Falling Off the Wagon Isn’t the End: Learning from Lapses in Exercise & Recovery

During a routine follow-up, my patient “Larry Lapes,” who has chronic ankle and back pain, asked me a question that stopped me in my tracks: “Do you have any strategies that help your patients stick to their exercise routines?” His question prompted me to reflect more deeply on lapses and relapses in behavior change.

Behavioral Medicine:

Jeremy Lewis and Peter O’Sullivan propose that non-traumatic musculoskeletal pain should follow the principles of behavioral medicine that have been successful in the management of other chronic health conditions, like diabetes, obesity, or cardiovascular disease. ¹

Behavioral medicine approach uses:

• Comprehensive approach using a biopsychosocial model.
• Prevention
• Promoting alliance between the individual and the healthcare professional.
• Focuses on changing behavior.

The goal of intervention shifts from fixing or curing the problem to empowering the individual to manage the chronic health condition, maintain mobility, and participate in life activities as fully as possible. Shift from fixing to facilitating. ²

Behavioral medicine emphasizes the patient's active role in their recovery, using techniques like goal setting, self-monitoring, and problem-solving to promote long-term behavior change and improve functional outcomes.

The feature of behavioral medicine in question, which speaks to Larry Lapes’s question, is “changing behaviors.”

Johanna Fritz and Thomas Overmeer have identified broad approaches for behavior change, including: ³

• Social reward: external recognition.
• Prompts/cues reminders
• Self-monitoring or behavior follows up auditing.
• Goal setting
• Encouraging self-reward
• Encouraging generalization of target behavior
• Using shaping or rewards
• Problem Solving, including addressing relapses.

Falling off the wagon is a problem that needs solving.

The expression “fell off the wagon” is when someone lapses or relapses to negative behavior, such as smoking, eating too much, or not exercising.

Cedric DiClemente and Michele Crisafulli propose several strategies to learn from failures related to efforts of behavior change. ⁴ They cite the aviation industry as a model for learning from mistakes,s the “Black Box Thinking”. This approach involves being open to review and analysis of mistakes and implementing changes.

In medicine, Blackbox Thinking is reflected in M & M rounds—meetings to analyze cases of morbidity and mortality to address hospital adverse outcomes. Surprisingly, M & M rounds aren't routinely held in outpatient settings.

A key principle in behavioral medicine, relevant to Larry Lapes’s question about maintaining his exercise routine, is collaboration between the patient and healthcare professionals. Both parties must engage in the Black Box Thinking process.

A barrier to the Black Box Thinking process is the stigma and shame of failing to stick to a commitment. Failure to sustain a behavior change and lapse is ubiquitous.

Self-compassion is the antidote for shame. Excessive self-criticism undermines motivation. When self-esteem is low, self-compassion needs to be high.

Alcoholics Anonymous (AA) provides a model of therapeutic alliance for changing behaviors related to chronic musculoskeletal pain. Like the AA sponsor-sponsee relationship, the Physical Therapist and patient form a “therapeutic alliance.” Both the Physical Therapist and the patient need compassion.

Larry Lapes trusted that I, the Physical Therapist, would not shame or blame him for not sticking with his exercise.

The following are my thoughts on a potential checklist as part of Black Box Thinking related to lapses in changing behavior to deal with chronic musculoskeletal pain.

• Did previous Physical Therapy interventions use principles of behavioral medicine and behavior change? ²
• Did we spend enough time on how to self-monitor?
• Should we schedule booster sessions/reminders and an annual follow-up visit?
• Which is more motivating: focusing on pain, impairment, or dysfunction?
• Would a multi-tiered level of expectations/goals to include easily achievable, moderately challenging, or a stretch goal result in intelligent failure?
• Would different or additional tactics for behavior change be more effective?
• What is the thought process we can use to unlearn behaviors?
• What are other tactics to prevent lapses?

Going forward I resolve to change my behaviors as a healthcare provider. When finishing a Physical Therapy session with a client, I plan to make it routine to discuss lapses.

Potential scripts:

• Let’s talk about what to do if you fail to stick to the plan.
• This is last visit, but please reach back to me in the future if I can be of any additional assistance.
• If you want, we can schedule an annual visit for reassessment, adjustment of your self-management program, and progression of remedial exercises.

Larry’s question reminded me that lapses are not the enemy—they are part of the process. The key is to anticipate them, learn from them, and prevent them from becoming permanent. As Custer’s quote reminds us, success lies not in never falling, but in always rising again.

References:

1. Lewis J, O'Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med. 2018;52(24):1543-1544.
2. Lewis J, Mintken PE, McDevitt AW. Treating musculoskeletal conditions with a bit of exercise and manual therapy: are you kidding me? It's time for us to evolve again. J Man Manip Ther. 2025;33(3):167-172.
3. Fritz J, Overmeer T. Do Physical Therapists Practice a Behavioral Medicine Approach? A Comparison of Perceived and Observed Practice Behaviors. Phys Ther. 2023;103(5).
4. DiClemente CC, Crisafulli MA. Relapse on the Road to Recovery: Learning the Lessons of Failure on the Way to Successful Behavior Change. J Health Serv Psychol. 2022;48(2):59-68.

The information on this website is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. You are encouraged to perform additional research regarding any information available through this website, with other sources, and consult with your physician