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Finding Time. The Battle for Adherence.

So, have you done your exercises?As an MSK physiotherapist I frequently prescribe exercise as part of my treatment.   Patients often report that they find it difficult to complete exercises. This has led me to question my understanding of the factors influencing adherence to exercise, and the ways in which I can help this.  In this series of posts I will explore adherence to home exercise, looking at the barriers to adherence and also interventions to help improve it in patients with low back pain (LBP). In this initial post, I will look at the definition of adherence and the possible barriers to it.

I have chosen to focus on adherence in patients with LBP, which is reflective of my clinical caseload that has a large proportion of LBP patients. Additionally, LBP is a common health problem worldwide with an estimated “lifetime prevalence of 84%” (Balague et al., 2012). Prescribing a home exercise programme (HEP) regularly forms part of my treatment and this approach is encouraged by NICE Guidelines for LBP and Sciatica (2016). Therefore, understanding and facilitating adherence is a really important factor in ensuring effective treatment for this condition.

Adherence

The term adherence is often used interchangeably with the term compliance. When the term adherence is used in this blog it is in relation to the definition by the World Health Organisation (2003), “the extent to which a person’s behaviour corresponds with agreed recommendations from a healthcare provider”.

The literature reported in Table 1 shows there is much agreement in adherence studies with non adherence reported to be as high as 27% (Alexandre et al., 2002).

Table 1. Summary of Literature Reporting Adherence Levels to Home Exercise in LBP

 

Kolt and McEvoy (2003) measured adherence differently, looking at the percentage of home exercises completed by patients (71.6% in this case). This presents the question of which is better; the percentage of home exercises that patients adhere to, or the percentage of patients adhering?

Measuring adherence is difficult as there is no ‘gold standard’ outcome measure (Bollen et al., 2014, Holden et al., 2014). Sluijs et al. (1993), Alexandre et al. (2002) and Kolt and McEvoy (2003) all use different self-reported questionnaires to measure adherence. They all gather information differently and may be open to patient bias, leading to under or over reporting with the patient feeling obliged to give the desired answer to the clinician (Bollen et al., 2014, Stone et al., 2003) and results may not, therefore, be a true reflection of adherence. The number of outcome measures used throughout research continues to make understanding patients’ true level of adherence extremely difficult and comparing the most effective treatment interventions difficult. I feel the percentage of home exercise actually adhered to probably provides more useful information, allowing a more accurate understanding of how much patients adhere to their HEP.

There is now a recognised need for a validated outcome measure (Bollen et al. 2014, Holden et al. 2014, Beinhart et al. 2013). As a result of their previous study, Newman-Beinhart et al. (2016) have developed a measure called the Exercise Adherence Rating Scaling (EARS) which they report is the first validated measure of HEP adherence. Yet, the authors, themselves identify that their measure has similar limitations to the self-reported diaries noted previously (as it is a self-reported six item questionnaire) and that an objective measure to be used alongside this may be useful in the musculoskeletal setting.  This makes me question, was the validation of this measure useful? For objective measures, electronic devices such as activity trackers, apps and pedometers are commonly used but, currently, there is no device readily available to reflect movements associated with a specific home exercise.  Any measurement tool is affected by the patient being aware that they are being monitored, which can create motivation to adhere and an inaccurate reflection of true adherence. Clinically, if a patient’s adherence has improved I, personally, would be less concerned that I am not measuring true adherence, as long as it is having a positive impact upon rehabilitation.

Factors Associated with Non-Adherence

So what are the barriers that prevent patients from adhering to their HEP? I’ve summarised several sources’ findings in Table 2. A massive 272 problems with completing a HEP were recorded in research by Sluijs et al. (1993), using questionnaires. A questionnaire was also used by Alexandre et al. (2002), to identify barriers to HEP adherence but this was extremely limited in its implementation, allowing patients to only identify one potential barrier to treatment adherence. The paper by Sluijs et al. (1993) allowed more expansion: Patients were asked to note any problems and questionnaires with a likert scale were used to assess attitudes towards exercise.

In comparison, papers by Palazzo et al. (2016) and Dean et al. (2005) have endeavoured to gain a more in depth understanding of patient experience in relation to home exercise using semi-structured interviews. Dean et al. (2005) utilised Interpretative Phenomenological Analysis, which aims to gain an understanding of a patient’s lived experience (Smith et al. 2009). Palazzo et al. (2016) did not identify their methodology so it is unclear how they completed thematic analysis.  They did, however, identify a number of themes; highlighting problem areas that were deemed as barriers to exercise adherence, which are described further in Table 2.

Dean et al. (2005) investigated not just patients’ thoughts but also those of the therapists. They identified a lack of perceived time as a key theme, reporting that patients felt this impeded their ability to complete exercises and finding the right time to complete exercises was difficult. The therapist identified that a lack of time during treatment sessions may impede their ability to build rapport with the patient, leading to a reduced understanding of patients’ needs and expectations and, ultimately, reduced adherence.  In reading both papers, I have linked the key theme of time from Dean et al. (2008) to some of Palazzo et al.’s (2016) findings, such as; problems with the exercise programme being too complex, a burden to complete and too many exercises, reduced motivation and breakdown of supervised sessions or a lack of follow up. All this can result in non-adherence due to the patient feeling unsupported and struggling to complete an exercise programme which is perceived to be too difficult.  The difference in depth of information and number of themes identified by both papers may be due to the timeframe utilised to complete each study. Dean et al. (2005) questioned patients during their first week of their HEP, whereas Palazzo et al. (2016) questioned patients after two months of a HEP, which may have facilitated the more detailed information gathered by this paper.

