Chapter 3
Principles of Self Management
and Exercise Instruction
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Teaching in the Clinic
Role has changed
from full-time
rehabilitation services
to incorporate parttime educators.
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Safety
To ensure adherence and
positive outcomes, the
therapist should help the
patient understand which
signs and symptoms
predict an exacerbation,
so that modification is
appropriate.
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Self-Management
Patient education can empower the patient to
self-manage the situation.
Gently guide the partner (patient) to improve
chances for a successful outcome.
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Adherence and Motivation
Health Behavior Model
Transtheoretical model
 Precontemplation (PT has no intention of changing)
 Contemplation (seriously considering change, but not
yet initiated)
 Preparation (planning to change soon or may have
initiated small changes not yet complete)
 Action (have changed in last 6 month – quit smoking)
 Maintenance (changed more than 6 months earlier)
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Applications
Build rapport with each visit.
Link treatment directly to patient’s personal
functional goals and needs.
Use a program that requires the fewest
lifestyle changes.
Attempt to blend the exercise program into
the patient’s daily routine.
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Clinician–Patient Communication
Personalities, values, teaching, and learning
styles ultimately affect adherence and outcomes.
The ability to assess the patient’s willingness
and style of communication is paramount.
Improvement in the quality of interaction can be
achieved by being sensitive to the patient’s
verbal and non-verbal cues.
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Clinician–Patient Communication
(cont.)
Clinician’s attention to patient’s needs can guide
appropriate communication style.
Fundamental skills – close observation of the
patient’s words, intonation, body language,
affirmation, and reflection of the patient’s report
and eye contact (if it doesn’t intrude on cultural
boundaries).
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Issues in Home Exercise Program
Prescription
Clarity in goals and
exercise procedures
is essential!!
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Understanding Instructions
The clinician must be conscious of:
Cultural barriers (e.g., religion, cultural customs)
Clarity of instruction (e.g., pictures and written
instructions, involvement of family members,
etc.)
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Proper Exercise Execution
Have patients perform exercises under direction.
Consider reciprocating and have patient “teach”
exercises.
Encourage patients to take notes.
Have family members observe—helpful.
Videotaping.
Upon return, patient demonstrates the exercises.
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Equipment and Environment
Exercises using body weight, objects at home
or office—more functional.
Consider perception of patient’s expectations.
Adherence may improve if equipment
purchase is expected by the patient.
Assess home surroundings & limitations prior
to prescribing exercise and/or purchase of
equipment.
Involve social support/environment in process
to ensure understanding of the plan of care.
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Home Exercise Prescription
Factors include:
1. Stage of healing.
2. Tissue irritability and symptom stability.
3. Patient’s time and willingness to learn.
4. Time between physical therapy visits.
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Stages of Healing
Early Stages – Appointments may be more
frequent.
– Exercise program may also
change more frequently.
Intermediate-Late Stage – Patient’s symptoms
and function change more slowly.
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Tissue Irritability and Symptom Stability
What activities or positions increase symptoms?
How much time can be spent in a specific
activity or position before symptoms begin?
When symptoms begin, do they continue or
progress despite discontinuing the activity? Will
changing the activity or position alleviate the
symptoms?
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Assessing Tissue Irritability
After initiation, how long do symptoms last? How
long before returning to baseline?
Is there anything you can do to relieve your
symptoms?
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Patient’s Time and Willingness to Learn
Availability of time the patient possesses
affects exercise prescription.
Educate, prioritize, and agree on the
program. Requires empathy for the patient.
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Time Between Physical Therapy Visits
Increased visits – May allow for more
challenging programs.
Longer intervals between visits – Provide
exercises less likely to overwork the patient
and provide supplementation (additional
instructions for exercises, etc.).
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Determining Exercise Levels
Determining exercise levels and
educating the patient regarding pain
during exercise is important.
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Classification for Determining the Appropriate Level of
Discomfort Associated with Home Exercise Prescription
Curwin and Stanish
1.
2.
3.
4.
5.
6.
No Pain
Pain only with extreme
exertion and 1–2 hrs after
Pain with extreme
exertion and 1–2 hrs after
Pain during and after any
vigorous activities
Pain during activity and
forceful termination
Pain during daily activities
• Normal
• Normal
• Normal or slightly decreased
• Somewhat decreased
• Markedly decreased
• Unable to perform
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Self Management and Exercise
Instruction – Summary
 Patient safety comes first.
 Make the patient a partner in the program – PT
education and self management.
 Determine what motivates the patient.
 Prescription of exercises should contain the fewest
lifestyle changes possible. Mimic the patients usual
activities.
 Determine a patient’s needs and willingness to learn
by becoming an active listener.
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