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Everything You Wanted To Know About OA Of The Hip

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I wrote a post a few years back about a mistake I made helping someone who had osteoporosis in their hip and how to avoid my mistake.

We’ve also been posting lots around different hip pathologies lately.

It can be confusing, to say the least, trying to determine exactly what is going on with a patient experiencing hip pain. Coming up with what we “think” is a diagnosis, then attempting to differentiate which pathology they are experiencing if there even is one.

Then, of course, using our clinical decision making to develop a treatment plan and homecare.

But, are we really sure we’re doing the right thing for each pathology?

Well since we’ve already done posts on the SI joint and Femoroacetabular Impingement, I figured it was time to take a look at the research on Osteoarthritis and what we can do to help.

Finding A Diagnosis

Yes, I know…we’re not allowed to diagnose.

But!, that doesn’t mean we shouldn’t have some knowledge around how this is diagnosed so we can better educate our patients on what they are dealing with.

OA of the hip is usually seen in middle-aged and elderly people, most often over the age of 601, with men having a higher prevalence.

It affects the joint capsule (as well as other structures around the joint) which in turn causes some muscle weakness and limits the range of motion1, mostly with internal rotation and flexion.

When we look at the clinical guidelines around OA of the hip1 there is a list of things used in the diagnosis:

  • Moderate anterior or lateral hip pain during weight-bearing activities.
  • Morning stiffness less than one hour in duration after waking.
  • Hip internal rotation of less than 24°, or internal rotation and hip flexion 15° less than the non-painful side.
  • Increased hip pain with passive internal rotation.
  • Above the age of 50.

So if we are seeing someone and we suspect possible OA, or we are unsure of the diagnosis and their symptoms aren’t matching up to the above, this would be a good opportunity for us to refer out to get a possible differential diagnosis.1

Part of what we should assess is also what the daily function looks like for the patient sitting in front of us. What activities would they normally be doing that are being hindered because of the pain associated with this?

Also extremely important to take into account are: What are their goals? What are they hoping to get out of the treatment? What would a successful treatment look like to them?

The cited paper 1 gives four different activity tests which could be useful for you in your practice:

  • 30 Second Chair Stand Test
    • Seated on a chair, feet shoulder-width apart, arms crossed, patient stands up and repeats this as many times as possible for 30 seconds
  • 4-Square Step Test
    • Four canes placed with handles out at 90° angles to form four squares. The patient stands in square 1, steps forward with both feet into square 2, then steps right into square 3, then steps back into square 4. Sequence is then done in reverse and is timed.
  • Step Test
    • Patient steps on and off a 15cm step maintaining stance on the painful leg, both feet are placed on the step, then down to the floor on the opposite side. This is done for 15 seconds with the full number of steps counted.
  • Timed Single Leg Stance
    • The patient places hands on their hips and stands on the affected leg, with the knee of non-stance leg flexed so the foot is behind. The patient stands on 1 leg for as long as possible up to 30 seconds.
  • Six Minute Walk Test 2
    • You guessed it! Go for a walk with your patient. See how far they can go on a flat surface for 6 minutes in duration.

What I love about these assessments is how they all help to measure strength, balance, endurance, and flexibility…which are also the recommendations for exercise or homecare interventions for people with OA of the hip. So these could easily be part of homecare instructions to increase strength, balance, endurance, and flexibility and you can watch them all by clicking HERE.

In addition to these active assessments it is also important to document 1 flexion, abduction, and external rotation (FABER test) along with passive hip ROM and strength (which might be tough to do via special testing), which is where the above activities will help.

Now that you have an understanding of how individuals are diagnosed, and how we can do some assessment, it’s important to know what the research says on treatment.

The biggest recommendations are patient education, exercise, and manual therapy1.

Now, I’m not about to lecture you on the manual therapy end of things. You all have your favourite techniques and your patients come and see you because of what you do, so keep it up! When it comes to education, we aren’t so much educating patients on OA itself (we can leave that to the doctors and rheumatologists) but we can teach them some activity modifications and…you guessed it again…exercise. If the work you’re doing or if the guideline recommendations aren’t helping the patient see some improvement, this would also be a good time to refer out.

So let’s look at what the evidence says on exercise!

Exercise For Hip OA

Now it’s important to mention that weight loss is one of the main recommendations to help OA of the hip, however, counseling a patient on this is well out of our scope. Also, as Greg Lehman puts it, losing weight is really hard!

So let’s focus on what we can do (which in turn may help with a bit of weight loss), EXERCISE!

