and patients accountable?

Thanks for reading.  Until next time Happy Rehabbing!