Features Management Operations
Where Do We Fit In The Model?

A couple of days ago I invited an old friend over for dinner. He is an anesthesiologist and researcher. While explaining to me what type of research he is currently doing we began to talk about research in general and more specifically its actual relevance, in terms of application, for quality of life issues.

He had just finished telling me about the prevalence of prescription drugs, supplements and various devices when he took a pause and said,” Of course all we know for sure is that at base level, in order to maintain the highest quality of life, don’t smoke, exercise and pray for good genes. Oh yeah … and you guys too. You help people feel better before major things go wrong. Everything else is on the downside. The quality of life can be very high but it’s much more difficult to maintain.”

Now, he happens to be a good fellow and I am sure that he included me in his assessment because it was his heartfelt opinion and not because I had yet to feed him. But it did get me to thinking that if we make the assumption, perhaps a large assumption, that the vast majority of people we deal with follow a diet that meets their basic needs and do not overly abuse their bodies with drugs and alcohol, where do we fit in the model “don’t smoke, exercise, and pray for good genes?” It turns out to be an interesting question.

Using Daily Activities As A Base For Home Care Exercise Programs
When you provide people with a respite from their world of stress, or shore up the balance in someone’s muscles or restore range of motion etc., you provide them with the ability to make the choice to exercise. If you can then make the extra step to provide them with an exercise strategy that is in tune with their own physical abilities and/or physical needs/desires you become central to their health care needs.

Whether they are recovering from an injury/disease and are in need of rehabilitation or they are trying to optimize their current ability to enjoy a diverse number of activities, they all know they should exercise in some way shape or form. In my experience very few people know how to inject balance into their exercise strategy so that they are working the body in ways that are at once enjoyable, surprising and effective.

We actually have a head start when it comes to providing clients with an exercise strategy. They book with us and freely provide us with information that often takes a great deal longer for others in the healthcare field to gather. They may come to us with a muscle ache, tendonitis, sprain, strain, or because it said in all the magazines that massage was good for you. They arrive ready and willing to tell you all about their lack of exercise (“How much exercise do you get?” “Not enough.”) as if someone on high has decreed the exact amount for them. Many of them are actually over exercising since their focus is very narrow. They provide you with an overview of their lives that allows you to get an idea of how much exercise they get just from living.

When I hear a mother of two small children saying that she doesn’t have time to exercise I make it my mission to point out to her how much exercise she is already getting. The fact that she is not getting the results she wants from exercise is another issue entirely. But one thing you can do for someone like that is to remove the “I don’t work hard enough at exercise” thing. Once you have established the routine of daily life you begin to get a sense of not only how much they are doing but how it is affecting their body. But often we don’t see the client until the gym membership, trainer, running club etc. has not given them the results that they expected or wanted.

When we talk about rehabilitation from surgery, or when an injury has occurred and rehab is necessary, often we will see the clients after they have gone through the accepted chain of command, i.e. doctor, physiotherapist, chiropractor, back to physiotherapist and chiropractor and then the massage therapist. I have heard many massage therapist colleagues bemoan this state of affairs. What a missed opportunity!

The client you are about to see is at a new beginning and, make no mistake, any recovery process whether from recreational activity or recovery from a pathological process, is a new arena for any and all involved. You as the therapist of the moment have the opportunity to create something new and lasting. Something that is relevant to their lives. Why? Because you can look at the entirety of the activity contained within their everyday life. You have the time. And you can adapt and inform them about that life in a way that is ignored (I believe unintentionally) by other aspects of the healthcare world.

When was the last time anyone in your client’s team of health care workers asked how they carved a standing rib roast after thoracic surgery? It is not considered important. But ask that same team about sustained deltoid contraction combined with low resistance pectoralis major and latissimus dorsi contractions, and oh my, how the debates will begin.

It is absolutely essential that we stop thinking of ourselves as third place and recognize where we could sit, if we would only recognize our true place in the health care hierarchy. We are front line workers. No more, and no less. We are asked to recognize when things go “south” for our clients, and we are asked to assist our client’s in maintaining their health when they decide to gain control of their lives. Give me a better definition of front line and I will gladly defer.

