Exercise Compliance: Improving Exercise Compliance in Chronic Back Pain Patients Using a Pocket Diary.

This article examines the question of how to improve rehabilitation exercise compliance.  This is particularly important for patients who are recovering from chronic back pain who have lost the discipline of regular activity.

Assuming that the prescribed exercises are not unduly painful, the question is not “how do we help people to exercise more”, rather it is “how do we help people to develop self-discipline”.  

Evidence from other industries demonstrates that setting goals and keeping a diary of the new habit is the most effective way to maintain self-discipline to arrive at a goal.  I propose the use of pocket diaries as a key tool to improve rehabilitation exercise compliance for people with chronic back pain.

At the bottom of this post you can get a word document which explains to patients the purpose of the diary and how they can benefit from using the diary (you can have this in your patient info folder in reception or to give to new patients.)


How many clinics just give their patients a set of printed or hand written exercise instructions and essentially leave it to the patient to get on with it … or not?  I hear it all the time, patients don’t do their exercises.

Patients are people, who are also in pain.  Think of one thing you should do more of?  Why don’t you?

Is it to do regular exercise, weekly budgeting, retirement planning, investment evaluation, losing weight?

Whatever it is, it’s not about the thing, it’s about self-discipline.  To tackle exercise compliance therefore is to tackle self-discipline.

It is often said that the best innovation comes not from thinking “outside of the box”, but from thinking “Inside a different box”.  So let’s leave exercise and examine what other industries do to instill and create self-discipline.

Thinking Inside A Different Box

Here are some examples of how other industries develop self-discipline:

Personal Development: In order to develop habits to get you to where you want in life, it is universally acknowledged that we need goals.  Not just any goals, but WRITTEN down goals.  (See Tony Robbins, Jim Rohn, Bryan Tracey et al)

Financial: ‘Too much month, not enough money’? (Michael Heppel).  What is the first recommendation of any financial advisor when someone is having trouble making ends meet?  Write down and record everything you spend.  Then write down a budget and stick to it and record what you spend.

Weight Loss:  You’ve seen the programmes of people who have been clinically obese for years.  First they begin by recording everything they eat.  Then they measure and write down their key stats, then they set a diet/lifestyle plan and as they begin they monitor and write down what they did and how they progress.

School Homework:  My youngest daughter has a reading diary.  Her school expects her to read something every day and then write down what she read with comments from a parent.  In her mind, it is not an option for her to arrive at school without her teacher being able to see she has read something – even if that means reading in the car on the way to school!

The pattern is emerging and it isn’t rocket science.  What about exercise?

Olympic athletes: They write down and plan every training session and write down what they actually did in that training session.  It is impossible to reach that level without planning and recording.

Gym-goers: There are gym goers who arrive with a diary.  They have planned their exercise and they tick off what they do as they go around the different cardio and strength stations.  Whenever I do this myself, my workouts are 100% more effective … and fulfilling.


My principal interest is helping chronic back pain patients who have IDD Therapy Spinal Decompression treatment progress through their rehabilitation exercises.  However, this works for any patient who NEEDS to be doing exercise for rehabilitation.

Pocket Diary:  Patients should use a simple pocket diary to record their activity.  

GOAL: On the first page they should write down their goal, strictly with a timeframe but that can be difficult for certain patients and there is a balance of compliance and unrealistic patient expectation.

PLAN 1: Give your patient the exercises they need to perform and give each exercise a short name.  The patient will write down short names for each exercise they are going to perform in their diary.  It is important that THEY write them in THEIR diary to hardwire their brain into the process.

PLAN 2:  You should help them plan their first month of when and how many of each exercise they are going to do (this can include a walk to the shop to buy the paper).  Here you will identify the time slots when it is feasible for them to actually fit the exercise in.  Yes, we can all make time, but collecting kids from a swimming lesson or going to the pub with a friend creates excuse opportunities.

When you finish writing the plan, ask them one important question:  “Are you going to do it?”

HABIT: It is well documented that it takes 30 days to form a habit.  You need to hold their hand for that first month.  By setting achievable targets they are more likely to be able to ACCOMPLISH the targets.  That brings personal reward, fulfilment, belief and … self-discipline.

RECORD: Patient is going to write down EVERY activity they did and every exercise they did.  They have to write it down in their diary.

