Panel Discussion: Exercise Selection - To Replace or Add?
How do you make the decision to replace a technique, modality, or exercise with another, versus, adding that technique to your planning/programing?
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page - https://www.facebook.com/brent.brookbush - on 8/11/13
Joshua Morton I do my best to interview and test the patient to rule out physical issues that might get in the way of what I am doing. Use a conservative approach to form, load, reps etc. n short if whatever it is I am doing does not yield the results I expect, I move on to the next thing I know how to do. I give myself no more than 3, maybe 4 sessions before I use a different exercise with my patients. Sometimes the mental/emotional piece is just as big if not bigger than the physical but in general I believe if what I am doing is correct, the physical will improve regardless. There are always exceptions. If I am unable to get the result I expect after going through my battery of protocols I refer out.
Saturday at 1:14pm
Brent Brookbush That's great general recommendations for anyone in practice Joshua Morton, but let me get a little more specific with you… If you go to a seminar and learn a new "release" or "soft-tissue" technique, how would you decide whether to use that technique instead of another technique you were using before, or add the technique to the work you are already doing?
Saturday at 1:17pm
Joshua Morton I trust my understanding of the body and my intuition with this one. I have certain things that are my "go to" of course and I nearly always begin there. If i have just come from a seminar where I believe I have learned something that is applicable to the patient in front of me I use it and gauge the result by end of treatment. Either it was beneficial or not. The proof comes quickly with most people. I guess that is more or less a rehash of what I already said so maybe Im not sure what your getting at….How can I be anything but general unless you want to talk about modality vs modality. If someone is unstable I will not stretch them unless it serves purely to begin reeducation of the neurology. Then I would immediately follow up with stabilization. Is that more the type of example you are looking for?
Saturday at 1:22pm
Dan Hellman Brent Brookbush - Paul Chek years made a statement that has resonated with me to this very day and I tell my students the same thing when lecturing. "Do not believe a single thing I tell you until you try it for yourself" Now when is the last time you heard a university professor say that? I probably have taken more continuing education than anyone on the planet. First I have my "core" beliefs. The big one being… We are physical, emotional, mental and spiritual beings. This belief has not changed for 12 plus years. The second "core" belief is we are what we eat (Eugen Sandow said back in the late 1800's you can't have healthy muscles without first having healthy organs and healthy glands) and the third "core" belief is all forms of stress summate in the body. So, when I take a continuing education class my core beliefs are with me and I see everything else as a "tool" It is up to me to know when to apply that "tool" or not at all. The only way this can be done on a "rational" level is to actually try the new "tool" and see if it works with my clients and fits into my "core" beliefs. I have found out over the years that if I stick to my "core" beliefs that "MOST" new techniques work in some way shape or form. I am not sure if this answers your question or not?
Saturday at 1:47pm
Shawn Fears I find that time is my deciding factor in the end for a lot of my selection. I have an hour, I can't really add anything to a program most of the time unless I am increasing work density.
I plug new exercises into a progression/regression continuum and see if there is an exercise that needs to be replaced or does this new exercise better fit the needs of my client. This adds to my programming tool box.
I never just throw any exercise to the way side because if a new one. All my choices are based on needs analysis and desired training effect.
Saturday at 1:52pm
Brent Brookbush Hey Joshua Morton, that is more of what I was getting at. So you would decide whether a technique replaces or adds to your model by the intended outcome of the technique and where that fits with in your treatment approach? For example, you would not replace a stabilization exercise with a stretch because they have two different goals, but you may replace one stabilization exercise with another if you thought it would result in better outcomes.
Saturday at 2:30pm
Brent Brookbush Hey Dan Hellman, So you determine whether a technique fits within your system of core values, if it does you "add" it? This is definitely an integrated approach, but as you mentioned you have been to a ton of CEC courses. You can't possibly use everything you have ever learned. How did you boil your practice down to the techniques you use most commonly (lets say your top 50)?
Saturday at 2:34pm
Brent Brookbush I like Shawn Fears. Progression and regression are always a wonderful way to think, and if your diligent enough to put this down on paper you can create some pretty slick progressions with time and practice. Most importantly you mentioned goal specificity. Nice.
