The Monday Memo
September 24, 2018 PITT DPT STUDENTS
Imagine the average outpatient orthopedic patient that comes in to your clinic. In many cases, this patient is middle-aged, give or take, with non-traumatic subacute or chronic musculoskeletal pain or pain with acute onset from a seemingly benign cause related to activities of daily living. Picture the out of shape, overweight, oftentimes frail patient whose goal is to simply return to navigating stairs and putting dishes into an overhead cabinet without pain. Or the patients with nagging back or neck pain who sit for 10 hours per day and are lucky if they get 5,000 steps in, let alone a productive strength training session. They present with global weakness, especially in the core stabilizers of the spine, hips and shoulders. Manual muscle testing of the glutes and rotator cuff are all 3/5, and don’t even get me started on what their single leg squats and lateral step downs look like. So we create an exercise program to address these strength and motor control deficits. We do a little manual therapy, grab some therabands and durabands for preliminary strengthening, toss an ankle weight or two into the patient’s table exercises, hit some machines, and then finally get into good stuff like squatting and deadlifting mechanics to optimize the patient’s function. When we’re really feeling crazy, we’ll throw a 15 pound dumbbell into the mix to increase the difficulty in the latter stages of the program. If we’re lucky, we might even see a droplet of sweat or two begin to appear on the patient’s brows.
After a few weeks of this approach the patient’s pain diminishes and their functional ability begins to return. We educate them on the importance of exercise and maybe even give them a maintenance program for them to stick with as we send them on their merry way. They stick with the maintenance program for a time, but after a short period they begin to find the band, plank, and dumbbell exercises to be boring and ultimately abandon them. They return to their routine of sitting 10 hours per day. Life begins to creep back to its normal daily grind, work and family-related stresses spike, and suddenly the patient’s pain starts to rear its ugly head once again. The cycle continues.
This story should sound all-too-familiar to many of us working in the average outpatient orthopedic clinic. We achieve good short-term results, but once the patient falls back into their previous lifestyle patterns, their previous pain returns or some new pain emerges. We become the liposuction of rehab; we suck the proverbial fat from the patient by giving them some targeted exercises, but then they return to their prior unhealthy diets consisting of sedentary behavior and quickly find that they were right back where they started before treatment. We generally are not doing a good enough job at instructing and inspiring patients to change their behavior to get active and get strong. Many of the exercises we prescribe and equipment we use in the clinic do not translate to the behavioral changes necessary to create a lasting effect. We can’t achieve long-term outcomes unless we change behavior.
One solution staring us in the face is to include equipment like barbells and kettlebells in our clinics. On one hand, this equipment helps to enforce functional, compound movements in the context of loads that are not currently attainable in the standard clinic but may be encountered by the patient in daily life. Unlike machines, this equipment allows for multiplanar and, as is often the case with kettlebells, unorthodox movements that better replicate the variable demands placed on the body in daily life. What is perhaps more important, however, is that by putting this equipment in the hands of our patients and educating them on how to use it safely, we are diffusing the stigma and fear surrounding squats, deadlifts, swings, and other crucial fundamental exercises associated with barbells and kettlebells. By reducing fear and increasing awareness of the benefits of this kind of physical training, we are empowering our patients to take control of their own health by adjusting their lifestyles to include barbell and kettlebell training as a regular staple rather than regressing to their previous sedentary behavior. If we incorporate this into our treatment paradigm (and offer cash-based strength and conditioning services to compound the effects of rehab), we will likely see meaningful behavioral changes from our patients that will in turn lead to the longstanding pain reduction and functional outcomes that we are currently striving toward in our practices.
Don’t be the liposuction of rehab. Demand excellence out of your patients, your clinic, and yourself by making barbell and kettlebell training part of rehab culture.
-Brooks Kenderdine, SPT