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Home Care Plans: Instructions Vs. Adherence

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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.

Articles Of The Week October 14, 2018

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We talk lots about exercise and strengthening around here, but is it always necessary? While I’m a firm believer in movement and loading tissue, sometimes a “mythical dysfunction” comes along and we’re taught very specific exercises to fix said dysfunction. But is it really necessary? Give this article a read to find out.

“Deep Cervical Flexor Training” – Paul Ingraham

Therapists quite often get caught up in “corrective exercises”. In line with these corrective exercises, they’re talking to their patients about how dysfunctional, or weak they are, rather than instilling strength and resilience. When the reality is, just getting stronger is corrective to whatever their treatment goals or issues are.

“Getting Stronger Is Corrective” – Tony Gentilcore

This one has a GREAT infographic along with some great information regarding the biopsychosocial aspects of therapy and how it can be explained to patients.

“Simple Tips To Improve Mental Health” – Keith McCarroll

Knowledge about pain has come a long way in the past few years. However, the teachings around it haven’t kept up the pace quite as well. That’s where some great posts like this one come out and help all of us gain a better understanding of chronic pain.

“A Better Understanding Of Chronic Pain” – Mark Olson

There are just as many misconceptions around exercise as there is about manual therapy. Fortunately, guys like Nick are out there sharing quality information. In this post, he shares lots of information and demonstrations of some lower body exercises (many of which you could perform right in your treatment room with patients) along with the explanations about why they’re important.

“The Missing Lower Body Exercises For Strength” – Nick Tumminello

Qualities Of Muscle And Changes In Sensation

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Once in a while, I’ll get called out on something in a blog post.

Fortunately, I don’t take it personally anymore, cause well…we all make mistakes.

In one particular instance, it wasn’t so much a mistake as it was just something I hadn’t remembered learning about, so the post wasn’t as clear and concise as it could or should have been. So in doing some research on the topic, it essentially led to writing this post (but I’ll still need to go back and edit the other one afterwards).

The post was about whether we lengthen a muscle in a treatment and the person said that I didn’t take muscle extensibility into account, so it made the information sound wrong (that’s not what was said verbatim, but it’s the general gist of it).

But there are some other physiological properties of muscle we should take into account as well so that we can always give our patients an accurate description of what is going on with them.

Excitability

Or more accurately, electrical excitability.

Action potentials, or, an impulse travels along a cell’s membrane due to voltage-gated channels. In a muscle, there are autorhythmic signals that come from the muscle itself (think the heart). The other is chemical stimulus like neurotransmitters released by neurons, hormones from the blood, or local changes in pH level.

This quality of excitability is one of the things that generates movement, the muscles respond to these electrical, or chemical stimulus and produce tension or movement via a contraction. 

Contractility

Contractility is the ability of muscles to contract forcefully when stimulated, thus generating tension. If the tension generated is enough to overcome the resistance of an object, the muscle shortens and movement takes place.

As we mentioned with excitability there is an electrical stimulus, when a stimulus is generated it then creates a twitch response (or contraction), one contraction or twitch response occurs for each stimulus. So, contraction begins as an electrical stimulation, which in turn becomes a mechanical response, thus overcoming the resistance of that object you are trying to lift.

This is probably one of the main things we are trying to have an effect on when working through rehab exercises with our patients, making contractility easier, so they can continue on their activities of daily living pain-free (and yes I realize we are having an effect on the other qualities as well). 

Elasticity

Elasticity is the ability for a muscle to return to its original length and shape after a contraction, or extension.

When looking through textbooks most refer to plastic and viscoelastic properties which enable this return to length to occur. However, as you will see when we talk about extensibility below, this may not be the case. 

Extensibility

So, this is where I got called out!

Extensibility is the ability of a muscle to be stretched to a predetermined endpoint of sensation and then return to its original shape when the stretch is removed, without being damaged.

If you remember talking about agonist and antagonist contractions in college, this demonstrates an example of extensibility. As you flex your biceps (agonist), the triceps (antagonist) have to relax and stretch (or lengthen) in order for the contraction to take place.

But in order for a muscle to have extensibility, it also has elasticity, which enables the muscle to return to its original, normal length.

This is where research must come in. There are a number of theories used in trying to explain how muscles can be lengthened, or have extensibility increased. Most of them are trying to say there is a mechanically increased length of the muscle but is this really possible?

There are four of these theories and here are their explanations:

  • Viscoelastic Deformation
    • A decline in resistance to stretch after being held in a stretched position for a period of time.
  • Plastic Deformation Of Connective Tissue
    • Increase in muscle length, immediately after stretching that causes a muscle to remain in a permanently lengthened state.
  • Increased Sarcomeres in Series
    • If muscles are immobilized in fully extended positions, there is an increase in the number of sarcomeres in series.
  • Neuromuscular Relaxation
    • Slowly applied stretch causes neuromuscular reflexes to relax the muscle.

