I was watching a show called "This American Life" and one of the stories shared was how pig farming has evolved over time. Pigs meant for human consumption are genetically modified, just like any other industry involved with mass food production. They are designed to be more muscular and less fat. Because they were less fat, they could not survive cold winters and made to live indoors in small enclosures. "Genetically-improved pigs are more panicky and high strung" aggravated by the administration of muscle-building supplement called Paylean. When it is time for them to walk out of their pens for slaughter, it is literally the longest walk they take. Since they are not used to getting out of their pens, walking out makes them very anxious. Apparently, they get so anxious that their muscles get very rigid that they cannot move. The pig farmer recounted that in some cases, they can die "frozen" in place before they get to the slaughter-house. 

In the SNF, we see this severe anxiety in some patients. We label these patients as "resisting treatment" and with poor potential for improvement. (This labeling itself dramatically compounds the problem. In an "insular" therapy department, it can inadvertently manifest as "cancel culture" where therapists discuss the patient negatively). In some cases, the patient might be referred to a psychologist or psychiatrist, but this whole process might take weeks or months. In the meantime, the patient continues to decline functionally. This is more catastrophic for patients who are medically-complex (i.e. those who are dependent or who require maximum assistance). For these patients, our go-to exercise to induce functional muscle activation is to get them to the standing position. So, the most common treatment currently used in the clinic is "forcing" a very anxious patient to stand-up.

As a profession, we need to exhibit more creativity in designing exercises / activities which can transcend immobility-inducing anxiety. We have to develop exercises / activities  as alternatives to standing which will result in visually-verifiable (for the benefit of both the therapist and the patient) muscle activation of anti-gravity lower extremity muscles. Anxiety is just one "non-physical" factor we have to contend with. We also have to consider, among other things cognitive effort and sense of agency, important determinants which can immediately influence engagement, a precursor to performance. Until every therapist in the SNF realizes this need for an alternative to standing when managing these patients, at least initially during the episode of care, among some patients, we will continue to be ineffective in eliminating the cycle of anxiety and immobility which eventually leads to wheelchair dependence. We should not dismiss the problem as a "psychological" issue, and throw our arms up in the air. Patient education is an option. In the SNF, in most situations, by the time patient education works, if it does, the patient might be out of SNF days. A better alternative is to address the problem through thoughtful exercise prescription which commences on day one.