Hi guys. I am currently doing Musculoskeletal Outpatients and am thoroughly enjoying the placement. One of the issues I have been confronted with in my first week of prac, is patient compliance with their home exercise program. I currently am seeing a patient who suffered a fractured medial malleolus during a game of soccer 3 months ago, surgery was required and an ORIF was performed of the ankle.
Currently the patient is complaining of pain in the anterior, medial, lateral, and posterior aspects of the ankle, which is aggravated by extended periods of walking, standing and also any single leg standing activities. There is still substantial residual swelling and the medial malleolus is significantly larger than the unaffected side. When questioned about the HEP that was prescribed by a student at his initial consultation in December ’07, which consisted of ROM, muscle strengthening, and proprioception activities, he admitted that he had only done them ‘once or twice in the last month’. His reason for not following his HEP was simply that he always forgets to do it. The problem was however, that he was quite concerned that his ankle was still ‘fat and painful’, and he then went to say that he was told by his doctor that it should ‘getting better by now’.
I thought that my primary management of this patient should be education, regarding the healing process and the importance of a structured rehabilitation program to be carried out in both the short and long term. I also informed him of the risks involved in not managing his ankle in the correct way and the long term consequences which can occur. I modified his HEP a little, so he could complete it easily at work which was his request.
I guess the lesson I learnt from this situation, is not matter the patient’s problem, education is paramount so they are fully aware of their problem and understand the importance of rehabilitation to optimize their recovery of function. If anyone has any ideas regarding increasing patient compliance that I could have handy if a similar patient comes through the door that would be great.
Steve
Sunday, January 13, 2008
Patient Compliance
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2 comments:
Hi Steve. I’ve just started my musculoskeletal outpatients placement and I had the same problem. I had one patient last week that had a patella fracture, had surgery and have been coming to physio to regain ROM and muscle strength. In his review (after 3 weeks break) I asked about his HEP and he said that did 1% of his exercises and when I asked why, he said that “he was lazy”. The patient was still complaining of stiffness and feeling the knee week. I had to reinforce the importance of the home program, even though the other student and the supervisor had already done that. The way I found to engage him was finding some activity limitations that he was having and thinks that he wanted to achieve eg. being more confident dealing with steps. I explained that the reason why he was having trouble with those activities was due to his lack of ROM and muscle strength and the way of overcoming that was by doing regularly his home exercises. Because the ROM was lacking only few degrees from normal, at this stage the home exercise would be more important than manual therapy, therefore it was more up to the patient to maintain the range gained on the session and overcome that. I explained to him that what had been done on the physio, was only one hour of the 24hs of the day and that the treatment wouldn’t have a significant effect and would take longer to progress if he didn’t continue with his exercises at home. I also reduced the number of exercises to only 3 exercises, practiced with him during the session giving explanations why he was doing each exercise and gave him a handout with simple instructions. At the end of the session the patient seemed to have understood better the importance of the home program and that he would have to have more responsibility on his treatment to have better results and not only rely on passive treatment.
I hope it helps..
Caroline
Hi Steve,
From everything I've heard it sounds like this is a pretty common problem in physio. Like we've been told in the past a patient can sometimes come in expecting the physio to do everything for them, and that everything will get better from what we're doing, rather than the patient managing their problem themselves.
During my last placement, which was cardiorespiratory, I treated a number of patients who were admitted with an exacerbation of their COPD. Obviously a huge part of the treatment of COPD is education, and teaching the patient how to manage their condition themselves. This usually involves a structured home exercise program. The home exercise programs i prescribed were often begun while the patient was an inpatient, so it was quite easy to follow their progress. After having a similar patient to you, who was not completing the prescribed exercises because they simply forgot, i found giving the patients a handout, with each day of the week in a column, and 3 rows of morning, afternoon and evening, they were able to keep this by their bedside and record when they did their exercises and walking program, and specifically what exercises they did, and how far they walked. This seemed to give the patients something solid that they could see they were getting something done, and the visual cue of seeing the handout prompted them to complete the exercises.
I would think something similar could be applied in your situation, getitng the patient to keep a diary or something similar of when they complete the HEP, and the reps and sets completed. It may also give the patient some idea about the progress they are making.
Hope this helps, or that you get some good ideas from it :-)
James
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