Chronic condition management is a large part of
my role as an Exercise Physiologist and contains a wide scope of issues in
which people may present to me with. A large portion of my practice involves
musculoskeletal issues which are usually ongoing (chronic) in nature. A lot of
the time people have been told to “work around it” or to “get a massage to rub
it out”. I find that sort of advice quite tiresome as it gives the individual
absolutely no guidance on how to fix their issues, and tends to make it seem
like the problem is bigger than it actually might be. Within this blog, I am
going to go through a step by step approach which will help you understand pain
better, and to formulate an action plan to eventually getting better. Yes,
injuries and niggles take time to overcome, but with a step by step approach
and the right people helping you, you should be able to overcome a lot of
injuries. No plan is fool proof and some injuries require specialist attention,
but I am not talking about ACL ruptures here, I am referring to the ongoing
aches within the back, shoulder, knees etc. Hopefully this blog can help you
address some issues and gain back some control over your body.
Assessment:
A plan cannot be put in place without a thorough assessment first. Assessments
are two-fold and include a verbal portion where by the history of the client
and their injuries will be discussed, followed by a movement screening. If you
have ever sat down with a trainer who only wants to know about your goals and
not your history, find a new trainer. In my opinion, understanding the wear and
tear the body has been through over time will really help make sense of its
current presentation. From there, like I mentioned, a movement screen will
proceed. I like to use both a Functional Movement Screen as it is standardised
and has an excellent range of movements, and then I go into specific tests
based on the person. I feel as though the more variety of movement you can give
somebody, the more obvious it can be to see where they struggle. It’s extremely
important to gather information regarding total range of motion, single leg
strength and stability as well as gathering verbal information from the client
as to what things they feel they can and cannot do. The more information you
can gather, the better your intervention and action plan can be. If your
trainer has no idea how well you can or cannot move, how can they attempt to
fix you?
Plan:
In order to formulate a successful training intervention, the plan needs to be
constructed using the results from the testing session. This is not an
opportunity to flex your training brain and try and create something that looks
like a work of art. This intervention needs to be specific and often looks a
tad boring. Some of the simplest exercises could be the key to overcoming a
life time of pain and nothing should be overlooked. This is where communication
becomes paramount and a good understanding of the “why” behind the exercise
selection is vital. If as a client, you have no idea why a trainer has
prescribed an exercise to you, this is your time to ask. If as a trainer, you
have put in an exercise to simply fill a gap, stop, and start again. It is
important to strike a balance between the exercises that are necessary to
overcome pain and improve function, as well as exercises that are comfortable
and can be used to improve performance. A good example of this would be
somebody who presents with lower back pain without an acute trauma taking
place. Upon assessment, they present with tightness throughout their upper back
and shoulder, as well as through the glute and hamstring/calf. From there,
during a single leg balance assessment, they struggle to stay stable on that
same side, however move well on the opposite side. The question can then be
asked, are they sore in the lower back because they are tight, or because they
are weak which is making them tight? In this case, you cannot just stretch and
hope for the best. If you never go about correcting the strength asymmetry and
improving stability, you may find that the tightness won’t go away, regardless
of your stretching routine.
Intervention:
Like I mentioned in the paragraph above, the exercise intervention needs to
address all aspects of the assessment and findings. If somebody is sore but has
no reason as to why, then investigation is usually going to find a few
underlying things. With your plan, you need to be thorough and be thinking both
short and long term. I like to think of rehab and performance as being on the
same spectrum, with rehab at the start and performance at the end. Along the
way, we are aiming to get from one end of the scale to the other, with exercise
selection that both addresses the condition but also provides a road to the
finish line, being performance. Somebody with an injury is not going to just
overcome that problem and then walk away, not in my experiences anyway. Having
an exercise intervention that is progressive, with measurable outcomes along
the way is key. Both objective as well as subjective measures and feedback need
to be deployed to guide your decision making process and give you feedback for
the next steps along the way. Initially, the intervention may have range of
motion measures which are to be achieved before moving forwards, but over time,
performance goals should be introduced. This continuum should be spoken about
within the planning phase of your program design so that you have a clear
understanding of what it is going to take to hopefully become pain free. I well
and truly agree that there is no one size fits all approach to rehab, and you
need to expect a little bit of trial and error initially.
Re-assessment:
I think one of the biggest down falls in strength and conditioning / rehab, is
the lack of re-assessment. It’s easy to get caught up in the process of program
design and coaching, but at some point, you need to be ensuring you are meeting
your targets. I like to include a few key movements within a session which are
similar to those undertaken during testing on day 1. These measures help me see
if improvements are taking place and also if pain is easing. A good example of
this can be the hamstring length using the straight leg raise or the supine
shoulder flexion to address lat length. If these movements become part of your
dynamic warm up routine, you are always testing. This gives immediate on the spot
feedback and will guide future exercise selection. Of course, I do advocate a
testing based consultation for approximately 8 to 10 weeks into the training
intervention but do not feel as though this is mandatory. As long as your
exercise selection is objectively chosen with performance outcomes in mind, you
are on the right track. Subjective feedback regarding pain levels and overall
enjoyment/improvements on behalf of the client is also very important. Finding
ways to make rehab engaging and enjoyable is not an easy task, but will be very
rewarding for all those involved.
Take away points:
1)All pain should be assessed and addressed by a qualified professional.
Your three go to professions are a Physiotherapist, Chiropractor and Exercise
Physiologist.
2)Assessments need to be thorough and include an injury history as well
as movement screening.
3)Plans need to be holistic and include rehab as well as performance
outcomes.
4)Interventions cannot be rushed, however need to have everybody on board
as to “why” certain exercises have been chosen.
5)Re-assessment is vital to guide future interventions. Objective and
subjective feedback is key.