Physical therapy is one of the most recommended ways to treat chronic low back issues. Low back pain guidelines regularly recommend physical therapy as a first line treatment for chronic low back pain as it can help improve function and prevent disability from getting worse.
During the course of treatment physical therapists will do an assessment, identify the factors that have contributed to the problem and design an individualized treatment plan. Treatment can consist of a variety of things including (but not limited to):
Strengthening and flexibility exercises
Education on how to care for your back
Home Education Program (HEP)
What Is A Home Exercise Program/ H.E.P?
The Home Exercise Program (HEP) is a vital part of the treatment but it is often overlooked and undervalued. Physical therapy has been proven to help speed up recovery from low back issues and help to restore mobility and reduce pain, but it is not a magical wand that you can wave with instant results. It takes time, and time, apparently, is something that we are all short of.
Unfortunately most patients don’t have the time or the financial ability to see a physical therapist four or five times a week unless they are in an in-patient rehabilitation setting, which is generally not how low back pain is treated. Physical therapy is a partnership between therapist and client. The therapist will evaluate and educate but the client has to be actively involved with their recovery plan and commit to doing whatever they can to carry out the plan.
Cue the Home Exercise Program. An effective HEP can be vital to how a client progresses with their therapy and it can sometimes be the deciding factor in whether or not a client makes full recovery. By taking just 15-20 minutes each day you can make significant strides in between PT appointments. HEPs can bring significant gains in a client’s stability, strength, and mobility that can’t be achieved in just a few hours at the clinic. When you continue to build on what you learn during your PT sessions you can improve your daily performance and give yourself a step up in progress before your next PT session.
Do I Really Need To Do My Physical Therapy Homework?
Physical therapists regularly encounter the question, “Do I really have to do my at-home exercises?”. Clients are paying for PT sessions so surely those are going to be good enough to help them get better? Unfortunately a large part of the recovery process just takes time and practice. Studies have shown that people who adhere to their prescribed exercise program are “significantly better at achieving their goals and demonstrate a greater increase in physical function.”
Unfortunately the opposite is also true with home exercise programs. People who don’t stick to their home exercise programs are often at increased risk of recurrent injuries or flare-ups and tend to have less positive long-term results.
Sadly the data shows that in general, there is fairly poor adherence to prescribed home exercise programs. The numbers vary in research but estimates range anywhere from 35% to as high as 70%! Non-adherence for general musculo-skeletal conditions is generally around 50-65%. This poses a significant challenge for physical therapists to help them get the results that clients want in the time frame that they are looking for. It can be highly challenging to fix something as complex as low back pain in just 12 sessions.
It is essential to realize that physical therapy isn’t just the time spent at the clinic. Physical therapy homework is just as much PT as the time spent with your physical therapist. Getting an 'A' for effort on your homework can have a major impact on your recovery journey, making your time spent as effective as possible and speeding up your recovery timeline.
Your at-home exercises help to supplement what you are doing during the in-clinic visits, helping you make even more progress than you would if you were only doing the clinic visits. This can not only speed up your recovery but could also cut down on the number of visits that you need to do overall, ultimately saving you time, and money.
Factors Affecting Adherence To Home Exercise Programs
Most people leave their PT session with full intentions to do their homework but research shows that there are some common reasons why these intentions often fall short. Some of the main reasons that people don’t adhere to their exercise program include:
1. Self-Efficacy. This relates to a person’s belief in their ability to do something that will get the desired result. Client’s often doubt their own ability to perform the exercises well enough and so they end up not even trying, or trying a couple of exercises and then giving up.
2. Time. Many of us feel that there are simply not enough hours in the day to get everything done. Work schedules, taking care of families, prior commitments all compete for our attention and it can be hard to fit one more activity into your day.
3. Their beliefs. Sometimes we think we just can’t do something. That we are never going to get better. That we will never be able to do the things we were once able to do. That the pain is just too great. The injury, too severe. These beliefs can hold us back and make us afraid to try something new. It can really stunt our progress.
4. Pain. Pain is a very common barrier to participation in a HEP. The pain could either be so intense that even simple exercises trigger it, or it could be just the fear of experiencing pain during an exercise. Avoidance of fear is a powerful thing and it can definitely decrease adherence to HEPs.
5. Depression. When patients are significantly depressed, something that can often accompany chronic pain (see our article on How To Break The Chronic Pain Cycle) it can be hard to find the motivation to participate in activities. Motivating yourself to get moving again can be extremely challenging for depressed patients who are also experiencing chronic pain.
6. Activity Levels. Research has shown that clients who were physically active before starting PT were more likely to adhere to HEPs than those who had not been physically active before. Starting a new activity program can be challenging and daunting to those who have not done it before.
Reasons To Stick To Your Home Exercise Program
We know, there are a million reasons why we are too busy to do our homework, so we thought we would share some reasons why you SHOULD do your homework.
1. HEPs Give You Control Over Your Recovery
Your PT isn’t just designed for the here and now. A good physical therapist is thinking of the future. Of your goals and long term health. Having access to these exercises and doing them consistently after PT will give you the ability to stay healthy and active long after your injury. Any time you have issues in the future (which, sadly, is somewhat inevitable) you will be able to refer back to these exercises and get back to mobility again without having to reach out for more physical therapy. It gives you a plan for pain management for the future.
2. HEPs Help Speed Up Recovery
Studies have shown that clients who complete their HEPs heal faster and make more significant progress during the course of their treatment than those who don’t do their exercises. Your physical therapists (hopefully) didn’t just throw together a random program.
