Home Care Plans: Instructions Vs. Adherence

I remember going to physiotherapy when I was in high school and having my exercises prescribed to me for my knee pain. I was instructed to do them every day, which I think I may have managed to do for about a week. Past that, they tapered down to as little as once per week only, followed by lies to my physio about doing them regularly.

Was I just a bad client? Maybe.  Let’s fast-forward a decade or so, though.

When I began my career as an Athletic Therapist, I would instruct my patients along the same lines. Do the exercises every single day in order to get better. It’s the standard I wanted and, if nothing else, it would make the clients exercise to some extent.

But my method didn’t work.

Adherence to my instructions was poor and my clients had a difficult time getting better. Truth, maybe there are “bad clients” out there, but at some point, you have to look at the coach rather than the players. Which brings us to the key error so common to many of our practices:

“I tell my clients to do their exercises every single day knowing that they won’t, but at least, then, they’ll do them every other day.”

Does this sound familiar?

As health practitioners, we’re used to working with patients who are only partially or completely non-compliant when it comes to their exercise rehab. As a result, we become accustomed to “tricks” in order to get them to exercise and be able to recover.

However, if you’ve used the above trick in the past, I’m sorry to say that you’re terribly misguided. (As I was.)

Let’s consider that by saying this, we’re raising the expectations for a patient to what is, for all intents and purposes, an unrealistic level. (If it was realistic, then we wouldn’t be assuming failure on the client’s part.) Now ask yourself, have unrealistic expectations ever proven to be a formula for success?

We know this to not work with raising children or dieting, so why in the world do we assume this to be effective when it comes to rehab?

Poor exercise adherence has been shown to be, in large part, due to anxiety regarding the process and an expectation of failure. Think about it; if we’re told that we absolutely need to do 100% to recover, but we know we won’t achieve that 100%, are we going to be motivated to do 50% in hopes that it will be enough? Not likely!

More likely, the guilt of not adhering completely will derail the behaviour change altogether.

So, I’m sorry, there is no easy and effective “trick” such as simply telling a patient to perform a mile while expecting an inch. Instead, actual investment in coaching patients through their exercise barriers is required.

Such coaching techniques include:

  • Helping them understand the starting process and develop a feeling of control
  • Understanding their hesitations regarding exercise
  • Finding exercise and time routines that work with their lifestyles
  • Making small changes at a time
  • Developing relapse expectation and management

So, let’s look into how we can take those points and put them into action with our patients.

Education

As clinical professionals trying to induce behavioural changes, we need to ensure our patients have a thorough understanding of the recovery process and the importance of exercise. With this understanding, clients will develop a feeling of control over their recovery and become motivated by being able to see the direct benefit of their actions.

Exploring Barriers

If a patient has barriers to physical activity, you’re allowed to dig a little bit to understand them for yourself.

Perhaps it’s that anxiety about the process, which education will address. Maybe it’s a time constraint or limited equipment-availability, which signals the need to carefully strategize with their plan. The patient could simply hate the idea of exercising, and so you might have to come up with something that does not necessarily feel like formal exercise.

Discussing these obstacles with your patient will let them know you’re investing time and energy in creating the right plan for them and create trust between the two of you.

Which brings us to…

Individualizing Their Routine

If you have a go-to-patient that is hyped and happy to set aside 30 minutes per day and run through all of their rehab homework daily, then great. For the rest, we need to explore different methods.

For some patients, requesting their rehab exercises to be done every 2-3 days might be the realistic and attainable option. You can also consider programming them as a warm-up before working out, sports, or even just going out to walk, which is great for those with perceived time-restrictions.

Split-routines are an effective method as well, especially when it comes to combatting boredom or monotony. If you have six exercises you want your patient to do, try splitting them into three on one day and three on the other.

Finally, for those who are averse to traditional exercise, in general, you might have to be a bit more creative and find movements that are fun or don’t resemble the “work” of a workout. What I find beneficial is simply reintroducing the activities that patients want to do upon recovery as graded-exposure therapy.

Throughout all this, though, let’s remember to make small changes to lifestyle at a time. As we know, gradual modifications are much more successful in the long-term than massive overhauls.

Develop A Relapse Plan

Finally, it’s crucial we create somewhat of a risk-management plan with our clients.

