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 part-
time 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. No Pain
2. Pain only with extreme
exertion and 1–2 hrs after
3. Pain with extreme
exertion and 1–2 hrs after
4. Pain during and after any
vigorous activities
5. Pain during activity and
forceful termination
6. 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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