Reha Sport.
Here in Germany we have a program called Reha Sport, it consists of exercise classes, run by rehab centres and sports clubs, aimed at people with chronic complaints. I run these classes ten times a week and would like to share some of my experiences, ideas and programming. I’m entirely sure that I will display a large amount of confirmation bias, I don't have all the answers and that this is not scientific, but hopefully somebody will find it interesting.
So my first point is the patients - all suffer from a chronic complaint, from non-specific low back pain through medical conditions such as cancer and diabetes to those who’ve had orthopaedic procedures such as hip or knee replacements. After they have finished their normal course of treatment, with a physio for example, the exercise classes can be prescribed by their doctors, with the health insurance pays for 50 classes spread over a maximum of 18 months (or in extreme cases 120 classes over 18 months).
The physical, cognitive and social benefits of exercise are well know and well documented, but I’ll include a brief synopsis, as justification for my programming choices.
Physical benefits - Use it or lose it.
Exercise delays age related degeneration of bone and muscle mass. One of the most famous papers on this comes from Wrobleski et al 2011, which included this image:
The Khan and Scott 2009 paper on Mechanotherapy provides a very good overview of how this is achieved and is essential reading for anybody involved in rehab. The introduction sums it up well:
Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses. These cellular responses, in turn, promote structural change. A classic example mechanotransduction in action is bone adapting to load. A small, relatively weak bone can become larger and stronger in response to the appropriate load through the process of mechanotransduction.
Cognitive and Social.
Short term positive affects of exercise on everyday memory function were found by Whitbourne et al, 2008. They found that on days were an individual participated in physical activity they had fewer memory failures. This positive affect also carried over to the following day and was more pronounced in in older adults. My Reha Sport classes do have younger adults, including a couple of teenagers, but the majority definitely fall into an ‘older adult’ category.
Looking at the older group led me to Wu et al 2009, who looked at a ‘Preventing Loss of Independence through Exercise’ (PLIÉ) program. Though their n was relatively small and they relied on qualitative data, their conclusions - Functional, Emotional and Social benefits add weight to my stated goals for Reha Sport patients. Of further note (or added confirmational bias depending on your viewpoint) is their use of basic functional movements such as ‘sit-to-stand’, I use a lot of squatting based movements in my programming, probably irritating all of those personal trainers who say squats aren't functional.
The use of games as a form of social interaction is also something I’ve taken on board, an added benefit is that it is, in my opinion, a much less boring way of performing endless movement reps. As H. Moksnes said at the 2015 RTP conference, “ACL rehab is long and boring, make a group in a fun environment for better outcomes. Or to put it more bluntly, by Adam Meakins “when shit is fun, shit gets done”.
The Mental Health Foundation on their website listed the following benefits of an active lifestyle:
less tension, stress and mental fatigue
a natural energy boost
improved sleep
a sense of achievement
focus in life and motivation
less anger or frustration
a healthy appetite
better social life
having fun
Of course 45mins twice a week can't really be counted as an active lifestyle, but if we can reduce movement anxiety and encourage people to worry less about their conditions/injuries and get out and about more then we can certainly help to promote one.
Program design.
So now I come to nitty-gritty of what I actual do in a class. Please note though, that this class runs ten times a week, for something like 40 weeks a year. I need to introduce lots of different exercises and lots of variation to keep the patients progressing, to maintain high levels of variability in the movement patterns, to maintain patient motivation and for the sake of my own sanity. The following is just an example.
The warm-up follows a basic ramp protocol:
Raise - heart rate, respiratory rate, blood flow, joint fluid viscosity
Activate - muscles and neural systems
Mobilise - joints and tissues
Potentiate - prepare for the movements to follow
So we may, for example, walk around playing with tennis balls and stop occasionally to perform balance, coordination or mobility tasks. Different walking styles will be introduced (e.g. on toes, lunges, sideways) as recommended by Schwenk et al 2014 in their paper on gait training for dementia patients. Schwenk also recommended complex cognitive tasks, which I feel are met by playing with balls whilst walking.
There then comes a resistance training element, this focusses on large complex movements, mainly using sit-stand/squatting movements as spoken about above but also with more multiplanar movements. People constantly join and leave the groups, which combined with the widely varying demographics means I have to offer a range of resistances and progressions/regressions to any exercise, here are some some examples of commonly uses exercises and progressions:
Deadlifts - sumo
KB swings - diagonal
Lunges - lunge and twist - lunge and touch - clock lunges
Squats - goblet - overhead - split stance
Push press
PNF patterns
It is important to note that one of the stipulations from the health insurers is that the classes can only use small pieces of equipment - balls, matts etc. and no machines. I probably push the boundaries by using kettle bells and small weight bars but can’t go as far as squat racks etc. This is usually not a problem for the 90 year old woman, but loading a teenage boy can be more difficult. The real challenge is when you have both in the same class.
Of course it may be that somebody has a shoulder injury (or indeed no injury) so please remember that whilst the above exercises are good examples, when it’s taken as a whole I’ll try to include something for all of the basic movement patterns in each session:
Push - Pull
Squat - Lunge
Brace - Bend - Twist
Finally I’ll often introduce some sort of game. I discussed them a bit earlier but here are some of my reasonings for including games:
Complex cognitive tasks
Hand-eye coordination
Fun
Social interaction
Neurobic tasks - e.g. throwing a ball with the wrong hand
Unconscious repetitions of previously used movement patterns, e.g. lunging to reach for a ball that’s been badly thrown.
Conclusion.
The Reha Sport classes are definitely challenging to organise and with everybody having different abilities and motivations keeping everybody happy all of the time is near impossible. They don't work for everybody, overall though I see good (anecdotal) results from my classes. An elderly cancer patient has said that it’s the highlight of his week, a young mechanic has done the annual winter-to-summer wheel swapping frenzy without back ache, a retired lady has said that she suddenly noticed going up stairs without knee pain and so on.
Whilst I have stated that the lowering of movement based fears is an aim, so that patients can get out and about more and enjoy the beautiful Black Forrest in which we live, there are patients for whom the social aspects of the course are very important (see the cancer patient above). Some of these will choose to pay privately and keep coming even after their course is finished. I’ve also had a patient say that she’d asked the health insurers for a second round of classes, but was refused because “if you haven't learnt any exercises after 50 sessions why do you think another 50 would be any different?” Her answer was that she knows the exercises, she has a cupboard full of exercise gadgets, but the motivation to use them at home is low. When she has a fixed appointment then she’ll go and do it. I have to be careful to strike a balance between people enjoying the classes and becoming dependant on them, “I have to go to Rehab, I have a bad back”.
It’s not a perfect system. It’s certainly an interesting business model when you encourage people to go off and join the local sports club, swimming pool etc. rather than hard selling your own classes. Overall though, I do think it’s better than ‘6 physio sessions and out’ for a lot of the participants.
I’d be interested to hear from anybody else who either runs Reha Sport groups here in Germany or similar ideas in other countries and maybe we can compare notes.