Emphasizing Progressive Overload and Patient Progress in Therapeutic Exercise

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

In today's episode of the PT on ICE Daily Show, Extremity lead faculty Cody Gingerich explores the concept of "entertaining" patients by constantly introducing new & exciting exercises. Cody challenges listeners that just because they are bored, their patient may not be bored with PT, especially if they're seeing demonstrable progress with their rehab.

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

CODY GINGERICHAll right, good morning everybody. My name is Cody Gingrich and I am one of the lead faculty in our extremity division. The big thing I want to come on and talk about today, it's going to be the title of today is called Are You Not Entertained? And really what today's conversation is going to be around is a bit of a blend between a couple of the lectures that we have in both of our extremity management division and then some of our spine division in our build a bike conversation. So if you've ever taken a course through the spine division we always talk about building the bike and then in extremity division the conversation is around dosage. Okay so the title of today called are you not entertained is really I want to focus in on are we as physical therapists, is our job to entertain our patients or is it to get them better, right? HELPING PATIENTS RECOVER VS. ENTERTAINING PATIENTS And so what we want to talk about is really our job is to get people better. We want people to improve health-wise, we want to improve their pain and all of those things, right? But where we see that tend to get a little bit lost in translation is when with our exercise dosage. Okay. We have so many, so many exercises at our disposal in physical therapy. We see things on Instagram, we see things all over the place. Right. And that leads to so many things swirling in our brain about like, Oh, let's do this exercise. Plus this exercise, plus this exercise, plus this exercise. Okay. And so what that does is that also clouds our judgment on what is actually bumping our patients forward. Okay. And when we talk about exercise dosage prescription, what that needs to be is a very methodical approach and then progressions over time. Of the same exercise, assuming that first exercise that you chose is showing benefit to your patient, right? And I think we veer from that too quickly, oftentimes. So let's take a shoulder pain, for instance, right? And we just give them a side, we've determined that it's coming from the posterior cuff and we really need to work on getting infraspinatus stronger, some of the teres group stronger, and that posterior shoulder really needs to build up some strength. So we start giving them side lying external rotation, okay? Now, is that the most fun exercise in the world? Potentially not, but we know that from EMG activity, that sideline external rotation is the best exercise that we could possibly give that person in front of us to build the capacity of their rotator cuff. And let's say up front, they can tolerate a two pound dumbbell for eight to seven to 10 reps somewhere in that neighborhood, which in extremity division, we would call that more in our rehab dosage. It falls in line with our rehab dosage and that's probably going to fall somewhere in there 70 to 80 percent of their one rep max shoulder external rotation. Now how does build the bike fall into that conversation? The building the bite comes the next visit when they show up and you have your subjective and objective asterisk signs. You have given them that one exercise and say, Hey, this is the best exercise for you. You need to do it seven to 10 reps, three sets, and you need to do that one time a day. You have a very specific rehab dosage laid out in front of them. and they come back in and your objective asterisk signs and subjectively, hey, they are sleeping better. They only woke up one time in the evening as opposed to three times. They were able to get through their workout, and they didn't have to stop or modify, or their pain was at a two out of 10 as opposed to a six out of 10. They were able to pick up their kid. Then, in your objective, they were able to raise their arm overhead, and they only had a very small window of a painful arc that was only a one or a two out of 10 as opposed to a five out of 10 the previous time. Now, your job at that point is saying, great, that exercise right there is working, We're going to go from a two pound dumbbell tip from that prescription to a three pound dumbbell. STAY FOCUSED ON WHAT IS WORKING That is not the time to decide, great, let me pull all of those other exercises that I have in the back of my brain that I've seen on Instagram and start giving them six to 10 different things or just like time to shift away. No, you have proven to that patient in front of you that that one thing that you gave them at the prescription and the dosage that you gave them was the right thing. Okay? So, Exercise and strength and conditioning principles tell us we need progressive overload. If you decide you wanted to get your back squat stronger, what is your back squat cycle look like? You are back squatting at least once, maybe twice a week, every week, and you add five pounds to that back squat and you do the exact same thing week over week. People don't get bored of that because they see progression. They see that they're getting stronger in that. IS YOUR PATIENT BORED OR ARE YOU? And I think we as physical therapists, I think sometimes it's us getting bored, not our patients. And we think that we, our job is to just be entertained or entertain them because we think the patients are getting bored of what they're doing. And so we need to give them the new fangled thing. Well, the reality becomes our patients are entertained by getting better and doing all of the things that they've told you that they haven't been able to do and now they can. Right. But, They will get bored and they will get frustrated if we don't also prove to them that they are getting better. It's not our patient's job to say, yes, I'm getting better. No, I'm not. Most of the time patients will feel they either have pain or they don't and you might get them that first time. Maybe they only could raise their arm to here and then the next time they're here and they're like, yeah, but it's still kind of bothering me. Your job then is to say, well, right, but last time you were able to get, you only were to hear, and now we're here. That's at least a 60 or 70% improvement. Now all of a sudden we're like, oh yeah, that is actually true. And I was able, I only woke up the one time last night. man, I am getting better. I need to keep doing that exercise. And you say, yeah, I wholeheartedly agree. But the thing is that seven to 10 reps for three sets now is getting too easy for you. So we need to bump that to the three pounder or the four pounder or whatever it is. Exactly the same