A limitation I have noted is that these studies are short term, lasting between 1 to 8 weeks (see Table 2). Further research is required to improve our understanding of factors associated with long term adherence and whether these are different to those affecting short term adherence. This is something to be aware of when considering adherence with patients in the clinical setting as there is often an expectation by the therapist that patients will continue with exercise as a long term management strategy.

 

Behavioural Change & Relevance to Adherence

Adherence to an exercise programme quite obviously has a positive influence on the effectiveness of treatment (Hayden et al. 2005) but, where home exercises are prescribed, this often requires a behavioural change on behalf of the patient (Liddle et al. 2004, Hay- Smith et al. 2016).

Factors associated with non adherence and those that facilitate adherence can be considered behavioural determinants (factors that negatively or positively influence behaviour change) (Bassett, 2015).  This post has explored factors associated with non-adherence with the theme of time appearing to be most important. My next post will explore the interventions to improve adherence, with discussion on behaviour change theory and how these link to behaviour change techniques, many of which are interventions.

Bridget Gould (MSc Musculoskeletal Physiotherapy student) 

Table 2. Summary of Key Barriers to Home Exercise Adherence

 

 

References

Alexandre, N.M.C., Nordin, M., Hiebert, R. and Campello, M. (2002) ‘Predictors of compliance with short-term treatment among patients with back pain’, Revista Panamericana de Salud Pública, 12(2), pp. 86–95.

Balagué, F., Mannion, A.F., Pellisé, F. and Cedraschi, C. (2012) ‘Non-specific low back pain’, The Lancet, 379(9814), pp. 482–491. 

Beinart, N.A., Goodchild, C.E., Weinman, J.A., Ayis, S. and Godfrey, E.L. (2013) ‘Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: A systematic review’, The Spine Journal, 13(12), pp. 1940–1950.

Bassett, S. (2015) ‘Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence’, New Zealand Journal of Physiotherapy, 43(3), pp. 105–111. 

Bollen, J.C., Dean, S.G., Siegert, R.J., Howe, T.E. and Goodwin, V.A. (2014) ‘A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties’, BMJ Open, 4(6), pp. e005044–e005044.

Dean, S.G., Smith, J.A., Payne, S. and Weinman, J. (2005) ‘Managing time: An interpretative phenomenological analysis of patients“ and physiotherapists” perceptions of adherence to therapeutic exercise for low back pain’, Disability and Rehabilitation, 27(11), pp. 625–636.

Hayden, J.A. (2005) ‘Systematic review: Strategies for using exercise therapy to improve outcomes in chronic low back pain’, Annals of Internal Medicine, 142(9), p. 776.

Hay-Smith, E.J.C., McClurg, D., Frawley, H. and Dean, S.G. (2016) ‘Exercise adherence: Integrating theory, evidence and behaviour change techniques’, Physiotherapy, 102(1), pp. 7–9.

Holden, M.A., Haywood, K.L., Potia, T.A., Gee, M. and McLean, S. (2014) ‘Recommendations for exercise adherence measures in musculoskeletal settings: A systematic review and consensus meeting (protocol)’, Systematic Reviews, 3(1), p. 10. 

 Kolt, G.S. and McEvoy, J.F. (2003) ‘Adherence to rehabilitation in patients with low back pain’, Manual Therapy, 8(2), pp. 110–116.

Liddle, S.D., Baxter, D.G. and Gracey, J.H. (2004) ‘Exercise and chronic low back pain: What works?’, Pain, 107(1), pp. 176–190. 

NICE (2016) Low back pain and sciatica in over 16s: Assessment and management. Available at: https://www.nice.org.uk/guidance/ng59 (Accessed: 10/12/2016).

Newman-Beinart, N.A., Norton, S., Dowling, D., Gavriloff, D., Vari, C., Weinman, J.A. and Godfrey, E.L. (2016) ‘The development and initial psychometric evaluation of a measure assessing adherence to prescribed exercise: The exercise adherence rating scale (EARS)’, Physiotherapy, In Press. Available from: http://www.physiotherapyjournal.com/article/S0031-9406(16)30480-1/abstract (Accessed 28/12/2016)

Palazzo, C., Klinger, E., Dorner, V., Kadri, A., Thierry, O., Boumenir, Y., Martin, W., Poiraudeau, S. and Ville, I. (2016) ‘Barriers to home-based exercise program adherence with chronic low back pain: Patient expectations regarding new technologies’, Annals of Physical and Rehabilitation Medicine, 59(2), pp. 107–113. 

Sluijs, E., Kok, GJ. and Van Der Zee, J. (1993) ‘Correlates of Exercise Compliance in Physical Therapy’, Physical Therapy, 73(11), pp771 -782.

Smith, J., Flowers, P. and Larkin, M. (2009). Interpretative Phenomenological Analysis, Theory, Method and Research. London: SAGE Publications Ltd.

Stone, A.A., Shiffman, S., Schwartz, J.E., Broderick, J.E. and Hufford, M.R. (2003) ‘Patient compliance with paper and electronic diaries’, Controlled Clinical Trials, 24(2), pp. 182–199.

WHO (2003) Adherence to Long Term Therapies: Evidence for Action. Available  at:http://www.who.int/chp/knowledge/publications/adherence_report/en/ (Accessed: 03/12/2016)