A lot of things can potentially derail an individual’s adherence to change. Missing a day or two of exercise might demotivate someone from continuing further. A relapse of pain might be the clincher that causes a patient to give up and think they failed. Even simple life events might throw a wedge into the ability for someone to focus on their health.

In these cases, I drive home the point that relapses and derails are likely to happen. By predicting the possibility, we can create methods of coping and moving on. Let a patient know that it’s ok if they miss a day or even a week of exercise and that they’ll continue to reap the benefits as soon as they get back on the horse.

Pain relapses should be normalized as an expected event, and if the patient can use it as a learning opportunity rather than as a sign of a failed recovery. Like with anything we do in life, recovery will involve ups, downs, and plateaus to work around.

In truth, this ability to work with a client to create longer-term habits and adherence is something that many fitness professionals commonly excel at over medical ones. Personal trainers know that it’s an easy way to lose their client by telling them to do cardio six times per week or that they need to work out for three hours per day. Bringing those expectations back down to a realistic level and adjusting their plans as the client changes are the sure-fire way to success. Cookie-cutting a method for motivating that person to exercise is as bad as cookie-cutting the program itself. We have a duty to individualize our patients routine which includes the frequency basis on which it’s performed. And don’t expect failure; aim for success.

Why Do Isometrics Work So Well?

 

A question I often get asked is “Why do isometrics work well to isolate pain?” I started adding isometrics to improve pain during motion and pain and end range with active and passive testing.

They work great! Forget “muscle energy technique” and other theories. They are too mechanical. I go over the reason why isometrics work well as a compliment to manual therapy and repeated loading strategies.

Fear Instilling Behaviours

A recent post in one of the many groups here to which I belong got me thinking about how easily swayed a  patient can become to accept the views of the clinician.

These views often conflict with what the patient’s primary MD or medical specialist might put forth and often stem from the results of testing unique to that particular line of intervention. I am working hard not to cast shade on one particular group or sub-group, as many different professions can be seen as guilty of such sins.

The post which got me thinking was one where the health professional warned the patient not to look up or fully turn their head to either out of fear of damage to their spine. If they did do so, they were instructed to return to the clinician immediately to see if they knocked things out of place and needed more treatment. This despite having been seen by a spine specialist (MD) who ran enough tests to assure that the pain was not overtly pathology-driven, with no fracture or overt spine/nerve compression issues.

I do realize that many patients trust the word of MD’s less than others in the medical profession, but why allow FEAR to drive you?

Are we so fragile that looking up or hitting a pothole with your car (another one of my favourite fear-building warnings..ARGH!!!) that we cannot hope to live a quality existence without the constant oversight and (expensive) micromanaging by a healthcare professional? I cannot hope to know the rationale from which all different healthcare professionals are trained, but with what is known about pain and it is often not an indication of damage/injury/pathology, building a model of fear in our brains could make us more vulnerable to future problems, not to mention paying for the boat of that professional who planted the FEAR SEEDS.

My N=1 story. 20 years ago I suffered two spiral crush fractures of my lumbar spine, all while riding on a pasture horse named Sweetie (true story, true name). Sweetie was actually a fairly old horse who happened to be grey…an old grey mare. I had 2-3 years of regular, daily pain, attributed to the secondary issues of what was at that time diagnosed as disc herniation-type pain.

I DID live in fear for many years, even after the primary pain subsided, fueled by 3-4 time per year reoccurrences of some pretty bad back region pain. I heeded my health practitioners’ advice, initially from my MD as well as the other people who helped me return to function, but some of this advice was avoidance warnings as well as predictions of limitations in mobility and function for the remainder of my life.

I’m not always the best patient, at least when it comes to heeding warnings.

Yesterday I shovelled 4 yards of dirt into a wheelbarrow and moved it to a job site on a different part of my property. I woke up this morning stiff, but not my low back, which feels as strong as before Sweetie and I met. There was a period of time when I would hear those health professional’s words in my ear, warning me not to do such work as I would injure myself further, risking permanent damage. But I had a life to live and I worked my way to a point where I can live a fully healthy and active lifestyle.

I ignored the warnings which did not come from my MD. He basically told me to stay active and see what happens. He told me to let pain be my guide but not my master.

I am not at all trying to say that you are me. Maybe you have a condition that truly should cause you to live and act with caution. But ask yourself a question: is the health professional who is planting these fears telling you a story that contradicts all of the other health professionals you have seen? Even if that person is seeming to help you, might you be better served finding a provider who does not use fear as a primary motivator?

