Tuesday, June 3, 2008

Patient compliance with home exercise program

My first placement was an outpatient musculoskeletal placement. Due to the nature of this placement, the treatment consistent mostly of hand on treatment and home exercise program to retain or even improve the effect gained from hands on treatment.
One of my patients has PFJ problem, and has been having treatment from this clinic for over one year. She is a amateur dancer and a part time dance instructor, she dances for upto a few hours a night, and on average 3 nights a week. The longest dance session I recalled was 5 hours. She often experiences pain on her right knee which is the leg she spins on, usually after 2 hours of dances. The pain level was averaging 5/10. The pain persists for the whole night until the morning after. On objective assessment, she has mod tightness in medial glide of her right patella, slight reduced muscle bulk of VMO on the right, reduced muscle length of TFL and calf muscles bilaterally, reduced muscle strength of glut med, and also flat and inverted feet
From handover summary, she has a home exercise program which includes mini squats, calf stretches, TFL stretch and clam shell exercises.

My treatment with her included STM of TFL and calves, med glides of R patella, and strengthening exercise for glut med and mini squats. And I updated the HEP and give her the exact reps and sets to do a day.
There are some improvements after each treatment, over a few sessions, her med glides were only slightly less than the other side. However her TFL and calves length were only slightly improved. And there’s minimal change with glut med and vmo strength. She has reported pain required longer dancing session to reproduce. From a hands on point of view she has almost plateaued.
However when I ask her about home exercise in every treatment, she always say she’s done a bit, not as much as she should. From what she said, I understand she’s only doing stretches max 3 times a week instead of 3 times a day. And every time I should educate her on how important it is to do the exercises, how it is linked to her pain experiences at dances and that she should take responsibility of her PFJ problem. I also tried to incorporate the exercises into her daily activities, include do a calf stretch on step when need to go up the stairs, do clam shell before getting up and before sleep etc. There’s no change with her motivation to do exercises. If she was a public patient, due to waiting list she could have been discharged and self manage at home.

From what I heard, there are other clients in musculoskeletal outpatients like this. Just turn up for treatment, and only expect hands on treatment to “fix” them and reluctant to do home exercises.

Anyone has patients like this? Do you have any good strategy to improve their motivation? Any input will be helpful.

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