The Problem with an Unwritten Physio Rule….

I know I promised to post a video outlining assessment/treatment/exercises for tibial internal rotation, but it can be a little tricky to find both a cameraman and a body to demonstrate on. Hopefully will get it done in the near future!

Instead I thought I would post about another topic on my mind lately which is this unwritten rule amongst physiotherapists that we should never give more than a few exercises to a patient at a time. Now before I begin, I should note that I relatively do prescribe to this theory as well. I think it is valid in terms of not overloading the patient and can be a great way to introduce a few self-care concepts to them to manage their issue. The unfortunate truth though is most patients need so much more.

There are many cases where 2-3 exercises may do the trick, a minor injury for example or sometimes even a chronic injury that has been mismanaged can have huge results from giving an awesome few spot on exercises. Also, often times the exercises can pile up after 3-4 visits so the patient then actually has the more comprehensive plan of 10-12 exercises they probably needed from the get go. The issue of course though is, if we throw 10-12 exercises at the patient from the get go, will they be compliant? Probably not, but I see people all the time coming in for quick fixes. Manual therapy, soft tissue techniques and dry needling/IMS are great tools to help manage pain, improve movement dysfunctions, and create a window of opportunity for patients to move better. The effects are short lived though and the true time they can make improvements is through their own efforts with a home exercise program.

Is a patellafemoral pain patient with symptoms for a year really going to get better with some quad foam rolling, hip flexor stretching, hip bridges? Probably not, though it could be a good starting point if they haven’t done anything even in that realm of things for the year before. This patient (and many others) probably needs a comprehensive strengthening/rehab program to address likely many different issues. This is on top of probably needing to modify activities, but probably not eliminating them completely though sometimes would be warranted. Thats right, probably will have to cut back on those 20 km runs or crossfit WODs for a while until things are feeling a bit better. Finally, not only do they have to be willing to modify their current lifestyle and find the time to attack their dysfunctions in a more comprehensive manner, but they need to bring a certain level of focus to not only their exercise plan, but to their daily lives as well. What I mean by this is being aware of their dysfunctions through out the day and focussing on making the necessary changes during daily activities. This could be postural changes through out the day, picking things up with proper hip hinging, managing your knee positioning during different activities, or focussing on your foot control during walking. Doing those small things can be way more important than 3 x 10 dead bug once a day.

It takes patients years of poor movement to get to your office and will often take weeks or months (or years!) to reverse. That run they did a month ago that they think might have kick started their issue probably was just the cherry on top of years of building up to that point. This is a key point in patient education that needs to be emphasized.

More and more I am having patients come in for initial assessment and after the first session or 2 I am trying to convince them that the best approach they can take for their rehab is to initiate a more comprehensive strengthening program 2-3 days a week vs 3 home exercises daily and seeing me once a week for a few months. If the patient is able to and seems like they may need more on-going movement coaching vs one session and go, I often refer to strength coaches/trainers who can better suit the patients needs on a weekly basis moving forward. If that is too much of a financial commitment I will take the patient through a movement based/gym routine myself and make sure their technique is appropriate so they can do it themselves moving forward.

In conclusion, I don’t really expect much to change as most of you readers and myself included will probably still continue to give 2-3 exercises for the first visit or two. I think this unwritten rule is fair and agree with the fact that if you did more off the get go it could just overload patients that will then become even less compliant. The reason I wrote this article is to speak to the point that often so much more is needed.

  1. Activity modification (almost never stop everything completely though!!)
  2. A comprehensive rehab plan
  3. Focus during the rehab plan instead of just going through the motions (all so common!)
  4. and focus all day on correcting the various mundane issues that can add up and lead to injury or cause it to persist.

The key is to educate the patient as best you can on their injury and all the things they can be doing to stop it from being exacerbated. This includes both additions to their daily life and subtractions (excessive activity). And finally, educate them that a more comprehensive plan likely needs to be undertaken to address underlying issues and education on how to get the most bang for your buck out of said plan. This is especially the case in more sedentary patients as well as cardio junky patients. Weird to group these two together I know, but both need comprehensive plans to avoid injury typically. Gym rat, team sport athletes and Crossfit patients are often already decently strong and need primarily to modify activities in the gym/field to work around their injury while working on their various mobility/stability issues in a comprehensive warm up.

Let me know your thoughts!

Dave Leyland

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