Exercise is self-discipline and comes from within.  If they need to get a buddy or partner involved, or even a personal trainer to help them, great, whatever works.


The killer point about the diary is the need to please others, ie you and not to lose face.

They have a written down plan and they have made a personal commitment to you and themself, verbally.

Tell them you want to see them in two weeks (or a month) and ask them to bring their (homework) diary.  You are holding them accountable and the inky plan on the pages of their diary is far more likely to hold them accountable to their activity than an idea floating in their head, some scribbles on a piece of paper or an exercise video sitting in their inbox.


You can get some branded pocket diaries very cheaply, or just have plain ones.  The cost is minimal so as a “value added service”, you can just give the diary to your patient or sell them at cost/ small profit.


Doing anything is always better than nothing.  The diary helps instill the self-discipline to do what is required to help resolve chronic back pain.

Doing what is required leads to improvement and reduced pain.  Improvement reinforces beliefs about what is possible.  Beliefs reinforce self-discipline.  Self-discipline leads to doing what is required, doing what is required leads to improvement …

Off the vicious and onto the virtuous circle. 

To receive a document which explains to patients the purposes of using the diary as part of your compliance process, complete the form below.

About the Author
Stephen Small is Director of Steadfast Clinics Ltd

Conflict of interest:  None

[contact-form-7 404 "Not Found"] .

FAR Infrared: The Reinvention of FAR Infrared (FIR) Therapy as a Clinical Modality to Help Relieve Pain, Assist Rehabilitation and Aid Healing.

This article is intended to raise awareness of the clinical benefits of heat therapy and to improve understanding of the growing evidence supporting the non-thermal effects and benefits of FAR infrared (FIR) therapy.


Use of heat as part of physical therapy treatment is not common because heating product applications have tended to be cumbersome, time-consuming to apply and carry the risk of causing burns.  Whether boiling gel packs straight from a hydrocollator or a wheat bag from the microwave, the impracticality of heat has meant that in practical terms, it is rarely used.

Thermal therapy is largely ignored by western mainstream manual therapy professions and there is very little awareness of the clinical application and effects of FAR infrared for pain relief and as an aid to healing.

Heat, notably moist heat, is used primarily to provide comfort and ease chronic pain and stiffness.  Evidence shows that heat can increase the extensibility of soft tissues and thus aid mobility.

FAR infrared is a resonant energy and was traditionally applied for a variety of conditions using an infrared lamp.  The lamps went out of vogue because of the awkward application, the risk of skin drying from the visible light component of some of the bulbs and the potential risk of eye damage.

Carbon Fabric Infrared ElementA new generation of carbon fabric infrared elements is rapidly emerging which deliver heat quickly and conveniently from a safe FAR infrared heat source which can be moulded to the joint or easily applied to the painful area.

The new carbon fabric infrared elements are used predominantly in the markets where they are made, namely Asia.  Scientific research to understand the mechanisms which drive observed clinical outcomes of FAR infrared therapy, for a variety of conditions, is thus centred in China and Taiwan.


The evidence-base for heat therapy and FIR therapy is diverse and compelling.  There is significant growth in scientific interest in the non-thermal effects of FIR therapy itself, whilst the convenience of the carbon fabric heat element enables clinicians interested in the benefits of thermal therapy, to have a tool which they can practicably use to help patients.

I have collated studies and papers and experiments to highlight the diversity of questions and depth of analysis about the thermal and non-thermal effects of FIR energy and the benefits of using heat to relieve pain. Click here to see INFRARED EVIDENCE.

Here is an example of one of the references:

FAR Infrared treatment leads to a 57% decrease in pain for patients with 6 year chronic low back pain.
Forty patients with chronic low back pain of over six years’ duration. Mean NRS scores in the FIR treatment group fell from 6.9 of 10 to 3 of 10 at the end of the study. The mean NRS in the placebo group fell from 7.4 of 10 to 6 of 10. The FIR therapy unit used was demonstrated to be effective in reducing chronic low back pain and no adverse effects were observed.

Gale GD, Rothbart PJ, Li Y. Infrared therapy for chronic low back pain: a randomized, controlled trial. Pain Research and Management 2006,11(3):193-196

It is my intent that you will be able to connect insights from the different studies and articles to raise your own questions to develop new hypotheses regarding the use and application of FAR Infrared Therapy to manage pain and assist injury rehabilitation.

