Determining the most effective exercises for patients with back and neck problems is not always easy. Exercise is an important key to full recovery of function, so we are inclined to recommend all appropriate exercises. The result is frequently an extensive list of exercises given to each patient, including stretching, strengthening, stabilizing and coordination exercises. In reality, however, most patients have a limited amount of time (and enthusiasm) to exercise.
When preparing an effective rehab program, don't overwhelm a patient with exercises. Unfortunately, it seems that the more knowledgeable doctors are in rehab procedures, the more likely they are to do just that.
The Road to Overload
The condition commonly referred to as "overload" occurs if a patient is instructed to do too many exercises even once a day. The health care professional strongly believes in the benefits to be gained from these various exercises, and the patient is eager to get better. Problems begin by the second day, when the patient realizes this amount of commitment is simply not compatible with real life.
To benefit from active exercising, patients have to actually do the exercises. If they don't, no improvement will take place, even when they have been given beautifully planned programs. Moreover, exercise recommendations must be designed so patients can actually follow them.
Simplify to Improve Compliance
The best way to avoid the overload problem is to recognize that all patients have their own lives. We must advise and treat our patients the same way we would treat ourselves. We often have a hard time finding an extra hour or two in each day to do the exercises we know we should be doing; we can't expect our patients to be able to find that time any easier than we can.
A 1999 study examined home exercise performance in adults over 65 years of age (an age group previously found to have difficulty with exercise compliance). Volunteer subjects, 67 to 82 years of age, were instructed in either two or eight exercises to be performed daily. When they were checked 10 days later, the group that had been shown only two exercises performed significantly better than the group that had been shown eight exercises.1 While the results may seem self-evident, many doctors and therapists apparently need this evidence-based reminder.
Consistency From the Start
The most effective way to begin an exercise program is to start small, but consistently. This means that the patient starts with one or two exercises he or she really needs, and performs them frequently (daily is preferred). Once-a-day exercising is the quickest and easiest way to establish a regular exercise routine. Patients are allowed to fit the exercises into their daily schedules whenever it's best for them - mornings, during lunch breaks, or evenings. Initially, we are not asking our patients to do heavy resistance, muscle tear-down exercises, so the traditional "day of rest in between" is not needed. We want to establish a new habit of regular, consistent exercising of the problem area.
Building From Success
As the patient begins to respond and an exercise routine is established, we can add one or two more exercises to address adjacent or more involved areas. Even so, it is vital that we continue to monitor the patient's level of compliance and commitment, and provide praise and recognition. We all do better and are more motivated when we have achieved some small success before tackling larger projects. The confidence that comes from succeeding at the initial exercises makes it much easier to integrate more complex or time-consuming exercise routines.
One Typical Example
One of the more common postural problems seen in chiropractic offices is "forward- head syndrome." This condition is frequently a major factor in chronic headaches, recurring neck pain, and persistent upper-back myofascial pain. It is also very commonly part of the "whiplash syndrome," and can still be present years after the initial injury. For this condition, it is important to start the patient on the one or two exercises that will bring the most rapid change in this posture, while also decreasing the symptoms.
A patient with forward head syndrome generally will start his or her exercise rehab with only one exercise to begin with: posterior translation of the cervical spine. When this exercise is done correctly, it changes chronic postural habits and rapidly re-educates the neural network that maintains head position. In addition to strengthening the weak paracervical muscles, the exercise also stretches the tight myofascia (taking advantage of reciprocal inhibition) and improves coordination of the spinal proprioceptors. It is easy for any patient to perform this exercise daily, since it takes no more than 10 minutes to do three sets of six repetitions in a slow, controlled rhythm.
Small Steps to Success
When we incorporate rehabilitative exercises into our regular chiropractic care, our patients recognize that we are knowledgeable experts. When we keep our recommendations small and achievable, patients are successful in their exercising, and their rapid progress is a tremendous motivating factor. When patients follow our exercise recommendations, they respond much better. The end results are more consistent chiropractic results, and patients who recognize our expertise in the field of musculoskeletal problems. These patients are able to continue to exercise on a regular basis because they have directly experienced the benefits and seen how exercising can be integrated into a busy schedule - and they will gladly refer their friends and co-workers to your office for your excellent care.
Reference
- Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Phys Ther 1999; 79:270-277.
Kim Christensen, DC, DACRB, CCSP, CSCS
Ridgefield, Washington
