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Rehabilitation prescription & outcome measures…when, why, how?

January 5, 2012

A few posts-a-go I spoke of the selection of sound outcome measures to guide the application of soft tissue therapy (of note, many confused the point of the article thinking I was discussing the outcome measures of the treatment encounter…if this is you, may I suggest a re-read of the article to bring it into context).  Another question I am often presented with by practitioners is what are sound outcome measures for rehabilitation?  The other scenario where this question presents itself is when patients come to see me with the claim that their previous therapist/doctor/trainer had noted that they had “a weak core,” “muscle imbalance,” “weak hamstring to quad ratio,” etc.  Upon questioning these individuals as to the method by which they were determined to have said affliction, I am often surprised to hear that no challenge of the purposed ‘problem’ was undertaken.  In other words, no direct testing was performed in order to make such a conclusion.  It would seem for example that having a “weak core” is often simply an assumption made in association with a presentation of low back pain.  Further, it is often as if the assumption is made to retrospectively match the presenting symptoms.  A good example is the claim that the patient has “weak glutes” BECAUSE they are presenting with Iliotibial Band Syndrome.  Of course I am aware of the work of Fredricson who, in his sample populations, determined a direct connection between “weak glutes” and ITB problems…however does the condition necessitate it?

In scenarios where testing is in fact undertaken during the course of the examination other problems are raised.  Take for example the patient with an ACL tear.  Often the charge is made that they are suffering from a weak “Ham-to-quad” ratio.  The frequency of this conclusion would lead me to believe that there are several more clinics equipped with a Cybex machine than would be assumed based on their inordinate price.  More likely though, this conclusion was attained based on either the assumption, as noted above, that the condition somehow ‘warrants’ the cause, or that more ‘primitive’ outcome measures have be utilized; say the incredibly subjective, and in my opinion useless, ‘manual muscle testing.’  Another example would be the even more common charge of “muscle imbalance.”  Said charge is problematic as it is often accompanied by outcome measures (Yanda patterns, movement screens) that are inherently riddled with the fact that they rely on the problematic concept of reciprocal inhibition, which has been discarded in the literature for several years.

This problem is also seen when considering exercise prescription.  If the outcome measure is not clear, how then does the practitioner select the proper exercises to attain a desirable result?  Further, how do we decide when to progress these exercises?  This problem leads to ‘cookie-cutter’ approaches to rehabilitation whereby exercise are selected based on the diagnosis rather than for the purposes of attaining a necessary goal.  This also leads to the performance of the same exercises far after the benefit of said exercise has been exhausted.  My best example of this can be seen with any high level athlete still performing “Bird-Dogs” several years after their brief run-in with a generic lower back condition.

I propose instead “Ability-based” outcome measures based on basic human movement, then progressing to more advanced human movement and function.  In other words, a certain goal is set for the patient, once said goal is attained, then a progressively harder form of a similar movement is prescribed with a similar goal, and so on until the particular movement is mastered.  This way the therapist/trainer has a direct way of knowing when exercises are to be advanced, if patients are becoming stronger, etc.  Here is an example of such a program that I posted a while ago using Bridging progressions.

Which exercises are selected?  This question can only be answered by the practitioner who has performed the assessment.  What movement patterns are commonly utilized by the patient?  Which are necessary?  Which can conceivable be contributing to the problem?  In most all cases, I believe that the initial selection will frequently mirror some of the more basic movement patterns (Squat, back extension or dead lift, bridging, etc.).  This then, if the patient adheres to them, will lead to the perception of more complex human movement exercises.

In future posts I hope to provide more specific examples of exercise prescription relating to actual patient.  This post was more intend to be a thought provoking one for the reader, so please share your thoughts and techniques.


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