A closely monitored home exercise program provides cost-efficient and effective rehabilitative care

When a patient needs to regain spinal function after an injury, or as part of treatment for a chronic problem, rehabilitative exercises are frequently needed. But where should these exercises be done? Can patients perform the exercises at home, or should they go to a special facility? What are the concerns about home exercising versus institutional exercising?

Independent Means
Independent exercising (done at home or in a gym) has a number of benefits, but also some serious drawbacks. While exercising under supervision (such as at the doctor’s office or in a rehabilitation facility) can bring tremendous gains, there is also a price to be paid. In fact, the pros and cons to both approaches break down into four main areas: 1) patient compliance, 2) level of complexity, 3) doctor-patient communication, and 4) expense. When these four topics are understood and mastered, doctors of chiropractic are well positioned to provide the best care for patients with musculoskeletal problems.

Patient Compliance. To receive any benefit from exercise recommendations, patients have to actually do the exercises. Getting patients to follow recommendations is a challenge, but this is especially true when trying to have patients do stretching and strengthening exercises to improve musculoskeletal function. The only way to ensure complete compliance is to have patients perform the exercises while someone knowledgeable is watching and recording.

One study found that patients with low back pain were much more likely to go to the gym for their rehab when there was a trainer assigned to accompany them.¹ Even a well-designed rehab program that provided free home-exercise equipment had only minimal results since the patients did not do their exercises.² Because of poor compliance, researchers concluded that “unsupervised home exercise programs may benefit few patients.”

Level of Complexity. Patients are easily overwhelmed with exercise instructions. In an institutional setting, this is easily handled by repeatedly reviewing the exercises and correcting the errors made by the patient. Under supervision, patients can tolerate more complicated exercise routines and learn to properly use complex rehab equipment. However, when given home exercises, most patients have difficulty remembering and correctly performing their exercises, unless the number of exercises is kept low. Investigators found that patients over the age of 65 were unable to properly perform more than two exercises when tested a week later.³ Multiple sets, weekly schedules, and exercises for several body regions can all add to the complexity of exercise recommendations, making it difficult for many patients to independently achieve the desired results.

Doctor-Patient Communication. A clear advantage of supervised exercising is the opportunity for multiple channels of communication. Verbal instructions are not sufficient to get patients to exercise; at a minimum, written directions with diagrams must also be provided.⁴ Better still are good visuals—photographs or even videos of the exercises being done. And best of all is when the patients can see the doctor or therapist perform the exercises and ask questions.

Expense. If resources were unlimited, everyone could be assigned to institution-based, supervised exercising. However, in reality, the cost of the doctor’s or therapist’s time and the additional space and equipment make supervised exercising quite expensive. With additional costs of administration, management, and other overhead, the fees for exercising in a facility under supervision rapidly add up. Whether the patient or a third party is paying, both are interested in keeping costs down.

Striking a Balance
The solution is to compromise by combining a home-based program with a few (or several) supervised exercise sessions in the office. This approach works with the vast majority of patients by including most of the benefits of an institutional exercise program and yet still keeping costs reasonable.

Since patients are seen frequently (at least initially), doctors of chiropractic have the opportunity to monitor patients closely. This enables doctors to establish an inexpensive home-based program and review compliance and performance regularly. Patients on a home-exercise program should be asked to demonstrate their exercises weekly. Knowing that doctors will be checking up on them motivates patients to exercise regularly.

Initially, patients should be shown only a couple of exercises, which are to be done daily. As consistency is successfully established, implement additional and more complex exercises (with increased resistance). Keeping the hurdles low in the beginning avoids discouragement and disappointment. It is also a good way to minimize the sense of effort, pain, and soreness.

Avoid multiple sets and other complex exercise methods initially. For most patients (especially for those who are not used to exercising) a single set of 10 to 12 repetitions is found to be effective.⁵ Single-set programs are also less time-consuming, which generally translates into improved compliance. It is also a good idea to have the patient do the exercises every day. This establishes regularity and avoids the complexity of a weekly schedule.

Have your rehab patients fill out an exercise diary and bring it in with each visit. This tends to motivate them to do the exercises, since they will want to show you their exercise log to receive praise and recognition. By having to record each home exercise session, patients realize that this is a necessary part of their treatment.

Make sure the patient knows which exercises to do and how to do them correctly. This is best achieved by demonstrating the exercise, watching the patient do the exercise, and then correcting the mistakes. In most cases, when patients need to strengthen and re-train, they will not be able to do the exercise properly, and will substitute, improvise, and cheat. Exercises performed incorrectly will impede progress and be detrimental.

A cost-effective rehab program is achievable with a monitored home exercise program. While a few patients may need to be enrolled in an institutional program, they are generally the exception, not the rule, such as those with complex injuries, severe cardiovascular disease or other complicating morbidities, and a history of noncompliance to home exercise. The doctor and patient can work together to improve spinal function, decrease current symptoms, and prevent persisting disability. CP

Kim D. Christensen, DC, CCSP, DACBR, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team physician to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, and the president of the ACA Rehab Council. Christensen is also a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached via email: kimdchris tensen@hotmail.com.

References
1. Reilly K, Lovejoy B. Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. J Occup Med. 1989;31:547–550.
2. Daltroy LH, Robb-Nicholson C, Iverson MD. Effectiveness of minimally supervised home aerobic training in patients with systemic rheumatic disease. Br J Rheumatol. 1995;34:1064–1069.
3. Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Phys Ther. 1999;79:270–277.
4. Schneiders AG, Zusman M, Singer KP. Exercise therapy compliance in acute low back pain patients. Man Therap. 1998; 3:147–152.
5. Feigenbaum MS, Pollock ML. Prescription of resistance training for health and disease. Med Sci Sports Exer. 1999;31:38–45.