Saturday at 2:35pm
Barbara Kay All of the above comments are wonderful ways to think about integrating and/or replacing techniques. For me, it comes down to the research. Even if I learn something new, until it has been tested and shown to produce a positive effect, I don't implement it into program design. I will always try things myself and see whether it is something that would be beneficial, but I like to really look at research involving outcomes assessments based on EMG, VO2 Max, etc. I may "add" something to my routine when I don't know too much about its effectiveness, but I don't really "replace" anything unless there is evidence of something that will be more effective and time efficient.
Saturday at 3:11pm
Dan Hellman Good question Brent: You are right I don't use "everything" it is not possible. I go into a con-ed class with this in mind… If I learn just "one" amazing technique the class was worth it. How I came up with my "top 50" was through careful consideration of the technique itself, the track record of the person delivering the information, if my clients would be "open" to the concept and I guess, old fashion intuition. This is a good debate and a tough one to answer. At the end of the day I try to get my ego out of the way, listen to what the client has to say and when I build the program rely on my instincts to show me the way. I believe program design, rehabilitation and fitness in general is 50% science and 50% art. It is the art that some have and some do not have…
Saturday at 3:14pm
Brent Brookbush Hey Barbara Kay, I just had a great discussion with another professional I will be posting this week on my forum, but there is a problem with relying completely on research - You will be at least 15 years behind what is happening right now in gyms and clinics across the country. Remember it takes time to innovate, gain popularity, be considered for research, acquire grants, publish the research, leading to a body of research on the topic, and eventually a systematic review that may or may not give us a definitive answer. This is where we have to rely on our didactic knowledge, theory and clinical reasoning to make the best possible selections… we can then compare our own outcomes and the research that is currently available to our decision.
Saturday at 3:32pm
Brent Brookbush I like where you are headed Dan Hellman, but the word "intuition" can be a little bothersome. My guess is you are far more systematic than you give yourself credit for. Can you think about your process a little bit and give us a couple of points that have helped you make decisions?
Saturday at 3:34pm
Dan Hellman It is very difficult to do research on the human body. This drove me nuts in PT school. How do you factor in the human being is an emotional mental spiritual and physical being?
Saturday at 3:35pm via mobile
Dan Hellman OK I will have to think about that one a bit more . But I do use intuition quite a bit. Or whatever you want to call it . We all have it! It's just that most people don't trust it!
Saturday at 3:37pm
Brent Brookbush So what is your process Dan Hellman, do you look at the short-term effect, outcomes, is all based on client perception and compliance… Yes we all have intuition, but I am asking you to teach others how you are intuitive - meta-cognition if you will. You can leave it up to educators like myself to dictate the course of practice patterns moving forward, or you can help us learn how you do things and add your voice to helping the readers of this post learn from your methods I am sorry if this comes across hypercritical, I am actually smiling and am trying to give you a little motive for some deeper thought.
Saturday at 3:40pm
Jason Erickson I choose the classes I take and the people I study under with care. If I learn some new things, that's great… but I need to use them before I can determine how best to employ them. To some extent, that requires a willingness to risk being wrong. Since very few methods/modalities are well-supported by quality evidence, particularly those methods/modalities employed in manual therapies, I don't have the luxury of waiting on research that may/may not ever be conducted.
For clients at a higher level of athletic ability, there seems (to me) to be more good science about what may work best. However, I think there is little disagreement that the best results are obtained when the training is individualized for the specific athlete. To me, this means to tailor the application of the science to the person once you have gotten a feeling for how their body responds (or doesn't).
For clients that have hired me for long-term training to pursue more general wellness goals, or to improve functional ability, I don't always follow the traditional concept of linear progressions. Instead, we will sometimes pursue what I call "lateral progressions", wherein they develop a broader skill set, learning to use their body in novel ways even if their GPP levels don't improve. Over time, I have found this to be a helpful strategy in keeping low-motivation clients engaged, and sometimes we find something that actually excites them… THEN we pursue it and they improve more rapidly than if we'd stuck with something they dislike. Perhaps more importantly, they stick with it and are more motivated to do their "homework" between training sessions.
As a massage therapist, I am hampered by the fact that most massage CE classes are based on outdated and inaccurate concepts of how the body works. Some are premised on completely ludicrous notions that I find intellectually painful. Though I try to avoid these, sometimes the instructors are renowned for their results, and so I may study to learn their methods… then I discard the explanations and try to determine what the underlying mechanisms might actually be. Fortunately, I have found some good mentors and a whole lot of critical-thinking colleagues to help me out. Ultimately, I choose to use "new" methods with my massage clients based on my understanding of A&P and how that method may impact their body.
