The problem with rehab exercises…

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

Adam

 

23 thoughts on “The problem with rehab exercises…

  1. Thanks for the post – I am only 2 years in to my career but what has struck me time and time again is the ability of successful / popular / leading physios to talk to patients. Their ability to explian “why” is powerful enough to get buy in. I think this is an area we should be doing more research and spending more time on, trying to improve in the clinic. It has always seemed odd to me that we don’t take any education or psychology classes to get better at this. Thoughts?

    • Hi David, thanks for your comments and thoughts, and I agree! The ‘best’ clinicans do tend to ve the one that connect well with patients, that explain things clearly and well! What used to be called good bed side manner in the good old days, and agree that it isnt taught well if at all in medical or physio schools! It needs to be! I have a saying I use a lot! Your interaction often out weighs your intervention…

  2. Hi Adam,
    I am grateful to have recently discovered your blog since returning to Physiotherapy having taken a diversion in my career towards counselling and psychotherapy. Your article raises a couple of questions which I have pondered upon here….
    Firstly you talk about the ‘shift in perception of identity’ and while I agree that ‘identity’ issues may be underlying, you state that a change in ‘perception of identity’ comes following an injury which has resulted in them becoming ‘less able’. I would suggest that it might even be the other way around and that the change in identity perception come first. This leads to poor movement quality and posture which creates imbalances resulting in predisposition to injury.
    Surely then, there is the question of whether we are talking about a fit athlete presenting to us with an injury and who is currently less able than usual thus affecting self esteem or whether we are presented with a client who has been suffering from poor quality movement for some time combined with sedate lifestyle and self esteem/postural issues.
    You suggest that by prescribing exercises, the therapist may be inadvertently creating a perception of weakness and dependency in the client and I wish to compound this idea by stating that I believe that the ‘quality of the relationship’ between client and therapist is of the upmost importance. The ‘quality of the relationship’ not only establishes trust, but it assists in creating a situation where the client feels empowered, strong and motivated rather than weak, dependant or even resistant.
    The recent post modern approach in psychotherapy has been to examine the ‘definition of relationship’ and indeed to recognize that the very act of defining our role as ‘therapist’ means that we are placing ourselves in positions of superior knowledge to our ‘clients’ and I believe that as ‘therapists’ we ought to be mindful of this. It might even be possible to gain more success with our clients if we think of them as ‘guests’ rather than ‘clients’ or worse still ‘patients’!
    I am always reluctant to use the word ‘teaching’ when it comes to working with ‘clients’. Our role is definitely educational but I fear a tendency to be prescriptive and the offering of advice again sets us up as ‘the expert’. For me, this further raises the question of responsibility. Who is responsible for fixing the injury? The client may attend with the expectation that it is the therapist (who is after all the expert)’s role to ‘fix’ it while they may remain passive during the whole process. How one changes those deeply held attitudes is a question that the NHS as a whole is facing right now, but I believe that herein is the answer to client willingness or reluctance to take their treatment home.

    In summary, I believe that much can be gained from the understanding of psychology when it comes to working with ‘people’ and I would agree with you completely that the barrier towards clients taking full responsibility for their recovery lie in the dynamic of the relationship and indeed by how we define that relationship and continue to define that relationship as it progresses through treatment and recovery stages.
    .
    Keep up the interesting and thought provoking posts!
    Thanks, from Louise.

    • Hi Louise

      Thanks for your great comments! I think the idea of a shift in a persons idenitity could create poor movement and poor posture is plausable, but what is poor posture/movement! We now realise that plumb line assessments and text book aligments are false and flawed. Movement variablity is a more important factor rather than posture position, so perhaps a shift in indentity causing lack of movement maybe, maybe more likely

      You make some great points about the rehab exercises and the athelte perceptions of being broken and needing to be fixed and I agree here 99% the therapist does need to build a realtionship of trust and promote a sense of robustness and optimisim, this is key and more important than any exercise plan in my opinion. I never tell a patient/athelte/client they are doing rehab, rather conditioning or simple exercise or movements

      Next the use of words treaching, again you make some good points and the teacher/student expert/patient relationshiop isnt the best for a successful outcome. I like the term coaching or facilitating and I also like to tell my clients that this is a consultation between two experts!

