The 5 Deadly Sins of Rehab & Exercise Prescription
This one’s for my fellow clinicians (and coaches) out there. I am so passionate about this topic, probably because this was one of my biggest fails when I first started dipping my toes in the rehab world. (Disclaimer: rather than coming from a place of “I know everything and do everything perfectly”, because trust me, I do not, I really tried to write this based on the many mistakes I’ve made, and continue to make, with my own patients.) I’ve always seen great value and learned so much from others sharing their experiences and insights, so this is me sharing mine. I like to think I’ve picked up a few helpful nuggets along the way, and I look forward to making many more mistakes in the future as I continue to grow and learn.
One of the cringiest things I did when I first started into practice was over-compartmentalizing conditions in my brain. “Oh, anterior hip pain, yes I’ve seen this before, and XYZ worked for that person, so I’ll just rinse and repeat and hope it works for this patient”. Yikes. I massively violated what is now my biggest mantra in practice: There are no cookie cutter treatment plans! Below I’ve outlined common mistakes and some of my biggest takeaways when it comes to effective rehab and exercise prescription.
- Failure to assess. The assessment is SO important. It’s your entire roadmap for how you will craft your treatment plan. A good assessment should ideally include a thorough history as well as some form of movement assessment or orthopedic exam. We really cannot have one without the other. I know plenty of clinicians (and I’m guilty of this also sometimes) who are so excited to start assessing that they totally skim over the history. A proper history is one of the most valuable tools you have! Not only that, but it’s one of your first opportunities to really establish trust and rapport with your patient. I like to think that if you ask good questions and listen closely enough, the patient will tell you exactly what it is they need. For example, anterior shoulder pain could be coming from 1000 different things. Is it a biomechanical issue? Mobility? Stability? Is it a loading issue? Too little load? Too much load? The history will give you direction and set you up for a great exam. Then assess and treat accordingly.
- Failure to integrate. Oftentimes we assign an exercise or introduce a new concept, but we fail to integrate it, meaning we fail to provide practical ways to incorporate that concept into the patient’s actual activity. I love DNS. I talk about the diaphragm and breathing with almost every single one of my patients. But I’m not doing my powerlifter patients any good if I don’t teach them how to then integrate this breath with their bracing techniques or teach them how to breathe/brace differently depending on the lift or activity. Just like I’m not doing my runners any good if I don’t teach them how to practically apply the breathing and rib cage positioning to their stride and cadence. We need to make sure we incorporate the concept into whatever specific activity applies to that patient, or we’re leaving them without a huge piece of the puzzle.
- Failure to cue. One cue does not fit all. This is a big one. Everyone learns differently, conceptualizes differently, and has different levels of body awareness, and we as clinicians/coaches should have a wide array of cues for the same exercise. If we are utilizing a cue for an exercise that the patient is not grasping, this is an us problem, not a them problem. Try a different verbal or tactile cue, draw a picture, demonstrate on yourself, use metaphors—whatever is best for that specific patient.
- Failure to progress. Failure to progress is one of the deadliest rehab sins if you ask me. I’ll use DNS as an example again. DNS is phenomenal and one of my most-used techniques in my rehab strategies. But you can’t keep athletes, or any patient for that matter, in closed-chain exercises forever. Most sports (and daily activities) involve open-chain functions and should be progressed accordingly. Exercises should start looking more and more functional and activity-specific as care progresses. And do not forget about load! Tissues heal under proper stress and load. Failure to progress stress/load = failure to adapt and heal. This is where we can see recurring injuries, even if the patient became “pain free” with their treatment plan. Eric Cressey put it best when he said “There is a big difference between ‘asymptomatic’ and ‘rehabilitated’”. I try to drive home the point to my patients that they don’t graduate care when they are out of pain—they graduate care when they have regained full function again. Sometimes there is a big gap between the two. This is also why assigning “rest” or the PRICE model for injuries is almost never a good idea.
- Failure to return to sport. We should design our treatment plans with the goal of returning our patient to his/her activity or sport and ultimately utilize “sport-specific” exercises. A shoulder exercise for a softball player will probably look MUCH different than a shoulder exercise for a CrossFit athlete. It’s important as a sports chiropractor or sports therapist to “talk the talk” of your athlete/patient and have an understanding of their specific sport or activity. I once had a patient who came to me after a trial of care at a different office. She was completely relieved when I knew what a hang clean was because her previous provider had no clue and therefore was unable to understand her pain or tailor her treatment specifically.
In conclusion, each patient or client deserves care that takes into account his/her specific goals, needs, learning style, sport/activity, and work capacity. My vision for my practice and for this field is to ultimately change the culture of healthcare and to set a new standard of excellence. To create a space where people feel cared for, where they get their provider’s full attention and energy, and they receive a treatment plan that sets them in full motion to return to doing what they love as soon as possible. I have incredible colleagues and clinicians in my circle who I know are moving forward in this same direction, and it gives me so much hope for the future of chiropractic, rehab, and healthcare as a whole.
Thanks for reading, friends. As always, please don’t hesitate to reach out with any questions or comments or if you’d like to discuss anything more in depth. You can reach me via the contact tab. 🙂