The Decision to Exercise in the Moment
While preparing for the exam to be a Board-Certified Clinical Specialist in Geriatric Physical Therapy, I encountered a discussion on Health Behavioral Models endorsed by the Academy of Geriatric Physical Therapy - the Transtheoretical Model and Self-Determination Theory. It provided a framework for discussing patient engagement and participation in the physical rehabilitation process. There is no question as to the applicability and effectiveness of these health behavior models. I would posit, though, that at the exact moment when I ask a patient to move their post-operative leg, these are not the patient's primary considerations.
I think that different DETERMINANTS supersede these health behavioral models when a patient is deciding whether to move on command at the moment they are being asked to exercise, especially during the acute and subacute phases of healing with advancing age. From my experience, ease of movement initiation is the primary and most important factor during this period at this age.
Other factors which determine patient engagement in the moment can include:
anticipated pain with movement
fear of falling
cognitive effort
maintaining a sense of agency (when the patient requires extensive assistance to move)
confidence that they have sufficient upper extremity, lower extremity and trunk strength
These factors are taken into consideration with Assisted Priming in Supine - it minimizes the first three and enhances the last two.
There is an ongoing debate in the profession as to the great variability in practice between clinicians. There is one exception to this variability - how we manage patients who are medically complex. In every inpatient setting, for patients who are medically complex, the primary intervention is physiologic standing to facilitate muscle activation. Once in a while, a patient would scream or physically resist being coerced into the standing position. In some instances, this "resistance" would persist in the first few sessions of an episode of care. Nothing is written about this phenomenon in the literature.
How does this affect the patient? How does this affect the patient's perception of physical therapy? Does this impact the patient's engagement in physical therapy in the future? How do other patients in the clinic perceive this during their treatment sessions? Can this result in PTSD?
There is an effective alternative to standing for eliciting muscle activation among patients who are medically complex - Assisted Priming in Supine. Refer to the "Links to Journal Articles" for a short summary on the treatment technique.