Let’s take the example of the 85- year-old man that arrives as the recipient of a gift certificate from his daughter for a thirty-minute massage. Marvelous! A little propping of the torso with a couple of pillows and some mid-depth work around the upper back and chest and Bob’s your uncle. Except in this case you find out that he has just had a cardiac stent put in and the kidneys are no longer functioning. A little in depth questioning and you discover that he had a dissecting aneurism and continues to have a vegetative growth on his aortic valve that is staphylococcus and he is going to be on antibiotics for the rest of his life.

There are other medications involved but suffice it to say that the situation is now substantially different than what you thought it was going to be. What is interesting to me is not that the massage itself will actually be that different (except in terms of watchfulness) from what you were initially thinking. In fact, it will be more about what you won’t do than what you will do. You may decide to perform the massage seated but that really is about it for the differences.

What will be substantially different will be your investigation into how much education they have been given, does their doctor know they are having massage and what, if any advice was given around regaining, as much as possible, their lost, physical, quality of life? Here is where you can make a substantial contribution.

Find out what their activities of daily living are in a much more targeted way: Do they have stairs they need to climb every day? What sports did they used to play and do they have a desire to return to them in the future? What kinds of food are they allowed and how would that impact on caloric input/output, i.e. no potassium for some heart surgery patients due to a history of fibrillation? Pets? Grandkids? Family dinners? Do they do any of the cooking or grocery shopping? When do they expect to drive again, if at all?

Every single one of these questions will have a tremendous impact on how you design and monitor a rehab program for this individual client. If they have stairs you can safely say that that will be their entire exercise component for the first and possibly second month following their cardiac surgery. Please recall we are talking about a client that walked into your clinic not one in which you were a member of the Phase I cardiac recovery in the hospital. The stairs are more difficult than walking on a flat surface but in their case let us say they are necessary given the geography of their house, which
they do not want changed.

Once the doctor gives the okay, you can move into Phase II rehabilitation and resistance training. There is good evidence that resistance training is a major component in reconditioning the heart muscle so your client can resume participation in the activities of daily living, without which life would lose some of its flavour.1

Because this type of client is slowly being introduced back into their body, the opportunity for the first morning stretch can set the tone for the day. They don’t need to move from their bed and they could still do some of the exercises that are part of the Qigong repertoire, for example.

Various breathing techniques that are combined with arm movements will help them feel revitalized before they step out of bed. The advantage of these types of exercise is that they stress even inhalations and exhalations. Therefore, you are able to help your client without the risk of the client inadvertently performing a Valsalva Maneuver which is contraindicated for post surgical cardiac patients’ phase I and II.2

Using the routine of getting their breakfast as both a stretch and strength allows them to fulfill part of their daily regimen and yet keeps them fro  becoming non-compliant due to dread of the “exercise program.” A box of cereal or a loaf of bread from a high cupboard quickly becomes an Overhead Press when repeated eight to ten times as they are getting the cereal out of the cupboard. It also serves to demonstrate the “why” of a resistance program, which is essential for the client desiring to continue.3

There are a myriad of ways to approach this with a client that is basically going from square one and I would encourage you to view this as an opportunity second to none.

Virtually every client that walks through your door is in some need of either rebalancing or rebuilding and most are looking for a reason to do so, as long as they can afford the time and energy. That becomes your job. When someone shows up in your clinic with a shoulder problem due to the new tennis league he or she just joined you have a choice.

You can either work the problem area (usually the rotator cuff with this scenario) to release the trigger points, reduce adhesions, promote blood flow etc., or you can figure out why the dysfunction occurred in the first place and not only do the above but become involved in the client’s training as a bio-mechanical specialist.

They will return in order to hear you say, “This is looking and feeling good, and the balance is being maintained.” But for that relationship to happen you need to let them know you are clear on how the mechanical system is supposed to work. And this is stuff you already know.
Let’s review.