Final Word

FAR infrared provides a safe, non-invasive, cost-effective therapeutic modality which is easy to administer.

I have witnessed and heard countless anecdotal public and clinical examples of how patients with a variety of chronic conditions have experienced pain relief over-and above what they have been able to receive from standard moist heat, cold therapy, electrotherapy or indeed pharmacological treatments.

That is not evidenced-based, however such a wealth of comments and observations begs many profound questions to clearly understand and explain the reported outcomes.

I have no doubt that the new FAR infrared technology will have wide reaching accepted applications in a variety of fields as awareness and scientific research into the benefits of FAR infrared expands.

One might go so far as to imagine the time when GPs will prescribe FAR infrared as a therapeutic modality in the place of medication, for certain conditions.

To see the new caron-fabric FAR infrared applications visit www.thermedic.co.uk or www.steadfastclinics.co.uk

If you are interested in using Infrared in your clinic or would like more details, please use the form below to request an information pack.

[contact-form-7 404 "Not Found"]

IDD Therapy Spinal Decompression of Targeted Intervertebral Discs

This article examines the physics and mechanics of how IDD Therapy Spinal Decompression is able to distract and mobilise specfic segments of the spine and thus decompress a targeted intervertebral disc.

Traditional traction has been outmoded for a number of years and one of the shortcomings of traction was the inability to focus and control forces at specifc spinal levels.

The four goals of IDD Therapy spinal decompression are to:

  1. Release pressure on nerves
  2. Improve Disc Health
  3. Re-educate soft tissues
  4. Re-align spinal structures

IDD Therapy treatment is applied by distracting and mobilising targeted spinal segments at precisely measured angles, using high distraction forces which incorporate joint mobilisation in a longitudinal plane.

Controlled forces are high enough to comfortably stretch the paraspinal tissues, open and create pressure differentials in the disc space and are applied for sufficient time to have a therapeutic effect.

Ergonomic pelvic and thoracic harnesses secure the patient to the bed and a computer controlled cyclic distraction force is applied.  Treatment is delivered by CE & FDA cleared Class II SPINA devices.  All aspects of treatment and outcomes are recorded as part of a commitment to evidence-based medicine.

Decompression of a Targeted Spinal Segment.Vector Diagram Showing Application of Forces at Varying Angles

In order to decompress a targeted level, engineers applied the principles of vector forces from physics to the spine.  They observed that by focussing a controlled distraction force at a specific angle, they could open targeted spinal segments by between 5mm -7mm1.

As the angle which a pulling force makes with the horizontal increases, the component of force in the horizontal direction (Fx) decreases and the vertical component of force (Fy) increases.

This causes the relative direction of the pulling force to change and therefore the focus point of application of the pulling force to move progressively along the x-axis.

Measured changes in the angle of applied pulling force enable clinicians to focus and direct distraction forces accurately to injured spinal segments.

Sinusoidal distraction force:  This patented waveform replaces linear pulling forces allowing greater comfort and application of higher distraction forces of up to half body weight plus 5-10kgs.


Longer treatment duration:  Twenty-five minute treatment during which time joints are distracted for 13 times to a high tension, whilst soft tissues are worked and remain under constant tension.

Joint Mobilisation:  The sinusoidal waveform allows for the application of oscillatory forces to mobilise the joint in a longitudinal, rather than anterior-posterior plane at the point when the joint is distracted.

Low frequency    Mid Frequency  High Frequency     Low Amplitude     High Amplitude

The sum of the parts:  Improved harnessing secures the pelvis, measured angle of distraction, computer controlled sinusoidal waveform, cyclical distraction and patient remains completely relaxed for 25 minutes.

Low Back Pain Treatment Programme


In order to decompress (take pressure off) a joint, it is necessary to distract it in the opposite direction to the compressive force.  Where a joint has become stiff and immobile, gentle mobilisation at the point of distraction helps to improve mobility in the joint and allow the natural mechanisms which keep joints healthy to operate freely.

IDD Therapy Spinal Decompression applies new technology to physical laws to enable clinicians to distract and mobilise targeted spinal segments as part of a complete programme of care, including manual therapy and exercise rehabilitation.

