Finding the Minimum Effective Dose

My brother called me recently. He told me he sprained his ankle a few weeks ago and he continues to have pain and has not been able to play soccer as much. We continued to talk more and realized it’s not his first ankle sprain and this is probably more likely chronic ankle instability. He tells me he’s been Icing and take NSAIDs which I said is fine for pain but that’s not solving the root cause of his issues which is mainly going to be proprioception and strength at his ankle that needs to be address and he should probably look at completing other exercises that address hip strength and plyometrics. He immediately told me that he really called me hoping that I would tell him that what he was doing would work with time and he had no interest in doing exercises. He then called me useless and hung up the phone…

Although this was obviously a family member being a jackass it does remind me of some of the issues I face treating patients and even how I approach general wellness and fitness for myself.?

When I first started out as an Athletic Trainer, I wanted to make sure I never missed anything that could be possibly related to why someone got hurt. Lateral ankle sprain? Alright let’s hit soft tissue work to the Tricep’s Surae and plantar muscle of the foot due to their limited dorsiflexion. After that let’s hit some Posterior Talus Mobs to improve ankle dorsiflexion. Alright let’s re-educate how to land from jumping. Oh maybe you sprained your ankle due to weak glutes and weak core, let’s do some strengthening for that. Alright now we can do some traditional ankle strengthening and now we can attack proprioception/balance. Maybe before the session we did some heat and stim as well or afterwards we used the GameReady (Ice and pneumatic compression)

So after doing everything we’re looking at a 1.5 hour treatment session. I’ve had post surgical athletes with 2 hour treatment sessions. At times, especially in the beginning of a new phase of rehab or early on I think I can defend the amount of time it took for these treatments and the importance of it. But that was during a time that I worked with highly motivated collegiate athletes trying to get back to a high level of activity . Even then, athletes would start to get disinterested pretty quickly. Apply this type of rehab to a 45 year old truck driver and I would probably never see them again. The loss of interest in some of these programs and a changing population that I started dealing with caused me to start trying to figure out how to keep people engaged and get them to do what would be most important to make a change in their pain. This is how I started trying to find each person’s minimum effective dose (this is not a new idea or original but one that helps me focus on goals). In research, this is something looked at typically in therapeutic drugs to see what is the lowest amount of drug that can be delivered to get the desired result. In this field this is important because most of the time these drugs have unwanted side effects and if those can be avoided at lower doses and you get the desired result (usually disease regression) then you got something great on your hand. This idea is something I now implement anytime I treat someone. Typically I want to get my patients very good at 2-3 exercises first based on my evaluation that I think will benefit them the most and get them out of pain the quickest.

For example:

I have someone come in with L Sacroiliac Joint Dysfunction. Upon my evaluation they poor core stability, weak hip abduction and in general just have limited hip ROM.

Old me thinking would have either massaged or had them roll out/massage gun their low/glutes/hip flexors/TFL followed by specific stretches for each followed by a synchronized core activation series and working on Neuromuscular stabilization of the pelvis in a functional movement. Perhaps heat and stim as well and you’re looking at an hour rehab session. All of this is probably not necessary but would have helped the patient either way. But most of the time if I tried having them do any of this on their own it most likely didn’t happen. It felt overwhelming at times and they really probably just did not find it enjoyable.

Now I keep it Simple, Effective, and Enjoyable (SEE… thanks Michael Bruno )for that one). I now give one exercise focusing on how to posteriorly tilt the pelvis followed by something as simple as doing a side lying hip abduction exercise shown correctly and then ending with a pigeon stretch. I make sure they know how to do and feel those exercises appropriately and I send them on their way and want to see them again in a few days. Most of the time in the current population I deal with (high school athletes) this works great.

Sometimes the pain may not be as physical as you think and the intervention may be as simple as figuring out how to get better sleep or just be physically active in general. To be able to figure this out this is where a thorough evaluation and history is important.

Either way, one thing I know for sure is that it is much easier to get someone to do the simpler intervention that is not as time consuming as opposed to the very long and confusing plan that may be perfect but over the top. By starting simple you can maybe get that person more interested and wanting to do more to get the best results for them. This idea of minimum effective dose can be expanded to how someone just trains in general or stays in shape. Most people don’t want to workout for 2 hours a day or they don’t want to hit what is deemed the necessary amount of aerobic exercise to limit risk of disease (typically somewhere between 150-300 minutes of moderate to vigorous aerobic activity per week). But maybe there is a way to hit that many minutes by having them do something that they find enjoyable and still make them feel like they accomplished something. Perhaps it’s yard work that helps get them to that magic number… who knows.

Taking this mindset of minimum effective dosing has helped me in my own life in figuring out what gets me my greatest results in training, academics, and how I approach some aspects of life in general. I hope whoever reads this thinks about how to take this approach to better their patients and themselves. In the end, adherence to programs can be the hardest thing to accomplish because it feels so daunting and confusing for people. This way of thinking I feel has helped improve adherence for my patients and myself.