The Glenohumeral joint is generally considered the most mobile joint in the body because it has these four great little muscles we call the rotator cuff. They are the supraspinatus, the infraspinatus, subscapularis and the teres minor. These little fellas act as “dynamic ligaments” that help maintain the head of the humerus in the glenoid fossa during activity (and to some extent at rest). They are not terribly strong (and many people actually give themselves problems by trying to over strengthen these muscles) but they are vital. They are responsible for the transfer of power that comes from the lower body through the upper body and out the through the arm.4 There is a reason that every tennis player, baseball pitcher, cricketer, and football quarterback dreads the diagnosis of a torn rotator cuff.

When you approach the idea of the tennis shot you need to think in terms of those planes of movement that are in use at any given time. Is it the serve that is the problem? Now you are into the kinetic chain that begins in the sagittal, moves through the frontal, coronal and back to the sagittal … with power. The transfer of power needs to move through each motor unit with the pass off being smooth so that the power generated by the toe lift, followed by the torque is transferred from the posterior extension through to the anterior extension and hip flexion without a blockage. If you think that involves the entire body, you would be correct. Where is the block? Ask the client to show you the serve in slow motion. What they show you is probably what they have been taught by their coach and is a great basis to begin with as they are more than likely not performing the serve quite like that when they get excited during a game. Ask them what their coach has pointed out as their “bad habits.”

Notice the interplay of the different muscle units that are contained within those “bad habits” and begin by going after the physical dysfunction that will be there since they are using the motor unit improperly. Find out what the stroke should look like and train them using touch. If the scapular retractors are not holding the scapula in place with the extension/abduction/rotation of the humerus, then stroke the medial border as they perform the movement and let the touch remind them and the motor unit what is supposed to be happening.5

The idea here is not to turn you into purely sports therapists. But I do think that it must be acknowledged that activity and client specific exercise are a core values in what we do to be called health care professionals. In my experience what used to be called Remedial Exercise rarely worked when given in isolation.

So how do we tie the exercise to the individual client? We can begin by being interested not just in our clients as individual human beings but also partly as social individuals, and sport/exercise/activity is a big part of the social individual. So by helping the clients to understand how to use the different motor units in order to perform their sport of choice as mentioned above, we allow for their exercise component (sport) to remain a central force in their lives.

Of course, aside from the social individual there is also the working individual. If we look at our working atmosphere we can pretty much appreciate why the rise of the repetitive strain injury is no real surprise. In fact, I think that you could say that for the average office employee the “ergonomic work space” is a contradiction in terms.

Yes, we have come a long way from straight-back chairs with too-high desks and bad lighting, but we are still talking about sitting for long periods of time with the focus always forward and minimal use of the muscle pump through inactivity.

That being the case, why is that when I see someone with either full blown or developing carpal tunnel syndrome, all I hear is “They gave me a brace and a new chair?” We know the main reason, for carpal tunnel is repetitive wrist action associated with professions that use intrinsic movements of the hand.6 Much of the time this is related to postural concerns combined with muscular imbalance.

So, while we may work with them either before it is fully developed or perhaps after surgery has been performed, we should be incorporating the active and the passive. Yes, you need to release the fascial restrictions and trigger points, but it is as important, if not more important, to teach them how to rebalance their musculature so that they are supporting the repetitive movements they are required to do for their job.

The challenge is not the exercises which are relatively straight forward (chest press, Lat pull down, reverse fly, etc.), but rather how to do them so they are not further compressing the wrist through the grasping of the weight, etc. If you have them wear the brace and then attach the weight or tube to the brace they can then focus on the muscle group or the series of co-ordinated movements that will end up challenging and changing the root problem.
This kind of thinking can be applied consistently throughout your practice and it will keep you fresh and on top of your game as a consistently effective therapist. It’s actually fun.

How do you start to rehab back the person that arrives in your clinic after ACL reconstruction surgery and as follow up after their physiotherapy? I get them to find a set of swings near their home and spend 10 to 15 minutes a day trying to go as high as they can. It works their arms, abdominals, lats, with good range of motion for the knees. There is no weight, lots of intention and it doesn’t feel like work. Once they are comfortable you can introduce some resistance, first with a closed kinetic chain and then an open chain series of exercises. Be creative and people will appreciate the thought that goes into their care.

Once they are strong with some resistance introduce plyometric work by having them join in a game of tag or hop-scotch with the local kids. I know it sounds hokey – but it works!

