Tuesday, June 18, 2019

PT Home Exercise Programs : Improving Compliance thru Behavioral Economics.

In 2017, Dr. Richard Thaler received the Nobel Peace prize for his work in Economics. His book, Nudge, discussed some of the finer points of behavioral economics as they pertained to the psychology behind many economic decisions. A prime example? Eating food that you don’t necessarily like because you spent money on it at the store a few days prior. (This is the idea of sunk cost which we’ll get into later). This area of economics however, can applied to a lot of areas in life including physical therapy. Having read some of Thaler’s work, as well as some studies revolving around behavioral economics, I wanted to put together a blog which might not only discuss some of these ideas, but also start a dialogue about a tough area of care in the PT clinic, the patient home exercise program and compliance. 

Patient compliance to prescribed home exercise programs can vary wildly. Clinically, I see patients who complete every exercise that is asked of them and do so religiously. However, there are others who struggle or don’t see the value in the program for their recovery. Recently, I had a patient who I saw in the clinic weekly. We would work on improving joint mobility and then focus on treating her specifically for weakness in her Deep Neck flexors. Regularly, she would finish her exercise program and stand up and note all her pain had improved as well as her neck mobility. However, the week following she would always start the session noting she had done none of the things I had asked of her. Why? I thought. What could I have done better to improve her outcomes. Below are three behavioral economic ideas which may help clinically.

The power of a Nudge

Thaler, in his book Nudge, discusses how nudges exist and can work to influence much of what we do in life. For example, if you were designing a buffet for people with more healthy eating in mind, you may start by placing the salad at the beginning of the buffet versus in the middle or the end. This would be a scuttle nudge to fill people’s plate with healthy greens versus starchy or meaty foods. Another example can be seen when you enter a car.  Immediately after turning it on, you are reminded to buckle your seatbelt to ensure your safety. The idea is to nudge the user into a healthy or favorable outcome without much thought or effort. 

Home exercise programs can be a little tougher. How might clinicians nudge their patients into improved compliance? Currently, in our day and age, we are blessed with exercise program apps and text software that can assist. Clinically, there are home exercise apps which can nudge a patient into doing their exercises via text reminders. In his book, Inside Google : Work Rules, Laslo Bock discusses this specifically noting that patient compliance improved when patients received reminders of when to do their exercises. 

Not every clinic will have specific exercise programs with this technology.  Alternately, I’ve used reminders on smart phones to pop up 1-2 x daily to encourage compliance. In some cases, I have patients who like being nudged in this manner, where as others maybe not so much. However, a nudge such as this is a simple tool can pay big dividends.

Framing as a way to improve compliance

Much of how we communicate is dependent on the way an idea is communicated. In rehabilitation, this may play out in one of two ways. (Before, I present the scenario, I want you to ask yourself which one you’d be more likely to accept and comply with.) Scenario one - “Mrs. Smith, these exercises are important as they’ll help improve your knee and hip strength and limit the forces being placed upon your knee. If you do them regularly we will see strength changes in 6-8 weeks.” Scenario two - “Mrs. Smith, I want you to be able to dance at your son’s wedding, doing these exercises daily will help you achieve this. Also, with many of the patients in your age group with this same problem, the knee pain improves drastically with doing these exercises daily”.  In scenario one, the clinician frames his argument around classic anatomical approach which although not wrong, doesn’t particularly have social or personal meaning to a patient. In scenario two, the clinician frames her argument around both personal meaning ( helping patient dance at son’s wedding ) and social norms ( places patient in her respective age group with compliant patients with knee pain ). Framing-wise this may resonate and have more personal meaning to the patient. However, I’ll finish by asking, if you were the patient, which scenario would resonate more specifically with you?