thing, right? And that's where the patient gets entertained by seeing that they're getting stronger. improving all of their objective metrics that you're coming in to see, plus their subjective day-to-day life stuff. That's where the entertainment comes in. So don't get lost in the weeds of thinking, I need to give them the coolest brand new thing that I saw this week, right? Or I need to give them three, four, five different things. It is way, way, way more valuable for your patient, for you to know exactly right prescription, you've tested their one rep max, or you've tested a five rep max, or you have a very good understanding of their percentages of whatever movement that you're doing, that's going to challenge them appropriately, and that easily lets you determine whether or not that was the right prescription for them when they walked in, or that prescription needs to be adjusted. If they come in and they're a little bit worse, but it's the same symptoms, Great, that's not the wrong exercise still. That might be that you overdosed it up front and you can just pull that back. Maybe you handed them a five pound dumbbell and you said, okay, this is your exercise for the week. Maybe that needed to be a three pound dumbbell, not potentially a brand new exercise, right? And that's where the magic in rehab lives. Right? And that's where the entertainment factor comes in. Like you need to be entertained yourself because like I said, I think a lot of us as PTs, we're the ones that get bored before the actual patients do. Your entertainment needs to come from really figuring out the detailed prescription of what is going to be best for that patient, right? Use that as a puzzle each time they walk in and say, okay, well where, how can I dial this prescription in perfectly? And when they come in week over week, then you have to build that bike in front of them and say, okay, I'm proving to myself and to you that what I gave you previously worked and we can bump you forward with this same thing, but changing just the dosage. Don't go from, If you're trying to like, again, going back to that back squat, if you're trying to improve the back squat, how many different exercises can you do for your legs? You can do plenty. You can do back squat, you can do Bulgarian split squats, you can do hack squats, you can do leg press, you can do leg extensions, right? All of those things may get you stronger for sure. But if you want to improve your back squat, you are going to have to back squat and you're going to need to methodically and strategically bump that weight up time and time again. Once you feel like you have exhausted that thing and they come in and say, I have been getting better with this. You know, I followed exactly what you're doing. And this time, you know, we haven't seen as good of a bump. Maybe now we need to challenge that tissue in a different way, right? And that's when all of a sudden you can decide to switch exercises, okay? Find a new exercise, challenge the tissue in a different way, right? If that means that we need to go from really here and stop from this position here, maybe we raise it to a 90-90 here, or we do that wall slide that we talk about, that exercise is in the extremity management course, right? One of those two things, now we're challenging that through a little bit of a different range of motion. If we're doing a wall slide with a band, you start a light band, then you move to a medium band, then you move to a heavier band, right? And you dose that prescription the exact same way and we methodically take that approach to just adding resistance. REHAB EXERCISES DO NOT NEED TO ALWAYS BE DIFFERENT It does not need to be constantly shifting, constantly changing, constantly adjusting every single thing. that we're doing time and time again, right? So that's the big thing that I want to get on here and talk about that we see oftentimes throughout going around weekends is just that everyone wants all of the new things. And really they, it seems like the goal is trying to entertain our patients. We need to get our patients like they need to be able to like what they're doing. Absolutely. but they like when they get better. It's the same thing when people, this might be my own bias, but like if you're playing sports and everyone says like, Oh, I just, I want to be, I want to have fun. Well, you know what's really fun is when you're win, right? So like I have a lot more fun playing sports if I can also win at that sport. Right. And so that's the same thing. It's like, I might do some of the boring things because that's going to get me to win. which then therefore is fun. Same conversation here is like some of these boring activities or boring exercises, if you can prove to the patient that they're winning, now all of a sudden those boring exercises feel like fun because they can see the progress and they can see what's happening time and time again, week over week over week. And now they don't care about some monotony and some potential boring exercises if you have to prove that it is going in the right direction week over week over week. The second that you can't prove that to them, that's when all of a sudden compliance starts to dip. And once compliance starts to dip, now all of a sudden you're chasing yourself trying to figure out, well, what can I just do to get my patient to like do their exercises? Well, that's it. Prove to them that are getting better. Prove to yourself, right? Make sure every time they walk in, you're checking their subjective, you're checking their objective asterisk signs. So I want to challenge you this week, when your patients come in, give them the same exercises that if, assuming that things are getting better, don't abandon ship on that exercise. Add one pound, add the next band up, add three reps instead of it being a 10 rep, make it 13 or make it 12, same exact thing. at a set, right? These are the small details that we know bump people forward and actually progressively strength train. Okay, that's the podcast today. What I wanna talk about, are you not entertained, right? Entertain yourself by really dialing in that prescription dosage, right? Make sure that you have a good understanding and that's the fun part for you. It's like, well, last week we did 10, so this week we're gonna do 12, or it was two pounds or three pounds. That is the fun in rehab. Entertain your patients by proving to them that they're getting better, right? Using the dosage that you talk about and you're methodical over. Prove to them that they are getting better week over week over week. And now all of a sudden they're having a good time, right? Because they can do the things that they want to do. Catch us out on the road, extremity management. Myself, Mark, Lindsey, we're all over the country moving into the next couple weeks, so we appreciate you being on with me on this clinical Tuesday. Hope you all have a great day.

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