I will never forget my first geriatric clinical affiliation as a physio student.
I was training at a skilled nursing facility and there was one therapist working the entire department. I was riveted by her. She would arrive in the morning, sit down on a rolling stool and (OK, being a tad hyperbolic, here) never rise again.
Every patient received an identical treatment. She would park her trusty steed in front of patient #1’s wheelchair, lean over, place a red cuff weight on the right ankle, sit up, breathe, lean over, place a red cuff weight on the left ankle. She would then lead the patient through (what appeared to my student eyes to be) an unending set of chair-based marching exercises.
About the time a look of quiet desperation overtook the patient’s visage, she would switch it up. Long arc quad sets! Kick! And kick again. And… wait for it… back to marching.
About 10 minutes in, it was time for water. Zoom! Off would go the stool, zipping across the open gym floor. (Side note: The woman never crashed. I have to hand it to her; she had an uncanny ability to maintain her centre of mass within that tight base of support).
Sip, sip. Water break for all. Perfect time to jot a note or two.
Now what? Time to reposition those weights. Lean over, unstrap velcro on right ankle, sit up, breathe, repeat. Time for arms! Time for patient #2. Oh look, #3 in in the house! Time for lunch. And so on and so on.
It was mesmerising. But, it wasn’t functional. (And it wasn’t a great clinician affiliation, but that is another story).
The kind of therapy this therapist was providing could be described as cookbook. There was no clinical awareness, no ah-ha moments of vision or clarity. There was just THE ROUTINE.
So, the question becomes: what (if anything) could have led her away from the cookbook and towards individualised decision-making?
Truly, how can any therapist make sure he or she is always working towards new ground? Towards a functional “progression”?
In a classic 2004 article in the Journal of Neurologic Physical Therapy, 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.
Change the Level of Assistance the Therapist Provides
One way to progress an exercise or activity is to gradually withdraw any assistance provided.
This is second nature to most therapists and yet, the continued provision of physical assistance can hamper progression, especially if the therapist is too ready to ‘jump in’ and do the task for the patient.
The point of lending assistance is to allow the patient to move past current restrictions and to attempt novel challenges which would be impossible otherwise. Unfortunately, we often overplay our ‘assisting’ hands.
This is often seen in gait and balance training where the therapist does all the balance righting reactions and never allows the patient to experience movement errors. It can also be seen when working with patients on dressing or self-cares where there is a fine line between facilitating a task and simply taking-over.
Reduce the Patient’s Use of Supportive Devices
Another method of withdrawing assistance — and thus progressing a task — is the removal of the support gained from an assistive device.
This is a well-used method of advancing balance and ambulation skills: the patient is first issued a walker, then a quad cane, then a single point cane and finally graduates to no external support. From a motor learning standpoint, this progression may give the patient opportunities to practise using the affected system.
In some cases, the patient will continue to have issues that cause him to be unsafe without the extra help of a supportive device. However, long-term dependence on an external device may rob the patient of the opportunity for specificity of learning and set the patient up for a future full of potential failure-points.
Interestingly, the question remains whether there is a role for ongoing use of assistive devices such as robotic exoskeletons. Perhaps there may even come a time when it no longer makes sense to work towards freedom from supportive devices, but to work towards integration of them.
Withdraw Your Verbal or Physical Feedback
One of the foundational concepts of therapy is the idea that feedback (whether verbal or tactile) is useful.
When a patient is executing an exercise – say a bridge – we believe that strong verbal encouragement (some might call it coaching) will produce a response, more specifically, a positive response. If this is true, then the removal of this feedback is another means of progression.
Initially, feedback should be provided externally, with the therapist providing either knowledge of results (KR) or knowledge of performance (KP) or both. Over time, the therapist should make a conscious effort to decrease external feedback and allow the patient to substitute their own internal cues. This allows a slow wean from dependence on the almighty therapist’s ‘wisdom’ to self-awareness. It also allows the patient to move down the learning curve from the skill acquisition stage to the mastery stage.
Require More with Less (Attention)
The concept of ‘dual task processing’ or divided task attention has been given a lot of press recently; and for good reason. By merely reducing the degree to which the patient is allowed to attend to the function to be performed, the task becomes more difficult. Older adults appear to require greater cognitive resources for postural control and locomotion. There is less attentional processing capacity available for balance control during dual-task activity.
For more on this topic, explore the systematic review by Muir-Hunter & Wittwer (2016) which investigated the association between dual-task testing protocols and fall risk. This review gives a nice overview on how dual task processing differs from single task processing and how this deterioration can help predict future falls.
