Integrating Exercise Therapies into General Podiatry Practice

For many clinicians new to musculoskeletal pathology management, or those who work predominantly in general podiatry care, seeing a patient booked in for a musculoskeletal injury can be anxiety-inducing...

If you're a clinician (or soon-to-be clinician) this article will help shed some light on how you can leverage your general podiatry practice to build some of the essential skills required for musculoskeletal pathology management (even if you don't have a large cohort of msk clients!).

Q: Why is General Podiatry Practice the BEST Place to Start?

A: Because is takes some of the elements of stress out of the equation in a low-risk setting
AND
it gives you an opportunity to refine some of the skills required to tackle the hardest elements of musculoskeletal rehabilitation & exercise prescription.

If we have a client that we are seeing for routine care (nail, skin etc) at already established intervals (6, 8, 10, 12 weeks) and throughout our conversation they mention something that a small doses of therapeutic movement may help with.

They may have mentioned this simply in passing, in the sense that it is annoying, but not overtly disruptive to their every-day-life.

This creates a lower risk setting because a) it may not be considered an 'active' pathology, b) it isn't disrupting their every-day-life and c) you already have your review sessions booked for their other treatment. 

BUT it also creates an opportunity for you to build your skills in the hard parts of rehab.

For example; foot & ankle stiffness as a result of osteoarthritis & a lack of regular physical activity. 

You may suggest some simple, low-dose exercises that may assist with improving the feeling of stiffness.
Toe waves, toe scrunches, the short foot exercise etc...

This isn't creating a scenario of over-servicing,
you are simply ADDING VALUE to your existing consultations.

When you see your client for their scheduled routine follow-up, you can review their response & progress with the exercises you may have prescribed, and THIS is where your rehab skills can grow.

How Does This Low-Risk Setting Build My Skills?

This is where I want to circle back to what I mentioned earlier, where I mentioned we have an opportunity to build skills in the hard parts of rehab.

If we stop and think about all the elements that comprise an effective rehabilitation program, we know that it's more complex than simply selecting the "best exercise".

The best exercise is the one that gets done

What you will find is that for many clients, adhering to a prescribed exercise program is often one of the biggest obstacles in achieving treatment success. 
There are a number of reasons that may lead a client to having a decreased level of adherence (one of the best papers exploring this - here).

By improving our understanding of our client we can begin to improve our outcomes.

Now one thing we know for certain, it's that the highly intrinsically-motivated clients aren't the ones we need to worry about, it's those with lower levels of intrinsic motivation.

If we have a client who is highly active and their musculoskeletal injury is keeping them from engaging in activities they love, they're more than likely going to have a higher level of motivation than a client who has a problem that isn't overly disruptive to their life. 
If it's not disruptive we don't have that much of a motivator to leverage, so we need to dig deeper and explore more elements that will create "buy in".

So, the routine client with some symptoms of joint "stiffness" who is still able to do most things in life is going to require us building our skills in exploring client motivators, improving our ability to explain pathologies, symptoms, and how & why therapeutic exercise may benefit. 

This then leads to us identifying treatment goals, and with any treatment we need to have a goal. 

Goals

Our client will have their goal - ie: what they are seeking to achieve from consulting with us. 

Then we have our therapeutic goals - ie: what our treatment intervention(s) is hoping to achieve to help our client achieve their goal. 

When managing musculoskeletal pathologies we will often need to develop both macro & micro goals.

Successful rehabilitation is often a result of a clinician being able to link a client's goals to their therapeutic goals (more here).

Macro Goals - are what our overarching treatment goal(s) is.

Micro Goals - are the breakdown of our macro goal into smaller, achievable steps and are typically what we work towards from appointment to appointment. 

In order for us to work towards our micro & macro goals, and ensure we're on track is by reviewing our clients and having a conversation.

The purpose of our reviews are to gain an understanding of how our client is progressing. 
- Are symptoms improving, regressing or stagnating?
- Have there been any issues arising?
- Has the client been engaging in our prescribed exercises?

Essentially, have we achieved our micro goal(s) from last session?

Where General Podiatry Practice & Skills Start to Shine

As mentioned, understanding our clients is one of the key elements for adherence. 
So, when you're reviewing your client for their already-scheduled routine appointment ask how they went with your prescribed exercises.

- Were they doing them? Why / Why not?
- Were they enjoying them? Why / Why not?

If they were engaging and enjoying them, great, start progressing and doing more (if they want to).

If not, get curious... (more here)
- What was keeping them from doing them?
- If they didn't enjoy them, what other exercises might they enjoy more?

It's not in the easily progressing rehab programs that we find how truly skilled a clinician is, it's when things aren't going to plan that a clinician's knowledge, skills & confidence become apparent.

You will find it is this conversation that is one of the most important when it comes to determining the success (or failure) of our rehab programs. 

What if I'm not confident with prescribing sets & reps?

There are a number of ways in which we can dose an exercise (more here), sets and reps are only a part of the equation, at times we don't even need to use these to dose an exercise. 

AMRAP for TIME
As Many Reps As Possible for Time

In these low-risk scenarios I am referring to here sometimes AMRAP for time is the perfect place to start. 

1) It's often not invasive to daily schedules (most people can find 120 seconds within their day). - if they can't get your curiosity hat on and figure out why...

2) It takes the stress (from client and clinician) out of the equation for sets & reps, especially if neither are well-versed in sets-reps.

3) The client can use their body feedback to self-dose.

For example, I may say something along the lines of;

"With _____________ exercise, we're going to look at doing this 3 times per day.
Once after breakfast, once after lunch and once after dinner.You're going to do as many slow, controlled movements in 30 seconds as you can. It's not about getting as many done, we're after quality over quantity, so if you only get 5 done, that's great.
So you'll start the clock, start the movements, once the 30 seconds is up, you're done."

The reason I choose this method (time and frequency may change) for many general podiatry starting points for foot osteoarthritis is;

- In scenarios where the self-reported "stiffness" isn't the primary reason for the client attending the consultation and the symptom isn't overly disruptive, I don't want the intervention to be overly disruptive. If If our intervention is more disruptive than the complaint, you'll be hard pressed in the early stages of getting adherence. 

- When it comes to OA, low- load, low-dose & high-frequency can often be the best approach for improving symptoms. Once a person (hopefully) experiences the benefit from a small dose, they may be more open to a larger dose. 

The more practice you get with this, the better your rehab will become.

If you'd like to explore this more in-depth listen to episode #38 of the P3 Podcast  

Hopefully this article has shared some insights for how you can leverage your existing patient cohort to add value to your existing clients and improve your skill-set at the same time.