Practitioner Seed #12: Plan Like a Pro

So you have kicked off your very first role in private practice….

How can you possibly know the times it takes to rehab a chronic achilles tendinopathy?

Even more arbitrary…

A patient who presents with a 3 year history Non -specific low back pain?

 

This is where an ability to completely listen to your patient, will provide the answers. To read more about active listening and motivational interviewing, head all the way back to Practitioner Seed #1 – Listen to your Patient! – Clinicalx foundations.

 

Begin with the end in mind

Why has this patient made an appointment to see you at this time?

On face value, this might be to relieve pain……….. but there is always a deep -seated functional limitation, something they are held back from that has significance in their life, creating an emotional response.

It’s our job to dig deep into the weeds and establish the patients Why in those early sessions.

 

“What can’t you currently do because of your knee pain, that you would like to be able to do?”

 

When it comes to planning & goal -setting we must advise our patients with candour ……… what is realistic for the human in front of you?

Consider tissue status – A severely degenerative knee with osteophytic lipping, subchondral cysts and macerated chondral surfaces may not get back to the ultra iron man event (Although we have all heard of superhuman cases where the impossible has happened!)

While the exceptional does occur, we are more likely to experience the converse ………that is conservatism!

The vast majority of patients will proceed with extreme caution..

 

This is where you become the coach & motivator OR the voice of reason!

Educate your patient that if they want to be able to run, moderate amounts of running are actually not detrimental for mild to moderate knee or hip OA.

So now that you have an end goal, how might you structure everything in between? & apply timeframes?

We must consider the physical qualities that will provide the patient with the ability to achieve their goal through each step of the journey …..

In any one period, are we aiming for

• Pain reduction
• ROM
• Graduated movement exposure
• Tissue adaptation
• Muscle strength
• Rate of force loading
• Muscular endurance/ repetitive power….

 

 

Apply this Clinical Tip……

 

Make a habit of providing every patient with a summary of the session and their targets for next session

Next week I want you to come back with

Knee to wall = 12cm

SLHR Max reps = 20+ reps

This gives your patient something tangible to work towards.

Much better than wandering aimlessly through a week of doing 3×10 calf raises every day!

 It’s imperative that you make this goal achievable, so it’s not difficult for your patient to get a win. Early wins are good for morale and good for rapport!

 

 

What about timelines?

A ballpark of 12 weeks is a good place to start as a VERY general rule.

Why 12 weeks?

When analysing the effectiveness of a conservative v surgical approach in hip related pain ,  Kemp et al (2019) concluded that at least a 12- week program of strengthening seemed to have the best effect.

Silbernagel et al (2020) describe a progressive Achilles tendon rehab program involving direct tendon adaptation over a 12 week block, followed by sport specific training 3-6 months.

If we are considering tissue adaptation, the majority of studies that assess strength benefits use periodised protocols of on average 8 weeks.

As we progress through university, we are taught that it takes a minimum of 6 weeks to gain basic level strength changes.

In reality, we might see neuromuscular changes happening earlier – ie in the initial 2-6 weeks (Pending individual training history) but the true myofiber changes take at least 8 weeks.

This is on the proviso that the program meets the requirements for strength changes to occur – For more here read  Practitioner Seed #8: Strive for Specificity! – Clinicalx foundations

 

If we are aiming for connective tissue adaptations, the magic of 12 weeks is realised again!

Bohm et al (2019) highlight the optimal conditions for morphological and material adaptation in tendon tissue

• High magnitude force (4.5-6.5% of tendon strain or 90-100% MVC)
• 3s:3s contract/ relax
• 4 reps
• 5 sets
• 2min rest between sets
• 4x/wk for 12 weeks

 

So….

 

When that question hits you from your 9am patient tomorrow – and it undoubtedly will!

 

How long will this take?

 

 

You have the key concepts to be able to form a realistic and confident response…..

Your patient will develop appropriate expectations……

You will create that first building block of rapport……..

& you are well on your way toward a successful patient outcome!

 

 

Reference

Bohm, Sebastian & Mersmann, Falk & Arampatzis, Adamantios. (2019). Functional adaptation of connective tissue by training. Deutsche Zeitschrift für Sportmedizin. 2019.

Kemp JL, Mosler AB, Hart H, Bizzini M, Chang S, Scholes MJ, Semciw AI, Crossley KM. Improving function in people with hip-related pain: a systematic review and meta-analysis of physiotherapist-led interventions for hip-related pain. Br J Sports Med. 2020 Dec;54(23):1382-1394.

Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May;55(5):438-447. doi: 10.4085/1062-6050-356-19. Epub 2020 Apr 8