Why shouldn’t we just stick to stick men and be done with it?


There is a rather dry clinical conversation that can be had about evidence based research pointing to better patient adherence and performance accuracy using exercise videos instead of stick men or line drawings. However, in my opinion this shouldn’t be the basis for choosing exercise software. There is a deeper, more probing way of approaching the question which would be to ask yourself…what would my patient want ? what would they expect ? what would they prefer ? and how can I impress them ? Not just in this regard but in every aspect of your business. Many physiotherapists begin their conversations ‘I prefer…’, ‘We’ve always done it this way’ and when asked ‘what do you think your patients might want..?’ a fair bit of back tracking ensues often with a presumption ‘we’ve never had any complaints’… which isn’t probably the best outcome clinic owners should be seeking. There are many examples of companies not moving with the times. Woolworth stores thought they would be selling Pick ‘n’ Mix forever regardless of the changing face of the High Street. Blockbusters felt that it could ignore the internet and keep renting videos despite the changes in how we now view our movies. HMV didn’t react quickly enough to the emergence of film and music downloads and had to be bailed out by investors who understood they would have to do more than sell DVDS and CDs. I could go on. These companies took a path of complacency and didn’t realise their dominant position could be threatened until it was too late to react. The lesson learnt in their cases and in our businesses is that we can’t afford to stand still, what we’ve always done in the past cannot guarantee success in the future. In short we need to be focused, stay on the back foot, be humble and continually question the strengths, weaknesses, opportunities and threats to our businesses. Providing your patient with the highest quality of care within an evidence based framework is the best chance of thriving in a fast moving healthcare market.

What is the evidence for the efficacy of exercise software and its use in ensuring adherence to the programmes we give our patients?

The evidence supports using exercise videos over static line drawings. This shouldn’t surprise us, we live in a video based world. If you want to know how to bleed a radiator, cook a favourite recipe, learn steps to the Cha Cha or pretty much anything then we head straight for You Tube or we ‘Google it’.

If proof is needed over common sense then the Cochrane Review of 2010 [1] has pretty much all the evidence you need. Patient’s adherence levels are greater, performance accuracy is better (twice as many errors with static line drawings compared to video) [2]…and here’s the biggie…patients UNANIMOUSLY prefer videos over static line drawings [3]. Interestingly there is also no difference in performance accuracy between you doing the exercises in front of your patient and them watching a video instruction…this has implications in terms of how you manage your time and what to fit into the patient’s treatment time [3].

The exercises are simple enough…anyone can do them….right ?

It is easy to fall into the trap of thinking that exercises are easy to follow but that’s only because as physiotherapists it’s what we do day in…day out. We are not burdened like the patient with the concern they may be doing themselves more harm than good and that any pain attributed to performing the exercises constitutes more damage. Put another way if a plumber was to scribble down a few steps to change the cistern flush in a WC and tell you it’s pretty straight forward…how confident would you be ? Your adherence would be pretty poor I’d imagine. If you were given full video instruction you might be tempted (along with 265,000 others on You Tube) to attempt it [4]. In short we don’t know what we don’t know. That’s why there should be no guess work involved.

‘I’m doing all the right moves….but not necessarily in the right order’

We’ve all seen the patient that comes back to us with some elaborate hybrid of the exercise they were prescribed. Not only is it frustrating but time lost whilst your patient is doing the wrong thing means a greater chance of worse outcomes and patient satisfaction. If you have limited sessions allocated to the patient then you are playing catch up to improve. Worse still, this incorrect performance could lead to injury …not great in an increasingly litigious society.

It may come as a shock to many therapists that there is more within your patient’s life than their physiotherapy session. It is just one, small interaction within their busy day…a scribbled stick man and your verbal instructions at 9am are a distant memory by the time they look at that crumpled piece of paper after a hard day at work. It’s important to understand patients are no different to us. They think the same, they work the same, they learn the same…they have the same expectation that we have when buying or using a service….they want to experience high quality and innovation and yes, even the older generation or ‘silver surfers’ that many clinicians assume do not engage with technology.

Why shouldn’t I just use my patient’s mobile phone or an app to film their exercises ?

Why not indeed…it depends on whether you want to skirt round keeping accurate clinical records of the exercises prescribed to your patient..a CQC/HPC/CSP requirement. The patient’s mobile phone heads out the door with it’s owner and so does your clinical record. ‘If it’s not recorded it didn’t happen’. Not only that..get proficient with your favourite exercise software and you can send your content out in seconds rather than spending so much time instructing your patient. This means you can do more ‘hands on’ or see more patients.

Are software packages cost-effective?

