As a physiotherapist, you’ve probably seen this countless times. You prescribe the same exercise to two different patients with similar conditions, yet one does it with enthusiasm while the other approaches it with dread and eventually stops doing it.
One is excited that they have been offered a potential solution for their condition and is hopeful about their recovery, while the other is doubtful that the exercise will be of any benefit.
Too often, as PTs, we obsess over prescribing the “right” exercise or movement, when in many scenarios the specific exercise isn’t the main determining factor in recovery… the relationship to the exercise is.
As PTs, it is not uncommon for us to blame patients by saying they were “non-compliant” with their home exercise program. However, in my humble opinion, it is not wise to blame a patient for not doing their prescribed exercises. If anything, the therapist should take much of the responsibility for not understanding the patient well enough in the first place. The PT obviously prescribed something that the patient had little desire or ability to do.
Here’s an example. A PT prescribes aqua fitness to a patient with lumbar stenosis based on evidence suggesting it can be an excellent activity for someone with that condition.
However, when the patient returns a week later, they are asked: “So, did you go to the pool and do the aqua fitness exercises?”
The patient replies: “No! Because I don’t have access to a pool. I don’t like the water, I’m sensitive to chlorine, and on top of that, I feel uncomfortable using public change rooms.”
So, if the patient did not follow your recommendation for aqua fitness, whose “fault” was that exactly?
The strongest predictor of adherence to any exercise program is the patient’s reason for wanting to do it.
I often tell my patients this… “When it comes to our motivations, we are often either escaping or pursuing.
If you exercise with the mindset of ‘fixing your pain,’ then you are in ‘escape mode.’
If you exercise with the mindset of losing weight, again you are in ‘escape mode’ because you are telling your brain that you wish to escape your own body.
Being in ‘escape mode’ is stressful. It’s similar to being in fight-or-flight mode.
I don’t ever wish to see patients in ‘escape mode’ because it is not conducive to healing and recovery.
On the other hand, if you exercise with the mindset of pursuing a meaningful goal such as playing with your grandkids, getting back to yoga, going dancing with friends, or hiking in the mountains… then you are in ‘pursuit mode,’ where your nervous system is primed for healing.
So, what is your reason for wanting to exercise? What do you wish to be able to do again?”
As you can see, exercise is not just exercise. The mindset matters. The reason one wishes to exercise matters.
If a patient cannot come up with any reason to exercise other than, “Get rid of my pain,” then I ask them, “If you were pain-free right now, what activity would you do?”
After careful thought they reply, “I just want to be my normal self.”
So I ask them again, “What would your normal self be doing that you are currently unable to do?”
They may once again answer, “I just want to be pain-free.”
Then I offer them ideas for meaningful activity goals by asking, “Do you enjoy any sports? Gardening? Playing a musical instrument? Any hobbies that bring you joy? Is there a job you would like to return to?”
Again, they answer, “No, I have no hobbies, and I am not currently employed… I just want to be pain-free.”
A person who admits to having no activities or hobbies that bring them joy may be showing signs of depression. Regrettably, the prognosis for recovery from chronic musculoskeletal conditions is often poorer in those with depression.
In my opinion, if a patient with chronic pain cannot identify at least one meaningful activity they wish to return to, then physiotherapy may no longer be the priority. The chances are high that they will not comply with your suggested exercises, and even if they do, it will likely be from an “escaping mindset,” which can become a barrier to recovery.
At that point, they may benefit more from medical and/or psychological support than physiotherapy alone.
You may view this 5-minute video I created on this topic.