Progressing a Patient too Quickly

I have had a few "higher level" patients in the past few weeks and one consistent trend I found in my practice is that I have been progressing them too quickly. I am not exactly sure why this in the case. Both groups of people present with the same impairments so why would I treat them differently? My assumptions are that I do not want them to become bored with a basic HEP or maybe because they are starting at a higher level they should require higher level exercises. Both of these are fallacies. 

Despite starting from a higher functional baseline the higher level patients presented with similar impairments as the low level patient. A 3+/5 muscle grade is a 3+/5 no matter how you look at it. For example, with a low level patient, I gave the clamshell exercise to strengthen the posterior gluteus medius. For the higher level, I gave the clamshell exercise in a modified side plank position. Both exercises target similar muscle groups, but the higher level exercise is much more demanding across the entire system. I have given similar exercise prescriptions like this is the past and consistently found that the patient returns to the clinic performing the exercise improperly or having pain while performing it. 

Lessons Learned:
1. A weak muscle is a weak muscle regardless of what type of patient you find it on. 
2. Start basic. In my example above, I added side planks to a clam exercise during the initial HEP. When prescribing this, I made sure the patient had adequate abdominal control, but it took away from the true target of my treatment. The primary impairment was gluteus medius weakness. I needed to start in the least aggressive position and isolate the glut medius.  
3. Educate appropriately. My assumption is fairly true in that higher level patients get bored easily with low level exercises. This patient population is used to performing strenuous exercises. Generally, despite being in pain, they want to perform something hard. As a therapist, educating them on the importance of the low level exercises and discussing the exercise progression in future visits will allow for more patient buy-in to your treatment. 

Do not be afraid to start at the most basic level. You are the expert and you no why they need to start at that level. 

-Jim  

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