"The Good Go To Heaven, The Bad Go To Hell"

When working with a client status post hip, knee or ankle surgery, we must ensure that they will be safe when they are moving around in their home.  Many people have stairs that they will need to navigate to enter or exit their home or to move from one floor to the next.  Initially, they may have too much pain when fully weight-bearing on the surgical leg.  So we use the saying "The Good Go To Heaven, and The Bad Go To Hell" in order to explain that the "good" or stronger leg goes up first upon ascending the stairs, while the "Bad" or weaker leg goes down first, upon descending the stairs.  Basically, the stronger leg is in control of the body weight completely when ascending as well as descending the stairs.  It does the work of controlling the body safely up and down while the weaker, surgical leg goes along for the ride.  Many patients/clients receive home care treatments immediately following their surgery and may receive therapy for up to 2 months.  I have seen these patients many times towards the end of their 2 months, and when I ask them to show me how they climb stairs, they continue to perform the task with "The Good Go To Heaven, and The Bad Go To Hell" strategy.  I think many times, as therapists, we get so caught up in educating a patient to perform this task the safest way possible, that we never progress them to the next step.  As therapists, it should be our goal to get our patient/client as close to their prior activity level as safely possible.  There is nothing wrong with being safe, and advising our patients to perform stair-climbing this way.  However, when they no longer have us by their side, what happens if they accidentally forget and try to go up or down the stairs using the weaker leg to control their body weight?  They never practiced the technique this way while we were with them because we were so intent on doing it the "safest way."  We actually limited their functional improvment by 'protecting' them so much.  In general, the #1 most important thing is to be safe.  But we also want to challenge, progress and move forward.  If your patient/client independently climbs stairs using the "Good go, Bad go" rule, begin strengthening the surgical leg in the same manner so that they are symmetrical, safe and confident if they ever need to use it (Do this as long as their doctor allows full weight bearing on the surgical leg, of course).  Remember, if they didn't have to think about it before, you do not want them to have to think about it now.  Do not fall into the routine of doing the same treatment day in and day out.  Challenge your patient/client and take them to the next level.

Osteoporosis: Wolff's Law

As defined in Wikipedia, Wolff's law is a theory developed by the German Anatomist/Surgeon Julius Wolff (1836–1902) in the 19th century that states that bone in a healthy person or animal will adapt to the loads it is placed under.^[1] If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. The internal architecture of the trabeculae undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone,^[2] perhaps becoming thicker as a result. The converse is true as well: if the loading on a bone decreases, the bone will become weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for continued remodeling that is required to maintain bone mass.<sup>[3(See Wikipedia Wolff's Law)

Basically, this means that resistive training will help to "strengthen" and improve bone density.  Therefore, if you have a client with the diagonsis of osteoporosis, you need to incorporate strength training, especially in  upright functional positions in order to assist the recovery from, as well as reduce their chance of fractures.  See prior postings for exercises that should be avoided with client's who have osteoporosis.  So if your client with osteoporosis seems hesitant to train with you, now you can explain the benefits to them.</sup>

Functional Training & Observation Skills

We have all heard of Functional Training.  Many of us think of High Intensity Training using Kettlebells, Sandbags, Suspension Training, but it does not stop there.  That may be beneficial for an athlete to maximize his/her performance.  However, what about clients in their 50s, 60s or older, who are looking to improve their quality of life, not their athletic performance?  How do we incorporate Functional Training into their life? 

Just like any of your other clients, find out what their goals are upon the initial evaluation.  For example, presently I have a patient who is recovering from a fractured femur.  She had corrective surgery and during her first session, she stated how happy she would be if she could get down into the bath tub again.  My first goal is to improve her 'quality of life' by helping her return to her prior functional level.  I need to get her to be able to take a bath again.  Initially, if she is having trouble with the basics, such as getting up and down from a chair or is unsteady when walking, I will need to give her a standard strength and balance program (for her legs especially).  I will also need to assess her bathroom, including the size of the tub and the direction of the faucet controls so that I can make the transfer as efficient as possible.

Now here is where the task observation comes into play.  In order for her to transfer safely into the tub I need to break the entire task down into its individual parts, and focus on each part prior to attempting the entire task.  First, she needs to be able to approach the tub, and lift each leg high enough to get into the tub.  Then she needs to be able to transfer into a lunge, then tall kneeling, side-sitting, and sitting with legs stretched in front of her.  To get out of the tub she will need to roll over into quadruped (on hands and knees), into tall kneeling, lunging, standing and finally lift each leg high enough to get out of the tub safely. 

Who would have thought it took so much work to get in and out of the bath tub?  Each session, I work on these individual components, and will eventually take her into her bathroom in order to practice the entire task. 

Your goal is to be observant of the task at hand.  Learn your client's strengths and weaknesses and customize the task to their abilities.  Break down the activity that your client is trying to relearn into its component parts, which will be easier for your client to initially learn and master.   Then, for proper carryover, you need to have your client perform as many of the individual components in proper order as soon as possible, so that it makes sense to your client why she is performing all these exercises/activities.  

Repetition of the task will establish motor patterns in the brain. And before you know it, your goal will be accomplished.   Remember, if you must break the task down into component parts, the trick is to 'bring it all together' as soon as safely possible for actual learning and retention to occur.