How to Improve Home Exercise Adherence-Use Just the Right Amount of Equipment

One of the most common challenges in physical therapy practice is getting patients to actually do their exercises at home. As I’ve written about previously, we see about a 50% adherence rate to home exercises, despite the low cost and time commitments of most programs. 

It is easy for us to dismiss patients as being lazy or illogical for not being able to perform a few minutes of exercise. However, I see this often with people who are otherwise hard working and highly motivated in other areas of life. I have worked with lawyers who work 10+ hour days, yet struggle to perform 10 minutes of home exercises. 

One of the lowest hanging fruits to help patients perform exercises is our choice of equipment. The amount and type of equipment impacts how likely patients are to adhere to the program.

Here are a few common barriers and how to address them with your choice of equipment:

  • The need to setup or find equipment decreases adherence. For some patients, the act of having to find or setup equipment makes them less likely to actually perform exercises. This might seem ridiculous, but when adding a new behavior to someone’s life, small hurdles such as having to wrap a band around a doorknob, can prevent adherence. With these patients, we need to ask questions about when in the day they might have time to do exercises, where, etc. Then pick exercises that have minimal equipment setup needs. Rather than a band resisted row at a doorway, the patient could perform bent over reverse flies without weight. 
  • When the “busyness” of the day makes them forget about performing exercises. Some patients actually perform exercises once they remember, but they just get caught up in the demands of daily life. Here, equipment such as a band or dowel actually serves as a visual reminder.  For example, an office worker might have a red band by their keyboard which cues them to perform a few band pull aparts when they take breaks during the day.
  • When the patient wants exercises that look specific and technical. Patients come to physical therapists for our professional expertise. For certain personalities, if an exercise seems too simple it actually cheapens its value. For example, performing forward shoulder flexion (lifting your arms straight out front) can feel just like it sounds, just lifting your arms out in front of you. However, if we assign a patient a D2 band resisted diagonal (lifting out front at a slight angle with a resistance band) this feels more technical and specific. The context of exercise matters. 

The choice of equipment depends on the specific barrier and personality of the patient in front of you. Our expertise as doctors of physical therapy goes behind our clinical skills. Seemingly minor decisions, such as exercise equipment choice, play a key role in our patients feeling better and returning to the activities they love.

Winter is Coming Again (The Myth of Perfect Conditions)

A client of mine recently said “Once the weather warms up, then I’ll start walking more.”

They had struggled to reach their walking goal for the week. The cloudy, chilly days made walks unappealing. And, like many people, their mood and energy dipped in the winter.

I said to this client “You know winter is coming again.” The point being, that conditions are never optimal.

If it’s not winter, it’s some other circumstance. Moving to a new city. A busy period at work. An injury.

Waiting for perfect conditions feeds the formula of “Once my life is in X condition, then everything will be better”. It hinders us from making progress, even if it is slower than we would like. It hinders us from taking any action at all.

We cannot wait for conditions to improve, we just need to do the best we can given the situation.

We cannot wait for conditions to improve, we just need to do the best we can given the situation.

I’ve seen this mindset in my own life. When I was first getting into barbell training, I told myself “Once I have squat shoes, Olympic micro plates, and a lifting belt, then I’ll be ready to train.” Unfortunately, this led to months of not lifting, since I wanted to lift in supposedly ideal circumstances. Waiting for those “optimal” conditions led to me doing nothing at all.

Fitting in exercise (or any other behavior), even in sub-optimal conditions, is critical because:

  • You create blocks in your schedule for exercise. For example, if you walk 10 minutes, 3 days a week, you now have three blocks of time for walking. The hard part, creating the blocks of time, is already done. Those blocks form a strong foundation that can be built on later. Once you have the habit of walking for 10 minutes, adding 5 more minutes is quite easy.
  • You can progress, maintain, or at least minimize losses. At the start of the COVID-19 pandemic, I had limited access to barbells. So I did weighted push ups in place of the bench press. Push ups maintained some degree of strength and muscle, until I could get back to a barbell. Had I simply stopped exercising altogether, I would have lost significant muscle and strength. And the return to the bench press would have been that much harder.
  • You maintain a sense of control over your training. It is fragile if your whole exercise routine depends on the perfect set of external conditions. Changes in equipment availability, time, etc. can easily derail you. By continuing exercise, you maintain control over your training, even when circumstances force a change in plans.

