S3-E68-How to Overcome this Patient Roadblock & Avoid Exercise Despair

Welcome to the unleash, your best clinical self podcast. I'm your host, Andrew Cobian. If you're a physiotherapist or other movement professional, who feels like you're stuck in a rut, then my podcast is for you. This podcast is focused on helping you move from frustration to flow in your clinical practice. And each episode I'll share strategies, approaches, and my latest thinking on how to improve your clinical performance and keep loving what you do. This is episode number 68. And this episode, I'll be talking about patient exercise adherence. And some practical reframing of how to approach building exercise, adherence capacity in your patients. I want to let you know that I have a newsletter where I dive into topics relating to improving clinical performance. And you can sign up for free by heading over to 360 clinician.com. Before I dive into today's episode, I want to share a message from this episode sponsor. Jane app. Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane payments. Although the world of payment processing can be complex. Jane payments was built to make things as simple as possible to help you get paid. And it's easy to get started. You can head over to jane.app forward slash payments. To book a one-on-one demo with a member of Jane's support team. And they'll be able to give you a better sense of how Jane payments can integrate with your practice. By them showing you some of the popular features in action. And if you're ready to get started, you can sign up for Jane. Use the code 360 1 emo for a one month grace period. Once you're in your new Jane account. You can flip the switch on for Jane payments at any time. Jane's promise to you is transparent rates and unlimited support from a team that cares. All right. Let's get started with today's show. Patient's not doing their exercises. Frustrating. I'm just going to say it. It, I think frustrates all of us as clinicians. You know, we can spend so much time teaching exercises and we feel confident that they know the parameters of the exercise for what they need to do at home. But then we can ask them the next time they come in, how did it go with their exercises? And we can often get a lukewarm response. Or even hesitation from our patients. When we press a little deeper, we come to understand that they didn't actually do their exercises or they did them quote, unquote, occasionally. You know, it can be frustrating for us. I think that sometimes that frustration can definitely impact, the therapeutic relationship and it can impact how much we're enjoying our work. And whether we can stay in a place of clinical flow. The reality is it's not uncommon at all. It's actually very common in studies regarding exercise adherence. And there was a study by Eckerd and all in 2015, it showed that exercise adherence can be around or even below 50%. So if we're not really tackling this issue of exercise adherence, Then I think we're really missing the boat with a lot of our patients who may not be doing exercises consistently. Exercise adherence has been a real interest of mine for some time now. I see it as such a powerful lever to help patients get better results. Better exercise adherence helps guide treatment. And I find that it gives us a stronger signal regarding how effective our treatment and exercise recommendations have been. And it helps us to be able to know with more confidence, if we're going the right direction or not from a treatment planning standpoint. I've talked before about this idea, what I call the exercise spiral of despair. And it's something that I've observed in my own clinical practice, as well as in conversations that I've had with other clinicians. And it's oftentimes a place where poor exercise adherence. Can result in poor treatment outcomes. But it can often be, I think, a bit of the catalyst to shifting to more of a passive treatment approach. Let me just explain what I mean by this exercise spiral of despair. We give the patient exercises. The patient maybe has done them initially, or maybe it hasn't really been that successful doing them, right off the bat. And then we check in with them and maybe they may then maybe they're honest with how they're doing, or maybe they're not honest. Regardless, they maybe don't feel all that confident. And in terms of doing exercises, So we maybe encourage them to say, Hey, you know, that's okay. Just keep at it to takes a bit of time. And, and more often than not, we actually ended up giving more exercises to the patient. And oftentimes what happens is that the patient feels bad. You know, here I am not living up to the expectations that I have. For my therapist. And then what ends up happening is it becomes a bit of this awkward exchange, or it can be, between ourselves and the patient. As we're trying to navigate the situation and one of two things can happen. When does that? Well, first off, I think we'll typically not see a lot of change in terms of patient symptoms or functional outcomes. but more often than not, we'll find ourselves in a situation where either the patient drops off because they're not seeing the change or we end up almost subconsciously reverting more to passive treatments. I think in part it's because we find ourselves maybe frustrated with maybe the lack of adherence. And so we sort of almost inadvertently ask ourselves what's the point of getting more exercises if they're not going to do the ones. That we've already given. And so then we end up doing more passive treatment within the session. Because really giving more exercises or reviewing the existing exercises, isn't really going to move the needle. And I really do think that helping our patients with behavior change. Extends way beyond exercise adherence. And I think it has impacts in terms of changes that we would encourage our patients to make around stress management. Sleep habits. So many different areas and that's why I think it's such an important area for us as physios too. Uh, get more comfortable with and improve how we approach this area. A few years back, I had developed a framework, which I presented. For a workshop I did around patient exercise adherence. And it looks at what I think are the essential ingredients necessary to see patients achieve success with building new exercise and movement habits. And really it answers the what to the, who, the how and the why. I think we have at the core, we have the exercise parameters. The exercise and the exercise parameters, which is really the what, but I think there's really three key areas that we need to also address beyond the exercise and the exercise parameters. And that's how we need to bring meaning to the exercise. Why did you give me this exercise? We have to connect the dots for our patients. And then we have to make sure that there's trust. I'm trusting what you're saying and my trust in you, that therapeutic Alliance. Is going to give me that confidence to step forward and doing an exercise that I'm really not sure if it's going to have an impact for me. And then the third component is structure. And this is the how. When are you going to do this? How are you going to do this? Really it's this to behavior design component