Home or institutional rehab
Why not a combination?
By John K. Hyland, DC, DACBO, DACBR

Rehabilitative exercises are necessary when a patient needs to regain spinal function after an injury or as part of treatment for a chronic problem. But where should patients perform these exercises?

Can they do them at home, or should they go to a special facility? What are the concerns about home rehabilitation instead of institutional rehab?

Independent exercising that can be done at home or in a gym has a number of benefits, but, because it is not supervised, it is not always the best option. Exercising under supervision (at your office or in a rehab facility) can result in tremendous gains — but at a high price.

The pros and cons to both approaches can be divided into four areas: Compliance, complexity, communication, and cost. When you understand these topics, you are well-positioned to provide the best care for patients with all types of musculoskeletal problems.

• Compliance. To benefit from exercise recommendations, patients have to actually do the exercises. Getting patients to comply with your recommendations is a challenge — especially when you want them to perform stretching and strengthening exercises to improve the function of the musculoskeletal system. Without a doubt, the best way to ensure complete compliance with exercise recommendations is to have the patient do the exercises while someone knowledgeable is observing and recording what is accomplished.

One study found that patients with low back pain were more likely to come to the gym and do their rehab if a trainer was assigned to monitor the exercise sessions.¹ Even a well-designed home-exercise rehab program produced only minimal results because patient compliance was so low.² The researchers determined that due to poor compliance, unsupervised home-exercise programs may benefit few patients.

Exercise instructions can easily overwhelm patients. You can overcome this hurdle in an institutional setting by repeatedly reviewing the exercises and correcting errors made by the patient.

• Complexity. With supervision, patients can tolerate more complicated exercise routines and learn how to use complex rehab equipment properly. Unfortunately, in a home environment, most patients have a difficult time remembering and correctly performing their exercises, unless the number of exercises is kept to a minimum.

Investigators found that patients older than age 65 could not properly execute more than two exercises when they were tested a week later.³ If you assign multiple sets, weekly schedules, and exercises for several body regions, the complexity of exercise recommendations will be difficult for many patients to complete on their own.

• Communication. A clear advantage of supervised exercising is the opportunity for multiple channels of communication. Verbal instructions are not enough. At a minimum, you must provide written directions with diagrams.⁴

Better still are good visuals— photographs, or even videos of the exercises being done. Best of all is when patients can see the doctor or a therapist actually perform the exercises.

• Cost. If resources were unlimited, you could assign all of your patients to institution-based supervised exercising. In the real world, the cost of the doctor's or therapist's time — and the additional space and equipment — make supervised exercising quite expensive.

Add in the cost of administration, management, and other overhead expenses, and it's easy to see why the fees for supervised exercising in a facility mount up rapidly. Whether the patient or a third party is paying, both are interested in keeping costs down.

A SOLUTION

A compromise solution is available: A home-based program that also includes a few (or several) supervised exercise sessions done in the office. This approach works with the majority of patients and can achieve most of the benefits of an institutional exercise program. It is also cost-effective for the patient, as well as revenue-producing for you.

Here are five steps to this approach:

1. Assign exercises and an exercise log. Since you see your patients frequently (at least initially), you have the opportunity to monitor them closely. This enables you to establish an inexpensive home-based program and review compliance and performance regularly.

Ask your patients to fill out an exercise diary and bring it in each visit. This assignment tends to help motivate them to do the exercises, since they will want to show you their diary to get praise and recognition. Patients will realize rehab is a necessary part of their treatment if they have to record each exercise session in writing.

Also ask your patients to demonstrate their exercises weekly. Because they know you will be checking up on them, patients are motivated to exercise regularly.

You can charge a fee for this monitoring service, because it is extra to the adjustment.

2. Start small. At first, show patients only a couple of exercises to perform daily. Once they can consistently and successfully do these exercises, add more complex exercises (with increased resistance). Keep the hurdles low in the beginning to avoid discouragement and disappointment.

3. Demonstrate. Make sure the patient knows which exercises to do, and how to do them correctly by demonstrating the exercise, watching the patient do the exercise, and correcting the inevitable mistakes.

Demonstration and teaching is another billable service because it's additional to the chiropractic adjustment.

4. Provide home-exercise equipment. Exercises performed incorrectly will not contribute to progress and could even be detrimental to the patient. Supply your office with rehab equipment to help ensure your patients perform the exercises correctly.

You can also provide inexpensive equipment similar to the equipment you use in your office for patients to use at home. This helps eliminate the worry about patients performing exercises incorrectly, because you've already seen them demonstrated on similar equipment in your office. It can also generate additional revenue for your practice.

Rehab equipment that provides simple, pain-free exercises for the cervical spine, thoracolumbar spine, and extremities can help increase patient compliance by minimizing pain and complexity.

5. Keep it simple. Avoid multiple sets and other complex exercise methods. For most patients (and especially for those who aren't used to exercising), a single set of 10 to 12 repetitions of each exercise has been found to be effective.⁵

Single-set programs are less time consuming, which generally ensures improved compliance. It's a good idea to have the patient do the exercises every day to establish regularity and avoid the complication of a weekly schedule.

A cost-effective rehab program is achievable with a monitored home-exercise program. In most cases, a closely monitored home-exercise program enables you to provide cost-efficient, yet very effective, rehabilitative care.

In this way, you and the patient can work together to improve spinal function, decrease current symptoms, and prevent persisting disability.

John K. Hyland, DC, DACBO, DACBR, is an expert in the active rehabilitation of chiropractic patients. He was the developer and director of four chiropractic rehabilitation practices for more than eight years. Now, he consults, advises, and trains doctors of chiropractic in the concepts and procedures of spinal rehabilitation. He can be reached at 303-819-9159 or by e-mail at drhyland@comcast.net.

REFERENCES
¹ Reilly K, Lovejoy B et al. Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. J Occup Med 1989; 31:547-550.
² Daltroy LH, Robb-Nicholson C, Iverson MD et al. Effectiveness of minimally supervised home aerobic training in patients with systemic rheumatic disease. Br J Rheumatol 1995; 34:1064-1069.
³ Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Phys Ther 1999; 79:270-277.
⁴ Schneiders AG, Zusman M, Singer KP. Exercise therapy compliance in acute low back pain patients. Man Therap 1998; 3:147-152.
⁵ Feigenbaum MS, Pollock ML. Prescription of resistance training for health and disease. Med Sci Sports Exer 1999; 31:38-45.