Exercises - Clinical reasoning of exercise selection, progression & regression
Objective: Develop the knowledge, skills & clinical reasoning of exercise selection, progression & regression for NGs so they can assess & treat patients effectively without resorting to a cookie-cutter approach.
Universal S&C principles (Ways in which exercise selection, progression and regression for people with pain is very similar to those without pain)
Painful considerations (ways in which exercise selection, progression and regression for people with pain can be very different to those without pain).
Painless (pros and cons)
Painful (pros and cons)
Flare management advise
Refer back to and pick the clinical pearls form Paula's "Fearful of flare-ups? Graded activity, pacing and beyond to self-efficacy" presentation
Essential points to cover at the start of the presentation
No.1 Exercises don’t happen in a vacuum! There is always context, meaning and narratives that accompany exercise, movement, PA etc. There are no good/bad exercises only more and less useful for a particular person at a particular point. A huge pitfall I have made in the past and see many clinicians make is to deem a movement or exercise as being “dysfunctional”, “maladaptive”, “bad” or “off limits”, whether that be explicit of implicit. If the narrative and messaging about a particular exercise or movement is not clarified at the start or revised it can have enduring impacts later down the track.
No.2. A core element of the clinical reasoning of exercise selectin is to identify the barriers and facilitators of compliance and adherence to exercise . Relate back to importance of creating significance, meaning and relevance witht the patient.
Gamechanging questions
How do you feel about this exercise?
Do you feel that this is threatening for your X?
Do you confident in performance this exercise into your programme?
What do you think that this exercise is useful in your recovery?
What do you think this exercise is doing?
The COM-B model to influence behaviour. In order to impact behaviour. A patient should have each of the following and as such provide target areas that you might not have considered in your clinical reasoning for exercise. Ask yourself "Does my patient have the capacity/capability to do this exercise?""Does my patient have the opportunity to do this exercise?""Does my patient have the motivation?"
Opportunity
Motivation
Capabilty/Capacity
Behaviour
Pros
• If want to modify/modulate pain
• Increase function
• As part of sense making
• Graded approach
Cons
• Does it add to the rollercoaster ride?
• Does it take away from other treatment aims?
• Sometimes it’s not possible
Pros
Cons
• It gets people on the first rung of the exercise ladder
• Can get people loading sooner
• Greater short term benefit as per Ben Smith an colleagues 2017 S/R although in the medium and long term there is no clear superiority of one treatment over another.
• Can reinforce our sense making messages
• Can get people living well with pain
• Can damage therapeutic rapport
• May cause flare
• Can decrease engagement
• Can reinforce negative beliefs
If your patient doesn't have the capacity/capability then this is where the focus should go on building capacity/capability or else selecting a different exercise
If your patient doesn't have the opportunity then you need to think about the planning of the exercise/programme e.g. they don't have the equipment/time/resources/support etc
If your patient doesn't have the motivation, question whether the significant, relevance and meaning of the exercise has been clearly identified and conveyed. See transtheoretical model stages of change. Precontemplation, contemplation, preparation, action, maintence
Both require person centeredness
What is the target mechanism for exercise for this person (acknowledging that mechanisms and interventions targeting mechansims are often overlapping, fluid and dynamic)
Neurophysiological
Cardiometabolic
Tissue healing
Neuromuscular
Psychological/Social
Exercise should be fun, not a burden
♦ Discuss the content of the exercise protocol with the patient; it should fit the needs and requests of the patient
♦ Be careful with eccentric exercise
♦ Include exercise of non-painful parts of the body
♦ Allow increased pain during and shortly following exercise but avoid continuously increasing pain intensity over time (i.e. modify exercise)
♦ Use a time/volume-contingent approach with appropriate baseline
♦ Be conservative when setting the baseline; prefer a lower baseline to guarantee that is well within the capabilities of the patient’s body
♦ Use multiple and long recovery breaks in between exercises
♦ Monitor symptom flares, especially during initiation of treatment and during grading, and adopt exercise modalities accordingly
♦ Minor symptom flares are natural during initial stages of exercise therapy, but should cease once an exercise routine is established
♦ Do not grade the exercise protocol in the case of major symptom flares
Specific vs general
Prac video. See accompanying google doc for full run sheet of intended videos
Video examples with model of how to do each of the following. Flesh out case scenarios for a patient that presents with shoulder pain, knee pain, back pain. Link in with team on any specific cases that they have used in their NGP to see if they would like their case to be used in this instance.
- Reduce the load. Lighter weight/less frequency (more rest)/ fewer kms/ less hills/ slower. It seems simple….AND IT IS but its often overlooked and often very effective when applied.
3.Modify- Change the stance/ adjust the set up/ tweak the form/change the focus with your verbal cues/ more extension/less extension we are going to go into this in much more detail in just a few minutes. It can be more load through the heels, more through the toes. More or less contraction through muscles.
- Limit the ROM temporarily- again once we are clear with our patients that his is not necessarily a “forever thing”, most patients are fine with it and happy to being doing what they love.
- Swap in an alternative- with this I try to have it relatively similar to the painful or provocative exercise but when it is not possible “getting the win” with an alternative is an awesome plan B.
- Take a look. Bring a torch not a hammer. Rather than getting nitpicky just take a look. Is there anything when the person is exerciseing or moving that strikes you and your working hypothesis, clinical reasoning and info that you have obtained from subjective and objective. If so start there, this will guide the below
- Reintegrate the inital exercise/ movement with guidance around the following
- How much load should I start with?
- How many reps should I do?
- How frequently should I do the exercise?
- How should I increase the load?
- What happens if it starts to hurt again?