Sunk Cost: knowing when to cut your losses

Sunk cost is a behavioral economics concept which centers or revolves around not giving up on an object or idea based upon the time or money already invested in it. How many of us are guilty of finishing a meal or using a jacket or shirt we did not particularly like because of the money we spent on it. This is the idea of sunk cost - we have already spent the money on the item and it can’t be necessarily be brought back (unless you’re able to send the meal or shirt back) so we opt to “get our money’s worth” out of the item. In the clinic, sunk cost occurs when a clinician has invested heavily in a particular exercise or approach without much return in regards to patient progress. In terms of outcomes, a clinician may “double down’ and really push forward with a specific exercise or approach in hopes that it will eventually pay off. In these specific instances, the most optimal approach would be to most likely self reflect and utilize clinical reasoning to modify the approach and collaborate with the patient to see what other ways may be more successful in achieving optimal outcomes. In some cases, this may mean abandoning an exercise program and focusing on activity re-education improve patient outcomes. 

    In the clinical world, a home exercise program and compliance to it can prove to be quite difficult. By attempting to utilize some base behavioral economic principles such as nudges, framing, and sunk costs, a clinician might have a bit more success in assisting a patient in achieving optimal outcomes. What other ways have you found that improve compliance? I would love to know - please share in our comments sections and I’ll respond as able. 

Jiten ( Jay ) Bhatt is a physical therapist at Kaiser Permanente Panorama City. He is a Movement Links Certified Clinician and instructor. Jay has been published in JOSPT and has presented at APTA CSM conferences. He is also a graduate of the Kaiser Permanente fellowship program. 


Bock, L. (2015). Work rules!: Insights from inside Google that will transform how you live and lead.

Thaler, R. H., & Sunstein, C. R. (2008). Nudge: Improving decisions about health, wealth, and happiness. New Haven, CT, US: Yale University Press.

Tuesday, May 28, 2019

Sleep Hygiene and the Movement System- Part II

Sleep and Injury Mitigation/Recovery

In PartI of this two-part series on sleep hygiene and the movement system, we discussed how sleep helps solidify newly learned movement skills and even improves them, particularly in the last two hours of an eight-hour sleep.

Now, we will discuss sleep and its relationship to mitigation of injury and recovery. A 2014 study of adolescent competitive athletes demonstrated a significant higher risk of injury with chronic lack of sleep.

Additionally, evidence is demonstrating sufficient sleep to be vital not only for upcoming physical performance but for physical recovery after performance.  Adequate and quality sleep in the days after a performance is linked to faster recovery from inflammation and quicker initiation of muscle repair.

Finally, Matthew Walker’s early career findings about the relationship between sleep and recovery from brain damage are continuing to be validated, with research discovering that the brain, with the help of sleep, re-organizes remaining neural connections after a stroke. When sleep is integrated into an individual’s recovery program post-neural injury, the quality of sleep is related to motor function return and movement skill re-learning.

Tips to getting our Zzzzzzzs may appear to be obvious. But in the words of motivational coach, Brendon Burchard, “Common sense is not often common practice.”

Tips to improving sleep hygiene (seriously, read Matthew Walker’s “Why We Sleep?” for deeper reasoning behind these suggestions)

1. Stick to a schedule: go to bed and wake up at the same time each day.
2. Try not to exercise within 2-3 hours prior to bedtime.
3. Avoid caffeine too late in the day, avoid alcohol before bed, avoid large meals and beverages late at night.
4. Create a nighttime routine that allows you to wind down, relax, and prepare your body for sleep. This may include: music, reading, a hot bath, a cup of tea.
5. Create a dark, cool, gadget-free bedroom. Do not lie in bed awake >20-30 min if you can’t fall asleep.
6. Get at least 30 minutes of daylight per day in the morning and turn lights down at night to cue your circadian rhythm appropriately.


