Tailoring Exercise Prescription in Home Exercise Programs for Optimal Tissue Response

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses tips to build the perfect HEP: time availability, equipment availability, and dosage.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

CODY GINGERIC All right, good morning, PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity management division, and I'm coming on here today to talk about building out the perfect HEP. Okay, so there's several factors revolving around building out what is considered the perfect HEP. Now, perfect means best ability for our patients to complete the HEP that we want them to, okay? And so what I'm going to go through is all the different factors that you need to consider, including what you are deciding you're doing, but also the patient's expectations and what they have the ability to accomplish when you are trying to say, all right, these are the HEPs. These are the exercises that I want you to do at home. What factors do you need to consider to build out the HEP that is going to give you the most compliance? Cause ultimately you can build out the perfect HEP as far as these are the exact exercises that I want them doing. These are going to be what I consider the perfect exercises for what I found. But if the patient doesn't do them, that HEP is no longer perfect because they can't get it done and they're not going to progress the way that you want them to. Okay.

HOW MUCH TIME DOES YOUR PATIENT HAVE? So starting off the, the number one thing that you have to figure out is what time does your patient have? Okay. I know a lot of times when you know, you're going through your, if it's an initial examination, you're trying to figure out the first HEP, you're, you could have multiple different exercises available to you. Um, so let's say, you know, it's a shoulder issue and you're wanting to give them three, four, maybe five exercises that immediately you're like, Oh, okay. This would be good. That would be good. This also would be good. But if it takes 20 minutes for your patient to do and they have five, they're not going to say, oh, well, I'll just do a couple of them and get, they'll do none. Okay. So the first thing that you have to figure out with the patient is what time available do you have to, do you think to get these things done? Some people will say, whatever you tell me I'm going to do. And those people are great, right? You know, they're going to do it. Whatever you think is best. That's great. There are other people that said, you know, they've got kids, they've got to take care of family members. They've got jobs that are stressful. They've got all kinds of things. Maybe they're traveling a ton. And so they're like, you know, honestly, I may have five minutes at the end of the day to be able to get something done. Or they say, I can get to the gym five to 10 minutes early to get things done. Or, you know, I can get to the gym, I'm like running in like two minutes late every time, I'm barely, you know, either for class or it's like right at the end of the day. And they're like, well, yeah, but I could end class and stay 10 minutes extra. Um, and so that's where you then have to start figuring out, all right, well, if I choose two things in each and I give them a rep scheme that can get accomplished what I want and still get them in and out and under 10 minutes. Now, all of a sudden we have something that they feel confident that they can get done. Okay, what I would consider then 1A and 1B is like time is 1A, but 1B or maybe flip-flop those two things would be, you know, what are you trying to accomplish as far as your exercises in general?

DOSING So in extremity management, we talk about dosing a lot, and that's one of the primary factors as far as when you're treating people out is dosage, and it matters. And there's a strength dose, and there's a rehab dose, and there's a power dose. And you need to make sure the HEP is equally as dialed into that as what you're doing with them in clinic. So up front, you need to think, am I trying to get this tissue legitimately stronger? in which case you are building them out their HEP for probably closer to that five by five right at about 80 percent of their one rep max or around that like three sets of six to eight somewhere like that where it is heavy load being lifted on whatever tissue you're trying to accomplish And in that moment, they may not need to do that multiple times a day, maybe not even every day. So if your brain is saying, well, this tissue needs to get stronger and I'm going to dose this out as a strength dose, then you could say, hey, you know, I might ask you to do this. It might take you more like 15 to 20 minutes, but can we do this three times a week? We want to really hit this hard. We want to make sure your tissues are going to significant fatigue. but then we're going to give you at least a full day of recovery in between. Those tissues also need to be able to recovery, repair, and then come back stronger. So then you have a day in between. Now I'm only asking you to do this three days a week. Could you do that for me? If you're thinking more of that rehab dose, you're wanting more blood perfusion to those tissues. Maybe now you give your one exercise that you think is going to be best, but they're highly irritable, and you need to get just as much blood pumping to that system as possible. Maybe you give them something that takes one minute, but you ask them to do that four, five, six times throughout the day. Because we need a lot of touch points on that tissue often throughout the day, as opposed to saying, I need you to do a lot X amount of time for this specific thing. But if you're saying I need blood pumping, they're sitting at a desk for eight hours a day, but they then have. 20 or 15 minutes where they do something to their shoulder, it's probably not going to bump them forward as fast as possible. But if you say, Hey, 30 seconds to a minute of this, I just, anytime you think about it, like set an hour timer, can you do one minute every hour or every two hours? A lot of times that becomes, um, more manageable for people to do. And then even if they, you know, you're like, Hey, could you do the six to eight times in a day? They say, yes, maybe though that gets accomplished three to four times and you're still doing okay. Okay. Those are kind of your one A, one B. What time do they have and really what are you trying to accomplish with their tasks that you're giving them?

