How to Utilize Post Rehab Professionals?

How should the medical community utilize the post rehab professional and post rehab programs?

First and foremost, the post rehab professional (PRP) is not trained to nor has the ability to replace the physical therapist, chiropractor or any other medical professional. The PRP should limit his or her practice to the development of functional conditioning programs for clients after their discharge from physical therapy and/or chiropractic care. The post rehab program should be developed based on feedback from the client's physician and physical therapist. This maximizes the possibility of a positive functional outcome.

With the aging of North America, or the "silver tsunami", the number of babyboomers being discharged from rehab in the next 10 years will become staggering. Research studies estimate more than 800,000 total knee and hip replacements were performed in 2004. That number is expected to increase 22% by 2010 for total hip replacements and 63% by 2010 for total knee replacements. Babyboomers between ages 50 and 75 will need the bulk of these total joint replacements. Each patient will need a regimen of physical therapy but the bigger issue is the maintenance of the functional gains made in rehab and the use of exercise to manage the residual functional deficits that remain after rehab. These deficits include lack of strength and endurance; balance dysfunction, joint instability, minimal muscle fiber recruitment, limited proprioception and power and restricted flexibility. Each of these deficits is treated by the physical therapist or chiropractor using various treatment modalities but at some point, due to insurance restrictions or the patient's plateau of progress, the patient must be discharged. This is the point where the licensed rehabilitation professional should refer the client to a certified post rehab professional or program (the term aftercare fitness is also used).

Physical therapists, occupational therapists and chiropractors over the next decade will be overwhelmed by a steady stream of boomers seeking treatment for a wide range of musculoskeletal, cardiovascular, neurological and metabolic disorders. The smart therapist or chiropractor will establish a network of trained and certified medical exercise specialists and post rehab conditioning specialists to refer his or her patients to at the time of their discharge. The MES' and PRCS' should be well trained in post rehab program design as well as being adept at identifying post rehab "red flags" that indicate the need to refer the client back to the physical therapist, physician or chiropractor. As you can see, the post rehab professional can augment the physical therapist's treatment plan and ensure the highest possible functional outcome for the client.

There are a few important basics that make the "post rehab model" work. They are 1) the client when discharged and referred to the PRP must be "medically stable". Medically stable means no radiating pain or significant swelling; no night pain or significant functional loss; normal vital signs, no open wounds and the client must have fair+ strength in the effected region. It is the medical professionals responsibility to ensure the client is medically stable before referring the client to a post rehab program. If the client demonstrates these "red flags" the possibility of a positive outcome is significantly decreased. The "red flag" client needs further medical treatment and is not a good candidate for referral to post rehab. The medical professional should not refer this client until the client is medically stable. 2) The post rehab professional must understand his or her role is to develop the post rehab exercise program and progress the client through the exercise sessions. The PRP must assess the client's progress at 30-day intervals and report that progress to the referring medical professional. Not reporting the client's progress to the referral source impairs the overall medical management of the client's condition. This is also unprofessional and should warrant the elimination of any future referrals to the PRP. 3) The client must be compliant with the program and attend as well as participate in the post rehab exercise sessions. 4) the PRP must have skills and knowledge to design of post rehab programs for a wide range of medical conditions. The PRP should hold a certification to design programs for post rehab clients. 5) All the members of the rehab spectrum; physician, physical therapist, occupational therapist, nurse, chiropractor and post rehab professional; must understand the post rehab program is not part of the treatment process but it is a means of improving on or maintaining the functional gains made during rehabilitation program provided by the licensed medical professional. The treatment is performed by the medical professionals, once the client is stable, the PRP steps in and provides safe and effective functional conditioning programs. If the PRP fully understands and accepts his or her role, the utilization of PRP's will become an essential part of the rehab spectrum as well as positively affecting the functional outcome of rehab programs. I predict, over the next decade, the PRP will become a more integral part and accepted member of the rehab network.

What do you have in your post rehab library?

Do you have the essential post rehab resources and references in your library? There are a few essentials texts every post rehab professional must have in his or her library. There are so many fitness and rehab textbooks available but I will narrow the list to six essential textbooks and a couple of periodicals. Take a look at the list of PR library essentials and/or click on the link below to listen to my descriptions of these resources and the reasons I consider them the Post Rehab Library Essentials.

1. Gray's Anatomy - this is the gold standard in anatomy. This text is used to train physical therapy, chiropractic, nursing, medical and other allied health professional students around the world. I know many of you have other anatomy books but as I stated earlier, Gray's is the gold standard. Having a copy of Gray's in your library is a good purchase.