So instead of waiting for winter to end, get started, even in small ways. Then the arrival of spring is just a bonus, rather than a prerequisite to exercise.

What if you can’t do the “perfect” exercise to get fit?

He was frustrated and confused. Jason (I’m using a fictional name for this individual) came in with low back pain after exercising.

Jason was in his 50’s and decided he finally wanted to get fit. He excitedly hired a trainer and began a weight training program. But then he started having low back pain. It seemed to always come after doing bent over barbell rows. The trainer insisted that bent over barbell rows were an important exercise, so Jason kept at it. The pain continued session after session. And it got worse. Finally, Jason decided to see a doctor. The doctor gave him pain-relieving medications, recommended physical therapy, and told him that weight training is dangerous.

So, Jason comes to the PT clinic with conflicting advice. The trainer insists that the exercise (the bent over barbell row) is fantastic and crucial to getting fit. The doctor says that weight training is dangerous.

Sound familiar?

Unfortunately, this happens all too often. Trainers fetishize certain exercises. They insist on the superiority of a particular exercise to get fit. Then on the other hand, some doctors and physical therapists say that certain exercises are inherently dangerous.

So what does someone new to exercise do?

In the example with Jason, we first ruled out a more insidious, “red flag” cause of the low back pain. Note that in the vast majority of people with low back pain, there is not an insidious, “red flag” cause of pain (such as tumor or fracture) (Hartvigsen 2018), (Seizer 2007).

Next we zoomed out to ask, “Why do bent over barbell rows?”

We do them to strengthen the upper body pulling muscles like the biceps, latissimus dorsi, rear deltoids, and trapezii.

The next question, “How else can we strengthen those upper body pulling muscles?”

There are many options; seated cable rows, arm supported dumbbell rows, and more.

We found exercises to work those upper body pulling muscles, while not aggravating his low back. This might seem like an obvious solution. But many coaches fixate on certain exercises as being of vital importance. They fit the person to the exercise, rather than fit the exercise to the person.

Why do coaches prize certain exercises?

Well-intentioned coaches may focus on certain exercises because of their training. Some training organizations and influential fitness gurus prefer certain exercises. Aspiring coaches learn from them and then carry on the tradition.

For example, some coaches dogmatically state that low bar back squats are superior. However, research suggests that many squat styles, both back and front squats, produce similar muscle activation (Yavuz, 2015). Anecdotally, you observe people building plenty of muscle and strength using different squat styles.

Further, the squat is not even necessary for everyone. Research shows that for those new to lifting, the leg press exercise can build just as much strength and muscle as a squat (Rossi, 2018).

A caveat. If you want to compete in a sport like powerlifting or must perform a specific exercise for athletic testing, that is a different story. In that case, you have to specifically train that exercise at some point.

Are bent over barbell rows “bad”? Is weight training dangerous?

There is nothing inherently dangerous or “bad” about the bent over barbell row. I use them for myself and clients. They can be a fantastic exercise. But certain people, at certain phases in their life, may not tolerate them well.

For Jason at that point in his life, the bent over barbell row was not a good exercise. But later, when his back was feeling less aggravated, we could reintroduce it. Just because an exercise is not well tolerated now, does not mean we cannot return to it later.

Broadly speaking, there is nothing inherently dangerous about weight training. Research suggests that the injury rate of weight training is low (similar to that of walking for exercise – quite low) (Powell, 1998). This is not to say that walking is dangerous. Rather, that weight training is a safe, healthy activity just like walking. Further, the Center for Disease Control (CDC) actually recommends “muscle-strengthening activities” at least 2 days per week for adults.


So, to wrap up, there are no “perfect” exercises that you need to get fit. And most exercises aren’t inherently dangerous or “bad”. In weight training, we have a menu of options for different people in different phases of life. 

*Medical Disclaimer: Please be advised, the information provided in this article is educational in nature and not meant to diagnose or treat any disease, illness, or condition. For individualized recommendations it is best to follow up with a licensed provider, like myself or another physical therapist.

The Real “Secret” to Getting and Staying Fit

Getting and staying fit can be tough. And we have limited time and energy. So how should we allocate our precious resources of energy and time?

