Home Exercise Programs and Patient (Self) Trust

Whether you are a patient or healthcare provider we have all dealt with the issue of patient compliance, or lack thereof, with rehab.  According to Brewer et al, 2002, compliance rates to rehab range from 40-91%.  While some 20-30% of the clients do not even show for scheduled appointments.  That is a tremendous number to think about.  More then 1/3 of our patients may not only be non-compliant but they actually will not even show up for their appointments!  We can talk about "missed visits" another day, with this blog I would like to focus specifically on patient compliance as it pertains to a prescribed Home Exercise Program.

We did it!  Completed an awesome evaluation, educated the patient in what their diagnosis/prognosis was and had a positive result the VERY FIRST visit in terms of function and symptoms.

You did it!  You went to PT to take control of your pain, understood exactly what the PT said and performed your "homework" like it was your job for a day or two, heck maybe even the first week.

Then reality set in.  We ask the question, "How is your homework going?  Do you have any questions about it?"  And we are met with a blank stare, a guilty smile, or worse someone who tries to perform there exercises in front of us and fails......badly.  We can give them an A for effort I suppose but performing movements improperly is likely what landed them in our office in the first place.  

Why is this?  I have read a lot of articles recently which point to some factors indicating that a patient is more likely to comply with a Home Exercise Program if the following things fall into their favor:  demographic factors (higher socioeconomic status, living alone); health status (fewer health conditions, better self-rated health, taking fewer medications); physical factors (better physical abilities); and psychological factors (better cognitive ability, fewer depressive symptoms).  Another factor in getting patients to comply appears to be in the number of exercises prescribed to them.  In a study on elderly subjects, those who were prescribed 2 exercises performed better than subjects who were prescribed 8 exercises.  The group that was prescribed 5 did not show significant difference either way.  So the question of an optimal number of exercises to prescribe to elderly people continues to warrant further study. 

I tend to believe that we really cannot predict who will or won't comply to PT, (I have been "sure" on several occasions and have been proven wrong more often then not) but in recently reading "The Speed of Trust" I have thought of another reason why patients do not comply, and it all comes down to Self Trust.

Trust comes down to two key ingredients:  Character and Competence.  Think about this, research shows that almost HALF of all American's set a New Year's Resolution.  Do you know how many keep them?  ONLY 8%!  So what happens when we set out to do something and then do not come through or rationalize a reason not to?  It weakens self confidence and hurts our character.  I would argue that those of us that are non-compliant with something as simple as a home exercise program are probably the same people who set alarms to go to the gym and then hit "snooze", wait to the last minute to meet deadlines (if we even meet them), or fail to trust others.    

"The best time to plant a tree was 20 years ago, the second best time is today." - Chinese Proverb

The good news is that we can improve self trust and  can change if we really want to which we will dive into in our next blog, however I will leave you with the advice of Toyota and start by asking yourself the "5 Why's".  The idea is to start with the problem, work backward by asking "5 Why's" to determine the root cause of the problem - typically after this process you are able to identify and come up with a solution or reach our for help if needed.  For Example:  

  1. Why don't I perform my HEP even if my PT tells me to and it makes me feel better?  

    • I do not have enough time.

  2. Why don't I have enough time?

    • I work long hours and have kids and family that take priority

  3. Why can I not communicate with work or my family that I need help in performing my Home Exercise Program to stay healthy and productive?

    • I do not want to bother them and work would not understand.

  4. Why do you think it would be a bother to your family?  And more importantly if you are in less pain at work wouldn't you be more productive and accomplish more tasks?

    • No one else has pain in my family or my job so taking the time away from them to perform exercises will make me look bad.

  5. Where are their times at ANY point in your day that you can take 2-5 minutes for yourself at any given moment to perform your homework?

    • Perhaps when I wake up by setting the alarm a few minutes early, before I go to sleep, while using the bathroom at work or be incorporating my kids into the exercises at home.  

This is a very general example but one I typically encounter on a weekly basis.  Your answers may be completely different.  Whatever the case may be start by trying to identify the root cause and a reasonable solution.  In my opinion in begins and ends with trusting yourself.  So patients I challenge you to "plant your tree" today, and for healthcare providers I challenge youto stop prescribing "sheets" for homework.  Make it specific to your patient and seek out ways to empower them to perform these activities in any environment (i.e. no bands/straps/bells and whistles) that way we can all get to working, and trusting each other, together.  

What have you done to improve patient compliance and build trust?

Until next time Happy Rehabbing!