When reading over the research on this, the first statement that popped out to me was:

Pain is the dominant symptom although it is important to note that the severity of pain and the extent of changes on x-ray are not well correlated 3

This is crucially important as quite often people will get the x-ray to confirm a diagnosis and take this as an indication they shouldn’t exercise or can catastrophize over this, thinking they are so damaged exercise isn’t an option.

Pain along with joint stiffness, instability, swelling, and muscle weakness can lead to not only physical but psychological changes and impaired quality of life. 3 However, when we look at the benefits of exercise it can not only improve physical activities but can also help to improve a wide range of other functions including social, domestic, occupational, and recreation activities.

It can also help with fall risk, which is not only an immediate benefit but also a very long term benefit in preventing traumatic injuries due to fall accidents.

When looking at the type of exercise that would be most useful, it was determined that using supervised therapeutic exercise for strengthening the area is most beneficial and surprisingly (at least I was surprised) water-based exercise wasn’t as effective, nor was there as much research done in that area. Part of why this is not as effective is due to less of a load on the joint which does not correlate to walking ability or an increase in joint ROM. Also access to facilities is harder to come by compared to just being able to go for a walk outside.

However, it is suggested that for obese patients (I’m not about to make that assessment, this would be better coming from a doctor), or those who have more severe changes, aquatic exercise would probably be more beneficial until more load could be tolerated.

So, digging deeper into the research it goes back and forth as to what is more effective strengthening, or aerobic. However, the reason it seems to go back and forth is because it always comes down to what is most important, and or, more effective for the patient sitting in front of you. This way there is no “one” recommendation as far as exercise goes. To provide a good exercise recommendation is to look at what is affecting the patient more. Is it more important to strengthen the area according to the person’s daily needs? Or is aerobic exercise more important? What are the patients goals? Is going for a daily walk more important, or is being able to do a squat, climb a flight of stairs, or playing a game of tennis the top priorities.

I love these two quotes from our friend Bronnie Lennox Thompson:

Whatever the reason, tapping into that is more important than the form of the exercise.

and

Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time.

Now don’t get me wrong, exercise is never a waste of time and the evidence shows us, in this case, it can assist with daily function and help with pain (it will never completely get rid of pain). However, if we aren’t making the exercise applicable to, and enjoyable for the person, the likeliness they will do it is low. We also have to take into account they will likely have some discomfort with exercise but we must educate them on how this is not correlated to the condition getting worse. If we recommend an activity and 48 hours later there is some swelling, or the pain worsens this demonstrates that we have overdone it a bit and may have to back off the homecare dosage we have given them. We must use our clinical decision making not only in our dosage but also in what’s important to the person sitting in front of us.

References

 

1. Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.
2. American College Of Rheumatology. Six Minute Walk Test. https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Six-Minute-Walk-Test-SMWT.[August 10, 2020]
3. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal of Science and Medicine in Sport. 2011 Jan 1;14(1):4-9.

Making Movement More About The Person, Not The Exercise

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So I was on Facebook the other day.

And I saw somebody trying to make the argument that this exercise with a Theraband should be retired from anybody’s rehab toolkit.

And their argument was that there’s far better exercises for a rotator cuff injury.

And I’m sure there are, and I’m sure that you could even use this in different planes and do different things in order to help a rotator cuff injury.

But what we have to understand is that it’s not necessarily about the exercise itself.

It’s about the person who’s standing in front of us and we have to make that exercise meaningful to them.

Because maybe their biggest goal is to just be able to put their groceries away pain free, or maybe it’s to pick their child up and if this becomes a meaningful exercise to them that helps build capacity, build resilience and makes it so that they can do those activities we just talked about, then this is just fine as an exercise.

 

 

Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

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This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

Crossed Arm Syndrome

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I understand the trend toward patient-empowerment, trying to build self-efficacy without risking dependency on the clinician. This has elevated the interventions of education and exercise over manual therapy in terms of best-practice recommendations for physical therapists.

As a long-term PT, I can understand this movement, but the trend comes at a price.

First off is the belief that manual therapy, viewed as a passive intervention, should be dosed sparingly as to not encourage dependency. In contrast, I contend that if manual therapy allows movement with less fear, pain, and caution, this, in itself, builds independence.

I do accept that more common view of PT is the exercise-based model, though I have HUGE issues with intellectual lazy PTs who blame weakness on pain. What I don’t and will not accept is an apparent lack of engagement on the part of my profession.

I have great respect for the time, patience, money, and emotional investment that a budding PT student makes to become a DPT, as it is not an easy path. But what are we building?

