Shownotes
In this episode, I'll be talking about exercise adherence and how it can be such a powerful lever to helping patients get better results. First, I'll go over the exercise spiral of despair and two traps, we as clinicians, can fall into. Then I will share the surprising solution that I've come to realize and what exactly we can do about it to help our patients achieve greater recovery.
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Transcripts
Welcome to the unleash, your best clinical self podcast.
Speaker:I'm your host, Andrew Cobian.
Speaker:If you're a physiotherapist or other movement professional,
Speaker:who feels like you're stuck in a rut, then my podcast is for you.
Speaker:This podcast is focused on helping you move from frustration to
Speaker:flow in your clinical practice.
Speaker:And each episode I'll share strategies, approaches, and my latest thinking
Speaker:on how to improve your clinical performance and keep loving what you do.
Speaker:This is episode number 68.
Speaker:And this episode, I'll be talking about patient exercise adherence.
Speaker:And some practical reframing of how to approach building exercise,
Speaker:adherence capacity in your patients.
Speaker:I want to let you know that I have a newsletter where I
Speaker:dive into topics relating to improving clinical performance.
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Speaker:Patient's not doing their exercises.
Speaker:Frustrating.
Speaker:I'm just going to say it.
Speaker:It, I think frustrates all of us as clinicians.
Speaker:You know, we can spend so much time teaching exercises and we feel confident
Speaker:that they know the parameters of the exercise for what they need to do at home.
Speaker:But then we can ask them the next time they come in, how
Speaker:did it go with their exercises?
Speaker:And we can often get a lukewarm response.
Speaker:Or even hesitation from our patients.
Speaker:When we press a little deeper, we come to understand that they didn't
Speaker:actually do their exercises or they did them quote, unquote, occasionally.
Speaker:You know, it can be frustrating for us.
Speaker:I think that sometimes that frustration can definitely impact, the therapeutic
Speaker:relationship and it can impact how much we're enjoying our work.
Speaker:And whether we can stay in a place of clinical flow.
Speaker:The reality is it's not uncommon at all.
Speaker:It's actually very common in studies regarding exercise adherence.
Speaker:And there was a study by Eckerd and all in 2015, it showed that exercise
Speaker:adherence can be around or even below 50%.
Speaker:So if we're not really tackling this issue of exercise adherence, Then I
Speaker:think we're really missing the boat with a lot of our patients who may
Speaker:not be doing exercises consistently.
Speaker:Exercise adherence has been a real interest of mine for some time now.
Speaker:I see it as such a powerful lever to help patients get better results.
Speaker:Better exercise adherence helps guide treatment.
Speaker:And I find that it gives us a stronger signal regarding how
Speaker:effective our treatment and exercise recommendations have been.
Speaker:And it helps us to be able to know with more confidence, if we're going
Speaker:the right direction or not from a treatment planning standpoint.
Speaker:I've talked before about this idea, what I call the exercise spiral of despair.
Speaker:And it's something that I've observed in my own clinical practice, as
Speaker:well as in conversations that I've had with other clinicians.
Speaker:And it's oftentimes a place where poor exercise adherence.
Speaker:Can result in poor treatment outcomes.
Speaker:But it can often be, I think, a bit of the catalyst to shifting to more
Speaker:of a passive treatment approach.
Speaker:Let me just explain what I mean by this exercise spiral of despair.
Speaker:We give the patient exercises.
Speaker:The patient maybe has done them initially, or maybe it hasn't really been that
Speaker:successful doing them, right off the bat.
Speaker:And then we check in with them and maybe they may then maybe
Speaker:they're honest with how they're doing, or maybe they're not honest.
Speaker:Regardless, they maybe don't feel all that confident.
Speaker:And in terms of doing exercises, So we maybe encourage them to
Speaker:say, Hey, you know, that's okay.
Speaker:Just keep at it to takes a bit of time.
Speaker:And, and more often than not, we actually ended up giving
Speaker:more exercises to the patient.
Speaker:And oftentimes what happens is that the patient feels bad.
Speaker:You know, here I am not living up to the expectations that I have.
Speaker:For my therapist.
Speaker:And then what ends up happening is it becomes a bit of this awkward
Speaker:exchange, or it can be, between ourselves and the patient.
Speaker:As we're trying to navigate the situation and one of two things can happen.
Speaker:When does that?
Speaker:Well, first off, I think we'll typically not see a lot of change in terms of
Speaker:patient symptoms or functional outcomes.
Speaker:but more often than not, we'll find ourselves in a situation where
Speaker:either the patient drops off because they're not seeing the change or
Speaker:we end up almost subconsciously reverting more to passive treatments.
