Have you been doing your home exercises?
That routine question yields various amusing responses, most of which could be summed up with a simple “no.”
Somewhere between 1/3 and 2/3 of all home exercise recommendations are not implemented by patients. (1-4) Many well-developed plans end up sitting in a drawer because the patient did not understand the importance of rehab or was not sufficiently motivated. Here are seven proven ways to improve patient adherence to your exercise prescription.
Patients who adhere to their prescribed home exercise programs have better clinical outcomes (5-11) with lower chances of recurrent injuries and flareups. (12) Those who decline to play an active role in their recovery through home exercise may extend the duration of care and negatively impact the doctor-patient relationship. (8,13)
1. Highlight the Problem & Relay the Importance of Correction
“An Educated Patient is a Compliant Patient”
– ChiroUp Subscriber Dr. Craig Revermann
The first step in any recovery program is to recognize the problem. Patients who clearly understand the etiology of their pain are more likely to take action. Providers must ensure that each patient understands what’s causing their problem and how that dysfunction contributes to their symptoms. Many times, this involves a discussion of functional deficits.
Be sure to reinforce that while your treatment can provide relief, a lasting solution will likely require correction of faulty postures and movements through rehab exercise.
“Finding the prime patient motivator is critical for compliance. For some people, it’s pain, others, performance, and for a few its money. Picking the right motivator for the right patient is a sage move by an experienced clinician.”
-ChiroUp Advisor Dr. David Flatt
Choose the motivators that matter most:
- For patients who are frustrated by pain or difficulty in performing specific activities of daily living, a little dose of FOMO for a pain-free life might be in order.
- For patients who desire peak performance, explain that every Olympic, MLB, and NFL athlete has access to a chiropractor AND diligently performs their prescribed training plan because they understand the value of optimal function.
- For patients who may be motivated by money, this would be an opportune time to discuss how compliance leads to fewer visits and lower overall costs of care.
2. Provide A Simple Solution
Recipe for any successful sales pitch:
- Describe a familiar pain point
- Share a vision of a better way
- Facilitate simple implementation
Assuming that you’ve sufficiently motivated your patient, it’s time to sell your specific exercises. This means your prescription’s perceived benefit must outweigh the costs of time, effort, and discomfort. When selecting exercises, you’ll need to avoid the costly terrible too’s:
Research has suggested that exercise prescriptions be limited to no more than four exercises at a time, preferably two. (14,15) Prescribing more than four exercises may create confusion and diminish compliance. (15,16)
Avoiding exercises that are too difficult means more than not asking great aunt Gertrude to perform a dozen side planks. Patients with substantial or long-standing functional deficits will not likely complete a single quality rep of anything challenging. i.e., a 70-year old with chronic gluteal tendinopathy may attempt to perform a side plank with hip abduction, but not without several compensations- and, those compensations come with a physical cost. Strive for quality over attempts at completion.
“Performing exercises improperly strengthens dysfunctional patterns; kind of like asking Shaq to practice free throws on his own. The result is only more of the same crappy shot.”
– Dr. Corey Campbell -MPI Vice President
See #3 below
3. Deliver Supportive Materials
There’s one sure way to know if your patient attempted their home stretch for the TFL or infraspinatus, or any other challenging muscle- they’ll ask you how to do it again on the next visit. And confusion is not exclusive to only the most challenging movements. Many well-developed exercise plans end up sitting on the counter because the exercise looked simple in-office, but performing it at home was different.
Patients who know they are performing a task correctly are more likely to adhere. (17) Make sure you provide written and visual demonstrations to reinforce your in-office exercise training.
4. Set Realistic Goals & Expectations
Just like explaining that your patient might be sore following their first treatment and may take a couple of visits to see results, you’ll need to relay similar real-world expectations for your exercise program.
Ensure that your patient understands that no one develops optimal strength, posture, or mechanics in the first week or two. Early positive feedback from the provider should include observations about improved range of motion and other objective findings.
5. Address Barriers
Perhaps the most significant deterrent to completing a home program is pain during exercise. (4,12) Patients must understand there is a tremendous difference between hurt and harm.