Author: Stephen Small www.steadfastclinics.co.uk

1 Shealy N, Leroy P: New Concepts in Back Pain Management. AJPM (1) 20:239241 1998 

[contact-form-7 404 "Not Found"]

Clinic Marketing Tip – Patient of the Month

The success of a clinic is in the detail and attention to detail is the driving force behind patient loyalty.

“Clinic Marketing Tips” looks at the details in your clinic and how you can improve them.  Here is an idea you can quickly implement to show your patients that they are in the right place for treatment.


At my gym in Bishops Stortford, UK, they have a Success of the Month wall.  Each month they display a case study.  This is a picture of someone and a story of what going to the gym has done for them.

Most of the case studies describe people who joined the gym and over the course of 9 months, lost 15kgs / got more confidence / did their first marathon etc.

I find these stories really motivating.  Without question seeing these stories each month reaffirm why I must keep going to the gym and why this gym (Challenge Active) is the place for me.  The people are real and I have seen many of them in the gym.


This got me thinking about related ideas such as why should restaurants/ businesses display an employee of the month?  2 reasons:

1/ to show staff that they are valued, to motivate other staff members and to give positive encouragement to the team to aspire to success.

2/ to provide evidence to customers that this restaurant looks after its staff, that they are good … and therefore if the staff are good, their dining experience at the restaurant is going to be good too.


Thinking about these two ideas, I applied the psychology drivers to the clinic business and created the Patient of the Month concept to display in waiting rooms.

You treat someone successfully … let other people know you can help them too.

Make it easy for everyone (you!) 3 paragraphs maximum, with a photo, to display in your waiting area.  That is it.  (Need a template? – use the form below to request yours)

Patients coming to your reception will be interested to read it and this will make a positive impression.

Of course, patient stories are used in all aspects of raising the profile of a successful clinic.  From a newsletter, to social media and more to give a powerful boost to your word of mouth and name recognition.

If you want some free materials on how to improve your visibility, request our clinic ’12 x 12′ marketing blueprint.
Good luck.

Stephen Small

[contact-form-7 404 "Not Found"]

IDD Therapy Spinal Decompression for the Herniated Disc: A Clinician’s View

Osteopath Robert Shanks is the co-founding Clinical Director of Spine Plus, a group of multi-disciplinary back pain clinics based in London and Essex. He trained with The British Medical Acupuncture Society and is also a qualified electrotherapist.

Robert’s area of special interest is chronic low back pain and neck pain associated with bulging or herniated discs.  He is an advocate of innovation and technological advances in spinal care and uses IDD Therapy non-surgical spinal decompression to treat his chronic disc patients.

I first became interested in mechanical spinal distraction in 2002 and I started using a home-made cervical traction device based on pioneering osteopath, Alan Stoddard’s model featured in a book from the 1950’s!  Yes, it sounds a bit Wallace & Gromit but it did the job more effectively than using my hands alone.  I then started using portable traction beds which featured a manual pump allowing for intermittent sustained traction.

The object of these devices was of course, to distract the spine in order to take some pressure off the disc(s) and any pinched nerves.  We used it as part of a standard 30 minute treatment session.  

Developments in spinal decompression have come a long way since those primitive traction devices.  Indeed, traction per se created a divide amongst clinicians in its heyday: there were those like myself who found the tool a useful addition to manual therapy and there were others who saw too many shortcomings for it to be fully effective.  

One of the key shortcomings of traditional traction was the imprecise nature in which the treatment was applied, for example, the traction force was aimed non-specifically at the entire vertebrae and not at the particular segment we were trying to treat.  Moreover, as the linear ‘pull’ was unnatural to the body, it could actually cause muscles to spasm, leading to an increase in pressure and pain!  This meant that in order to ensure relative comfort for a patient, the treatment tended to be administered in short bursts of 10 to 15 minutes with a low traction force – which proved ineffective for many chronic conditions.

