Ep. 129 - How to Progress a Patient Without Overthinking It

Progressing exercise is something we all do every day as EPs, whether you're a new grad or experienced, it's part of the job. But it's also something we see getting made much, much harder than it needs to be on a day-to-day basis. So today I want to give you a really simple way of deciding when to progress, what to progress, and when doing nothing might actually be the right decision. This is the EP Growth Podcast from Hunter Rehabilitation and Health. We are here to grow the exercise physiology profession through supporting the professional and personal growth of young EPs in the industry. Thanks for joining me again on the EP Growth Podcast. Let's get into it. Progressing exercises. I think when you're in experience, particularly, this pressure to demonstrate value by changing things. You can experience that sort of pressure when you're experienced as well, I suppose. But particularly when you're a newer grad, less experienced, you can feel, I've got to move things along a bit of show that I'm adding value. I've got to show you what I'm talking about. And that can feel like a new session needs new exercises. That's how you're going to demonstrate value to this person. They should keep coming back because of the next session. I'll give them a new exercise. It can feel like the patient needs to have a little bit of sawness after a session to show that they're progressing, to show that the exercises are doing something. It can feel like more weight automatically means improvement. You can see that in some of the reporting and whatnot, particularly in work colour. It will go out to the various stakeholders and increasing how much weight and load this person can manipulate shows they're progressing. You have your more sophisticated program to demonstrate your clinical experience. We can feel like that. If you've got a program that's just got basic squats, for example. And then you've got someone over here that buddy doing single leg, boss, you ball, distractions, squat, you have all the rest of it. Maybe that's more sophisticated than my program, so they're a better EP than I am. Or perhaps just repeating the same exercises. It means you haven't done enough. You've not put any thought into this. You're lazy. My patient's not progressing. I'm not giving you any thought. We can feel all of those things I think as EPs and they're definitely not all correct. I would challenge you. I would say that if you're feeling those things at times, you're making it all about you. The need to progress things and these things we're feeling are your own self-conscious beliefs. And I think that they, I would say that because if you're just thinking these things, they're not based in anything that the patient has said. They're not based in any sort of objective reality. It's just things that you're thinking. And we can be thinking those things for a whole heap of reasons. So we need to distinguish that from the start. But as a, it's not always the exclusive related. You need to consider things which we'll get to. But I would offer this if you are thinking those things. Some of the most effective programs that I've seen delivered here in our clinic. And that's not just by myself. But here across our whole clinic have been some of the most basic programs. You could look at them and think, geez, that's boring when you look at it on paper. But that would be boring to me. Like that would be boring in my exercise history and background and what I understand. You can say, well, that's boring to me. But it completely indicates anything about the patient that's doing the program. And what their views are of that program and what's their history and do they enjoy the program is that right for them. Like so to that end, I've had a patient and with going into all the glory details about a patient and talking to her about her exercise history and background. She says, oh, I'm very active. I'm very active. I'm like, oh, okay, tell me more about what your activity looks like. So I walked to the mailbox and back every day. And this isn't someone who lives on a farm with a 10-kiloma tribe way. This is a residential house, normal side block. Like this is not an active person. But that was her belief. So you start adding literally any exercises on top of that. And this person is going to start to believe that their physical activity levels are through the roof. We're not going to want a program with 10 exercises on it. So that's an important time to stand from the get-go. Like what you're prescribing, what you think might be boring and not enough to that individual could be quite significant. So those beliefs we have right from the get-go, we need to check if they are your beliefs or are they founded in something. But when we look at that program that the individual is doing, they just said that the really boring program on paper. Why was it effective? Well, patients improving, they're tolerating the load, moving towards their goal. They just didn't need six new exercises. It was fully appropriate. All the things that we needed to get out of the program, we were getting. It just didn't warrant being made harder. And I think that's the important thing that we need to consider when we look to progress patients. So we're not progressing because the calendar says it's time. We progress because the patient gives you a reason to progress the program. And I think a slightly different thing to think of when we're talking about exercise progressions. But at least we see this in practice, it can be really book frequency. So it's not necessarily just taking these exercises and making it harder or easier. It can be how much structured input from major you need. And we will see it at times where session frequency will go from two sessions per week to once a week to once a four nights a month. Based on nothing else but time or sessions attended. So those sorts of progressions as well as what happens within the session needs to happen based on something objective that the patient is showing you or they're telling you the circumstances are changing. Not just because of these arbitrary measures that you've made up or you're all you're thinking. So what would be helpful within all that and all sort of framework and all sort of framework you can follow to know how when, why to progress your sessions, what you're doing within them, how frequently you'll have them, things like that. So where should you start? What are we trying to improve? They're really fundamental start there before touching search reps or weights. What is the purpose of this exercise now I've talked about this before within initial consults and like what are we what are we trying to test for why are you doing that assessment. It's going to be the same concept with describing exercises like what are you trying to get