I haven’t done my Exercises
I haven’t done my exercises was the message received. Please cancel my scheduled appointment – this was the 2nd cancellation in succession since previous review 2 months ago.
This got me thinking on the notion of home exercise in relation to
Patient perception of exercise
Physiotherapist prescription objectives.
It is fairly intuitive for most Physiotherapists (at least in the musculoskeletal field) to prescribe some form of home exercise as part of a patient management plan. In fact I would go so far as to say its pretty much second nature. Now we can debate the type of exercise prescribed and the relative merits of the multiplicity of options available – but that’s for another day. We recommend exercises because we believe it will improve the outcome.
The implicit assumptions include the following:
Prescribing home exercise will empower the patient to facilitate their own recovery
Speed up the rehabilitation process
Address-underlying cause or factors which may have precipitate the issue
Minimise dependence on health care providers which may result from a failure to control symptoms.
Whilst all of these objectives are admirable and are hard to criticise, the problem is that many patients do not perceive exercise in the same context. In fact many patient satisfaction surveys highlight the fact that prescription of home exercise is a “turn off” for significant numbers of patients, particularly those who are paying for treatment. In the field of manipulative therapy it is one of those determinants, which dictates whether patients may seek Chiropractic, Osteopathy or Physiotherapy as their primary input – “physiotherapists just give exercises”, “the chiropractor understands my spine” the osteopath knew exactly what was wrong”
But what can we conclude from such patient perspectives?
Are they lazy?
Do patients think that physiotherapists prescribing exercises is a delegation of our duty of care to treat and solve the problem? “my problem is more complicated than just needing exercises”
Have we failed to communicate our message by clarifying the purpose of the exercise?
Do we have clear indications whether the exercises we prescribe are providing practical benefit?
Each of these headings warrants discussion in its own right (and will be the subject of future posts) because failure to recognise mutual perspectives can place considerable strain on the patient/therapist relationship and ultimately the ability to deliver care. We have discussed the patient therapist relationship previously.
The platform for healthcare delivery can dictate part of the management strategy. In my naive assumption, 20 years ago, when I left the NHS I thought patients paying for treatment would be more compliant with their home exercise regime. I can say without hesitation that I have not found this to be the case so the logic that paying for treatment increases compliance would not appear to apply.
In a Public Healthcare System, the continuous pressure of waiting lists can present an attractive opportunity to prescribe home exercises and self-efficacy based care simply as a means of reducing pressure on the system. Indeed we have seen some move towards this with the clinical standards on low back pain guidelines suggesting that general advice is as effective as other forms of manual therapy.
Whilst I disagree with this assertion, unless clinicians can prove otherwise, this will stand as the reference standard for management of low back pain. My old friend and colleague Nick Carter in Portsmouth, UK is a great exponent of the methodological process by which Physiotherapists select, deliver and monitor patient home exercise programmes.
We spend sometime discussing this on a course we present collaboratively called Therapeutic Exercise and it’s a topic we will return to in future. Suffice is to say at this point that if a random selection of exercises are simply thrown at a patient in the last two minutes of a treatment session it is not surprising patients don’t attach much credibility to it or value it as part of their management plan. If such a haphazard approach is part of the message delivered it is unlikely to have the desired impact.
So clearly there is an onus on the physiotherapist to determine which patients specifically need home exercise, which ones are likely to comply and which ones have no interest. It used to be a major source of frustration when patients continuously made excuses for not doing their exercises or as it was more frequently the case, “not doing your exercises”. As I mellow with time I am now less judgemental regarding patients commitment to facilitate their own recovery. Understanding the Stages of Change paradigm is a helpful concept in this situation.
However, I now make it my business to determine which patients seek this type of management strategy, which ones aren’t interested and which ones remain to be convinced – provided the efficacy of home exercise can be demonstrated either in terms of symptom reduction or frequency of recurrence. Adopting this type of strategy has been of great benefit in relieving frustration and creating the classic patient/therapist barrier where the Physiotherapist castigates a patient because they haven’t “done their exercise”. It is so easy to assume that lack of compliance is the reason for non-responsiveness to treatment. In order to maintain clinical credibility it is very important that we Physiotherapist perform critical self-analysis to determine whether the lack of adherence to a home exercise regime is in fact a critical component of the patient’s symptoms, whether we have selected the appropriate exercises ( this is a huge separate topic), whether there is a need for routine “maintenance” exercises or whether there is no role for home exercise.
These are important factors to consider because they profoundly influence the type of care delivered and the quality of the patient/therapist relationship.
Do you find patient compliance to be a source of strain on your therapeutic relationship?
Do you think patients have the right to choose to comply or not with a prescribed home exercise programme?
Do you think we have clear criteria for appropriate exercise selection tailored to individual requirements?
Let us know your thoughts.
Enjoy the clinical challenge.
DavidGHTime Code(s): nc nc nc nc nc