Ultimately, I am trying to become less wrong about what I do with all of my clients.
"I saw the angel in the marble and chiseled until I set it free." ~ Michaelangelo
Saturday at 3:49pm
Brent Brookbush Nice Jason Erickson, although it is part of our previous discussion - I had not considered how mentors often help us make the choice on whether to add or replace. If not mentors, colleagues. I often call colleagues whom I consider friends to bounce ideas off of… Usually it starts with… "So have you ever seen this before…"
Saturday at 3:54pm
Jason Erickson Sometimes my mentees become my mentors.
Saturday at 3:56pm
Dan Hellman Doesn't come across hypocritical at all. It is very difficult to explain what one has been working on since 1988! I wish I could explain it better..
Saturday at 5:13pm
Ken O'Neill Observation is the key element, as well as client feedback. Borrowing from Carl Roger, I advocate a client-centered approach to personalized training instead of cookie cutter formula personal training! Postural irregularities, limited range of movements, injuries (not merely from training, instead from life events) all have to be taken into consideration. Even then, it's when the rubber meets the road that observation and/or client feedback raises a big flag informing it's time to do something different, preferably congruent with the client's unique embodiment.
I should add I don't train bodies and don't give much of a hoot about motivation. Training whole persons, they begin from the outset learning simple mindfulness techniques before training and then apply them slowly to training. That helps remodel brain/mind function, shifting from a limbic/amygdala fight/flight fear based stress modality to repopulating gray matter supporting arising of left pre-frontal cortex higher level operation and organization. As such, we remodel whole persons. Motivation issues are resolved as stressors dissipate, and lives improve across the board.
Saturday at 8:11pm
Fred Hatfield · Friends with Ken O'Neill and 221 others
GOOD STUFF, KEN!
Saturday at 8:55pm
Barbara Kay Brent will appreciate your discussion of the stress response Ken I am sure. I just had a whole conversation with him about that last week regarding stress and the body's ability to train and heal itself - will be interesting to see his response.
Saturday at 9:06pm
Perry Nickelston Mine is pretty simple. Did what I do help you move better than before I did it AND does it last when challenged.
Stabilization rules my corrective choice. Did it make you more stable and hold a mobility release if I had to do one. If not, then bye bye.
Saturday at 9:26pm
Joshua Morton Exactly Brent! Sometimes mobility requires stability not flexibility. Ive noticed it is easy to get caught up in "what you do". In a manner of speaking, I call myself a flexibility expert. But I have the wisdom to know that the tightness can also be caused by weakness. In those moments stretching is almost a contraindication. It can reap benefits of increased circulation and help with neurological reeducation but in the end, if you do not strengthen it it will never loosen up. And visa versa. Sometimes strengthening only continues to tighten the joint when it needs to be relaxed aka stretched. The trick is to know the difference.
Saturday at 10:39pm
Joshua Morton Maybe Ive seen that before
Saturday at 10:39pm
Brent Brookbush Thanks for keeping it simple Perry Nickelston, great thoughts Ken O'Neill I know there is much being done in the realms of "behavior modification" and "positive psychology" that would support your idea, and Joshua Morton I really like the focus on intent.
10 hours ago
Brent Brookbush One thing I am finding interesting Joshua Morton, Perry Nickelston, Barbara Kay, Ken O'Neill, Dan Hellman, Jason Erickson, and Shawn Fears…. No one has mentioned physiology, anatomy, pathology, intended effect on tissues… all of that didactic knowledge. Is there a reason why, or is this just a given that everyone uses this information when deciding whether a technique should be added to, or replace a technique you are currently using?
Personally, I consider my didactic knowledge my filter. If something has no plausible way of working, that is there is a huge glaring issue with the hypothesized effect on tissues, it may never reach my clients.
Dan Hellman Guy
3 hours ago
Dan Hellman Well Brent Brookbush that is what I used to believe too. But after one class with Dr Voyer, I had to throw my anatomy didactic work (3 full cadaver dissections) out the window! I guess I am having a damn hard time answering your question!
3 hours ago