You achieve the same result as the gym routine with no large outlay of money on the client’s part. Of course, you have to monitor the stage they are at before suggesting some of these things but the point is this kind of work will help in some cases more than the work that is perceived as work since the compliance is higher.

For mature men and women, getting to a gym or hiring a personal trainer can be cost prohibitive. They may come and see you once every two months if you can give them a reasonable routine to do at home. You already know the results that you want: maintain balance, co-ordination, axial load, abdominal strength, etc.7

The fun is in figuring out how they can achieve these results while performing their activities of daily living, i.e. gardening, cleaning, walking, shopping, etc. Clearly, this can apply to every population.

What you will also find is that the search for application gives you an effective assessment tool. Each time a client describes what hurts, when it hurts and where it hurts, your investigations into what muscles, joints, etc. are used in different activities will allow you to pinpoint the structures at issue very quickly. That’s money in your bank. So the next time someone says, “Oh yeah … and you guys too.” You can respond with, “You’re absolutely correct!”

CITED REFERENCES
1. Jeremy L Spence, MS, CSCS Resistance Training in Outpatient Cardiac Rehabilitation Strength and Conditioning Journal,Volume 29, Number 1, pages 18-23
2. Kaye Ehlke,CSCS, Mike Grennwood,PhD,CSCS,*D;FACSM Resistance Exercise for Post-Myocardial Infarction Patients: Current Guidelines and Future Considerations Strength and Conditioning  Journal, Volume 28, Number 6, pages 56-62
3. Jeremy L Spence, MS, CSCS Resistance Training in Outpatient  Cardiac Rehabilitation Strength and Conditioning Journal,Volume 29, Number 1, pages 18-23
4. Ryan Pretz MPT, CSCS, Plyometric Exercises for Overhead  throwing Athletes Strength and Conditioning Journal, Volume 28, Number 1, pages 36-42
5. Kris E Berg, EdD University of Nebraska, Comprehensive Training  for Sport: Implications for the Strength and Conditioning Professional Strength and Conditioning Journal, Volume 28, Number 5 pages 10-18
6. Amanda J. Sinclair, EdD,ATC, Thomas J Pujol, EdD, CSCS, Adapting Upper-Body Resistance Training Exercises for Clients with Carpal Tunnel Syndrome Strength and Conditioning Journal, Volume 28, Number 6, pages 30 – 36
7. Elaine M Mansfield, NSCA-CPT, Designing Exercise Programs to  Lower Fracture Risk in Mature Women Strength and Conditioning Journal, Volume 28, Number 1, pages 24 -29

Andrew Lewarne, RMT/NSCA-CPT

About Andrew Lewarne:
Andrew graduated from Sutherland-Chan in 1997 and began work in a multi-disciplinary medical clinic in downtown Toronto. In 1998, he joined the Sutherland-Chan professional clinics and helped open the Metro Centre clinic. One of the tools he discovered missing from his education was a more in-depth understanding of the effects of active exercise on the rehabilitation of common musculoskeletal injuries found in athletes. To correct this, he pursued and obtained his National Strength and Conditioning Certified Personal Trainer from the top certification body in the North America. At the same time he also branched out and opened his own single-room practice.

Before entering the health care field, Andrew worked as an actor and stuntman across the country in theatre, film and television. Concurrently with his other studies, he began to work as a Standardized Patient for the Clinical Skills Assessment Unit at the University of Toronto Medical School. He soon graduated to becoming a Patient Trainer and was asked to join the Cross-Cultural Communication workshop and the Inter-professional Communication Workshop with Dr. Cleo Boyd and Dr. Brian Hodges. These workshops were run by the University to develop and implement new Objectively Structured Clinical Evaluation cases for the International Medical Graduate Program with CSAU and the Canadian Medical Council Qualifying Exam Part 2. He found this experience invaluable when he accepted the post of Examinations Officer with The College of Massage Therapist of Ontario from March, 2001 to June, 2006. He oversaw the creation and content of the provincial licensing examination that evaluates all massage therapy graduates from across the province. To effectively examine the graduates Andrew trained both the examiners and clients in preparation for the provincial examinations. Since June 2006, he has been focusing primarily on his clinic, The Body Wise.