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Patient adherence to home/gym programs following regimen of physical therapy – A first hand clinical perspective

I asked my coworker to write a guest blog post on anything he wanted to write about.  Naturally, he chose to write about home exercise programs for the patient.  This is a great read for anyone from therapist to the rehabilitated.  Check it out, and be sure to look up Ben Sherr as he is a tremendously smart therapist and definitely helps me on a daily basis.

During a course of physical therapy treatment, a patient may be seen up to 2-3 times a week for an extended period of time.  In my short history as a PT, many outpatient orthopedic PT programs will not come to an end with the clearance and official discharge by a PT.  Many people will self discharge, or not return to PT. Those are the cases that I will not be visiting in this blog. However, those who are officially discharged from physical therapy, where do they end up?  Are they compliant with their programs that are set up for them? Are we as PTs working hard enough to ensure that the programs are sufficient for them after they finish their formal PT? The answers to these questions do not seem too clear.  This is just one PT’s self reflection regarding patient’s adherence to their gym/home program following outpatient physical therapy care.

Recently, I have had several patients for whom I have set up gym or home programs to work on their PT exercises following successful completion of PT care.  Whether they will complete their program at home, at the gym, with a trainer, or with a CSCS, they are all discharged with a plan going forward. I work in a clinic where there is a gym next door and there are plenty of terrific, certified personal trainers who are willing to help at a reasonable price.  A goal may be to have them work with the trainer and then become independent and join the gym, once again at a reasonable price. I have found that many patients have a hard time following through with this or start this program and then fall off the wagon. The same speaks to the patients that will “complete their program at home”. Unfortunately, compliance to these home programs is usually slim to none. Some patients may leave physical therapy “pain free” but predictably down the road, they return with the same issues they started with. I put much thought into each individual home program to help my patients be successful. With a lack of adherence to these programs what do I get to show for it?

Most of these patients do very well while in PT, so when they return, are they using PT as a crutch?  That is something that we as PT’s cannot enable, but that is a whole other topic, for another day. Back at the topic at hand.  

Why do patients have such a hard time following through with their plan of care.  Is it because they feel great and no longer need to do it? Is it because of differing mentalities?  Is life just too busy? There could be many reasons. Well, research does back it up that most patients are not completing their PT home programs after PT, as documented by Rizzo, et al in 2014, stating “patient adherence to physical therapy home exercise programs (HEP) is estimated between 35 and 72%”.  In addition to this statistic, the article also discusses mental models, which is basically how individuals view the world and how they think. Bottom line was that most patients and PT providers have differing mental models, so PT’s have to work extra hard to change their thought process to connect with the patient. Should we be the ones adjusting to them, or should they be adjusting their mentality to match ours? Again, difficult to answer.

I went into PT to help people.  It is as simple as that. I unfortunately have to ask myself am I doing so?  I believe that I am. I can only take a patient so far. If the patient is committed to PT as well, then they will do a great job.  Not only during their official treatment time, but also when they’re on their own. I have come across some tips that may help a patient stay with their routine following PT. First off, finding a purpose.  Why should this patient continue their exercises? Mostly, it will help them avoid re-injury and maintain their improvements. Maybe they are training for something, or maybe they want to better themselves in general.  Any of these are reasonable. Another tip would be connecting to the patient in a more effective manner. The patient may feel more accountable to complete their exercises following completion of PT. From Campbell et al, “initial compliance with PT is high because of loyalty to the therapist.”  It did not state that it drops off as time goes on, but I am sure that it does.  Lastly, education. Educate the patient to the best of your ability as to why they must continue their rehab to avoid decline in their status.  Or put a positive spin on it and educate them on how much improvements they will make by continuing the exercises. Use a goal as an example.  Just a thought. In all honesty, and according to research, somewhere around half of the time it will not work.

Back to the personal cases that I have come in contact with in the outpatient orthopedic setting.  I have had plenty of situations where past patients have followed through on their programs and eventually do not have to continue them.  Mostly this is a post-operative patient who has done great. Those who continue their programs in the long term are most likely athletes who play a sport or in training for an event.  These patients do great with continuation of care. The general public on the other hand, are very challenging. You try your hardest to adjust your mindset to think like the patient. Set them with plan for success.  I have had three gentlemen in the past month who have been set with gym programs, and have not returned once. Is this my fault? I do not believe so. I set them up for great success and put in a lot of effort. The patient themself needs to be accountable at some point, and that starts right after discharge.  