If your clinic makes a profit then definitely. It’s tax deductable as an operating expense and so helps improve your service, that said, you could pay more to the tax man …your choice of course. The other point is that by choosing an exercise software package that emails exercise videos you are saving on the cost of printer ink and paper. If you prefer your exercise instructions to be more sketchy (hem, hem) have you considered the time it takes to draw your stickmen and run through the exercises ? And for what ? poorer adherence, performance and patient satisfaction when you could be spending your time doing more useful things with your patients (or shortening your treatment times and getting more patients in).

Take back control

Exercise software puts you in control, no more rushed instructions with only moments to spare in the appointment time, no more hanging around the photocopier or filing cabinet with your patient. Just tell them you will be emailing them some videos when you have a gap in your diary/have a no-show/on the train home…whenever you like. Take back control – you might find it liberating. Many exercise software providers also provide patient infopages about the patient’s condition. You should be providing this along with verbal advice to be most effective [5] ; if a patient knows why they are doing the exercise they are more likely to do it…right ? it will reassure them and improve adherence. Anecdotally we’ve all seen the patient who has come from the GP with a diagnosis of a ‘crumbling spine’ ; it’s human nature to only recall the worse bits of the explanation and disregard the rest. Providing online infopages also saves you the cost of buying booklets or printing off more paper…you’ll be doing your bit for the environment too.

What should we look for when considering buying a product?

Usability, usability, usability.

Like any great software you should be able to dive straight into it as though you’ve been using it all your life. If you don’t find it intuitive then try a different software provider. Some software can take you as long to send an exercise program as it did to treat the patient…this is not good use of your time.

Cost….of course

Most products are relatively cheap but can become expensive with multiple users. You can often cheat by using a generic name but sending output to a patient without the treating clinicians name on it….it looks pretty amateurish and is pretty poor in terms of clinical governance.

Multiple users at multiple locations

You may work from different sites and want to match the clinic details to where the patient was seen. Some may charge for this or may not offer it as an option at all. You may have multiple users so you’ll want to elegantly switch from one user to another without any fuss.

Fit for your purpose…avoid the glitz

We’ve all been suckered in to buying an expensive product like a mobile phone or laptop and then never used half of the functionality. Be thoughtful as to whether the product you choose matches your current needs and aspirations. If you think that offering a 24/7 opportunity for patients to contact you directly through a chat feature is a good move then it may suit you. Similarly if you want to create and scrutinise elaborate graphs of a patient’s daily performance and adherence levels (of their home exercise) then it is all out there for you. Good luck with that !

The patient’s output

We nearly forgot about the patient again didn’t we ? What would impress them, how helpful is your output ? …does your software give narrated, video instructions for both the left and or right side…or do they have to try work that out for themselves. Is the output slick and professional or does it look like something from the 1980’s ?

Your patient’s data…be concerned..very concerned

Congratulations….you’re a Data Controller now. It’s your responsibility to ensure your patient’s details remain with you even if you’re a sole trader. Avoid a ‘Talk-Talk’esque fiasco. Look for an ISO27001 accreditation on their website.

Is the server in the EEC and therefore complying with the new EU data protection regulations ? They should be. There are 10 things you need to know about this found in the references below [6]



Gary Martin is the Managing Director of exerciseprescriber.com (EP). It’s mantra is ‘Making clinical lives easier…patient lives better’. The software is used mainly in the corporate sector and has the largest healthcare provider in the UK as one of its many clients. EP is proud to be a British Company, employing a talented British workforce and paying UK taxes. It is ISO27001 accredited. In coming months Exerciseprescriber.com will be addressing the business of physiotherapy…look out for development updates on Facebook and Twitter (@ExPrescriber). It welcomes forward thinking private clinic owners to take a free trial at www.exerciseprescriber.com.

[1] Jordan J et al. (2010) Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database System Review http://www.ncbi.nlm.nih.gov/pubmed/20091582

[2] Reo and Mercer (2004) Effects of Live, videotaped or written instruction on learning an upper extremity exercise program http://www.ncbi.nlm.nih.gov/pubmed/15225081

[3] Weeks D et al. (2002) Videotape instruction versus illustrations for influencing quality of performance, motivation and confidence to perform simple and complex exercises in health subjects http://www.ingentaconnect.com/search/articleoption1=tka&value1=videotape+instruction+versus+illustrations&pageSize=10&index=1

[4] How to Change a Toilet Flush or Syphon Unit – Plumbing Tips from Plumberparts.com https://www.youtube.com/watch?v=Wj-5YXnY-_Y

[5] Watson PW, McKinstry B: A systematic review of interventions to improve recall of medical advice in healthcare consultations. J R Soc Med. 2009, 102: 235-43. 10.1258/jrsm.2009.090013.


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