Pain does not always equate to damage and “damage” can be overcome.

 

4 Tissue Loading Progressions To Help With Knee Pain

We have discussed therapeutic exercise/movement many times on this blog before.

Not too long ago we went over the different phases of healing and discussed appropriate measures to take in loading tissues to help with healing. Movement is a great way to reinforce the manual therapy you help your patient with while they’re on the table, so we encourage you to start making a practice of tissue loading and movement once they’re off of it.

After you’ve done your interview and concluded it is safe to begin loading (which you can read about here), here are some progressions for the knee you can do right in your treatment room. These are good for someone with anterior knee pain, a quad contusion, patellar tendinopathy, or a quad strain. 

If the injury is more severe like a ligament tear, more specific interventions and movements should be chosen.

In the acute stage, (the first 24-48 hours) these isometric exercises (joint angle doesn’t change during contraction) would be appropriate. You’ll notice there is some movement to get into a bent knee, but then the contraction is actually a hold with the knee kept bent. 

 

When your patient comes in for their second treatment, you can start to progress the movement as you are now in the proliferative phase of healing.

In this case, you can progress to an eccentric load, but make sure to stay within the patient’s pain tolerance.  A little bit of discomfort is okay, but we don’t want to aggravate the injury by causing any significant pain.

Hopefully, by this point, your patient is getting into more pain-free movement because you’ve been doing lots of great treatment and also getting them to load the tissue. 

So, if they could do the above eccentric movements by the third or fourth visit, you can progress them to concentric movements as they have probably progressed to the remodelling phase of healing.

Here is a final progression you can try if your patient is up for it.

Plyometrics! It may take a bit of encouragement to get them to try, but if they can do this, it’s a great progressive load for athletes who may be on a return to play rehab scenario or a return to work for an injured worker.

If the patient has any balance issues, it might be best to avoid this until they regain more strength and their balance has improved. 

Takeaways

  • Make sure you are monitoring the area for swelling, redness, and heat, or anything else that could indicate chronic inflammation.
  • Encourage the patient to move, they may be apprehensive to start a loading program.
  • Communication is essential both for the instructions you give, and the feedback you get from the patient.
  • Educate them on how a little bit of pain and discomfort is okay during the movement, they just don’t want to overdo it.

Articles Of The Week July 29, 2018

We have preached about these kind of things many times, but it’s great to see bigger organizations like the AMTA spreading the word as well. Let’s get rid of these many myths in our profession and start sharing quality information with our patients. 

“Myths Vs. Truths In The Massage Therapy Profession” – Renee Zagozdan

This is just a simple quick video, but it’s an important message that NEEDS to be shared. So many practitioners are still using language like “slipped disc” when talking to patients about pain. Well, that needs to stop.

“You Can’t Slip A Disc” – Lorimer Moseley

We quite often promote looking at research, making sure it’s good research, and making sure it’s up to date. But, as pointed out in this article, there’s still lots we can learn from older research that can still be applied and used within our practice.

“Learning From Old Research, (Digging Into History)” – Bronnie Lennox Thompson

This is a great post that outlines 50 quotes on pain from Louis Gifford. They are well worth the read, and many of them you could use to help explain some things to your patients.

“Louis Gifford And His Legacy” – Lars Avemarie

Quite often we hold on to old theories because we believed they worked, and have had some success with them in practice. However, sometimes those things need to be challenged, and in this post the rotation of the sacrum on the ilium and treatment of it is discussed. Give the videos a watch as Sam gives a good explanation of what is actually happening and how we can reshape our testing and treatment of the area in our practice.

“Reconsider Those Theories: Cognitive Biases In Action” – Samuel Jarman

Understanding Depression, Ways To Recognize And Help

A couple of weeks ago, I was on my way to the gym when my mom called.

She started the conversation by saying she was thinking about me. My response was “why?”

I hadn’t heard the news yet, but she let me know that someone I’m a huge fan of had died. As the news about his death rolled in, it was confirmed that Anthony Bourdain had taken his own life. I’d read some of his books, cooked his food from one of my favourite cookbooks, watched his shows, and basically loved everything he did. I looked up to him.

Strange that someone who you’ve never met, can have an impact on you. Some may even think, strange for a mom to think about their son because of what a famous person did. But, perhaps she was thinking of me because of the way he did it.

