Why Patients Don’t Do Their Home Exercises: And Why They Should. Bridging the Gap.
Updated: Dec 31, 2020
If you ask any professional in the therapy world what their biggest pet peeve is, nine times out of ten it is that their patient or client hasn't done their home care. It might not sound like a big deal, many GP patients don’t take the medication that they were prescribed either. As we go through this blog I hope you can see that, actually it is a big deal. It lowers patient outcomes which at the end of the day affects the patient in resolving their issue. It also puts extra pressure on the wider health care services due to backlogs and a build-up of patients not getting better due to noncompliance. But is it the patient's fault of the practitioners? Let us have a look.
Chiropractors in Cardiff and all over the world have done (I hope) extra training in patient compliance, some resort to scare tactics as well to get their patients to do their home exercises. “Mrs. Jones, if you don’t do your home exercises your pain is going to get a whole lot worse”. And others have gotten grey hairs trying to reach that holy grail of patient compliance to do their home care to help in getting better. When I started this blog I thought it would be pretty straightforward, but as I got deeper into the subject I realised you could write a book on it. I will do my best to keep it as concise as possible.
Before I list the top 5 reasons you need to do your chiropractic home care, I want to delve a little into why patients seem to brush over home care and turn up on the next session with their tail between their legs apologizing that they had “completely forgot”, “the internet was down, and the exercises were in the email”, “I was too tired”, “I didn't understand the exercises”, “the exercises made the pain worse”, “oh they were for me?”, “Why should I do them if I am seeing you?”. I could write a longer list but I’m sure you get the idea. Let us break down the different reasons patient don’t comply
Why don’t patients do their home care?
Compliance: Let's start with a big word in a doctor-patient - relationship, compliance. What does compliance mean? Compliance means to follow the guidance of a professional to help that person in whatever the issue may be. It is built on trusting the professional that what they are saying/advising is going to help. Trust! The most important aspect of compliance. If a patient does not trust the professional giving advice, then the likely hood of them listening and complying to you is low to non-existent. It may seem simple, yet it’s not, not at all. Take, for example, lower back pain. A study showed that only 37% of patients do their home exercises. That is incredibly low. And there have to be reasons. Reasons that are obvious and reasons that are less obvious. It is important to build a relationship with a patient, no, not to go to the pub with them on a Friday night but to "actually" listen to their concerns. Communication is really that imperative to compliance.
Poor communication: I wish I knew better communication when I first started practicing as a chiropractor. It is a learned skill, yes some people do it naturally very well, but it is, in most cases a learned skill. Communication breakdown is top of the list when it comes to trust and compliance. Listening is an art. Sometimes we may think we are listening but we can still miss the most important points the patient is feeling and trying to communicate. Chronic pain is an all-encompassing experience that has many layers of emotions, behaviors, and complexities. We have to know when to give the patient what they want and when to explain and educate that what they want is not the right thing for them at that moment in time. Often home care is given and not truly explained why it has been given in the first place. If I give a stretch for the lower back I explain what it does, how it helps, how it is done, when, for how long and to contact me if they are still not sure. I will also explain again in a follow-up. I also ask, is there anything they are unsure of, sometimes three times. People often just say yes when they are not sure to save face. If it is a patient's first experience in therapy, it is normal for them to feel nervous and fearful. It is a lot of information to process, which is why communication is key.
Fear. Chiropractors deals with pain mostly in practice. Pain can have different fear levels from person to person. Some people deal with it and get on with life. They choose treatment because the pain is interfering with their life. For others, pain can turn their life upside down. Stop working, take medication, and become fearful to move, get it looked at, and not change anything in case it makes the pain worse. We all have different tolerances to physical and emotional pain. So when home care is given, it can be quite scary for a patient who has become fearful of change. Fear is also an emotion related to the fear of failure. There are cases where someone has never done any exercise before. It’s no wonder that can be scary for people. A patient may think, not always consciously “if I do these exercises, work hard at them and they don’t work and make my pain worse, I’ll be a failure”. No one wants to feel like a failure, so the best thing to avoid that unpleasant emotion is simply not to do it. My job is to guide, slowly, show them that they are capable and work on their negative self-talk.