Recently I had dropped my car off for a service at a local repair facility. Rather than join the squad impatient chair-sitters, waiting for word of the bill in need of payment, I chose instead to take a long walk. This walk afforded me an opportunity to cruise through the nearby picturesque village, able to see the sights while getting my exercise. My walk took me past the village PT clinic…twice, once on my outbound journey, and again on my way back to the garage.

On my first pass, I was easily able to view a good handful of patients dutifully working out on at their respective stations, all seeming to be completely engaged in their tasks. But at the center of the facility, I viewed two individuals who I am assuming where the resident PTs. How did I know this?

Apparel, for one. They were the only ones NOT engaged.

Instead, they stood side by side, talking with each other, in the dreaded arms-crossed posture. Argh! OK, I thought, as I passed, maybe I caught them at a bad moment. Maybe it was a fluke. I’ll take a look on my way back, hoping that they would not be caught in such a compromising position.

The walk took me through the rest of the village and, with a bit of a divergence, along a roaring creek. Quite lovely. But as I again approached the PT clinic my suspicions rose and, sure enough, there they stood. Maybe they have moved and returned to the exact same spot to converse again…or maybe not. But there they stood, arms-crossed and conversing, while their patients dutifully went through their paces.

A PT may argue that those patients were engaged in self-helping behaviors, learning self-reliance, and building upon their own potential. Quite possibly.

But why did the PTs need to be standing there so unengaged? We can be more than arm crossers, we can be cheerleaders, encouragers, coaches, teachers, and, yes, occasionally, applying manual interventions. Self-reliance is key, but what has the PT profession become; a bunch of arm crossers? Manual therapy PT has its own skulls in the closet, but that’s not what this post is about. It’s about arm crossing.

My bias is toward using manual therapy as a primary intervention and evidence exists for this as a viable treatment strategy. I strongly discourage dependency of any sort and abhor it in other professionals. My work is set up to empower my patient to feel like they can move and with less fear. I teach them to self-treat, based on my examples, and make it a strong encouragement to engage in the movement of their choosing. I recognize that a good majority of patients seen for exercise-based PT improve, though those that don’t often come through my door.

As a profession, PT and other similar professions, the view of us by the public matters. Arm-crossing and spending a good amount of your time conversing with your peer instead of your patient is simply a lame way to spend medical dollars, not to mention a very expensive education.

Next time I make that walk, my hope is to see PTs engaged with their patient. They may not be touching, using manual therapy as I do, but I hope to see them spending time speaking to their patients, coaching and encouraging, aiding and correcting, prescribing, and adapting. I hope to see them doing the things our profession(s) are capable of and not resorting to the stereotypes that pockmark our profession.

BAN ARM-CROSSING

Level Up The Prone Press Up

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The Prone Press Up is one of the best ways to prevent and treat acute low back pain. Even if you get a massage, adjustment/manipulation, or other treatment in a clinic, you still need to maintain the improvement at home (unless you want to pay for a passive solution forever).

A patient is more likely to get better if they do a high dosage of repetitions throughout the day of whatever resets their system. If it hurts, they’re less likely to dose or to get to end range. Here are some of my favorite ways to make the prone press up pain-free or to eliminate the perception of tightness at end range

  1. Alternating Isometric Contralateral Arm/Leg raises
  2. Bilateral Isometric Hip Extensions
  3. Diaphragmatic Breathing at End Range

 

Any or all of these strategies should make the press up pain-free or as comfortable as possible so a high dosage should be easier to accomplish.

 

Painful Exercise In Rehab – Yes, No, Or A Lot To Think About

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Whether rehab exercises should be painful or not has become a recent topic of much discussion. As we have started to value the role of (optimal) loading in rehab, and that we can get patients back to moving and loading pretty early in the rehab process, we have also got to appreciate that this is unlikely to happen without experiencing any pain.

If you have any type of understanding about pain then the simple question of “should we use painful exercise?” suddenly might not look so simple!

Rather than a simple yes or no, there are a bunch of questions to be answered, such as how much pain is OK? Who may or may not benefit? And what is the best way to manage the process? Especially if all does not go to plan!

Research

From a data standpoint it would be great if we had have something that we can use to guide us here. Low and behold we do, and its open access.

Smith et al looked at this question in 2017.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis

This systematic review and meta analysis looked at 9 trials in which varying degrees of painful exercise were used. They found that painful exercise did NOT result in statistically worse outcomes across a short, medium or long term follow up. There was a small statistical benefit in the short-term for painful exercises as highlighted by the standardised mean difference of around 0.2 (SMD = effect size for a meta analysis). So from a research standpoint this is positive news.

