Simplifying Exercise Prescription in Rehab

While manual therapy and education may play a crucial role in injury rehabilitation, injuries and pain respond the best in the long-term to progressive loading through exercise.  In fact, exercise is said to be "the closest thing to a miracle cure" (1), and is widely accepted as the means through which you can attain complete recovery.

Prescribing exercise can be intimidating for some therapists, so I wanted to provide some facts and guidelines that may help make this easier!

Fitting the Diagnosis to the Injury

Attaining an accurate diagnosis CAN be difficult, but is often the first stage to developing a treatment plan, including exercise. 

1. Do we know the actual pathology/diagnosis?
An over-reliance on imaging and unreliable ‘special’ tests may mean that the true pathology (AKA reason for the client’s pain) may not fully be understood. 
A) Imaging typically looks at the injury site at a specific moment in time. To develop a true understanding of the pathology, this information must be examined along with the patient's subjective history and movement patterns. A common example in knee pain would be that an x-ray finding of moderate osteoarthritis of the patella is an additional finding, when the true reason for the patient's knee pain is trigger points in the quadriceps caused by suboptimal movement control.
B) Many Special Tests are not that special.  A special test should look to confirm suspicions of a specific diagnosis - they should not be used initially when developing a diagnosis.  We know that many special tests lack sensitivity and specificity, and as a result are not helpful in confirming the diagnosis (even with a proper history and objective exam). Nicklaus Biederwolf, a physiotherapist and researcher, has this to say about special tests specific to the shoulder: "A great lack of consistency with regard to how, when, and what special tests to use in clinical examination for shoulder differential diagnosis is evident" (2).
C) Different health care practitioners may develop different diagnoses that fit the information gathered during their assessment, and their bias.  It is important to do a comprehensive assessment (including the client's previous medical history, mechanism of injury, pattern of pain, global movement patterns, and a specific joint/tissue/nervous system/vascular assessment).

2. Without imaging, we depend on clinical patterns to develop an accurate diagnosis, however similar pathologies may behave differently in the clinical setting. For example a partial thickness supraspinatus tear (one of the shoulder's rotator cuff muscles) may behave differently in one client versus other clients - and this may be for a wide variety of reasons:
A) Anatomical variations: The acromion (a protrusion on our shoulder blade, under which the supraspinatus tendon glides) come in all shapes and sizes. The same applies to the rest of our bones, and muscles/tendons in our body - we are not as symmetrical and standardized as you may think!
B) Regional Interdependence: Canadian Physiotherapists are known as 'The Movement Specialists' (3), so keep connecting the dots to determine how one area of the body may be affecting another!  The thoracic spine, neck, scapula and all of its connecting muscles and ligaments alter the dynamic control and posture of the shoulder, which ultimately impact the supraspinatus tendon.
C) Variations in nociception (sensing pain): Fewer pain nerve endings near the injury site, previous injury to nerve or blood supply at the area, or differences in central nervous system perception of pain on a global level will affect how a patient feels potentially harmful stimuli.
D) Multiple injuries: A mechanism of injury that may tear the supraspinatus may also injure other tissues in the area.  For example, there could also be an injury of the labrum, chondral surface of the humerus, biceps tendon, pec major, or subacromial bursa.  It is nearly impossible to identify/distinguish all of these pathologies in the clinic without imaging... BUT does it really matter? Read on!

What To Do.. in a World of Unknowns?

It can all get quite confusing..
The items above paint a muddled picture: It can be quite difficult to come up with the correct diagnosis due to many(!!!) factors. Luckily, despite this fact, there are a few things we can do that will promote successful recovery. 

1. It may be more important to focus on movement deficits first.
Our bodies are exceptional at healing themselves.  In fact, the best athletes in the world are the ones that recover the quickest (from training, games, or injuries). Most of the time, the injured tissue will heal on their own, but will leave us with tight muscles and poor movement patterns as a result of compensation. This means that pursuing imaging and specialist appointments may just end up being a waste of  time, health care dollars, and stress.  To start, the patient shoulder obtain a couple of opinions (physician and physiotherapist) to determine whether medical testing may be needed.  Following these opinions, it is usually best to focus on improving flexibility and movement control.

2. Zoom out; Broaden your perspective!
Often we warn patients against performing certain exercises, based on the fact that they have a certain pathology (e.g. with an acute partial tear of the supraspinatus tendon, stay away from dips or deep bench press).  Take a step back and look at global movement patterns - are there any other restrictions / dysfunctions that you could work on first? In our case example: Do you need to work on thoracic mobility, activating scapular upward rotators, releasing scapular downward rotators, activating deep neck flexors, releasing posterior rotator cuff, releasing adhesions at the interface of pec major / supraspinatus / long head of biceps? Maybe a further step back would even suggest asymmetries in lower body, lower back, or neck strength/mobility.

3. Prescribing the exercise.
Suggesting that the patient does a specific exercise is not enough.  Ensure that the correct exercise is performed correctly; Spend time on coaching form and don’t expect that your client knows how to do the exercise properly.  Lastly, discuss the importance of correct exercise:
    1. Volume
    2. Intensity
    3. Rest
    4. Tempo
By changing these four variables, we can ultimately train the tissue work for its intended purpose and improve
A) Muscular endurance
B) Muscular power
C) Muscular reactivity (plyometrics)
D) Tendon loading capacity

4. Test, and Re-Test
If you've taught the exercises well, allow adequate time for a beneficial result to occur, and re-test the client's functional deficits.

5. Lastly, a client’s most effective exercises may change overtime due to movement quality, tissue quality, perceived effort/challenge, ability to recover quickly, or the applicability to sport and life specific challenges.  Follow up a few weeks or months down the road to provide the best possible care to your client.

References

(1) Academy of Medical Royal Colleges. Exercise: The miracle cure and the role of the doctor in promoting it. AOMRC.org.uk. 2015 Feb

(2) Biederwolf, Nicklaus E. "A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature." International journal of sports physical therapy 8.4 (2013): 427.

3) Physiotherapy Alberta: About Physiotherapy. Accessed February 1, 2018.  https://www.physiotherapyalberta.ca/public_and_patients/about_physiotherapy