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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management: An Experts' Roundtable
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

How to Compel Patients to Complete Home Exercises

These tips from the field may help encourage patients with chronic pain toward an exercise regimen.
Pages 60-61

with Erik Shaw, DO, and Mark Jensen, PhD

Spurring a patient with chronic pain to execute a simple home exercise routine may require more than handing over a physical therapy worksheet. Fear avoidance,1 finances, and even depression2 can get in a patient’s way.

“You have to be respectful of the obstacles in a patient’s life,” said Erik Shaw, DO, medical director of Shepherd Spine and Pain Institute in Atlanta. “They have losses, tragedies, surgeries. You have to be mindful and modify your therapy plan based on what’s going on.”

According to a recent study of patients with low back pain, reported adherence to prescribed home-based exercise is between 50 and 70%.3 Pain practitioners often see patients who fail to perform the home exercises that would help their agonizing back or neck pain, but what are the keys to overcoming patients’ barriers? Researchers from Sweden, Switzerland, and France, as well as experts from two of the top 10 rehabilitation centers in the United States, according to rankings compiled by US News & World Report, share the following eight tactics to increase patients’ home exercise compliance.

Several recommendations to influencing patients towards an exercise regimen. (Source: 123RF)

Look Under the Hood

Repairing fear avoidance regarding exercise may be compared to fixing a car engine, explained Mark Jensen, PhD, professor and vice chair for research in the Department of Rehabilitation Medicine, at the University of Washington School of Medicine. “It’s hard to change what you do and what you feel without opening the hood and going in and changing your thoughts.” Clinicians could spend two minutes asking open-ended questions and then mirroring the patient’s answers back to them. Here’s a potential scenario:

Provider: What are your thoughts about stretching exercises for your low back pain?
Patient: Well, I tried to do them, but I stopped because they hurt.
Regardless of the response, reflect back to the patient’s core values/needs. Provider: So, what you truly want is to hurt less. Where could we start with that, I wonder?

Letting patients mull over their own logic may be more effective than pointing out flaws in their thinking. “It’s much more effective than lecturing them,” said Dr. Jensen.

Allowing a patient to think through and help plan home exercises is a must, according to a 2018 study by researchers at Zurich University of Applied Sciences in Switzerland.3 A key finding was that higher adherence to home-based exercises occurred when the exercise plans were self-initiated and self-organized.3 To facilitate continued home exercises at the end of physiotherapy, patients can be coached. As the study authors noted, “a good coaching process initiates self-efficacy and independence from medical interventions.”3

List the Benefits that Go Beyond Pain Relief

Sometimes it is not the pleasure of pain relief itself but other positive side effects that may strike a chord with patients and spark adherence to home exercise regimens. “Pain interferes with all kinds of things—employment, relationships, sleep,” said Dr. Jensen. For example, a patient who values employment may perform the exercises solely as a means to that end. A recent study of pain acceptance conducted by researchers at Linköping University in Sweden found that the impetus to proceed with home exercises for many patients is accomplishing these side goals versus eliminating pain.1 “[Pain] acceptance is not about struggling with eliminating pain, but about performing activities that are in line with one’s own goals of daily life,” wrote the study authors.1

Try Motivational Therapy

Another approach worth trying is motivational therapy. Ask patients to name a personal trait that has served them well in life, advised Dr. Jensen. If the patient says he or she is a hard worker, then ask the patient to name three examples of good life outcomes that resulted from this hard work. This approach may get patients thinking about their own character strengths, rather than ruminating on their own poor fortitude that prevents them from undertaking home exercises.

The goal, Dr. Jensen explained, is to alter the thoughts that run through patients’ heads. “You want to alter [their] beliefs about outcomes and their self-efficacy. That’s really the underlying target.”

Consider Informal Hypnotic Therapy

Clinicians do not need to be trained in hypnotherapy to facilitate a simple openness to new thoughts in their patients. Instead, “hypnotic language,” or affirmative suggestions, may be used, advised Dr. Jensen. If a chronic pain patient wants to stop smoking, for example, a clinician could respond with: “I think it’s possible for you to quit smoking sometime this year.” Avoid the words “try,” “must,” and “should.” Instead, state what you think is possible for the patient.

This approach may be useful in helping patients endure pain that may occur when initially performing certain home exercises as well. For instance, a clinician could urge the patient to: “Imagine the [pain] sensations as an image, maybe a fire or a bunch of knots. Now imagine pouring water on the fire. Picture the knots unraveling.”

Establish a Routine After a Spinal Injection

If a patient is in too much pain to move, a spinal injection to silence a screaming back, for instance, may be all that is necessary to free a patient to launch a home exercise routine that will provide long-lasting relief. Dr. Shaw noted that in his practice, an injection often helps to “break down the barrier” and provide the momentum a patient needs to be successful with physical therapy.

Tweak Approaches to the Patient’s Ability

This step may seem obvious enough, but keep in mind that young, athletic patients may find simple exercises too boring, while older patients may find any more than four exercises too complex.3 Dr. Shaw noted that he accounts for age, debility, and comorbidities when assigning home exercises.

If a patient is wheelchair bound, advised Dr. Shaw, a provider could state: “I’m not asking you to run a marathon, I’m asking you to exercise a little bit. Then, as you get stronger, you can do a little bit more, then a little bit more.” He also encourages patience. “It is going to be slow,” he advises his patients, but points out that, “Everything that’s worthwhile is going to take a little bit of time to build.”

A recent study of patients with lower back pain showed that customized home-based exercises improved compliance.3 Participants who perceived the exercises as “individualized to their life situation and targeted to their back pain problem [helped]… improve adherence to exercise.”3

As well, it is important to focus on what the patient can do. Sometimes, patients “can be very fatalistic, saying, ‘I can’t do this. I can’t do anything,’” noted Dr. Shaw. He tries to break that thought pattern by saying, “You can’t do this, but you can do that. I reinforce the things that they are capable of doing.”

Involve Family and Peers

When possible, help the patient create a home support team.2 Family members can provide words of encouragement or press play on a patient’s favorite music to energize the exerciser. A favorite playlist or TV show played during exercise has been shown to enhance adherence.2 In addition to family members, peer involvement, whether via a social media forum that unites a group of patients with back pain, or a weekly exercise session, can create a positive network for patients that helps them adhere to home exercise. 3

Follow Up

Patients often prefer to be held accountable with physical therapists or physicians, whether in the form of a follow-up appointment, a diary, or a weekly spreadsheet of completed exercises that they email to a provider.2 In a qualitative study of 29 patients with lower back pain, the patients interviewed “reported the need to be supported and to have close follow-up to maintain their motivation to exercise.”2 

Last updated on: April 12, 2019
Continue Reading:
How to Talk to Your Chronic Pain Patients
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