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.