Rehab Rules…

So I gave a talk this weekend at a Dutch Physio conference and laid out my “Rehab Rules” for most things that hurt and cause disability in musculoskeletal physiotherapy. It seemed to go down well so I thought I would give a brief overview of them here and see what you lot think.

These rules, or perhaps I should say guidelines are how I approach most of my rehab with most of the patients I see. However, I will be the first to admit that they are not perfect and there are always exceptions to every rule/s. But I find if I stick to these and don’t stray too far then things tend to work out for most patients I see, so here they are…

No1: Individualise it

One of the things I hate loathe and detest the most about physiotherapy rehab are those pre-printed handout sheets of exercise many physios love to use. This lazy, lethargic, couldn’t give a shit attitude towards patients problems and exercise needs to be banished and eradicated from our profession.

If you are a physio who hands out pre-printed sheets of exercise, hang your head in shame. You are a bane, a plight, and a scourge on my profession and the reason I, and many other good physios struggle to improve the reputation of our exercise interventions and to get patients to engage with them. If I had £1 for everytime I heard a patient say “all I got was a sheet of exercises” I could have retired years ago.

When giving patients exercises its vital to remember that they and their problems are unique, therefore the exercises to help them will also need to be unique. Now don’t get me wrong I give a lot of patients the same exercises but never the SAME exercise, there are always differences in the load, effort, dosage, frequency, volume etc etc.

We see a wide, diverse, and varied population in physio with wide, diverse, and varied problems. Therefore our exercise interventions also need to be wide, diverse and varied. Using any treatment homogenously for a hetrogenous problem is never going to work well.

No2: Keep it simple

Physios often fall foul of what I call the rehab paradox. That is they over simply why things hurt patients and then over complicate how to treat them. More physios need to recognise and realise that things hurt patients due to many complex reasons and factors, but our interventions to help them can be really, really simple.

For example, many physios tend to focus on improving the quality or control of a movement or task that’s painful or difficult for a patient, and not on building the patients capacity, tolerance, or resilience to the movement or task. I think if more physios focused on simply getting their patients tolerance and capacity to movements increased rather than focusing on the control and complexity of the movement they would see far greater results.

No3: Keep it challenging 

Exercises can be challenging not only because they hurt, but also because they are effortful or even fearful. I think if more physios get their patients to focus on the effort of an exercise rather than just the pain, then again I think we would see far greater results

How much pain, effort, or fear is sufficient, or needed or safe to ask a patient to push into is very difficult to say as it will depend on so many different factors, and will need to be decided on a case by case basis. But I do think physios need to be much better at reassuring, encouraging, and motivating patients to push harder than most want to.

No4: Be patient

The saying ‘patience is a virtue’ is one I think more physios need to remember. It is understandable for patients to be impatient when in pain, but when physios get impatient and fail to recognise how long things take to show signs of improvement with exercise it can and does lead to unnecessary further investigations and treatments for patients.

Of course, we need to be alert to patients who may be deteriorating or not improving due to other factors, but more physios need to realise that the effects of exercise are not immediate and that it takes time for muscles to get stronger, tissue tolerance to improve, and sensitive nervous systems to calm down. Just because there isn’t any significant or noticeable change in your patient after a week or two doesn’t mean the exercises are not working.

More physios need to hold their nerve better and reassure patients to stick with their exercises longer before they start to panic and send them on for further tests and investigations, which often lead to over diagnosis and over treatment for things that could have got better if they just stuck with the exercises a bit longer.

No5: Think movements not muscles

Physios need to understand that one exercise does not mean one muscle. Just because a patient has 3 or 4 weak muscles, doesn’t mean they need 3-4 separate isolation exercises. Sometimes one compound movement can get all of these muscles working as well as if not better than 3-4 so-called isolated exercises. And because a patient has fewer exercises to do the adherence and compliance often tends to be better.

No6: There are (almost) NO bad exercises

There is no doubt that there are many silly, daft, and ridiculous exercises. but there are in my opinion very few dangerous exercises. However, physios, trainers, and many others including patients often tend to get hung up on the technique and execution of exercises waaaay too much worrying that if they don’t do them in exactly the right way they will hurt, harm or damage themselves.

In my opinion, there are very few dangerous exercises. The danger with any exercise tends to arise from poor load management rather than poor technique. Doing any exercise too much, too often is far more likely to cause issues than doing an exercise with a so-called incorrect technique.

This is not to say that we don’t worry about the technique or performance of an exercise at all. There are times when some advice and coaching to do an exercise more efficiently, comfortably or even just better looking can be helpful. But when this coaching and advice becomes too prescriptive, too constraining, too limiting for patients it can be more harmful than just letting them do it unsupervised.

So there you go these are my six rehab ‘rules’ that I think will make physio rehab more enjoyable and more effective. Let me know what you think.

As always thanks for reading

Adam

4 thoughts on “Rehab Rules…

  1. Love this – I use the same principles to train my horse! The exercise sheet thing is a pain; if you work in the NHS you often have to hand out the routine sheet or you get your ass handed to you… but, you can pick and choose which of those exercises are appropriate and add a few of your own to individualise the programme. I’m good at drawing stick person diagrams.

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