A PSA from Karen Bonney, DPT
What is a Home Exercise Program (HEP)?
It seems pretty intuitive, right? A home exercise program is the group of exercises we usually give out to our patients in order to reinforce our hard work in the session. But what about education and exercise principles? Or prescribing rest? Or utilizing medications? Do those count as the HEP? Is there a standard operating definition for home exercise programs that we gain from our past education, or does this change to accommodate the patient, scenario, or goal?
The HEP should be unique and can focus on a few very specific stretches, resistance training exercises or postural cues. It could even emphasize rest and recovery or modifications to currentroutines. Most clinicians rely heavily on the HEP to provide the best patient outcomes as we can’t expect a quick 30 minute in-clinic session to produce the same long term carry-over. The milliondollar question though is, “Why does it take so much effort to get patients to comply with our suggested HEP that will ultimately help their symptoms and dysfunctions?”
As it turns out, a HEP is a bit more involved than I thought when I started my career. More importantly, it’s not as easily accepted as I assumed it would be. I wanted to share my experience, thoughts, and suggestions, and ultimately highlight some things I wish I knew when I started!
Why is it necessary?
First, let’s start with, “What’s The Point?” The HEP is intended to assist in reducing pain, improving function, and restoring overall quality of life. Tse, et al1, found that upon completion of the physical exercise program, there was significant decrease in pain intensity and a significant increase in range of motion with their population of adults with chronic pain. Some would suggest that the adherence to the HEP is the most critical factor of its effectiveness. Nava-Bringas, et al2, found that adherence is reported to be approximately 30-50% for clinically based exercises and can vary between 35 and 84% for home-based programs. These stats aren’t too impressive, but I’m honestly not surprised!
I am amazed at how often I see one of two limiting factors involving the implementation of the HEP. One factor: patients with programs that they mindlessly follow with no true understanding of why they are doing them. Basically, they have no invested interest in exercising, or in the handout they received. As you can imagine, the handout and program disappear before they even get home. Another limiting factor that is even more astonishing to me is the vast number of patients who never received anything at all! As a clinician, you can choose to empower your patients to invest and participate in the process of change or not, but just remember the goal of the HEP is to reiterate and solidify the changes that are made during the in-clinic treatment session.
Does it have to be so boring?
On a daily basis I witness eye rolls and comments like,"I barely have time to go to the bathroom, let alone sit down and perform 20-30 minutes of my HEP.” Why does it seem patients are willing to brush their teeth daily without hesitation, but they cringe upon prescription of a HEP? I blame the microwave! Society as a whole and patients in particular seem to want to “nuke” their aches and pains away. Or maybe it’s the fact that the HEP is isolated and can be pretty boring, if I must admit. Why do we as clinicians need to convince our patients to do something so simple? The HEP isn’t exactly a sexy routine; it often requires a lot of patience and very little immediate reward. It requires that we “trust the process” and endure the mundane while abstaining from activities that we deeply love. It’s a tough pill to swallow for many, and I believe that it's our job as clinicians, to create by-in for our patients.
What’s the ideal version of a HEP?
As a clinician, accepting diversity in learning styles will help the teacher to create an environment for learning that will enable patients to reach their full potential. Keefe’s3 definition focuses on the way that learners learn, taking into account cognitive, affective, and physiological factors that alter how they perceive and respond to the learning environment. The Bronfort, et al4, study found that including advice, basic anatomy, postural instruction, demonstrations of daily actions, and a HEP has a larger effect on the pain scale when compared to medication or spinal manipulations.
But what about the size of the HEP? The Henry et al5 study demonstrated that subjects who were prescribed two exercises performed better than subjects who were prescribed eight exercises. Interestingly, Andersen, et al6, found that there was no difference in the effectiveness between the 2-minute and 12-minute HEP programs. Research has proven that the smaller the HEP, the more likely the patient will remain in compliance. Patients who do not comply with their prescribed exercises have shown to demonstrate less positive outcomes long term7.
A clinician should consider designing the HEP to emphasize both strength and endurance training with the proper utilization of visuals via handouts, emails or videos. But outside of the perfect handout, a clinician may find more buy-in if they appropriately share how the HEP will affect the patient’s functional goals. If your patient’s goal is to better prepare for her quest to become a Viking Princess Warrior, then your three sets of alternating lunges with cable resisted chops seem a little more purposeful and necessary.
Providing structure while allowing for freedom will empower the patient to make the HEP work for them. Anar, et al8, found that the factors affecting adherence to exercise are multi-dimensional. Even though factors specific to individuals are prominent, social differences can be effective predictors of dedication. Clinicians must estimate an adherence level when recommending home-based exercises and should make necessary changes to exercise programs in order to increase probability for patient follow-through. That brings us to the question of buy-in.
How can we create buy-in?
Patient education is a crucial method of ensuring compliance. Manage your patients’ expectations by educating them on tissue healing timelines, their prognosis, and the importance of their own involvement in their treatment plan9. Our best HEP design will provide individualized routines (short in duration) that keep our patients intrigued and encouraged. What if our patients felt like they weren’t alone in the minutia? I can speak for a number of clinicians out there — we are probably just as (if not more) broken and in pain than our patients. Which means we too have a HEP routine to adhere to in order to be pain free and at our maximum performance potential. We talk the talk on a daily basis, but it doesn’t mean we walk the walk with any more ease than our patients. And this should be more transparent.
Recommend that your patients keep logs or journals to track progress. More importantly set the right expectation to help ensure compliance. Share with your patients methods to make these routines more fun; encourage your patients to incorporate their HEP into previously established habits and time lines. Ultimately, we must provide the education on the functional importance of the HEP and encourage an option for flexibility to ensure our patients comply.
The HEP is a necessary evil and unfortunately sometimes difficult to present as any more than a nuance to your patients’ current habits and routines. I think the results speak volumes — the more open and honest you are with your patients about what is required of them, the more likely they will buy in and be successful. The HEP may be lame to most but we as clinicians have the ability to present the reality of its necessity and improve its bad rap!
“It’s never easy and always worth it.”
Karen Bonney is a physical therapist and the Director of MedStar’s Sports Performance Clinic at Lafayette in Washington, DC, with over eight years of experience. She is also the Founder of Elite Performance and Rehab, PLLC, and has been an assistant instructor for KinetaCore FDN 1 courses since 2016.