Speaker:I think in part it's because we find ourselves maybe frustrated
Speaker:with maybe the lack of adherence.
Speaker:And so we sort of almost inadvertently ask ourselves what's the point
Speaker:of getting more exercises if they're not going to do the ones.
Speaker:That we've already given.
Speaker:And so then we end up doing more passive treatment within the session.
Speaker:Because really giving more exercises or reviewing the existing exercises,
Speaker:isn't really going to move the needle.
Speaker:And I really do think that helping our patients with behavior change.
Speaker:Extends way beyond exercise adherence.
Speaker:And I think it has impacts in terms of changes that we would encourage our
Speaker:patients to make around stress management.
Speaker:Sleep habits.
Speaker:So many different areas and that's why I think it's such an important
Speaker:area for us as physios too.
Speaker:Uh, get more comfortable with and improve how we approach this area.
Speaker:A few years back, I had developed a framework, which I presented.
Speaker:For a workshop I did around patient exercise adherence.
Speaker:And it looks at what I think are the essential ingredients necessary to see
Speaker:patients achieve success with building new exercise and movement habits.
Speaker:And really it answers the what to the, who, the how and the why.
Speaker:I think we have at the core, we have the exercise parameters.
Speaker:The exercise and the exercise parameters, which is really the what, but I think
Speaker:there's really three key areas that we need to also address beyond the
Speaker:exercise and the exercise parameters.
Speaker:And that's how we need to bring meaning to the exercise.
Speaker:Why did you give me this exercise?
Speaker:We have to connect the dots for our patients.
Speaker:And then we have to make sure that there's trust.
Speaker:I'm trusting what you're saying and my trust in you, that therapeutic Alliance.
Speaker:Is going to give me that confidence to step forward and doing an exercise
Speaker:that I'm really not sure if it's going to have an impact for me.
Speaker:And then the third component is structure.
Speaker:And this is the how.
Speaker:When are you going to do this?
Speaker:How are you going to do this?
Speaker:Really it's this to behavior design component that is also really important.
Speaker:And I think often gets missed.
Speaker:So we really have at the core, we have the exercise and the parameters around that
Speaker:exercise, but then around that we have.
Speaker:The meaning.
Speaker:Of the exercise, the trust factor around the exercise and then the structure.
Speaker:Of the exercise.
Speaker:While back.
Speaker:I had a patient who experienced regular headaches, neck, and jaw pain.
Speaker:And after a few sessions to address the neck and the jaw, she shared how she felt.
Speaker:A lot of her symptoms were triggered by.
Speaker:Her chronic stress response.
Speaker:She'd always been interested in meditation.
Speaker:She was open to it.
Speaker:She had tried in the past, but she just really found it difficult
Speaker:to develop a meditation habit.
Speaker:And in this situation, I think there would be all the ingredients were
Speaker:necessary that were there, you know, there was meaning with the activity.
Speaker:We had a supportive therapeutic Alliance, but we were missing
Speaker:an important ingredient here, which was behavior design.
Speaker:So what could be the reason why a patient wouldn't end up doing an
Speaker:exercise, even when they're motivated and able to perform the exercise?
Speaker:Well, I think at times a lack of consistency with exercise may be
Speaker:a result of a patient not being ready to engage in the activity.
Speaker:Which is what you know is explored around with the trans
Speaker:theoretical model of change.
Speaker:But I found that more often than not the patient lacks a system to integrate
Speaker:the movement practices into their life.
Speaker:I've come to realize that patients who quickly adopt an exercise
Speaker:program are those who are already skilled and experienced at developing
Speaker:exercise, routines, and habits.
Speaker:But there are many people who struggle or have had little experience in
Speaker:developing movement or exercise routines.
Speaker:And those are the people that we need to help.
Speaker:We can fall into one of two traps.
Speaker:When we encounter these situations where the patient's not doing the exercise.
Speaker:We may encourage our patients to try harder in the upcoming week.
Speaker:And we can even acknowledge that maybe doing exercise consistently
Speaker:can be challenging, but we just say, Hey, pull up your bootstraps.
Speaker:Try again.
Speaker:Let's do better next week.
Speaker:And the other option is that we just ignore this lack of exercise
Speaker:consistency, and we just end up giving more exercises, hoping that
Speaker:somehow their exercise adherence.
Speaker:Habit will just kick in automatically.
Speaker:Unfortunately, both of these responses, don't really equip our patients
Speaker:with the tools and strategies.
Speaker:To make progress toward better exercise consistency.
Speaker:I found that oftentimes an insidious belief that can creep into our thinking.
Speaker:Is one where we end up placing the responsibility solely on the
Speaker:shoulders of the patient for not being consistent with their exercises.
