Small Steps Lead to Rehab Success

Choosing the best exercises for pa-tients with neck and back problems is not easy. We know that exercise is an important key to full recovery of func­tion, and we don't want to skip any of the recommended exercises. The re­sult is frequently a long laundry list of exercises given to each patient, such as stretching, strengthening, stabiliz­ing, and coordination exercises. In the real world, though, patients have a lim­ited amount of time (and willingness) to exercise. When designing an effective rehab program, don't overwhelm a patient with exercises. Unfortunately, it seems that the more knowledgeable doctors are in rehab procedures, the more likely they are to overwhelm their patients with exercises. Overload The condition commonly referred to as "overload" occurs when a patient is instructed to do six or more exercises once or even twice a day. The doctor or therapist strongly believes in the benefits to be gained from these various exercises, and the patient is gung-ho to get better. Problems begin by the second day, when the patient realizes that this amount of commitment is simply not compatible with real life. In order to get the benefits of active exercising, patients have to actually do the exercises. If they don't do the exercises, they just won't derive the benefits, even when they have been given beautifully planned programs. Exercise recommendations must be designed so patients can actually follow them. Think Like a Patient The best way to avoid this problem is to recognize that all patients have their own lives. We must advise and treat our patients the same way we would treat ourselves. Since we often have a hard time finding an extra hour or two in each day to do the exercises we know we should be doing, we can't expect our patients to have an easier time. A 1999 study looked at home exercise performance in adults over 65 years of age (an age group that has previously been found to have difficulty with exercise compliance). Volunteer subjects aged 67-to-82 years were instructed in either two or eight exercises to be done daily. When they were checked ten days later, the group who had been shown only two exercises performed significantly better than the group who had been shown eight exer­cises.1 While the results may seem self-evident, many doctors and therapists apparently need this evidence-based re­minder. The First Step: Consistency The most effective way to begin an exercise program is small, but consis­tent. This means that the patient starts with the one or two exercises they re­ally need, and they perform the exer­cises frequently (daily). Once-a-day ex­ercising is the quickest and easiest way to establish a regular exercise routine. Patients are allowed to fit the exercise(s) into their daily schedules whenever it's best for them—mornings, during lunch breaks, or evenings. Initially, we are not asking our patients to do heavy resis­tance, muscle tear-down exercises, so the traditional "day of rest in between" is not needed. We want to establish a new habit of regular, consistent exercis­ing of the problem area(s). The Next Step: Build from Success As patients begin to respond, and a routine has been estab­lished, we can start to add one or two more exercises to address adjacent or more involved areas. Even so, it is vital that we continue to monitor our patient's level of compliance and com­mitment, and provide praise and recognition. We all do better and are more motivated when we have achieved some small success before we tackle larger projects. The confidence that comes from succeeding at the initial exercises makes it much easier to integrate more complex or time-consuming exercise rou­tines. A Clinical Example One of the more common postural problems seen in chiroprac­tic offices is the "forward head syndrome." This condition is frequently a major factor in chronic headaches, recurring neck pain, and persistent upper back myofascial pain. It is also very commonly part of the "whiplash syndrome," and can still be present years after such an injury. For this condition, it is impor­tant to start the patient on the one or two exercises that will bring about the most rapid change in this posture, while also decreasing the symptoms. Patients with for­ward head syn­drome should start their exercise with posterior translation of the cervical spine—just this one exercise, to begin with (See Figure 1). When this exercise is done correctly it changes chronic postural habits and rapidly re-educates the neural network that maintains head position. In addition to strengthening the weak paracervical muscles, the exercise also stretches the tight myofascia (taking advantage of reciprocal inhibition) and improves the coordination of the spinal proprio-ceptors. It is easy for any patient to perform this exercise daily, since it takes no more than a few minutes to do three sets of six repetitions in a slow and controlled rhythm. Conclusion Patients should begin with a graduated exercise program that starts with minimal commitment, and then builds upon the exer­cise habit that they establish. This should be integrated into our early phases of chiropractic care, in order to gain the most advantage from the benefits of exercising problem areas. We should avoid giving exercise recommendations that overwhelm or ask too much from patients. And we really should try out the exercises ourselves for a week or so, to see how much time and effort is really required to follow our exercise programs. When we incorporate rehabilitative exercises into our expert chiropractic care, our patients will recognize that we are knowl­edgeable experts. If we keep our recommendations small and achievable, they will be successful in their exercising, and their rapid progress will be a tremendous motivating factor. Once our patients actually follow through on our exercise recommenda­tions, they will respond much better. The end result will be more consistent chiropractic results, and patients who recognize our expertise in the field of musculoskeletal problems. These pa­tients will now be able to continue to exercise on a regular ba­sis—they will have experienced, directly, the benefits and seen how exercising can be integrated into a busy schedule. And they will gladly refer their friends and co-workers to your office for your excellent care. EZQ Kim D. Christensen. DC. CCS.P.. D.A.C.R.B.. founded the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. He is currently a postgraduate /acuity mem­ber of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilita­tion and nutrition, lie can he reached at Chiropractic Rehabilitation Consulting. 1X604 NW 64th Ave.. Ridgejield. WA 98642 or by e-mail at [email protected]. com. Reference 1. Henry KD, Roscmond C. Eckert LB. Effect of number of home exer­cises on compliance and performance in adults over 65 years of age. Phys Ther 1999; 79:270-277.