When you prescribe a home exercise program, how much time do you spend thinking about how the patient or client interprets that program? I’m not talking about whether or not they enjoy it, or how it affects their symptoms. I’m talking about how it makes them feel about themselves.
As therapists, we think of home exercise programs as a tool. When working with patients with persistent concussion symptoms, home exercises might include balance training, some specific movements to help neck dysfunction, vestibular habituation exercises, or aerobic exercise to improve exertion tolerance. We labour over how to help our patients get the most benefit from the exercises, but we acknowledge that with these exercises, patients risk exacerbating their symptoms. So we educate patients about how to handle that. If all goes well, they do the exercises, and they slowly begin to improve.
The flip side
But think about it from the perspective of a patient. They feel rotten, and if symptoms are chronic, they’re likely struggling emotionally. Most patients with persistent symptoms are confronted with a lot of “can’t”s - they can’t do what they used to do, or as much, or as well, or for as long. There is a big emotional component to persistent concussion symptoms, regardless of what the symptoms actually are. This can be made worse if that patient is dealing with anxiety or depression, both of which are common and understandable.
In this emotional landscape, a home exercise program can become a daily goal, and meeting or not meeting that goal can affect how a patient feels about themselves. Meeting a daily goal can feel like a big accomplishment, especially if it’s the only success they experience that day. Not meeting that goal can be one more “can’t” on the long list for that day. You didn’t mean for it to be a goal, but your patient made it one, and now meeting or not meeting that target can feed into a lot of emotions:
Am I doing enough = Am I good enough?
Will this ever get easier = Will I ever get better?
This makes me feel rotten = I feel so different from before.
Think I’m exaggerating? Ask your patients with chronic, persistent, debilitating post-concussion symptoms.
So what’s the solution?
Let’s acknowledge one thing: A home exercise is a patient goal. They want to complete the exercises, they want to succeed at the exercises. You might not like the emotional baggage that these programs can be saddled with, but for some patients, this will not change. How they feel after attempting their exercises will affect their emotional state, the rest of their day, and their overall symptom burden.
As a therapist, you need to accept that. And you need to bear that in mind when you construct home exercise programs.
When you think of a home exercise program the way your patient does - as an outcome-focused goal - it can be performance-based or symptom-based.
Performance-based programs: “Stop after ____ minutes/metres/reps”
This type of program becomes a goal focused on accomplishing something. How many reps of their neck exercises should they do? How many minutes of vestibular rehab? How many blocks or kilometres or steps should they walk?
Symptom-focused programs: “Stop when your current symptoms worsen or when new symptoms develop”
This type of program disregards metrics other than how the patient feels. They monitor their symptoms, and make an individual decision about when to stop exercising.
Both types of programs have pros and cons
If a perfomance-based program has appropriate and achievable goals, the patient has a sense of being successful - which can be really valuable for patients who feel like they’re failing in other areas of life. The downside, though, is if the patient is not in touch with their symptoms, they aren’t learning self-awareness and not learning to respect their own limits.
On the other hand, a symptom-based program can be essential in teaching a patient to self-monitor, and places the patient in control of his or her own care. It can also teach the patient that they can control their own symptoms, rather than feeling like their symptoms control them. But for patients who are already symptom-focused and anxious, this type of program can make them hyper-aware and even more anxious about exacerbating symptoms. It can also send the message that symptom-provocation is a bad thing (which is not always true).
Neither type of program is always good or always bad, and both are better for some patients than for others
Sometimes one type of program is better early in the rehab program, but later you need to choose another strategy. Taking the time to understand your patient and their perspective will allow you to set up the best program at the best time - yet again, another reason why concussion rehab is not a DIY project!