I asked my coworker to write a guest blog post on anything he wanted to write about. Naturally, he chose to write about home exercise programs for the patient. This is a great read for anyone from therapist to the rehabilitated. Check it out, and be sure to look up Ben Sherr as he is a tremendously smart therapist and definitely helps me on a daily basis.
During a course of physical therapy treatment, a patient may be seen up to 2-3 times a week for an extended period of time. In my short history as a PT, many outpatient orthopedic PT programs will not come to an end with the clearance and official discharge by a PT. Many people will self discharge, or not return to PT. Those are the cases that I will not be visiting in this blog. However, those who are officially discharged from physical therapy, where do they end up? Are they compliant with their programs that are set up for them? Are we as PTs working hard enough to ensure that the programs are sufficient for them after they finish their formal PT? The answers to these questions do not seem too clear. This is just one PT’s self reflection regarding patient’s adherence to their gym/home program following outpatient physical therapy care.
Recently, I have had several patients for whom I have set up gym or home programs to work on their PT exercises following successful completion of PT care. Whether they will complete their program at home, at the gym, with a trainer, or with a CSCS, they are all discharged with a plan going forward. I work in a clinic where there is a gym next door and there are plenty of terrific, certified personal trainers who are willing to help at a reasonable price. A goal may be to have them work with the trainer and then become independent and join the gym, once again at a reasonable price. I have found that many patients have a hard time following through with this or start this program and then fall off the wagon. The same speaks to the patients that will “complete their program at home”. Unfortunately, compliance to these home programs is usually slim to none. Some patients may leave physical therapy “pain free” but predictably down the road, they return with the same issues they started with. I put much thought into each individual home program to help my patients be successful. With a lack of adherence to these programs what do I get to show for it?
Most of these patients do very well while in PT, so when they return, are they using PT as a crutch? That is something that we as PT’s cannot enable, but that is a whole other topic, for another day. Back at the topic at hand.
Why do patients have such a hard time following through with their plan of care. Is it because they feel great and no longer need to do it? Is it because of differing mentalities? Is life just too busy? There could be many reasons. Well, research does back it up that most patients are not completing their PT home programs after PT, as documented by Rizzo, et al in 2014, stating “patient adherence to physical therapy home exercise programs (HEP) is estimated between 35 and 72%”. In addition to this statistic, the article also discusses mental models, which is basically how individuals view the world and how they think. Bottom line was that most patients and PT providers have differing mental models, so PT’s have to work extra hard to change their thought process to connect with the patient. Should we be the ones adjusting to them, or should they be adjusting their mentality to match ours? Again, difficult to answer.
I went into PT to help people. It is as simple as that. I unfortunately have to ask myself am I doing so? I believe that I am. I can only take a patient so far. If the patient is committed to PT as well, then they will do a great job. Not only during their official treatment time, but also when they’re on their own. I have come across some tips that may help a patient stay with their routine following PT. First off, finding a purpose. Why should this patient continue their exercises? Mostly, it will help them avoid re-injury and maintain their improvements. Maybe they are training for something, or maybe they want to better themselves in general. Any of these are reasonable. Another tip would be connecting to the patient in a more effective manner. The patient may feel more accountable to complete their exercises following completion of PT. From Campbell et al, “initial compliance with PT is high because of loyalty to the therapist.” It did not state that it drops off as time goes on, but I am sure that it does. Lastly, education. Educate the patient to the best of your ability as to why they must continue their rehab to avoid decline in their status. Or put a positive spin on it and educate them on how much improvements they will make by continuing the exercises. Use a goal as an example. Just a thought. In all honesty, and according to research, somewhere around half of the time it will not work.
Back to the personal cases that I have come in contact with in the outpatient orthopedic setting. I have had plenty of situations where past patients have followed through on their programs and eventually do not have to continue them. Mostly this is a post-operative patient who has done great. Those who continue their programs in the long term are most likely athletes who play a sport or in training for an event. These patients do great with continuation of care. The general public on the other hand, are very challenging. You try your hardest to adjust your mindset to think like the patient. Set them with plan for success. I have had three gentlemen in the past month who have been set with gym programs, and have not returned once. Is this my fault? I do not believe so. I set them up for great success and put in a lot of effort. The patient themself needs to be accountable at some point, and that starts right after discharge.
Maybe it is a possibly jaded view on the subject, but it seems that some patients just do not want to help themselves. In the healthcare system we have today, these people want a quick fix, and some get it, albeit sometimes temporary. Unfortunately, these patients are the ones who are the returning patients. And what do I do? Treat them with the best care possible. And will they follow their home program when finished? Maybe. Maybe not.