      Thanks again

      Cheers

      Adam

      • Thank you for your response. I like your use of the term facilitating and particularly that you describe your sessions as a consultation between two experts.
        As a returner to practice I am still catching up with the latest movement theories and I will now go on to research ‘plumb line assessments’ which I naively have not come across before. The idea of ‘poor posture and poor movement’ warrants further investigation since as you say, what is it exactly?! Perhaps you might suggest some useful links. I also think that there is a whole other concept relating to posture and that is one of body awareness (whatever that may mean!). Again if you (or anyone) could suggest some useful links I would appreciate it.

        Thanks again for your willingness to share thoughts and ideas!

  3. Adam, you brought up an interesting point. Patients can present with various types of barriers – obscure pain perception, low self-efficacy, etc- which prevent adherence to home exercises. As therapists, we can spot the barriers, but the challenge is to connect with the patient to get them moving again.
    I strongly agree with the idea of implementing patient education as part of a curriculum in various rehab field is exceptionally essential.
    Thanks,
    Marina

  4. Nice post Adam,

    Being almost 20 years down the line… I’m happy to say I have minimal issues around patient compliance with exercise.

    Using a coaching style, reflective questioning, motivational interviewing … The penny drops for patients, it’s uplifting to witness their shift in belief leading to a natural shift in behaviour….

    I don’t tell them to do anything…. I just ask ask ask, pointing out discrepancies in their beliefs, and they tell me what they need… It’s so powerful, no longer exhausting or heart sinking …

    And just sometimes they’re just not ready to make those changes, and that’s ok…. They’ll be back…

    We shouldn’t be advisors, or tellers, we should be facilitators. Some of us can do this naturally, but really these skill should be taught (or facilitated) undergrad…

  5. Hey Adam

    Great points (you don’t happen to know Mike Stewart do you?!). The third wave cbt model of ACT may offer a value based framework to agree and motivate exercise/activity. What are your thoughts?

    Cheers Tom

  6. I’m interested in this discussion here (not least because it involves what has been summarised as the bias of compliance to explain the outcome of some clinical trials but also as someone who is currently reconditioning with a SEM adviser).

    I’ve been intrigued for some time by the high level of compliance reported as part of the BEST study and the achievements of the participants in that and in the subsequent years after the project notionally ended. (E.g., reasonable overview of the project:
    Metcalfe, L., Lohman, T., Going, S., Houtkooper, L., Ferriera, D., Flint-Wagner, H., Guido, T., Martin, J., Wright, J. and Cussler, E. Postmenopausal women and exercise for the prevention of Osteoporosis: The Bone, Estrogen, and Strength Training (BEST) Study. ACSM’s Health & Fitness Journal. Vol 5(3), 6-14, 2001.
    One of the follow-ups:
    Med Sci Sports Exerc. 2010 Jul;42(7):1286-95. doi: 10.1249/MSS.0b013e3181ca8115.
    Resistance training predicts 6-yr body composition change in postmenopausal women.
    Bea JW1, Cussler EC, Going SB, Blew RM, Metcalfe LL, Lohman TG. )

    The reported results are remarkable – the headlines being that in addition to the improvements in BMC, relative to baselines, after 1 year the women’s leg press had improved 67% with less but still striking improvements to the upper body strength (in particular, some of the women were able to leg press 500lbs+). Some of the non-physical aspects were remarked upon and I believe one of the findings was a greater sense of resilience and self-efficacy as an outcome their progress (which strikes me as germane to your discussion but I may be wrong).

  7. Adam, I have no problems with the idea of our role being ‘teachers’ and also patients especially in the NHS context that i work in is fine too —I dont really like ‘clients’ but this isn’t the topic ! I I think some of the problems are that the the ‘exercises’ are often pointless, especially the complex series of ‘muscle imbalance’ physio tools type protocols …..They are commonly given out as a prescription and just like complex prescriptions (see the medical cabinets of many elderly people ) they are often jettisoned very quickly . We perform movements for functional activities –living… and they are multiplaner and often require little thought …Working more functionally for ADL with very simple exercises that can be incorporated very easily are the way forward for the majority in GP outpatients……..hypercomplex shoulder rehab regimes may be ‘skillful’ and perhaps be required with a multidimenisonal hypermobile person performing at elite swimming – but role out this kind of stuff to the general population and you tend to confuse and miss the boat……..Interesting ideas about the self and having a goal —this is where’ sports focussed’ approaches seem logical and sports medicine is a popular area to work in. Having much better approaches to varied teaching strategies (and valuing this at undergrad level) making things relevant to individuals and their aspirations is the most important aspect of the job I believe .