Some level of discomfort will accompany most new exercise programs. Let your patients know that mild, or sometimes even moderate discomfort is expected- and beneficial. Patients should work through soreness and healthy discomfort; however, they should discontinue their program and check with you if they experience:
- Significant reproduction of the chief complaint
- Pain beyond 3 or 4 out of 10
- Peripheralization of symptoms (i.e., sciatica radiating further)
- Reproduction of numbness, weakness, or other neurologic signs
- Pain lasting more than 24 hours or increasing at night
Any of these signs mean it’s time to reassess the movement, move slower, or possibly select a new exercise.
Other potential barriers include lack of time, not fitting into the daily routine, work schedules, child care needs, family dependents, financial constraints, convenience, forgetting, and anxiety or depression, (4,12,18-20) Emphasizing the idea that exercise will lead to higher productivity, with less pain, anxiety, and depression tends to lower barriers.
6. Provide Ongoing Oversight & Positive Feedback
Providers must be willing to monitor progress each visit and make appropriate modifications- up or down. Make sure the patient understands that you will be continually assessing their participation. A sense of accountability is a potent tool as most patients want to please their providers. Never forget that a pat on the back from a respected advisor is more potent reinforcement than a slap on the hand.
Home exercise should be viewed as a continuum that takes patients from where they are to where they need to be to achieve their goals. Avoid the temptation to advance too quickly. Slow progression is key. Patients should advance only after they can perform an exercise appropriately and with limited discomfort.
Pro Tip: For tendinopathies, let night-time pain be your guide. Back off if the patient has redevelopment of discomfort during sleep.
The first six components are faith-based, meaning the patient believes in you and your plan. However, like diet and exercise, achieving the patient’s desired result is the only metric that will fuel a long-term commitment.
Evidence-based chiropractors understand that choosing the most appropriate exercises is crucial to obtaining results. Look beyond the symptomatic tight muscles and create an individualized plan that restores function and resolves the real reason your patient called you in the first place.
“There’s a vast difference between prescribing and prescribing well.”
– Me (or someone else who once told me that)
ChiroUp condition reports manage every single one of these components for you and your patients.
Prescribing reports for every new clinical presentation will automatically send your patients home with everything they need to know about their condition, including video demonstrations of their exercises & ADLs. Then you, as the provider, can track their compliance & satisfaction through patient data profiles.
ProTip: For simplicity, many providers choose to print and store ChiroUp Condition Report & Exercise Rx Pads in each treatment room to quickly & accurately relay prescriptions to staff, or as a reminder to themselves. These forms could also be printed and laminated for reuse. The form is available in three versions:
Not yet a subscriber? Start your free trial now and access all of ChiroUp’s resources in the next 60 seconds!
- Beinart NA, Goodchild CE, Weinman JA, Ayis S, Godfrey EL. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The Spine Journal, 2013, 13:1940–195
- Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. NZ J Physiother, 2003, 31: 60–66
- Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient- practitioner relationship. J Rehabil Med, 2014, 46: 153–158
- Argent R, Daly A, Caulfield B. Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?. JMIR Mhealth Uhealth. 2018;6(3):e47. Published 2018 Mar 1. doi:10.2196/mhealth.8518
- Di Fabio RP, Mackey G, Holte JB. Disability and functional status in patients with low back pain receiving workers’ compensation: a descriptive study with implications for the efficacy of physical therapy. Physical Therapy. 1995 Mar 1;75(3):180-93.
- Pinto BM, Rabin C, Dunsiger S. Home‐based exercise among cancer survivors: adherence and its predictors. Psycho‐Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer. 2009 Apr;18(4):369-76
- Karnad P, McLean S. Physiotherapists’ perceptions of patient adherence to home exercises in chronic musculoskeletal rehabilitation. International Journal of Physiotherapy. 2011 Jun;1(2):14-29
- Holden MA, Haywood KL, Potia TA, Gee M, McLean S. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol) Syst Rev. 2014 Feb 10;3:10. doi: 10.1186/2046-4053-3-10.
- Friedrich M, Cermak T, Maderbacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Phys Ther. 1996 Oct;76(10):1082–8.
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- Marshall A, Donovan-Hall M, Ryall S. An exploration of athletes’ views on their adherence to physiotherapy rehabilitation after sport injury. J Sport Rehabil. 2012 Feb;21(1):18–25.
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About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as past president of the executive board.
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