Add exercises? You haven't even bought me dinner yet!
I overheard a conversation yesterday walking through the gym between a therapist and a patient, and though I only heard a few words, I could piece together the rest of the conversation easily, because I have had it myself.
Therapist: "I guess what I am wondering is that if you have only done these exercises once in the past three weeks, are you ready to start adding exercises?"
When I have said something like this to an athlete or a patient, it's because the client has expressed frustration with a lack of success of the treatment plan. Part of the issue is that they didn't follow the treatment plan. This makes the clinician a little bit dumbfounded.
Unwillingness to make positive changes might be part of it, but it is also an issue of expectations and subconscious desires. Why is someone asking for new medicine when they haven't taken the first as directed? The thought process here is really a matter of seeking a better intervention, as if there were a more-effective exercise that was being withheld for people who were really in pain, as opposed to everyone else.
The cliche of how we all want something for nothing these days has been discussed ad nauseum, and points are easily made for that in sports by noting the popularity of performance enhancing drugs, or clinically by noting the number of people who choose to take a pill instead of change their lifestyle, or who are eager to have surgery rather than exercise. We've all disconnected the smoke alarm rather than change the batteries, and there is satisfaction in the quick fix. But there's something else going on here as well. It's not only that we're eager for the maximal results with minimal effort. It's that the quick-fix provides an instant answer. As humans we crave certainty. When someone embarks on a diet or exercise program, or any other lifestyle modification, there is no guarantee that at the end of it they will be healthier, or feel better about themselves. And when do we know if it's working or not? Contrast this with a pill. Pain decreases, blood sugar normalizes, or mood evens out pretty quickly, and there is certainty that you've taken the right step. What a relief!
Consider diagnostic imaging. Though symptoms may not be significant, or responding abnormally to treatment, or there is nothing that will change the way an injury is managed, we frequently want MRIs anyway, just 'so we know exactly what's going on in there.' Though it's clear from the research that many times having these tests don't provide better outcomes, there is still something to point at and say "THAT is what is causing my problem." I once had a patient who faithfully completed her rehab program, was pain-free for weeks, and participated in all of the work and recreational activities she wanted to and had been doing previously. On the day of her discharge she told me "that when she saw her Dr. next she would get an MRI and see what exactly is going on in there." It's not always laziness, and as coaches and clinicians it is helpful for us to understand and acknowledge that.
The first step to providing more certainty is to simply discuss the diagnosis or problem. For many people giving them a name to hang their symptoms on is enough to satisfy them at first, but for most a detailed explanation of what impingement syndrome or a bulging disc is will help them get a real handle on what's going on. Then, address the why. It is key that people think of their problem as not a diagnosis, but a symptom. In the case of impingement syndrome, they should know that it is caused by weakness, posture or abnormal scapular mechanics (or whatever). The people that don't have this message communicated to them properly are the ones that after 10 years of being free of shoulder pain attribute a new onset to their rotor cup injury.
Next, set expectations. If you've had pain for 3-4 months, things might not be better in two visits. Sometimes, there might not even be a noticeable difference. It's not what anyone wants to hear, but it's true and should be pointed out. Then identify the plan. What are you going to do, and why are you doing what you are doing?
Typically, the above steps come easily. The difficult part is often setting goals along the way that are both optimistic and realistic. In the absence of injury, setting performance goals are often easier: there are plenty of established norms available, and figuring out where someone should be in different weeks and months into the future can be a simple as mixing some experience with a little math. When pain is present however, it can be a lot more challenging. I know many therapists who despise doing this portion of the evaluation, and I've had evals in the past that have languished on my desk awaiting a moment of enthusiastic motivation (or boredom).
One key is to change the mental approach to setting goals. Instead of thinking of it as a hoop to jump through to please an insurance provider, it's important to think of it as an orienteering course to the final goal: take stock of all of the existing qualities that need to be changed: posture, biomechanics, motor control, joint mobility, pain, spasm, etc and make some long term goals to completely ameliorate them. If that isn't realistic, make them as optimistic as possible, knowing that perhaps you won't achieve all of them while you are seeing them (due to insurance limitations or the fact that a patient may have met their goal of being pain-free or returning to competition before all of your goals are met). Then set up some intermediate goals along the way.
The other key is to share those goals with the patient. Many times those goals are written after the client is gone. That's ok, the problem is that they are written and then never referred to again. Remember that after an initial visit clients are processing a great deal of information. They are not going to remember it all. When you see them again, use the process of reviewing the timeline for the goals that you have (hopefully there is some mention of goals they have) as an opportunity to explain again their diagnosis, the underlying source of their symptoms, and the interventions that you will embark on together to achieve resolution of the above.
Remember that exercise and rehabilitation are somewhat foreign to your clients--that is why they have chosen to pay you for your expertise. When you are not getting the effort that you want from your clients, focus on what you can do to increase the buy-in: reduce uncertainty regarding your certainty about their diagnosis, explain why the pathology is present, manage expectations, and involve them in goal-setting so that they are able see where they are at in their rehabilitation process. Following these steps will help ensure that clients will do what you need them to do to help them achieve their goals.