  8. Made it a rule a while ago not to leave a patient an exercise that didn’t have demonstrable in-session impact on their pain or function level. Now compliance is rarely a problem as the exercise has already been shown to them to have a positive, instant effect and patient is empowered. See too many examples of “go away and try this exercise and I’ll see you in x days/ weeks” with patient having little motivation to keep it up.

  9. Yep – self concept can completely change when people are experiencing injury/pain/disability. In my PhD I found people were stuck in what they call “the never-ending now” or a sort of stasis until they’d made sense of what was going on. If it’s a confusing, complex problem it’s going to take longer to make sense of it.
    I also think we don’t always consider how these “tasks” we give people might relate to everyday life. One study I read some time ago suggested that balance exercises for elderly people living at home were more likely to be carried out if they were tied to everyday household activities/occupations. This means that every time the person does that normal everyday thing, they’re reminded to do that exercise. It seemed to provide greater adherence and better outcomes as a result. Sorry I can’t remember the name of the article.
    Another question to ponder is whether the people we’re working with have ever had routines, or perhaps they live fairly chaotic lives – and of course, the degree to which they’ve ever carried out any exercise at all!
    If these are new behaviours, and we dish out a set of exercises without exploring how the person feels about it, or whether they believe it’s a priority (amongst all the other priorities), and if we don’t explain why they might be important – why on earth would you do them?

    Another wee study I looked at was a brief problem solving exercise to help the person identify the potential obstacles to carrying the exercises out, and developing a set of options to help overcome those obstacles. Only takes a few minutes to do, but really does help to counter the automatic thoughts around “Ahhh it won’t matter if I miss this one”, or “but it’s too cold out” or “this is really boring”. Anchoring the exercises to another daily habit can be useful as well – such as while the jug is boiling for the morning cuppa, what about doing a few of those exercises?

    cheers
    Bronnie

  10. Ask them on a scale from 1-10 (10 is 100 % realistic) how realistic is it to complete the assigned exercises and with the frequency you want. Unless it is a 9-10, go with lower frequency/exercises.

    Make your client’s plan time in their calendar when to do the exercises, as they book an appointment with you, they book time with them selve. And maybe make a compliance sheet where they have to mark if they have done the exercises.

    Establish their goals and find the value behind it. You can use the 5-why’s question technique. If they don’t know why they want to accomplish it, it’s hard to make em do it.

  11. How would you go about maintaining motivation and enthusiasm for rehab exercises long term? I am entering my second year of trying to treat a running injury in my hip. When I first saw the physio I was dedicated and managed to commit to 3times a day every day for 4-5 months, tailing off to once a day and then fizzling out by about 10months, until a major flare up where again I am trying to do the exercises as often as instructed. But what can you say to someone who has invested hours and hours (and not to mention hundreds of pounds) into following a recovery programming when they aren’t seeing any results? I’m finding it really hard to have faith in the exercises.

  12. Hi Adam,
    Thanks for this article, it rung true for me. I am currently undergoing physio rehab exercises for an injury related full thickness rotator cuff tear and a broken wrist. Although I have regained almost full range of movement, my strengthening physio regime is causing problems as it causes a flare up of pain, and then as you accurately observed, this reinforces the fact that I am indeed injured and have a degree of weakness, so I start to avoid them. If not for the physio exercises I might just forget the injury, but then of course, I might not fully recover. Too complicate things further my ortho surgeon (wrist surgery but no rotator cuff repair) is not 100% convinced that physio is exactly the right option for me, but my GP disagrees…
    So being only human, I take the path of least resistance, and exercise only lightly and intermittently.
    In addition, unless I really push, my physio does not explain the benefits of individual exercises.
    From a patients viewpoint, things are rather problematic.
    Regards,
    Susan.

  13. Good read again.

    I’ve recently tried to make a habit of asking the pt how motivated they are to complete exercise on a scale of 1-10.

    Usually you find people are 5-6/10 and I guess I’m lucky I get quite a few who are 8-9/10 and really determined. I try to then ask why they are not LESS motivated (much their bemusement sometimes haha). Just another way to look at it, after reviewing why they want to do them and see physio and not why they can’t or don’t.. they find that score can change a bit and hey presto, hopefully more compliance!

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