Prescribing patients home exercises can be critical for their recovery, but getting patients to exercise – not so easy.
Stick figures and line drawings have served the profession well for decades. Typically, the patient dutifully nods when asked if they understand what to do. Back at home, however, exercise positions are easily forgotten, inanimate drawings are misunderstood, and patients have no way to ask questions or seek feedback until they return to the clinic.
Patients can become de-motivated and give up trying, a fact born out of research indicating that at best, 33 percent of patients actually do their home exercises.1 And we all suspect the percentage is probably half or less that number! In frustration, many patients are starting to ask their DCs to videotape and instruct them on proper form — using the patient's smartphone, but there is no way to include required sets and reps, notes or feedback.
In either case, DCs are not able to monitor patient progress and must rely on self reporting they know is false. They have little data to help patients improve, which is becoming a more critical consideration, as payers are increasingly moving to requirements for documented outcomes.
At the same time, there are more than 10,000 medical and fitness apps in the iTunes Store, and patients expect, and can get, an app for just about everything.2 Technology has spurred the "quantified self" movement: the social phenomena of measuring vital statistics of every breath, step, and beat of everyday living.3
All this leads to the observation that the question is not if, but when, most clinics will go online with exercise instruction.
Online Solutions Explained
Online exercise prescription systems allow practitioners to select exercise videos, animations or pictures, customize instructions to each patient, and create programs. Templates can be used to standardize treatment protocols and minimize prescription creation time. Patients can see the precise exercise positions to use, follow prescribed exercise frequencies, and schedule and run workouts on a computer or mobile device.
At one end of the technology spectrum, online home exercise programs (HEPs) permit clinics to select and e-mail line drawings. At the other end, programs are available today that provide thousands of animated or video-based exercises, full customization of every exercise, private labeling, and video creation capabilities. The more sophisticated programs even have various patient-engagement techniques and marketing components. And starting this summer, at least one motion-sensing PT "game" using the Microsoft Kinect system goes live, tracking and correcting patients as they follow online rehab instruction in front of their TV.
The Advantages of Going Online
The prospect of adopting another software solution can appear daunting, but the good news is that online exercise prescription systems are now simple to learn and use. None of them requires a lot of up-front investment of time or resources, and they are typically served from the "cloud," which means there is no software to manage or update. Users only need Internet access to create or access their program.
To be successful, each clinic should put someone in charge of managing program adoption, create a few templates and test prescriptions, and the benefits of the new service will become evident in a couple of months. Let's review the advantages of going online from different perspectives.
Clinic Benefits: Patients know, at least intellectually, that they'll get better if they exercise. Receiving a customized program, personalized with their name on it, creates a personal connection between their care and your clinic. The efficacy of the exercise prescription is enhanced when patients understand what to do and can watch their progress. In short, they become more involved in the healing process and their sense of satisfaction with the services you provide is reinforced.
Some of the new online programs can be branded to each clinic, reinforcing a cutting-edge image. With both web and mobile versions now available, online exercise systems can also allow patients to "like" their clinic and share their progress among friends and family through social media.
In this sense, online exercise systems give each clinic its own tech program and/or "app," private labeling proprietary systems to their own brand. Most clinics barely have time to serve their patients and manage paperwork, let alone get smart about marketing. The branding potential of these online programs can do that job for them by harnessing the power of social media.
As measuring outcomes becomes increasingly important to payers, standardization of care becomes more important. With online exercise prescriptions, a clinic can now start to standardize protocols, leading to greater efficiencies of care.
Chiropractor Benefits: Practitioners want to improve the quality of care they provide every patient, and they want to deepen the one-on-one connection that is at the heart of chiropractic. Online programs help patients avoid making common mistakes, and customization features can modify instructions for each exercise to address patient needs.
In most systems, the clinician controls the program activation and deactivation, its elements and instructions, so patients can only view current prescriptions. Of course, any system that adds time to the day won't be used, and the good ones take but a minute or two to create and update each prescription. Following the practice of some clinics, an individual CA or admin person can create prescriptions for the busy DC, freeing up time previously spent explaining how to do home exercises.
Most DCs don't have time to create their own videos; online programs address this through pre-populated exercise libraries with hundreds or even thousands of videos and animations. Ultimately, the more the better, but there can be a challenge in finding specific exercises when they can go by different names. It also seems that most rehab professionals tend to settle on about 20 to 40 exercises they like to use with all their patients.