EQUIPMENT AVAILABILITY Okay. The third thing is what equipment do they have available to them and how willing are they to potentially go and get equipment? So that means before you start doing anything, you need to ask, do they have bands? Do they have weights? What kind of things do they have at their house? What access do they have to anything at a gym? Different gyms have different equipment, right? Do they have kettlebells? Do they have dumbbells? Do they have small looped bands? Do they have big pull-up type of bands? You can manufacture exercises from almost anything and your goal There is no one perfect exercise. There is the exercise that's going to get the person doing what you want them to, to the tissue that you think is most involved, and then you build that exercise for that person, right? So, let's say they have absolutely nothing at their house, but they go to the gym five or six days a week. That first visit is not the time where you say, you know what, I need you to go by XYZ. Nope. You say, great, your HEP is only going to be done at the gym. I need you to do this every time you step in the gym for five minutes, whether that's before or whether that's after you can make that choice, but you need to build out the HEP so that they can get that accomplished as simply and easily as possible when they go to the gym. That's the only way that they're going to get it done. Alternative, if they have nothing at their house, at our clinic a really good option is have either bands for sale or an Amazon link or something. The best one is bands for sale right there and then. Or if you can find them in bulk somewhere and can just hand those out, if they're like a dollar a piece, maybe eat that cost and give them out. But that's a really good way to say, okay, well I need you to do, you know, some band pull aparts or some 90 90 raises or something. And you have one of those like booty bands that you can hand them. And now all of a sudden they have something to accomplish at home. So that's where you need to get a little bit creative up front and maybe at home they've got like a two pound dumbbell or a five pound dumbbell or they've got one band, right? That is again where you start navigating that whole question of what exercise can I build based on the equipment that they have available to them. Potentially then after you have built a little bit of rapport or if that person in front of you is like, Hey, I'm going to do anything you want. You just tell me what to go and I'll go get it. That's when you can start shooting off Amazon links. Be like, Hey, go to play it again. I need you to get a 10 pound dumbbell. I need you to get a kettlebell. I need you to get this band. There are those people, but those questions have to be asked before you say, here's what I want you to do for your HEP.

SUMMARY You first have to ask how much time do you think you have in a day? Your own brain has to be saying, what's my goal for these HEP exercises? Is it strength dose? Is it more rehab dose and blood perfusion? Then you say, okay, well, what do you have at your house? Do you have anything, any type of equipment that can be built on weights or whatever? Or is everything that you do at the gym cool? What is your gym routine look like? Do you get there super early in the morning? Do you get there in the evening? Do you have more time before? Do you have more time afterwards? Right? All of those questions have to be asked. Ideally, before you start thinking, I need them to do this exercise, this exercise, and this exercise. Now on that first visit, you might pitch optimal a little bit more heavily and say, Hey, this is really what I would like to do. And like for you to do, even based on those equations, Then they come in and say, Hey, you know, I don't think I was, I wasn't really able to get those things accomplished as much as you told me. After the first visit, if they're not able to do that, that first time is on you because then you have to say, okay, well what can I do to make your life easier? I have other options that we can do. There are more things, more different ways that we can make this HEP more accessible to you. If you don't answer that or ask that question, then the reason they're not doing their HEP still falls in your hands, not on theirs. If they say, you know, this is really easy. I should be able to get this done. And they take responsibility for it. Great. But until that happens, I would still say that you need to figure out how can you still make it easier? pitch optimal, then we negotiate acceptable. And you can still have that conversation and say, look, this isn't exactly how I would like it to be, but I think we can get the job done if this is really all you can commit to. Okay. So in that sense, now they know that like, Hey, this probably my, you know, my shoulder pain isn't going to go away quite as quickly as Cody probably hoped because I'm not able to do exactly what he was thinking. But if I still do something, it's still going to bump forward. And as long as they're okay with that, you have to set those clear expectations. But overall, that's how we are building out a really nice HEP that people are going to also be compliant with. Bring them into that. Use your creative mind as far as exercises are concerned, because really it's not the exercise that matters, it's the dosage. You need to know what tissue that you're hitting, and you need to know what dosage that you are trying to use to try to make those tissues happier. If they need to be stronger, we could potentially pull back the actual number of times per week that they do it. Give them an opportunity to recover. If it's more blood perfusion and a rehab dose, maybe make that incredibly short where they can do that one time for 30 seconds to a minute. You give them one exercise and say, hey, you're hammering this over the next week. You're pumping as much blood to that. When you come back in next week, then we're gonna adjust and do something different. But overall, you then need to know what equipment do they have, what do they have access to, what are they willing to go and get? Can you provide them with something that will help them get that accomplished? Whether that is selling something in store or in house, whether that's handing them something that costs a dollar to $2, something like that, that again, lets them be more compliant with what you're hoping for. Okay, so those are three things building out a perfect HEP. The perfect HEP, shocker, is not the exercise that is the best one. It is the exercise that they're gonna get done, that you have dosed out perfectly, that is going to be compliant, and you know what dosage and tissue that you're hitting. Okay. That's all I got for today's PT on ice. If you want to catch extremity on the road, we've got two courses happening this coming week, one down in Texas, one up in, um, Wisconsin. And then in a couple of weeks from that, we've got one happening out in Utah. So hit one of those up sometime in the next couple of weeks, we're all over the country and I will see you next time.

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