Life. It’s a busy world and people are busy. Adults have kids, jobs, sometimes three, bills, visiting people here and there, cars break down, hobbies, volunteering, etc. A common reason for patients to not do their exercises is because they don’t have the time. I understand this but feel there is a workaround. I usually start by asking the patient if treatment right now is suitable for them. For me to do my job at its best I need a certain level of commitment from them to get their problem resolved. Home care is one of them. I explain that the treatment we do will help and the home care will help just as much because it is their body. Whether it’s a lack of movement in their life, an injury, or something else, the patient has to take a role in their own care. The aim is to get them to a point where they can manage their issue by themselves. This creates resilience, robustness and an increased confidence in their abilities to self-manage. This is done through education, guidance, and sometimes a drip-fed approach for people who are failing in their home care. I also explain that time has to be put aside for home care or treatment will either take a long time which costs money, or depending on the issue it might not actually get better without home care and self-management. In some cases, we adopt a coach like relationship.
They prefer drugs: Codeine, Fentanyl patch, hydrocodone ,hydromorphone, meperidine, morphine, oxycodone, tramadol, naproxen, gabapentin, ibuprofen, aspirin, amitriptyline, diamorphine, Pethidine, Caffeine, alcohol, cannabis, amphetamines, heroin, nicotine. That’s a lot of pain drugs! Many chronic pain patients may be on a few of these and for a long time. Often patients who have taken long-term medication for pain are reliant on these drugs, which creates its own issues. Opiate based medication is a huge issue, increasingly in the UK. Often the thought of exercises over pain medication is an easy decision. “Let’s take the drugs and leave the exercises for now. I’ll do them tomorrow because today is a bad day”. Our aim is to get people off their pain medication with the guidance of their GP. Drugs have harmful effects and exercises are natural, and research shows exercise may be just as effective as pain medication. Also, the efficacy of pain medication wears off generally after 6 weeks. That’s why many patients are on such large doses of pain medication to gain the same pain relief. Taking a tablet is much easier than a backstretch/strengthening routine.
“According to the World Health Organization (WHO), approximately 125,000 people with treatable ailments die each year in the United States because they do not take their medication properly.”
It might make the pain worse: Sure, it does happen, some may say it’s even normal in the beginning. It’s a normal response to want to stop exercising because it hurts. This is where communication is imperative. We need to explain that when the body starts something new, then the body may and can react. Someone who has never been to a gym or exercised will feel achy, because the body is not used to it. Communicating that starting off slow and increasing exercise therapy over time, limits increased pain levels. We want it to be enjoyable, not a chore so we have to approach exercise and movement in a positive light, rather than exercise being the enemy.
Lack of support: As a practitioner, we have to remember that we have the knowledge. We spent many years learning the intricate anatomy we have, movement, gait, exercise therapy, and rehab. A patient may know next to nothing about chiropractic or physical therapy. Keeping medical terminology simple, helps in better communicating what their issue is and how to help it. Often patients are given a piece of paper with exercises and sent on their way. That piece of paper may be looked at and then thrown away lost in the depths of time never to be seen again. It is one reason patients no show at the next appointment because of either embarrassment they did not do them or feel unsupported. In most cases I will go through the exercises with them, making sure they are comfortable and understand how to do it on their own. If they need extra support then I offer it to them. They can call me, or send an email. I always say there is never a silly question. I would ask if
there are any family members or friends that can help them too.
Cost: Chiropractic is not the most expensive treatment in the world, but it’s also not cheap for someone on a low income or out of work We are private healthcare. Depending on the issue we are treating, it can take time. If a person has had 20 years of chronic lower back pain, then it is unlikely they will be pain-free after one session. Most people will be given exercises on their first session, but it’s not uncommon for them not to return due to finances. We can only do so much for how much time we physically see them. Many patients will go for one session hoping for a quick fix. Quick fixes do happen but not as regularly as we would want. The body takes time to heal. Some people have long-standing issues that will need regular treatment to keep their pain at bay.
Mental health: Anxiety, depression, bipolar, schizophrenia, PTSD, OCD. To name a few, it’s no surprise that mental health is at the forefront of the news and social media. Especially during a pandemic and during the festive period. People struggling with mental health issues can struggle with the many things we take for granted like going outside, let alone their prescribed 20 squat thrusts. We have a list of mental health professionals to refer to if we feel that their mental health issues need addressing first. We can still help people but we have to prioritise and triage. People with mental health issues may have low motivation, negative thinking, and self-destructive behavior. Trying to add positivity into someone’s life can be met with resistance. In this case, we either refer to a mental health professional or start off with say, one exercise and build up gradually. It is important to understand what a patient is going through too and put yourself in their situation.
I feel the above is a pretty exhaustive list of reasons patients choose not to do their home care. Let's discover the benefits!
The benefits of home care:
It helps with pain: Yes! Exercise has been shown to reduce pain levels, and dramatically. It has to be done in a controlled and manageable way of course. Exercise releases neurotransmitters called endorphins. These are happy chemicals that flood the brain and body making us feel good. The body has an incredible ability to adapt to stressors. The body can be broken down but it can also rebuild, get stronger, get tougher even as we get older. Exercise acts as a natural pain analgesic. Not only does exercise help with the pain it is important to all of our organs and bones. A hip fracture in later life can be fatal. It’s literally a no brainer to do start doing prescribed (by a professional) exercises at home.
