Utilizing Corrective Re-assessments to Enhance Program Success

Learning Objectives:

1. To highlight the mental and physical benefits of performing musculoskeletal re-assessments
2. To provide the reader with two re-assessment examples and describe how the results can be interpreted to increase client confidence and adherence to their corrective exercise program
3. To teach the reader the importance of assigning and reviewing exercise homework

One of the most overlooked skills of a successful corrective exercise specialist is the ability to conduct simple and effective re-assessments with their clients. When incorporated into a well-structured exercise program, the re-assessment process can increase client adherence and greatly improve chances of long-term success.

Re-assessing Is Beneficial for You and Your Client

Incorporating re-assessment procedures into your exercise programs, regardless of whether the goal of such programs is pain-reduction or performance enhancement, is useful for both you and your client for a variety of reasons. Firstly, re-assessments provide you with the opportunity to ensure that your client understands what they are supposed to be doing with respect to their program variables, including if they are indeed doing those things correctly. Secondly, incorporating re-assessment protocols helps to shape clients’ expectations about the overall plan and requirements of the program. Shaping these expectations enables you both to have a clear vision for how to accomplish the desired outcomes. Most importantly, re-assessment procedures allow you to create a pattern of dialogue with clients that will shift the ultimate responsibility for the success of the program, from you to the client (Whitworth, et al., 2007).

How to Formulate Effective Re-assessment Procedures

The key to utilizing re-assessments to help clients achieve long-term success is to use your practical assessment and communication skills to build a working relationship, that fosters an equitable partnership, between you and your clients. This is very important because clients will view you as the expert when you first begin working together (which means that they will ultimately view you as responsible for the success or failure of their program) (Milgram, 1974). Although it will be necessary for you at times to demonstrate your expertise, the eventual goal is to help your clients feel confident in making decisions that will help them progress and succeed on their own. You can achieve this by facilitating an alternation between the roles of "leader" and "supporter" during the re-assessment process. The following explanation provides an illustration of how to do this.

Once you have conducted your initial assessments and the first exercise session with your client, you will schedule your next appointment with them. In between those first and second sessions, it is highly recommended that you provide the client with "corrective exercise homework" to perform in order to help facilitate their goals of eliminating pain and improving their function (Price, 2010). When the time for the second session arrives, you can begin by establishing the framework for the re-assessment process that will eventually become a permanent feature of the client’s program.

Starting Off: You Take the Lead

When your client comes in for their second session, repeat some of the musculoskeletal assessments you performed on them during their initial evaluation. Choose simple assessments you know will reveal change or progress, but make sure that your client understands them too and can easily evaluate any changes for themselves. Conducting these repeat assessments (or re-assessments) at the beginning of the session puts you in the role of "leader" and establishes that you are the person whose job it is to investigate change and interpret results for your client. Leading the direction of the session is very important during this initial stage. This is because your client may have anxiety and/or negative thoughts surrounding the program and establishing yourself as the expert allows the client an opportunity to temporarily relinquish feelings of responsibility for the program. This will enable the client to relax and let down their guard. It also gives you a chance to redirect the focus of the program by pointing out progress and achievements the client has made (no matter how small). You can use the objective feedback obtained from the assessments to help your clients see the progress they are making. This will help your client see the obvious benefits of the program and increase their trust in both you and the recommendations you make. You can also use the results to steer the discussion so that the client moves away from any subjective negative emotions they may be feeling from having pain or limited function. Once the client is less anxious, you can start to facilitate the change in your role from "leader" to "supporter" and put the client into the leader position.

Let’s first look at two simple musculoskeletal assessments you can use to reassess your clients’ posture. We will then discuss how you can use the results of these re-assessments to influence a positive client mindset and increase their adherence to the program.

• Example #1 " Measure Their Height Against a Wall – During the initial consultation, have your client stand with their back to the wall and measure their height. Mark their height on the wall (or in their client folder) and date it. When you are finished with the measurement, explain to the person that if they do their corrective exercise homework on a regular basis they should start to see the excessive curves (if they have any) in their spine (i.e., excessive lumbar lordosis and/or excessive thoracic kyphosis) lessen over time (American Council on Exercise, 2010). When you begin the second session, re-measure your client to see if the mark is now higher on the wall (i.e., they are taller). A simple assessment like this can do wonders to help motivate your client to want to do their corrective exercise homework. It can actually be a lot more effective as a motivation tool than complex movement-based assessments. This is because clients can actually understand what is being measured (and why) and what subsequent measurements reveal about changes in their bodies.

• Example #2: Dowel Rod on Hips -
  • Another very simple assessment can be conducted by placing a dowel rod across the back of your client’s hips and checking to see if it is level (which indicates whether your client’s hips are level). For this assessment/re-assessment, stand behind your client as both of you face forward looking into a mirror so that you can consider the results together.
  • Hold the dowel rod in both hands between your thumbs and forefingers with your hands about 6 – 8 inches apart. Place your index fingers on the back of your clients’ hips on the highest point of their Ilium. Evaluate the angle of the dowel rod to see if your clients’ hips are level.
  • When performing this assessment initially, you can explain to your client that if the dowel rod indicates that their hips are not level, then this is suggestive that the base of their spine (i.e., sacrum and coccyx) has shifted towards the higher side. You could further explain that there is a very important joint located where their spine meets their pelvis (i.e., sacroiliac joint) where a lot of nerves exit the spine and when the hips are not level it can adversely affect this joint causing pain and/or dysfunction (Kendal, et al., 2005). Again, this is a very easy assessment for your client to understand and allows them to objectively observe changes (if they have made any) between their first assessment subsequent re-assessments.

