Clinical Practice Top 13 - Part II

Seven down, and six to go. No further waiting ... let's get on with number 8 ...

8. Principles And Practices - Stephen Covey, in his "Seven Habits Of Highly Effective People", discusses the concept of "principles" versus "practices". Principles are the "why" we do something, whereas practices are the "what" we do. Much of our time is spent thinking in terms of practices - or as many educators and clinicians will say, "having more tools for the toolbox". I think this is misguided at times. A screwdriver can't be used for everything, nor can a hammer. It is the decision making skill of when to use what tool that is ultimately key - and of course this comes down to learning how to think and process clinical information. 9. Posture - As I once read, "posture follows movement like a shadow". In other words, everything we do is based on posture. This is also intimately related to "patient education" in that patients need to understand the cause and effect relationship between posture (or changes in posture) and symptoms. Posture provides the basis for all movements and activities. Simply telling someone to "sit up straight" is almost pointless - it's back to that issue of "telling" someone to do something when they may not understand "why".

10. Prescription - Treatment interventions (especially movement-based) are just like medicine. If you are taking too little medicine, you won't attain the desired effect. If you are taking too much medicine, you will overdose. The same rules apply for exercise - too little, and you won't provide the necessary stimulus, and too much and you will be unable to adapt to the demands. Knowing the desired effect of the intervention (and the physiological mechanisms involved) will define the appropriate exercise prescription. An example would be strength training. If the goal is to increase muscle fiber recruitment, then we need load, not repetition. If we know that this is the goal, then the means to accomplish it should be pretty clear, especially at the cellular level. A close relative of this is ...

11. Parameters - Not only do you need to pick the right intervention, but you also need to understand the necessary parameters to attain the goal response or adaptation. Going back to the strength training example - in order to increase muscle fiber recruitment, we need load - enough to challenge the tissues. Do we need many repetitions to attain this? No. But we do need resistance. The goal always needs to be to have the necessary parameters to attain the required stimulus for adaptation, otherwise we're wasting our time (and the patient's). Four weeks of using that yellow theraband for ankle plantarflexion strengthening when the patient is already ambulatory probably isn't getting the job done.

12. Performance - Exercises must be performed correctly for the desired effect to be attained. Along with this is the critical relationship between optimal tissue development/remodeling and the mechanisms related to human performance. You can't have an optimal response with a sub-optimal stimulus or mechanism. Knowing "human performance" guides us very accurately in the direction of "optimal exercise intervention". If patients understand what they are doing, and how to accomplish it correctly, then they can effectively apply the appropriate loads/exercises and monitor the responses to them. Again, this speaks to our skills as educators and mentors instead of gurus and fixers.

13. Progression - Last but certainly not least, something that is oftentimes forgotten - progression. The body will readily adapt to the imposed demands. If it didn't, we'd have great difficulty surviving our day-to-day challenges. The human body is constantly facing different stimuli, and responding in the most appropriate fashion to that stimuli. It doesn't typically take months for change to occur. As the body responds and adapts to the imposed demands, we need to be persistent in progression - of loads, of exercises, of functional activities.

So there we have it - my Top 13. But it would not be complete without adding the one phrase that I am heard saying most frequently and that defines what we do in the grand scheme of things - "form follows function". Our anatomical and biomechanical form will follow the functional demands imposed on the system. If we load tissues, they respond. If you apply the proper stresses to any tissues of the human body, they respond.

But I guess that would make 14 ... if I was to spell it as "Pform Pfollows Pfunction" to meet the "P" criteria! So for now, let's call it 13 ... and one guiding principle added for good measure.

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