When 12-year-old Alana Gude first walked on her own at age six, she was “excited and happy because [the] hard work paid off,” she says. Gude, who developed pneumonia after she was born, resulting in an enlarged liver and visual impairment, was not expected to live past her first birthday. “She was unfortunate to get those things,” says her father Alex Gude. “But, she was fortunate enough to be strong and fight through them.”

Today, Alana has shown great progress and anticipates walking without assistance. You have to keep trying, she says. Gude also looks forward to therapy sessions because she knows her therapists are helping her become more independent. “I’m doing a lot of exercising,” she says. “One day at therapy, I was standing on the parallel bars without holding on at all. I just started walking a little, completely by myself and I was so excited.”

Gude’s physical therapist, Darci Debaun, PT, at Children’s Health Care of Atlanta (CHOA) at Mt. Zion in Morrow, Ga., says she creates specific home programs “that are easy for parents to follow,” using dated grids to track patients’ progress. She also tries to make therapy fun by rewarding her pediatric patients with stickers, cars or nail polish.

When it comes to motivating patients, Debaun recommends that therapists “set goals that are meaningful to the patient.” She also says therapists should always explain the important role patients and parents play in reaching their goals.

In addition, Debaun stresses that setting expectations early on in treatment and “holding parents and patients accountable for completing home programs” is important, but says it is equally important to also remind patients of their progress.

Gude, who will turn 13 in March, says Debaun’s encouragement helps her to get through challenging therapy sessions. “When I didn’t get it right the first time, she taught me how to sit up straight,” Gude says. “At one time I had a problem with backing up and my exercises. Ms. Darci told me that I could do it. To hear her say ‘you can do it’ made me feel so excited.”

In pediatrics, the responsibility to comply with therapy regime recommendations falls on parents. Debaun says she works to increase patient compliance, especially with younger patients, through maintaining an open dialogue with family members.

Debaun utilizes several specific methods to motivate patients and encourage parents to complete home therapy regimes. First, she works to create home programs that are easily incorporated into patient’s daily lives “by slightly modifying an activity they already do to promote a therapeutic goal.”

For example, when working with infants diagnosed with torticollis, the exercise program may include teaching parents’ to hold their children in a manner that stretches specific neck muscles, Debaun says. When working with toddlers, Debaun has parents work on single limb balance by requesting that they put their child’s shoes, socks and pants on while the child is standing.

Another way Debaun enhances patient compliance is by informing parents that if they follow treatment regimes on a daily basis, they will help their child “more than a therapist can in one hour once or twice a week,” she says. “We are here to help them help their child.”

Furthermore, Debaun sets specific therapy goals and timeframes so patients and parents clearly understand the treatment objectives. She ensures her patients’ parents know how to facilitate home programs using return demonstration. She also holds parents accountable by requesting that during subsequent appointments they perform home programs for the therapist. However, the most important motivator, Debaun says, is to “get excited about patient’s success and progress.”

When working with older patients or teenagers, Debaun recommends community programs such as Atlanta-based Blaze Sports America. She encourages families and patients to be “as physically active as possible” and assists them in acquiring adaptive equipment, such as adapted tricycles or gait trainers.

Debaun encourages other therapists to promote active behavior with patients by setting meaningful goals that “will make a difference in [patients’] daily lives, not just [programs] out of a standardized test booklet,” Debaun says. “Showing patients how they can be active by encouraging involvement in community groups or acquiring necessary adaptive equipment,” is an important motivator.

CHOA holds group activity days including a fall festival, field day, winter festival and summer games where patients participate in planned group activities with their peers. “It is an opportunity for our patients to train for several months to complete specific events at and to receive medals for their accomplishments,” Debaun says.

However, although therapist support is essential, the patient will not progress if they aren’t motivated. Working to create a sense of intrinsic motivation in patients who may be reluctant is often a matter of presenting tangible results.

Debaun says showing patients their progress in a concrete form is very motivating. For example, when measuring knee flexion for a 9-year-old girl with a fractured femur, Debaun says she “showed her the actual goniometer, [which measures angles] showing how many degrees of motion she gained. Then, we set a new goal for the next week.”

When working to increase patient compliance, Debaun suggests therapists “find out what motivates the patient and use a reward system. Hold the patients and their families accountable for understanding and committing to do their part in the rehabilitative process.”

The psychosocial aspects of patient compliance and motivation intrigue medical sociologists. Unlike Gude, not all patients are active participants in their own care. According to Emerson Smith, PhD, medical sociologist and president of Columbia, S.C.-based Metromark Market Research and Business Solutions, people may find self-motivation challenging if they “become ill and take the sick, or patient role.”

Smith explains, “This is a subservient role that may take decision-making away from the person and may isolate the person from active roles in their family, community and on the job. For some patients, the sick role is desirable since they can avoid having to take on other roles in society.”

Smith encourages therapists to call patients by their title and last name. He also suggests they ask patients about their social, family and work life. “Many healthcare workers often call patients by their first names, demeaning the community stature of the person with undeserved familiarity,” he says. Smith maintains that keeping inpatients associated with their active roles in society will ease their transition back into the community.

Occasionally, patients develop a dependency on therapists, which lengthens the recovery process and makes reintegration into productive social roles more challenging. To avoid this, Smith says, “We need to identify the patient not only with a name and ID number, but by occupation and title, so the staff sees the patient as more than just the ‘patient’ in room 304.”

He also maintains that inpatients should be encouraged to bring books, laptops, printers and be able to use cell phones at will, adding that hospitals should solve the problem of interference by shielding equipment. Other suggested improvements include providing long-term inpatients with private rooms, visiting hours on an open schedule, a selection of the latest DVDs and TVs and daily delivery of local and national newspapers; when combined, these amenities allow patients to keep in touch with the outside world.

While challenging to implement, this type of hospital set-up already exists in some major specialty hospitals, such as M.D. Anderson Cancer Center in Houston and Children’s Hospital of Philadelphia.

Smith says this or a similar set-up “helps to reduce the isolation and will reduce the patient assuming the sick role.” He also says patients should be allowed to bring bedclothes and day clothes from home, except, obviously, for surgery.

“If we can keep the patient’s productive social, work and community roles present in the life of the patient while undergoing medical treatment, then we can reduce the chance that the patient will assume a ‘sick person’ role,” Smith says.

Patients like Alana Gude serve as an example of determination and encouragement for others, says her father Alex. “We kept trying to let her know we loved her, she never gave up and we never gave up on her. She will be 13 [this year] and we are ecstatic for every day we have with her.”

Kate DeBevois is the staff writer for Therapy Times. Questions or comments can be directed to kdebevois@TherapyTimes.com.