However, most of the above theories have been done as animal tests, could not be performed on humans, provided no evidence of length change according to the description, and provided no lasting change.

Ironically I would have thought neuromuscular relaxation would be the best explanation, however, the studies showed that increased movement after short-term stretching could not be attributed to this. I’m wrong again!

As this review points out, there is a better theory with a better explanation.

The studies reviewed show that increases in extensibility are more likely due to a change in sensation, not an increase in muscle length. It even suggests there is a psychological role in allowing for greater extensibility.

One study showed that an intensive four-week stretch program actually didn’t make a difference in extensibility, but rather increased the subject’s tolerance to uncomfortable stretching sensations and also points out the underlying mechanism may be psychological. The argument was also made in this study, that the four-week stretching program may not have been long enough to make a noticeable change.

This would explain why when I go to a yoga class once in a while, I don’t see any real difference in the amount of movement I can do from one class to the next. My tolerance to the stretch or movements hasn’t increased enough for me to do that damn supta virasana pose (and I don’t think I’ll ever be able to, my body doesn’t bend that way!). However, those folks who go a couple times a week and make a practice of it have a far more increased tolerance to the movement after doing it regularly for an extended period of time. 

For some of you, this may be a simple review and you already know this stuff while some of you may be wondering how or why it’s applicable clinically. Well, we quite often tell our patients we are trying to “lengthen” the muscle when we apply a stretch after treatment. We even use the comparisons of people who do yoga and refer to their “long” muscles.

Well, the reality is there is no length difference in the muscle, but there could be a change in their extensibility. Even as we try to explain to them what extensibility is and the changes we make, we need to be accurate in our description of what’s happening. Just like the when we begin rehab exercises and introduce graded exposure to fearful movements, all we are doing when we provide a stretch is a graded exposure to the stretch sensation. We aren’t even going to make a massive change to extensibility in one treatment, but maybe we can increase a little more tolerance to certain movements. Great, now I have to go back and edit that other post, and we’ll see if I get called out on this one!

Articles Of The Week October 7, 2018

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It’s great to see that some major outlets are starting to share sensible information. This article about back pain is great and actually shares some quality knowledge. Movement for back pain is probably the best medicine we can use and this article agrees!

“Babying Your Back May Delay Healing” – Harvard Women’s Health Watch

I’m absolutely honoured that this guy has been following me from early on, and I’ve been following him. The beauty is how he’s started doing videos. He’s an absolute pro when it comes to runners, so if you work with that population, make sure you follow this guy, cause he’s an absolute PRO!

“How Stretching Can Delay Recovery” – Matt Phillips

I refer to Bronnie a lot, cause she puts out great stuff. How’s your assessment, is it time to change? Well, it might be, give this post a read and decide for yourself.

“From The Particular To The General – Clinical Reasoning In The Real World” – Bronnie Lennox Thompson

“Ergonomics do not have a firm basis in science.” How many patients do you have, who have been told their ergonomics need to be fixed to get rid ‘of pain!? Well, you may want to share this article with them.

“A Difficult Position: Experts Question Whether Ergonomics Holds Up” – Liam Mannix

This one comes from one of my favourite massage therapy people, so you’d better listen up! If you’re debating going out on your own, or just debating starting your own business, Rajam has some great advice for you, and I suggest you heed it!

“How To Start A Massage Therapy Business” – Rajam Roose

 

Why Do Isometrics Work So Well?

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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.

Articles Of The Week September 30, 2018

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Sometimes when we treat patients who are dealing with chronic pain it can be difficult to come up with appropriate home care for them as they are often afraid to move. What about if we took a totally different approach and gave them directions to find joy?

“Finding Joy” – Devra Joy

We’ve been putting up lots of posts on tissue loading lately as it’s a VERY important part of helping patients rehab injuries and overcoming pain. This is a great post with videos of exercises for platar surface foot pain.

“Midfoot Mobility – Toe Extension – Strength” – Jeff Cubos

This is another one of those “try looking outside the box” kind of articles. It comes from a medical doctor’s approach of using poetry to connect with and creating a real connection to help his patients.

“Expanding The Time We Have With Patients Through Poetry” – Rafael Campo

Last week Readers Digest put out an article about 14 exercises you should never do after the age of 50 (I think they’ve since changed the title). The physical therapist in this youtube video disagrees and so do we!

“5 Exercises You Can (And Often Should) Do at Any Age| A Physical Therapist Explains Why!” – Ryan Smith

This is another video which shows for one the importance of tissue loading with tendionpathies and also how the motor cortex of the brain is involved. It also shows creative ways of using a metronome to effectively tailor an exercise session for the patient. 

“How The Brain Is Involved In Tendon Pain” – Ebonie Rio

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