As clinicians we typically spend a lot of time on treatment approach and progression. Perhaps more so than anything else our focus always seems drawn to Therapeutic Exercise Prescription. How, when, why to prescribe exercises and what specific interventions should be used, and what the heck is "functional" exercise? Whenever I take or teach continuing education courses there seems to be a universal agreement that there is a lack of courses/literature/etc to give clinicians tools for exercise prescription. It is one thing to learn or practice an exercise with a patient, and a complete other to understand regression/progressions and adaptations of that exercise. In order to help clinicians and patients better understand exercise prescription I have tried to develop something easy to remember - the idea to instill F.E.A.R. into your workouts and therapy. Now before you jump to conclusions let me explain what I mean by F.E.A.R.:
Functional: The best way to think about Functional Exercises is simply exercises that incorporate a wide array of posture/muscles rather then simply working muscles in isolation. Think "more bang for your buck". Some great functional exercises include the deadlift, kettlebell carry's/holds and swings, breathing, turkish get ups, chops and lifts in various positions, rather than straight leg raises, bicep curls, or rotator cuff band work. I would not consider the latter "bad" but I would argue that as movement specialists teaching someone a straight leg raise is not exactly skilled care.
Enjoyable: Yes, believe it or not rehab is allowed to be fun! Finding a way to engage your patients, especially if they have kids, is a great way to ensure that they will adhere to a HEP. I often use the "smile test". Can your patient smile in that position? If they can it is probably not painful and something they can repeat safely without having to worry about pain. Furthermore adding a ball toss, mirroring, or super setting activities (rather than have long breaks between exercises) can keep your patient engaged. Go home and have your patients play with their kids, hold their babies, or play catch - just do so in tall or half kneeling, quadruped or in advanced cases you can even throw in a single leg stance.
Adaptable: One of the biggest issues patients have had in the past is that they do not have "space" or "equipment" or lose every band you ever give them. With that being said it is simple to view exercise prescription or progression in the same way as development. We can "work" any muscle or movement in different positions rather then trying to change the color of a band or adding more weights or sets. Furthermore by utilizing postures the only amount of space your patient needs to perform a HEP simply depends on how tall they are. So there should be plenty of room even in those studio apartments in NYC. The positions we utilize most in our rehab approaches are:
- Supine/Prone: The ground provides maximal stability so you can focus efforts on mobility work, breathing, or gravity eliminated resisted movements. This is also a good start point for graded exposure. For instance if a patient has difficulty bending/extending then performing long sit and reach or prone press ups will still produce the same "physiological" movement but may perhaps be less threatening for the brain.
- Sphinx: A great transitional posture. Easy position to begin postural re-education, scapular stabilization, thoracic mobility, and cervical disassociation.
- Quadruped: A position of increasing stability demands for the body but continues to de-load the spine. This can allow for reflexive firing and activation of the spinal stabilizers by practicing such things as crawling, bird dogs, cat/camels. This position can further be altered by raising the level of the ground to incorporate raising the hips to become inverted, or by raising the hands to make the exercise/weight-bearing requirement easier.
- Tall and 1/2 Kneeling: The first posture to include a loaded spine against gravity. A great position to utilize to begin understanding and maintaining midline stability, building reflexive stability of the hips and to introduce asymmetrical hip positions. This can also be used for knee/ankle surgery patients especially if they are NWB earlier in rehab in order to maintain/incorporate fitness into their routines. Yes we also mentioned post op knees - aside from some discomfort which is usually driven by real "fear"a kneeling position is NOT loading the knee and it is safe for your post op patients assuming they meet the range of motion requirements, typically 90 degrees.
Repeatable: By repeatable we simply mean that the exercises should have an impact on the patients "comparable" sign when repeated. For instance if dealing with a shoulder patient who has pain at end range flexion at the end of your session and therapeutic prescription repeat their test, in this case shoulder flexion to see if you have made an impact. This should give you instant feedback if you were on the right track and furthermore if you are prescribing the right things your patients will more easily and willingly buy in to rehab.
We hope this was helpful! If you would like to see any of the above variations just let us know and we would be happy to share!
Until next time Happy Rehabbing!