One thing to note here from a clinical standpoint is, that using painful exercise is no GUARANTEE that it will have a positive effect for your patient. All statistical tests only give us the PROBABILITY of an effect, so the likelihood is that it will, but when we look at the confidence intervals (measure of variability) for the mean SMD for painful exercise, for the majority of the studies we can also see that they cross into a negative effect and in some of the studies quite substantially.

The variable effect of exercise on pain (although over a shorter time frame) was also shown by O Neill et al’s recent look at the acute effects of isometrics *Here*. Although, of course, isometric exercise and painful exercise is not the same thing, the point here is the highlighting of the variable effects from exercise. For patients with higher baseline pain isometrics actually increased their pain post exercise and this is the benefit of looking at individual responders within a study not just the group average. Those with lower pain at baseline seemed to receive more analgesia from isometric exercise.

BUT at the very least I think we can say that the likelihood is that it will not have detrimental effect. So as rehab can often be painful we can be reasonably confident but without seeing painful exercise as some sort of fire and forget panacea and also appreciate the individual nature of pain.

We could debate the mechanisms of HOW painful exercise might work from pain habituation to conditioned pain modulation and perceptual mechanisms but in essence we don’t really know at this point in time and this might be different or in different combinations for different people.

Benefits

The benefits can be both physical AND psychological.

Firstly, it allows patients to get in MORE exercise. If they are not being limited by pain (or pain contingent if we are being fancy :) then they can get a greater dosing than if they stopped due to it being painful. It is important to add though that we currently don’t know what optimal dosing is for exercise having an effect on pain!

Secondly, it sends the message that hurt does not equal harm. The problem can be painful and still settle down if managed in the right way. This may give people a new insight into their pain and how they can manage it.

Pain self-efficacy may also be built experientially, so using painful exercise as a tool might be an option to help do this.

Clinical Application

So it’s great to have some objective data on this subject, but as we know getting that into clinical application is not always straightforward.

Firstly don’t be afraid of some pain! The likelihood is that it won’t cause a worse outcome. But as we are dealing with thinking, feeling HUMANS, it is OF COURSE not as simple as this, but more on that later.

One of the issues with always looking to be pain free with exercise or continually treating pain, is what does that say ABOUT pain? On one hand we are telling people hurt does not mean harm but our actions might not be saying the same thing. If pain is OK, if it is normal then in the process of getting it better we might have to endure a little bit of it.

But how much is OK is a key question? Studies that have allowed painful exercise have ranged from not increasing baseline symptoms during or post exercise up to 5/10 on the VAS.

We know the limitations of the VAS as a REALLY subjective scale so perhaps we could introduce the idea of pain being tolerable or intolerable rather than a numerical score.

Screen Shot 2019 01 21 At 13.16.00

 

Now tolerable might be a bit sore but it does not really get in the way. Intolerable might be thought of as getting in the way of our daily activates, maybe having an effect on our sleep and generally making life a bit miserable. This is going to be different for different folk so hence why the concept of tolerable becomes important.

We would also like to know how the pain is settling down. So pain that is not really calming down after the exercise stimulus or keeps on getting progressively worse over a number of days as the exercises are performed is probably not a great idea. We would like to see a nice stimulus response with only slight increases above baseline (tolerable remember : ) that calms down gradually over 24-36 hours, quite similar to delayed onset muscle soreness (DOMS)

So on the issue of DOMS, it is important to identify if the increase in pain is actually the same as the original symptom. Post exercise soreness is quite normal but for those that are unaccustomed to exercise this might not be recognisable especially for a currently painful area. Defining what is pain and what is soreness might be a good sense making exercise for some patients. Although we don’t know that progressive overload is required with exercise in rehab, it probably ia a good idea, so having some sort of tolerable baseline for patients to progress or regress from is a great idea too. This is also might have an effect their self efficacy using exercise too which, of course, is a bonus.

Pain Is Not The Only Issue

Potentially the most problematic area with painful exercise, and one that is really under discussed, may be more about the psychological aspects that are associated with the pain and how they can affect the person. One of the best prognostic factors for recovery in a number of body areas appears to be pain self efficacy, *here* is a recent paper from Chester et al and also from Foster et al *here*  Pain self efficacy, something I have written about before also *here*, is the ability to carry on normal functioning despite of pain. It is important to note that those with higher pain self efficacy also tend to adhere to exercise better.

So someone’s pain self efficacy is going to be a KEY factor in whether they are able to tolerate having pain and being able to carry on functioning which maybe a fundamental skill at the heart of painful exercise especially if it can take 24-36 hrs to settle.

