The Instant Physio 5 Step Method
Introduction
By Edward Thompson (Founder of Instant Physio).
I developed the 5 step method after working in sport where the ultimate goal is to return to activity in the fastest and safest time and for the problem to have the lowest chance of returning. When I started helping the general population I noticed a few things:
Patients would often get a reduction in pain from physio but not return to a level where they had their trust and confidence back. Put another way, they would not return to what is known as thoughtless, fearless movement.
Patients would be given an exercise programme that in the patients eyes, completely ignored the fact they were in pain. The patient would feel disillusioned because of the daily pain they were in that was not being addressed, not do the exercises or self discharge from treatment.
Patients would be told they could go back to their normal activity only to find the pain would come back as soon as they did leading to huge frustration.
And finally, when people had returned to activity there was a lack of emphasis on continuing to make progress, maintain, prevent and protect their recovery through rehabilitation
Step 1: Action Planning
This is by far the most important step
Think of it like when you are trying to get to a specific destination. Before you go on the journey you need to buy the right map. In physio, this means identifying the problem (the diagnosis), identifying the possible causes (root cause analysis) and putting a step by step plan in place of how we can tackle this problem and prevent it from coming back. This will include identifying deficits are or areas that need to be improved such as range of motion (flexibility) or it could swelling. As part of the planning we will also set out milestones for our patients to achieve along the way to getting better. Small goals help physio’s know that we are on or off track and for patients helps them feel empowered, gives the treatment purpose and gives them lots of emotional wins along the way.
Emotional wins
The idea of emotional wins is important when going through treatment. When you see a chiropractor the moment your back cracks on the table feels like an emotional win. It feels very much like something is being done and there is a specific effect. At Instant Physio, our methodology more centred around exercise it can be harder to have the same tangible “high five moments”. So achieving lots of milestones along the way is a great way to achieve this.
Where it goes wrong
If people have the wrong diagnosis or the root cause analysis has not been done, people can make progress early on and then plateau. Or worse, get worse because the wrong treatment has been chosen. When patients don’t get adequate assessment they are effectively buying the wrong map for the journey. They may think they are going to York but they’ve bought a map for Manchester. For example, if a knee pain sufferer is being treated as if they have a meniscus injury but they actually patella-femoral pain syndrome, they may given exercises that provoke the injury leading to more pain. Not only does a very comprehensive physio assessment need to take place but this needs to be repeated, to a lesser extent, every session.
Step 2: Kickstart recovery
Reducing daily pain
This is the stage where would be doing the work to reduce the pain that someone faces on a daily basis. For example, someone waking up with back stiffness, someone with heel pain waking up with what is know as “*first step pain” or someone who gets knee pain climbing the stairs.
We can do this in many ways. You may think that relieving pain through treatment is what we need to do. But actually, we can modify activity without doing any treatment to allow someone to carry on with what they want to do. For example, we may advised a runner to run much slower, a gardener to take many more breaks, or a young mum with back pain to change the her lifting strategy. These changes would allow them to carry on with what they need or want to do but in less pain while the injury heals and settles down. This is great because it doesn’t require the patient to be laid on the couch getting treatment to see the benefit. We can teach you how to do things more easily so you can make progress in the absence of us.
Having said that, there are lots of pain relieving techniques that we would want to deploy to help kick start someones recovery as well. The source of the pain will dictate what could be used to help. Massage, hands on treatment, heat, electrotherapy and acupuncture may be more beneficial for back and neck pain. For knee pain however, we may favour more exercise based treatment such as isometric exercise or use taping, or even biomechanical modifications (e.g. walking wider while climbing stairs can alleviate knee pain).
*The pain that you feel when you take your first step in the morning.
Where it can go wrong
This step can go wrong when people are only getting treatment that is from the therapist. So they have to be laid down on the couch in the clinic for them to see any benefit. That’s great for the patient who has loads of money and loads of time.
The other problem we see with step 2 is people not graduating on to step 3 and their progress plateaus. They become reliant on feeling better every time they see their physio.
The final problem with this stage is that it is skipped altogether and the patient is given treatment for step 3 despite being in constant daily pain. If we don’t take care of the short term problems then it will be much harder to make progress and for the patient to stay motivated.
There are definitely injuries that we see where we have to educate our patients on what to expect. For some injuries, it can be difficult to find treatments that really do reduce pain significantly such as acute sciatica. If we have mechanical pressure on a nerve, it can be very difficult to help the patient find relief. If this happens and the therapist becomes aware of this they need to make sure that education is a huge part of their treatment so the patient knows what to expect.
Step 3: Fix the root cause
This is the stage where someone is experiencing minimal daily pain and may only experience pain when they are doing certain activities. For a runner it may be that they are able to get through the day without noticing their pain but as soon as they do any running they will feel pain. For a young mum, they may get through their normal daily activities of lifting their new born but only on particularly strenuous days do they experience pain. This is the stage where we are building confidence, trust and what we call thoughtless fearless movement. We would be doing more challenging rehabilitation work at this stage for example strength training, plyometric training or explosive movements.
Where it goes wrong
The problem I see here is the therapist skipping step 2 and moving straight on step 3. Without proper education, patients will become disillusioned and stop coming in because they are still experience daily pain.
The other problem that can easily happen in this stage is that the exercise are too challenging leading to a flare up. Patients may either over do the exercises or the therapist may misjudge how challenging to make the rehab which can lead to a small flare up. Adequate assessment should mitigate this risk of that but sometimes it can be difficult.
The other problem we see here is people getting off to a great start with their rehab which is pitched at the right level but then is not progressed. So their progress stagnates, the patient feels like they are wasting their time and are not getting value for money and discharge themselves early. But continue the rehab that wasn’t working and continue to not see results. In reality, step 3 needs to be progressive. It needs to get more and more challenging every week. This is how people get better faster, which is what we all want!
Step 4: Returning to thoughtless fearless movement
This would be the stage where are doing what we call return to activity tests. We are looking to stress test the injury to make sure it can tolerate everything that life will throw at it. For example, for a runner we would want to do various different hopping tests, running at different speeds, and for differing amounts of time. For someone with knee pain we may do a series of strength tests to make sure they had adequate and symmetrical strength on both sides of their body.
Where it can go wrong
The main problem we see is people just not doing it. It is very powerful for patients to see them pass their return to activity tests and see that their strength is back to where it should be.
Step 5: Prevent and protect
After someone has passed their return to activity tests we are at the stage where we are looking to prevent and protect their progress. This means continuing to build their resilience in the gym, continuing to educate them on what is a suitable amount of stress for their body to tolerate and what to strategies they need to continue using. We do this using massage, strength training and coaching.
Proper education is required to make the patient aware that they need to keep their rehab and strength training going. We offer programmes to help make this easy and small group classes. An example is me and my shoulder. I have had various shoulder injuries on my right side and funnily enough if I don’t strength train for around 1 week I notice it. It doesn’t ruin my day or cause major pain, but I see it as warning shot that if I completely fall of the band wagon it will lead to a bigger problem.
Where it goes wrong
In truth, step 5 is about changing your life. Changing your pretties to put health higher up the list. You can’t just pay someone and do physio for 12 weeks get better and then just forget everything and go back to what you were doing.
The other problem that may occur is that someone may stop progressing their strength and rehab training so their resilience either plateaus or regress.