Speaker:We come to believe that it's a patient problem.
Speaker:But I've come to realize over the years that it's actually a design
Speaker:problem and not a people problem.
Speaker:One of the common causes of patients for getting to do their exercises is the lack
Speaker:of a trigger or a prompt to help integrate a new exercise behavior into their day.
Speaker:I've heard so often patients telling me how they remembered their exercises
Speaker:as they were laying in bed at night.
Speaker:Unfortunately, I haven't had many patients who told me that they would then
Speaker:do their exercises with that reminder.
Speaker:And I think we need better reminders and explore that with our patients.
Speaker:With the constant barrage of distractions that exist today with
Speaker:the pervasive use of technology.
Speaker:I think it's really easy to forget our exercises.
Speaker:Well, I won't be going through all the components today of how
Speaker:to design new exercise behavior.
Speaker:I do want to talk about this important area.
Speaker:Of helping our patients identify a successful trigger, a way to
Speaker:remember to do their exercises.
Speaker:There are so many different triggers that can prompt us to take action.
Speaker:BJ Fogg outlines in his book, tiny habits that we can have internal triggers.
Speaker:Environmental triggers.
Speaker:And then we can have existing action or routine triggers.
Speaker:So let's take the example of brushing our teeth.
Speaker:And internal trigger may be the taste in your mouth after eating or drinking.
Speaker:Something that prompts you to actually brush your teeth.
Speaker:And environmental trigger may be walking into the bathroom
Speaker:and seeing your toothbrush.
Speaker:And then an existing action trigger would be brushing your teeth
Speaker:after you've completed your meal.
Speaker:When it comes to exercise adherence.
Speaker:A common internal prompt, maybe doing an exercise when you feel pain or discomfort.
Speaker:And an environmental prompt may be seen a yoga mat on the floor in the living room
Speaker:that triggers you to do your exercise.
Speaker:And an existing action trigger may be doing the exercise.
Speaker:After you have.
Speaker:Uh, washed your hands, going to the bathroom.
Speaker:And now you do three wall slides after you've done that.
Speaker:Now a lot of times we think, well, I reminder in your phone is enough.
Speaker:And for some people, technology prompts can be a great way
Speaker:to trigger doing exercises.
Speaker:But I would say that given the number of notifications that we
Speaker:have on our phones and our watches.
Speaker:It's something that can really fail quite easily.
Speaker:For most of us.
Speaker:And I know for myself too, we're just conditioned to ignore technology prompts.
Speaker:More often than not.
Speaker:We rely on internal prompts with exercise adherence.
Speaker:Patients will be reminded to do their exercises when they're experiencing pain.
Speaker:And BJ Fogg shares that habits need an anchor.
Speaker:He's found that existing actions routines can often be the most reliable triggers
Speaker:to help with instilling desired behaviors.
Speaker:So if we can attach an existing habit or routine, and couple that with a new habit.
Speaker:Now, all of a sudden that becomes a really powerful reminder system
Speaker:to take action with the new habit.
Speaker:So what happened to my patient who is struggling to meditate?
Speaker:So we brainstorm some different types of habit triggers as
Speaker:well as a desire time of day.
Speaker:We explored different triggers and landed on the trigger
Speaker:of doing a short meditation.
Speaker:After she ate breakfast each morning.
Speaker:The following week.
Speaker:She came back to see me.
Speaker:And she had a big grin on her face.
Speaker:As she shared how consistent she had been with her meditation practice.
Speaker:And how she hadn't had any headaches that week It was amazing and i think
Speaker:it really opened our eyes to see how powerful it was to be consistent with
Speaker:small daily action So to recap today's episode i think there's a few things
Speaker:that i want you to take away from this It's one i think we want to avoid that
Speaker:exercise spiral of despair and take a look at your own clinical practice and see if
Speaker:that's something that you've noticed with patients who maybe struggle with exercise.
Speaker:Second i think we have to remind ourselves that when patients are struggling with
Speaker:exercise That we don't put the blame on them instead recognize that it's a design
Speaker:problem not a people problem And then third we need to make sure that we not
Speaker:only give good exercise parameters and good exercises but we also have to ensure
Speaker:that we are including meaning structure and trust to the exercises that we give.
Speaker:Thank you for hanging out with me today and hearing about how you can improve
Speaker:exercise adherence with your patients Make sure to subscribe on itunes or
Speaker:spotify To stay up to date on future episodes And if you've enjoyed this
Speaker:podcast I'd truly appreciate if you could leave a five-star review on itunes
Speaker:Here's to less frustration more flow and better clinical results till next time