Predicted outcome is another key prognostic factor and if someone believes that increased pain will result in a negative outcome then this could have a negative effect on the actual outcome.

Jack et al *here* found that the number one reason for poor adherence to exercise programs was that people did not want to make the problem worse. So painful exercise coupled with negative beliefs about pain, low pain self efficacy and a poor predicted outcome may not sit well together.

A qualitative piece “Exploring experiences, barriers, and enablers to home- and class-based exercise in rotator cuff tendinopathy” from Sandford et al also found that a fear of making the issue worse was a key factor in reduced adherence to exercise.

What Can We Do?

Firstly you could screen people for these factors if you feel they are required. We have tools such the Pain Self Efficacy Questionnaire  (PSEQ) and the shorter version the PSEQ-2.

One caveat with using questionnaires, in my opinion : ), is it does allow us to get a score to assess confidence and resilience in managing pain but it perhaps does not tell us about things that are specific to our patients. So being able to weave this into a good subjective that teases these more personal parts of the narrative out is a must.

Also ASK about their expected outcome from the treatment and what would it mean to you if it was painful.

“Do you feel like this exercise will work for you?”

“Do you have any concerns about doing this exercise?”

It might be that someone tells you that they have tried exercises before and they did not work or that they feel it might make the issue worse, especially if it hurts.

It might also be important to discuss with ALL patients what their beliefs are around pain. These might be that pain indicates they are doing more damage to their bodies or they will not be able to work because they have pain or implications for future functioning. It can often be what the pain MEANS to the patient that is the real issue rather than just the sensation of the pain itself.

A key factor to remember is regardless of whether painful exercise is positive or no worse than non painful exercise, a negative belief may stop your patient from exercising

Education

One of the most powerful tools we have at our disposal is EDUCATION, I am not always a huge fan of this term as it can imply a teacher pupil relationship. But in order to provide effective education to people we first have to build rapport and then understand what they may need to know more about.

We can educate on a range of things from the effectiveness of exercise for many issues, that painful exercise is often not detrimental, that pain self efficacy is an important prognostic factor and what pain may actually mean and its relationship with physical damage. It may also be worth talking about the process and what to expect, and often that it is a process of trial and error to get the right level and desired response.

This has to start with understanding the patient, their history and belief structure.

Where You Start Is Not Where You Have To Finish

Do we have to jump straight into painful exercise? I don’t think so. It is not REQUIRED but it is also not harmful.

An important point to make is that for someone with very negative beliefs about pain, reduced pain self efficacy and poor beliefs about the outcome, challenging them right off the bat with painful exercise might not always be the best thing to do. As they build trust in you and confidence in their bodies then pushing into pain progressively might sometimes be a better route.

We know that giving people the option to avoid pain can actually maintain pain avoidance, so whilst not advocating avoidance behaviour confronting these things may take a little time, confidence and education, especially if the person has a lot of negative pain and avoidance based beliefs.

Those that persist in doing painful things that have NOT provide a therapeutic effect may benefit from non painful exercise for a while too. If you feel that pushing into pain has not given the desired response when looking at their history then a break or change in dosage could be just the ticket.

Those with higher levels of pain at baseline on average seem to have worse clinical outcomes so this might also lead me to reason that maintaining this level of pain through exercise might not always be a good idea.

There are no real hard and fast rules here only individuals and individual considerations.

What If It All Goes Wrong???

This is where self efficacy may come into its own. Empowering your patients to self manage maybe valuable in the exercise process.

As we hopefully have told the patient BEFORE they embark on an exercise program I can often be trial and error. Have we enabled our patients to adapt their exercise dosage if it goes a bit wrong? *Here* is a short piece on dosage in rehab

So do your patients know what to look out for in terms of symptoms?

Do they know how to adjust the dosage? This could be in exercise frequency, intensity and time, sets and reps (volume).

Are they able to contact you to ask questions? Do they know this?

I think these are all required aspects of pushing into pain.

A patient I saw last week had religiously persisted at pushing into his painful rehab exercises every 48hrs. He believed if he did what he was told he would get better (the trust!). But after 3 months there was not the desired outcome. In this case he was given no indication what to do if this happened, just blind faith on all sides that he would get better.

Key Points

  • Painful exercise DOES NOT produce worse outcomes from the research we have
  • Research does not guarantee your patients response to painful exercise
  • It is not just about the PAIN sensation! What does the pain mean and how does it affect behaviour such as exercise adherence?
  • Pain self efficacy and predicted outcome are important psychological measures and can be discussed and measured
  • Think about education around the exercise and the pain response
  • It does not need to start with painful exercise!
  • Empower your patients to self manage

 

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