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Get into the car. Battle traffic for an hour. Find a parking place. Schlep your stuff into the gym. Work out for an hour. Shower and dress. Schlep your stuff back to the car. Drive another hour to get home at the end of a long workday. Does it make you feel tired just thinking about it? Doesn’t sound like much fun? Your patients probably would agree.
That’s why adherence to exercise programs often is low, contend researchers at the State University of New York (SUNY) at Buffalo.
Exercise is a tough habit to develop, and when life gets in the way, it’s easy to drop it off the agenda, even when extenuating circumstances, like a heart attack, make it an urgent priority, says SUNY Buffalo lead researcher Joan Dorn, PhD, associate professor of social and preventive medicine.1 "People who have had a heart attack are pretty good about exercise at the beginning of their programs, but it’s hard to stick with behavioral interventions. People are looking for a drug and an easy way," she says.
Making exercise easy and fun is the key to developing that long-term health habit, says Dorn, whose study showed that 80% of the men assigned to the exercise program adhered to the program at the beginning of the study, but only 13% were still in the thrice weekly exercise program three years after their heart attacks. In addition, there was little improvement in the dropout rates with reports of self-directed exercise programs away from the approved sites, which included clinics, gyms, and swimming pools.
Smokers had the greatest difficulty sticking to the program, Dorn says. Eighteen percent of former smokers were still exercising at the end of three years, but only 10% of current smokers were. Overweight people also were less likely to stick with the regimen, she says, possibly because exercise may be more difficult for them. "People with the highest risk factors were coming less."
This is a chicken-and-egg situation, says Dorn, who says the data don’t show if people with the highest risk factors had a distaste for exercise or found exercise more difficult, so were less likely to adhere to a program. Dorn, who formerly directed a cardiac rehabilitation program, contends that the more convenient it is for a patient to exercise, the more likely that person will continue a program. University of Toronto researchers designed a program that got 80% compliance by letting people exercise where they want. "That may mean home exercise or some other option for patients who are self-starters," she says.
Carl Foster, PhD, University of Wisconsin at LaCrosse physiology professor, says that solo exercise can be a stress-relieving option to the stress-inducing trek through traffic to the gym. "For some people, the peace and quiet of a brisk walk in the woods or even a run or bike ride can be perfect," he says. "For others, an hour on the treadmill while watching the news or even a home gym may be the perfect answer."
Foster advocates individualizing exercise programs. "Find a structure that will work for the patient. It doesn’t matter what it is, if the patient feels comfortable with it," he says. Talking with the patient can give you a good handle on personality type and interests, says Foster. "There are some people who thrive on the social interaction that takes place in a more organized exercise setting, and there are those who are just fine on their own."
Dorn also advocates lots of contact between staff and patients to encourage adherence to the program. "We usually can identify those who will have trouble sticking with the program, so we make frequent phone calls and give them lots of encouragement and help them develop a sense of camaraderie among fellow participants," says Dorn. "It’s time-consuming for staff members, but it does pay off."
What’s the bottom line? "The most common reason people give for dropping out of an exercise program is time," says Dorn.
Foster likes to give patients a calendar and work with them to develop an exercise schedule. Those who are self-monitoring can be encouraged to mark off the dates on a calendar or keep a diary. You can even help them set up a reward system when they’ve reached a goal, such as 30 days without missing a scheduled exercise session.
Dorn agrees this can be helpful; if patients are more likely to stick to a home exercise program, encourage it — and then set up a weekly staff call to encourage them to continue. We don’t diminish our contact at all with a home exercise program; it’s just done on a different basis."
A home gym is a great idea, if the patient will use it, says Foster. He recommends setting up the gym in a well-ventilated room of its own, if possible and equipping the room with a radio, TV, fan, and maybe an air freshener to assuage the objections of housemates who may object to living in a place that smells like a gym.
Dorn suggests that people likely will quit exercise programs if they are challenged beyond their comfort zones. "Yes, they need to be challenged, but overchallenge is almost a guarantee of a dropout. Sometimes we need to help them start more slowly," she says.
Foster also recommends determining if a person is most alert in the morning or evening and tailoring a program to biorhythms. "Morning people are more compliant with exercise programs because they really will pop out of bed and get their exercise in first thing in the morning," says Foster. "Obviously, this is optimal, but some people simply are not made that way, and they will resist and finally abandon a program that forces them into an early morning routine. So try helping them find a time they can feel more comfortable with."
For night owls, Foster recommends scheduling the exercise on a calendar and working with the patient to help him or her see the exercise time as an unbreakable appointment. "So many times other things get in the way, and the exercise time gets pushed back and pushed back until it disappears," he says.
Another personality profiling that may be helpful, says Foster, is to determine if a patient is a game player or a nature lover or a bookworm. There’s something for everyone, he contends. A game player may not be interested in walking a treadmill and riding an exercise bike at the gym, but would get really excited about joining a soccer league or even participating in pick-up softball three times a week at the local park. A nature lover will almost always opt to walk, run, bicycle, or maybe even skate rather than be stuck in a scheduled activity dependent on other people. And bookworms may be very happy riding the exercise bike or hand bike with their noses in a book.
"The bottom line is whatever works, works," says Foster. "Make it fun, and they’ll do it. Make it a drag, and they won’t."
1. Dorn J, et al. Correlates of compliance in a randomized exercise trial in myocardial infarction patients. Med Sci Sports Exerc 2001; 33:1,081-1,089.