I’ve written a little bit about it on this blog before, but have never gotten really personal with it. I debated hard whether I would write this post because it’s so personal. Depression is something I’ve dealt with a lot in my life, (I’m not sure if depression is actually a genetic thing, but it’s something that is certainly prevalent in our family) and was faced with suicide for the first time when I was around 12 years old. My uncle had taken his own life, years later my best friends dad, then one of my mentors at the firehall,  just a few years ago my brother, and a couple of months ago, a childhood friend.

So, any time something like this happens, maybe it hits a bit close to home.

Of course, when it’s a famous person, inevitably there is a lot of media attention. People take to social media to voice their opinions, mourn, share stories, and ask questions.

Most of the time people are left bewildered how someone who has “the ultimate life,” could possibly do something like this, they have it all!?

Then, of course, a barrage of the comments centre around how suicide is a selfish act because the person isn’t thinking about what they left behind, what they’ve done to family and friends, or that they took the easy way out.

Many friends who I’ve talked with since Bourdain’s death, haven’t really dealt with depression in their lives, so they have a difficult time understanding what could lead to this. I’m sure every person who deals with depression has varied experiences and different ranges of severity, so I can’t speak for others, or their experiences, but I will speak of mine.

Now for the personal part.

What Depression Feels Like

I can’t make a blanket statement on this as it’s going to be different for everyone.

Depression isn’t just simply a case of being “down” or feeling “blue” for a little while, it goes far beyond that. We are all meant to have a range of emotions and some days not feel as good as we do others. How could we ever experience how great happiness feels if we’ve never experienced grief or sadness?

Sadness can come and go depending on the experiences we have during the day. When you’re depressed, it’s like there’s a scratch on a record being played that is constantly skipping, playing the same line of a song over and over again. Only the line of the song is negative thoughts and no matter how hard you try, you can’t turn it off.

The longer it goes, the worse the negative thoughts get, and the harder it is to turn it off.

Possibly the worst part, is that you know those thoughts are wrong, you know they’re irrational, but there’s nothing you can do about it, they just keep pounding into your head. Then, you start to believe them.

When you start believing them is when things get really tough. You start to pull away from others because those negative thoughts aren’t just a matter of a feeling of sadness, it’s a feeling of worthlessness. You start to think that no one cares, that you’re not loveable, that maybe, just maybe, you’re as worthless as the thoughts in your head.

You could be laying in bed with someone you’re totally in love with, and when they tell you they love you, you don’t really believe it because, why would they!? When you already believe the negative thoughts in your head, why would anyone else think any differently? You assume everyone else thinks the same thing.

As it persists, things continue on that downward spiral. Sometimes laying in bed just thinking “maybe the world is a better place without me,” “maybe my friends and family would find it so much easier not having me around.” And the thoughts just won’t shut off, they won’t go away.

Then some of the isolation begins. You pull away from everything social because you’re not likeable anyway right?, so why subject your loved ones to HAVING to put up with you being around. It’s such an irrational thought, your loved ones having to PUT UP with you. It makes no sense, but you just can’t help it, it makes sense to you at the moment!

One of the strange things is that it doesn’t matter how good everything else in life is going, you could literally experience the greatest highs, and still have those negative thoughts constantly spinning in your head. One of the greatest experiences of my career was travelling to Russia this year with hockey, it was a major accomplishment, but there was still a night where I had to lock myself in the bathroom to have a good cry…damn those negative thoughts!

According to Mental Health First Aid Canadasome of the outward signs of depression can have both a physical appearance and a shift in attitude. 

Some signs of a change in physical appearance can be:

  • Looking sad, dejected, or anxious.
  • Speaking slowly in monotones.
  • Have a lack of attention to their physical appearance (look unkept).
  • Slowed thinking and body movements, agitation, pacing, or unable to sit still.
  • Decreased energy, tiredness, and fatigue.

With changes in attitude, a person may say things like:

  • I’m a failure.
  • I’ve let everyone down.
  • It’s all my fault.
  • I’m worthless.
  • I’m so alone.
  • Life is not worth living.
  • No one loves me.

Take a moment and just think about what it would be like having those thoughts repeatedly playing in your head. So, yeah I can see and understand why these famous people with the “ultimate lives” can get to a point where it seems like their only option is to end it all.

Treating Depression

There has been lots of discussion about what works for treating depression, that we need to raise awareness, and we certainly need to talk about it (the main reason for me writing this post).

