Negotiating With Your Patients

Negotiating With Your Patients

 

 

You would think that a patient would do anything in their power to return to their prior functional level.  Unfortunately, this is not always true.  For patients who were in the hospital for an extended period of time, they usually return home extremely deconditioned, with low self-confidence, feeling hopeless.  They may receive Home Care Physical Therapy 2-3 times a week with the therapist establishing a Home Exercise Program to be performed on the days the therapist is not there.  However, in my experience, when discussing rehabilitation with these patients, they want to get better but are non-compliant with their exercise program.  I admit, some of the exercises become monotonous after a while.  I have come to the realization that I must choose my battles, and negotiate in order to "win the war."  If a patient is not performing the exercises on his 'non-PT days,' then I try to find something that they will do...something less complex than a list of exercises.  For these deconditioned patients, I found that walking is a an all-around conditioning exercise that they are not so resistant to.  Because many of them are deconditioned, I usually recommend short frequent walks in their home.  Many of them spend a great deal of time on the couch watching TV.  Because of this, I recommend getting up and walking a lap around the house whenever a commercial comes on.  When their show returns, they can go back to their seat to watch it.  They will repeat these short frequent walks every time a series of commercials comes on.  You would be amazed at how much exercise this is.  This is one way to get your patient to increase the volume of activity without being so resistant to it.

Common Physical Therapy Questions

Common Physical Therapy Questions

 

As a Physical Therapist, I have heard certain questions frequently over the years.  This past week, I have been treating numerous patients following a Total Hip or Total Knee Replacement Surgery.  Many of these patients have trouble lifting their operative leg into bed when transferring from the sitting to the supine position.  My previous post explains how using the S.O.D. Stretch Strap can assist the patient with maintaining independence while performing this technique.  However, most patients do not have a strap so soon following their return home from the hospital.  They accept the fact that they can't lift their leg and rely on a family member to lift it into bed for them.  Even weeks after surgery, they may rely on someone else's help for this.  When the family asks me if this is normal, I tell them that the weakness is normal.  However, it is not only muscle weakness that is the cause.  The patient must begin to redevelop the motor pattern to lift their leg into bed by practicing it over and over.  Many times, if I perform the leg raise while cueing the patient to assist, after a few times, the patient is amazed at how quickly the movement returns.  It is as if they must re-establish the brain-leg connection in order to perform the task again.  I advise family members to assist only after the patient has made an effort first.  This will help the patient recover quicker and will prevent the family member from injuring themselves in the process of helping.

 

I have also been working with many Worker's Compensation patients who have injured their backs.  Most of them tell me that they bent over to pick something up and felt it "go out" at that moment.  After weeks of successful therapy, including core stabilization activities, body mechanics and lifting education,  I usually get the same question:  "When can I go back to lifting like I used to, without having to think about it?" 

 

And I answer them with: "Never.  You should have never lifted like that to begin with.  That's why I have been teaching you body mechanics and lifting techniques.  It is your goal to establish new posture and body mechanics so that you don't have to think about it the next time you are required to bend to lift something."

 



 



So although most of us have rarely thought about how we are to lift something off the floor, if we are taught the correct way to do it, and practice it repetitively, our new habit will minimize the risk of lower back injury in the future.  Just because we have been lifting a certain way all of our lives, does'nt mean that we have been doing it correctly.  The older we get, the higher the chance that poor lifting techniques will catch up with us. 

 

Using a S.O.D. Stretch Strap to Assist With Post-Surgical Transfers

Using a S.O.D. Stretch Strap to Assist With Post-Surgical Transfers

 

Very often patients who I evaluate after their hip or knee surgery have a great deal of difficulty lifting their surgical leg into bed in order to lie down. Many of these patients also have weak upper bodies with diminished trunk flexibility and are therefore unable to use their arms to lift their weaker leg into bed.  The Stretch Strap helps them to transfer from sitting to lying down efficiently and safely.



 

 

 



The above 3 pictures shows a typical transfer from sitting to lying down when no strength deficits are present

 

 

 

 

In the above second group of pictures, I use the Stretch Strap to assist lifting the weaker leg into bed.  There is minimal strain to my arms or trunk.  This is especially helpful when there are post-surgical precautions such as those following a total hip replacement which limit how far you can flex forward at your hips

 

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Rotational Stability of The Trunk

Rotational Stability of The Trunk

The Renegade Row

 

The previous blog posts discuss exercises that are beneficial for developing rotational stability of the trunk using body weight.  These should be performed correctly prior to performing stability exercises using weight/resistance. 

 

Assuming you are able to maintain stability with the prior exercises, you may attempt Renegade Rows, using Kettlebells or Dumbbells.

 

Start Position Renegade Rows - Notice the flat lower back

Here, I shift my body weight onto my right arm in order to row the kettlebell using my left arm.  My hips and shoulders remain "squared-off" with the ground - Next I lower the left arm, shift my body weight to my left arm and row using the right arm

Incorrect Form: My hips and shoulders are not "squared-off" with the ground

Incorrect From: My lower back is not flat, but jacknifes prior to the row

The above two incorrect techniques are very commonly seen with clients who do not have the rotational stability to perform this exercise.  They may have trunk weakness or may just need additional verbal and manual cues in order to improve the motor planning/coordination of the activity. 