We can use the analogy of big rocks. Focusing on big rocks helps us get results, rather than get distracted and confused by minor or irrelevant things. It is a mantra I repeat to myself and clients to stay focused on what matters.

The Big Rocks Analogy

Imagine you have some small stones, big rocks, and a jar. If you first put the small stones in the jar, you’ll fill up the jar but not have room for the big rocks. However, if you start with the big rocks, you’ll fit all the big rocks in the jar AND have room for the small stones.

Similarly, in fitness there are big rocks and small stones. And there are some things that shouldn’t even go in the jar.

Example: Big Rocks for Weight Loss

Let’s take weight loss as an example.

One of the big rocks for weight loss is eating whole, minimally processed foods that keep you full. Another big rock is eating fewer processed foods and liquid calories (like soda, juice, and alcohol). Both of these big rocks reduce overall caloric intake which contributes to weight loss.*

On the other hand, a small stone for weight loss is eating an exact ratio of carbs, protein, and fat. This might be relevant once someone has lost a lot of weight and wants to get a 6-pack. However, for the majority of weight loss, focus on the big rocks first.

Lastly, there are things that don’t even belong in the jar. For weight loss this would be gimmicks like apple cider vinegar shots and green tea extracts. At best, they are a waste of time and money. At worst, they are a distraction from the big rocks that truly matter for weight loss.

Most Fitness Goals Have Big Rocks

The big rocks analogy holds for goals other than weight loss. For example, a big rock to get stronger is to lift increasingly heavier weights consistently over time. Choosing the best brand of lifting belt is a small stone.

Usually big rocks are not cool or sexy. The results take longer, but are real and sustainable.

Whatever your fitness goal, first ask what are the big rocks?


*There are other big rocks for weight loss, but for brevity, I’ve just listed two big rocks in this article.

Does Stretching Pre-Workout Decrease Strength?

We hear lots of narratives about stretching before lifting. Some lifters insist on stretching before training. Others claim that it hurts performance.

But what does the research say?

Behm et all did a systematic review of research on the effects stretching.1 They looked at the effect of stretching pre-exercise on strength. They examined other variables too, but we’ll focus on strength today.

What studies were included?

The review included 125 studies looking at:

  1. Static stretching – holding a muscle at its lengthened position.
  2. Dynamic stretching – moving joints through their full range of motion.
  3. Proprioceptive Neuromuscular Facilitation (PNF) stretching – a technique of contracting and relaxing muscles to increase flexibility.

How did stretching pre-exercise affect strength?

Generally, static stretching and PNF stretching caused a decrease in strength afterwards. Dynamic stretching did not affect strength much afterwards.

Static Stretching

Static stretching was associated with a 4.8% decrease in strength.

But the story doesn’t end there. The researchers found a “dose-response relationship”. Meaning that as stretch duration increased, strength was further decreased. For stretches performed for < 60 seconds, strength decreased by 2.8%. However, when stretches were held for > 60 seconds, strength decreased by 5.1%.

Dynamic Stretching

Dynamic stretching had trivial effects on strength. Strength decreased by only 0.23%.

PNF Stretching

PNF stretching was similar to static stretching – it was associated with a 5.5% decrease in strength.

It makes sense that PNF stretching would follow the same trend as static stretching. Both involve relaxing and holding muscles at their end range.

What does this mean for lifting?

-If you want to maximize strength, do static stretching after training.
-If you really want to do static stretching before training, keep it brief (30 seconds per stretch). Research suggests that a 30 second stretch increases flexibility as much as a 60 second stretch.2
-Dynamic stretching before training has trivial effects on strength.

I personally do not have clients stretch before lifting. In addition to this research, I’ve observed that static stretching is relaxing and calming. Before training, we want to get amped up and excited – the opposite of lying on the ground relaxing into stretches.

Static stretching can feel great. But to maximize lifting performance, save it for after training.


References

  1. Behm, D. G., Blazevich, A. J., Kay, A. D., & McHugh, M. (2016). Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme41(1), 1–11. https://doi.org/10.1139/apnm-2015-0235
  2. Bandy, W. D., Irion, J. M., & Briggler, M. (1997). The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Physical therapy77(10), 1090–1096. https://doi.org/10.1093/ptj/77.10.1090