More likely they will have taken the time to consider your specific condition, analyzing your range of motion, strength and conditioning. They will then create a specific plan to address reducing pain, improving balance and mobility, and help to prevent any further injury. If your PT has taken the time to create such an individualized program for you then it is probably a good idea to take them seriously and do them to the best of your ability.
3. HEPs Help Relieve Pain
Pain plays a huge role in low back issues and is often one of the main reasons that people seek medical care for the condition. With that in mind, the exercises that your physical therapist will prescribe for you are aimed at reducing pain and decreasing discomfort. Pain medication is not always effective at controlling chronic back pain and it is key to complete your HEP so that you can achieve the maximum pain reducing results from your PT.
When you are able to get your body moving again you can reduce stiffness and improve mobility and this can have a significant impact on the pain that you experience in your day to day activities. The exercises you do should not increase or trigger pain, but help you to decrease your sensitivity and increase your range of motion.
4. HEPs Build Strength
If you haven’t been active for a while due to your low back injury it is quite likely that your muscles may have started to weaken. If you are only seeing your PT once or twice a week it isn’t possible to make a big difference in muscle strength. If all you do is the exercises with your physical therapist in the 30-60 minute session it will be hard to make real muscle gains, and your body will probably lose those gains before the next session. Daily exercises can help to increase your strength and stamina and help to maintain any gains achieved during PT.
Tips For Sticking To Your Home Exercise Program
Now that you know all of the benefits of doing your home exercise program how do you go about motivating yourself to do it, and better yet, sticking to it? We have some ideas to get you going!
This is probably the most important thing you can do. Find your ‘Why’. Physical therapy isn’t just about reducing pain - although that is certainly a huge part of it. If you really ask yourself why you are at PT there is generally a reason. Most people want to be able to do something that they used to be able to do and have found that back pain is getting in the way. It might be returning to work, getting back on the golf course, playing with your kids, being able to travel again.
The ‘Why’ looks different for everyone, but when you find it, it can be a powerful motivator. No longer are you just showing up and going through the motions but you have a real goal. A vision of what your life is going to be like when you finish. Think about what activities you like to do. Who, or what, is important to you. Your physical therapist can help you connect your exercises to your purpose and create micro goals that can help you see the progress you are making. Micro goals are great for helping people stay motivated towards a bigger goal.
When you are doing your HEP you can picture your goal in your mind and this can help you stay strong and motivated towards something that is important to you.
We have already seen that time can be a huge challenge for people, in fact it is the number one reason that people give for not completing their at-home exercises. The fact is that most physical therapists don’t give homework that lasts longer than 10-15 minutes so it is more about time management than not having the time at all. There is a famous quote that says “If you don’t make time for wellness then you will have to make time for illness”.
Work with your PT to review your calendar and try to find small moments during the day when you can exercise. Lunch, when you wake up, right before bed - these are all perfect opportunities to turn off the TV or get off your phone and squeeze in a quick session.
Create A Routine
Getting into the habit of working out can be hard but once you have done it your life is going to be so much easier. Finding specific times during the day that work for you is key. Linking your exercises to certain activities can be helpful such as completing your exercises while watching your favorite TV show or doing them in your office during lunch.
They say it takes 2 weeks to form good habits so use technology to help set you up for success. Setting reminders and alarms can be helpful to get your started in forming a routine. There are also apps out there that can help with some HEPs even having the technology to help remind you to complete your workout. When you create a routine it is easier to stick to your program and you won’t have to consciously decide to exercise each time. You might even start to look forward to a nice stretching session first thing in the morning, or last thing at night.
Just like dieting it can be easy to give up if you end up missing a session or two. Often when this happens people tend to think, “Well, I can’t catch up now so I may as well just give up altogether”. Nothing could be further from the truth. The reality is that life happens. Things get in the way. We have bad days. Missing a session or two is probably expected but that isn’t a reason to give up completely. Just pick up again at your next scheduled time slot and get back to getting strong again. Consistency is key and missing a session every now and again is not going to completely derail your progress.
Modern technology has provided us with new tools to be able to do home exercises like never before. Using mobile phones and tablets, new software programs and devices can help to provide next level HEPs for clients. Programs with motion-tracking, specialized sensors, interactive videos, and digital coaching are changing the way we see HEPs.
Companies such as Physera, Sword Health, and Hinge Health are using data-driven approaches that help increase adherence to exercises using digital coaching, education, and self-monitoring. This allows the physical therapist to have even more insights into the training that is being done at home. Many clients like the idea of having a digital coach or a video to help them see exactly how the exercise should be done. Digital coaching using special sensors can also help clients feel safer and less worried about doing the exercises wrong and injuring themselves further. This is an exciting landscape and there are sure to be many more new products on the market in the near future.
Much like a doctor will tell you to go home and take your medication to get better, physical therapy homework is a vital part of your recovery journey. To make sure that you are getting the most out of your physical therapy program it is essential that you also complete your HEP, especially if you want to get better as quickly as possible.
Excuses like, “The dog ate my homework.” aren’t going to fly in PT and the only one you will be cheating will be yourself. Failing your HEP will only mean that you have to go to PT longer than you had planned, which will ultimately cost you more in both time and money. Your PT is there to help you, not to punish you or be lazy.
Speak with your physical therapist about any concerns you might have about the program. Don’t be afraid to speak up if you are worried about pain or don’t know how to fit it into your schedule. A good physical therapist will take the time to go over these concerns with you and help set you both up for success. Let’s get you that A+!