Rotational Stability of The Trunk

Rotational Stability of The Trunk

 

The Super Plank is a great trunk stabilization technique.  It actually requires you to maintain a stable trunk while transitioning from a static position, 'dynamically' to another static position.  At the point of incorporating this activity into your program, you should have no problem maintaining static trunk positions.  The challenge here is dynamic stabilization.  You are moving from the Low Plank position to the High Plank position with minimal trunk rotation.   

 

Start Position: Low Plank

 I transfer my body weight onto my right arm in order to change the position of my left arm to the high plank position.  With this, a rotational load is placed on my trunk

Incorrect: This would need a correction, as you can see my left hip is no longer "squared-off" with the ground.  I gave in to the rotational force

Correct High Plank Position

Incorrect High Plank Position: I am in a jacknifed position rather than a high plank position

Transition from High Plank to Low Plank: Here, I transfer my bodyweight onto my right arm in order to reposition my left arm into a low plank position without losing the "squared-off" hip position with the ground

Incorrect transition of High Plank to Low Plank.  My right hip is higher than my left hip.  Both hips should be level and parallel to the ground

If you see your client performing the Super Plank technique with any of the "incorrect" behaviors mentioned above, attempt to correct them verbally or manually.  If they can not correct it, then this may be too advanced at this time.  Check out the previous posts for less aggressive stability techniques to master prior to returning to the Super Plank



Rotational Stability of The Trunk

Rotational Stability of The Trunk

 

In the last post, I talked about maintaining stability of the trunk while performing the High Plank Shoulder/Elbow Tap, with various foot positions.  In this post, I will disucss maintaining trunk rotational stability while performing the High Plank Hip Extension technique, with modified hand positioning.

 

 

Start position - Notice the hand and foot position - The hips are "squared-off" with the ground

Slowly lift one leg while maintaining the hip "squared-off" position - If you place a  broomstick across the lower back horizontally from one hip to the other, the stick should be parallel to the ground - One side of the stick should not be higher than the other (This is a good feedback technique)

 

Progress the exercise by adjusting the base of support - Decreasing the base (hand position)increases the difficulty

Completion of the level two exercise

Incorrect Performance - It is subtle, but if you look at my right hip, it is slightly higher than my left - I lost the "squared-off" positioning of my hips - This would be more noticeable using the broomstick to assess - I lost the rotational stability slightly - Look for this compensation with clients when training rotational stability



Another common compensation for inability to stabilize the trunk is the jacknifed position seen here prior to hip extension.  This is no longer the High Plank Position

 



Rotational Stability of the Trunk

Rotational Stability of the Trunk

 

When training your trunk (or core) for stability, resisting rotational forces is one complex and important aspect.  Many of the single arm activities that we do, such as the one arm kettlebell deadlift, apply a weight to one side of our body.  This asymmetrical load applies a force on our trunk, which causes it to rotate to one side (our body gives in to the weight).  To stabilize our trunk, we must fight this rotation, and remain "squared off." 

In this picture, the kettlebell in the right hand creates a trunk rotation to the left.  He must stabilize in order to keep his hips and shoulders squared off with a target in front of him

 

There are many beneficial trunk stabilization exercises.  Some are basic, while others are more complex.  Unfortunately, I have seen people in the gym performing most of them with poor technique.  Many people are in a hurry to progress themselves to the more complicated techniques before they really should.  This post will discuss some of the more popular basic trunk stability exercises, proper technique and common errors that I see each day.  It is your job as a trainer to assess your client's abilities in order to progress them properly and avoid injury. 

 

First is the Low Plank and the High Plank.  These are not focused on rotational stability but are more introductory.

Low Plank: Correct - Goal is high reps, holding each one for 5-7sec

High Plank: Correct

 

Low Plank - Incorrect:  This is not acceptable, as you can notice the hyperextension in my lower back and the protruding scapulae.  I am not maintaining stability

  Once you perfect the low and high plank, you may progress to the rotational stability exercise called the High Plank Elbow or Shoulder Tap. 

Wide Base Elbow Tap Start Position

Wide Base Elbow Tap Finish Position: Notice my hips remain "squared off" with the ground

Incorrect Wide Base Elbow Tap: I lost my rotational stability and begin turning my trunk

Progress the above rotational stabilization exercise by modifying the base of support:

Narrow Base Elbow Tap: Start Position and more aggressive due to modified base of support

 

Correct Narrow Base Elbow Tap



Incorrect Narrow Base Elbow Tap: Again notice my rising left hip - If your client is compensating like this even following your verbal and manual corrective cues, they are not ready for this yet

These are just a few of the progressions you can perform when training trunk stability.  Stay tuned for the next post which will discuss other beneficial techniques