A Lesson Learnt From A Failed Exercise Prescription And How I Adapted To Make A Difference. Case Study #2

A plan without a how, when and where is just a wish

I’d like to share a lesson learnt from a failed exercise prescription and how I adapted to make a difference to the patient’s life.

A lady came to see me with chronic hamstring tendinitis.

This lady was in her early 50s, fit and had an extremely busy working life which included two sessions of supervised PT which was part of her work commitments. 

She exercised on the days with no PT by either walking up to 10km, running or cycling. Stretching only happened if made to.

Going to the gym and remedial exercises were not her choice of fitness training. This lady liked the feeling of working hard and had a habit of exercising but only doing what she enjoyed.

She had seen a number of highly skilled physiotherapists with postgraduate qualifications all of whom had successfully diagnosed the problem. The condition was not difficult to diagnose. Seeing different clinicians happened due to her moving interstate with her occupation.

Each physiotherapist had explained the condition and what she needed to do to get better. They had also clearly explained and demonstrated the exercises that they had created for her. 

The patient knew what she had to do but she had either not complied with the exercise programs or had started them and within a few days had given up and returned to her old exercise habits. As you would understand, this was making the condition more resistant to improving.

Some may say that she was not serious about getting better. Others may say that she was lazy. Neither were true.

What was going on?

The physiotherapists were explaining both the condition and the treatment from their perspective. Each clinician had failed to appreciate the demands of her working life, her intrenched exercise habits and her beliefs with regards to exercise. They had also not been able to elicit from her, full engagement, only an agreement to do the exercises. Agreeing to do the exercises is very different from the taking the action to do them.

What could I do differently?

Instead of going over the value of the stretches and the exercises I decided to ask her some questions that might help her connect with her own reasons for doing the exercises rather than those of a physiotherapist.

Question One

“Why she might want to do the remedial exercises?”

To this replied that she wanted to get back to her running and cycling as she really enjoyed these activities. She also wanted to participate fully in the organised work PT sessions.

Question Two

“Imagine being back running again what would the positive outcomes be?”

She replied that most importantly, it would help her keep her weight under control. Managing stress and the pressures of her work and not be seen as someone who was not putting in during the PT sessions were also important. 

Question Three

“Why were those outcomes important to you?”

A summary of her response to this question after some thought, was that the outcomes she’d wanted helped her feel good about herself. Her outcomes were linked closely to her self-worth.

Question Four

“What would be her next  step, if any?

It was her choice as to whether she would do the remedial work. I refrained from telling her what she needed to do.

She said that she would commit to doing the exercises that she’d been given as she now had very good reasons to do them and they had nothing to do with the reasons the physiotherapists had for her doing remedial exercises.

Question Five

“What needed to happen for her to fit these exercises into her already busy daily schedule?”

When was she going to do them, where was she going to do them and what would need to be adjusted in her day to fit them in?

This question made her think about the reality of what needed to happen and is an extremely important question.

Interestingly she asked me:

“Why didn’t anyone ask me these questions before?” She had finally connected to her own reasons for doing the exercises and this influenced her decision-making on a daily basis.

She looked at the program and was realistic about what she could successfully commit to doing. She had been given a range of excellent exercises but there was no way they were all going to get done in a day.

We negotiated what aspects of the program would be most beneficial to help her achieve her goals. This was not being lazy or resistant. It was being realistic.

It is a really important concept to grasp- that a plan without a how, when and where is just a wish.

She decided to put more emphasis on stretching and looked for time in the day to fit this in. Adapting her personal exercise program so as not to sabotage her recovery became important. It look longer for her to improve but she gradually returned to her running and cycling.

What are the lessons that can be learnt from this case study?

  • Patients make choices relative to what’s important in their lives. Not what’s important to the clinician
  • Be prepared to consider your exercise program from the perspective of the patient, not yours
  • Spending more time on the negotiation rather than exercise demonstration may pay more dividends in the long run for both parties
  • Never be satisfied with an agreement to a plan without a how, when, where and consideration of obstacles
  • Frequently relate to the positive outcomes the patient tells you and not your clinical signs when reviewing progress

Yes, some patients can be lazy. But more often I believe the majority of non compliant patients haven’t connected to why they might want to do the exercises. This means more to the patient than why they should do the exercises.

If you have a patient that is non compliant, consider what you can do differently. It will make your consulting life more interesting, decrease your frustration and you will help more people.

To read more on question that can shift patients thinking consider reading “Instant Influence” by Michael Pantanlon PhD

To learn more about motivational tools through effective communication download my eBook:

“Improving Patient Motivation In Physiotherapy”

I wrote this eBook in response to the most common question I get asked and that is “How do I motivate my patients?”

If you would like to fine-tune your communication skills when working with resistant patients, you might consider working with a coach or mentor.

Or perhaps your staff would benefit from training in this area.

Contact us, and find out more about what we can offer you.

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