Friday, 9 November 2018

Rehab like you mean it!

Guest blog by Cat Taylor (GB Orienteer & blogger @

It’s official: it’s not what you do, but how. The concept of deliberate, purposeful or deep practice has entered the public consciousness by way of books such as Matthew Syed’s UK bestseller Bounce, and Daniel Boyle's The Talent Code and become pop-psychology buzzwords. Case studies of superstars, prodigies and championsin invarious fields and how they reach dizzying heights through practice have caught our imagination. The idea that the key to success lies in the quality of practice and depth of application clearly hold implications for prospective virtuosos, but what about the rest of us? And how might understanding them help physios and their clients? This link may seem like clutching at straws, but think about it:

Focused and concentrating on delibrate practice.
You book a physio appointment for an injury. You’re diagnosed and the problem seems simple enough. You’re given some daily exercises and start your new programme with enthusiasm - well, for a day or two. You continue on autopilot and it all becomes a bit half-hearted, maybe forgetting on some days, gradually falling out of routine. If only we could harness just a little of that super-practice to help.

First, let’s elaborate: what exactly are we talking about? “Deliberate practice” (Ericsson) or “purposeful practice” as Syed calls it are fundamentally the same thing and hinges on a central idea that’s great news for busy patients: the amount of time spent practising isn’t all-important. Instead, progress happens when practice is smart. Firstly, practice is most effective when each activity has its own highly specific and constant aim, which then links back to the overall purpose of the training. Secondly, it should be undertaken with “deep” engagement. That is, with conscious effort, or “to engage so deeply in the task that one leaves the training session, literally, a changed person.” Thirdly, activities should offer the correct level of challenge. Too easy and progress will plateau, too difficult and it will be impossible to have positive feedback. They should also be progressive over time, to keep challenging an improving subject: further, higher, faster… The role of the athlete or performer is to engage fully in practice and provide accurate feedback. The role of the coach is to identify that sweet spot of exactly the right level and progression of practice, and to work with the athlete to evaluate feedback and adjust the programme accordingly.

Adavnced balance exercise on uneven surface!
What does that mean for your treatment? The physio essentially takes on the role of the coach, guiding the patient back towards their desired activity level - be it a return to competition, to work or to being able to enjoy a favourite leisure activity. They need to ensure all exercises prescribed are at the correct level and intensity for each individual patient, and that difficulty is increased over time towards the treatment goal.

Of course, with healing tissues it is particularly important to hit the right balance between reaching high enough to improve without overloading these recovering areas too much too soon. Steering this increasing load requires accurate feedback from the patient of what worked, what was enjoyable and what was a struggle, and the physio uses this feedback to adjust the rehab programme accordingly. Executing the exercises effectively requires the patient to engage in their recovery programme and take on a proactive role. While this is in part up to them, engagement and ownership is helped greatly by understanding the process. This is where the patient should challenge the physio, and the physio should explain: Why are we working on exactly this aspect of strength, flexibility or movement pattern? How are this week’s exercises then going to progress to allow the person to return to sport and stay healthy? Where is it all going?

When done correctly, using these principles to guide treatment should optimise recovery and ensure goals are achieved as quickly and effectively as possible. This requires joint work by the physiotherapist and the patient, a partnership promoting deliberate practice:

Finally, it’s also important to accept that rehab won’t be perfect. As cheesy as it sounds, recovery is a journey, and mistakes and setbacks are an integral part of it. Being aware of this can be vital for maintaining motivation when something doesn’t go according to plan. To finish with another great cut-out-and-keep point from Bounce, “Excellence is about stepping outside the comfort zone, training with the spirit of endeavour, and accepting the inevitability of trials and tribulations. Progress is built, in effect, upon the foundations of necessary failure. That is the essential paradox of expert performance.”


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