Tackling Rehab Barriers: A clinician and client approach
Kinesiologist Erin Brucker, explores how clinicians and clients can work together to overcome a variety of barriers that pop up over the course of a rehab journey.
Self Management When Forming New Habits
Exercise is known to improve pain and function in those with ongoing musculoskeletal injury, but in practice adherence tends to be low. There’s a number of possible explanations and some may relate to certain injuries while others relate to self management.
The first barrier involves self management techniques to adopt a new routine or habit. Clients often report having difficulty implementing exercise into their daily or weekly routine due to a variety of reasons like:
- Lack of knowledge about how to do the exercises,
- Not remembering how to do perform exercise once they leave the appointment
- Adding something new into their schedule (and their to-do list really).
To facilitate self management, additional support and realistic treatment expectations are important for both the physiotherapist and client participants. Some helpful tools would be to use an online modality to record or demonstrate exercises, a printed copy of the exercises or a video of the therapist or client performing them.
Environmental Barriers to Exercise
Environmental barriers are also another component associated with lack of adherence in sticking to rehab routines. Patients report dedicated spaces at home or at the gym help them perform exercises. And really the reasons why adherence falters tends to boil down to:
- A feeling that too many exercises were assigned
- The exercise plan doesn’t fit into a client’s schedule
- Simply forgetting to perform the exercises
The therapeutic relationship has an influence on adherence to rehabilitation as well. The concentration on making collaborative goals, monitoring adherence and following up on progress keeps people accountable. It is important to understand the clients needs, listen and understand their readiness to exercise before prescription. Patients report their need to feel heard in reports of pain, or aspects of exercise readiness by their practitioner was important and affected their willingness to take direction and adhere to exercise.
Ultimately, it’s important for therapists and clients to discuss what is manageable and realistic, so adherence is do-able. Improvement has been shown when patients are involved in the goal setting and exercise prescription process.
Understanding Locus of Control in Rehab
Another aspect of self management falls under the perspective known as locus of control. Patients can associate their success to that of their own doing or something outside of themselves (internal vs. external). Those who have an internal locus of control are more likely to comply with exercises and take charge of their rehabilitation. Whereas, those with external locus of control feel the opposite; that it’s something or someone else’s duty to help them achieve recovery.
Client’s don’t often expect therapists to give them ‘homework’, and are expecting a quick fix while therapists expect a client to take more control over their rehabilitation. In this case, it is important for the therapist to educate the client around expectations like what an exercise(s) will accomplish, and how that will work toward their goals (this is the approach we take at The Physio Shop). The locus of control comes into play here as well:
If clients have an external locus of control, their compliance to unexpected exercise regimes will be very low as they feel that someone else should be in control of their recovery and therefore, not themselves.
Pain Management – Clients and Physios Working Together
Pain is an immediate barrier which plays a big role in adherence. People report concern about experiencing pain when doing exercise, or if they are already experiencing pain, they see that as a barrier to start exercising. There’s also the opposite experience, where patients feel pain and this motivates them to exercise to try and relieve that pain. And then there’s the group of folks who feel pain, but are confused as to what that means for an injury.
They don’t necessarily know how to interpret that experience and relate it as a positive or negative for their body. This unknown factor, can then cause a client to avoid sticking with exercise for fear of worsening their injury.
One of the primary solutions suggested is education from the therapist on pain management and what pain might mean for the client’s particular injury.
Negative affect plays a role in pain, and some clients report feeling guilt as a result of incomplete exercises. Importantly, some patients experience negative affect or feel bad about their injury and are not motivated to adhere to the exercises either way.
Clients also report that a feeling of helplessness with their injury and that completing exercise won’t improve it and therefore are not compliant.
As a client, it’s important you’re referred to a therapist who can provide support for mental health if your physiotherapist is unable to provide you education around this, ultimately in service of achieving optimal and complete recovery.
What’s the take? How do clients and therapists get over all these challenges in rehab?
Ultimately, client education on compliance and exercise benefits plays a huge overarching role in adherence to exercise, as well as creating achievable goals for the client, with the client. The therapeutic alliance model is made of three parts:
- Agreement of treatment goals
- Agreement on the tasks
- Development of a personal bond between the client and the healthcare professional.
These factors have been found to be a determinant in engagement in physical rehabilitation and found to be associated with the perceived ability to control pain in musculoskeletal pain patients. These studies show that targeting each component of this model can improve support of exercise adherence.
And really, the rehab journey could have many obstacles. Keeping in mind each part of the model in mind will help you stay engaged and motivated as a client.
Sluijs, E. M., Kok, G. J., Zee, J. V. D., Turk, D. C., & Riolo, L. (1993). Correlates of exercise compliance in physical therapy. Physical Therapy, 73(11), 771+. https://link.gale.com/apps/doc/A14674786/HRCA?u=ubcolumbia&sid=HRCA&xid=5ac8dcb7
Laura B. Meade, Lindsay M. Bearne & Emma L. Godfrey (2019): “It’s important.to.buy.in.to.the.new.lifestyle”: barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain, Disability and Rehabilitation, DOI:10.1080/09638288.2019.1629700
Babatunde, F., MacDermid, J., & MacIntyre, N. (2017). Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: A scoping review of the literature. BMC Health Services Research, 17(1), 375-375. doi:10.1186/s12913-017-2311-3
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