The Hruska Clinic Integrator
Guest Blog from Student Karl Busch
Posted on 10/20/2016
Over the first few weeks here at the Hruska clinic there has been one glaring attribute that every clinician owns and tries to consistently incorporate into their practice, Keeping It Simple. This is a concept we all know very well and have heard multiple times, but occasionally lose touch with due to the large arsenal of information available. Over the first three weeks, this concept has reigned true with each therapist I’ve observed. It is the concrete foundation in how they decide which tests and activities to utilize, also influencing how they cue and educate each patient. I have had the opportunity to observe each therapist here, and I believe the maximum number of exercises given has been four and the max numbers of cues were a few per exercise. In my opinion, the reason for this simplicity comes down to two key attributes, the patient’s responsibility and their brain’s perceptibility.
Many patients’ lead hectic lives and it is difficult enough for them to squeeze in three exercises per day, never mind four, five, or six. And contrary to what many of us believe, our patients’ lives don’t revolve around PT and rehab. They usually have these huge inconveniences (joking) of their families, careers, errands, and duties that they have to tend to before they can even think about getting on their backs and do a 90-90 hip lift, adductor pullback, and left glute medius exercise for 5 sets of 5 breathes. It is usually easy to find many areas that need addressing in our patients, but the skill is to determine which ones are the most pertinent. There have been many times where the therapist has asked the patient, “How busy will you be over the next two weeks?” and tailor their number of exercises to the response. Because how effective can a program truly be if the patient doesn’t follow through with it?
The second reason falls under cuing, and I believe they try to keep it simple here because of the brain’s limited perceptibility or potential lack of ability to appreciate non-patterned sensation. The majority of our patients are in our clinics because they are patterned in their movement, as well as their sensory awareness and perception of the world around them, which can then lead to patterned movement outputs, it’s a vicious cycle. Our objective is to try and disrupt that pattern with a novel stimulus. The objective through PRI is to influence these patterns through conscious attention to specific sensations and muscles that will successfully impact the brains neuroplasticity. To maximize this potential, you need the brain to perceive the reference centers and sense the muscles engaging over and over again to promote the long term rewiring and subconscious competence we are after. Appropriate cuing brings these sensations to the forefront of the brains consciousness during PRI exercises, while each cue can influence a different area of our system.
I will admit that I have fallen victim to over coaching my patients. It is just so tempting, and easy, and the more the merrier, right? After every course I went go to, I wanted to implement all the new cues and reference centers to every single exercise I taught, but in hindsight, I was doing more harm than good. If your normal list of cues looks like this: feel L heel, R arch, L low back, bring left knee back and in and R knee forward and out, R arm reach on the exhale, L shoulder down, shift your weight to left foot, protrude your mandible and shift it to the right, gingerly touch your left teeth together, and now slightly bring your gaze to the left, they are going to lose their left heel by the time they even think about an adductor, and you are missed the boat on why these activities can be so effective in the first place. Next time cueing an exercise try saying less and see if you get the same result. Keeping it simple to allow the patient to consciously feel the correct areas first, thus creating the long-term cortical changes we are aiming for. Once they have achieved this, then progress the exercise and cues as you see fit.
There are many examples in the clinic of keeping it simple and reasons why it works, but I wanted to keep true to the post. I hope this gave you a new perspective on why “simple” is so valuable and how making things complex might not be as beneficial as you think. Thanks for reading my post, if you have any questions feel free to ask.
Karl Busch, SPT
University of Rhode Island