Maybe it is a possibly jaded view on the subject, but it seems that some patients just do not want to help themselves.  In the healthcare system we have today, these people want a quick fix, and some get it, albeit sometimes temporary. Unfortunately, these patients are the ones who are the returning patients.  And what do I do? Treat them with the best care possible. And will they follow their home program when finished? Maybe. Maybe not.

 

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Core is more than a 6 Pack

There are certain things in the strength and conditioning/personal training field that make you cringe every time you hear them.  Core is toward the top of that list, however, sometimes living in cliche phrases is what we need to do in order to communicate better with our patients/clients.

To better define what it is, let’s describe what connects to it.

First and foremost, when we think of the core, we think of the 6 pack–known as the rectus abdominus.  The muscle is essentially a sheet that connects the front portion of your ribs to the front of you pelvis.  It gets it’s shape from a central tendon–linea alba–and tendons that run horizontally from there.

But, if that was all there was, we would be in trouble.  We have external obliques, internal obliques, and transverse abdominus that all band together to create a lattice of protection.  This is great, because without this protection we would basically rupture our internal organs housed in the area.

If we all addressed the strength and endurance of this area we would probably all be a little better off.  However, that is definitely not all that represents the core.  We have these fancy postural muscles that help hold us upright.  Commonly referred to the erector spinae group which is composed of three different pairs of muscles along the spine.  There are little tiny muscles that run between each vertebra in the spine, there is the QL, which runs from the hips to the lower ribs.  There is the iliopsoas group that runs from the lower spine to the hips.  One of the bigger players, I feel, is the lats.  They run from the upper arm and course all the way down to the hips.  They can create shoulder stability and a great extension moment in the spine.

Clearly, it is difficult to find balance.  Any imbalance, if great enough, will create movement dysfunction and surely pain.  In my experience, the majority of kids coming in can’t do a pull up or even some sort of inverted row which is essentially a lesser version.  They also present with a great amount of anterior tilt showing that their abs probably aren’t working all that well.  How do they conquer gravity then?

When taking part in a workout program, especially in the lower training ages (you haven’t worked out in a couple of months) then make sure to keep it semi balanced.  Realize that all your big lifts essentially have an extension moment on the spine, really requiring those meaty lats to hold down the fort.  I would encourage you to find some sort of flexion moment at the trunk level.

Please leave any feedback below!

 

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Two Things That Anyone Can Make Better

A common denominator for anyone and everyone walking in the door of our facility is a lack in strength or stability in particular areas of the body.  Aesthetically, people want to know if they’ll get bigger (insert body part here), but realistically, two that are tremendously important should get better.  Without further adieu, here they are:

1. Anterior Core

Almost everyone I see is tremendously weak here.  It becomes even more clear when you ask someone to perform a simple push up.  They literally just hang on the ligaments of the spine.  How have you made it this far in life without learning how to perform a proper push up???

When I say anterior core, I’m referring to the portion known anatomically as rectus abdominus.  Fancy latin.  It connects the front portion of the ribs to the pelvis and when contracting forces the hips into a posterior pelvic tilt.  Not always great to be in that position, but with proper opposition/apposition it is fairly balanced to our normal 13 degrees of anterior pelvic tilt.

When this is weak, you see a lot of extra anterior pelvic tilt.  Your body just hangs out on whatever it knows will create stability…ligaments of your hips and spine.  Is it any wonder that we have soo much low back pain!?

Strengthen the abs, it will help create stability.  It isn’t the only answer as there are a few other abdominal muscles that are needed to help create that apposition we are looking for (different topic for a different day).

2. Buttcheeks

This is something that we work on almost every day in the facility.  To create almost all athletic motion, you need the glutes.  When developed, they can also have an aesthetic side to them too.

Glutes are great players in power, stability, multi direction motion.  We all have a gluteus maximus, gluteus medius, and gluteus minimus.  The hip joint (where the femur articulates with the acetabulum of the pelvis) also has a great deal of mobility, three planes actually.  Contracting here will create an external rotation element on the femur (thigh) as well as an extension moment.  It can create stability to the pelvis in a closed chain contraction taking shear off the low back.  And it gives us great power and push off in the sagittal, frontal, and transverse planes of motion.