2. Merck Manual - the Merck Manual lists and reviews every medical condition known to mankind. Each condition is reviewed in detail with discussion covering etiology, signs and symptoms as well as treatment guidelines. This is a must when dealing with complicated post rehab clients.

3. Examination of the Spine and Extremities - this is another classic that every post rehab professional should have. This text is used in the orthopedic training of physical therapy, occupational therapy, chiropractic and medical students. This is an easy to use text with great illustrations and diagrams. If you don't understand all the tests the physician or therapist performs on your client, get a copy of Hoppenfeld so you can understand. This text is a must for massage therapists, Pilates instructors, aquatic therapists as well as fitness professionals.

4. Physician's Desk Reference (PDR) - Though sometimes difficult to understand, the PDR lists all the medications known to man and their indications for usage. The biochemical action of the medication is outlined in the PDR but more importantly; the PDR lists side effects of these medications. The effect of these medications on exercise is your chief concern as a post rehab professional. This text should be updated no less than every two years.

5. PostRehabWorks - this is an interactive post rehab reference/resource with the 60 most common medical conditions encountered in a fitness setting reviewed. We provide post rehab exercise protocols, exercise flowcharts, post rehab assessment guidelines and more than 220 video clips of exercises, muscle and range of motion testing procedures as well as post rehab administrative forms. This is the most comprehensive post rehab resource available. If you are digging through physical therapy or chiropracitc textbooks trying to figure out what to do with your post rehab client, try PostRehabWorks. It takes the guesswork out of post rehab program design.

6. Post Rehab Exercise Protocols (PREPS) - PREPS is a simple use manual containing 62 post rehab exercise protocols for the most common medical conditions found in a fitness setting. These protocols are based on clinical observation with 1989 patients in a physical therapy/sportsmedicine clinical setting over a three-year period. These protocols are used by Medical Exercise Specialists, Post Rehab Conditioning Specialists, physical therapy and chiropractic clinics and fitness facilities around the world. These protocols provide step-by-step post rehab guidelines.

7. Journals/Periodicals - I highly recommend the "Journal of Orthopedic and Sports Physical Therapy" (JOSPT) for post rehab professionals and sports conditioning specialists. This journal is geared toward physical therapist but you will find some of the articles useful in post rehab program design. The other journal I would recommend for those "hard core" fitness professionals with an interest in human performance research, the European Journal of Applied Physiology (EJAP). I have found research topics in this journal I could not find everywhere else. Such topics as advanced muscle physiology and muscle function are regularly reviewed inn EJAP.

Click on the link below to download the MP3 file and listen to my discussion of each of these resources and my reasoning as to why they are on our "Post Rehab Library Essentials" list. Go to www.postrehablibrary.com for information on where to buy these resources.

Post Rehab Library Essentials MP3

Earth Day and Post Rehab Fitness

Tomorrow is Earth Day and the morning news broadcasts are all over it. With price of gas so high and the noticeable environmental changes we see, I have started to take a greater interest in conservation and global warming. I now have a granddaughter and I am concerned about her development but I must also be concerned with the planet I will leave behind for her. With this blog I realize the significant number of PRP's out there. As I sit here listening to the segments on GMA I wonder what can PRP's do to help conserve, I would like your assistance in putting together a list of environmentally friendly and responsible products that are easily used by PRP's to deliver post rehab services. Now I must admit I am not well versed in the conservation movement. So please forgive my ignorance but please share any thoughts you have on environmental friendly post rehab products. Please limit your posts to rehab-related products. We all are innudated with information on daily-use products that are more environmentally friendly but I feel the real savings for the planet might be in the modifications of everyone's professional lives in additional to their personal lives. Thanks for your responses and think about the Earth. In the future we will post a list of your responses.

Managing swelling in the post rehab client - the key to successful outcomes!!

Today I went to physical therapy with my mother-in-law. It was her first outpatient physical therapy session since her total knee replacement on March 31st. I have worked with her when I arrived on Monday. I focused on getting her swelling under control, thus giving her more flexion/extension and muscle fiber recruitment. I can't emphasize the importance with all rehab and post rehab clients of minimizing swelling. As a post rehab professional you are limited in your approach to managing swelling but advising the client to use ice liberally is certainly within your scope of practice. Another option for management of swelling is aquatic training. The water temperature as well as hydrostatic pressure are major aquatic factors in decreasing swelling. Remember, if swelling is decreased ROM increases, pain decreases, muscle recruitment and strength increase and overall functional capacity improves. Swelling is a byproduct of inflammation that we must respect. NEVER WORK THROUGH SWELLING!!

