#6 Treatment Progressions - Build a Foundation

     Hey there. Tonight’s post is going to be a brief overview of my 2nd clinical rotation in-service. I’ll be presenting this in-service tomorrow during lunch, and my audience is employees of the clinic, including physical therapists and physical therapy assistants. This topic was chosen after several weeks of observing improper advancements of treatment interventions. In this post, I’m going to focus on sharing information from my primary source and leave out the details that are unique to my clinic.

     The presentation starts with an overview of treatment progressions. I included progressions for balance training, spinal stabilization, and sit-to-stand because the majority of people seen within my clinic include patients who have a fall risk, low back pain, or lower extremity weakness.

Spinal Stabilization Progressions:

Non-weight Bearing -> Weight-bearing

Local Musculature -> Global

 Simple -> Complex

 No External Load -> Resistance

 No Stimuli -> Perturbations

 Non-Functional -> Functional

Balance Training Progressions:

Bilateral Lower Extremity -> Unilateral

Eyes Open -> Eyes Closed

External Support -> No Support

Stable Surface -> Unstable Surface

No Stimuli -> Perturbations / External Stimuli

Slow -> Fast

Sit-to-Stand Progression:

Sit2Stand Machine -> Standard Chair

Elevated Seat Height -> Standard Height -> Decreased Height

Lower Extremity Biasing with a Step (Target leg on the ground surface)

No Stimuli -> Handling an Item/ Cognitive Challenge

     My clinic has a Biodex Sit2Stand™ Trainer, a piece of equipment that facilitates lower extremity strengthening. The machine replicates a functional sit-to-stand, but supplies assistance, making the task easier for lower level patients. Check it out here.


     The presentation continues with a discussion about a new theoretical model for treatment progressions.  The following information is pulled from an article found in Physical Therapy in Sport, the reference can be found below. This model can be used to attain any goal or perform any activity that involves combining multiple skills in order to execute.  

     The X-axis represents time, and the Y-axis represents the level of difficulty. Each grouping, moving along the Y-axis, is a combination of skills. At skill (1), the patient has the most control by using intrinsic factors, such as what they feel or see. The therapist can provide external control by way of providing feedback or cues. This element, skill (1), remains consistent throughout.  You can progress within this skill level by increasing hold time or repetitions. Skill (2) is the addition of an extrinsic component, which is a change in stimulus or environment, and skill (3) is the addition of another advancement. Skill (2) can be removed and replaced with skill (3) to ensure proper form and mechanics before combining all three skills, as seen in the fourth column.

     Now if that was confusing, I hope these two examples will help you understand how to apply this progression model.

Spinal Stabilization/ Core Strengthening

(1)   Abdominal activation

(2)  Extremity movements

(3)  Sitting on a Theraball

(4)  Perturbations

            Standing Balance

(1)    Postural control and abdominal activation

(2)   Unstable surface – foam pad

(3)  Upper extremity manipulation / Perturbations

 

     Using the model, you want to ensure the patient obtains stability and core control on a stable surface before progressing. Following completion of skill (1), the patient can then be placed on an unstable surface. Next you would put the patient onto a firm surface and introduce perturbations. Once skill (2) and (3) are mastered independently with skill (1), you can place the patient on an unstable surface with perturbations. The next example is adjusted the same, with the addition of a 4th skill.

     To determine whether an activity is too difficult and requires a downgrade, the therapist needs to look for various compensations. Including the following examples:

Spinal Stabilization:

Arching the Back

Bearing Down/ Global Activation

Holding Breath

Loss of Abdominal Contraction

Balance:

Increased Postural Sway

UE Support

Excessive Hip/Ankle Strategy

Disorientation

 

     The bottom line is that an activity cannot be performed correctly unless it is built upon a strong foundation. The body cannot function as a whole without correct activation and use of its’ parts.

- Patrick Berner, SPT

 

References:

Blanchard S, Glasgow P. Masterclass: A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy In Sport [serial online]. August 1, 2014;15:131-135. Available from: ScienceDirect, Ipswich, MA. Accessed October 10, 2015.