The best solutions to these dilemmas are free text-search functions and the ability to create "favorites" so each clinic or practitioner can find and tag preferred exercises, just like their stack of drawings kept in a file folder. Evidence-based protocols and the ability to create personal or shared templates are other nice touches that save effort in quickly creating individual prescriptions.
At the same time, everyone has their own special exercises, and the different theories and methodologies on what is effective have filled many books. New exercises are coined and marketed every year, and even if just getting the patient to move is what matters most, online systems need to be flexible. Just like stick-figure instruction, most online systems allow each clinician to add their own exercise pictures and videos.
Patient Benefits: In contrast to flat drawings, the high-definition videos, animations and/or pictures featured in online exercise systems allow patients to better understand what they are supposed to do. They also allow patients to schedule their own workouts and receive automated reminders. Software technology allows every exercise or workout to be tracked – and herein lies one of the biggest benefits of going online. Both the patient and DC can view patient progress in doing their exercises, motivating compliance and helping engage the patient in their health improvement.
While the focus of online exercise systems is typically simple instruction, there also is an interesting opportunity to improve on a more fundamental question — the goal of the rehab in the first place. While most electronic health records (EHR) systems can set patient goals, they offer no way to communicate the goals to the patient! Psychology 101 tells us that engaging the patient in goal-setting instills motivation. As a result, there is an effort to better integrate these goals within exercise systems, tying the patient condition to a goal, a method to heal and data that demonstrates progress.
As a side benefit, systems that communicate rehab goals also serve to manage expectations when a patient expects to heal in an unreasonably short time. Talking through a rehab goal that is front and center makes it easier to confirm what is expected and what is required to recover.
We also know that every patient has a different learning style, whether visual, auditory and/or tactile. Engaging every patient in a multimedia experience strengthens the connection between the patient and practitioner. Several online programs are structured to allow clinicians to instruct and videotape the patient in one step, auto-populating their program with exercise instruction that addresses proper form from the get-go. Although this takes an investment of time to create patient videos, for some, there's nothing more educational than watching oneself; plus, creating baseline and follow-up patient videos ensure understanding and motivate compliance.
Patient videos can take just a minute to create and sync, with frequencies and quantities set in a second step. The theory is that if you take the time to demo proper exercise form anyway, why not just videotape your patient doing each exercise and correct them in one fell swoop?
Regardless of what type of exercise is prescribed — standard, custom or patient — DCs don't have to show patients a second time what to do when they come back, saving precious time at the next visit when the patient asks: "Now what exactly did you want me to do?"
Giving the Modern Patient the Options They Expect
As our understanding of personal motivation evolves, we know that feedback systems are crucial. Patients increasingly expect to be able send and receive feedback from their health care providers, to ask questions in order to course correct, and to receive real-time feedback so important to patient satisfaction. While the debate about whether this can be done in HIPAA-compliant form continues, patients expect it regardless, and clinics and online programs that meet this expectation will benefit in the long run.
For those who want to keep up with social media and the "quantified self" movement, some programs also allow patients to share their progress on social media, while others offer airline-type "points" or other ways to aid increased compliance. There is no doubt that patients simply need to be motivated in new ways, and now there are options to serve patients what they expect.
The end result of these intriguing programs is a movement away from traditional paper HEPs to online patient-engagement systems that set goals, demonstrate proper form, improve compliance and measure what each can do. This helps patients heal faster and feel better about their home exercise experience, ultimately, increasing the value each clinic offers its patients.
- Shaughnessy M, Resick B, Macko RF. Testing a model of post-stroke exercise behavior. Rehabilitation Nursing, 2006;31(1):15-21.
- Brustein J. "Coming Next: Using an App as Prescribed." New York Times, Aug. 19, 2012.
- "The Quantified Self: Counting Every Moment." The Economist, March 3, 2012.
Dr. Brian Graham, a graduate of Palmer College of Chiropractic, is a chiropractic sports physician with a specialty in whiplash injuries. He is the founder of Graham Rehabilitation Center (www.grahamrehab.com) in Seattle, Wash., emphasizing patient education while treating professional, college and high-school athletes, as well as the typical weekend warrior.
Michael Richards is the CEO of GoMotive (www.gomotive.com), a patient-engagement system for chiropractors; and the founder of PRR, a national PR and marketing firm focused on health and wellness.