Around 2008 I began hearing about Intervertebral Differential Dynamics (IDD) Therapy, a non-surgical spinal decompression treatment which appeared to address the failings of traction quite systematically.  These sophisticated IDD treatment machines were developed in the US in the late Nineties by a team of engineers and clinicians whose aim was to mechanically decompress the disc by improving upon traditional traction methods.Patient having IDD Therapy spinal decompression treatment

With modifications and revisions along the way and advances in computer technology, the team finally produced an FDA cleared class II decompression machine which, with computer-controlled forces directed at precise angles, was shown to distract targeted segments of the spine, e.g. L4/L5 from between 5 and 7mm – which had significant therapeutic implications. 

The decompression unit also included a unique oscillation feature capable of mobilising the joint at the point of maximum distraction – in much the same way as manual therapists mobilise other joints – but which given the strength of the spine, is difficult to do with the hands alone.  Moreover, because the device used a gently progressing pulling force (sinusoidal waveform) which mimics the natural contraction mechanism of a muscle, the muscle remained relaxed and lengthened throughout the slow and consistent stretch without going into spasm.  Thus patients could enjoy the necessary higher pulling forces for longer, whilst remaining completely relaxed.

I read all of the clinical research papers on IDD Therapy but I was more interested to see the treatment in action and hear the experiences of clinicians in the UK who were already using it as part of a specialised rehabilitation programme for their herniated disc patients.

The clinicians I spoke to viewed IDD Therapy as a structured programme with patients having a series of regular hourly treatments spread over a number of weeks.  The sessions consisted of some heat therapy to warm up the target area followed by 25 minutes on the IDD machine.  After the mechanical decompression, patients would have some cold therapy to prevent any temporary soreness caused by the soft tissues being worked in a new way.   Corrective exercise was introduced gradually as the programme progressed to help achieve lasting success.

I tried the treatment for myself on the latest IDD machine (the SDS Spina); I could really feel the differences which I’d heard and read about.  I decided to introduce the treatment at one of my clinics in April 2011.

In the last year the clinic has treated over a hundred patients with IDD Therapy.  These have tended to be patients with herniated or prolapsed discs whose symptoms of chronic back pain, neck pain and sciatica had prevailed despite standard manual treatments.  The clinical outcomes have been impressive: I would say that 70% of these patients have made good to excellent improvement.

A typical patient is 63 year old Rita from Chigwell who achieved an exceptional outcome with IDD Therapy after suffering for four years with an L1/2 disc bulge which surgeons would not operate on.  She had undergone countless manual treatments, facet joint injections and epidural injections without any lasting improvement.  After a series of IDD treatments she became pain and spasm-free and was able to return to work and carry out her daily household chores again.

Another patient had a considerable L4/5 disc bulge; after a programme of IDD Therapy the bulge had shrunk to less than a third of its size.

Although I have used IDD Therapy to treat acute pain, most IDD candidates have been in pain for several months, even years and have tried one or more manual treatments and/or injections without success.  For these patients, a programme of treatments spread over a number of weeks is necessary to achieve long lasting therapeutic changes to chronic conditions which have built up over time.

When patients first come to me, some are in so much pain that they are physically and emotionally exhausted and fearful of making the slightest movement.  Over the course of the IDD programme, we can help to change their outlook and expectations, setting them the realistic goal of becoming pain-free and being able to get back to their normal daily activities.  We track all patients with research tools such as the Oswestry Disability Index, Visual Analogue Scale and other objective outcomes measures.

IDD Therapy is an invaluable treatment tool to me.  It has finally enabled me to offer something meaningful for disc patients which, in my experience, is preferable to surgery and more therapeutic than epidurals, nerve root blocks and facet joint injections.  

It’s hard to find a negative side to the treatment: an IDD session takes longer than a standard 30 minute manual treatment but we cannot cut elements of the session without having a detrimental effect on our treatment goals.   By having IDD as a treatment tool to use alongside manual therapy, we are seeing more patients at the clinic and as our experience grows, we are better able to predict how to progress patients who of course, all have individual needs.

Since introducing IDD we have been able to treat several lumbar-surgery candidates; I know of patients who have been booked in for an operation and have tried IDD as a last resort and are now pain-free and active again.

Naturally, there are some patients who do not respond to treatment but generally speaking, my patients have had very good outcomes and from a personal perspective, it’s hugely satisfying to know that I have been able to do more for them.

Robert Shanks BSc (Hons) Ost

For information about IDD Therapy, call Steadfast Clinics on 01279 602030 or visit www.iddtherapy.co.uk