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The Dichotomy of Dosing



How much is enough?

- a simple question you should be asking all the time in rehab.


Figuring it out

-a challenging process.



The process of problem solving to get the best possible answer on exercise dosing is more complicated than you’d expect.


That is, if you actually put in the work.





When dosing you can’t forget you are dealing with a complex system. Small change can produce a large effect but it can also produce no or minimal change. You can't be sure in advance which solution will work best because of the dynamic nature of sub-system and environmental interactions.


Despite this uncertainty you should still have a target. That target for dosing is called the minimal effective dose (MED). Minimal effective dose can be defined as the least amount of “x” you need to do, to get the change (results) you want.




The MED which lies somewhere on a spectrum between not enough and too much. #Goldilocks



So when you first get asked the “how much?” question your initial response should be


“IT DEPENDS”



This inevitably leads to another question:


"What does it depend on?"


Answer: The Individual




Using the following framework can assist you in dosing for the individual:


Step 1. : Goal setting

Step 2. : Gather more information

Step 3. : Formulate a “best guess starting point”

Step 4. : Test-Intervene-Retest

Step 5. : Educate



Lets dig a little deeper into these steps:




Step 1. : Goal setting



What do you want to change? (eg. pain, strength, mobility, motor control)


The answer to this question comes from your assessment, both subjective and objective.


To invoke change you need to stress the system. Tissue change (muscle, tendon, bone, nervous) happens in response to load.

You can’t isolate the tissue you are trying to affect but research is starting to demonstrate that load management may differ based on the tissue type you are addressing.




Step 2. : Gather more information



What intrinsic and extrinsic factors might influence the process?


You want to find out if there are barriers to accomplishing Step 1 goals.


Alternatively you want to consider the strengths that can facilitate achieving the outcome you desire.


Things to learn:

  • Patient readiness: fitness level, phase of healing, motivation, experience

  • Environment: detailed knowledge of their home, workplace and gym or other athletic environment, relationships

  • Scheduling factors: discussing this helps with accountability


The intervention you administer is a stress meant to produce a change for the better. You need to know if it is competing with other stressors.




Step 3. : Formulate a “best guess starting point”



Where do you start?


Combine science (measurements and evidence) and Step 2 knowledge to formulate your best guess starting point.


If you don’t have a lot of experience dosing you should

  • learn more

  • apply and

  • experiment

**See below for some good resources.


With respect to exercise you have multiple parameters to consider and modulate.

  • Volume: Reps, sets

  • Intensity: Load, Time under tension, Range of movement, Contraction type/velocity

  • Frequency: daily, weekly, etc.

  • Rest: That’s right – dose your Rest


These all matter but your overall goal is getting them to an intensity that produces change with a plan that is progressive.




Step 4. : Test-Intervene-Retest



Is it the right dose?


Inherent in any intervention should be some type of test-retest process. That can, but hopefully doesn’t, only involve asking them “how do you feel?”


If you call yourself a movement practitioner- test how they move.


Be creative and come up with pre- and post tests that your patients can do themselves.


Sometimes immediate change isn’t expected and that should be communicated.


Dose response can be assessed via subjective measures as well. RPE (rate of perceived exertion), fatigue or presence of soreness or pain.


Whether it is an objective or subjective measure you need to know if you are reaching your Step 1 goal




Step 5. : Educate



How can you make your patient independent?


Education is the medium rehab practitioners can use to maximize long-term results.


Time spent coaching an exercise well will have a large return on investment.

This is critical for all practitioners but especially those only seeing patients once per week or less frequently.

You’ve figured out where you want them to start on dosing but how do they proceed for the next week or two, or more? Besides exercise mechanics, you must teach patients how to be independent.




Address concepts like Expectations and Autoregulation to facilitate this process.


Expectations:


Advise your patient what they might feel; what you want them to feel. For example: If I want my unconditioned patient to get stronger I want them doing enough that they feel some level of DOMS (delayed onset of muscle soreness).


Tell them they shouldn’t expect immediate change if that’s the realistic expectation.

Ask your patients what they think about the exercises you give them. If they hate the exercise, change it.


Autoregulation:


Autoregulation is seen more often in strength & conditioning but has a place in rehab. It involves teaching your patient how to navigate on his or her own.


I give my patients what I like to think of as a decision tree based on monitoring their response to their exercises; how to progress or adjust.


This approach can be helpful for all patients, from high performing athletes to patients with persistent pain focusing on graded exposure.


Emphasize the goal and what is needed to cause adaptation but also instruct on flexibility and the place it has in the program for their individual progression.


Concepts you may cover here include:

  • Modified Borg Scale/Rate of Perceived Exertion (RPE)

  • Form fatigue

  • Interoception

  • Pacing



Why is this important?


When it comes to exercise prescription folks (clinicians and patients) want to be spoon-fed because it's a lot easier to be told what to do than to figure it out for yourself. But that won't lead to the best results.


If you want the best results for your patients you need to help them learn how to ride their own wave - respond- and adapt.


Surfing Uncertainty



Minimal Effective Dose is quality control > a time hack.


In rehab if you don't establish a proper baseline and formulate a best guess at MED you are likely under-dosing exercises.


Time invested in optimal dosing will lead to the best LONG-term outcomes and LONG-term change should be the goal.



Lastly some Food For Thought:



What I'm thinking about :)



Asking “how much is enough?” and dosing should not be limited to exercise.


Have you ever asked yourself:

  • “How many passes at a joint mobilization is enough?” with manual therapy (passive load).

  • How many sciatic nerve sliders is enough? (active load)

  • How about dosing pain education (cognitive load): is 10 min or 30 minutes better?


Think About It





A Few Helpful Resources


Haff G, Triplett N. Essentials of Strength Training and Conditioning. 4th Edition. Human Kinetics Publishers; 2016


Reiman MP, Lorenz DS. Integration of Strength and Conditioning Principles into a Rehabilitation Program. Int J Sports Phys Ther. 2011: 6(3): 241-253.


Lorenz DS, Morrison, S. Current Concepts in Periodization of Strength and Conditioning for the Sports Physical Therapist. Int J Sports Phys Ther. 2015: 10(6): 734-747.


Mueller MJ, Maluf KS. Tissue adaptation to physical stress: A Proposed “Physical Stress Theory” to Guide Physical Therapist Practice, Education, and Research. Phys Ther. 2002: 82:383-403.




#minimaleffectivedose #strengthtraining #rehab #levelup

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