out of doing this. And I think this is where we can get lost at time to see peace. Right. So as an example, let's go. You've got someone doing a little bit of knee rehabilitation using a squat. Why are you using the squat? Is the goal quad strength? Is it confidence with knee flexion? Is it for work capacity? Is it tolerance of repeat lifting? Is it getting up and down off and I can't speak and getting up and down off the floor or is it something like return to running because all these things about it because the appropriate progression changes depending on the answer. If we're developing strength, then adding more resistance as we go might make sense if we're developing work tolerance but then perhaps volume is going to be more important there. If it's about confidence, then perhaps it's increasing depth or reducing external supports. Things of that nature might be the thing you're trying to really extrapolate out to help that person with achieving the end goal. If we're talking about someone lifting a work, eventually the movement needs to resemble that work demand. So it might be lifting on different surfaces, different sized objects, lifting different heights, lifting off a teat that can come into it. So there's different things you're going to consider there when you're narrowing in on what is the thing we're going to progress. So I would say the main teaching point out of that is you can't choose the right progression if you don't know what you're progressing towards. We need to nail that as a foundation before we get into any of this. Once we've got that in place, let's run a little simple progression check. It should take you five minutes. Before progressing, ask three questions. Shocking this first one, can they do it? Technique and execution. If you've got someone in front of you that have never exercised before in their life, you can see straight away from any initial movements that you're giving them that it requires lots of coaching instruction. You'd be present to correct their movements. They're very not sure. They're lacking confidence. All of those things, I'm sure we've all seen that type of patient. It's not their fault. But if you've got that type of patient, we're not going to go and prescribe them some sort of Olympic lift. You know what I mean? Like something really complicated. Keep it basic. Okay. But even then, we're not looking at, is their movement perfect? Is it safe? Is it controlled? And can they reproduce it? So those are the things we're going to look for there. Can they tolerate it? Would be the second question to ask yourself. So we're going to look at the symptoms during the response off. What about the next day response for T throughout that exercise and then their confidence throughout the exercise? Now one of the things I've just said there is the next day response. This is important and I'll ask back to what I was just saying there before about session frequency. If you prescribe someone this exercise program, it's got new progressions in it and then you're like all right, go and work on that I'll see you in two weeks. How are you going to know their next day response to that exercise program? And even more so if it's a poor response they've got that for the next two weeks so you could be leaving that person with a. Let's just say sub optimal program for the next two weeks that can really impair your progress and could send progress backwards due to your progression. It could cause more harm all because your progression was poor and you didn't set an appropriate session frequency progression to go with that so. But to be more specific there you might have someone that's coming once per week once per four night because that was appropriate on their current exercise prescription but then you change their prescription. You might need to change their session frequency back to twice per week as they move through a new set of exercises if that makes sense like all of these things can work together. But that list there can they tolerate it there's going to be really important in I think what is the typical client base that we'll be seeing as EEPs is. Occupational rehab okay can they tolerate these things and they change is you want to be staying in touch there so. A third point to consider here is it still challenging the thing we're trying to improve. This is big okay if the answer here is question one yes question two yes question three no. Then you probably got a reason to progress okay can they perform it can they tolerate it but no longer provides enough stimulus for the intended adaptation that's much more useful okay then that's more useful than. They're done for two weeks so I'll progress. So when you put all these together in like a framework as we're talking about a little checklist makes the decision of progressing much much easier. Once we've decided that we're going to progress again I've touched on this there's different levers you can pull here it's not always just add more weight to it. We all know from from our university days you can adjust things like load volume and range tempo complexity stability and support not going to spend all podcast going through those things is there's more and more you can adjust. But there's multiple different levers at the end of the day that you can be adjusting here to make sure that we're causing change in the thing that we want to change. So if we were to use a work an example let's talk about a warehouse worker okay let's say they needed to repeat what we left 15 kilo box from from four to waste. So really rudimentary examples here let's say they're going to start with an eight kilo deadlift that's controlled environment and they've got low volume. So you might go from you could progress from eight kilos to 10 kilos to 12 kilos. But eventually we're going to go volume so we won't repeat the lifts and we want specificity so you can go with an actual box. And then you can go with the changing environment a little bit so different heights different positions and then perhaps we're going to go with a bit of density so repeated lifts with realistic work and rest periods. Just a little bit more for teas much more job specific you're not just making the deadlift heavier but with a dead set a deadlift bar like we're making this much more task specific. So I guess the key lesson within that is don't confuse different with progress. Okay so another scenario here let's go similar sort of work our week one goblet squad week two split squad week three leg press week four step up. On paper oh wow that's varied that's cool really technical teaching them lots of different exercises what's actually progressed. Probably nothing each week they're learning a different skill they're not getting better in terms of anyone function anyone capacity. Possibly won't be a little bit of adaptation but then how would you