Rather provocative title eh? Welcome to post 22 of Strength & Conditioning for Therapists … if you’re still here and reading this 😉

The reason for the title, and the topic, is that I’ve been asked this specific question several times over past couple of months – and by physiotherapists too! Whether it be on podcasts, interviews or in general chit chat over Twitter, I’m asked my opinion on what therapists are dong wrong quite a lot.

Let me say off the bat, I prefer not to point the finger and say that therapists are doing things wrong! I’m most definitely not the font of all knowledge and in actual fact I enjoy learning all the time from others, including therapists. I prefer to offer my knowledge and experience in a way that might be helpful to rehabilitation practitioners to shape their intervention more effectively to achieve better patient outcomes; maximising the input-output equation you might say.

In this light, let me share with you the (requested) ‘3 things’ … where I think a little more attention could reap significant rewards. Let me add also here, that I am fully appreciative of what a full case-load of patients looks like in a busy clinic, or NHS practice!

Managing Patients On The Fly

OR Lack Of Planning

You’re busy with patients day in, day out. You’ve a limited time with each and you’re trying to be all things to them to try get their buy-in … The temptation to manage patients on the fly is huge. I get it. But if you can carve our a few minutes at the start of someone’s rehab journey, the rewards can be well worth it.

Specifically, and ideally we’d have a clear idea of the patient’s goal and then construct a rehab plan of how we can enable them to get there. Let’s think about the consequences of no planning for a moment. Each time you see the patient you’re effectively managing the symptoms and issues that present there and then. Worst case, it’s like a new consultation each appointment and you’re missing opportunities for patients to improve.

The other side of the coin is that you’ve planned each phase of rehabilitation, determined the principal goal of each phase (for example ‘strength development in the first 4 weeks’) and you have already strategies in place to progress and regress exercise prescription as required. These could have been shared with the patient such that they can adapt the exercise in the event of pain, for example, which means they can continue to make progress in the weeks separating the next appointment.

The post I wrote on periodisation in rehabilitation offers a detailed strategy of how to do this, which you may find useful.

Generic Exercise Advice

OR Lack Of Individualisation

Here’s another one – exercise sheets with ‘3 sets of 10’. They’re everywhere. What’s the point of this exercise? Seriously, what’s the aim …?

Are 3 sets of 10 appropriate for all?

If you’ve ever given out this exercise prescription, do you have a clear vision of what it’s for? Let me exemplify, have you got answers to the following questions…

  • Is it the correct load? This is directly related to the goal of the exercise, whether that be familiarisation, through to strength training?
  • What’s the intensity? – i.e. what stops them at 10? Have you assessed properly how hard the exercise is and whether that is the appropriate overload for your goal? Do they stop because they’re bored, or because they fail?
  • What’s their baseline ability? Does this exercise have the same stimulus across multiple people with different abilities, age etc? Generally this is a ‘no’, yet I frequently see 3 x 10 given to all ages and abilities because that’s what it says on the sheet, not because it aligns with the rehab goal.
  • AND progression – where do you go after this…? This aligns with all of the above. Do patients have clear idea of what they’re doing and how to progress? Do they just do more more reps (I’d say no here by the way), or should they be failing at, say 10, and then be looking to increase the resistance (overload)

For more detail on this, check out the post I wrote a while back on this:

Paying a little more attention to individualising exercise prescription can save time in the long run.

Underloading Patients

OR Lack of load

Finally, the third ‘thing’ links with the above two points. Is enough time devoted to really considering what specifically we want to improve? Yes, we may want to improve proprioception, endurance and strength of the rotator cuff, but how do we do this optimally? One exercise will not deliver adaptation across all of these indices of function.

I’ve spoken about loading before, and it’s important. For example, 3 sets of 10 is NOT a good strengthening exercise, especially if your patient isn’t working to failure. Seriously.

Incidentally, see the link above for the explanation why and on training loads.

If we want our patients to make decent gains in muscle strength, we need to assign a pretty big load – one that they can only lift 3-5 times. I get that there’s a fear of loading people who are injured, but if it’s clinically okay to do so, and you’re doing it in a safe environment, with warm up etc…AND it offers far greater strength gains, then what’s the rationale? (you can even start with maximal isometrics).

I’m yet to read any research papers that have reported any adverse effects of strength training in patients. In fact, when I conducted a systematic review on the topic in knee OA, the rationale cited in several randomised controlled trials for avoiding heavy loads was that it may cause injury. When I traced the reference back (that incidentally they all used), it was an unpublished Spanish MSc thesis. Even worse, the statement wasn’t supported by any data, it was just a cautious approach adopted by the candidate with no reasoning! We can absolutely understand this in a student population, but the rest of the academic community….hmmm, wouldn’t we want a more reasoned approach?

Summary

I hope my musings on these ‘3 things’ have been helpful. I understand the demands of contemporary clinical practice and the pressures that come with a lack of time especially. However, even if you manage to consider just one of these things within your rehabilitation practice, I’m certain that it will reap the rewards with both patient outcomes and time savings in the long run.

Let me know if you agree, if you do this already. I’d love to hear. Or indeed if you have a contrary opinion; what’s your approach and why?

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