- Physical therapist, Dr. Shawn Berger discusses his evidence-based approach to prescribing home exercise programs.
- To create an individualized treatment plan, identify the patient’s values and barriers to exercise in addition to assessing the injury or pain.
- When prescribing a home exercise program, only prescribe 2 exercises - single set and higher repetitions.
- Encourage your patients to create goals that allow them to actively participate in their own recovery!
Do you as a clinician dose home exercise programs (HEPs)? Do you feel confident that your patients do their HEPs?
A good home exercise program allows a patient to increase physical function so that progress is gained rather than lost from one visit to another. However, research shows only 35% of physical therapy patients comply with their HEP.2 There are many reasons for this: lack of motivation, limited time, and perceived barriers to exercise. So, what can you do as a clinician to help improve patient compliance?
Dr. Shawn Berger (PT, DPT, CSCS) breaks down the history of HEPs and discusses his evidence-based approach to prescribing home exercise programs.
Watch the full video here!
3 Objectives of this Article
- Learn how you can identify the patient’s values and customize a treatment plan based on what goals the patient has for their recovery.
- Review the pros and cons of exercise frequency and duration when dosing home exercise programs.
- Learn what other best practices you can use in your clinic to help improve patient compliance.
What is the Goal of Your Patient’s Recovery?
It’s important to ask your patient, what do you want to get out of physical therapy? During his webinar, Burger shares a story about a woman in her mid 50’s who came to PT following a serious fall. She suffered a fractured elbow that required surgery and had since left with her limited range of motion. Even 6 weeks post-surgical, her elbow range of motion was –60 degrees flexion and –30 degrees extension.
After a few visits to his clinic, Burger noticed she was struggling to commit to her HEP and instead of prescribing more exercises to do at home, he instead asked her what her biggest goal was. She excitedly replied that she missed being able to do her own hair and makeup without having to bend her head forward to reach. Burger then prioritized her HEP on exercises that would soon help her do her own hair and makeup again which led to increased results.
In addition to assessing injuries and pain, talk to your patients about their lifestyles, habits, and individualized needs as Burger did with his 50-year-old patient. What kind of daily activities have been impacted since their recent surgery or injury? Is it getting dressed and grooming? Bathing and toileting? Bringing food to their mouth? Educate your patients on the importance of their HEP and how it can impact their goals. Patients need to feel confident with their HEP so they feel comfortable consistently performing the exercises.
History of Dosing Frequency and Duration
Historically, patients are recommended to perform exercises in sets of 3, 10 repetitions each set. But where does this number come from? Is it because it is easier to explain to patients and short enough for patients to adhere to it? When examining a patient in an acute or chronic phase of an injury, ask what the goals of physical therapy are.
- If the goal is to increase strength and power, prescribe 3-6 repetitions.
- If the goal is to focus on high-intensity endurance and speed work, prescribe 10-12 repetitions.
- If the goal is to focus on low-intensity endurance, prescribe 20-25 repetitions.
For those higher repetitions, have your patients increase the intensity of resistance to higher levels.
During a visit to the clinic, a patient may be required to do anywhere from 8-12 different movement patterns to rehabilitate an injury. This visit can take up to 45 minutes – 1 hour. However, the home exercise program is designed to maximize the results of therapy while accommodating busy schedules. When a patient is prescribed more than 3 exercises to do at home, compliance decreases. Reasons for that are often because of the time allotted in a day to doing these exercises. To increase compliance, it is suggested to prescribe a patient no more than 2 exercises.
- As exercises decrease, compliance increases: suggest 2 exercises or less that work multiple muscle groups.
- As sets decrease, compliance increases: suggest single set dosing, compliance is shown to decrease with multiple sets.
Based on his professional experience, Burger tells us that less is more. Clinicians have the option to change these exercises after each visit to the clinic. If a patient visits the clinic on Monday and performs 8-10 stability movements, prescribe 2-3 of those same exercises for them to continue at home over the next couple days. After the next scheduled PT session, assess and change the exercises! For patients with a lot of pain and chronic conditions, it is best to recommend single-set dosing. For example: 1 set of 30 repetitions. If the exercise is not challenging enough for the patient, increase the resistance levels.
Looking for some exercises to recommend to your patients? Here are some suggestions!
3 Best Practices to Consider
Evidence-based research has taught us that pain is not functional. It is a barrier which can be a deterrent for exercise program compliance than the patient’s goals. A patient can be highly motivated, but pain is what limits patients from continuing exercise outside the clinic. Consider using these best practices in your clinic to help improve patient compliance!
- Provide clear instructions, both printed and verbal instructions, when introducing a new exercise program. For patients experiencing knee or hip pain, demonstrate how to lower into a chair that can reduce risk of injury.
- During each visit, assess and progress. Ask the patient to demonstrate the exercises you prescribed for them to do at home. If the patient is having difficulty performing an exercise at home, reduce the repetitions or adjust the resistance level. If the patient is improving, suggest a more challenging exercise with greater resistance.
- Both the patient and the PT are responsible for compliance. As clinicians, it is important to utilize the best research and science and guide patients. Dedicate time at the beginning of your session for patients to ask questions about their home exercise program and how it contributes to their recovery.
About Dr. Shawn Burger
Shawn Burger, PT, DPT, CSCS, received his master’s degree in physical therapy in 1998 from Loma Linda University School of Allied Health. Today, he operates Burger Physical Therapy, providing outpatient, acute, and long-term care rehab services. Shawn led the early adoption of electronic health records, becoming one of the first practices in California to adopt a solution in 2003. Shawn has a personal interest in identifying value-added solutions to rehab therapy. He has extensive experience working with HMO and Capitation contracts and teaches others how to maximize best practices.
1. Heffernan, Conor. (2017). 3 Sets x 10 Reps: The History, Logic and Reasoning. Physical Culture Study. Retrieved from https://bit.ly/2WOePgC
2. Parsons, Andy. (2018). 4 Tips to Maximize Home Exercise Program Participation. MedBridge Blog. Retrieved from https://bit.ly/3BsrC78
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