What I haven’t seen much on, is how does the depressed person feel about all of these things?

This article was being shared around last week about the great effects of resistance exercise in reducing depressive symptoms. While this is great (and is hopefully used as a preventative measure), when you’re going through dark bouts of depression, the last thing you want to do is exercise. Just getting out of bed can be hard enough.

Raising awareness, yes we need to do this and fortunately, mental health, in general, is becoming more recognized and talked about. However, when you’re dealing with it, the last thing you want to do is raise awareness around your mental health. There’s a lot of fear associated with it.

Again, maybe irrational thoughts, but all you can think is:

  • No one would want to date someone who deals with this.
  • I could get turned down for that job I’m applying for if they find out.
  • People are going to look at me differently.
  • I’ll get less professional opportunities if people know.
  • No one would want to read a blog post I’m writing.

Talking about it, yes let’s get this going! However, it’s important to keep in mind that whether we like it or not, there is still a lot of stigma surrounding mental health (at this point). So, the depressed person may not want to talk to anyone about it, because remember, it’s also possible they think that NO ONE cares anyway.

While exercise and massage therapy are both recommended as lifestyle and alternative treatments for mild to moderate depression, anything more severe, the person should seek medical attention. This can be both medical and psychological treatment. Some of the best scientific evidence points to antidepressants, Electroconvulsive Therapy (ECT), and Cognitive Behaviour Therapy (CBT) as the best approaches for the treatment of depression.

The best thing we can do is start building relationships with medical professionals who provide the above therapies, so we can refer our patients when they need it. 

Assessing Risk Of Harm

This is one of the reasons it drives me bananas when some of our regulatory bodies say the biopsychosocial approach is out of our scope. Not only is massage therapy recommended as a treatment for depression, it’s also our responsibility to recognize and refer out should our patient need it.

How do we handle it if our patient is dealing with a mental health crisis and it gets to be too much for them?

Mental Health First Aid Canada gives four steps as crisis first aid in these situations:

  1. Engage the person in a serious conversation
    • Connect in a personal way.
    • Ask if they are feeling hopeless, or engaging in risky behaviour.
    • Show sensitivity and let them describe their feelings.
    • Listen for anything that could be an invitation to talk about suicide.
  2. Ask about suicide
    • Are you thinking about killing yourself, or having suicidal thoughts?
    • Asking this will not encourage suicidal thoughts, but rather it shows you care and are willing to talk with them, which can be a great relief for them.
    • Creating this conversation can identify you as a safe person to talk to.
  3. Explore and assess risk
    • Ask if they have a plan in place.
      • Have they made arrangements, or have things they could use to do it?
    • Ask about prior suicidal behaviour.
      • If they do, see if they need extra support, or if there are things that helped them in the past.
    • Ask about their supports.
      • See if they have people to turn to (at this point it might be you).
  4. Engage them in a plan for safety
    • Try and make sure they don’t have access to the means of killing themselves.
    • Develop a safety plan for a manageable period of time along with emergency or crisis line information.
    • Try to ensure no access to drugs/alcohol.
    • Listen to them.
    • Refer them to appropriate professional help.
    • Connect them with their support resources (and try not to leave them alone).
    • If necessary call 9-1-1.
    • Ensure your own safety.

While I hope this is something you never have to deal with, it’s an important conversation to have, as it could quite literally save one of your patients (or loved ones) lives.

While this is just a blog post, it should not be used as a substitute for more education about mental health, or suicide. I would encourage anyone reading this (healthcare professional or not) to take a mental health first aid course to better equip you to handle these situations should you ever need it. 

Whenever a famous person succumbs to mental health issues and takes their own life, it raises lots of awareness online. Along with that is discussions and opinions about the act of suicide itself. People make statements like: “it’s a selfish act,” and “why couldn’t they think about the ones they left behind?” While those things are all valid statements, as the ones left behind are left with nothing but hurt, and questions about how they didn’t see it coming, or just disbelief that it could ever happen. It may seem like a selfish act, but as we talked about earlier in the post, the person doesn’t believe that anyone cares, loves them, or that there is any other way out. From my own experiences, I’m not concerned about whether the person was selfish, it’s more sadness that whatever was going on in life was so bad, that the only thing they thought would fix it, was to end it all. So please, if you have any concern surrounding this with one of your patients, assist them to get the help they need.