measure it? How could you accurately say they've progressed in one thing when every week they're doing a different thing. It's really hard to speak back to that patient and anyone else involved in if it's a work public claim what is actually what is actually changing and improving. So the key thing that novelties not progression what are those changes there probably for you not for that worker. So yeah keeping the same exercise over that duration would probably give you a much better opportunity to observe that that patient so you can say then like doing this movement I kill those is turned into 20 kilos. Turned into 12 reps the painful range became a comfortable range you have supported movement became independent movement you really couldn't comment on any of those. If you had changed it as much as we're shown in the original examples so what you've achieved is visible progress as opposed to just random changes with a sake of change what about pain. So oftentimes when we're seeing these patients it's pain is a driving factor as much as function capacity and things like that so we'll be looking to progress or not progress based on reported pain. I find probably a void giving a universal pain rule like anything about this level of pain stop stuff like that like try to avoid that and have individual discussions with individuals but I think a general one there is you'd say like pain doesn't automatically mean stop pain free doesn't automatically mean progress. So look at the response in context was it expected was tolerable did it settle did function change afterwards. The response consistent with what was seen previously and is there anything genuinely concerning about that presentation. So the answers to those questions provide more detail about what you should do next in terms of progressing or not progressing. So let's go again more detail with an example if you've got a patient they report like two out of 10 need discomfort during squats it settles immediately there's no worsening afterwards and capacity continues improving that's a very different scenario from new unexplained symptoms. Deteriation in function and escalating symptoms after every session there's a very very different. So I guess they're lucky for you to take away one little teaching point is don't progress the number progress the person look at it all as one integrated person. So let's summarize all those things there okay when should you not progress. Don't progress simply because it's in your appointment or you feel pressure to demonstrate value or the patient found one set a little bit easy. Or you want the program to look sophisticated there's not a lot of reasons hold steady could be appropriate when you think the patient is still adapting they're showing that they're adapting techniques not established symptoms are changing conferences still developing. So for the information perhaps is life workload substantially increased. Perhaps the current dose is already producing the desired outcome like we're flying progresses that we don't need things harder. So sometimes the most experienced decision you can make is to leave the program alone just let it do its thing. So let's run with a nice little example to finish this one off okay we're going to 45 year old worker with persistent low back pain needs to return to manual handling that's their job. So within the initial you can see there hasn't with bending their very low confidence and they're reducing their lifting tolerance it's pretty consistent presentation. So within your early exercise perhaps we're going to do a box lift perhaps that's tolerable and appropriate all right. So let's start with let's go with five kilos for six reps and we'll do it from a step so we're reducing the range motion required. So realistically there we're focusing on techniques a little bit of confidence a little bit of capacity short range motion a little bit of strengthening capacity. But that's it that's the nuts and bolts of at the start. As I get through that they're looking okay instead of immediately increasing weight perhaps the first progression is simply to improve the comfortable range. So perhaps we take away the step there and then we can go from five kilos for six reps to 10 reps. Then we go eight kilos eight reps perhaps then we go if you haven't already done it go from full forward waist lifting. Let's go 12 kilos with the box then we're going to repeat that lift how many reps of those how many reps of that can you get out. Perhaps then we might progress it to lifting combined with carrying again we're staying to get close to what might be required within the job role. And then perhaps it's going to be work specific loads and durations so full loads required work we're going to do it on repeat so this person's required to just lift forward waist ongoing they're picking up boxes putting it onto pallets ongoing for duration of their shift. Perhaps for their whole session with you that's what they're going to do just on repeat forward waist lifting perhaps that's right into the session we're going to learn pretty quickly if they can do it or not. But as well it will be a conditioning tool for them so the goal there is not necessarily let's improve your dead lifting although that will probably come with it the goal really is restore confidence and capacity for their manual handling task so it's a little bit different. So what can you do on Monday for every exercise you prescribe ask yourself three questions what are you trying to improve. How will I know when these exercises done it's job and what is the smallest progression that moves the client closer to their goal. And from there, if you can't answer those questions, don't change the exercise yet. I think that's the main takeaway out of that. So there we are guys, if you take one thing from today's episode, progression isn't about finding a harder exercise. It's about understanding what you're trying to change and then manipulating the smallest variable that moves your patient or client closer towards their goal. Don't progress because another week has passed, don't change exercise just to make the program look different. The patient's response tell you what needs to happen next. Try out those three questions with your clients this week. See whether they simplify your decision making and I'm sure it'll make all the difference to how you progress your sessions. That's it for now guys. Thank you for cheering, and I will catch you guys in the next one. Bye for now. Hey guys, thank you so much for listening to another episode of the EP Growth Podcast. I would be forever grateful if you left a review, subscribe to our channel, and also share this podcast with any of your friends. So we could ultimately grow this profession together. If you'd like any further information, please check us out on hunterrehab.com.au. Bye for now.