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Toni Talks about PT Today

Home Programs

Published March 5, 2009 12:17 PM by Toni Patt
Home exercise programs are a part of physical therapy. We give them out regularly in just about every setting. A lot of thought and effort goes into developing the best program for each patient. Now that frequency and duration of therapy is decreasing, HEPs are taking on added significance. The more exercises I can get a patient to do at home, the more I can accomplish in the few visits I have with the patient. Therapists approach HEPs as a method to increase the effectiveness of treatment. There is a direct relationship between exercise and increased strength, balance, etc. That's how I've always thought about HEPs. I never thought about it from the patient perspective until recently.

Patients don't always see the HEP program as an extension of therapy. Non-compliance is a universal problem. Over the years I've tried many things to improve compliance. I've given fewer exercises. I've explained repeatedly the importance of the program and what it is supposed to accomplish. I've had patients practice over and over again before sending them home with the written program. I frequently wondered if the patient would perform the program. I never wondered if the patient could follow the program. After all, we had just practiced it in therapy. I think all therapists assume if we give a written program the patient will be able to follow it. What if the patient can't?

One reason is a language barrier. In Texas we have a large population of Spanish speakers. Texas isn't the only state like this. Many of these individuals find their way to therapy. Back in the day, before computer generated programs, I had to rely on stick drawings and a Spanish-speaking co-worker to translate.  Now I have computer programs that translate the program I just developed in English into Spanish. I'm sure this has improved compliance. While many Spanish speakers don't read English, they do read Spanish.

A less obvious, but more far reaching problem is the inability to read the program. Many of our patients can't read any language. They aren't able to follow the HEP because they can't read the directions. This occurred to me as I researched illiteracy and physical therapy for a recent assignment. I've always taken for granted that my patients were able to read whatever I gave them. And, considering the settings I've worked in, that is probably true. It would never occur to me that the reason for non-compliance is inability to read the program itself.

The problem isn't limited to language and illiteracy. Inability to read can also arise from visual problems. I can't read something if I can't see it clearly. Many elderly have vision problems. It never occurred to me that an elderly patient wouldn't be able to see the directions. I work with the elderly all the time. I automatically raise my voice and speak slowly. I'm careful to avoid white on white when working on mobility. Until a few days ago it never occurred to me to use larger print when issuing a HEP. I've started wearing cheaters to see smaller print. If I didn't have them I would probably have some trouble reading written directions in normal-sized type. I can easily see how doing the exercises isn't worth the effort of trying to read the instructions.

From now on I'm going to ask my older adult patients if they can read the HEP before I issue it. With all of today's modern technology there must be a way to increase font size if necessary. It's been awhile since I've used one of the computerized exercise programs.  Next time I do I'm definitely experimenting with changing font size.  I'm also going to print it as dark as possible to increase the contrast on the white background. Darker printing is easier to read. It's been a long time since I've used a copier that couldn't enlarge. That's always a last resort.

I'm amazed how I took this for granted. I've started to wonder what else I might be missing.


Dear Toni,

Good post.  Too many therapists do not put any critical thinking behind their home exercise program. I see problems such as:

1. Giving an exercise that isn't really necessary...I've seen too many therapists give "scapular strengthening" exericises for someone with a rotator cuff dysfunction, but who demonstrate excellent scapulohumeral rhythm.  Rather, these therapists are falling into the "cookbook" regemine...Back patients get set of exercises A and shoulder patients get program B instead of critically thinking about the patient's individual needs.

2. Designing a program that is redundant or contradictory.  Programs that include basic, intermediate and advanced exercises for one muscle group when all they really need is advanced.  Or a program that's contradictory: You need extension biased exercises, but also do double knees to chest

3. Just plain not thinking about the critical value of the exercise

4. Not explaining to the patient the purpose of the exercise and attempting to lead the patient by "blind faith." Remember, we have to "sell" it to the patient

5. Give the patient expected outcomes: what to do if there is pain, what is acceptable, what is not, what to do if there is a flare up.

6. Giving exercises that are too easy or failing to take out old exercises that are no longer necessary.  I still have too many patients I pick up who've moved on to eccentric loading on a stair at home, but their therapist still has them doing SLRs.

7.  ...this is in my opinion, the most important: It has to be realistic. One of our resource therapists the other day gave a brand new patient a 24 exercise home program and expected her to do it three times a day! Let's forget the fact she never reviewed the exercises with her nor asked her on follow up how she did with them. I don't know of any individual who can perform a 45 minute program 3 times a day, come to PT three times a week (why), work 40 hours a week and take care of their kids.  We are responsible for helping patients problem solve about how they can incorperate their program into their day...sometimes that means giving less, or giving strategies about alternatives to do when they can't drop on the floor of their office to exercise.  

...critical thinking about a HEP is one skill many therapists lack

Christie , PT March 6, 2009 6:18 PM
Streamwood IL

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