Saves money! The more someone is self-reliant on home care, the less in house treatment they will need. We offer maintenance sessions for people who enjoy the treatment, have certain orthopedic issues that need more care. But we have found the people who follow their home care have the best outcomes.
Better outcomes: Homecare was never put on this world to annoy someone or make a patient feel bad about themselves. Unfortunately, it can have that effect when you look deeper into this subject. None the less, people who are proactive in the treatment and home care have far better results than if they don’t do the exercises. Patients come to us to get better but often do not realise what it can take to get the desired effect.
It’s not as difficult as our mind tells us it is: Starting something new can be daunting, scary, anxiety-inducing, and filled with negative self chatter and thoughts. “I can’t do it”, “I’m too heavy”, “the pain is too much”, “I'll fail”, “my back will break if I do that”. The more time we have to think about it, the more likely we won’t do it. Patients find that when they have done a home care routine, they feel a sense of achievement. Chiropractic home care is not about running a marathon or becoming an Olympian. It is about resorting the function to the body so it can complete everyday tasks again. The exercises for most people are simple, easy to perform but effective. When someone who has never exercised and asked to do so, they might have an image of an athlete, a hench marvel character, or Mike Tyson. We are not looking for that. Using mental imagery can help. A bit on that later.
Life will be better! The best part of being a chiropractor is achieving great outcomes. When a patient comes back and says they feel fantastic and went for their first run yesterday, the high fives come out. Getting people back on the feet is a goal of mine but when it’s a goal for both of us, great things happen. Goal setting is essential in a patient-doctor relationship. It is a patients goals that really matter, but it’s important for me to set the right goals so they get better. Most patient's goals are to relieve their pain. Great, it’s a great goal to have. Some want to go back to the gym, some want to have sex again (yes pain can affect someone's sex life) with their partner. Following care is not always easy due to life, mental health, finances, etc. Working together and compromising here and there in most cases gets the results people are looking for.
1. Create a space: Make a space that is yours for your home care. Whether that is applying pain lotion, an ice pack, or performing your home exercises. Make this space comfortable and welcoming. This is your “healing time” if you like. Creating a space creates structure. It’s also setting a mini-goal for yourself. Because you have created this space, now you have to use it.
2. Set aside time: Most home exercise prescriptions don’t take that long to complete. 20-30 minutes max! Setting a time each day again creates structure and makes you more likely to do it. Having a daily routine not only helps with pain but gives you the benefits of health improvements. Exercising helps the heart, lungs, brain, gut, and much more. Don’t be surprised if you feel more relaxed and sleep better too.
3. Use mental imagery: This is not voodoo but what professional athletes are thought by their coaches and sports psychologists. Our mind is very active and powerful. It can work with us or against us. As I mentioned, when people who are not versed in exercising and when asked to do so, they may think of a god-like pro athlete, glistening in the sun and glowing of fitness ready to win a medal. This looks like a positive image but not if a patient is comparing themselves to this god-like pro athlete. They may feel deflated and feel that the image in their mind is unattainable yet, that is their mental image of fitness. We want to set a realistic goal. Imagine life without pain, the things you could do again. Imagine life without pain in your own house, smiling and being happy. Positive mental imagery can have dramatic effects on pain levels and well-being. It’s beneficial to practice this while doing the exercises. When you are in this mental imagery, a more therapeutic and realistic outcome is acheived.
4. Ask for help: If you feel you need support from home and have a loving family ask them, friends?, ask them. Going through the movements with another person can add an element of fun. It can also show you what you are capable of and perform them on your own with no problems.
5. Push yourself: It might sound aggressive but we have to push ourselves. Success is built on hard work. The exercises themselves are usually quite simple yet we all have different levels of ability. Some people are stiff, some are too loose, everyone is different. To get the results we want we have to keep at it. In the clinic here in Cardiff, many people stop doing their exercises because they feel better. That’s great they are feeling better, but guess what? They come back in a few months because the pain is coming back. We are not sure why pain comes back after a period of time. It could be a lifestyle, a new issue, something we had missed or something they are not telling us. I believe that staying active is key to a healthy life. Many people keep up the exercises prescribed as they enjoy it. Some even take up sports and start new hobbies. Once you start we hope you never stop.
I hope you have enjoyed this blog. Any questions can be sent to firstname.lastname@example.org
Matthew Corbin D.C
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