Treatment Session: How to Prioritize Your Interventions

A few weeks back Chris wrote a great post on Sequencing Your Treatment Session. His post focused heavily on manual treatment and the importance of checking and rechecking your asterisk (concordant) sign. This post is intended to be a quick and dirty outline regarding how to prioritize interventions from start to finish. Not all apply to every patient, but knowing the sequence is fundamental.

1) Brief Subjective/Objective Recheck: This should be viewed as a mini-reassessment. Was there any change in symptoms since their last visit? How did they tolerate the their HEP? How did the patient respond 24-hours after the last treatment? Objectively, are the same restrictions and movement impairments present?
2) Manual Therapy: During the objective, you likely found a joint restriction or movement pattern that needs correcting. Perform the necessary manual techniques and re-check your asterisk sign. 
3) Corrective Exercise: Performing corrective exercises immediately following manual therapy will maximize the patient's ability to find and recruit muscles that were previously not recruiting normally.
4) Functional Warm-up: The warm-up should increase core temperature targeting the muscle groups that are dysfunctional. Examples: bicycle, total gym, elliptical. 
5) Power Exercises: Incorporate power/ plyometric exercises following the warm-up when the muscles are not fatigued. Since form is essential during these exercises, performing them while the muscles are fresh is very important. It should be noted that not all patients will be ready for power-type exercises during their first few visits.
6) Strength Exercises: Strength exercises include those performed in the 4-8 repetition range, 3-4 sets with 2-3 minutes of rest between each set. Similar to power, not all patients can tolerate pure strengthening early on. Many times patients require a few sessions of neuromuscular re-education and form re-training prior to pure strengthening.
7) Conditioning and Endurance: Often we find ourselves going directly to this stage following a functional warm-up. Since pain and movement impairments our the primary focus early on, performing conditioning or retraining exercises is acceptable. The dosage of these exercises is typically 3 sets of >10 repetitions with less rest in between sets. A main focus is on proper form and controlling the movement throughout the ROM.  
8) Warm Down

Appropriately structuring a treatment session is a key component to the patient's success. One question you need to continually ask yourself: "how do you dose pain?" There is no perfect answer. Pain generally leads to muscle inhibition and form breakdown which often categorizes the patient in the conditioning and retraining exercises section. As your patient progresses it is essential to perform the exercises in an appropriate order to maintain form and maximize gains throughout the session. 

-Jim