We could definitely have a good, and potentially lively, discussion over what makes a great rehab program and with no gold standard here, we will have to settle for some well reasoned opinion.
This being my blog………here is mine!
Exercise & movement are not golden bullets to a successful recovery, far from it, but they do show promising results and can be done BY someone rather than being done TO someone, which is a real positive for behaviour change and on-going self-management.
Commonly when we discuss what makes up the BEST rehab program it will be about promoting some specific type of training or a magic exercise with the highest activation or program design process that gives the best results across ALL people, but perhaps we need to start to think about how we can help just that one person currently in front of us. We also often talk a bit more about the exercises themselves rather than the rehab process.
As always the most powerful exercise available to us is the REASONING process behind the program. I would also add how we then FRAME and EXPLAIN it is pretty important too.
This a reasoning model I made recently that firsts asks the question of what is the outcome you want to get from your rehab? This idea of the desired outcome then influences what we do and how we do it.
Does all this thinking make things more complex? Perhaps a touch. But just because something is simple does not automatically make it more effective. Simple is also not a well-defined term, one persons simple maybe another’s complex and visa versa.
We often are still seduced by seemingly easy answers that are purported to work for everybody and this is a great quote from Don Marquis that sums it up nicely.
“If you make people think they're thinking, they'll love you; But if you really make them think, they'll hate you.”
Anyway, enough philosophising, what does make a good rehab program?
Rather than think in the finer details of program design perhaps we should think in broader brush strokes. Why? Well so far we don’t have much good information on exactly WHAT is the best type of exercise for many painful complaints or exactly how they help.
Rotator cuff tendinopathy HERE
Lower back pain HERE
Achilles tendinopathy HERE
Back pain (again) HERE
Perhaps we could say that doing SOMETHING seems superior to doing NOTHING so finding out some of the things that influence people actually doing their rehab is beneficial.
A very basic reason that exercises don’t even get performed in the first place, a prerequisite for any training effect, is that they don’t fit in with people’s lives and the time they take to perform. People are time poor with work pressures and family and social pressures and these stressors may even be a contributor to the problem in the first place.
This paper found time to be the number one predictive factor to adherence for a home exercise program HERE.
A rehab plan that does not take into account the doability factor (yes I made that word up) could even ADD to the stress someone is experiencing beyond the fact that it is simply not getting done and is an exercise in futility (get it!). A 12 exercise program requiring specific equipment that is only available a 20 minute drive from the house and requires spending an hour doing them fails miserably when we look at the doability (there it is again) factor.
Simple might be (opinion alert) a small number of exercises that can be easily performed with minimal equipment at a convenient location and time of the day. Rather than it being a specific we can fill in the blanks by interacting with the person who actually has to do it. Although of course as SIMPLE is very subjective it could also be a shit ton of other stuff too! Essentially it is the recipient, the patient, who must define simplicity.
Maybe the actual EXERCISE itself is less important? If there are a whole bunch of ways to skin a cat then we can make the process easier by not being too attached to any single type of exercise.
If you don’t believe something will work why would you invest the time and effort in it? So even if the primary mechanism of action of a rehab program is a physical/biological one it may be limited by a belief structure.
This paper here HERE found that the benefit gained from exercise might be mediated by the predicted expectation of the benefit. We have to appreciate that OUR perceived benefit of a specific type of activity may not match the PERSONS. As it their beliefs that mediate the outcome this matters a fair bit.
Previous experiences influence our expectations that in turn may drive future outcomes. If I have previously failed using a specific exercise then this may affect my expectations of something similar having success in the future. This could be by reducing the perceived benefit AND also the effort put into it at a physical level.
So finding out about expectations, taking them in to account when designing a rehab program and potentially addressing them with explanations about WHY certain elements maybe beneficial could have a dramatic effect on the outcome with certain people. The way the exercise is FRAMED maybe as important as the exercise itself.
Exercises that fit in with previous successes or are enjoyable might drive an increased perception of benefit and adherence. How do we find this out? Well this is where we get super simple, just ASK, what activities do you enjoy? Have things worked for this problem in the past? What things haven’t worked?
Imagine someone has failed with rehab after being given a sheet of exercises, would it be best practice to just give them another sheet of exercise?
We could dig a little deeper to find out why did they previously fail?
Did they do the exercises?
If not, why not?
What was their perception of them?
What may need to improve is the ACTUAL use of this information to improve rehab programs.
Don’t forget ACTIVITY
Activity can be a really useful tool as well as more specific targeted exercises and those with long-term pain issues often find that their activity levels can drop and this could contribute to how they feel both physically and psychologically. This could be thing’s that are loved and cherished such as dancing or playing with their kids or activities around the house that need to get done on a regular basis.
People can simply rule out activities because they have previously hurt. This does not mean that they are automatically bad but can be perceived that way. Restarting or maintain activities does not have to have a binary yes or no answer, instead they can be graded and we can attempt to find a tolerable dose.
This paper from Darlow HERE looked at beliefs around back pain with some interesting results.
- 59% believe if an activity causes pain it should be avoided in the future
- 55% believe exercise risk outweighs the benefit
These are some of the perceptions and beliefs that may have to be overcome about activities, especially pain provoking ones, before you even get to the business of moving.
Which activities did they previously do, especially enjoyable ones?
Why don’t they do them anymore?
Did someone suggest they should stop?
Can you find a tolerable dosage and maintain activity or slowly build up?
Advice and On-going support
Advice about the actual process might have a huge influence on the outcome and could make the exercises a whole lot more effective.
- You actually HAVE to do the exercises for them to work (no shit)
- Sometimes put in real EFFORT
- They may take time to work
- They may make you sore - Maybe explain what this means
- Rehab has ups & downs
- If you are stressed and/or time poor do a bit less
- If you are time rich and/or feeling good do a bit more
Another key part of a rehab program is offering on-going support. Ever started to build a piece of flat back furniture and found that the instructions were just to difficult to follow or were incomplete? Who can you call to help? Often nobody. How many pieces of furniture still remain uncompleted? I bet a whole bunch. Probably about as many as we have rehab plans that have not been completed!
Making sure someone is aware that they can access on-going support could make a difference here, even just the knowledge they CAN access some.
- We don’t know what type of exercise is BEST for painful complaints
- The one that get’s done probably is the BEST
- That maybe individually defined
- Time matters
- Perception matters
- Activity matters
- Advice matters
- Support matters