Making Successful Transitions

Although you will initially be leading the discussion about the re-assessment findings, the key is to do so in such a way that the client begins to see that the positive results they have achieved is because of the direct effort they are putting into doing their exercise program and their homework. Alternatively, if they have not made much progress, you can use the re-assessment results to help reinforce the behaviors they need to adapt to increase their adherence to doing their homework and ensure success of the program.

Let's look at how you can use the two re-assessment strategies discussed previously to transition your client into the leader role.

• Example #1: Measure Their Height against the Wall -
  • If the re-assessment reveals that your client is a little bit taller than they were in their initial evaluation, ask them why they think this is the case. They may come up with any number of answers to this question, or they may have no clue. Either type of response is ok. The point of asking the question is to encourage the client to think about and/or discover for themselves the changes they are making that are having a positive effect on their musculoskeletal system. For example, you may have recommended that they do some self-myofascial release work for their hip flexors and upper back and as a result of performing these exercises they now feel as though they can stand up straighter and taller. This type of conscientious thinking about their homework exercises prompted by your question about the assessment results will promote exercise adherence. Another person may reply that they feel a lot less stressed out this week and as a result feel like they are standing taller. You can use such a response to explain to them how stress can affect their posture (rounded shoulders, etc.) and further probe to find out what specifically they did that helped them feel less stressed (since those behaviors will want to be repeated). Alternatively, a client may tell you that they changed their work setup to incorporate a standup desk which they feel is helping keep their shoulders back and their torso more upright. This response would provide you with the opportunity to congratulate them on pursuing this non-exercise related change, thereby reinforcing their confidence in making decisions for themselves.
  • On the other hand, if a client is unsure why they are taller this week you can ask probing questions about both the corrective exercises you assigned them for homework and the non-exercise related changes you suggested they make in their first session. If you find that your client is not taller or perhaps even shorter than they were previously, you can ask them why they think this is the case and lead into a discussion about what they can do differently to achieve the desired results next time. You should also do a physical review of their homework exercises to make sure they are doing things correctly.
• Example #2: Dowel Rod on Hips – Similar to the first scenario, you can use the results of this re-assessment to help your clients understand what they are doing that is having a positive effect on their body. Asking the client why they think their re-assessment findings are different than before provides an opportunity to highlight the changes they have made that are working well for them. For example, the person may have integrated the use of orthotics in their shoes which is now addressing the overpronation problem of their left foot. This one-sided overpronation issue may have been what was causing the hip on the same side to drop with their collapsing foot, consequently making the level of their pelvis uneven. Discussing the results of the re-assessment may inspire the client to wear the orthotics consistently or consider changing the types of shoes they wear altogether. Alternatively, performing a homework exercise you recommended to help strengthen the hip abductors on the higher side may have helped the person stabilize that side from shifting quite so much which has helped level out their hips. The client being able to see demonstrable results from doing their exercises will motivate them to perform them regularly, which will ensure long-term success.

Regardless of the responses a client gives to your question about the assessment finding, the trick is to use the results to coach your client about the behaviors they are in control of that are helping them see positive results. This will improve their self-confidence and adherence to the program.

Support the Client as they Lead the Way

Following your discussion about what the client thinks they have done to help their situation, ask them to perform their homework exercises so you can evaluate their progress in this area and make any helpful adjustments, progressions and/or regressions.

Communicating with your client about their homework in this way and devising strategies together to remove any barriers to them completing their homework, ultimately puts them in control of the success of their program (Whitworth, et al., 2007). Additionally, reviewing homework with clients and explaining how the exercises they have been doing (or not been doing as the case may be) influenced their re-assessment results also helps you praise appropriate behaviors, reshape undesired actions, and adjust program variables (i.e., progress or regress) as necessary so that clients feel emboldened to achieve their goals.

Conclusion: Putting It All Together

The key to providing outstanding exercise services lies not only in your ability to assess and design effective programs, but also in your skill to be able to engage your clients verbally in ways that will make them feel confident in taking the steps needed to reach their desired goals. Incorporating re-assessments in your session protocols will enable you to provide objective feedback about the progress of a client’s program and highlight those behaviors the client has made that are influencing their success (Bandura, 1986). Furthermore, utilizing homework review as an additional re-assessment tool enables you to further encourage your client’s participation in the program, increase their confidence and provides you with the valuable information you need for successful program design.

References:

1. American Council on Exercise. 2010. ACE Personal Trainer Manual (Fourth Edition). American Council on Exercise.
2. Bandura, Albert. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, 1986.
3. Kendall, F.P. et al. 2005. Muscles Testing and Function with Posture and Pain (5th ed.). Baltimore, MD.: Lippincott Williams & Wilkins.
4. Milgram, Stanley. 1974. Obedience to Authority. New York: Harper and Row.
5. Price, J. 2010. Corrective Exercise Program Design. Module 4 Reference Manual of The BioMechanics Method Educational Program. www.thebiomechanicsmethod.com.
6. Whitworth, L., et al. 2007. Co-Active Coaching: New Skills for Coaching People Toward Success in Work and Life (2nd ed). Palo Alto, CA: Davies-Black Publishing.