Exercise and movement is my go to, primary treatment for all patients I see. From an acute hamstring strain, to a long standing rotator cuff tendinopathy, to a persistent and recurrent low back issue. But there is a BIG problem with all the exercises I give… compliance.
Simply put, it doesn’t matter how good exercise is, if its not being done!
We know that exercise reduces pain (ref). We know that exercise is great for a host of other health and psychological benefits (ref). We know that it really doesn’t matter which exercise you give someone in pain (ref). And we know most people don’t do enough of it (ref).
I am under no illusions that there are many, many barriers to motivating, engaging and convincing people to do exercise, even more so when they are injured and in pain! (ref).
But this doesn’t stop me being frustrated, confused, and annoyed nearly every day when I hear patients telling me they haven’t done their exercises or activities like I asked them to do.
Why don’t some patients do their exercises?
A lack of time is the most common reason I hear from patients, and I understand this when patients are given loads of different exercises to do by physios, which if done as directed (usually 3x a day) would take hours to complete.
However, I only ever tend to give my patients 2-3 things to do, some only just get one thing to do. I usually only ask them to do them once a day, usually just after work, or in evening, doing about 8-15 reps, with a load that fatigues them, for at least three sets ensuring that they usually dont take any more than about 30 minutes to do. I even let them have a couple of days off a week completely, usually asking them to do them only 5 days in a week. Yet still many come back telling me they didn’t have time?
Picture thanks to @TheAwesome_PT
Shift in perception?
Why is this? Why is less than 30 minutes a day, a few days a week too much? Is it patients just being lazy and using a lack of time as an excuse?
Well possibly! But it could also be due to a shift in a patients perception of their identity, something I had never considered until I read this paper forcing me to rethink some more about the barriers to exercise complaince in a slightly different way.
Normally most of us don’t consider our self identity that much, until something like an injury comes along. Then it can quickly become evident that we are no longer the normal, active, busy, independent person we used to be. Instead pain and injury now interrupts life and our activities. This can cause some to perceive themselves as being broken, weak, handicapped and dependant on others.
So along comes a well meaning physio and introduces some rehab exercises and activities to try and restore life back to normal, but these exercises are hard, painful and further interrupt normal daily life and activities, and so can further reinforce perceptions of weakness and dependancy.
Maybe these exercises are for some reinforcing beliefs that they are damaged and broken. Maybe the time barrier and other excuses is a reluctance to admit of highlight that they are weak and need help?
I think more of us physios need to be aware of this, and need to be a little more careful in our descriptions and language when giving exercises, ensuring we don’t reinforce these perceptions or beliefs. Being careful when using terms and words like weak etc.
That’s not to say we can’t ever tell or demonstrate to a patient they have something they need to work on, I just think we need to be a little careful in how we explain it.
We should always try and instill a sense of realistic optimism in our patients, making them feel that they can achieve robustness and resliance right from the start, and not to just focus on their deficits or weaknesses but also their strengths.
Us or them?
So we need to acknowledge that some, if not most of the barriers with exercise compliance could be more due to our inability as therapists to motivate, teach and educate patients effectively rather than any issues with the patient?
We know that educating and teaching anything to anyone is a skill. Some do it very well, very naturally. Most do not. We know that many therapists have not been taught the skills of education, and this has been highlighted a lot in pain education at the moment, with my colleague Mike Stewart and others such as the Explain Pain and the PainEd.com groups, all doing their bit to try and change this.
Also If you want a nice quick read about trying to motivate the unmotivated to exercises this is a nice paper that gives some suggestions and also points you towards further reading
But what about our ability as therapists to teach and educate patients abkut exercises? And I don’t mean our ability to teach patients HOW to perform them, but rather our ability to educate patients WHY to do them?
Is a lack of compliance with rehab exercises less about patient barriers, and more about lack of therapist skill in teaching?
As always thanks for reading