The American Physical Therapy Association describes physical therapists as "movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education" (Becoming a PT, n.d.). Home exercise programs encompass both education and exercise and are a strategy widely used by home healthcare therapists. However, evidence suggests low patient adherence to therapist-prescribed home exercise programs (Beinart et al., 2013) despite good adherence being important to achieving positive outcomes (Essery et al., 2017). Therefore, the therapist's approach to exercise dosing may be an important contributor to successful patient outcomes. This column overviews potential barriers to adherence and ideas of varied exercise dosing approaches to foster improved exercise adherence by patients.
Self-motivation to exercise, self-efficacy, previous adherence to exercise-related behaviors, and social support are key contributors to home exercise program adherence (Essery et al., 2017; Ormel et al., 2018). Known barriers to exercise adherence include "boring exercises," restrictions in the personal environment, and lack of support (Ormel et al., 2018). Approaches to exercise dosing including frequency, intensity, duration, environment, and functional relevance are among factors to be considered in the exercise program design. The Applied Functional Science approach of the Gray Institute (2022) coined the "Toothbrush Method" of dosing functional exercise and is an approach often used in entry-level physical therapy instruction. This approach incorporates exercise into daily tasks which ultimately becomes ingrained into daily routines. These activities are intended to be brief, related to patient goals and functional activities, not limited by environmental barriers in the place where the person lives, works, and recreates, and include multiple "exercise sessions" of short duration at varied intensities throughout each day.
An individual receiving home care who is non-weight bearing on the upper extremity after a recent open reduction internal fixation for a proximal humerus fracture with frailty-related comorbidities provides one scenario in which this approach can be applied. The therapist may have determined balance impairments that can be addressed through a multiplane mini lunge exercise. The exercise prescription could include performing one lunge in each direction every time the patient walks through a doorway. This brief, functionally focused activity could ultimately become part of the person's daily routine, reducing environmental barriers as the doorway offers some support while increasing exercise volume throughout the day.
Another example of this exercise approach is with an individual who had a recent debulking surgery for ovarian cancer and is currently receiving chemotherapy. The therapist's assessment identifies aerobic endurance impairments and deconditioning which limit the person's ability to go up and down the stairs to their bedroom. The individual also reports pain, stiffness in the front of the hip, and feels unsteady with walking. The Toothbrush Method approach might include instructing this individual to perform a hip flexor stretch at the bottom step every time they walk up the stairs and add a few extra step-ups at the top to work on their leg strength as they hold onto the stair railing. The therapist might also include washing dishes while standing at the sink as a balance activity. Specific instruction on where to stand near the sink, being mindful of challenging the balance without compromising safety, would be provided and then the activity of washing the dishes as a functional dynamic balance activity after every meal (versus just one time per day) is integrated into their daily routine.
A final example of incorporating the Toothbrush Method is illustrated in an individual seen after a total knee arthroplasty with concurrent stable heart failure. Range of motion, strength, balance, pain, and aerobic endurance impairments are identified. Additionally, difficulty rising from the toilet, or a recliner chair are observed. In conjunction with traditional total knee arthroplasty exercises, the home exercise program would also include moving from sit to stand an additional two times every time the individual transitions to and from a seated position. This would provide numerous exercise sessions for the patient with benefits including increasing knee flexion and extension range, providing an active muscle pump for lower extremity edema, challenging dynamic balance, and increasing patient confidence with functional tasks now and into the future.
Therapists are constantly tasked with providing exercise dosing and education to foster exercise adherence to promote safe and robust functional independence. The "Toothbrush Method" is a functional approach to dosing exercise in the home environment. This approach or other approaches that incorporate a functional focus to exercise prescription may be beneficial in enhancing patient self-efficacy and reducing barriers to exercise program adherence while ultimately improving outcomes.
Popular diabetes drugs compared in large trial
NIH: Metformin is the first-line medication for type 2 diabetes, combined with diet and exercise. If blood glucose becomes difficult to control, a second medication is added. A clinical trial directly compared four drugs used in combination with metformin. Over 5,000 people with type 2 diabetes who were already taking metformin were randomly placed into one of four groups. Three groups took metformin plus a medicine that increased insulin levels: sitagliptin, liraglutide, or glimepiride. The fourth group took metformin and insulin glargine U-100, a long-acting insulin. After five years, all four drugs improved blood glucose levels when added to metformin. But the groups taking metformin plus insulin glargine maintained their target glucose levels for the longest time. The outcome did not differ with age, sex, race, or ethnicity. None of the combinations overwhelmingly outperformed the others. Nearly three of four participants were unable to maintain the blood glucose target over the study period, underscoring the difficulty for patients with type 2 diabetes to maintain recommended targets. Severe hypoglycemia, or low blood glucose, was generally uncommon, but affected more participants assigned to glimepiride.
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