What happens when a patient is left to their own devices to comply with a home exercise program (HEP) after discharge from therapy or between clinic visits?
Too often the answer is inconsistency or complete failure to adhere. To change this pattern we can look at a few reasons patients may not comply, and implement strategies to help them get back on track.
Clinicians might find it difficult to understand why a patient wouldn’t comply with treatment, especially when patients appear to know that it’s “for their own good.” There are many complex personal, medical, social, and economic reasons that explain why patients might struggle.
Problem: Inadequate Instruction
Sometimes the patient simply doesn’t understand what they’re being asked to do. A patient might leave the office with a prescribed treatment plan and appear to be ready to begin — but in reality, has questions, concerns, or confusion that the therapist is unaware of. Regardless of discipline, it’s best practice to ask patients about their questions before they’re discharged.
Simply asking, “Do you have any questions?” is not a complete strategy. The patient might be embarrassed to say that they do. They might also not know how to articulate their concerns, or they may believe that they understand when they actually have some of the information incorrect.
Solution: Interactive Education
Using strategies to help patients understand not just what their treatment program calls for, but why it’s important, is a key component of promoting adherence.
“Teach Back” Method
One way to curb this information gap is with the “teach back” method.1 In this technique, the patient should teach treatment expectations, follow-up details, or other important information back to the clinician, mirroring what the clinician explained previously. This can help a physician gauge a patient’s understanding of their responsibilities in their care.
Video-based Patient Education
Video-based models that accompany a HEP prescription, or that are used to explain a diagnosis, can help a patient fully grasp their treatment. Research shows that these techniques build strong patient-provider relationships that positively impact the patient’s long-term adherence to their HEP.8
Even if treatment and HEP are understood, patients may run into barriers at home or outside the clinic. The size of their home, childcare and work responsibilities and motivation all may inhibit prescribed exercise. The number of exercises prescribed may occupy too much time in an already busy schedule.
Solution: Technology and Time Management
Through a combination of technology and encouraging time management skills, we can overcome barriers outside the clinic.
Optimize Time Management
Working with patients on time management can be effective in helping them carve out space in their day to perform their exercises. Many therapists find that framing exercise time around something that’s already part of a patient’s life — like watching television — is more effective than giving them a strict timeframe. For example, if a patient watches the evening news, the therapist might suggest that they perform their exercises during commercial breaks. In fact, this strategy is popular with lots of people looking to add exercise to their day, whether it’s part of a therapy protocol or not.9
Mobile apps that operate on a video-based model also serve as immediate and visual feedback tools to ensure patients not only adhere to exercises but complete each exercise with the correct technique. With a mobile exercise partner in their pocket, patients can complete HEP on their schedule in any location.
Time-Based Exercise Approach
Research shows that the number of exercises prescribed may impact adherence.2 Thinking of HEP as time-based programs instead of the number of sets and reps can help providers adjust accordingly to what patient schedules allow for. The MedBridge Go mobile app allows providers to see the total time a HEP might take a patient to perform.
Problem: Low Baselines, Comorbidities, or Perceived Lack of Support
Patients with low baseline physical activity, comorbid conditions, or a perceived lack of encouragement with their treatment are more likely to lose motivation with their HEP.4 These patients can present a financial burden to both themselves and the clinic as they may self-discharge as a result of one of these underlying factors. It’s important to fully grasp a patient’s background and status when assigning a treatment plan.
Solution: Identify Risk Factors and Adjust Accordingly
Understanding a patient’s emotional, social, and economic situation can better prepare therapists to work with them on HEPs. Therapists may be able to identify high-risk patients for noncompliance with HEP by looking at factors such as baseline physical activity, comorbid conditions like depression and anxiety, pain levels, perceived helplessness, and a lack of social support.4 Older adults are also more likely to have additional health problems which may cause balance or strength issues that negatively impact HEP outcomes.3 HEP should be tailored to each patient’s situation (beyond their ailment).
Leverage Technology and Mobile Apps
Age and other patient demographics impact compliance at all levels of treatment, but in terms of HEPs, technology can help immensely. For patients who are comfortable with smartphones, tablets, and other devices, apps like MedBridge Go can serve as an effective technological intermediary when patients are not with their therapist.
If a therapist truly knows and understands their patient, then encouragement should feel more natural, and hopefully, will be delivered in an effective manner.
Set Your Patients Up for Successful Outcomes
By talking to patients about their lifestyle, their concerns, and better understanding the challenges they face, you can use these research-backed strategies and tools to help create a program that your patient won’t just follow, but find success with.
- Brewer BW, Cornelius AE, Van Raalte JL, Tennen H, Armeli S. Predictors of Adherence to Home Rehabilitation Exercises Following Anterior Cruciate Ligament Reconstruction. Rehabilitation psychology. 2013;58(1):64-72. doi:10.1037/a0031297.
- Hill AM, et. al. Factors associated with older patients' engagement in exercise after hospital discharge. Arch Phys Med Rehabil. 2011 Sep;92(9):1395-403. doi: 10.1016/j.apmr.2011.04.009.
- Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy. 2010;15(3-2):220-228. doi:10.1016/j.math.2009.12.004.
- Sluijs E.M., Kok G.J., van der Zee J. Correlates of exercise compliance in physical therapy. Physical Therapy. 1993;73(11):771–782. (discussion 783–86)
- Henry, K. D., Rosemond, C., & Eckert, L. B. (1999). Effect of Number of Home Exercises on Compliance and Performance in Adults Over 65 Years of Age. Physical Therapy, 79(3), 270-277.
- Forkan, R., Pumper, B., Smyth, N., Wirkkala, H., Ciol, M. A., & Shumway-Cook, A. (2006). Exercise Adherence Following Physical Therapy Intervention in Older Adults With Impaired Balance. Physical Therapy, 86(3), 401-410.
- Hyde YM, Kautz DD. Enhancing health promotion during rehabilitation through information-giving, partnership-building, and teach-back. Rehabil Nurs. 2014 Jul-Aug;39(4):178-82. doi: 10.1002/rnj.124. Epub 2013 Aug 28.