Continued from Part 1: Ways to Progress any Rehabilitation Exercise, Task or Activity
The occupation of physiotherapy takes more than a decent set of clinical skills and a good set of hands. It takes intuition. It takes the ability to sort through data and create a clinical picture. It requires clinical decision-making. But most of all, it takes the willingness to push past natural barriers and to boldly go where no man has gone before! (…Well – let’s stick within anatomical limitations and known physiologic capacity for the human species, at this stage.)
But we all fall into ruts. It’s human nature to continue to do what we have always donewhich is why it is useful to look for paradigms that can be used to actively promote skilled care. In a classic 2004 article in the Journal of Neurologic Physical Therapy, PT author Fell offered clinicians 13 simple yet comprehensive methods to complicate or simplify any exercise, task or activity.
These 13 methods of progression have survived (and flourished during) the passage of time. They offer clinicians a clear decision-making pathway on how to progress any exercise, task or activity.
The first 6 methods (covered in Part 1 of this article) are as follows:
- Change the Level of Assistance the Therapist Provides
- Reduce the Patient’s Use of Supportive Devices
- Withdraw Your Verbal or Physical Feedback
- Require More with Less (Attention)
- Break Activities into Natural Components of Movement
- Introduce Variability
In this article, we will focus on 7 additional ways to bring skilled progression of care to the forefront.
Make Environmental Adjustments
One of the easiest adjustments to make in therapy is to alter some factor in the environment. There is almost no limiting factor to the number of variation that this method provides. Environmental progression can be accomplished by modifying any component of the surrounding conditions. For example, a patient working in a pool setting is subject to an astonishing number of opportunities for novelty. In water, the therapist can easily increase (or decrease) auditory, visual, proprioceptive, vestibular, and tactile information. The depth can be changed. The position (supine, prone, seated, standing, four-point) can be changed, as can be the water temperature, the turbulence of the surrounding water, the amount of acceleration provided, and the number of prepubescent children doing poorly-executed cannonballs into the pool.
Environmental progression typically goes from “typical surroundings” to novelty. This can be done by altering the terrain, removing visual cues, or by increasing the number of people present. Environmental progression should be carefully controlled so as not to engender a sense of failure by asking a patient to perform a task with too many variables; and yet, the environment must not remain static. It is important to allow movement errors.
Create a Regional Focus
A regional approach to progression includes a purposeful shift of focus from one anatomical region or area to another. One example is a focus on proximal muscle groups prior to distal muscle groups, which has been described as a common pattern for return of function following cerebrovascular accident, depending on the location of the cerebral lesion. It is also possible to focus on one muscle group (say the pelvic muscles) in order to effect a functional task, such as walking.
Fall Back on Developmental Sequencing
Another method of progression popular in rehab circles is the use of a deliberate developmental sequencing, similar to the steps an infant or toddler experiences. A typical developmental progression will start in prone with rolling and crawling. It will progress to prone on elbows, a prone pressup, to quadruped, to creeping then kneeling, half-kneeling, and so forth. Therapists use this sequencing concept naturally when they teach sitting balance prior to standing balance. Creeping, rolling from supine to prone, and crawling may seem irrelevant to geriatric populations, but these are valuable component parts to everyday life. Tasks such as climbing a ladder, rolling out of bed, and getting up off the floor require the same movement skills.
Make Changes in the Velocity of Movement
Progression of velocity of movement implies that the speed of movement or the overall speed of a functional task is altered as the rehabilitation progresses. Usually the patient progresses from slower to faster movements. Walking speed, often referred to as the sixth vital sign, is highly predictive of outcome and can even be used to predict success or failure after discharge. Of course, faster isn’t always better. For some activities, a faster pace merely produces counter-productive compensatory and overflow patterns.
Adjust the Amplitude of Movements
Progression of amplitude implies that the therapist intentionally asks the patient to change the magnitude of movement of an isolated muscle or in a task. Typically, this manifests as a simple increase in the arc or scope of movement; however, this concept can also be applied when working with patient who move in synergies and can initially only create large gross motor movements. By dampening the patient’s mass synergies, the arc or scope of movement may actually decrease, but the difficulty of the task increases.
Work Towards… More Work
The total amount of work produced by the patient during therapy can be progressed over time. This can be accomplished by increasing the total number of repetitions, increasing the duration of the task, decreasing the rest period, or increasing the intensity of the exercise (by lengthening the lever, increasing the weight used, etc.).
Endurance activities, such as those often chosen for patients with cardiac or respiratory conditions, are performed with less intensity and/or relative power of the task than would be used for strengthening. The focus here is on teaching the patient to do a slow-burn of energy and to tap into aerobic pathways of ATP-creation. Endurance is most often addressed by gradually increasing the duration of a task or activity. It is also possible to elongate the distance travelled to work on endurance. Exercises which emphasize endurance rarely tip the patient over their first ventilatory threshold and do not create an unrecoverable oxygen debt. In other words, they are sustainable.
Sometimes, patients are frail or cognitively impaired and exercises need to be simplified or dialed back. Other times, it’s necessary to pull out all the stops, to push to the point of failure. Either way, the therapist who continuously strives towards PROGRESSION will be able to offer their patient the best of both worlds.
- Fell, D. W. (2004). Progressing therapeutic intervention in patients with neuromuscular disorders: a framework to assist clinical decision making. Journal of Neurologic Physical Therapy, 28(1), 35.
- Lee, A. Y., Baek, S. O., Cho, Y. W., Lim, T. H., Jones, R., & Ahn, S. H. (2016). Pelvic floor muscle contraction and abdominal hollowing during walking can selectively activate local trunk stabilizing muscles. Journal of back and musculoskeletal rehabilitation, 29(4), 731-739.
- Lusardi, M. M., Fritz, S., Middleton, A., Allison, L., Wingood, M., Phillips, E., … & Chui, K. K. (2017). Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability. Journal of geriatric physical therapy (2001), 40(1), 1.
- Palau, P., Núñez, E., Domínguez, E., Sanchis, J., & Núñez, J. (2016). Physical therapy in heart failure with preserved ejection fraction: a systematic review. European journal of preventive cardiology, 23(1), 4-13.
- So, B. C., Kong, I. S., Lee, R. K., Man, R. W., Tse, W. H., Fong, A. K., & Tsang, W. W. (2017). The effect of Ai Chi aquatic therapy on individuals with knee osteoarthritis: a pilot study. Journal of Physical Therapy Science, 29(5), 884-890.