Looking Beyond Physical Capacity

If you deal with clients with chronic &/or complex musculoskeletal presentations and are continuing to fall short of reaching your (& your client's) outcome goals, it may be a capacity problem.

That is, we may not be approaching our management from a position where we are addressing their Individual load - capacity equation

Not sure if this may be the case?

In these situations, if you have had the following thoughts, then it may very well be.

What is Capacity in the Context of Physical Rehabilitation?

In its simplest definition, capacity is the amount of load a tissue/structure/person can tolerate.

If we exceed the load-tolerating capacity of the tissue/structure/person, adverse events such as injuries may occur.

Where clinicians can sell themselves (& their clients) short, is failing to recognise that;

Capacity & Loads are both

Physical AND Psychological.

How Can This Sell Them Short?

The more we are improving our understanding of chronic pain and the potential mechanisms that drive these presentations, the more we need to understand that not every clinical presentation we see is purely a physical one.

The relationship between pain and the state of the tissues becomes weaker as pain persists.

- Lorimer Moseley -

We may have two clients presenting with plantar fasciopathy, one may be very much a load-based injury (right). However, one presentation of a painful heel may be more driven by psychobehavioural mechanisms (left).

If we apply our treatment interventions the same (for example: straight into rehab exercises, changing footwear, applying shockwave &/or load management advice - today we aren't debating these interventions...), we may see two vastly different responses to the interventions & subsequent outcomes.

For someone with primarily psychological or psychobehavioral drivers, we may find reassurance, compassion, education and helping coach towards more positive health-related beliefs &/or behaviours more impactful than a specific exercise, orthomechanical &/or electrotherapeutic intervention.

What Are Psychobehavioural Mechanisms?

When referring to psychobehavioural mechanisms/barriers/factors, these are our Yellow Flags.

Beliefs - Locus of Control - Pain Catastrophising - Kinesiophobia - Anxiety - Low Self-Efficacy - Coping Strategies - Familial Factors

Those who have presentations dominated/driven by psychobehavioural factors will often need to have their management approached differently. Both clients obviously have an imbalance of the load-capacity equation, that's why they're here.

However, the factors that are contributing to their 'overload' and our interventions to increase their capacity will differ. Not to mention factors that may result in a 'flare' of symptoms will also differ as well

(hint: if you have a chronic presentation client going through a flare and take the time to explore what was happening in their life preceding the flare, it may give you an idea of if you need to address physical and/or psychological load/capacity)

How Do We Address Capacity?

Addressing capacity is relatively straightforward.

1. Identify desired capacity.
2. Identify current capacity.
3. Apply interventions/management to move the client from their current capacity to their desired capacity.

Where the complexities arise is the individual approach we take with our therapeutic interventions.

However, I am of the opinion that if we take our time during the initial consultations to thoroughly explore a client's history & get to know them, the pathway for selecting the most appropriate treatment interventions becomes a lot clearer.

Building Physical vs Psychological Capacity

For many clinicians, when it comes to building physical capacity, this is relatively straightforward. Apply a stressor, allow adaptation to occur, repeat.

Building psychological capacity, not-so-much, or is it? I believe it is.

How Can We Build Psychological Capacity?

Addressing psychobehavioural factors & increasing psychological capacity will often see us relying on our soft skills and building a therapeutic alliance with our clients.

Non-verbal communication

Responsive listening

Normalise somatic sensations

Goal-setting

Dose exercises to tolerance

Building body awareness

etc...

How May This Look Clinically?

A Change in Thinking

What many clinicians can struggle with initially, is falling for the illusion of action, that is we need to physically do something to be making a difference. It can be easy to forget that responsive listening, being aware of our body language, making statements that allow a client to feel heard etc is actually doing something, it just may not be what we're familiar with or what we think 'doing something' means.

This isn't to say we can't or shouldn't physically do something (eg: strapping, massage, mobilisations etc...), it is highlighting that;

a) Our communication skills and what we communicate can be equally, if not more important for some clients with chronic &/or complex musucloskeletal presentations.

b) We shouldn't physically do something just for the sake of doing something (ie: the theatrics of healthcare).

c) Our management approaches can & should be different between clients, if we are taking the time to identify their individual presentation, drivers and therapeutic needs.

Like many practicing clinicians who've graduated university and have had to advance their knowledge & skills in exercise prescription/strength & conditioning to build a client's capacity. We simply need to work on growing our skill-set to help a client build their psychological capacity.

In doing so, we will be able to apply therapeutic interventions that meet the individual needs of a client, to build their capacity and facilitate their recovery.

Treat the Person NOT the Pathology

In summary, it is important for us as clinicians to consider the person as a whole and not just the physical injury itself when it comes to how we approach our management.

If you're wanting to expand your knowledge, skills & confidence when it comes to rehabilitation lower limb musculoskeletal pathologies Exercise Therapies in Podiatric Practice will help you do just that.

Follow the link below to find out more.