The right side is usually a little weaker, again, different conversation for a different day.

This is anecdotal at best on my part.  When we screen our athletes and adults though, we see this to be consistent across the board.  Maybe it is indigenous to the Merrimack Valley, but I highly doubt it.  Let me know what you think by leaving a reply below.

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2017 year review

This past year has been a roller coaster for sure.  I have accomplished many life goals, changed things that I never thought I would change, and accepted life curveballs.  Here is a quick recap of 2017.

I made a couple of small life goals in 2017 that would help give me a hobby, something that was completely lacking.  Basically, I’ve spent my college and adult life to this point filling all available hours of my day with work or class.  Now that school is done and I am working a more modest schedule, hobbies will keep me sane.  First, I wanted to get to the mountains and snowboard.  2016 didn’t allow me to do that and it happens to be something serene once you get up to the mountain and check out the horizon.  Secondly, I wanted to pick up a guitar at least once per week.  This is something that is difficult to me because I feel I don’t have a musical bone in my body. I remain humbled.  That’s my personal life in a nutshell.

On a much larger scale, I passed my NPTE, the exam of all exams essentially.  This is what licenses you to actually perform your duties as a physical therapist.  Thank goodness that chapter has come to fruition.  So instead of working a modest 40 hours per week, I have decided to get a job in a clinic in addition to running a performance center.  I know, what was I thinking???

I made it a goal to get to more of my athletes games.  In 2016 I was really handcuffed with the job I had which didn’t offer much flexibility in terms of being able to see my athletes play.  Besides coaching lacrosse in the spring and seeing literally all of my teams games, I was also able to see both of the volleyball teams I work with, the girls soccer team I work with, and the ultimate highlight was being able to see Notre Dame vs. USC at Notre Dame where one of my athletes plays football.  I’m hoping that this year extends more opportunity to see the athletes in action–as well as more deep dish pizza.

Now with the new year, I would like to keep my hobbies going as well as really refine my skills in the PT arena as well as the sports performance realm.  I would like to get to do more networking this year and travel a bit more.  Kind of a rough outline for the new year, but it works.

 

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Guest Post: Time for a Change

This is a guest post from one of my interns from the summer and current sports performance coach.  Kathy is a very intelligent and driven individual who has donated her time around a hectic schedule to Young Performance.  She aspires to bridge the gap between PT and performance and has some really good ideas.  You can find more on her blog at blendingptandsc

             I’m a PT student who, like most people, has no solid idea of what field to practice in. After going on a few clinicals, I found out that my expectations of rehab didn’t really exist in the real world – at least not yet. Having this existential crisis, I decided to go figure it out. I began throwing myself into different jobs and internships in the health and fitness field. This summer alone, I’ve been a PT aide at 3 separate clinics, a personal trainer in training , a kickboxing instructor, and a strength coach intern – which has lead to the creation of this blog. There were two glaring problems that I kept noticing: 1. the health and fitness field is muddled with misinformation and 2. everyone is constantly trying to one-up each other.

1.  People are quick to believe what they hear or read without looking for evidence.

Carbohydrates are bad. All fats are bad. No rest during a workout is a good thing. There are so many health myths, so many “fads” backed with no scientific evidence, and, with the rise of social media, so much bad information posted by a lot of unqualified people. Not only is it dangerous, but it also creates another barrier for health providers who must spend their time re-educating and getting buy-in from their clients.

2. The health field, it’s a very “cut-throat” environment.

Everyone wants to have all of the credentials, the letters after their name in order to be the “best”. People also want to believe that their way of thinking is the right and only way. Hip vs foot, barefoot running vs orthotics – these topics cause a lot of frustration and bickering. It seems likewe’ve  all forgotten why we started in this field, forgotten that we are looking down on our peerswho are using their best judgement to get to the same goal. Just because their way looks different, doesn’t make it wrong. The first thing we learn is that everyone is different and something that might work for Joe Shmoe might not work for the next person – so why are we still stuck on trying to have one golden principle? It’s all theory at the end of the day and if it works, it works!

Long story short, everyone wihin the health and fitness field needs to come together and not only educate people but to encourage peers for their different perspectives and ways of thinking. Without that, we will not progress very far.Guest