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Improving the Outcome of Physical Therapy

Might a Mental Health Professional or Life Coach Help?

Recently, I had a conversation with an acquaintance, an experienced physical therapist who was complaining about how difficult it is to achieve success with his clients. “The problem,” he told me, “is that many refuse to comply with the exercises prescribed for them to do at home. Often it is because of the pain associated with doing the exercise, or the slowness in which any improvement is noticed. People expect results right away, and it is hard to convince them that it might take months to see a difference. And some of my clients won’t do anything unless the therapist is by their side telling them what to do, and watching them do it.”

Many of us have had personal contact with a physical therapist because of an injury such as a broken bone or torn tendon, rehabilitation after surgery, chronic pain such as lower back pain, neurological conditions like Parkinson’s disease, multiple sclerosis, spinal cord and brain injury and stroke, difficulty with balance and falling, and rehabilitation after brain injury. Even something as small as a broken finger may require physical therapy. A visit to an outpatient PT department often resembles a gym with everyone working out with a personal trainer. Except a physical therapist isn’t there only to motivate you to exercise and increase muscular strength: He or she is there to help you heal, restore your body to a level of fitness that was diminished by an accident, surgery, or illness, and to manage pain. Indeed, physical therapy seems to be an almost inevitable part of the recovery process after any accident or surgery, or a component of the interventions aimed at retarding loss of function in neurological conditions such as Parkinson’s Disease.

Yet physical therapists, such as my acquaintance, emphasize their frustration with the all too many clients who are reluctant to carry on at home the exercises they should be doing to achieve their goals, be it better mobility after a repair of a rotator cuff, or better balance following a severe concussion. “I don’t think the client realizes that if he or she does the exercise program at home, then the physical therapist is able to work on more advanced exercises when seeing the client at the PT clinic or outpatient facility,” he said.

The percent of clients who consistently follow the prescribed physical therapy home exercise program is quite low, about 35%- 50%, according to studies in the Netherlands and the United States. Such limited adherence has been linked to poor recovery following surgery, and may lead to medical or surgical interventions that would have been preventable, had compliance been better. Depression and anxiety may contribute to poor adherence to the home exercise regimens, and as the article by Argent el al. point out, even daily variation in stress levels affects whether the exercises are carried out. They recommend the use of psychological support to address these issues, and also urge the use of a social support network. If clients can be in contact with others going through the same experience, perhaps they may encourage each other to adhere to the exercise programs, even when they are dealing with chronic pain and debilitation.

But do physical therapists tell their clients about support groups for chronic illnesses like fibromyalgia and multiple sclerosis? And conversely, do these support groups encourage adherence to exercises prescribed by the physical therapist? If people anticipating hip or knee replacements were in contact with others who have undergone this surgery already, might they learn about the importance of post-surgical physical therapy, and adherence to the at-home exercise program, even though it may be painful to do so? Sometimes it seems that information about the healing process for such procedures comes only from friends and family who have already had the same procedures. Often someone recovering from a serious injury has no one to talk to, except the all-too-busy health care provider. A relative who had his Achilles tendon surgically repaired had limited physical therapy and no access to others with similar injuries to support him during the very long healing process.

One problem in delivering such support is that physical therapists are not mental health therapists, or dieticians, or life coaches, and therefore should not, and legally cannot, give the advice their clients might need. When a patient is given a medical referral to see a physical therapist, is there also a referral to a psychologist who might help with the stress of a chronic neurological condition or chronic pain? Is there a referral to a dietician if the patient’s weight makes it hard to exercise, and the stress of recovery causes emotional overeating? If the patient’s home and work situation make it difficult or impossible to carry out the at-home exercise regimen, who will suggest seeing a life coach to figure out solutions to the lack of time and space to do the exercises? Who will suggest to the patient that a support group for chronic back pain (or recovery from a debilitating sports injury) might be helpful and increase adherence to an exercise regimen?

Time, unfortunately, limits the ability of a physical therapist to deliver the comprehensive support needed by many of their clients. Appointments are strictly scheduled, and if minutes are spent talking with a client about issues that are preventing adherence to a program, that is time is taken away from having the client do those exercises in the clinic. The answer may be to assemble a team to help the client: a dietician if weight is an issue, a mental health therapist to help with pain or the consequences of a debilitating neurological condition, and a life coach to find a way of managing at-home exercise with demanding schedules. We know that weight loss is more likely to be achieved when the dieter is given support that goes beyond a food plan. Perhaps it is time for the physical therapy client to be given support that goes beyond the exercise plan.