1. Walker M. Why We Sleep: Unlocking the Power of Sleep and Dreams. New York, NY: Scribner; 2015.
2. Milewski MD et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. Journal of Paediatric Orthopaedics. 2014;34(2):129-33.
3. Berger K. In multibillion-dollar business of NBA, sleep is the biggest debt.  June 7, 2016. Accessed at https://www.cbssports.com/nba/news/in-multi-billion-dollar-business-of-nba-sleep-is-the-biggest-debt/ .
4. Mah CD, Mah KE, Kezirian EJ, Dement WC. The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep. 2011;34(7):943-50.
5. Herron K, Dijk D, Ellis J, Sanders J, Sterr AM> Sleep correlates of motor recovery in chronic stroke: a pilot study using sleep diaries and actigraphy. Journal of Sleep Research. 2008;17:103.
6. Siengsukon C, Boyd LA. Sleep enhances off-line spatial and temporal motor learning after stroke. Neurorehabilitation and Neural Repair. 2009;4(23):327-35.

Tuesday, May 14, 2019

Sleep Hygiene and the Movement System- Part I

The world is catching on to the value of sleep.  While quotes such as “I’ll sleep when I’m dead” were exclaimed and touted as a badge of honor, an indication of an individual squeezing the most out of life, sleep is now more and more valued as a key pillar of health and wellness. 

This blog series will cover sleep as it’s related to motor learning,  injury prevention, and recovery.  Today’s focus will be motor learning.  Much of the content here is inspired by a book that I’ve read and re-read multiple times over the past 1.5 years.  It’s called, “Why We Sleep: Unlocking thePower of Sleep and Dreams”, authored by Matthew Walker, PhD.  I highly recommend the book. It’s a fascinating read.

How does sleep help with motor skill acquisition, anything from learning to ride a bike, play a sport, drive a car?

For every skill we master, there is a routine associated with the skill that lives in the brain. 

Dr. Walker’s research demonstrates that after learning or practicing a skill, your brain will continue to improve the skill routine with a solid night’s sleep.  Thus, practice does not make perfect, but practice, followed by a night of sleep, makes perfect.

One of the key studies associated with this discovery involved a group of right-handed subjects who were asked to learn to type a number sequence on a keyboard.  Performance and improvement were tracked over the course of a training session.  Then subjects were given a 12-hour break, after which they were re-tested on their performance of the sequence.  Half the subjects learned the sequence in the morning, thus the re-testing period came 12 hours later after being awake during the day. The other half learned the sequence at the end of the day and were re-tested the following morning after a full eight hours of sleep.  The group that was  re-tested after a night’s sleep demonstrated a 20% jump in performance speed and a 35% improvement in accuracy whereas the group that was re-tested after a 12-hour period of being away did not demonstrate improvement.

Sleep transfers the motor programs from circuits that operate at the conscious level of control to brain circuits that operate below the level of consciousness (subcortical circuitry), embedding the skills as habits.

If you’ll recall, our nightly sleep cycle is divided into stages and we cycle between NREM (non-rapid eye movement) and REM (rapid eye movements) stages throughout the night.  Motor skill enhancement is related to stage 2 NREM, particularly in the last two hours of an eight-hour night of sleep. Additionally, Walker’s research found the highest amount of brainwave activity in the areas of the brain just above the motor cortex, which is indicative of the specificity with which sleep treats the brain. 

Given the above research, we and our patients should all think twice about cutting the last two hours of nightly sleep short as we so often do in order to get a jump start on the day.

Stay tuned for Part II in two weeks on sleep and injury prevention and recovery.

Kelly Grimes is a physiotherapist with Columbia University Medical Center in New York and an instructor with Movement Links.  She is interested in learning how to help herself, her clients, and those she loves reach for better versions themselves in all aspects of life.



1. Walker M. Why We Sleep: Unlocking the Power of Sleep and Dreams. New York, NY: Scribner; 2015.
2. Walker MP, Brakefield T, Morgan A, Hobson JA, Stickgold R. Practice with Sleep Makes Perfect: Sleep-Dependent Motor Skill Learning. Neuron. 2002;35:205-211.
3. Kuriyama K, Stickgold R, Walker MP. Sleep-dependent learning and motor-skill complexity. Sleep and Memory/Research. 2004;11:705-713.