Copyright 2005 Lippincott Williams & Wilkins Chapter 3 Principles of Self Management and Exercise Instruction

Copyright 2005 Lippincott Williams & Wilkins Teaching in the Clinic Role has changed from full-time rehabilitation services to incorporate part- time educators.

Copyright 2005 Lippincott Williams & Wilkins Safety To ensure adherence and positive outcomes, the therapist should help the patient understand which signs and symptoms predict an exacerbation, so that modification is appropriate.

Copyright 2005 Lippincott Williams & Wilkins Self-Management  Patient education can empower the patient to self-manage the situation.  Gently guide the partner (patient) to improve chances for a successful outcome.

Copyright 2005 Lippincott Williams & Wilkins Adherence and Motivation Health Behavior Model Transtheoretical model  Precontemplation (PT has no intention of changing)  Contemplation (seriously considering change, but not yet initiated)  Preparation (planning to change soon or may have initiated small changes not yet complete)  Action (have changed in last 6 month – quit smoking)  Maintenance (changed more than 6 months earlier)

Copyright 2005 Lippincott Williams & Wilkins Applications  Build rapport with each visit.  Link treatment directly to patient’s personal functional goals and needs.  Use a program that requires the fewest lifestyle changes.  Attempt to blend the exercise program into the patient’s daily routine.

Copyright 2005 Lippincott Williams & Wilkins Clinician–Patient Communication  Personalities, values, teaching, and learning styles ultimately affect adherence and outcomes.  The ability to assess the patient’s willingness and style of communication is paramount.  Improvement in the quality of interaction can be achieved by being sensitive to the patient’s verbal and non-verbal cues.

Copyright 2005 Lippincott Williams & Wilkins Clinician–Patient Communication (cont.)  Clinician’s attention to patient’s needs can guide appropriate communication style.  Fundamental skills – close observation of the patient’s words, intonation, body language, affirmation, and reflection of the patient’s report and eye contact (if it doesn’t intrude on cultural boundaries).

Copyright 2005 Lippincott Williams & Wilkins Issues in Home Exercise Program Prescription Clarity in goals and exercise procedures is essential!!

Copyright 2005 Lippincott Williams & Wilkins Understanding Instructions The clinician must be conscious of:  Cultural barriers (e.g., religion, cultural customs)  Clarity of instruction (e.g., pictures and written instructions, involvement of family members, etc.)

Copyright 2005 Lippincott Williams & Wilkins Proper Exercise Execution  Have patients perform exercises under direction. Consider reciprocating and have patient “teach” exercises.  Encourage patients to take notes.  Have family members observe—helpful.  Videotaping.  Upon return, patient demonstrates the exercises.

Copyright 2005 Lippincott Williams & Wilkins Equipment and Environment  Exercises using body weight, objects at home or office—more functional.  Consider perception of patient’s expectations. Adherence may improve if equipment purchase is expected by the patient.  Assess home surroundings & limitations prior to prescribing exercise and/or purchase of equipment.  Involve social support/environment in process to ensure understanding of the plan of care.

Copyright 2005 Lippincott Williams & Wilkins Home Exercise Prescription Factors include: 1. Stage of healing. 2. Tissue irritability and symptom stability. 3. Patient’s time and willingness to learn. 4. Time between physical therapy visits.

Copyright 2005 Lippincott Williams & Wilkins Stages of Healing Early Stages – Appointments may be more frequent. – Exercise program may also change more frequently. Intermediate-Late Stage – Patient’s symptoms and function change more slowly.

Copyright 2005 Lippincott Williams & Wilkins Tissue Irritability and Symptom Stability  What activities or positions increase symptoms?  How much time can be spent in a specific activity or position before symptoms begin?  When symptoms begin, do they continue or progress despite discontinuing the activity? Will changing the activity or position alleviate the symptoms?

Copyright 2005 Lippincott Williams & Wilkins Assessing Tissue Irritability  After initiation, how long do symptoms last? How long before returning to baseline?  Is there anything you can do to relieve your symptoms?

Copyright 2005 Lippincott Williams & Wilkins Patient’s Time and Willingness to Learn  Availability of time the patient possesses affects exercise prescription.  Educate, prioritize, and agree on the program. Requires empathy for the patient.

Copyright 2005 Lippincott Williams & Wilkins Time Between Physical Therapy Visits Increased visits – May allow for more challenging programs. Longer intervals between visits – Provide exercises less likely to overwork the patient and provide supplementation (additional instructions for exercises, etc.).

Copyright 2005 Lippincott Williams & Wilkins Determining Exercise Levels Determining exercise levels and educating the patient regarding pain during exercise is important.

Copyright 2005 Lippincott Williams & Wilkins Classification for Determining the Appropriate Level of Discomfort Associated with Home Exercise Prescription Curwin and Stanish 1.No Pain 2.Pain only with extreme exertion and 1–2 hrs after 3.Pain with extreme exertion and 1–2 hrs after 4.Pain during and after any vigorous activities 5.Pain during activity and forceful termination 6.Pain during daily activities Normal Normal or slightly decreased Somewhat decreased Markedly decreased Unable to perform

Copyright 2005 Lippincott Williams & Wilkins Self Management and Exercise Instruction – Summary  Patient safety comes first.  Make the patient a partner in the program – PT education and self management.  Determine what motivates the patient.  Prescription of exercises should contain the fewest lifestyle changes possible. Mimic the patients usual activities.  Determine a patient’s needs and willingness to learn by becoming an active listener.