On Adapting to Exercise

So, I walked out of my first physical therapy session with exercise instructions in hand:

a,  two standing balance routines,
b,  one head turning/visual fixation routine, and
c,  one head turning/side-lying routine.

All of these exercises are aimed at reducing my inner ear problem with its positional vertigo.

To have any effect, these routines need to be carried out at least once and preferably twice a day.  The routines themselves will make me dizzy, somewhat nauseous, and headache-y. But the long-term effect (I’m told) is to habituate my body to these movement-triggers; ultimately I won’t become dizzy and nauseous because of head positions and visual stimuli.

a.  I’m supposed to stand in a corner for the standing balance routines so I have something to block me if I start to fall.  I try out the corner of the kitchen counter and then the corner in the upstairs hallway.  Both spaces work for the exercises, so I end up using them both.

b.  For the visual/head turning exercise, I cast about for some way to display this 3-inch card with a large ‘X’ on it and settle on paper-clipping it to the kitchen calendar.  In that location, I can stand directly across from it, with my back against the door jamb, and do my head-turning and visual focusing exercise.

c.  The side-lying  exercise provides more of a challenge.  I try sitting on the side of the bed upstairs, turning my head to a 45 degree angle, and lying down sideways.  The bed location works fairly well, but doesn’t feel like it gives me quite enough support and is a little high.  After a couple days I try the sofa downstairs in the living room; the sofa is firm, has a small pillow on each end for me to put my head on when side-lying, and is more accessible during my daily life.  So I settle on the sofa.

ejercicios_Brandt_Daroff

The next question is when to do the exercises.  The side-lying exercise is the one that makes me dizzy and headache-y, so I tend to do that just before going to bed for the night. For this exercise, I decide once-a-day is the best I can do for now.  The other exercises I can do off and on throughout the day as they are easier to fit into my usual routine.

Today, I’m thinking back to what I was experiencing as I worked to fit an exercise routine into my daily life. My own experiences raised the question for me:  “What do clients — who leave occupational therapy with instructions for new exercise routines, new adaptive equipment and new ways to carry out their daily occupations — experience as they learn the new routines and fit them into their everyday lives at home?”  How much do we help clients think this through, and how open are we to compromises and modifications in how and where and when they fit these changes into their days?  And do we get and give feedback on what they have figured out the next time they come to therapy?

Has anyone done research on the phenomenology of embedding new therapeutic regimens and equipment into one’s life?  Wouldn’t new understandings of this phenomenon help get rid of that over-used, ill-gotten term “non-compliance?”

15 thoughts on “On Adapting to Exercise

  1. Excellent questions, Betty! Personal experience is certainly the best teacher, isn’t it?! I so hope these exercises move you toward more comfort and freer participation.

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  2. Right on!! I just heard the phrase ‘non compliance” on the radio today and couldn’t believe it is still a part of the conversation. It is really time we get beyond this!

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  3. I so agree. I’ve spent my entire career seeing patients and clients in their home, and sometimes I’m just dumbfounded by the instructions sent home with them (from a variety of professionals) with little or no thought given as to how these new activities will be incorporated into daily life. A year ago I heard Jim Prochaska talk about all the instructions and prescriptions given to patients, noting that every one is expecting a behavior or behaviors to be performed routinely, usually for life. (Health Literacy Out Loud, Podcast #100). WOW! No one considers this. OT claims habits, routines and rituals in our domain of practice, but seldom do these important aspects of occupation get addressed in practice. If we stepped up and claimed these aspects, we would contribute a great deal to health care and to the lives of our clients and patients.

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    • Thank you, Carol, for your very affirming comment! Don’t you think that practicing occupational therapy in the community opens one’s eyes to our clients in the real world. I loved community health, seeing clients in their home setting as they went about their daily routines. Thanks so much for your comment. Betty

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      • Great intuitive insight offered, Betty, et al, for all ages. I’m reminded of home programs that can be too involved for families to integrate into their routines–absolutely unrealistic!

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  4. Spot-on questions in my view, Betty. I hope you’re experiencing some success with embedding your exercises in your daily life, and that the vertigo is abating. Wendy

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  5. I wonder if the emerging service delivery model of ‘telehealth’ might be an opportunity for Occupational Therapy to help their clients integrate home programs into daily routines and facilitate the development of healthy habits. I would love to hear your thoughts!

