Improve patient compliance with customized handouts, observation, and functional and core exercises

The modern chiropractic approach of restoring patients to optimal levels of pain-free function and performance emphasizes the benefits of active rehabilitation procedures. Passive procedures are those done to the patient, while active procedures are those done by the patient. This approach is supported by several neck/back injury research studies.^1–5

Getting patients to accept and comply with a recommended rehabilitation regimen can be a daunting task. After all, active rehabilitation is effective only if the patient performs the required movements. A few ideas and concepts are useful in encouraging this active approach in patients (who often do not want to put a lot of work into getting better).

Hierarchy of Results
While printed handouts are commonly available, it is not likely that a patient will do the exercises correctly based on an instruction sheet or even more than just a couple of times. Only a small percentage of patients (usually dedicated athletes) will perform exercise recommendations regularly without close supervision. This is a hierarchy of results (from lowest to highest) expected when the level of involvement by the doctor is elevated:

Series of generic exercises. It is unlikely that these exercises will be performed more than once or twice, and it is possible that the patient will do them improperly.

Series of customized exercises. Some doctors—using exercise booklets, computer printouts, or copy machines—create specific sets of exercises based on each patient’s examination findings or symptoms. These indicate to patients that their doctor has put some thought and effort into the exercises, and such rehabilitation procedures are more likely to be done at least a few times (see Figure 1).

Figure 1. Lumbar Rotation Stretch

Exercise videotapes/DVDs. Most patients can watch a video or DVD at home, which helps ensure better performance of the exercises. If the program is generic (ie, a “back” video), patients will be less likely to continue for more than a few days. Some doctors make their own customized videotapes or DVDs, but this can be time-consuming and expensive.

Importance of exercises discussion. If chiropractors explain the reason for each rehabilitation procedure, patients are usually more motivated, and the exercises may be done several times.

Modeling, observation, and correction. While somewhat time-consuming, this is the best way of ensuring that patients will do the exercises correctly. When doctors (or trained assistants) go through the exercises with patients, there is a much greater chance of the patients’ performing them several times. This is an additional professional service that deserves an additional fee.

Self-Direction Versus Supervision
The only way to ensure patients will perform the recommended exercises is to have someone monitor them. A supervised exercise program has been shown to be much more effective (in terms of decreased pain and disability scores and increased fitness) than unsupervised exercise in the treatment of low back pain, primarily because supervised patients complete more of the recommended exercise sessions.⁶

Supervising an exercise program is time-intensive and expensive. However, a balance of supervision and cost-effectiveness can be achieved by regularly monitoring home exercise programs.

Chiropractors have a definite advantage in overseeing active exercise programs since patients are usually seen for a series of visits, which provide the perfect opportunity to monitor home exercises. It is only with repeated follow-ups and some supervision that serious compliance with home rehabilitation programs can be expected. Doctors must ask patients during every visit whether they are doing the exercises and whether there are any problems or difficulties. In addition, regular demonstrations of the exercises by patients are highly recommended. These should be done weekly in the early part of the care program to determine whether patients are complying. As patients progress, additional or advanced exercises can be added to the program. Reviews of rehabilitation programs are billable services.

Exercise in functional positions. Some patients resist doing exercises that involve lying down on the floor. Since lying down is not an important functional position for the neck and back, it is not necessarily the best position to exercise the spine. The concept of specificity of exercise, which means that only what is exercised improves, is at work here.⁷ Floor-based exercises may not necessarily improve back function when the spine is upright and the joints and muscles are bearing weight.

Better acceptance and results can be achieved when patients are instructed to functionally exercise in the weight-bearing, upright positions of standing and sitting. These exercise positions stimulate and coordinate the proprioceptive control of the involved spinal support muscles (see Figure 2).

Figure 2. Trunk Extension with tubing (diagonal)

Strengthen the core. Avoid spending unnecessary time having patients exercise their extremities if their problem is primarily weakness of the muscles of the axial skeleton. The axial skeletal muscles stabilize, support, and move the spine. It is important to establish good strength and coordination of the core muscles around the spine and pelvis, especially in the early stages of rehabilitation. Patients have limited tolerance and time allotment for exercises. Chiropractors’ initial focus should be on the stabilization of the spinal support musculature. Only later should attention be directed to a general, overall body-strengthening program (see Figure 3).

Figure 3. Trunk stability forward lean (sitting)

DCs are in an excellent position to design and monitor active exercise procedures. With some thought and planning, it is not difficult to integrate an effective spinal rehabilitation program into most chiropractic practices. Encouragement and praise from the doctor and his or her staff help to ensure patient compliance. CP

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

References
1. Bigos S, Bowyer O, Braen G. Acute low back problems in adults. Clinical Practice Guideline, Quick Reference Guide Number 14. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub No 95-0643; 1994: 52–53.
2. Deyo RA. Non-operative treatment of low back disorders: differentiating useful from useless therapy. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. New York: Raven Press Ltd; 1991:1567–1580.
3. Sandstrom J, Hansson T. The bone mineral content of the lumbar spine in patients with chronic low back pain. Spine. 1985;10:158–160.
4. Biering-Sorensen P. Physical measurements as risk indicators for low back trouble over a one year period. Spine. 1984;9:106–119.
5. Malmivaara A, Häkkinen U. The treatment of acute low back pain: bed rest, exercises, or ordinary activity. NEJM. 1995;332:351–355.
6. Reilly K, Lovejoy B, Williams R, Roth H. Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. J Occ Med. 1989;31:547–550.
7. Kraemer WJ. General adaptations to resistance and endurance training programs. In: Baechle TR, ed. Essentials of Strength Training and Conditioning. Champaign, Ill: Human Kinetics; 1994:144.