Break Activities into Natural Components of Movement
Breaking up tasks into component parts during therapy can be a great way to prepare a patient to attempt to perform the entire task independently. Take the individual who cannot get up off the couch because of weakness and lack of knowledge. The transfer can be broken down into its component parts (sitting close to the edge, placing legs apart, putting the gluteals on stretch, using momentum, etc.).
Part-task training can be an effective way to retrain tasks that naturally fall into coherent component parts. The practice may start with simple repetitions of basic components or smaller ranges of a task, but becomes more and more complex and multifaceted as the patient performs the entire task.
Part-task training does NOT work well if the movement doesn’t naturally break down into parts. If your treatment feels artificial, it’s probably a poor use of this technique.
Variability in practice addresses the degree to which the performance an activity or exercise varies or changes over treatment sessions.
For patients in rehabilitation, several repetitions of a single activity without variability (blocked repetition) may be initially useful for educational purposes. This may familiarise the patient with an exercise or assist initial skill acquisition. However, there is a point at which simple blocked repetition becomes useless. In the process of rehabilitation, recall and transfer of motor skills, as well as learning, retention, and refinement of a skill are best facilitated by random repetition over blocked repetition.
In part two of this article, we investigate six more methods of progression. But, ultimately, it does not matter which method you naturally favour. The beauty of this process is that it removes the temptation for the novice or the weary therapist to treat patients using one-size-fits-all cookbook protocol. It coaxes therapists to remain on the lookout for the best way to meet the specific training needs of their geriatric patients. It makes them better therapists.
- Buszard, T & Masters, RS 2017, ‘Adapting, correcting and sequencing movements: does working-memory capacity play a role?’, International Review of Sport and Exercise Psychology, pp. 1-21, viewed 25 July 2017, http://www.tandfonline.com/doi/abs/10.1080/1750984X.2017.1323940
- Fell, DW 2004, ‘Progressing therapeutic intervention in patients with neuromuscular disorders: a framework to assist clinical decision making’, Journal of Neurologic Physical Therapy, vol. 28, no. 1, p. 35, viewed 25 July 2017, https://www.researchgate.net/publication/232171237_Progressing_Therapeutic…Clinical_Decision_Making
- Hollman, JH, Berling, TA, Crum, EO, Miller, KM, Simmons, BT & Youdas, JW 2017, ‘Do Verbal and Tactile Cueing Selectively Alter Gluteus Maximus and Hamstring Recruitment During a Supine Bridging Exercise in Active Females? A Randomized Controlled Trial’, Journal of sport rehabilitation, vol. 0, no. 0, pp. 1-22, viewed 25 July 2017, http://journals.humankinetics.com/doi/abs/10.1123/jsr.2016-0130
- Hornby, TG, Holleran, CL, Hennessy, PW, Leddy, AL, Connolly, M, Camardo, J, Woodward, J, Mahtani, G, Lovell, L & Roth, EJ 2016, ‘Variable Intensive Early Walking Poststroke (VIEWS) A Randomized Controlled Trial’, Neurorehabilitation and neural repair, vol. 30, no. 5, pp. 440-450, viewed 25 July 2017, http://journals.sagepub.com/doi/abs/10.1177/1545968315604396
- Mizukami, M, Yoshikawa, K, Kawamoto, H, Sano, A, Koseki, K, Asakwa, Y, Iwamoto, K, Nagata, H, Tsurushima, H, Nakai, K, Marushima, A, Sankai & Marushima, A 2017, ‘Gait training of subacute stroke patients using a hybrid assistive limb: a pilot study’, Disability and Rehabilitation: Assistive Technology, vol. 12, no. 2, pp. 197-204, viewed 25 July 2017, http://www.tandfonline.com/doi/abs/10.3109/17483107.2015.1129455
- Muir-Hunter, SW & Wittwer, JE 2016, ‘Dual-task testing to predict falls in community-dwelling older adults: a systematic review’, Physiotherapy, vol. 102, no. 1, pp. 29-40, viewed 25 July 2017, http://www.sciencedirect.com/science/article/pii/S0031940615037931
- Patel, V, Craig, J, Schumacher, M, Burns, MK, Florescu, I & Vinjamuri, R 2017, ‘Synergy repetition training versus task repetition. Training in acquiring new skill’, Frontiers in Bioengineering and Biotechnology, vol. 5, p. 9, viewed 25 July 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5326793/