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Seven blind spots in activity training

One reason why rehabilitation is not working...

Vita TU, Occupational Therapist and Project Manager

Sunshine Social Welfare Foundation


As burn patients carry out rehabilitation every day and every week, we should progressively see progress. But sometimes, “blind spots” in how we design and carry out activity training will reduce rehabilitation effectiveness or even worse, make it ineffective. Therapists and patients both invest a lot of efforts during the rehabilitation process so ineffective interventions are not desirable. This article will identify seven blind spots in activity training so that the rehabilitation effect can be maximized!

Blind spot 1: Activity does not achieve maximum range

Blind spot 2: Activity is done using incorrect posture

Blind spot 3: Adjacent joints are not immobilized or stabilized appropriately

Blind spot 4: Activity does not target the right problem or the right cause of the problem

Blind spot 5: Level of difficulty of activity is not properly graded

Blind spot 6: Activity focuses on single joint and overlooks multiple joints

Blind spot 7: Overreliance on scar massage

1. Activity does not achieve maximum range

Rehabilitation activities for burn patients are repeated every day, but if execution does not achieve maximum range, the effectiveness of the activity for stretching scars and joints is reduced. For example, to promote active elbow movement, a horizontal tower is placed parallel to the body plane, and the patient repeatedly practices active elbow flexion and extension. However, if elbow flexion and extension are both done within the existing range when the activity is performed, muscle strength and movement coordination will be trained, but elbow range of motion will not increase. If the goal is to gradually increase active elbow flexion and extension range of motion, each movement should be done until the maximum range of flexion and/or extension is achieved, then even stretch a bit more and pause in that position for a few seconds, so that a proper stretching effect is applied on the scars and the joint.

Blind spot for activity training - no maximum range
Patient pushes blocks away for elbow extension and pulls blocks towards him for elbow flexion.

2. Activity is done using incorrect posture

Blind spot in activity training - incorrect posture
While standing, knee and ankles are in flexion, and the trunk leans forward in a compensatory movement.

If the patient uses an incorrect posture to perform rehabilitation activities, it will look like he is doing rehabilitation, but in reality, the whole activity will not produce results. For example, if the goal of the activity of picking up building blocks with the thumb and forefinger is to practice palmar pinch, but instead the patient does the activity using lateral pinch movement, then the effect of thumb opposition and palmar pinch cannot be achieved.

When the patient has knee extension limitation, the knee and ankle joints will be in flexion when the patient is standing up. This will cause the trunk to lean forward as a compensatory movement. If excessive mobility training is performed in this posture, although muscles will be strengthened, the gait of the patient will be incorrect, which is something the therapist needs to avoid.

3. Adjacent joints are not immobilized or stabilized appropriately

During a training activity, if the joints adjacent to the target joint are not properly fixed or play the role of stable support, then the movement quality of the target joint will also be affected. Using the activity in the photo below as an example, it is important that the wrist be stabilized in extension at 0° or in slight extension when fingers are performing grip. That’s because we must consider the impact of tenodesis grasp: wrist flexion promotes finger joint extension, which is not conducive to performing grasping action. Therefore, properly stabilizing the wrist in extension should promote finger grasping. Many functional grasping postures feature wrist extension, such as holding a pen, counting banknotes, etc.

Blind spot in activity training - joints are not stabilized
Joints of the hand are the targeted joints for the activity, but the wrist is not in the correct posture and has not been stabilized in extension.

Based on the same principle, when training for shoulder flexion, the trunk should be properly stabilized, otherwise wrong compensatory movements are prone to occur, like lumbar lordosis, which will then result in inaccurate training of shoulder flexion.

4. Activity does not target the right problem or the right cause of the problem

Oftentimes, a patient will have multiple rehabilitation issues that need to be addressed, and when all these problems are mixed together, it’s easy to lose sight of the key problem. Our prioritization of issues may be flawed. Or we may have prioritized the right problem, but because we have failed to identify the right cause, our intervention will not be effective in addressing the problem.

Using the picture of the hand below, if the goal of the activity is grasp training and the therapist focuses on activities to enhance flexion of the 2nd to 4th fingers, it will not result in good grasping performance. That’s because the bigger issue is thumb opposition. In this example, we must first make sure that the first web space can open wide enough, then enhance thumb CMC joint opposition, which is the combined CMC flexion and CMC abduction, and at the same time combine thumb MP flexion. Only then can good palmar pinch be achieved.

Blind spot in activity training - wrong problem or wrong cause
Thumb opposition is more critical to grasp function.

Another example is the neck, which can move in multiple directions. However, if the scars of the patient are concentrated on the side of the neck, spending a lot of time on neck flexion and extension will not benefit much. Priority should be given to performing lateral flexion and rotation to better target the problem.

5. Level of difficulty of activity is not properly graded

One of the principles of designing training activities is that these activities must be graded into different levels of difficulty. The grading method may be based on different ways of performing the activity, or the length of execution time, or the size of tools used and level of the resistance of the activity. Failure to set an appropriate level of difficulty for the activity will not only fail to achieve the training effect, but may even have the opposite effect.

For example, excessive resistance or excessive load can easily induce incorrect compensatory postures, such as shrugging, trunk lumbar lordosis, etc., and the training effect on the main target joints will be compromised. On the other hand, if the activity is too simple and the execution is easy, obviously the training effect will not be achieved.

6. Activity focuses on single joint and overlooks multiple joints

The state of joint activity after burns is always our concern. However, it is not enough to improve the range of motion of a single joint, because the execution of functional movements in the human body is almost always a combination of multiple joints coordinating their actions at the same time. In the pictures below, the patient can perform forearm supination at full range when the elbow is in flexion. But when the shoulder is in flexion at 90° and the elbow is straight, performing supination becomes more difficult due to scar tightness. Supination is even more difficult when thumb abduction is added.In a case like this, if the therapist only looks at the effect of scars on single joint movement, it is easy to think that the rehabilitation goal has been achieved. But when the patient returns to his normal life, reaching for objects or manipulating objects at a distance from the center of the body will be extremely difficult, as scars affect his functional performance.

Blind spot in activity training - focus only on single joint
Full range of forearm supination can be achieved when elbow is in flexion. When shoulder is in 90° flexion and elbow is in extension, supination becomes difficult due to scar tightness.

Therefore, when designing rehabilitation activities, if we only focus on single-joint training and ignore multiple joint activity training, we will not be able to help the patient regain the best possible function.

7. Overreliance on scar massage

In many clinical settings, massaging scars is an intervention often used to increase the softness of the scar and also promote the flattening of the scar. However, if the therapist only focuses on scar massage as a scar management intervention and ignores joint mobility training, the patient will not be able to achieve optimal functional performance. Scars will be softened but joints will still be stiff!

Joint inactivity will lead to decreased muscle strength and poor coordination of movements. On the other hand, proper joint activities can promote the secretion of joint synovial fluid that acts as a lubricant. Joint activity also allows the brain, peripheral nerves, and muscles to achieve better integration of control. In clinical practice, we’ve seen patients whose shoulder flexion improved but still presented an unconscious shrugging compensatory movement during exercises, which shows that the correct movement control mechanism has not been re-learned and re-established.

Therefore, scar massage is not simply to soften scars, but should also be seen within the broader context of joint exercises: after massaging, as scars and tissues have softened, it is necessary to continue to perform joint movement training and functional movement training in order to achieve the best movement performance.

By paying attention to these blind spots, therapists can ensure that their interventions achieve the best impact as possible!

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