that is also really important. And I think often gets missed. So we really have at the core, we have the exercise and the parameters around that exercise, but then around that we have. The meaning. Of the exercise, the trust factor around the exercise and then the structure. Of the exercise. While back. I had a patient who experienced regular headaches, neck, and jaw pain. And after a few sessions to address the neck and the jaw, she shared how she felt. A lot of her symptoms were triggered by. Her chronic stress response. She'd always been interested in meditation. She was open to it. She had tried in the past, but she just really found it difficult to develop a meditation habit. And in this situation, I think there would be all the ingredients were necessary that were there, you know, there was meaning with the activity. We had a supportive therapeutic Alliance, but we were missing an important ingredient here, which was behavior design. So what could be the reason why a patient wouldn't end up doing an exercise, even when they're motivated and able to perform the exercise? Well, I think at times a lack of consistency with exercise may be a result of a patient not being ready to engage in the activity. Which is what you know is explored around with the trans theoretical model of change. But I found that more often than not the patient lacks a system to integrate the movement practices into their life. I've come to realize that patients who quickly adopt an exercise program are those who are already skilled and experienced at developing exercise, routines, and habits. But there are many people who struggle or have had little experience in developing movement or exercise routines. And those are the people that we need to help. We can fall into one of two traps. When we encounter these situations where the patient's not doing the exercise. We may encourage our patients to try harder in the upcoming week. And we can even acknowledge that maybe doing exercise consistently can be challenging, but we just say, Hey, pull up your bootstraps. Try again. Let's do better next week. And the other option is that we just ignore this lack of exercise consistency, and we just end up giving more exercises, hoping that somehow their exercise adherence. Habit will just kick in automatically. Unfortunately, both of these responses, don't really equip our patients with the tools and strategies. To make progress toward better exercise consistency. I found that oftentimes an insidious belief that can creep into our thinking. Is one where we end up placing the responsibility solely on the shoulders of the patient for not being consistent with their exercises. We come to believe that it's a patient problem. But I've come to realize over the years that it's actually a design problem and not a people problem. One of the common causes of patients for getting to do their exercises is the lack of a trigger or a prompt to help integrate a new exercise behavior into their day. I've heard so often patients telling me how they remembered their exercises as they were laying in bed at night. Unfortunately, I haven't had many patients who told me that they would then do their exercises with that reminder. And I think we need better reminders and explore that with our patients. With the constant barrage of distractions that exist today with the pervasive use of technology. I think it's really easy to forget our exercises. Well, I won't be going through all the components today of how to design new exercise behavior. I do want to talk about this important area. Of helping our patients identify a successful trigger, a way to remember to do their exercises. There are so many different triggers that can prompt us to take action. BJ Fogg outlines in his book, tiny habits that we can have internal triggers. Environmental triggers. And then we can have existing action or routine triggers. So let's take the example of brushing our teeth. And internal trigger may be the taste in your mouth after eating or drinking. Something that prompts you to actually brush your teeth. And environmental trigger may be walking into the bathroom and seeing your toothbrush. And then an existing action trigger would be brushing your teeth after you've completed your meal. When it comes to exercise adherence. A common internal prompt, maybe doing an exercise when you feel pain or discomfort. And an environmental prompt may be seen a yoga mat on the floor in the living room that triggers you to do your exercise. And an existing action trigger may be doing the exercise. After you have. Uh, washed your hands, going to the bathroom. And now you do three wall slides after you've done that. Now a lot of times we think, well, I reminder in your phone is enough. And for some people, technology prompts can be a great way to trigger doing exercises. But I would say that given the number of notifications that we have on our phones and our watches. It's something that can really fail quite easily. For most of us. And I know for myself too, we're just conditioned to ignore technology prompts. More often than not. We rely on internal prompts with exercise adherence. Patients will be reminded to do their exercises when they're experiencing pain. And BJ Fogg shares that habits need an anchor. He's found that existing actions routines can often be the most reliable triggers to help with instilling desired behaviors. So if we can attach an existing habit or routine, and couple that with a new habit. Now, all of a sudden that becomes a really powerful reminder system to take action with the new habit. So what happened to my patient who is struggling to meditate? So we brainstorm some different types of habit triggers as well as a desire time of day. We explored different triggers and landed on the trigger of doing a short meditation. After she ate breakfast each morning. The following week. She came back to see me. And she had a big grin on her face. As she shared how consistent she had been with her meditation practice. And how she hadn't had any headaches that week It was amazing and i think it really opened our eyes to see how powerful it was to be consistent with small daily action So to recap today's episode i think there's a few things that i want you to take away from this It's one i think we want to avoid that exercise spiral of despair and take a look at your own clinical practice and see if that's something that you've noticed with patients who maybe struggle with exercise. Second i think we have to remind ourselves that when patients are struggling with exercise That we don't put the blame on them instead recognize that it's a design problem not a people problem And then third we need to make sure that we not only give good exercise parameters and good exercises but we also have to ensure that we are including meaning structure and trust to the exercises that we give. Thank you for hanging out with me today and hearing about how you can improve exercise adherence with your patients Make sure to subscribe on itunes or spotify To stay up to date on future episodes And if you've enjoyed this podcast I'd truly appreciate if you could leave a five-star review on itunes Here's to less frustration more flow and better clinical results till next time