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    • Christa,
      The idea of using telehealth to address daily routines is an intriguing idea. EVERY behavior we want/expect clients to perform is an expectation that existing habits or routines will change, though we don’t usually think about this, or frame our instruction that way. We have expertise to tailor home programs and other instruction so that clients can INTEGRATE as well as IMPLEMENT. My perspective is that this should be part of OT across the board (especially since we claims these areas as part of our domain/scope) rather than “integration” being a niche within OT practice (whether telehealth or face to face)

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    • Hi Betty, I will begin with the disclaimer that I am not an expert in telehealth. I was introduced to the concept while working at Univ. of WI hospital. Around 2006, the Director of the Stroke Program began to use advances in communication technology (such as video-conferencing) to consult with ER physicians in rural areas of Wisconsin to improve access to drugs like tPA that must be given within several hours of onset of symptoms. Since then, I’ve noticed that many health providers have implemented ‘tele-nurse’ programs where patients can call in and talk to a nurse about their symptoms and either given a prescription (if a non-urgent condition is diagnosed) or scheduled for an appt. with the doctor. Recently, I’ve come across this concept being implemented in OT. There is a company called Tiny-Eye that began providing ‘virtual’ school-based therapy by SLP’s and they are now including virtual school based OT. I believe the company is primarily located in the Netherlands and Canada. Also, with the increased use of online gaming for home programs (like the Nintendo Wii or Kinect), I’ve talked with some outpatient OT’s who have used this to monitor how their clients are doing with home programs since they can track performance data such as accuracy. But I am particularly interested in how the technology might be beneficial when working in the area of wellness and prevention. I do believe a large percentage of OT requires a person to person interaction, which is extremely important for developing rapport. However, I think there are potential worthy applications for telehealth in OT.

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      • Telehealth is a broad term referring to services which are delivered/mediated through telecommunications technologies. It includes technology as basic as phone, to technologies as complicated as live video across state (or even national) boundaries. Telehealth can be delivered in real time, or it may be asynchronous (where the sent communication occurs at a different time than the received communication.) Given the shortages of OT personnel (particularly in remote rural areas where there are not only few OTs, but where distances to get to facilities/practices is beyond what most clients can manage) and the abundant needs for OT, telehealth is worth investigating, especially for OT to be part of the solutions to various population/societal health needs. The challenge is getting past the assumption that we have to touch a client or be in the same room with him or her in order to be effective.
        Many of us, especially in home care, have used telehealth (even if we didn’t call it that) for year when we called our clients between home visits to followup on instruction given at a visit. That’s still “intervention” and often as important or even more important than the face to face encounter in achieving desired outcomes.
        What’s intriguing in terms of incorporating new activities into existing habits and routines (or modifying existing habits and routines to be more healthful) is that telehealth can be a way to “be there” at the time of day (or week, or month) when it’s time for the activity, without having to be physically present. While taking a course on health literacy, I read about two different programs that use targeted text messages (where the recipients opt in to he program) to receive messages as reminders of the behaviors they are trying to routinize. Not everyone would want that, and not everyone would respond positively to that kind of prompt. But our ability to tailor interventions to be “just right” for a client has all new potential when telehealth is considered.
        FYI–OT is behind may other professions in embracing telehealth and ensuring that telehealth is recognized (and regulated) as practice in state practice acts. Telehealth isn’t a new practice area, it’s a new way to deliver what we already do (and it needs to be regulated just as the rest of our practice is). And that includes privacy and confidentiality of communications.\
        Sorry for the very long response.

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      • Thanks Christa. This seems like a shift in occupational therapy practice that is being recognized more and more as valuable, or even essential, to good practice in this day and age. After reading your comment, I realize that I take part in this with the online health records and communication system used here for at least two major health provider systems here in Madison. I have used it to send messages to a nurse, ask for advice, enter follow-up questions. It seems so make so much sense for OT to offer this to patients as well. There are huge possibilities here! Thank you so much for your elaboration of your first comment! Betty

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  6. Hello casotr. Your explanation of telehealth is very helpful — and no apologies are needed for the length! It does seem that its applicability is especially indicated in home care, outpatient care and rural health. But really, it seems potentially helpful in just about all areas of practice. I just had not thought about it in this way, nor put a name to it.

    As I stated above in my comment to Christa, I, myself,use a telehealth system for my own health care — to “talk” to the nurse about follow-up visit questions, new concerns, clarification, etc. One of the world’s largest health systems technology companies in the world (Epic) is headquartered here in Madison. It’s mind-boggling to think about the potential uses for health care providers, and for occupational therapy practice, As I think you indicated, there are always precautions against overuse or misuse that are needed, and the need to continue to recognize the value of face-to-face interaction seems to go without saying. But, for me, a between-visit contact with the physical therapist to help ,keep me on track plus to help interpret what was happening with the exercises I had for vertigo, would have been very helpful. As just a start.

    Your information and input here are much appreciated. Thank you! Betty

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