Patient compliance as homework

Journal of the American Chiropractic Association, Feb 2001 by Lew, Makani

Patient instructions amount to homework that will make or break a patient's speedy recovery. Just as students often regard homework as onerous, patients may adopt a similar attitude to their home instructions. Chiropractors who are truly serious about adjustive care having maximum and long-term consequences should attempt to help patients realize the importance and simplicity of the "homework" they provide.

Primarily, this entails a specific home exercise and stretching program and changes in the activities of daily living. Doctors who recommend home programs generally fall into two categories: those who give too much too often and those who don't assign patients anything at all. It's easy to guess what happens with both of those approaches, and the ideal solution is to prescribe by the code of moderation.

When you evaluate a patient's daily activities, you need to understand fully what the patients do every day. When they purport to "exercise," find out if that means dashing off to the kitchen during half-time-or 30 minutes spent walking each day. If they claim to "eat well," see if that means eating healthful fresh vegetables, or a peeled boiled potato just this last Thanksgiving. If they confide in you that they smoke "just a little," find out if that means just a few cigarettes or just a few packs of cigarettes a day. Finally, if a patient claims to be a "social drinker," perhaps "one drink a day," make sure it's not 27 ounces of cheap brandy in a 32-oz. King Kong cup from Universal Studios, flavored with a little bit of Coca-Cola.

A step-by-step approach, uniquely catered to patients, is the best way to ensure chiropractic homework compliance. After carefully interviewing the patients and learning all of their daily habits, especially those that induce negative feelings, work with them by creating step-by-step plans that will allow avoidance of self-destructive habits.

This female patient has a computer desk job, is 20 lbs. over her ideal weight, and has low-back pain and stiffness. Having heard that fruits and vegetables are good for her, she attempts to consume a few servings of vegetables a day-mostly frozen peas and the like-- but with only limited success. She manages to walk about 15 minutes a day during her lunch break.

Here are the recommendations we might offer:

Computer Desk Job:

Take a stretch break for the neck and upper back every 15 minutes, and for the low back every 30 minutes.

These would include:

(a) Stretch-contract for the neck muscles, where the patient stretches in one direction 10-20 seconds, followed by a slightly (20 percent) resisted contraction for 10-20 seconds; cycle repeated two times for all the neck ROMs. (This is modeled upon PNF, or proprioceptive neuromuscular facilitation.)

(b) Scapular pull-backs, where the Patient is asked to pull the shoulder blades together and hold a strong contraction for 7 to 10 seconds, repeating 1 to 3 times.

(c) Low-back stretch, in which the patient stands by the desk, raises her arms high into the air for 10to 20 seconds, and does side-bend stretches 10 to 20 seconds per side. Add back extension stretches for 5 to 15 seconds, and while seated, kneeto-chest flexion stretches.

Exercise:

Congratulate the patient on her daily walking regime. Encourage her to squeeze in another 15-minute walking break at the same or at another time of the day.

Show some injury prevention stretches. These would include calf stretches (both with the knee extended and the knee bent), with the ankle maximally dorsiflexed and the hip extended. This stretch will help prevent shin splints, calf spasms, and plantar fascia problems. In addition, the patient should be shown quadriceps and hamstring stretches.

Diet and Nutrition:

Explain to the patient that healthful foods will provide vitamins and minerals, and this makes for a healthy body.

Explain that low fat alone is not the answer. High-quality fats (like the essential fatty acids found in deep-sea fish, fish oils, avocados, flax seed, fresh nuts and seeds, etc.) enhance healing and decrease inflammation, while low-quality fats (like those found in potato chips, deep-fried foods, hydrogenated fats and oils, roasted nuts, etc.) are harmful to the body.

Encourage a good balance between protein and carbohydrates. (She might be advised to read Anne Louise Gittleman's book, Your Body Knows Best, to find out if her body does better with a higher protein/carbohydrate ratio or vice versa.)

Advise that carbohydrates (simple or complex) are the same as sugar. In the absence of high-quality fats and proteins, carbohydrates are immediately converted into body fat.

Alert the patient to the value of fresh fruit and vegetables, but do commend her for the ones she already eats-a good beginning. ther Activities of Daily Life:

Symmetrical body use: Remind the patient to use both sides of her body to engage in normal activities.

Vacuum the floors while favoring both the left and then the right hand, stir the batter with alternating hands, carry the baby on either hip, etc.