Quadricep or Extensor Lag - What is it?

The extensor lag describes the lack of full knee extension with full contraction of the quadricep. Limited knee extension range of motion may also cause the lack of full extension but eliminating limited ROM as the problem, quad weakness is the major issue. The extensor lag is commonly seen after total knee replacement, ACL reconstruction or patella tendon rupture. The weakness in the quadricep extensor mechanism causes the extensor lag. Vigorous strengthening of the quadriceps is necessary to remedy an extensor lag.

In the case of a patellectomy, the client should be able to fully extend the knee with the proper stregthening regimen. Though the patella does provide a fulcrum that makes knee extension easier and more efficient, the lack of a patella doesn't mean the inability to achieve full extension.

Here is a photo of extensor lag following total knee replacement. Notice the slight lack of full knee extension or the "extensor lag". If you do not look closely you might miss it. Standing terminal knee exercise, quadriceps strengthening, leg press, short arc quads will all help restore full active knee extension.



Please share your experiences working the post rehab clients with "extensor lag".

Senior Fitness Assessment with Post Rehab Clients

I recently received a call from an experienced MES with a specialization in aquatic fitness. She was interested in the incorporation of functional movement patterns into her aquatic fitness classes for seniors. As we discussed which movements might work best for the general senior fitness population I asked if she included an individual functional assessment in the intake process for new aquatic participants. She reported her facility did not because there were no functional assessments she found that were short and easy to perform as well as the the assessments were free to aquatic exercise participants. She needed a quick assessment that could easily be performed poolside and would take no more than 10 minutes. I immediately recommended the Functional Status Index (FSI). The FSI is more subjective than objective but it does give you an overall view of the client's functional status in a brief easy to use format. The FSI should take no more than 10-15 minutes to perform. If the assessment you provide is free, as in the case of this MES, then the FSI is the best choice because of its ease of use. Remember, if we assess function at the start of the program, we must reassess function at no greater than 30 day intervals to determine if our program is truly achieving the increase in function capacity we want. You may download a copy of the functional status index by clicking the link below.

We review the step by step procedure for administering the FSI along with eight other functional assessment scales in our Current Topics in Post Rehab DVD. The other functional assessments reviewed on the Current Topics DVD include the 1) Harris Hip Scale (commonly used with total hop replacements); 2) Lysholm's Scale (knee pathologies); 3) the Ankle Foot Scale (ankle and foot pathologies); 4) the Tinetti Gait and Balance Scale (balance dysfunction), 5) the Shoulder Strength Scale (shoulder pathologies); 6 & 7) and the Oswestry Scales for the lumbar and cervical spines (spinal pathologies). The Current Topics in Post Rehab 2005 DVD is part of our MES and Essentials of Post Rehab Fitness DVD workshops. For info on the MES or Essentials DVD workshops, please click on the link below.

Download the Functional Status Index

Link to the MES and PRCS Programs

There many functional assessment tools available. We (AAHFRP) have identified the eight we feel are most useful and easy to use for fitness professionals. I recommend you incorporate a functional assessment tool into your post rehab assessment.

Neural Pathways and the Post Rehab Professional

I am the proud grandfather of beautiful 3 year old enthusiastic little girl. I am also an addicted but pathetically terrible golfer. Let's put it this way, I look pretty good in golf clothes but don't ask me about my swing. Well I have started teaching my granddaughter to play golf. I have watched her closely and as a result I purchased a set of "Barbie" golf sets. Well she loves them! But one problem, I realized she naturally swings the golf club left-handed. She colors with her crayons using her right-hand. So I was amazed when she performed hitting the golf ball using the club backwards. So she hit the ball smoothly with her "Barbie"driver....BACKWARDS!! She hit the ball consistantly 20 to 30 yards. It was amazing as well as humbling to watch. But I realized her neural pathways must be overlapping. Next time you work with a client think about the neural pathways and proprioceptors the client uses to perform the task. You may find selecting exercises for your client might be easier if you introduce exercises that enhance neural performance rather than strength. Everything we do as humans begins and ends with neural transmission and neural integration. Start thinking about the neural aspect of movement, you find you can really fine tune the movements in some of your clients.